Authors

Dr Keran Sundaraj MBBS MSc (Trauma) FRACS FAOA

Wrist Fractures

Distal radius (AKA wrist or Colles) fractures are the most common break in the upper limb.

Anatomy

Bones

• Radius (long forearm bone)

• Ulnar (long forearm bone - which starts as the tip of the elbow)

• Carpal bones (scaphoid and lunate; these are two of eight of the small bones of the hand)

Ligaments

• Triangular fibrocartilage complex (TFCC) - attached to the ulnar 'styloid'. Sometimes a small piece of bone is broken from the ulnar as the strong TFCC ligaments attach to it and are pulled away as the distal radius fractures. It may be reported as a "second fracture", but its role in the wrist is less important. This may heal with scar tissue (rather than bone) and will look like a small piece of floating bone on an X-ray —this normal and expected.

• Carpal ligaments - which there are many of. These are less important when discussing acute wrist fractures.

Cause

The most common cause for this fracture is falling onto an outstretched arm. You may see this described in your medical notes as "FOOSH".

There are two types of distal radius fractures;

• Low energy

• High energy

In patients over the age of 60, a fall from a standing position is the likely cause. Osteoporosis (weak bones due to low density) may be the underlying cause. High energy injuries are seen in car accidents and falls from a bike.

Imaging Tests

X-Rays

• These are the first line of tests and most often are all that is required. Information about fracture pattern and displacement can be sort from X-rays.

• These will be used during follow-up to monitor the position of the wrist and ensure it remains in an appropriate position.

CT

• A CT scan gives a three-dimensional picture of the bones. This may be useful in wrist fractures if the X-rays don't provide enough information - such as whether the fracture enters the wrist joint or to measure any steps in the joint surface. For more complex fracture patterns, this will help plan for surgery.

MRI

• This is generally not helpful in managing acute wrist fractures.

Ultrasound

• This is generally not helpful in managing acute wrist fractures.

Treatment

For information on fracture healing and general management, see the link.

The goal of treatment is to place and maintain the bones in an appropriate position to heal in a 'functional' position.

Non-surgical treatment

• If the fracture is undisplaced or the overall alignment is acceptable for your age and functional requirements, immobilisation may be appropriate. This will involve a cast - usually a half-cast (known as a back slab) initially to allow for swelling.

• This is exchanged at 1 to 2 weeks for a full cast.

• This cast remains on for at least six weeks.

Closed Reduction (manipulation)

• Fractures that are slightly displaced and not in too many pieces may be treated with manipulation. This may be performed in the emergency department with a light anaesthetic or an operating theatre with a full anaesthetic. The arm may be 'sandwiched' between two plaster slabs or a full cast applied.

• Sandwich slabs are designed to allow for swelling, though they may become loose over the coming days. This should be reinforced by wrapping tape or crepe bandage, so the cast feels snug again.

• Ideally, you should be seen one to two weeks later with a repeat X-ray to check the position. Rarely, the fracture can move position, and a re-manipulation or an operation may be necessary.

Surgery

• Sometimes the wrist fracture is out of significant alignment or in multiple pieces that prevent a cast from holding the position of the bones.

• Surgery helps to realign and maintain the appropriate position.

• Surgery may involve the use of;

  • Plate and screws

  • Metal pins

  • External fixator (pins and bars that form a frame on the outside of the body)

• Most commonly, plates and screws are used with an incision on the palm side of your forearm. After the operation, you will be in a back slab to keep the wrist still. This helps significantly with pain relief and swelling. This is often removed at two weeks by the Surgeon, and a removable wrist splint is applied. This wrist splint can be removed during showers and for exercises. For the most part, this providers comfort and immobilises the wrist for pain relief.

Prevention strategies

• The best treatment for fractures is avoiding the injury in the first place. Treatment, once a fracture has occurred, should also include strategies to prevent future injuries.

  • Falls prevention - beneficial for elderly patients. This can be discussed with your GP or Geriatrician.

  • Wrist guards - these are usually not sufficient but may protect against some fractures. Patients who return to high risk or impact activities may benefit from using a rigid wrist guard during these times.

What to Discuss with Dr Sundaraj

• How long can I expect off work?

• When can I start driving?

• How long will I be in a cast/splint?

• Do I need to be screened for osteoporosis (weak bones)?

• When can I start physiotherapy?

• What is the likely outcome from this treatment?

• When do I need to come back?