HEALTHNET

Recent Advance in Treatment for Elderly Wrist Fracture

Obtaining a stable fixation in the elderly osteoporotic bone has always been challenging to surgeons...

(Posted on 26 April 2007)

Wrist (distal radial) fractures account for 14% of all extremity injuries and can occur as a result of a fall commonly seen in osteoporotic elderly patients. Obtaining a stable fixation in the elderly osteoporotic bone has always been challenging to surgeons. If the fixation is not stable enough, healing in an incorrect position may occur and result in a painful, stiff and dysfunctional wrist even after surgery.

Conventional Treatment Leads to Shortening and Malalignment

In the past, elderly wrist fractures were often treated with manipulation and casting, despite the fact that most cases would heal with significant shortening and malalignment. The generally accepted concept, proposed as early as in 1814 by Abraham Colles, is that after a certain period of time, the compromise in function would not be too significant in the patients with low functional demand. However, the need for a better outcome in these common fractures is recently revisited as newer methods of treatment are devised. The question of whether it is inadequate just to concentrate on the final functional recovery is raised regarding this problem. The time to return to a satisfactory functional level may, in fact, be crucial to many elderly patients.

Previously, it was generally not advisable to treat these elderly wrist fractures with conventional plating or other fixation instruments as the fixation was not rigid and might lead to complications like stiff shoulder. Plaster treatment would be given to the vast majority of such patients. With the introduction of new locking screws and fixed-angle metal implants, a good alignment can often be achieved and maintained by a fixed-angle plate placed in the palmar side of the wrist. Biomechanical studies show that in terms of load transmission, a palmer fixed-angle plating restores stability comparable to that of intact radius, and is superior to conventional plating. The surgical technique with new screws and implants is easier than the conventional methods and is associated with less soft tissue irritation. It also permits early wrist rehabilitation without the need of additional splintage.

HKU Introduce New Fixation Method with Satisfactory Operational Results

The Queen Mary Hospital, The University of Hong Kong is the first centre to introduce the new fixed-angle metal implants to treat elderly fractures in Asia in 2001. The overall results have been very satisfactory. In comparison with plaster treatment, there were significantly less shortening of the radius (on average 1mm as compared to 6mm) and less abnormal tilting of the wrist (3 degrees as compared to 20 degrees). Most of the patients had excellent or good result even at the early assessments 2 to 3 months after operation. Generally speaking, patients receiving plaster cast treatment need 4 to 6 months to regain satisfactory mobility of the wrist, while with the new fixation method, patients can perform simple self-care or even daily tasks as early as 2 to 3 weeks after surgery.

Encouraging Rehabilitation Progress in Patients

Patient cases who have received the new plating were reviewed in the Occupational Therapy Department of David Trench Rehabilitation Centre, Queen Mary Hospital. They were compared to those treated by conventional casting method. Advantages of the new fixation method include:

Early mobilization immediately after operation instead of waiting for 6 weeks in the casting group. Satisfactory wrist movement was attained 3 months after operation which was even better than the result in 6 months in the conventional group.
Without the application of casting, patients were more ready to involve the injured side in self care and leisure activities 2 to 3 weeks after operation. Complications like shoulder or finger stiffness were much reduced.
Strengthening could be started 4 weeks earlier compared with the casting group. Grip strength attained 75% and 90% in 3 months and 6 months after operation respectively. Grip strength in 6 months was 25% stronger than that of the casting group.
For patients who were employed, it was observed that earlier entry into work rehabilitation program resulted in earlier return to the workplace. They resumed work 5 months after operation on average (2.4 months earlier than the casting group).

Source: The University of Hong Kong Li Ka Shing Faculty of Medicine