# Upper Limb Orthotics/Distal Radial Fracture
## Describe your case study

    The patient is a 23 year old female basketball player who suffered a fracture to her right wrist during a game. Her injury was sustained as another player bumped into her and she fell on an outstretched hand, resulting in an undisplaced, distal radial fracture.
    She has presented to us three weeks after her injury, so far having a closed reduction and been in plaster casts during the first three weeks of her treatment.
    The patient is hoping for a fast recovery and a device that will allow her to still complete self-care activities as well as continue some training activities in and easy and hygienic manner.

## Written information
### Evidence

Distal radial fractures are the most common fractures seen in emergency departments Kennedy and Hanel (2013) with statistics showing that up to two hundred thousand fractures a year that of the distal radius (Liporace, Adams, Capo, & Koval, 2009) and up to 20% of all fractures attended to involving the distal aspect of the radius in the United States, every year (P. M. Simic & A. J. Weiland, 2003). There are two main groups that are most frequently seen in these emergency rooms are; young adults aged between eighteen and twenty-five years of age, who sustain their injuries through sports or motor vehicle accidents, and adults over the age of sixty-five caused by falls and fragile bones (Voda, 2011). The high incidence of this injury may be better understood once the anatomy and function of the bone is further discussed.
The radius is one of the two long bones that make up the forearm and it is positioned laterally when observing the arm in anatomical position. It is thin proximally and wide distally, which explains its large contribution to the wrist joint and its role in movement of the hand (Marieb & Hoehn, 2007). This joint articulation describes why the long bone has “three concave articular surfaces- the scaphoid fossa, the lunate fossa and the sigmoid notch” and furthermore, why a distal fracture of this bone is often referred to as a wrist fracture (Paul M Simic & Andrew J Weiland, 2003). Paul M Simic and Andrew J Weiland (2003) also state that at the metaphyseal flare of the radius, there is an increase in cancellous bone and decrease in the corticol bone, which results in a segment of the bone being more inclined to fracture, especially as it plays a large role in wrist motion and load transmission. Although the muscles of the forearm are not directly impacted by this injury, they do control the movements in this region which one may wish to prevent throughout the healing process of the fracture. Marieb and Hoehn (2007) displays how the muscles of the forearm are separated into two groups; the anterior muscles and the posterior compartments, with each group responsible for a general function, the anterior group known as the flexors which includes two pronator muscles, and the posterior, as the extensors, which includes a supinator muscle . The healing process of a fracture relies heavily on the blood supply to the fractured region, and Lamas et al. (2009) not only found that the distal radius relies on the “radial, ulnar, anterior interosseus and posterior interosseus arteries”, but that throughout the healing of non-displaced and closed fractures, the medullary circulation remains dominant. Walsh (2013) discusses the many factors that determine the type of fracture that results from falling on an outstretched hand (also known as FOOSH), and the impact that they can have on the fracture pattern. These factors include; the patient’s mass, the ulna and radius’ degree of deviation, and the extent of wrist flexion or extension at the time, which will all cumulatively determine the impact that the energy forces will have when going through the distal ends of the long bones. This variance in fracture patterns calls for a particular classification system that will allow clinicians to differentiate between the severity of fractures in a detailed manner as well as identify relative treatment options, and Paul M Simic and Andrew J Weiland (2003) and (Hanel, Jones, & Trumble, 2002) describe the AO classification system to be very “detailed”. The AO classification breaks down fractures of long bones into three categories; extra-articular, partial articular and complete articular, and these groups are furthered narrowed into subgroups based on the characteristics that the particular fracture presents.
According to Muller’s system, our client presents with a 23 A2.1 fracture which is defined as an non-displaced extra articular fracture of the metaphysis, involving neither the radiocarpal nor distal radioulnar joints and exhibits no abnormal palmar or dorsal tilt (Müller, Koch, Nazarian, & Schatzker, 1990). (Liporace et al., 2009) identified a non-displaced distal radial fracture as “4-mm overall shortening, less than 5-mm decrease in radial height, less than 10° change in volar tilt from the contralateral extremity, and less than 50% dorsal comminution”, which is what our client presents with. Before any treatment options can be considered for the management of the distal radial fracture, the nature of the fracture as well as the individual’s activity level must be established in order to determine whether closed, or open reduction will be performed (Voda, 2011). Closed reduction, also known as anatomical alignment of a fracture, is a common option for non-displaced and non-articulated fractures (Voda, 2011), and once this has been performed and it has been established that there has been no further displacement, orthotic management can be considered.

### Orthotic Treatment Options

The treatment of distal radial fractures is a very controversial topic as there is no single and definitive treatment that has been agreed upon and consistently used (ALTISSIMI, ANTENUCCI, FIACCA, & MANCINI, 1986); (Hanel et al., 2002) and this is most likely due to the fact that there is not enough evidence to determine the best treatment options (Handoll, Madhok, & Howe, 2006). Typically, plaster casting is commonly used from one to three weeks following the reduction or surgery of a wrist fracture, and subsequently, an orthotic device is prescribed after the initial period healing period (ALTISSIMI et al., 1986; Hanel et al., 2002). The role of an orthotic intervention for a fracture is to ensure that it immobilises the effected region whilst still maintaining function (Walsh, 2013).
A common device used to fulfil these requirements, is the sugar tong splint (Liporace et al., 2009) as it restricts forearm rotation, which is recommended for distal radial fracture recovery (Kim, Kook, & Kim, 2012). Kim et al. (2012) used a prefabricated sugar tong splint with its trim lines being somewhat proximal metacarpophalangeal joint dorsally and extended around the proximal and distal radioulnar joint and held in place by a four inch elastic bandage. It was found through this investigation that “active supination and pronation had decreased to 31% and 34% of the value with no immobilisation,” (Kim et al., 2012) which when compared to the results of a short arm cast; 33% and 36% respectively, is not the most efficient. A short arm cast of this nature is generally worn from weeks three through to six according to Hanel et al. (2002), and is more appropriate for our client as it will allow her to perform more activities of daily living when compared to a sugar tong splint. This extra activity is allowed mainly due to the trim lines of the device, which are situated proximally to the metacarpophalangeal joints and distal to the radioulnar crease Kim et al. (2012). This ultimately allows more elbow flexion than the sugar tong splint and will avoid capsular contracture to allow metacarpophalangeal joint flexion (Müller et al., 1990). Distal radial fractures of this nature are typically positioned in most devices with the forearm supinated to prevent the tugging of the brachioradialus, and with the wrist in a neutral position throughout the treatment process Hanel et al. (2002) which is what our client presents with in her initial plaster cast.

### Orthotic Treatment vs Surgical Intervention

Egol, Walsh, Romo-Cardoso, Dorsky, and Paksima (2010) state that it is imperative that a surgeon assess the risks, benefits and alternatives to any treatment when dealing with a fracture and ultimately choose what is best for the patient. Surgical intervention is often seeked when treating unstable distal radial fractures (Driessens et al., 2013) or in high energy injuries (Hanel et al., 2002) in the form of open reduction internal fixation (ORIF). ORIF has become more popular over the years, especially with the introduction of the volar locking plate as it is said that this internal fixation will allow immediate range of motion of the wrist, whilst ensuring that the correct anatomical alignment of the radius in maintained throughout this speedy healing process (Rozental et al., 2009). One factor that must be considered when contemplating ORIF, is the risk of superficial or deep infection at the fracture site, but based on results from an investigation conducted by Tan, Beredjiklian, and Weiland (2005), the chances of infections occuring are slim.
When taking into consideration all of the factors involved and discussed with relation to our patients fracture and goals, it is recommended that she have a short arm cast fabricated to ensure that she experiences a healthy recovery that accomodates for her needs.