Wrist Fractures

Three quarters of wrist injuries are fractures of the distal radius and ulna. The eight carpel bones are injured less frequently.¹ Accurate diagnosis and correct treatment helps to avoid long-term loss of function.¹

As with fractures elsewhere in the body, wrist fractures can be:

• Simple
• Compound
• Comminuted
• Greenstick

For a fracture to be compound, the bone does not have to be protruding through the skin. If the bone is fractured and the overlying skin is broken this is a compound fracture and must be treated as such.

The common wrist fractures that occur are:

• Colles' fracture (distal radius)
• Smith's fracture (distal radius)
• Scaphoid fracture
• Barton's fracture (fracture dislocation of the radio-carpal joint)
• Chauffeur's fracture (fracture of the radial styloid)
• Greenstick fracture (confined to children)
• Fracture of ulnar styloid

• Fractures of the wrist are common, representing about a quarter of all fractures of limbs.
• They are more common in children and young adults, especially if involved in risk-taking activities.
• They also become more common with advancing age, partly because advancing age is related to an increased risk of falls and partly because of osteoporosis.

The history of the fall is important. What was the mechanism of injury? Note the degree of trauma as fracture with a mild force suggests osteoporosis. Was there a sound or a feeling of something breaking on impact? Is there loss of function? Does the patient feel that it is unstable?

This should be as full as possible without causing the patient too much distress.
• Look at the patient: a person with a fracture often looks quite distressed and may be nursing and protecting the affected area.
• Look at the injured part: deformity indicates fracture or dislocation. A simple fracture of a bone may be swollen. Compare with the unaffected side. Look for any skin breakage indicating an open fracture. Specific classic deformities are described below.
• Palpate the bones: there is often marked tenderness over a fracture. The sign of crepitus in which each side of the fracture is grasped and moved to make the fractured end grate against each other should not be elicited. If there is much pain and moving the affected part causes distress there is most probably a fracture and X-ray will be required.
• Examine the remainder of the arm: an associated injury to the elbow, upper arm, or shoulder should be excluded.
• Examine the blood supply: feel for brachial and radial pulses and note warmth of the periphery. Is there pallor or cyanosis?
• Neurological examination: motor weakness may be due to pain but sensation can still be tested. Examine the radial, ulnar and median nerves which innervate the hand. The median nerve supplies the thumb, index, middle and radial half of the ring finger on the palmar side of the hand and the tip of the thumb, index, middle and ring finger on dorsum of the hand; the radial nerve supplies the dorsolateral aspect of the hand and the dorsal aspect of the thumb, index, middle and lateral half of the ring fingers; the ulnar nerve supplies the dorsal and palmar aspects of the medial half of the ring finger and the whole of the little finger.

Always X-ray. Even when a fracture is clinically obvious it must be X-rayed to check for unsuspected fractures or dislocation. Also look for soft tissue swelling.

General points

• Assess Airway, Breathing and Circulation and manage as necessary.
• Provide analgesia whilst waiting for X-ray. Temporary splinting may also help.
• If there is neurovascular compromise, urgent fracture reduction may be needed.
• Displacement of fractures or dislocation or subluxation must be reduced. In young people the aim of reduction is to get good alignment for a good cosmetic result but in older people the cosmetic result may be subservient to the need for a good functional result.

Reduction

• Manipulation of broken bones is very painful; some form of anaesthesia is required.
• General anaesthesia is effective but even a brief anaesthetic has risks, especially in the elderly or those with medical problems. It is also necessary to wait until at least 4 hours after anything was taken by mouth.
• A Cochrane review examined the main methods of anaesthesia: haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, conscious sedation and general anaesthesia. It also looked at associated physical techniques and drug adjuncts used for the management of distal radial fractures in adults. All methods were effective but regional block was probably more effective than haematoma block. However, haematoma block is quicker, easier to perform and less intensive on resources. They concluded that there was inadequate evidence of robust quality to make an adequate comparison of the various techniques.²
• Conscious sedation is increasingly being used.
• The method of reduction varies depending on the fracture.
• If it is not possible to get satisfactory reduction of a fracture, with or without dislocation, then operative treatment is required. This is more likely to be required if there is both a fracture and dislocation.

Immobilisation

• The treatment of a fracture involves immobilisation and the general principle is that the joint above and the joint below the fracture should both be immobilised.
• The trauma of a fracture is usually associated with local swelling and so a full plaster must be avoided initially as the swelling may impede the circulation and can produce ischaemic contractures.
• The usual technique is to apply a back slab, held in place by crepe bandages. A few days later the patient is seen in the fracture clinic, the part is often X-rayed to check that there has been no movement and a full plaster is applied.
• The management of a fractured scaphoid is an exception that will be considered under that heading.
• After a fracture has been reduced and immobilised with a back slab, a repeat X-ray is taken to ascertain that alignment is satisfactory.

• The classical definition is a fracture through the distal metaphysis of the radius, approximately 4cm proximal to the articular surface. The term is now more loosely used for any fracture of the distal radius, with or without involvement of the ulna, with dorsal (backward) displacement of the fracture fragments.
• Common in older people who fall and have osteoporosis. Osteoporosis should be considered in anyone with a Colles' fracture (see below).
• Can also occur in younger people with normal bones.
• A Colles' fracture is a stronger risk factor for a subsequent hip fracture in men than in women.³

History and examination

• Typically occurs from a fall onto an outstretched hand that results in forced dorsiflexion of the wrist.
• The characteristic dinner fork deformity makes it easy to recognise, along with the classical history. Deviation is backwards and laterally. The fracture may be unstable.
• Physical examination of a Colles' fracture should include checking the ulnar styloid for tenderness as well as the radial head. Both can also be fractured. The median nerve can be damaged.

Management

• The fracture needs to be reduced under whatever form of anaesthesia is appropriate. The manoeuvre involves disimpaction of the fracture and a movement forwards and medially (the opposite of the deformity).
• A back slab is applied and a repeat X-ray taken to assess the adequacy of reduction. If the position is unsatisfactory the procedure needs to be repeated. If the fracture appears unstable then orthopaedic help is required. Percutaneous pinning is sometimes necessary.
• Healing usually takes about 6 weeks.

Complications

• Median and/or ulnar nerve damage can occur acutely. There can be an acute carpel tunnel syndrome.
• Compartment syndrome can occur with excessive swelling.
• Deformity can occur on healing and result in long term loss of mobility and functional problems. Chronic pain can occur.
• Malunion/non-union are possible, as with all fractures.
• Arthritis is a late complication.
• Reflex sympathetic dystrophy.

• This is sometimes called a reverse Colles' fracture.
• The definition is a fracture of the distal radius, with or without ulna involvement, that has volar (anterior) displacement of the distal fragments.
• It is usually caused by landing with the wrist in flexion, a backward fall on the palm of an outstretched hand.
• The characteristic appearance is called a 'garden spade deformity'.
• The X-ray of a Smith's fracture is very similar to a Colles' fracture except with the displacement anteriorly instead of posteriorly.
• The fracture may be extra-articular, intra-articular, or part of a fracture dislocation (called types I, II and III respectively).
• Closed reduction is usually possible except for a type III where open reduction may be needed.
• The advice about reduction is the same as for Colles' fracture except that the movement for reduction is backwards and medially instead of forwards and medially.
• Complications are similar to Colles' fractures.

• This is a distal radius fracture with dislocation of the radio-carpal joint.
• It can be dorsal or volar depending on the direction of dislocation.
• Basically it is a Colles' or Smith's fracture with dislocation. A volar Barton's fracture is a Smith's type III fracture.
• History will be very much as for Colles' and Smith's fractures.
• There may be entrapment of tendons and/or the ulnar nerve/artery.
• Although it may be reasonable to attempt to reduce it as for a Colles' or Smith's fracture, the chance of success is substantially less and operative reduction with external or internal fixation is usually required.

• This is the most frequently injured carpal bone.
• It can easily be missed with serious consequences. 10-15% of scaphoid fractures are not identified on routine X-ray.¹
• It tends to occur in a younger age group than a Colles' fracture.
• Scaphoid fractures can be through the waist, the proximal pole or the tubercle. They can be displaced or non-displaced.

History and examination

• Classically occurs from a fall onto an outstretched hand.
• The complaint is usually just of local pain.
• The classical sign is tenderness in the anatomical snuff box.
• The anatomical snuffbox is on the radial aspect of the dorsum of the wrist. Get the patient to hyperextend the thumb with the wrist slightly deviated in the radial aspect. In this position, the tendons of extensor pollicis longus and extensor pollicis brevis/abductor pollicis longus that define the snuffbox become obvious. The scaphoid can be palpated proximally in the floor of the snuffbox. The trapezium can be palpated distally. This test is sensitive but not specific.⁴
• Tenderness of the scaphoid tubercle is also a sensitive test but is more specific. The examining doctor/nurse should extend the patient's wrist with one hand and put pressure on the scaphoid tuberosity at the proximal wrist crease with the other. If there is no tenderness with these two tests, a scaphoid fracture is unlikely.⁵

Management

• If a fractured scaphoid is suspected, make this clear on the X-ray request as specific views are taken to look at the scaphoid. This may help to reduce the time to diagnosis in difficult cases.⁶
• If no fracture is seen but a fracture of the scaphoid is still suspected clinically, treat as a fracture. The patient should be seen in the fracture clinic in 2 or 3 days and the X-rays repeated.
• If it is still suspected but inapparent on X-ray at this time, then further investigations are indicated. The healing area will show 'hot' on a bone scintillation scan. CT and MRI may also be useful.^7,8
• There is some debate about the optimum time for this further examination/investigation and many argue that clinically suspected scaphoid fractures that are not immediately apparent on X-ray should be investigated further as soon as possible after injury.^9,10 Most occult fractures are visible on X-ray at 2 weeks.¹¹
• If there is tenderness of the anatomical snuff box but normal radiology then other local pathology should be sought.¹¹
• A recent systematic review and meta-analysis looked at the treatment of acute scaphoid fractures. It compared operative and non-operative treatment and looked at which type of cast should be used for non-operative treatment. It found that operative treatment of acute non-displaced, or minimally displaced, fractures of the scaphoid waist does not provide benefits and causes more complications. There was not enough evidence to determine the best treatment for scaphoid proximal pole fractures. There was also insufficient evidence to determine which type of cast should be used for non-displaced fractures.¹²
• A fracture of the scaphoid is an exception to the rule that a back slab is applied initially, as there is usually no associated swelling. A scaphoid plaster is usually applied from the outset. This fixes the wrist in about 10º of flexion with slight radial deviation and the thumb and middle finger just able to appose. The position is that which would be assumed when using a pen.
• The duration of immobilisation depends upon the site of the fracture: fractures of distal third heal in 6 to 8 weeks; fractures of middle third heal in 8 to 12 weeks; fractures of proximal third take 12 to 24 weeks.
• Operative treatment may be needed for displaced fractures.

Complications

Complications can occur, especially if there is failure of diagnosis and inadequate treatment. They include:

• Avascular necrosis: the blood supply enters the scaphoid near its waist. Fractures in this area can potentially interrupt the blood supply to the proximal part of the scaphoid, leading to avascular necrosis, non-union and arthritis.
• Scaphoid non-union/delayed union
• Reduced grip strength and reduced range of motion
• Osteoarthritis of the radiocarpal joint

• This is an isolated fracture of the radial styloid.
• It is typically caused by a direct blow to the radial aspect of the wrist.
• The term 'chauffeur's fracture' refers to its initial description in people struck by the handcrank on early cars when the engine suddenly backfired during starting.¹
• It can also result from forced ulnar deviation and supination of the wrist as may occur in the sudden deceleration of a road traffic accident when the hands are on the steering wheel. Strong ligaments maintain the alignment of the styloid to the carpus but the styloid may be markedly displaced.
• Associated injuries include scapholunate dissociation and dorsal Barton's fracture.
• Operative fixation is required. This usually involves placement of K wires via an incision rather than percutaneously. Screws are occasionally used. Sometimes bone grafting is also required.

• Greenstick fracture is a fracture of children. The bone is broken and may be considerably distorted but the periosteum remains intact.
• Sometimes they have been present for days. If the child seems unduly protective of an injured arm there may be a greenstick fracture and it is worthy of X-ray.
• These fractures are usually either greenstick fracture of distal radius and ulna or greenstick fracture of mid-third of radius and ulna. The latter tends to occur in a child under 8 who falls on an outstretched arm.
• Please also refer to the separate article entitled 'Forearm injuries and fractures'.
• When only one bone is broken, the integrity of both proximal and distal radio-ulnar joints should be checked.
• If there is only a minor degree of dorsal angulation then reduction is unnecessary and remolding will take place as the child grows.
• Reduction involves slow, constant pressure to reduce the deformity, applied over 5 to 7 minutes until the intact dorsal cortex is broken. Failure to break the cortex may result in increasing deformity whilst in the plaster.
• The forearm is gently rotated into supination and a long arm cast is applied and kept on for 4 to 6 weeks.
• The commonest complication is recurrent deformity within the plaster. This is more likely with a volar than a dorsal fracture and if the ulna is intact. Median nerve entrapment can also occur.
• The ulnar styloid may be fractured in an injury to the wrist.

• Suggested by local tenderness. There is a shallow dorsal longitudinal groove through which runs the tendon of the extensor carpi ulnaris.
• Fracture of the ulnar styloid may be associated with a distal radius fracture.
• A fractured ulnar styloid process may not seem very apparent on X-ray if there is no displacement.
• A minimally displaced fracture can be treated by a long arm plaster in mid-supination for 3 or 4 weeks.
• Fractures at the base are more likely to lead to instability of the distal radioulnar joint. Closed reduction and pinning with a K wire or screw may be needed or open reduction may be necessary to achieve stability.

• If a Colles' fracture, in particular, seems to have occurred with less than the usual degree of trauma then osteoporosis should be suspected.¹³
• Many people who sustain a fragility fracture are not tested or treated for osteoporosis.^14,15
• The best investigation is a DEXA scan.
• If there is osteoporosis and treatment is started, this may prevent another fracture in the future.
• If a fracture is assumed to be osteoporotic in origin and the patient is over 75 then NICE recommend that treatment can be started without a DEXA scan. Bisphosphonates are first line.¹⁶

Please refer to the separate articles entitled Osteoporosis and Bisphosphonates and Drug Treatment of Osteoporosis.

• Abraham Colles(1773-1843), was elected president of the Royal College of Surgeons in Ireland in 1802 at the age of 28, in 1804 he was appointed professor of anatomy, physiology, and surgery at the college. He described his eponymous fracture of the distal radius in 1814.
• Robert Smith(1807-1873), founded the Dublin Pathological Society with Colles, Graves, Corrigan, and Stokes. In 1847 he wrote "A Treatise on Fractures in the Vicinity of Joints", and in it described his eponymous fracture, and Madelung's deformity before Madelung described it. His book a "Treatise on Pathology, Diagnosis, and Treatment of Neuroma" (1849) was said to be larger than a dining-room table when opened. He also wrote on neurofibromatosis in detail before von Recklinghausen did. Appointed to first chair in surgery at Trinity College Dublin.
• John Barton (1794-1871) was an American surgeon who worked in Pennsylvania. He was ambidextrous and once he had positioned himself did not need to move around the patient. He is best known for his innovative corrective osteotomies for ankylosed joints. He described his eponymous fracture in 1835.