Orthopaedic Surgery/Fractures and Dislocations:Forearm and Wrist

A fracture of the distal radius is the most common skeletal injury which is referred for acute orthopedic management. Recently volar locking plates as well as more comprehensive plating systems have come to effect the mode of treatment for this injury and in typical fashion have been adopted rather broadly to the treatment of an injury which can often be well managed by closed manipulation and immobilization. Decision making regarding choice of treatment is governed by context, ease of care, risk and benefit and expectation of outcome. What may have been an acceptable result allowing for deformity may no longer be considered acceptable. Traditionally the treatment goal is a pain free wrist achieved within a predictable and reasonable time frame allowing for return of strong grip, range of motion of the wrist and fingers. This result is still readily achievable by closed means for the majority of fractures of the distal radius, especially those which result from what is the most common mechanism, that being low energy trauma from a fall.

Patient expectation tends to shift. They will expect to hear about an operative alternative which offers early motion in a removable splint and a more predictable restoration of anatomical relationships and perhaps and enhanced prospect for a return to full function. They will increasingly be familiar with friends and family similarly treated. Other patients will remain pleased to hear that surgery may be avoidable and will be quite willing to put up with some short term inconvenience and even the prospect of residual deformity in order to avoid the cost and risk of surgery.

The process of informed consent will reveal which sentiment will hold sway in the patients decision making and thus skill in achieving the desired result by either operative or closed means will continue. The artful orthopedist will acquire a sense of which direction is best to advise weighing many factors in a calculus he or she will be at a loss to explain. Sometimes the wrong choice will be made and the patient will experience difficulties despite the best assessment that can be offered. An unexpectedly poor outcome will likely effect the subsequent treatment advise of the orthopedist and in this way his or her practice pattern will evolve. A ruptured tendon or infection subsequent to plating, or a malunion and stiff fingers following closed management.