EWJ June 61 2025 web - Flipbook - Page 39
Surgical techniques for wrist fractures include:
• Closed reduction with application of a moulded cast
(POP = Plaster of Paris)
• Percutaneous K-wires (like stainless steel cocktail
sticks) to “pin” the fracture fragments
• Open reduction internal fixation (ORIF) with plates
and screws
• External fixation
One of the most common complications is posttraumatic stiffness. This typically results from prolonged immobilisation, intra-articular involvement, or
capsular scarring. Patients often experience reduced
wrist range of motion, which commonly impacts wrist
extension or the ability to turn the hand palm-up
(supination) and palm-down (pronation).
Another frequent complication is persistent pain. This
can stem from malunion, nonunion, or post-traumatic
arthritis but may also be neuropathic in nature or result from complex regional pain syndrome (CRPS).
In medicolegal practice, it is essential to differentiate
between pain that arises due to structural problems
and that which is disproportionate or poorly
explained.
Volar plating (i.e. ORIF) is the most frequently utilised
technique due to its biomechanical advantages and
low-profile internal plate positioning.
Potential surgical complications include scarring,
bleeding, infection, nerve injury, vessel injury, tendon
irritation or rupture, pain, stiffness, swelling, CRPS,
malunion*, nonunion, metalwork failure or hardware
irritation, revision surgery or issues related to the
anaesthetic e.g. allergy, adverse reaction, deep vein
thrombosis or pulmonary embolism (i.e. blood clots in
the legs or the lungs).
Malunion (i.e. healed but not in the correct position)
remains a significant source of long-term symptoms.
Distal radius fractures that heal with dorsal angulation, radial shortening, or loss of congruity at the distal radioulnar joint (DRUJ – the joint between the two
forearm bones – radius & ulna), can lead to functional
impairment, reduced grip strength, and cosmetic
deformity.
*Malunion can still occur, particularly if fracture fragments are inadequately reduced or if hardware
loosens / fails.
Less frequently, tendon complications occur. Extensor
pollicis longus (EPL) rupture is a well-recognised delayed complication, particularly following dorsally displaced fractures or those treated with dorsal plating.
Flexor tendon injury is less common but may result
from volar plate fixation or hardware irritation of the
tendon. With EPL ruptures, these can occur spontaneously in both closed injuries that are treated with
casts, and those treated with surgery e.g. K-wire fixation or fixation with plates and screws. There are 2
main theories, and these are either that at the time of
the original injury the wrist went into maximum extension and “crimped” the tendon between the bones
in the wrist and the distal radius, thus injuring it. Or
that the blood supply to the tendon in this area is a
watershed zone and it fails due to a lack of nourishment. In cases that are treated surgically, it therefore
requires an expert witness to help determine whether
it was negligent surgery or whether it was the
sequelae of the natural history of the wrist injury.
From a medicolegal perspective, not all poor outcomes
following surgery imply negligence. For example, tendon ruptures may occur even with correct plate/screw
positioning, particularly in comminuted fractures.
Complications Following Wrist Fractures
Despite appropriate initial management, complications following wrist fractures are common and can
significantly affect the clinical outcome. From a medicolegal perspective, understanding these complications is critical in evaluating causation, prognosis, and
long-term disability.
Complications may arise due to the nature of the
fracture, patient-specific factors, the initial management strategy, or a combination of these elements.
Some complications are unavoidable despite best
practice, while others may suggest suboptimal
treatment or delays in diagnosis.
Complication
Stiffness
Common Complications of Wrist Fractures
Typical Causes
Medicolegal Significance
Normal injury course, or from
May limit function, very difficult to
prolonged immobilisation,
to reverse
intra-articular fractures
Malunion
Inadequate reduction, loss of position
in cast or failure of fixation
Functional and cosmetic impact, potential
for future surgery
Nonunion
Open fractures (e.g. infection), poor
vascularity, smoking
Delayed recovery, may require further
surgery
CRPS
Multifactorial, often idiopathic i.e.
unknown cause
Long-term disability, high variability in
outcome
Tendon rupture
Hardware irritation, fracture
displacement
May require tendon transfer or grafting
Nerve injury
Swelling, malunion, compartment
syndrome
Sensory or motor deficits, may be permanent
Arthritis
Intra-articular step-off, malalignment
Progressive symptoms, often irreversible
EXPERT WITNESS JOURNAL
37
JUNE 2025
