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Wrist Fractures

By Danielle Campagne, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of San Francisco - Fresno

Wrist fractures may involve the lower end of one or both of the forearm bones (radius or ulna) or, less often, a bone in the base of the hand.

The wrist consists of

  • The two long bones in the forearm (radius and ulna)

  • Eight small bones at the base of the hand (called carpal bones)

The carpal bones are located between the forearm bones and the bones of the hand.

Fractures of the Lower Forearm

(Colles Fracture; Smith Fracture)

Fractures usually involve the larger lower forearm bone (radius). Sometimes the smaller one (ulna) is also broken. These fractures are considered wrist fractures.

  • Wrist fractures usually result from a fall on an outstretched hand.

  • The fractured wrist is painful, swollen, and tender and sometimes becomes stiff and persistently painful.

  • Doctors can usually identify these fractures on x-rays, but occasionally, computed tomography is needed.

  • Often, the bone fragments can be put back in place (reduced) by manipulation, then held in place by a splint, but sometimes surgery is required.

Usually, the wrist is fractured when people fall on an outstretched hand (to break the fall), with the wrist bent back. As a result, the radius breaks near the wrist, and the broken end of the radius is displaced up, toward the back of the hand. This type of fracture is called a Colles fracture. Sometimes the wrist is obviously out of position. Often, part of ulna is also fractured. Colles fractures are common among older people, especially if they have osteoporosis, which weakens bone.

Less often, the wrist is fractured when people fall with the hand bent forward or when the back of the wrist is hit—for example, with a hockey or lacrosse stick. The broken end of the radius is displaced down, toward the palm side of the wrist. This type of fracture is called a Smith fracture.

Wrist Fractures: Colles and Smith

Wrist fractures include

  • Colles fracture: The wrist is fractured when people fall on an outstretched hand, with the wrist bent back. The larger forearm bone (radius) breaks near the wrist, and the broken end of the radius is displaced up, toward the back of the hand.

  • Smith fracture: The wrist is fractured when people fall with the hand bent forward. The broken end of the radius is displaced down, toward the palm side of the wrist.

Fractures of the radius may extend into the wrist joint.

The median nerve—the nerve involved in carpal tunnel syndrome—may be damaged. This nerve travels through the wrist to the palm and some fingers.

Symptoms

The wrist is painful, swollen, and tender. If the median nerve is damaged, the tip of the index finger is numb, and people may have difficulty pinching their thumb and little finger together.

A wrist fracture may result in stiffness, persistent pain, and/or osteoarthritis, particularly if the fracture extends into the wrist joint or the broken pieces are out of place.

Diagnosis

  • X-rays

  • Occasionally computed tomography

If people think they may have fractured their wrist, they should see a doctor.

Doctors can usually identify wrist fractures on x-rays (see Overview of Fractures : Diagnosis). Occasionally, computed tomography (CT) is necessary to identify joint fractures. CT combines x-rays with computer technology to produce a more detailed, three-dimensional image of the injured area.

Treatment

  • Realignment of the broken bones done with or without surgery

  • A cast or a metal frame with pins

For many wrist fractures, doctors realign (reduce) the broken pieces without surgery (closed reduction). Before realigning the fracture, doctors may do one of the following to prevent people from feeling pain:

For a hematoma block, a needle is inserted through the skin into the fracture where blood has collected (a hematoma is an accumulation of blood), and lidocaine (an anesthetic) is injected, numbing the fractured bones before the bones are realigned.

After the bones are realigned, a splint is applied. The person is then referred to an orthopedic surgeon for follow-up. Usually, the splint is removed, and a cast is applied. The cast is worn for about 4 to 6 weeks.

If the joint is affected or the broken bones are jammed close together, surgery (open reduction with internal fixation, or ORIF) may be done to realign and immobilize the broken pieces, especially in active adults who need to be able to fully use their wrist. The bone may be immobilized by attaching a plate directly to it during surgery. Or doctors may attach a frame of rods to the outside of the wrist with stainless steel pins inserted through the skin into the bone (called an external fixator). An external fixator is usually temporary. It is used until surgery to insert more permanent hardware devices can be done.

External Fixator

People are advised to move their fingers, elbow (if it is not immobilized), and shoulder every day to prevent stiffness. Elevating the hand helps control swelling. The comfort, flexibility, and strength of the wrist can continue to improve for 6 to 12 months after the fracture.

Scaphoid Fractures

Scaphoid fractures involve a bone in the wrist near the base of the thumb (scaphoid bone).

  • Scaphoid fractures usually result from a fall on an outstretched hand.

  • These fractures can disrupt blood flow to the scaphoid bone, causing osteoarthritis and loss of function.

  • The thumb side of the wrist is tender and swollen, and rotating the wrist is particularly painful.

  • X-rays are taken, but because scaphoid fractures may be hard to see soon after the injury, other imaging tests may be needed, or a splint may be placed and x-rays repeated after 7 to 10 days.

  • A thumb spica splint is often effective, but sometimes surgery is needed to put the broken pieces of bone in place and hold them in place.

The scaphoid bone is the most commonly injured of the eight wrist (carpal) bones, located between the bones of the forearm and those of the hand.

Bones in the Wrist

Scaphoid fractures usually result from a fall on an outstretched hand. These fractures often cause problems because they often disrupt the blood supply to the scaphoid bone. Without its blood supply, the following may occur:

  • The bone may not heal and may then deteriorate and collapse.

  • Tissue may die (called osteonecrosis), resulting in osteoarthritis and disability.

  • The bones may not grow back together (called nonunion).

These problems occur in about 5 to 10% of people and can occur even when treatment is optimal.

Symptoms

The thumb side of the wrist is tender and swollen. Rotating the wrist is particularly painful.

Diagnosis

  • A doctor's evaluation

  • X-rays

  • Sometimes magnetic resonance imaging

If people think they may have fractured their wrist, they should see a doctor.

Doctors suspect a scaphoid fracture based on symptoms and results of a physical examination. X-rays are taken, but these fractures may be hard to see soon after the injury.

If x-rays do not show a fracture but the physical examination suggests a fracture, most doctors apply a splint. People are asked to return in 7 to 10 days for another x-ray to check for a fracture. (Fractures may be seen more easily after they have been healing for a few days—see How Bones Heal.) Magnetic resonance imaging (MRI) can be done to check for a fracture when none is seen on a x-ray, but it is rarely used because of the expense.

Thumb Spica Splint

Treatment

  • A thumb spica splint

  • Sometimes surgery

After diagnosis is confirmed, many fractures can be effectively treated with a thumb spica splint that is worn for up to 6 to 8 weeks.

Sometimes surgery (open reduction and internal fixation, or ORIF) is required to realign and immobilize the broken pieces.

The bone may take 3 to 4 months to heal.

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