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THE MOST COMMON upper extremity fracture, distal radius fracture (DRF) accounts for an estimated 17% of fractures treated in the United States EDs and 16% of all fractures treated by orthopedic surgeons.1,2 The most common mechanism of injury is falling on an outstretched hand with the wrist in extension. A DRF usually causes immediate pain, tenderness, ecchymosis, and edema. The wrist may also be deformed, although in some cases, it retains a normal appearance.1
A DRF is any fracture in the distal articular and metaphyseal areas, which is where the distal radius and ulna form the wrist joint.3 (See Anatomy of the wrist.) This article describes nursing assessment and interventions for an adult with a DRF.
In adults, two age groups are especially susceptible to DRFs. Many young adults (ages 18 to 25) sustain DRFs from high-energy trauma related to motor vehicle crashes and sports.
In the second group, older adults (over age 65), this fracture is typically caused by a ground-level fall. Older adults have a greater fall risk for many reasons, including impaired physical mobility. Because of osteoporosis or osteopenia, older adults are vulnerable to fractures from low-energy trauma. This type of fracture is referred to as a fragility or insufficiency fracture in older adults. Other risk factors in older adults include female gender, Asian or White ethnicity, heredity, and early menopause.2,3
Various names have been used to classify the many types of DRFs, including Colles, Smith, and Barton fracture. (See What's in a name?) These eponymous classifications reflect the position of the wrist at the time of injury. Because these classifications have been inconsistently described and applied over the years, classification systems based on other criteria have been proposed; however, no consensus has emerged.2,3 Examples of classification systems widely used today include:
* the AO/OTA (Orthopedic Trauma Association) Classification, which categorizes bony injury as extra-articular, partial articular, and complete articular.3,4 (An articular fracture extends into the joint; an extra-articular fracture does not.)
* the Fernandez System, which is based on the mechanism of injury (bending, shearing, compression, avulsion, or a combination).5,6
* the Frykman System, which divides fractures into categories based on involvement of the radiocarpal and radioulnar joints.1,2
When you initiate nursing care for a patient with a DRF, immediately remove any jewelry from the affected hand and wrist-particularly rings, which may need to be removed with a ring cutter if edema prevents them from being pulled off.
Obtain the patient's history, determining the mechanism of injury and circumstances surrounding the injury. This is particularly important in older adults, who may have had a fall related to other conditions, such as a cardiac dysrhythmia, transient ischemic attack, or vertigo. Also ask about any conditions or other factors that may affect wrist anatomy, such as carpal tunnel syndrome and previous wrist surgery or injuries.
Perform a thorough pain assessment, paying special attention to signs and symptoms of possible median nerve injury, such as pain out of proportion to the injury or pain described as "burning."2 Your physical assessment should also include the following.
* Carefully inspect the entire affected upper extremity (including the elbow and shoulder), comparing it with the contralateral extremity. Note the presence of edema, ecchymoses, any obvious deformities, or open fractures. Perform a neurovascular assessment, including motor and sensory function of the median, radial, and ulnar nerves. (See Give nerves a hand.)
* Continuously assess for the loss of function or sensation in the patient's thumb and index finger, which indicates acute median nerve compression. The median nerve is always compressed after a fall on the palm of the hand.1,3 If the wrist is very edematous with a decrease in median nerve function, the patient may have a median nerve contusion or acute compressive neuropathy. If carpal tunnel syndrome develops, the patient requires surgical decompression.5
* Assess radial and ulnar pulses and capillary bed refill of the nail beds and fingertips. Assess range of motion of the wrist, if possible. (See Testing range of motion.)
Immobilize the wrist with a padded arm board or wrist splint to stabilize the fracture until it can be reduced and immobilized with a cast or skeletal pins. Stabilizing the fracture will help reduce pain. As prescribed, provide analgesia and manage the injury following the familiar RICE formula: rest, ice, compression, and elevation. Elevate the wrist and forearm to reduce edema and provide cold compresses to control pain and edema.
Prepare the patient for posterior-anterior and lateral X-rays of the distal radius, as prescribed. Computed tomography may also be indicated in some patients, especially if the fracture pattern isn't clear on plain radiographs or if surgery is planned.
The goal of treatment is to restore pain-free unrestricted range of motion and function of the wrist and forearm. Indications for reduction or operative treatment depend on the nature of the fracture; treatment is individualized according to the patient's activity level.3
Several options are available for maintaining the bone in alignment while the fracture heals. Closed reduction (alignment) is an option for nonarticular, nondisplaced, and reducible stable fractures. After closed reduction, a splint is applied for a few days to prevent further injury and help reduce pain. A cast is applied several days later, after edema subsides. An X-ray is obtained weekly for the first 3 weeks to check for displacement. The cast can be removed in about 6 weeks, followed by physical therapy to improve wrist motion.3
Another option for reducible and stable fractures is closed reduction and percutaneous pinning. In this technique, wires are placed in the radial styloid and dorsal ulnar corners of the radius.3
If the fracture is comminuted (fragmented into two or more pieces) and can't be reduced to proper alignment with a cast, external fixation is used to restore the length and intra-articular alignment of the bone.5 Pins and wires are anchored in the bone and attached to a frame on the outside of the skin, stabilizing the bone. Adjustments of length and alignment can be done after application.7
Open reduction and internal fixation may be necessary to treat complicated fractures such as displaced articular fractures with palmar dislocation of the carpus.4 A combination of pins and plates are used in internal fixation. Irreducible and complex fractures are also treated by this method. Follow-up for surgically reduced fractures occurs in 7 to 10 days.3 Provide wound care for surgical incisions as directed by the surgeon.
Complications from percutaneous pinning can include insertion problems, injury to the radial sensory nerve, and infection at pin sites. Tendon rupture is a possible complication from the use of plates to stabilize a DRF.3 Other possible complications include ligament injury causing chronic wrist pain, median nerve damage, or compression leading to carpal tunnel syndrome or arthritis.5 However, most patients have no complications and recover uneventfully.
Arthroscopy is another option to manage intra-articular fractures; however, outcome studies haven't demonstrated that outcomes from this procedure are superior to those for conventional therapy.2
If you're caring for a patient with an open reduction and fixation of the wrist, assess vital signs as indicated, perform neurovascular assessments of the affected extremity, and observe any pin sites for signs and symptoms of infection, including pain, erythema, edema, warmth, and purulent exudate. Perform a comprehensive pain assessment and aggressively manage pain, with both prescribed medications and nonpharmacologic interventions. Immediately report any abnormalities to the healthcare provider.
Reduction of a DRF can be performed as a same-day surgery procedure, or in an outpatient setting, such as a physician's office or clinic. Because the patient will be returning home shortly after treatment, both the patient and family must be educated about how to care for the fractured wrist.
Instruct patients to keep the hand and forearm elevated above the elbow. Explain that elevating the hand draws the swelling away from the fracture site. Teach the proper use of a sling, as indicated, and emphasize that the sling should be used to keep the hand higher than the elbow to help control edema and pain. Cool compresses may be used to decrease edema and pain.
For patients with a cast, explain the importance of keeping it dry. When showering, they can cover it with a plastic bag or another impervious plastic wrap.
Also explain how to recognize the hallmark signs of infection and when to notify the healthcare provider. For example, teach patients to immediately report the following signs and symptoms of compartment syndrome, a limb-threatening complication.
* discolored or pale fingers or nail beds
* decreased or absent peripheral pulses
* increasing edema
* paresthesias, such as numbness, tingling, or burning sensations
* decreased or lost ability to move fingers or hand
* increasing pain not relieved by pain medication.
For patients with pin stabilization, demonstrate and teach proper pin site care to both the patient and family members. According to the National Association of Orthopaedic Nurses, pin care can be done once a day, twice a day, or weekly depending on the amount of drainage and the stability of the bone and pin sites. Using clean technique, patients can clean pin sites with chlorhexidine 2 mg/mL solution or 0.9% sodium chloride solution on stable pins. Application of an antimicrobial ointment may be ordered to the pin sites. Pins may be covered with sterile gauze or left open to air.7,8 Give patients printed discharge instructions for site care, which should include early signs and symptoms of infection or a loose pin, and information on how to contact the healthcare provider if problems develop.8
For all patients, stress the importance of keeping follow-up appointments with the healthcare provider. Tell them that once their fracture is healed, they'll begin physical therapy sessions to increase range of motion and strengthen muscles in the hand and wrist. Physical therapy is individualized to each person's needs according to activities of daily living, age, or work requirements. Reinforce the surgeon's instructions for active or passive range of motion exercises that patients can do at home before beginning a formal physical therapy program. Once therapy begins, the physical therapist instructs patients on exercises to perform at home.
The number of wrist fractures in people with osteoporosis is estimated at 397,000.9 Because more older adults are living longer, more active lives, the incidence of DRF is expected to increase. Many people with fragility fractures of the wrist are unaware that this injury may indicate osteoporosis. An osteoporosis screening is indicated for patients over age 50 who sustain any fracture.4
Many clinicians involved in fracture repair miss the opportunity to screen patients, especially men, who present with fragility fractures.10 Nurses working on same-day surgery units, EDs, physician offices, and clinics can address risk factors for osteoporosis and discuss fall prevention with their patients. Nurses are essential for providing healthcare information and self-management strategies to prevent future fractures or falls and to keep patients safe and functioning independently.
The long-term prognosis for a properly treated DRF is good and most people can resume all of their previous activities. Light activities such as swimming can begin within a month of surgery or cast removal. Most patients can resume vigorous physical activity within 3 to 6 months. But inform patients that complete recovery takes at least a year, and that during this time, they should expect some residual pain and stiffness.11
1. Petron DJ. Distal radius fractures in adults. UpToDate. 2010;1-33. http://www.uptodate.com. [Context Link]
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3. Nelson DL. Distal fractures of the radius. Medscape Reference. 2011. http://www.emedicine.medscape.com/article/1245884-overview. [Context Link]
4. Wheeless CR. Wheeless' Textbook of Orthopaedics. 2011. http://www.wheelessonline.com. [Context Link]
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6. American Society for Surgery of the Hand. Fernandez classification of distal radius fractures. E-Hand.com. The Electronic Textbook of Hand Surgery. 2010. http://www.eatonhand.com/clf/clf521.htm. [Context Link]
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9. National Osteoporosis Foundation. Fast facts. http://www.nof.org/node/40. [Context Link]
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11. Distal radius fracture. American Academy of Orthopaedic Surgeons; 2007. http://orthoinfo.aaos.org/topic.cfm?topic+a00412. [Context Link]
12. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:602. [Context Link]
13. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:607. [Context Link]
14. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:606. [Context Link]
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