Musculo scenario 5 - wrist- Sheila Bramley

Pt is a retired seamstress, 61, sustained a Colles frac of the R wrist 8 weeks ago when she tripped and fell. Out of plaster for the last 2 weeks. X-ray now shows sound bony union.

Anatomy of area
Wrist is formed by the inferior surface of the lower end of the radius and an articular disc superiorly, and the proximal surface of the scaphoid, lunate and triquetral inferiorly, which together with the ulnar and radius styloid processes form a synovial ellipsoid joint.

Symptom profile/aetiology
- A CF is a frac to the distal end of radius, where the distal fragment is displaced posteriorly.
- Within 2.5cm of the wrist joint
- Occurs predominantkly in older people, following a fall onto outstretched hand.
- Common belief that CF is assoc'd with osteoporosis, as is common in post-menopausal women

- Union - normally takes place within 4-6 wks, ie initial bone repair. Bone will still give a little under pressure and still be painful. Full weight bearing through hand still not possible, some external support may still be needed.
- Consolidation- 8-12 wks- full bone repair. No movement at frac site. No frac lines visible on X-ray, and full function can commence with damaging fracture.
-expected outcome- 6 mths from frac, pt should have fully functional wrist, but may lack full movements, esp extension and supination. Should however regain full functional use.

Possible problems with a CF
- median nerve compression
- CTS
- rupture of extensor pollicis longus
- Sudeck's atrophy (severe pain and swelling, x-ray will show patchy osteoporosis)
- mal-union
- joint stiffness
- alteration to healing rate

Problems of patient
a) Physical - dull ache around wrist
- shooting pain in R forearm on wrist flexion
b) functional- unable to use R arm for > 5 mins
- can't lift heavy items
- no-one to do housework as hus has mobility problems due to hip OA and unable to help

Subjective
In addition to facts we are given, I would want to establish the following:
- R/L handed?
- general health ok?
- PMH- osteoporosis, bone disease, diabetes, HBP, respiratory disease, steroid use, major operations, previous fractures?
- recent weight loss?
- RA/FHRA
- FH of Dupuytrens disease?
- drugs being taken?
- claiming for compensation for accident?
-hobbies
- anyone else who may be able to help round the house, what sort of tasks is she struggling with?

Objective examination

Observations- appearance of wrist- pt still wearing a tubigrip for support- normal at this stage- she feels she still needs some external support.
- will be thickening of radius due to callus formation at frac site, on palpation. This will be emphasised due to muscle wasting in the forearm
- bone may still give a little under pressure at frac site, which will give pain.
- reduced muscle bulk- measure and compare girth of R and L forearms, and the same point, recording the precise point of measurement.

ROM tests
Would expect reduced range of movements and stiffness in the R wrist after only 2 wks out of plaster
- wrist- test flexion, extension, radial and ulnar deviation, active, passive and resisted. Would expect considerable weakness. Would take care to to place joint under too much pressure on flexion as pt reports sharp pain on this movement
- radioulnar joint- test pronation and supination. Weakness would be expected
- elbow- flex/ext. Would also expect weakness here as the R arm will have be used very little over the last 8 weeks, and elbow flexors and extensors will have weakened
- fingers- flex/ext- likely to be some weakness here also
-shoulder- would want to test as pt may have held injured arm close to body while injured, in an unnatural position- test flex/ext, ab- and adduction, int & ext rotation, may be some loss of power here
- grip strength- measure R and L to compare- handedness of pt needs to be borne in mind. strength of grip is likely to be reduced
- dexterity tests- grip tennis ball, pick up a 1cm peg, hold a key, touch thumb to little finger ( median nerve test)

Other issues
- discuss with patient occupational issues- may need assistance in the house for the next few weeks until she regains strength in the injured arm, discuss possible referral to OT or social services
- warning- joint will feel more painful for next couple of day following this examination- this is nothing to worry about and will subside, painkillers and ice treatment will help.
- pt seems to be a little behind where she might expect to be at this stage of recovery from a CF, but this is likely to be due to her age.

Gareth