Wrist injuries

Essentials

Fracture of the distal radius (wrist fracture) is the most common fracture of the upper limb in adults, and usually associated with falling.
• In younger patients, the criteria for an acceptable position should be fulfilled. For older patients (above 65 years of age) surgical treatment is probably not useful, but it can be considered case by case.
• The majority of typical fractures of the distal radius (Colles' fractures) can be treated conservatively in primary health care. In other types of wrist fracture, consulting a hand surgeon or orthopaedist should usually be considered.
• Final recovery may take 6–12 months. In most cases, there will be no permanent impairment of daily functionality, but some patients may continue to have wrist symptoms regardless of the method of treatment.
• The most common fractures of actual carpal bones are fractures of the scaphoid bone.Not all wrist fractures are treated in the same way, and x-rays should be studied in order to diagnose the type of fracture (picture ). Two weeks after the application of a plaster cast, a decision should be made regarding the success of conservative treatment. The possible development of complex regional pain syndrome (CRPS) should be borne in mind and identified. The treating physician should be able to suspect especially the following (poor management may lead to osteoarthritis): Fracture of the scaphoid bone (it is not always apparent on x-rays taken on presentation) Ligament rupture between the scaphoid and lunate bone (scapholunate dissociation) Bennett’s fracture at the base of the first metacarpal bone

Typical fracture of the distal radius (Colles’ fracture)

A fracture of the distal radial metaphysis with dorsal displacement of the distal fragment (pictures )
• A fissure may extend to the joint surface. The fracture area may be comminuted.
• Most cases can be treated conservatively.
• Criteria for an acceptable position in patients under 65:
  • dorsal tilt ≤ 15°
  • radial shortening ≤ 3 mm in relation to the ulna
  • articular step-off or gap ≤ 1 mm
  • radioulnar inclination angle ≥ 15°.
• If the position is unsatisfactory, perform reduction, i.e. move the fractured fragments into place before applying a plaster cast.
  • The patient should lie flat on his/her back.
  • Pain relief at the fracture site is essential to enable the patient to relax their upper limb muscles; provide local anaesthesia e.g. by injecting 10 ml of 1% lidocaine dorsally into the fracture line.
  • Apply steady traction to the hand, moving the fracture area to separate the fracture fragments. An assistant applies counter traction by pulling back on the upper arm.
  • Maintaining the traction, perform the actual reduction: first place the fracture in extension and then push the dorsally displaced fragment back into place by pressing it to volar direction with your thumb and simultaneously moving the fracture into slight flexion.
  • Hold the reduction position until the plaster has dried.
• Dorsal plaster cast from the upper third of the forearm to the knuckles
  • Place a stockinette on the skin, covered by 1–2 layers of cotton padding.
  • Apply wrist plaster cast in a functional position (0–20° extension). Slight flexion is acceptable but excessive wrist flexion, ulnar deviation and pronation should be avoided.
  • Elbow, metacarpophalangeal and thumb base joints must be able to move freely.
• Check the position by x-ray (at least PA and lateral views). If the position is unacceptable, the reduction may be repeated.
• The recommended time in plaster is 4–5 weeks.
  • X-rays of a fracture in an acceptable position should be repeated after 1 and 2 weeks, and, as necessary, after 5 weeks.
  • Repeat x-rays are not generally necessary if a fracture position not fulfilling the above radiological criteria was justifiably accepted in the first place.
  • Surgical treatment should be considered if the fracture position is unacceptable after reduction or has become worse on follow-up pictures taken at 1–2 weeks. A hand surgeon or orthopaedist should be consulted in such cases. Repeat closed reduction at 1–2 weeks is not recommended.
  • If an acceptable position in follow-up imaging is taken as a criterion for successful treatment, the same radiological criteria apply as at the primary stage.
• In patients over 65, the radiological findings do not predict the functional outcome, and surgical treatment is probably not useful even if the fracture position is unacceptable or becomes worse during plaster cast treatment, falling below acceptable limits. Surgical treatment can be considered in active elderly people in whom good functionality of the upper limb is important. Careful individual assessment of the need for surgical treatment is warranted in such cases.
• Further treatment
  • The patient should be given an information handout before being sent home.
  • In the early stage, the limb should be elevated and finger movement exercises done to reduce swelling and adhesions.
  • Active range of motion exercises of the shoulder, elbow, knuckle and finger joints should be done several times a day throughout the plaster cast treatment
  • If the plaster feels tight, it must be corrected or a new plaster cast applied. After replacement of the plaster cast, check the fracture position by repeat x-raying.
  • If an early fracture complication (nerve or tendon injury, inflammation) is suspected, urgent consultation of a hand surgeon or an orthopaedist is indicated.
  • Complex regional pain syndrome (CRPS; ) may develop as a fracture complication. Symptoms include unexpectedly severe pain, alternation of sensation and motor functions, and autonomic nervous system dysfunction. Treatment can be started in primary health care, with urgent referral to physical therapy or an outpatient pain clinic, as necessary. If CRPS is suspected of being due to nerve injury (CRPS type II), a hand surgeon should be consulted.
  • If recovery is delayed (6–12 months) despite appropriate treatment and the patient has a symptomatic fracture ossified in malposition or if their functional ability is significantly threatened, write a non-urgent referral to specialized care, as necessary.
• Possible associated injuries
  • Fracture of the ulnar styloid process and/or triangular fibrocartilage complex (TFCC) injuries are common.
  • Distal ulnar fractures (of the caput or neck) are rarer. As such fractures can easily cause instability of the forearm, surgical treatment is often indicated.
  • Injury to or pressure on the median nerve. After fracture or treatment, fingers I–III may show numbness but this should resolve in 24–48 hours. If not, a hand surgeon or orthopaedist should be consulted.
  • The abductor pollicis longus tendon may be severed during or after plaster cast treatment due to friction and inflammation of the fracture area.
  • Rupture of the ligament between the scaphoid and lunate bones (scapholunate ligament, scapholunate dissociation) in association with fractures extending to the radial joint surface
    • The diagnosis of ligamentous wrist injuries is based on clinical examination and magnetic resonance imaging, as necessary.
  • Fracture of the scaphoid bone
  Fracture of the distal radius where the distal fragment is dorsally displaced (pictures ). The fracture may be comminuted, and the proximal fragment is often impacted into the distal fragment causing radial shortening and a ”silver fork” deformity. The majority of cases can be successfully treated with the aid of reduction and plaster cast application . Pain relief at the fracture site is essential to enable the patient to relax the upper limb muscles. Analgesia and/or premedication if necessary Local anaesthesia with 10 ml of 1% lidocaine is injected dorsally into the fracture line and surrounding periosteum . If the fracture involves the ulnar styloid process, it should be anaesthetised separately. A padded plaster cast, extending from the upper forearm to the knuckles The elbow joint and all MCP joints must be allowed free movement. Closed reductionThe patient should lie flat on his/her back. The doctor applies even and firm traction to the fingers for an adequate length of time. An assistant applies counter traction by pulling back from the antecubital fossa or the upper arm with the elbow joint at an angle of 90°. The direction of initial traction should be dorsal in order to separate the fracture fragments and to correct a possible anterioposterior or lateral displacement at the same time. The displaced fragment is pushed back into place by applying dorsal pressure with the thumb, whilst maintaining the traction. The reduction is fixed into place by twisting the wrist into slight volar flexion and ulnar deviation. Flexion of more than 30° should be avoided because it will hinder finger movements and increase pressure on the median nerve. Pronation should be avoided as the fracture may easily heal in malalignment, and it will also adversely affect future functioning of the limb. A third person places the wetted plaster splint and padding in situ. The plaster is immediately fixed into place with the aid of a slightly elastic or non-elastic bandage. The reduction position is held until the plaster has dried. Acceptable position X-rays in PA projection show radial shortening of up to 2 mm in relation to the ulna. Articular step-off up to 1–2 mm A radial inclination angle of 20–25° with dorsal tilt up to 10° in lateral views The position should be checked radiographically immediately after reduction (at least PA and lateral views). If the position is unsatisfactory, the reduction may be repeated once or twice. If attempts to obtain a satisfactory position fail, a hand or orthopaedic surgeon should be consulted regarding the need for surgical management .
• A patient information handout should be given before the patient is sent home. The limb should be elevated to reduce swelling. Written exercise instructions with pictures Active exercises of the shoulder, elbow, knuckle, finger and thumb joints several times a day will make mobilisation easier following the removal of the plaster and will also assist in the prevention of complex regional pain syndrome (CRPS, see ). X-rays should be repeated after 5–7 days and again after 10–14 days , as the fracture is particularly prone to redisplacement. The criteria for an acceptable position are the same as those given for primary reduction. After the first radiographic check, in particular, it is possible to attempt remanipulation of a redisplaced fracture . A hand or orthopaedic surgeon should be consulted regarding the possibility of surgical management no later than after the radiographic check at two weeks if the position remains unsatisfactory. Surgical reduction after this is difficult, or impossible if union has taken place. Time in a plaster is usually 4–6 weeks, depending on the number of fracture fragments and the patient’s age. In the elderly and in comminuted fractures, a check x-ray should be taken without the plaster in situ to confirm union before allowing full mobility. If union cannot be fully confirmed, the time in plaster may be extended up to 7–8 weeks, but the plaster cast should be straightened to neutral position at this stage in order to facilitate later mobilisation. Only in undisplaced fractures are x-rays not necessary before mobilisation. Associated injuries Fracture of the ulnar styloid process is very common. Often reduces spontaneously when the radius is reduced. Displacement of small fracture fragments is usually of no consequence. A large basal, displaced fracture fragment should be fixed surgically if closed reduction is unsuccessful. DRUJ (distal radioulnar joint) injury Should be suspected if the DRUJ looks wide on x-rays or a lateral view shows dorsal or volar displacement of the ulna (compare with an x-ray of the uninjured limb!) or if the DRUJ is clinically unstable on presentation. Consult a hand or orthopaedic surgeon if necessary. Injury to the scapholunate ligament Should be suspected, if the gap between the scaphoid and lunar bones is wide (over 4 mm) in a PA projection; compare with an x-ray of the uninjured limb! The diagnosis of ligamentous injuries may necessitate magnetic resonance imaging or endoscopic examination of the wrist. Complications of Colles' fracture The plaster feels pressing Loosen the bandage by cutting through it with scissors. Apply a new, looser bandage immediately. It may also be possible to improve and round off the edges of the plaster. The limb should be elevated and finger movements encouraged in order to reduce swelling. The plaster should preferably stay in situ for 3 weeks. Signs and symptoms of a compressed median nerve (carpal tunnel): pain, numbness of fingers I–III May be associated with a volarly displaced fracture fragment, swelling or excessive volar flexion of the plaster cast. Relief is often obtained by elevating the limb and exercising the fingers. It may also be necessary to reapply the plaster and use less flexion, after which the position should be checked with x-rays. Should the numbness persist after about one week, a hand or orthopaedic surgeon should be consulted regarding a surgical exploration of the carpal tunnel. Complex regional pain syndrome (CRPS; ) Symptoms include unexpectedly severe pain with poor response to analgesics. The pain may extend to involve the entire upper limb. The moving of fingers and wrist may be difficult. Sometimes the patient presents with skin changes of both temperature and colour. Predisposing factors include: poor exercise compliance whilst in plaster, swelling, heavy plaster, excessive volar flexion. An undiagnosed condition may lead to chronic pain syndrome and, when appropriate, the syndrome should be suspected and the patient monitored. An early consultation with a hand surgeon may be warranted. Treatment consists of pain relief and mobilisation under the supervision of a physiotherapist. The best results are achieved when the treatment is initiated early, whilst still in plaster. Mobilisation problems are common after the plaster is removed, in particular supination may be restricted. Predisposing factors include immobilisation in excessive volar flexion or pronation. Exercising free joints whilst the limb is in plaster is beneficial for future functionality. If necessary, the patient should be referred to a physiotherapist whilst still in plaster. Malunion The initial treatment consists of intensive mobilisation under the supervision of a physiotherapist. There is little correlation between a radiographic malalignment and the functional end result. If the wrist remains problematic 6–12 months after the injury, a hand or orthopaedic surgeon should be consulted.

Fracture of the distal radius with volar angulation (Smith's fracture)

A fracture of the distal metaphysis with volar angulation of the distal fragment (picture )
• This type of fracture is often unstable and carries a significant risk of functionally poor outcome.
• Operative treatment is usually necessary, and a hand surgeon or orthopaedist should be consulted to assess the need for such treatment.
• If conservative treatment is chosen, immobilisation should be done with an angle cast applied from the proximal upper arm down to the knuckles. The plaster cast should be applied with the wrist slightly extended, the forearm in 45–60° supination and the elbow at an angle of 90°.

Shearing fracture of the edge of the distal radial joint surface (Barton's fracture)

A dorsal or volar shearing fracture of the distal radial joint surface (dorsal or volar Barton's fracture; picture ).
• This type of fracture is unstable and carries a high risk of losing the position and a functionally poor outcome.
• Wrist ligaments are often injured on the contralateral side to the fracture.
• Operative treatment is usually necessary, and a hand surgeon or orthopaedist should be consulted to assess the need for such treatment.

Fracture splitting the distal radial styloid process (Chauffeur's fracture)

A fracture of the joint surface of the radial styloid process facing the scaphoid bone (picture )
• The fracture is often associated with rupture of the scapholunate ligament, which can be suspected if plain PA x-ray shows widening of the scapholunate gap.
• An undisplaced fracture may be treated by immobilisation in a dorsal plaster cast, displaced fractures are often treated surgically.

Fracture of the joint surface of the distal radial bone facing the lunate bone (die punch fracture)

A fracture of the joint surface of the distal radial bone facing the lunate bone, where the radial joint surface is proximally depressed
• This type of fracture carries a high risk of poor functional outcome.
• Surgery should be considered if there is a ≥ 1 mm step-off on the joint surface.

Fracture of the scaphoid bone

There is typically a history of falling on the extended wrist.
• Tenderness on palpation in the anatomical snuff box (fossa tabatière)
• The wrist may be swollen.
• Radiography: PA, lateral and oblique views of the wrist and always also ”scaphoid views”
• If there is a strong suspicion of fracture but no fracture can be seen in plain x-ray, plain x-raying should be repeated in 1–2 weeks or a hand surgeon or orthopaedist consulted, as necessary. MRI may be justified to identify a suspected fracture.
• The method of treatment depends on the type of fracture.
  • An undisplaced mid-waist fracture can be treated by placing a plaster cast until the fracture has become ossified. An undisplaced mid-waist fracture usually becomes ossified in 6–8 weeks.
    • Circular cast from upper forearm to the knuckles
    • Place the wrist in its functional position (slight extension), leaving the thumb IP joint free; the thumb MP joint should probably also be left free. Pinch grip by the thumb and index finger should be possible with the plaster cast in place.
  • Where displacement of the mid-waist fracture exceeds 1 mm or the fracture is angulated, as well as if the fracture is proximal, it should usually be treated by surgery.
  • For fractures of the distal tuberculum, a plaster cast should be placed for 3–6 weeks.
    • Dorsal plaster cast from the proximal forearm to the knuckles
    • Wrist in slight extension
• Ossification is worse if the delay from fracture to beginning of treatment is more than 4 weeks.
• A hand surgeon or orthopaedist should usually be consulted on the treatment of scaphoid fracture. Assessment of the type of fracture and displacement often requires CT scanning.
• There are several procedures for following up on fractures treated with plaster cast, and this is another reason for consulting a hand surgeon or orthopaedist to ensure that the further treatment plan conforms to local practice.
  • Plain x-ray films (PA, lateral and scaphoid projections) without plaster cast are often taken for follow-up at 4 as well as 6–8 weeks. The ossification process cannot reliably be assessed by plain x-ray through the plaster cast.
  • CT scanning can also be used for follow-up and provides a more accurate assessment of ossification.
  • If ossification is not proceeding at repeat imaging, surgery should be considered at 6 weeks, for instance.
• About 5–10% of scaphoid fractures fail to unite. At a late stage, non-union can be observed by plain x-ray or CT scanning showing a fracture gap. A symptomatic non-united fracture should be treated surgically.History of falling on the outstretched hand. Tenderness on palpation in the anatomical snuff box Radiography: PA, lateral and oblique views of the wrist and also always ”scaphoid views” (picture ) X–rays should be studied to assess the location of the fracture, possible displacement and angulation, and the relationship of other wrist bones to the scaphoid bone (e.g. has the scapholunate gap widened, as a fracture of the scaphoid bone may be associated with scapholunate ligament injury). A recent fracture does not always show up on the first x-rays. X-rays should therefore be repeated after 1–2 weeks, and CT or MRI scanning may be warranted. Undisplaced fractures are treated with a scaphoid plaster. A scaphoid plaster extends from the upper forearm to the knuckles including the proximal phalanx of the thumb but leaves the thumb interphalangeal (IP) joint free. The thumb is positioned in its functional position so that it is able to form a circle with the index finger. In stable fractures, the time in plaster is 6–12 weeks. Fracture of the tuberculum of the scaphoid bone forms an exception as the time in plaster is only 3–4 weeks using a dorsal plaster splint. Where the displacement exceeds 1 mm or the fracture is angulated, the patient is referred for surgical assessment to a hand or orthopaedic surgeon on the next working day. The same applies if a scapholunate ligament injury is suspected. X-rays should be repeated after 3, 6 and, if necessary, after 9 and 12 weeks. The same projections are taken as for the primary fracture. Bone union should be checked from x-rays taken without the plaster in situ. If union remains uncertain, CT or MRI scanning is warranted. Immobilisation should not be extended beyond 3 months due to the increased risk of complications (restricted movement, osteoporosis, risk of CRPS). A fracture where union has not been considered to have taken place at three months may continue to ossify for up to 6 months. A fracture that is diagnosed late should be treated as a recent fracture at least up to 3–4 weeks post injury. The risk of non-union increases if the delay before the application of a plaster cast exceeds 3 weeks. Pseudoarthrosis (”false joint”) is a fracture that has failed to unite. Fracture of the scaphoid bone carries at least a 10% risk of non-union. The reasons include a delay in treatment onset as well as circulatory problems around the scaphoid bone. Proximal fractures, in particular, have a tendency not to unite. The treatment of pseudoarthrosis is surgery, usually employing screws and bone crafting. Some fractures that are presumed to be recent are probably old pseudoarthroses diagnosed from x-rays taken in association with a recent trauma.

Other fractures of the carpal bones

Fracture of the triquetral bone is the second most common carpal bone fracture.
• There is usually a small dorsal fracture fragment seen in a lateral or oblique view of the wrist.
• Treatment consists of 4–6 weeks of immobilisation in a dorsal plaster cast.
• Local pain may continue for several months but usually the fracture finally becomes asymptomatic even in the case of non-union.
• Other carpal bone fractures are rare. They may be associated with significant injuries; further imaging is therefore often indicated and consulting a hand surgeon useful.Isolated fractures of single carpal bones are rare. Dorsal avulsion fracture of the triquetral bone Visible on a lateral wrist x-ray. Treatment consists of 4 weeks of immobilisation in a dorsal plaster cast. Usually heals well with no residual symptoms even in the case of non-union.

Related resources

• Cochrane reviews
• Literature