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Wrist Fractures

by Danielle Campagne, MD

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 forearm bone (radius). Sometimes the smaller one (ulna) is also broken. These fractures are considered wrist fractures.

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.

Diagnosis

  • X-rays

  • Occasionally computed tomography

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

Doctors can usually identify these fractures on x-rays (see Overview of Fractures, Dislocations, and Sprains : 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:

  • People may be given a drug that makes them fall asleep (called a conscious sedation).

  • A hematoma block may be used.

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. Then a cast is applied. The cast may be worn for 3 to 6 weeks.

If the joint is affected or the broken bones are jammed close together, surgery (open reduction with internal fixation, or ORIF—see Fractures, Dislocations, and Sprains:Surgery) 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).

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).

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 (see Figure: Bones in the Wrist).

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 bone may not heal and may then deteriorate and collapse. Tissue may die (called osteonecrosis), resulting in osteoarthritis and disability. Also, 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 or computed tomography

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, magnetic resonance imaging (MRI), which is more likely to detect a fracture, or computed tomography (CT) may be done. Or doctors may treat the injury as a fracture and apply a thumb spica splint.

Thumb Spica Splint

If MRI or CT is not done, another x-ray is taken about 1 to 2 weeks later. This x-ray can usually show the fracture, confirming the diagnosis.

Treatment

  • A cast

  • Sometimes surgery

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

Sometimes surgery (open reduction and internal fixation, or ORIF—see Fractures, Dislocations, and Sprains:Surgery) is required to realign and immobilize the broken pieces.

The bone may take 3 to 4 months to heal.

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