Poll: surgery or cast?

[wabmester]

I always enjoy the candid medical discusions here, so here's my story of gore.

Saw an orthopedic surgeon. He agrees my wrist is broken -- distal radius fracture.

He says if I were 19, a cast would be a no-brainer. If I were 65, a metal plate would be a no-brainer. But I'm 45, so it's my call.

This highly recommended Harvard-educated doc wants to cut me open and put this shiny titanium plate in me:

shiny!

He says it will increase the odds of a good outcome, quick recovery, and full flexibility. As a surgeon, he'd want one for himself in my situation.

But, he says 7 out of 10 orthos would recommend a cast for me. And he gives a cast a 75% chance of a good outcome.

Worst case: cast, then chronic pain, then more complicated surgery to correct my bad choice.

I loathe the idea of surgery, but chronic pain doesn't thrill me either. I'm getting another opinion in a couple days....

[Moemg]

I've worked with several orthopedic doctors .Go with the surgery .If it doesn't heal right in a cast you'll still need surgery .More complicated surgery .The real shiny plates are small and give you the best chance of good mobility .

[lazygood4nothinbum]

i'm voting cast because that gives you a whole new hobby of getting people to sign it.

[TromboneAl]

Quote:

He says it will increase the odds of a good outcome, quick recovery, and full flexibility. As a surgeon, he'd want one for himself in my situation.

If you talk to the salesman at Circuit City he'll say "These are the speakers that I have in my house." If you talk to a surgeon, he'll say 'I'd have the surgery.'"

[Billy]

distal radius fracture...? I am not a doc., but all this tells me is that you have a fracture that's effecting the radius of the joint. The wrist is a complicated joint with many little bones working like a gearbox. Think about it. How many joints in your body have the same flexiblility as your wrist? Not many if any.

I, too, broke my wrist. It was the scafoid bone. A tiny bone, yet it seems we cannot do without any of them functioning correctly. In my case, I had to have surgery with a bone graft. But this thread is about what's right for you.

IMO, I would seek out the best hand surgon you could find, including professional sporting team surgeons. They are the ones who deal with these injuries regularly and it's their goal to "keep you in the game" meaning to bring you back to full recovery ASAP, without any pain.

Good Luck to you.

Billy
www.RetireEarlyLifestyle.com

[simple girl]

Quote:

Originally Posted by Billy IMO, I would seek out the best hand surgon you could find, including professional sporting team surgeons. They are the ones who deal with these injuries regularly and it's their goal to "keep you in the game" meaning to bring you back to full recovery ASAP, without any pain.

I second that. Definitely seek out a hand surgeon. Wrist fractures can be nasty. If it doesn't heal properly, you will have a very difficult time with daily activities.

FYI, you'll need rehab after either cast or surgery...it's also very critical for optimal outcomes.

[wabmester]

Good stuff. There is an ortho group downtown that handles all of the regional sports teams, but I didn't see a wrist specialist in their group.

FWIW, the radius is technically one of the forearm bones (with its pal, the ulna). The distal end interfaces at the wrist. Apparently, that end is not as strong as the rest of the bone. So, this fracture is pretty common (called a FOOSH for fall on an outstretched hand).

[Meadbh]

Wab, here's what MD Consult says about your wrist fracture. If you would like me to explain the gobbledegook or to check out individual references, just send me a PM.

Meadbh
Disclaimer: I'm not an orthopedic surgeon!



The Wrist: Common Injuries and Management

Katrina Parmelee-Peters, MD
Scott W. Eathorne, MD

DISTAL RADIUS FRACTURE
Distal radius fractures are very common in sports. This injury typically occurs with a FOOSH with hyperextension, impacting the distal radius. The athlete presents with pain, swelling, ecchymosis, and tenderness about the wrist. Initial radiographs should include PA, lateral, and oblique views of the wrist. The examiner needs to determine the type of distal radial fracture and assess displacement, shortening, and intra-articular involvement. The goal of treatment is to correct and maintain radial inclination, palmar tilt, length, and congruity of the distal radial articulations (carpal and ulnar).

A Colles' fracture, the most common distal radius fracture, is a closed fracture of the distal radial metaphysis in which the apex of the distal fragment points in the palmar direction and the hand and wrist are dorsally displaced (Fig. 7). This fracture usually occurs within 2 cm of the articular surface. Colles' fractures are common in adults and rare in children, because children tend to sustain injuries through the distal radial physis.

Stable distal radius fractures may be managed in a short arm cast. All others should be referred for reduction and fixation. A stable distal radius fracture is extra-articular, without comminution, and with minimal or no displacement, which, when reduced to anatomical alignment, does not redisplace back to the original deformity [30]. For optimal outcome, it is important that anatomic alignment of the radius is maintained (either at presentation or with reduction); however, authors differ slightly on the definition of acceptable anatomical alignment. Certainly, fractures must be referred for orthopedic consultation if there is greater than 20° dorsal tilt, loss of radial inclination (20° to 30° need to be maintained), articular step-off greater than 2 mm, or radial shortening greater than 5 mm (Fig. ) [31]. Maintaining radial inclination of 20° to 30°, 4° to 8° palmar tilt, and radial shortening no greater than 2 mm is recommended by Rettig and Trusler [32]. Some texts report that less than 20° of dorsal tilt is stable for closed reduction of a Colles' fracture [30], [33]; however, the reduction needs to be close to anatomic alignment. Laboratory studies demonstrate that alteration of palmar inclination by 20° or more can cause dorsal shift in the scaphoid and lunate, leading to decreased range of motion and high pressure areas on the distal radius [34]. In an individual who normally has 11° of palmar tilt, the maximum acceptable alteration in palmar inclination is 9° of dorsal tilt. Clinical studies also demonstrate that patients who have excessive dorsal tilt are more likely to have poor outcome. McQueen and Jaspers [35] reported on 30 patients who had a Colles' fracture at 4 years follow-up. Patients who had as little as 10° dorsal tilt were much more likely to have pain, stiffness, weakness, and poor function.

Fractures may “settle” or displace in the cast. If healing occurs with a displaced fracture fragment, wrist range of motion will be compromised. A distal radius fracture that is considered stable is managed with a short arm cast, but must be followed with weekly radiographs for at least 3 weeks to ensure that the fracture does not displace in the cast. If cast immobilization is not able to maintain less than 10° of dorsal radial inclination and less than 5 mm radial shortening, internal fixation is recommended [30].

Some surgeons are electing to manage even traditionally stable distal radius fractures with internal fixation. The reason seems to be twofold. The closer to anatomical alignment the fracture is maintained, particularly in palmar tilt, the better the outcome. Also, “stable” fractures may displace with cast immobilization, termed “secondary instability,” and require internal fixation. In a prospective radiological study performed on 170 Colles' fractures that were treated with closed reduction and cast immobilization [36], 29 fractures displaced, requiring further reduction and external fixation. Seventeen additional fractures suffered malunion, with significant increase in radial angulation and decrease in radius length.

[mb]

Minor change in topic.

WAB, is this from roller blading? Were you wearing wrist guards?

I got a new pair of knee guards and wrist guards for Christmas.

MB

[wabmester]

Roller skating on the old-school quads with my 3-year-old at a rink. Backward fall landing solely on one hand.

I've read that even a wrist guard wouldn't have helped much in that kind of compression fall. BTW, do you know how they test wrist guards? Hint: donate your body to science.

[mb]

Quote:

Originally Posted by wab Roller skating on the old-school quads with my 3-year-old at a rink. Backward fall landing solely on one hand. I've read that even a wrist guard wouldn't have helped much in that kind of compression fall. BTW, do you know how they test wrist guards? Hint: donate your body to science.

Ouch! Think I'll wear them anyway!

MB

[sgeeeee]

I'm voting for amputation.

[Brat]

I vote for the hand surgeon. And, since we have so many teaching hospitals around here make sure that "the master" is doing the job. This is one of those injuries where timeliness is more important than location. If the local talent is booked look in Portland, SF or LA. Flights are cheap.

[Toejam]

Hi Wab:

Sorry to hear about your wrist injury. Hope you make the best decision and that everything goes well. Wishing you a speedy recovery.

Toejam

[Moemg]

By the way the orthopedic doctors that I worked for were sports medicine .They are the doctors for the Us soccer team ,many of the tennis stars , the Pittsburg Pirates and (though they were lousy this year )the Tampa bay buccaneers
So I'm still voting surgery !

[USK Coastie]

Sorry about your fall!! Just one more thing if you decide surgery the installed plate/screws etc may well have you setting off metal detectors in airports. Make sure you get a laminated card from the Doc and carry it while flying. Noting more annoying than setting off the metal detectors in the security line.

[Texas Proud]

I read how you got the injury....

A long number of years ago... my boss was roller skating with his kid... did the same thing, falling backwards.. but he put both arms down to break his fall...and broke both arms....

He got the metal pins in each arm with the bridge or whatever it is called outside his arm... Kids were scared when they saw him coming with these things hanging on his arm... I had heard this is one of the most common ways adults break their arm...

[marpea]

Hi WAB,

I had this same type of wrist break in August after pulling ivy in the garden, losing my balance and falling backward on a terrace and down into a cement stairwell. The wrist was set and then they took another XRAY and recommended I have surgery to insert a titanium plate to hold bones in place. They put titanium in my wrist area to hold everything together. I was in a cast about 3 weeks and then started going to a physical therapist specializing in hand/wrist injuries. I wore a wrist brace for another 3-6 (?) weeks.

I was in physical therapy for two months and now have almost complete range of motion of hand and wrist back. I credit the skilled physical therapist with getting my range of motion back to my fingers, hand and wrist.

I was told there would be less likelihood of osteo arthritis with surgery and so far no residual pain. Also I was probably in a cast a much shorter time which seems important to getting range of motion back. Initially I had no range of motion in fingers, hand and wrist. I could barely wiggle two fingers, that was about it.

[wabmester]

Quote:

Originally Posted by Texas Proud He got the metal pins in each arm with the bridge or whatever it is called outside his arm... Kids were scared when they saw him coming with these things hanging on his arm...

Cool!



Those have been pretty much obsoleted by the internal volar plates that my doc wants to insert. Still barbaric, but not quite as freakish as the external fixator.

[wabmester]

Quote:

Originally Posted by marpea I was told there would be less likelihood of osteo arthritis with surgery and so far no residual pain. Also I was probably in a cast a much shorter time which seems important to getting range of motion back.

Thnanks -- that's great to hear. I'm pretty convinced that surgery will produce the best outcome, but I still need to get past my fear of being sliced up and drilled into.