The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for addressing Distal Forearm Fractures. These directives are designed to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in managing Distal Forearm Fractures can depend on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding the management of Distal Forearm Fractures should involve collaboration between the patient and their healthcare provider.
Distal Forearm Fractures in Adults
Adults can experience various types of distal forearm fractures, with Colles’ fracture being the most common. Colles’ fracture is characterized by dorsal displacement or angulation of fracture fragments on a lateral view x-ray.
Other types involve anterior angulation or palmar displacement of fracture fragments. Despite the severity, proper diagnosis and management typically lead to satisfactory outcomes. These fractures often result from traumatic forces, commonly associated with falling on an outstretched hand.
Clinical Presentation
Wrist injuries manifesting significant pain, swelling, ecchymosis, crepitance, or deformity should be presumed fractured until proven otherwise. Forearm fractures may also involve vascular, neurological, ligament, and tendon injuries. Given the traumatic nature of distal forearm fractures, a comprehensive examination for associated injuries in other areas such as the elbow, shoulder, neck, head, and hip is recommended. Orthopedic or hand surgeon consultation is generally advised for most distal forearm fractures.
Diagnostic Studies
X-ray for Suspected Distal Forearm Fractures
Recommended as the initial study, including posterior-anterior, lateral, and, if available, oblique views. Contralateral wrist x-ray images may enhance reliability for certain radiographic measurements, aiding in determining stability and treatment indications.
MRI
Recommended for suspected soft-tissue trauma after confirming complex displaced, unstable, or comminuted distal forearm fractures through x-rays. MRI helps evaluate soft tissue injuries related to distal radius fractures.
CT
Recommended for investigating occult and complex distal forearm fractures to provide clearer insights into fracture displacement, articular involvement, and subluxation of the distal radioulnar joint.
Medications
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Distal Forearm Fractures Pain
Recommended as first-line medications for most patients with acute, subacute, or chronic pain. Over-the-counter agents are suggested initially, with NSAIDs discontinued upon symptom resolution, lack of efficacy, or development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for high-risk patients in conjunction with cytoprotective medications. Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended to prevent gastrointestinal bleeding.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Discussion of risks and benefits is advised for patients with cardiovascular disease or multiple risk factors. Acetaminophen or aspirin is considered safer, and if NSAIDs are needed, non-selective ones are preferred.
Acetaminophen for Treatment of Distal Forearm Fractures Pain
Recommended for pain treatment, especially in patients with contraindications for NSAIDs. Dosing should follow manufacturer recommendations, with caution to avoid hepatic toxicity.
Opioids
Limited use (less than seven days) is recommended for acute and post-operative pain management as adjunctive therapy to more effective treatments. Opioids should be prescribed judiciously, particularly for nocturnal use, and gradually tapered off.
Treatments for Distal Forearm Fractures
Criteria for Treatment Recommendations
Treatment recommendations should be guided by assessing whether the fracture is open or closed, stable or unstable, and the likelihood of it becoming unstable.
Non-Displaced Distal Radial Fracture
Immobilization
- Cast Immobilization for Non-displaced or Minimally Displaced Distal Radius Fractures:
- Recommended for six weeks.
Displaced Distal Radial Fracture
Distal radial fractures with dorsal angulation of 10° or more, radial shortening exceeding 2 mm, or any degree of instability are considered fractures with bone loss or involvement requiring internal or external fixation.
Closed Reduction and Casting for Displaced Distal Radial Fractures
- Recommended for stable fractures after reduction.
Rehabilitation
Rehabilitation for work-related injuries should focus on restoring functional ability for daily and work activities. Active therapy, requiring patient effort, is emphasized over passive interventions, which rely on therapist-delivered modalities. Both active and passive therapies should be continued at home to sustain improvement, and assistive devices may be used to enhance functional gains.
Active Therapy
Therapeutic Exercise after Cast Removal for Acute Colles’ Fracture
- Recommended for patients with functional deficits or those unable to return to work.
- Frequency/Dose/Duration: Two to three visits for mild deficits, up to 12 to 15 for severe deficits, with ongoing documentation of functional improvement.
Education after Cast Removal for Acute Colles’ Fracture
- Recommended for select patients.
Passive Therapy
Low Frequency Electromagnetic Fields to Stimulate Bone Healing of Distal Radial Fractures
- Not Recommended for patients with non-displaced fractures.
Surgery
Closed Reduction
- Recommended for severely displaced extra-articular fractures that are stable post-reduction.
Medullary Pinning (k-wire) or Intramedullary Fixation Techniques
- Recommended in select patients.
Open Reduction and Internal Fixation
- Recommended if the fracture remains unstable with other treatment methods.
Triangular Fibrocartilage Complex (TFCC) Repair for Distal Radial Fractures
- Not Recommended.
Hardware Removal
- Recommended in select cases based on doctor/patient preference, considering protruding hardware, pain attributed to hardware, broken hardware on imaging, or a positive anesthetic injection response.
Cast Immobilization
- Recommended for extra-articular fractures or moderately displaced extra-articular fractures that are stable after reduction and non-comminuted or non-displaced intra-articular fractures.
