Episode 18 – Wrist Fractures
[00:00:00] Dr. Chehab: Welcome to IBJI i’s Ortho Form where we talk all things ortho to help you move better, live better. I’m your host, Dr. Eric Chehab with Ortho Inform. Our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. Today it’s my pleasure to welcome Dr. Surbhi Panchal.
As a brief introduction, Dr. Panchal graduated from Case Western University in 2002 with a degree in biomedical engineer. She then enrolled in medical school at the University of Maryland where she received her medical degree in 2006. Following medical school, she completed a residency training at Union Memorial Hospital in Baltimore, Maryland, and then subsequently returned to the Cleveland area for her hand and upper extremity fellowship at the Cleveland Clinic in 2013.
Since completing her fellowship, Dr. Panchal helped thousands of patients young and old with hand and upper extremity disorders. She has conducted outcomes research on upper extremity procedures and has authored several chapters in medical textbooks about upper extremity surgery. Surbhi, welcome to Ortho form and thanks for being here today.
[00:01:02] Dr. Panchal: Thank you for having me.
[00:01:04] Dr. Chehab: So we’re talking about wrist fractures today, and we should start with the anatomy. Can you tell a listener about the anatomy of the wrist.
[00:01:10] Dr. Panchal: It’s a little complicated, but yes. So the basics is that you have two bones, the radius and the ulna that are in your, for that go towards your wrist.
they make up part of your wrist, but then you have a whole bunch of little teeny tiny bones called the carpal bones that are in your wrist as well. And Basically based off of that, it could be a carpal fracture or a distal radius fracture. Those are the ones that we look at.
[00:01:34] Dr. Chehab: Okay. And so those carpal bones are.
Eight of ’em, Am I correct? Correct. I sometimes lose count. And what’s the most commonly injured of those carpal bones?
[00:01:44] Dr. Panchal: So the scaphoid bone, the little peanut bone on the top of the radius is one of the most commonly affected bones
[00:01:51] Dr. Chehab: under the thumb. And on the, that side of your forearm,
[00:01:53] Dr. Panchal: correct? Yes.
[00:01:54] Dr. Chehab: Okay. And then of the two forearm bones, the radius and the ulna, which is the most commonly injured one there?
[00:02:00] Dr. Panchal: The radius, which is the bigger one.
[00:02:02] Dr. Chehab: Okay. And if someone how does someone get a wrist fracture? What happens typical.
[00:02:05] Dr. Panchal: So most of the time what they’re doing is falling on an outstretched hand.
And we actually, gotta love orthopedics and all the acronyms. It’s a foosh injury, a foosh injury, a foosh, F O o S H. So it’s falling on an outstretched hand. . And depending on how your hand is in space, it could be either a scaphoid fracture or distal radius fracture.
[00:02:28] Dr. Chehab: Okay. So those are the two most common.
And then obviously there are sprains to the wrist as.
[00:02:32] Dr. Panchal: Correct.
[00:02:33] Dr. Chehab: Okay. And so what are some of the symptoms that patients will have after they’ve had a fall? Unknown outstretched hand of foosh. What symptoms do they typically have in the wrist?
[00:02:44] Dr. Panchal: So depending on the extent of the injury, they can have a deformity.
So you can look at it and you say, Okay, that’s a broken wrist.
[00:02:52] Dr. Chehab: It’s crooked.
[00:02:53] Dr. Panchal: It’s crooked, it looks like, um, a fork, you know, deformed in that way. But if it’s not, a lot of times it’s pain, swelling, inability, move, brusing. Things like that.
[00:03:04] Dr. Chehab: Okay. Yeah. And so someone who has a fall on an outstretched hand, who suspects that they’ve.
More of an injury. They come and see you. So are you looking for when you have a patient who presents with a wrist injury?
[00:03:15] Dr. Panchal: So the first thing you know for a clinical exam is to basically say, Okay, specifically where in the wrist is the pain? So is it along the radius? Is it the scaphoid?
What can and can you not do as far as range of motion, that type of thing. Is very easy to get an x-ray and that often will tell us what, where the fracture is.
[00:03:36] Dr. Chehab: Okay. And then are things like CT scans or mri. Typically needed to diagnose wrist fractures.
[00:03:42] Dr. Panchal: So both of those are very useful when we do things like scaphoid fractures because oftentimes you don’t see it on, on an x-ray.
So it’s often where I send them and be like, this is a non-displaced. We know you’re still having pain. Let’s go ahead and go ahead. Do the mri.
[00:03:59] Dr. Chehab: Okay. What is it about the scaphoid that you said sometimes you don’t see it on x-ray, but you can see it on CT scan or mri and it’s that tiny peanut shape bone near the thumb.
So what is it about the scaphoid that makes it hard to see or, difficult to diagnose initially with just an x-ray.
[00:04:15] Dr. Panchal: So it’s in the rest is one of the eight carbo bones, and so there’s a lot of stuff in the wrist. It’s a joint or It’s a bone that is um, within a lot of different things.
And it doesn’t displace like a femur, it’s not going to show everything.
[00:04:31] Dr. Chehab: It doesn’t shatter, it doesn’t displace very far. So it’s hard. It’s very subtle.
[00:04:35] Dr. Panchal: Correct.
[00:04:36] Dr. Chehab: Plus all those other bones make it hard to see it on the x-ray.
[00:04:39] Dr. Panchal: Correct. And then on top of that, it’s what we call a peanut. So when you look at the orientation, it doesn’t lay very cleanly on an x-ray. So oftentimes you have to get the MRI to, see it in 3d.
[00:04:53] Dr. Chehab: Okay.
And so let’s divide these fractures up. Let’s first talk about the scaphoid fractures. So if someone comes to you and you’ve evaluated them, they’ve had the fall on the outstretched hand, you suspect they have a scaphoid fracture.
You confirm they have a scaphoid fracture. What are some of the treatment options in front of that patient?
[00:05:12] Dr. Panchal: So oftentimes so most of the scaphoid fractures are gonna be through the waist, which is through the middle. And oftentimes scaphoid fractures tend to happen in teenagers, twenties, thirties, skateboarders, skiing, that type of thing.
[00:05:26] Dr. Chehab: Rugby players.
[00:05:27] Dr. Panchal: Rugby players.
[00:05:28] Dr. Chehab: I’ve had two .
[00:05:29] Dr. Panchal: Well Then, you know, So, as far as treatment of, So the first thing that I tell patients is that the scaphoid is a very finicky bone. It doesn’t like to heal, unlike some of the other bones in your body. So things are gonna take a little bit longer as far as healing.
If it’s truly non-displaced, we can treat this in a cast and there are. It’s up to the patient as well as a surgeon. Whether it’s a thumb spica um, cast where the thumb is immobilized or whether it’s not it depends on what they’re doing. But you can do that. But you have to tell the patient that it’s gonna be eight to 10 weeks solid for that
[00:06:08] Dr. Chehab: in long arm cast or short arm cast.
What’s the standard these.
[00:06:12] Dr. Panchal: These days what I do in my office is short arm. The thought is that it used to be a long arm cuz you wanna control for rotation mm-hmm. .. And so you wanna minimize the motion in the wrist. But it just hasn’t clinically worn out.
[00:06:26] Dr. Chehab: So it doesn’t matter whether it’s a long arm or short arm, but the immobilization itself does matter.
[00:06:31] Dr. Panchal: Correct.
[00:06:31] Dr. Chehab: For the non-displaced scaphoid fracture. Correct. So then, , Are there any circumstances where you would elect to operate on a non displaced scaphoid fracture.
[00:06:42] Dr. Panchal: So things have changed a little bit in that I make a small incision, but some people do it truly percutaneous. And so with the, What you can do is put in a headless compression screw.
You can put a screw basically to push the tube. Uh, Ends in the bone together, which if you have good contact, that accelerates the possibility of healing. And so for a lot of these patients, I say, Hey, we can do that. And that means that you’re not stuck in a cast for two months. And oftentimes, especially since these kids or young adults are active, they would much rather have that.
[00:07:17] Dr. Chehab: So tell me about that then. So if a percutaneous or. Small open approach screws put into this scaphoid. What’s the usual recovery? Timeline for that patient.
[00:07:28] Dr. Panchal: So I will have them see therapy even before they see me. So they’re seeing therapy in five to seven days. , therapy will put them in kind of a temporary, you know, thumb spike, a splint but then start working on range of motion, so immediately flexion, extension, rotation, all that stuff that they can do.
They just can’t put weight on it, get out of a chair and put their arm down, just that motion oftentimes will help with the swelling, will help with kind of just of the rest.
[00:07:56] Dr. Chehab: And when is that patient getting back to functional activities? Sports.
[00:08:01] Dr. Panchal: So sports, I still tell them, Hey, this probably should be two months.
Um, But doing functional daily activities within a month.
[00:08:09] Dr. Chehab: And what about the cast person? What’s their life like?
[00:08:11] Dr. Panchal: The cast person will stay in the cast for two months
[00:08:15] Dr. Chehab: and they get stiff is all,
[00:08:16] Dr. Panchal: and then they get stiff. So then, then they go to therapy. And so for them it’s gonna be three to four months.
[00:08:23] Dr. Chehab: So you’re shaving one or two months off of the recovery with a screw for a non-displaced scaphoid fracture. And that can be really meaningful to a lot of active young adults and teenagers.
[00:08:35] Dr. Panchal: Correct. And I think it’s, like you said, I think it’s the main like, Hey, what can I do right now? I mean, With our society.
Right now is the most important. So I think for that aspect of it, we can treat you and we can, you know, yes, you are subjecting yourself to a surgery. The surgery is not as big a deal as it used to be. . And so I think that helps.
[00:08:54] Dr. Chehab: So what percentage would you estimate in your practice, just in general, who have a nondisplaced scaphoid fracture, Get treated in a cast or get treated with the surgical.
[00:09:04] Dr. Panchal: I would almost say about 75% of people elect to have the surgery.
[00:09:09] Dr. Chehab: Got it. Okay. And then the displaced scaphoid fracture one that’s obviously broken. What are the treatment options for that? Injury.
[00:09:17] Dr. Panchal: So it depends on how much it’s displaced and whether we have something called a humpback deformity, whether the two pieces are flexed and, you basically have to reduce that. If it’s truly just displaced then you can still get away with a headless compression screw because the way that the screw is designed it. For
[00:09:37] Dr. Chehab: It pulls those two pieces together?
[00:09:39] Dr. Panchal: Correct.
[00:09:39] Dr. Chehab: Okay.
[00:09:39] Dr. Panchal: Correct.
[00:09:40] Dr. Chehab: Okay.
So you can do that one percutaneously, but when it’s deformed and misshape and then you have to make an incision and put the two pieces back together and then put
the screw in.
[00:09:48] Dr. Panchal: Correct. And sometimes you have to graft in between depending on how long the fracture has been there. , and the biggest thing is that if you do it percutaneously, you do it through the back of the wrist. , if you do it open, then you do it through the front of the wrist and the swelling, the pain, the is all gonna be a little different.
[00:10:06] Dr. Chehab: Got it. Okay. And what are some potential complications of surgical treatment? ,
[00:10:09] Dr. Panchal: Potential risk. So there’s always a risk that it’s not gonna heal. This, like I said, this scaphoid is a very finicky bone. . And so I will always tell patients about that. I also say, Hey, you broke the scaphoid and so you’re at a little bit of an increased risk for arthritis.
, if it doesn’t heal, there’s a particular pattern of arthritis called snack. We see, and so we know that can exist. We’re trying to prevent it with the surgery. , every once in a while you can have some hardware irritation, knock on wood. I haven’t seen that. So it’s usually not an issue.
I think that has changed.
[00:10:41] Dr. Chehab: And the screw is totally buried in the bone. Correct?
[00:10:43] Dr. Panchal: Correct.
[00:10:44] Dr. Chehab: So it’d be rare to have anything prominent that would. An issue. Okay. And so let’s shift gears a little bit now. Sure. The, to the distal radius, the, so that the forearm bone again, in line with the thumb between the thumb and the elbow with the distal radius injuries let’s take a look at a younger.
Kid a um, pre-adolescent who’s had a fall on an outstretched hand what type of fracture do they typically present with?
[00:11:07] Dr. Panchal: So most of the time they have something called the buckle fracture. Mm-hmm. .. So first of all, it is closer to the elbow than the growth plate. So it usually does not involve the growth plate.
[00:11:18] Dr. Chehab: Okay.
[00:11:18] Dr. Panchal: So you don’t have to worry about mile alignment. Growth disturbances, that type of thing. And with kids, the bones usually are pretty soft. And so what happens is that the bone basically crunches in on itself.
[00:11:32] Dr. Chehab: Yeah. I’d say it scrunches like an
[00:11:34] Dr. Panchal: Yeah. I used to start.
Used to tell patients about the, the sapling and all that stuff. And I feel like kids don’t just have no idea. So I tell ’em about the fact that the bones are soft and that’s what happens. .
[00:11:46] Dr. Chehab: And then how’s that treated? Usually?
[00:11:48] Dr. Panchal: Usually it’s just a brace. Sometimes a cast,
if the kids are very active and the parents are worried that the kids are just either gonna take off the brace, then you know, I kind of judge it based off of that. So I do both in my practice.
[00:12:05] Dr. Chehab: Okay. So patient specific, depending on their activity level. If they’re a hard charging kid, maybe the cast, and if they’re pretty rule compliant
[00:12:15] Dr. Panchal: Correct. And depending on the sporting activity too a cast sometimes is warranted cuz then the coach can pad the cast and they can still play soccer, football, things like that.
[00:12:27] Dr. Chehab: Got it. Okay. And then as we move on through life and our bones become less soft and more hard, the fractures change.
And so what is a typical distal radius fracture from a fall on an outstretched hand that you treat?
[00:12:40] Dr. Panchal: So most of them are gonna be what we call extra articular colles fracture. So if you fall in an outstretched hand hand the, the part that is closer to the wrist will fall backwards. ? The biggest thing that I, Determine is to see, okay, is there a lot of crunch in the back of the wrist so that even if I reduce it, it’s not going to be stable and reducing it is just putting it back where it needs to be.
[00:13:03] Dr. Chehab: Right.
Okay. And the cast, the ones that you can cast are stable, obviously. Or what are some other exceptions for using a cast or incident or occasions where you’d wanna use a cast?
[00:13:15] Dr. Panchal: Sometimes I do use cast for older patients. Mm-hmm. Who don’t functionally aren’t gonna be doing a lot with their hand or their wrist.
At that point then you start weighing well, okay, comorbidity wise, like if they’re diabetic, they have respiratory or heart issues or something like that. Taking them to surgery is gonna be a bigger deal. , I basically say, Okay, this is gonna be the limitations of us treating your wrist in a cast.
This is what you can do. But I do think that overall this is probably the best option for you.
[00:13:45] Dr. Chehab: And what are those limit?
[00:13:46] Dr. Panchal: The biggest limitation is going to be repetitive, gripping or holding things. So a lot of my patients will say, Hey, I can’t hold things for a long period of time. I can’t take the dish out of the cupboard.
I use both hands.
[00:13:59] Dr. Chehab: This is after cast treatment has been completed. They’re totally healed. And they still have trouble using their hand
[00:14:06] Dr. Panchal: Correct.
[00:14:06] Dr. Chehab: Based on their wrist injury?
[00:14:07] Dr. Panchal: Correct.
[00:14:08] Dr. Chehab: Why is that?
[00:14:09] Dr. Panchal: So part of the problem is that with the wrist and the fact that it’s what we call a malunion, or it’s deformed the mechanics of the wrist have changed, So what is now being loaded? What is taking the force is gonna change. If there’s a little bit of deformity, then people often have pain on the. The pinky side of their hand, their wrist, and that often can just, stop them from doing big things.
[00:14:36] Dr. Chehab: Got it. Okay. And then the surgery itself, What are you doing in the surgery?
[00:14:41] Dr. Panchal: So most of the time things have changed. So now that it’s a plate and screws on the front of the wrist ,
mm-hmm. , um, it used to be back in the day um, an external fixer or plates on the back of the wrist. But things have changed as far as technology to be able to do that
[00:14:58] Dr. Chehab: Back in the day. I’ve seen those external fixers and place. But yeah, thank you. And then ,
[00:15:04] Dr. Panchal: It’s really funny cuz I put one the other day and I was like, Oh, this is a little different. Cuz things have, things are still changing.
[00:15:10] Dr. Chehab: Yeah. And the hardware’s really intricate. It’s, It’s pretty fantastic hardware in that it’s rigid, but you can use it flexibly.
[00:15:19] Dr. Panchal: Correct. So things have changed in that it’s not just one plate for one bone depending on the pattern whether it’s into the joint whether it’s a different type of fracture, there are different types of plates. , So it’s something called fragment specific plates. . And so a lot of these, often you have two incisions.
So that you can piece together the wrist. But what that allows is for the maximal amount of function for a patient, so the flexion extension repetitive gripping to basically give them the best bang for their buck.
[00:15:53] Dr. Chehab: So if someone has surgery on the wrist, what’s their typical timeline for the distal radius fracture when you’re using the plates and screws and the fragment specific plates?
[00:16:01] Dr. Panchal: Sure. Usually what happens is that within a week they go see therapy once again. So that therapy can make them the splint, but then really work on the flexion, extension, swelling, not any sort of weight lifting or weight bearing. .
[00:16:16] Dr. Chehab: So similar to the scaphoid.
[00:16:17] Dr. Panchal: Correct.
[00:16:18] Dr. Chehab: Getting, moving earlier, getting swelling.
But limiting, putting weight through the hands, such as getting up from a chair,
[00:16:24] Dr. Panchal: Correct.
[00:16:25] Dr. Chehab: or pushing against something.
[00:16:26] Dr. Panchal: I think the biggest thing for patients, and even what has evolved over time is really getting ’em into therapy and getting them moving.
[00:16:33] Dr. Chehab: Okay.
Yeah. And then but wrist fractures themselves carry a sort of bigger significance than just, I’ve hurt my wrists and it’s difficult to use my hand.
There’s a correlation with wrist fractures and osteoporosis. Can you explain that
a little bit?
[00:16:47] Dr. Panchal: Correct. Distal radius fractures often happen just from standing. I tripped over my dog, I tripped over a rug, or I just fell. . And so it’s a low energy. Fracture and it’s common, it’s up to about 20% of fractures that show up in the emergency room.
People see it often. And what that basically signals to us as orthopedic surgeons is that, hey, this patient probably has osteoporosis because it is one of the fragility fractures.
[00:17:14] Dr. Chehab: Okay. So what’s, what are the next steps then? Obviously there’s some patients. Skydive and break their wrist or fall off their bicycle and they may not have brittle bones.
They just may have had a high energy injury. But for those patients with a suspected low, Injury who you think may have osteoporosis, what’s the next step in that evaluation?
[00:17:33] Dr. Panchal: So usually what I do is see if they’ve done any sort of DXA scan or bone mineral density scan. . Because I think by the time that they have fragility fractures and they present to me as opposed to a rheumatologist. Then they basically have failed some of the, just simple things like vitamin D and calcium. . And so if they have a bone density scan showing that they have osteopenia or osteoporosis, then I start ’em on medication.
[00:18:02] Dr. Chehab: So they should be treated
for that, right?
[00:18:03] Dr. Panchal: Yeah.
[00:18:04] Dr. Chehab: Okay. And then, When you look on the horizon for wrist fractures, it sounds like things have come a long way. Casting for eight weeks and all the immobilization problems that come with that can now be avoided with percutaneous surgeries or plate and screw surgeries that allow you to move the wrist within a week and get the swelling down to get the utility back.
But what do you see on the horizon? What are some of the improvements we can make in treatment or in prevention
[00:18:29] Dr. Panchal: so things that are out there are different types of more minimally invasive fixation. So I am nails or rods, Hey, I’m not gonna make your distal radius perfect, but it’s gonna be better than what you have right now.
[00:18:42] Dr. Chehab: So splinting it from the inside out,
[00:18:44] Dr. Panchal: splinting it from the inside out. So that we can minimize the time that really sick patient is in the operating room, but then still be able to functionally give them what they want. Cause the thing is that, things like ankle fractures will, or hip fractures will definitely impact the patient’s ability to get around.
But any sort of wrist fracture, you know, even if they’re sitting, is really gonna impact them day to day because they can’t do things like reading or knitting or, you know, Those are the things that my older patients really wanna do.
[00:19:16] Dr. Chehab: So one of my hand colleagues um, said to me, Hey, the whole reason why the shoulder, elbow, and wrist exists is to put the hammer you need it in space. And he wasn’t just saying that to trump up the importance of the hand surgery that he does. I mean, It actually is totally true. Your wrists and your elbow and your hand put your hand where you need it, and if any of that is dysfunctional, it affects your life. Just with the simple things that you’re mentioning.
Also, the. People enjoy doing.
[00:19:43] Dr. Panchal: Correct. And I think, you know, if you think about day to day like, hey, it takes me forever to get to the kitchen, but I wanna be able to cook, I wanna be able to read, I wanna be able to, you know, like I said, knitting and that type of thing. So those are the things that I hear over and over again.
And so it makes sense. So, uh, My goal is to basically take all the different tools that I have to be able to treat distal radius and then treat the patient for what they wanna.
[00:20:09] Dr. Chehab: My guest today is Dr. Surbhi Panchal,. Surbhi, thank you for being here today.
[00:20:13] Dr. Panchal: Thank you for having me.