Fractures of the wrist
What is it?
While any of the many bones in the wrist can break, fracture of the wrist normally refers to a break(s) of the end of the forearm bones, which are the 'radius' on the thumb side, and the 'ulna' on the little finger side. It is very commonly seen in children and in later life around the age of 60 due to osteopenia. In young adults, it is usually seen after high-energy injuries (biking accidents).
Is it called by any other name?
Colles’ fracture or Smiths’ fracture (named after Abraham Colles and Robert Smith who described patterns of these fractures in 1814 and 1847 respectively).
Colles described the fracture, which tips backwards, while Smith described the fracture that tips to the front.
What is its cause?
Fractures of the wrist are common fractures and occur mostly after falls on outstretched hands or bent wrists. The natural spot is usually where the radius bone widens (see x-ray above). The broken pieces can displace because of the force of the injury or because of the pull of the muscles attached to the fragments. The fragments will also collapse into one another and the bone will shorten.
What are the symptoms and how is the condition diagnosed?
Immediately after the fall, the patient will experience severe pain. The wrist will be deformed and swollen. The diagnosis can only be confirmed by an x-ray. The pattern of fracture seen on the x-rays will determine the treatment. The x-rays will show the Specialist how much the bones have moved apart (displaced) or collapsed (shortening), the number of bone fragments (comminution), and whether the fracture extends into the wrist joint (intra-articular fracture).
Sometimes patients may also sustain a wound and the fracture is called an ‘open fracture’. Open fractures are treated urgently to prevent further soft tissue damage and infection.
Symptoms like tingling/ numbness suggest pressure on the nerves (usually the median nerve) and need to be monitored.
Will further tests or investigations be needed?
In addition to the initial x-ray, your specialist may in certain cases, advice further investigations (usually CT) before planning treatment.
What is the treatment for acute fractures?
- The general principle in treating a fracture, is to reduce the displaced fracture and hold it in place. The method by which this can be achieved is dependent on the location of the fracture and whether the fracture extends into the wrist joint; the degree of fracture displacement; the extent of comminution (fracture fragments); the quality of bone stock and the functional demands of the patient. If it is an open fracture the wound needs to be cleaned, debrided and the fracture fixed urgently.
- Conservative treatment in a plaster cast:
Undisplaced fractures are treated with a plaster cast from below the elbow for about six weeks. An x-ray may be advised at one week to confirm that the position is maintained, as the fractures can slip within the plaster cast.
- Conservative (non-surgical) treatment with manipulation under local anaesthesia and plaster cast:
This is the conventional treatment of displaced wrist fractures and is practiced in fractures that occur after low energy accidents, are minimally displaced or those patients in whom anaesthesia or surgery will carry a greater risk. Such treatment usually takes place in the A&E department. Under local anaesthesia the fracture is realigned and the deformity reduced. The arm is put in a plaster cast from below the elbow for about six weeks. An x-ray will confirm that the fracture has realigned satisfactorily. An x-ray is usually advised again at one week and two weeks after manipulation, to confirm that the position is maintained, as the fractures can slip within the plaster cast.
- Surgical treatment by fracture reduction and internal fixation:
If the fracture extends into the wrist joint, or its pattern is determined to be unstable, then surgical treatment needs to be considered. There are various surgical techniques by which this can be achieved:
Closed reduction and K-wire fixation:
Under anaesthesia the fracture is reduced and then held by 2-3 pins (k-wires). The K-wires are not strong enough to hold the fracture by themselves and hence a plaster cast from below the elbow is still needed for 6 weeks. The advantage of this procedure is that no open surgery is required. It is well suited for those fractures with a good bone stock, with little or no comminution and which do not extend into the joint.
Open reduction and internal fixation by a plate:
This surgical technique is an open operation with an incision either on the front or back of the wrist, depending on the nature of the fracture. This procedure is indicated in high-energy fractures, fractures that extend into the joint, low energy but unstable fractures (comminuted, shortened or displaced), open fractures, Smiths’ fractures, fractures with associated nerve problems or patients who have sustained multiple fractures. The main advantage of this technique is that after precise alignment is achieved, the fracture fixation is strong enough to allow wrist motion soon afterwards. Specially designed plates and screws for the end of the radius are used to fix the fracture.
Closed reduction and external fixation:
In the past, this technique was used extensively, but nowadays, with newer designs in plates to fix fractures of the wrist, it is less commonly used. Under anaesthesia the fracture is reduced and then held by an external fixator. The fixator consists of pins going into the radius and the metacarpal (the long bone at the base of your index finger). An external rod then stabilizes these pins.
What happens if it is not treated?
If the wrist fracture is not appropriately treated it will heal but with a deformity. The deformity occurs because the bone heals in a tipped back position. It is possible that the deformity may not cause any trouble if the demands on the wrist are low. However if the functional demands on your wrist are high, patients may experience pain, especially on the little finger side of the wrist, have a weak grip and find it difficult to rotate the forearm (e.g. giving or taking change). If the fracture has extended into the wrist it is possible that in the long term the patient may develop arthritis in the wrist.
What is the success of treatment?
More than 75-80% of patients will have a successful result following appropriate treatment for such fractures. Recovery can take a long time especially in high-energy injuries, because there has been significant soft tissue damage.
What are the complications of treatment?
- Infection of the wound is possible and can usually be successfully treated with antibiotics.
- Wrist stiffness (especially after high energy injuries).
- Weak grip
- Unsightly scar and scar tenderness.
- Nerve or tendon damage.
- The implants will need to be removed.
- Severe complex regional pain syndrome (CRPS) is a rare but serious complication after hand and wrist injuries. Unfortunately it is not possible to predict this problem but needs to be monitored and treated (usually just with physiotherapy) if it develops.
- Any surgical intervention has the risk of developing complications that are unpredicted. These complications may have the potential to leave the patient worse than before surgery.
Is there anything I can do to improve the outcome?
- Keep the hand and wrist elevated to reduce swelling
- Keep the wounds dry and clean until they have healed.
- Be compliant with usage of the splint.
- Carry out any prescribed limb exercises regularly.
- It is advised against wearing rings on the operated hand for 4-6 weeks after surgery.
When can I do various activities?
Return to work depends on many factors including the nature of the job and hand dominance. After internal fixation of a fracture, you should be able to return to a desk job within 2 weeks of the operation and perform reasonable tasks with the limb by 4 weeks. Manual work should be avoided for 8 weeks.Driving should be possible within 1-2 weeks, if the wrist has been fixed. If you have been advised to use a plaster cast, return to driving will take longer. Before driving do check that you can manage all controls and start with short journeys.