Wrist Fractures

Wrist fractures – A.K.A. a broken wrist – are one of the most common orthopedic injuries treated every year, both in the United States and globally. The most common cause of the break is a fall on an outstretched hand. However, there are many other ways in which a wrist fracture can be produced. 

The Nature & Presentation of Wrist Fractures

Wrist fractures can vary in their nature and presentation. For example:

• The fracture will usually involve the radius bone, which is the most common bone to break in the wrist. However, fractures can also affect the end of the ulna or one of the small carpal bones. 
• When the fracture occurs, there may be tension forces on the bone that pull pieces apart. Alternatively, there may be compressive forces that compress or compact the bone together. 
• In the elderly, osteoporosis may lead to significant compression of the bone or produce multiple fragments (comminution). 
• Additionally, a fracture may not involve the actual wrist joint (extra-articular) or the wrist joint may be disrupted by the fracture (intra-articular).

The Treatment of Wrist Fractures

Although there are common fracture patterns among patients with a broken wrist, each fracture is ultimately unique and needs to be treated accordingly.

In addition to the break(s) associated with the fracture, there is also often injury to the surrounding soft tissues (i.e. the bone covering or periosteum, tendons, ligaments, or nerves) when the fracture occurs. These soft tissue injuries must be recognized and treated in order to prevent "soft tissue disease", which may result in scarring and stiffness. 

Finally, the patient and their health and history must also be considered. Factors such as age, general health, osteoporosis, smoking history, and malnutrition can each affect fracture healing.

The Examination of Wrist Fractures

Careful assessment of the full extent of a fracture and the affected joints or soft tissues is critical to prepare a complete, targeted fracture treatment plan. This may involve:

• taking multiple x-rays or a CT scan to completely evaluate the fracture pattern
• determining whether the fracture is stable or unstable due to the fracture pattern and muscular forces across the wrist
• evaluating for the presence of osteoporosis
• establishing the degree of comminution (number of fracture pieces) involved in the break
• determining whether the fracture is undisplaced and well aligned or displaced with angular or rotational deformity (which will affect healing and function)
• establishing the involvement of the adjacent joints by the fracture (intra-articular or extra-articular)
• considering the age and health of the patient, as well as their functional needs (musician versus heavy laborer)

The Treatment of Wrist Fractures

Conservative Care

In general broad terms, stable, undisplaced, extra-articular fractures of the wrist are usually treated conservatively, i.e. with a protective splint or cast. 

In such cases where osteoporosis is known or suspected, frequent repeated x-rays and evaluation may be necessary to avoid later compression and collapse of the fracture, even in a cast or splint. In these cases, an external fixator or percutaneous pins may be applied to help try and prevent such collapse. 

• An external fixator consists of pins that are placed through the skin into the bone; they are hooked together with clamps and a bar that help hold the bone in the correct configuration.
• Percutaneous pins are stainless steel pins that are driven through the skin and across the fracture to help hold it in place. 

A plaster splint may also be used together with these techniques to help hold the fracture. Usually, occupational therapy will be started right away to reduce swelling (edema control) and start finger motion exercising.

Surgical Care

For severely displaced fractures with an angular or rotational deformity - and for displaced fractures that involve the joint – open reduction and internal fixation surgery (ORIF) may be necessary. 

• In this surgery, an incision is made over the fracture. Pins, screws, or plates are used to reduce the fracture (i.e. correct its alignment).
• The soft tissues and skin are then closed and an additional splint is usually used. 
• In some cases, the internal fixation may allow an early controlled range of motion of the wrist.
• Our preference at Pittsburgh Foot and Hand Center is for rigid internal fixation in order to allow early range of motion when possible. This also helps to avoid "soft tissue disease" and resulting stiffness.
• Once the fracture is healed, the splint or cast may be removed, and a more aggressive range of motion and strengthening exercises are prescribed.

The Risks 

Despite our best efforts and external or internal fixation procedures, delayed healing or further settling of the fracture can occur. Arthritis of the affected joints can develop, as well a stiffness of the wrist and fingers. This is sometimes an unfortunate side effect of the fracture and affected bone, which cannot always be avoided.

Other risks are anesthesia-related problems, wound healing problems, and potential infection. 

Note that sometimes a second surgery may be required to remove the orthopedic hardware or correct some of the residual problems from the fracture.