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Three quarters of wrist injuries are fractures of the distal radius and ulna. The eight carpal bones are injured less frequently. Accurate diagnosis and correct treatment help to prevent long-term loss of function.
Classification of wrist fractures
As with fractures elsewhere in the body, wrist fractures can be:
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.
- Colles' fracture (distal radius)
- Smith's fracture (distal radius)
- Scaphoid fracture
- Barton's fracture (fracture dislocation of the radiocarpal joint)
- Chauffeur's fracture (fracture of the radial styloid)
- Greenstick fracture (confined to children)
- Fracture of the 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?
- 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.
- 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 four 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.
- 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.
- 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 cast 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 cast 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.
All patients should be given an appointment for orthopaedic follow-up in a fracture clinic.
- Scaphoid fractures are the most common fractures of the carpus, accounting for 79% of all carpal fractures.
- They occur most often in men aged 20-30 years. About 10% present with an associated 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, the fracture occurs from a fall on to an outstretched hand.
- The complaint is usually just of local pain.
- The classical sign is tenderness in the anatomical snuff box.
- Fewer than 20% of patients with a clinically suspected scaphoid fracture have a true fracture.
- The anatomical snuffbox is on the radial aspect of the dorsum of the wrist. Ask 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.
- Anatomical snuffbox tenderness on examination is a very sensitive indication of a scaphoid fracture, but it is nonspecific. Causes of a false-positive result can occur when the radial nerve sensory branch, which passes through the snuffbox, is pressed and causes pain.
- Tenderness of the scaphoid tubercle (extend the patient’s wrist with one hand and apply pressure to the tuberosity at the proximal wrist crease with the opposite hand) has a similar sensitivity but is more specific.
- Absence of tenderness with these two manoeuvres makes a scaphoid fracture very unlikely.
- Another manoeuvre that suggests fracture of the scaphoid is pain in the snuffbox with pronation of the wrist followed by ulnar deviation.
- 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.
- Scaphoid fractures are often difficult to identify on initial X-rays and may not be seen in 15-20% of cases.
- Repeating X-rays 10-14 days after the initial injury and presumptive casting to allow time for resorption to produce a visible fracture line has a relatively low sensitivity (91.1%).
- MRI is generally the most accurate imaging test for scaphoid fractures. MRI in this situation has a sensitivity of 97.7% and a specificity of 99.8% respectively. Bone scintigraphy has a sensitivity of 97.8% and specificity of 93.5%. CT has a sensitivity of 85.2% and specificity of 99.5%.
- MRI is especially sensitive for detecting minor displacements, which is important for determining the need for surgery. Additional carpal or radial bone, or soft tissue injuries which may otherwise be missed may also be identified. MRI is the most expensive imaging method.
- CT is the investigation of choice according to the American College of Radiology’s recommendations when initial X-rays are normal and MRI is not available, casting is not wanted owing to the patient’s wish for a quick return to activity, and/or surgical planning of complex fractures is needed.
- If there is tenderness of the anatomical snuff box but normal radiology, then other local pathology should be sought.
- Although surgical treatment has been shown to achieve better fracture union for undisplaced and minimally displaced scaphoid waist fractures, it is also associated with a significantly increased risk of complications. The current evidence does not therefore support routine surgical treatment, and aggressive conservative management is preferred.
- There is not enough evidence to determine the best treatment for scaphoid proximal pole fractures. There is also insufficient evidence to determine which type of cast should be used for non-displaced fractures.
- A fracture of the scaphoid is an exception to the rule that a back slab be applied initially, as there is usually no associated swelling. A scaphoid cast is usually applied from the outset. This fixes the wrist in about 10° of flexion with slight radial deviation and the thumb and middle finger just able to oppose. 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 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; non-union occurs in approximately 5-10% of undisplaced scaphoid fractures.
- Reduced grip strength and reduced range of motion.
- Osteoarthritis of the radiocarpal joint.
- The classical definition is a fracture through the distal metaphysis of the radius, approximately 4 cm 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.
- It is common in older people who fall and have osteoporosis. Osteoporosis should be considered in anyone with a Colles' fracture (see 'Osteoporosis and wrist fractures', below).
- It can also occur in younger people with normal bones.
- A systematic review found that despite worse radiographic outcomes associated with cast immobilisation, functional outcomes were no different from those of surgically treated groups for patients age 60 and over.
- A Colles' fracture is a stronger risk factor for a subsequent hip fracture in men than in women.
History and examination
- It typically occurs from a fall on to 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.
- 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 six weeks.
- Median and/or ulnar nerve damage can occur acutely. There can be an acute carpal tunnel syndrome.
- Compartment syndrome can occur with excessive swelling.
- Deformity can occur on healing and result in long-term loss of mobility and in 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 ulnar 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 radiocarpal 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.
- Open reduction and internal fixation of volar Barton's fracture can result in good to excellent function.
- Radial styloid fractures can occur in isolation or in association with other injuries, including complex intra-articular distal radius fractures, carpal fractures, carpal dislocations, and radiocarpal dislocations.
- 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.
- 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 aged under 8 who falls on an outstretched arm.
- See also the separate article on Forearm Injuries and Fractures.
- When only one bone is broken, the integrity of both proximal and distal radioulnar 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 cast.
- The forearm is gently rotated into supination and a long arm cast is applied and kept on for 4 to 6 weeks.
- The most common complication is recurrent deformity within the cast. This is more likely with a volar than with 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.
Ulnar styloid process fracture
- 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 cast 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.
- An accompanying ulnar styloid non-union in patients with distal radius malunion has no apparent adverse effect on outcome or function after corrective radial osteotomy. An accompanying non-union of the ulnar styloid can heal following corrective radial osteotomy.
Osteoporosis and wrist fractures
- If a Colles' fracture, in particular, seems to have occurred with less than the usual degree of trauma then osteoporosis should be suspected.
- Wrist fracture is the most common fragility fracture in perimenopausal and young postmenopausal women.
- Many people who sustain a fragility fracture are not tested or treated for osteoporosis.
- The best investigation is a dual-energy X-ray absorptiometry (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 aged over 75 then the National Institute for Health and Care Excellence (NICE) recommends that treatment can be started without a DEXA scan. Bisphosphonates are first-line.
Please refer to the separate article on 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. He was 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.
Further reading & references
- Wrist injuries; Wheeless' Textbook of Orthopaedics
- whonamedit.com; A biographical dictionary of medical eponyms
- Handoll HH, Madhok R, Dodds C; Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2002;(3):CD003320.
- Smith M, Bain GI, Turner PC, et al; Review of imaging of scaphoid fractures. ANZ J Surg. 2010 Jan;80(1-2):82-90. doi: 10.1111/j.1445-2197.2009.05204.x.
- Baldassarre RL, Hughes TH; Investigating suspected scaphoid fracture. BMJ. 2013 Mar 27;346:f1370. doi: 10.1136/bmj.f1370.
- Phillips TG, Reibach AM, Slomiany WP; Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004 Sep 1;70(5):879-84.
- Cheung GC, Lever CJ, Morris AD; X-ray diagnosis of acute scaphoid fractures. J Hand Surg [Br]. 2006 Feb;31(1):104-9. Epub 2005 Oct 28.
- Yin ZG, Zhang JB, Kan SL, et al; Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. J Bone Joint Surg Br. 2012 Aug;94(8):1077-85. doi: 10.1302/0301-620X.94B8.28998.
- Pillai A, Jain M; Management of clinical fractures of the scaphoid: results of an audit and literature review. Eur J Emerg Med. 2005 Apr;12(2):47-51.
- Ibrahim T, Qureshi A, Sutton AJ, et al; Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials. J Hand Surg Am. 2011 Nov;36(11):1759-1768.e1. doi: 10.1016/j.jhsa.2011.08.033.
- Yin Z, Zhang J, Kan S, et al; Treatment of Acute Scaphoid Fractures: Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2007 Feb 15;.
- Alshryda S, Shah A, Odak S, et al; Acute fractures of the scaphoid bone: Systematic review and meta-analysis. Surgeon. 2012 Aug;10(4):218-29. doi: 10.1016/j.surge.2012.03.004. Epub 2012 May 15.
- Diaz-Garcia RJ, Oda T, Shauver MJ, et al; A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005.
- Haentjens P, Autier P, Collins J, et al; Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am. 2003 Oct;85-A(10):1936-43.
- Aggarwal AK, Nagi ON; Open reduction and internal fixation of volar Barton's fractures: a prospective study. J Orthop Surg (Hong Kong). 2004 Dec;12(2):230-4.
- Reichel LM, Bell BR, Michnick SM, et al; Radial styloid fractures. J Hand Surg Am. 2012 Aug;37(8):1726-41. doi: 10.1016/j.jhsa.2012.06.002.
- Ozasa Y, Iba K, Oki G, et al; Nonunion of the ulnar styloid associated with distal radius malunion. J Hand Surg Am. 2013 Mar;38(3):526-31. doi: 10.1016/j.jhsa.2012.12.006. Epub 2013 Feb 4.
- Cerocchi I, Ghera S, Gasbarra E, et al; The clinical significance of wrist fracture in osteoporosis. Aging Clin Exp Res. 2013 Sep 18.
- Majumdar SR, Rowe BH, Folk D, et al; A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann Intern Med. 2004 Sep 7;141(5):366-73.
- Feldstein AC, Nichols GA, Elmer PJ, et al; Older women with fractures: patients falling through the cracks of guideline-recommended osteoporosis screening and treatment. J Bone Joint Surg Am. 2003 Dec;85-A(12):2294-302.
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