Wrist Fracture: Causes, Symptoms, and Treatment

Wrist fracture is the most common fracture that occurs in humans. This is because many people try to break falls with their hands, usually as a reflex, and the joint is affected. A wrist fracture is colloquially referred to as the fracture of the end of the radius (one of the forearm bones) that is far from the body and thus close to the wrist.

Epidemiology

With about 20 to 25% of all fractures, the wrist fracture leads to the list of common fracture injuries in humans.

In principle, it can occur at any age. Still, it is more common in young people between 14 and 18 (here mainly due to high-risk behavior involving falls) and older people over 60 (here primarily as a result of osteoporosis).

Causes of the wrist fracture

Usually, the cause of a radius fracture (wrist fracture) is a fall. When you fall, you try to support yourself and thus exert a massive force on the wrist, which it is often unable to withstand – so the fracture occurs.

Usually, this happens when the wrist is extended, the radius fracture is called Colles fracture in this case. The rarer case of a bent wrist in an accident is called a Smith fracture. The reasons for the fall can be very diverse.

In younger people, it is often sports injuries, for example, football, handball, skateboarding, or snowboarding, which lead to unfortunate falls.

In older people, on the other hand, falls are often caused by insecure gait and stumbling. The bones, which are usually already pre-damaged by osteoporosis, have an increased risk of suffering considerable damage even from minor injuries.

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Symptoms

Typically, a wrist fracture is directly associated with pain, which increases with pressure and movement.

Also, swelling of the joint usually develops quite quickly after the accident. A malposition of the wrist is also often found.

This is caused by the fact that the fracture shifts towards the back of the hand and the spoke, resulting in the classic picture of the bayonet position.

Since the mobility is limited due to the pain and swelling, the patient usually carries the hand in a normal relieving position to relieve the joint. If the hand is moved, after all, so-called “crepitations,” a crackling noise, can occur due to bone parts rubbing against each other. If this happens together with a malposition, a wrist fracture can be considered safe. In some cases, there is also a tingling or similar sensation in the area of the fingers, which suggests that the fracture has also irritated or damaged nerves.

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Diagnosis of the wrist fracture

X-ray of the wrist

The diagnosis of a wrist fracture can usually be made solely by taking the patient’s medical history (i.e., interviewing the patient) and the clinical picture, including a physical examination.

If a patient comes to us after a fall with a swollen, painful wrist, which also shows crepitations and the typical malposition, the diagnosis of a wrist fracture is practically assured.

During the physical examination, the mobility, blood circulation, and feeling in the wrist can also be checked.

To confirm the suspected diagnosis or to obtain more precise information (for example, where exactly in the bone the fracture is located or whether parts of the bone have come loose or shifted), the doctor can also request an X-ray. This is usually made in 2 planes, i.e., once from the front and once from the side, to have a good view of all bones of the wrist.

This is especially helpful to be able to decide on an appropriate therapy afterward. More rarely, computer tomography (CT) is used to diagnose a wrist fracture, for example, if the information provided by the X-ray is not accurate enough.

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Wrist fracture therapy

There are several options available for the treatment of a wrist fracture, which are preferred depending on the case.

In principle, a decision is made between conservative (i.e., non-operative) and operative therapies.

Both forms of therapy aim to completely restore the original shape of the joint, which means that the axes and lengths of the bones should be normal again so that the functionality of the wrist is completely restored.

In the case of a simple wrist fracture that is not displaced, the treatment simply consists of putting on a plaster cast, which must usually be worn for six weeks.

By immobilizing the arm, the bone fragments can grow together again correctly. However, it is essential to have regular x-ray checks made to see whether any bone displacement has occurred subsequently so that these can be detected at an early stage and then treated adequately.

If, on the other hand, the wrist fracture is displaced (dislocated), it must be set up (repositioned) before the plaster cast is applied. For this purpose, the fracture site is first anesthetized by injecting a local anesthetic into the fracture gap. The bones are then brought back into the correct position by simultaneous traction of the upper arm and fingers. This procedure should always be performed under X-ray control.

If the dislocation is more serious, but the fracture is still stable, a closed reduction can be performed. This is the insertion of wires to stabilize the fracture during the healing process. This procedure can be performed on an outpatient basis, but a plaster cast must still be worn for six weeks afterward.

In case of an unstable wrist fracture (a fracture is considered unstable if it has at least three of the following criteria: comminuted fracture, the involvement of the joint surface, dislocations, the involvement of the wrist, patient older than 60), open surgery is preferred. In this case, stabilization is achieved with the help of plates that are typically inserted on the flexion side, as they lead to fewer complications here. These plates can remain in the body for the rest of life. Although this type of surgery is more invasive and cannot be performed on an outpatient basis, it has the advantage that patients do not have to wear a cast and can put full weight on their wrist practically immediately.

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Surgery for a wrist fracture

Operative fracture treatment aims to bring the individual fragments into an optimal position so that they can grow together again without consequences. The original length and angle of the wrist bones must be restored.

Depending on the type of spoke fracture, there are different procedures for the surgical treatment of the fracture.

Common to all of them is that the operation is performed under general anesthesia or local anesthesia (regional/plexus anesthesia; only the affected arm is anesthetized) and the surgeon first repositions the broken pieces of bone back into the correct position (manual repositioning) before fixing them in this position afterward. How the spoke fracture is finally fixed depends decisively on the type of wrist book.

If, in addition to the spoke fracture, the stylus process of the spoke is also broken off in the context of the wrist fracture, screws are usually used for fixation to screw the bone fragments together again and stabilize the fracture (so-called screw osteosynthesis). An additional wire may also be inserted to provide even more strength in the fracture.

Here too, a plaster is applied afterward, but this can be removed after about one week so that a mobilising physiotherapy can be started immediately. The screws and wires in this type of hernia treatment are removed under local anesthesia after about four weeks. If the wrist fracture is particularly unstable, a joint surface is involved, or the fracture has shifted again after previous surgical therapy, often only the implantation of a metal plate can provide sufficient fixation (so-called plate osteosynthesis). This plate is usually placed on the flexor side and close to the wrist on the radius to straighten the joint surface, which is usually compressed.

The metal plate lies directly on the fracture gap and is fixed to the left and right of it with screws in the spoke. Thanks to the plating, the wrist fracture is generally stable for exercise so that no plaster has to be put on, and mobilizing physiotherapy can be started immediately. The plate and screw material can also remain in the body so that no further surgery is necessary. The disadvantage here is that the insertion of the plate requires a much larger skin incision than with wire fixation or screw osteosynthesis. Therefore, there is also a higher risk of nerve, vascular, and soft tissue injury.

If there are more than two fragments in a wrist fracture, or if it is even a comminuted fracture, an external fixator may also be the means of choice. In this case, the physician inserts two metal pins into the radius above the wrist and two into the second metacarpal bone during the operation, which are braced from the outside with rods. In this way, all fragments are held in the correct position from the outside. The disadvantage of this method compared to the other methods is the higher risk of infection, as bacteria can easily enter the body from the outside via the metal pins, and careful wound care is therefore necessary. The external fixator is usually removed after about six weeks and then immediately treated with physiotherapy.

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Aftercare

Regardless of whether the wrist fracture had to be treated surgically or was treated conservatively from the start – with or without reduction of the fracture – a plaster cast is usually applied to the forearm for 4-6 weeks (after surgical treatment, the duration of immobilization can also be shorter).

Regular change of plaster and X-ray checks as well as early movement exercises for the thumb and the remaining long fingers, which are not included in the cast #

The elbow and shoulder joint should also be actively mobilized during the immobilization period through specific movement exercises.

Besides, care should always be taken to ensure proper blood circulation and sensitivity, as well as undisturbed movement functions in all five fingers. In the same way, the intactness of the skin and smooth wound healing (e.g., in the case of surgical wounds) must be checked during all plaster changes. Any suture material should be removed after 10-14 days. Following immobilization, outpatient physiotherapeutic treatment is usually indicated to restore full function and load capacity in the affected wrist as quickly as possible.

Forecast

With the right therapy, the wrist fracture has an excellent prognosis. The dreaded permanent malposition of the wrist as a result of a fracture can almost always be prevented if surgery is performed in high-risk cases and if any treatment is accompanied by regular X-ray checks.

Otherwise, a radius fracture is accompanied by a few complications. As after every fracture, the risk of developing arthrosis in the affected joint is increased. In rare cases, it can also lead to a pain syndrome such as Sudeck’s disease.

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Healing of a wrist fracture

A complete fracture of a bone – also called a bone fracture – usually results in the complete severing of the bone structure into two or more fragments. If the bone is only incompletely interrupted, this is called a bone fissure. A wrist fracture – like any fracture of any bone – can heal in two different ways. A distinction is made between direct (primary) and indirect (secondary) fracture healing.

Direct fracture healing always takes place when the periosteum has remained intact (especially in the case of infantile flexural or greenwood fractures) or when the two ends of the fractured bone are in contact, cannot be displaced relative to each other and are well supplied with blood (e.g., after surgical treatment using screws and plates). Starting from the closely adjacent bone ends, newly formed bone cells are deposited in the fracture gap and gradually interlock the fragments. After only three weeks, the broken bone is mostly functional again, and the wrist can be progressively loaded again.

Indirect fracture healing always occurs when the two ends of the fracture are no longer in direct contact with each other and are slightly displaced from each other.

During immobilization with a splint or plaster, bone healing takes place in several phases. After the fracture phase, in which blood leaks from the ends of the beech into the fracture gap, an inflammatory reaction begins.

This leads to the activation of inflammatory cells that migrate into the coagulated blood in the fracture gap and activate the cells located there to form new bone. In the subsequent granulation phase, the coagulated blood is then converted into connective tissue (granulation tissue, soft callus), into which new blood vessels gradually grow. Bone resorbing cells remove broken and poorly supplied with blood at the fracture ends, bone-building cells replace them with new bone substance.

At least 4-6 weeks have passed before this happens, but the broken bone or wrist fracture is now considered to be resilient again. In the following phase of callus hardening, over time, minerals are incorporated into the newly formed bone so that it regains its original strength.

However, the fracture is only completely mineralized after 3-4 months. Over time, however, the newly formed bone substance of the hardened callus undergoes further remodeling (remodeling) until, after 6-24 months, it is finally wholly reoriented in the direction of the primary stress in the bone and corresponds to the original bone.

How long does the healing take?

The duration of complete healing of a wrist fracture depends on the severity of the fracture and the healing process, but also the age of the patient and the type of fracture treatment.

As a rule, surgically treated wrist fractures can be reloaded earlier than those treated conservatively. This is because the fracture ends are brought back into direct contact with each other through the surgical insertion of screws and plates, thus leading to direct bone healing, and the wrist can be subjected to stress again after only 3-4 weeks.

In contrast, wrist fractures treated purely conservatively – with a plaster cast – usually require a healing period of 4-6 weeks before the first mobilization exercises and light loads are applied. A complete healing of the fracture with unrestricted resilience is ultimately said to be achieved after 8-12 weeks.

Prophylaxis

The prevention of a wrist fracture is only possible to a limited extent.

High-risk sports should be avoided if possible.

In some areas, you can learn to fall “properly” without injuring yourself additionally when falling. However, since catching the fall with the hand is often a reflex action, this happens entirely unconsciously and cannot be prevented.

Summary

All in all, it can be said that although the fracture of the wrist is a widespread consequence of an accident, which leads acutely to massive functional impairment and pain, it is generally straightforward to treat due to modern therapy techniques and does not cause any permanent complaints.

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