(Modified) Original Photo by Dave Pape
Injury: Wrist Fracture, Distal Radius Fracture
Mechanism OF INJURY
Typically occurs with a direct force to the wrist, usually from a fall on an outstretched hand. In kids, we typically will see the injury occur from a fall off the monkey bars, trampoline, bouncy house or scooter to name a few. The injury usually occurs to distal shaft of the bone within a few centimeters of the joint. However the injury can occur anywhere along the forearm with this type of injury.
ExamINATION
Kids will typically have swelling over the wrist joint. Additionally, they will sometimes have a clear deformity to the bone either to the touch or direct visualization. Very young children may only have pain briefly at the time of the injury and simply restrict the use of that limb. However most individuals will have significant pain and inability to flex or extend the wrist. An evaluation should be be done to assess the nerves and the blood flow to the wrist. The patient can be asked to give a thumbs up, make an "Ok" sign, and spread their fingers against resistance to grossly asses nerve function. Also the pulse should be checked as well as finger tips monitored to checked for good blood flow to the area. An x-ray is the optimal test to confirm the diagnosis.
Treatment
The treatment depends on a few key aspects of the fracture. In my opinion, the most important factor is the age of the patient. Children who are less than 10 years of age generally are able to tolerate and recover from displaced or angulated fractures much better than children who have begun puberty. Non-operative treatment typically consists of a short arm cast (below the elbow) or if the fracture is minor a simple wrist brace. In pediatric patients, the indications for surgery include significant displacement or angulation of the fracture with certain criteria corresponding to each age. Additionally, surgery is usually required when the bone is sticking out of the skin, which is called an open fracture. Surgery in a younger child may consist of adjusting the bone with the patient asleep and casting or using pins or plates to stabilize the fracture. Typically pins are reserved for younger patients and plates are reserved for older pediatric patients, but the decision has many factors.
Return TO PLAY
Return to play after a fracture varies significantly based on the severity of the fracture and the sport of the individual. A very tiny fracture, called a buckle fracture, is represented as a dent or depression in the outer surface of the bone. With a buckle fracture full return to activity with protective brace or cast can be appropriate for sports such as cross-country or soccer. With more significant fractures, sports should be restricted until the medical provider feels that the fracture is stable and the risk of shifting is minimal. At that time, it may be acceptable to return an athlete to play with the cast and appropriate padding to protect other athletes.
Sports Considerations
Under certain circumstances an athlete may be able to play with a fractured wrist with the appropriate protection. As expected, this will vary among medical providers and is multi-factorial. Additionally, if the athlete is cleared they will have to provide appropriate padding to the cast or brace to protect others against injury. Additionally, the athlete will have to get permission from whichever league they are participating in so the proper documentation can occur.
Distal Radius Fracture
Below is an AP (Frontal) and Lateral (Side View) of a distal radius fracture. Note that ideally a medical provider needs at least two different views to make an accurate diagnosis. If one were to rely only on the frontal view the angulation seen on the lateral view would not be visualized. The fracture shown below is an angulated greenstick fracture of the distal radius.
(Modified) Original Photo by Dave Pape
Buckle Fracture of ULNA
Below is a (side view) of a distal ulna buckle fracture. The medical provider needs to pay close attention to note a buckle fracture as they may be easily missed. A very tiny fracture, called a buckle fracture, is represented as a dent or depression in the outer surface of the bone.
(Modified) Original Photo by Dave Pape