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Five worrying signs after treatment or operation on a wrist fracture

15 May, 2018

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In several of our previous conversations, Dr Piñal has insisted that a normal wrist is the one we’re not even aware it’s there, so therefore new or persistent sensations can point to the false resolution of a previous pathology or trauma. This is the case of wrist fractures, whose preceding treatment or subsequent surgery can break that rule of ‘non-being aware’, if certain series of situations that should constitute actual warning signs for the patient are present. wrist fracture

Sometimes, the traumatic contusion of a nerve associated with a fracture or surgery itself, the internal pressure generated by a hematoma or, simply, the need for a brief time to elapse, these elements does not allow us to talk yet directly about sequelae or signs that something is wrong.

However, and in the words of Dr Piñal himself –considered among the best hand surgeons in the worldafter two or three days of treatment or operation on a fractured wrist there should be no pain, mobility should improve quickly and there is no room for swollen fingers, with tingling or clicking, among other pains”.

From this base, Dr Piñal summarizes and analyses these warning signs into five groups, from the most common consultations received in this area at his centers. The Spanish surgeon recommends a medical consultation in case of appearance, swift if several of them occur simultaneously.

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Postoperative immobilization with plaster is a practice that does not provide any benefit and tends to point to poor surgery. In the right image, two erroneous practices can be seen: the already referred plaster after surgery and the immobilization in a forced posture that can compress the middle nerve, generating pain, tingling, swelling, etc.
  1. “My wrist hurts yet”

If a wrist fracture has been immobilized by a cast or splint, and after two or three days, the pain is there yet, we are before an anomalous situation. Something is wrong if we don’t get relief from pain with mild analgesics, since one of the central functions of immobilization is to avoid any type of disturbances to the patient.

The pain mentioned, which is usually accompanied by instability in the joint, can be due to several factors: a poor practice in the use of immobilization (by allowing movement in the area or by excessive compression of the cast, for example) or because of the treatment being a wrong one for that specific case.

Also, it should be noted that, in case of surgical intervention on the fracture, the pain must also cease after two, three days since the procedure is performed”.

2. “My fingers swell”

“In most cases, the swelling of fingers in a context of wrist fracture is caused by a bandage that’s too tight. We again see a symptom that shouldn’t appear, and it constitutes, therefore, a sign of negative evolution.

In parallel to the swelling, patients tend to suffer from tingling in the fingers, caused by immobilizations in forced positions, not physiological, which compress the middle nerve provoking the set of symptoms to which we alluded: pain, swelling, tingling, etc.

As a mixed, sensitive-motor nerve, the good condition of the median nerve is fundamental, since its role is key in the mobility of precision and sensitivity of the hand, in addition to enabling the maneuver of the thumb opposition that allows to make the clamp“.

3. “I can’t make a fist” – “It’s hard to close my hand”

“The most serious diagnosis for a symptom of these characteristics is its origin in a compartment syndrome or Volkmann contracture, caused, among other elements, by the condition and injuries caused by the fracture itself, the inappropriate use and with excessive pressure of the immobilization (plasters, bandages) or poor surgery.

Without a doubt this is the most important complication that we can face in a situation like the one we are dealing with: in essence, a loss of blood flow or ischemia in the affected area develops, which will result in irreversible damage if it is not treated immediately and correctly.

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Snapshot of Dr Piñal’s new book, ‘Atlas of Distal Radius Fractures’ (‘Atlas of Distal Radius Fractures © 2018 Thieme Medical Publishers Inc.), chapter 1, ‘Prolegomena: Some Initial Thoughts and Facts’.

A compression element that leaves the wrist in an overly bent position can also affect the median nerve (milder form in this case) and prevent the patient to exert normal strength with his hand or to make a fist”.

4. “My fingers crack”. “Feeling clicks in my fingers”

Crunches or clicks in the fingers are another warning sign that may appear after surgery, especially in the thumb. They tend to have to do with a tendinous irritation linked to a beak or fragment of the fracture itself or to an undesired effect of the placement of a plate in the surgical procedure.

We are talking about a symptom that, if not addressed, will be followed by mobility problems in extension or flexion of the affected finger when the tendon ends up breaking“.

5. “Can’t move well after my cast comes off” – “Don’t regain movement after surgery”

In a plaster treated fracture, when it is removed is normal that after a few days there are certain difficulties of mobility and feeling of stiffness. However, patients, even during this period, must perceive a progressive and rapid improvement.

In turn, surgery in a case of wrist fracture should allow the patient a certain degree of mobility in the affected area the very day after the intervention itself.

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Once the operation is performed, the patient should begin to move the wrist without delay. In the image above, new snapshot of the chapter 1 of ‘Atlas of Distal Radius Fractures (Dr Piñal – © Thieme Medical Publishers, Inc.).

If this improvement does not occur, it ‘stagnates’ so to speak, or postoperative phase mobility problems are appreciated, we are again facing a symptom that advises medical consultation as soon as possible.

As a final note, I would like to add that any patient with a wrist fracture should wonder why an immobilization with postoperative plaster is applied to him, if that’s his case. It is a technique that does not provide any benefit, but the opposite, and that usually point to the need to stabilize a badly operated area”.

Example of one of the video case study (english author voice-over, spanish subtitled for this entry) included in each chapter of Dr Piñal’s new book (‘Atlas of Distal Radius Fractures © 2018 Thieme Medical Publishers Inc), in this instance dedicated to rim fractures. The images show Dr Piñal’s approach towards a complex rim fracture with free osteochondral fragment in a sunk position.

Dr Piñal is an international benchmark in the treatment of different wrist pathologies, with works such as Arthroscopic Management of Distal Radius Fractures’ and Arthroscopic Management of Ulnar Pain‘ or the most recent ‘Atlas of Distal Radius Fractures’. He has also developed new techniques used worldwide such as the four corners arthrodesis for the SLAC wrist or the dry arthroscopy.