Wrist Fractures

Mr Mike Hayton
FRCS (Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon

Other common names

A variety of fracture patterns around the wrist have been described, usually after the surgeon who first described the occurrence. These include Colles fracture, Barton fracture, Smith's fracture and Chauffeur's fracture.

Who does it affect?

Distal radial fractures can occur in any patient, but tend to be more common in those patients over the age of 50 and, in particular, those patients with osteoporosis.

Why does it occur?

Patients who fall onto an outstretched wrist can heavily impact the radius, which may break.

Symptoms

Patients will immediately notice severe pain in the affected wrist and may notice a deformity around the wrist. A common deformity of a Colles type fracture is the 'dinner fork' deformity. When observed from the side-on, the wrist has a bump reminiscent of an upturned dinner fork.

Clinical examination

A distal radial fracture often is very easy to identify. Patients are in severe pain, with a restricted range of movement. Clinical examination by the doctor will include assessment of the sensation of the hand, to ensure no nerves have been injured, and assessment of the blood supply to the hand, to ensure no vessels have been injured, and also ensuring that all the fingers can straighten and bend, to ensure no tendons have been injured. Very quickly a patient will be placed in a temporary splint for comfort.

Investigations

Plain radiographs are the mainstay of investigations for distal radial fractures. These will often show the fracture pattern. Many classifications have been identified, but important features of plain x-rays involve whether the fracture line extends into the joint surface (articular surface), whether the fracture is displaced (fracture fragments have moved), and whether, on the back of the wrist, the bone has crumbled (so-called dorsal comminution). All these factors can suggest a more severe injury and more unstable fracture pattern. Occasionally, fractures are investigated with CT scans, and these are particularly common with intra-articular fractures, to assess any step in the articular surface, which may pre-dispose to osteoarthritis.

 

Non-operative treatment

Only undisplaced simple fractures of the distal radius are treated non-operatively, in a plaster of Paris. Plaster of Paris is usually in place for four to six weeks.

Types of displacement

The following x-rays demonstrate how the wrist can displace.

The left hand image shows the radius collapsing in the line of the black arrow and becoming shortering in the process. In this case, as the ulnar has not been fractured, it remains at it's normal length. This causes the ulnar to impact against the carpal bones shown with the red circle. The right hand image shows that as the radius collapses and shortens it also angulates backwards.

In the next x-ray the radius fracture has healed (red oval) but has shortened. The ulnar can now been seen clearly impacting against the triquetrum bone.

Operative treatment

There is a significant trend towards early operative fixation of distal radial fractures. This is particularly common in unstable fractures, occurring in osteoporotic patients. In the past distal radial fractures were manipulated and placed in a plaster of Paris, and held either by just the plaster of Paris or wire fixation. However, due to the poor quality of bone, the wire was often cut out, and patients were left with a recurrent deformity and significant problems. Over the last five to ten years there has been development of special surgical plates, which allow the fracture to be fixed in an extremely stable configuration, even in the presence of thin, poor quality bone. Having performed this operative fixation, with a scar usually through the front of the wrist, but occasionally on the back, patients are mobilised within the first week of surgery.

Post-operative rehabilitation

Patients who have had surgery using a modern generation plate are often allowed to mobilise within the first week of surgery. Range of movement rapidly recurs over the first four to six weeks, before strengthening exercises.

Return to activities of daily living

A plaster of Paris causes significant functional problems for the first six weeks, and then post-fracture stiffness can again occur for the next six to eight weeks. However, early operative intervention allows for rapid return to activities of daily living, including driving and return to work.

Complications

Distal radial fractures occur into the joint, with a step, and can pre-dispose to osteoarthritis. Distal radial fractures can cause ruptures of the tendons, particularly on the back of a hand. This would cause an inability to fully straighten the fingers. Surgery has its own specific risks. These include infection and hardware problems. However, the more your surgeon performs this type of operation hopefully the lower the specific complication rate becomes.