Fractures of the Distal Radius (Wrist Fractures)

Support us by buying our PDF booklet which contains over 100 OSCE checklists


Introduction

Fractures of the distal radius are common. They represent about a quarter of all fractures of limbs1 and usually present to general practice or the emergency department (ED). Many distal radius fractures will be seen and treated in the ED and then discharged for specialist follow up. Patients may attend with displaced fractures or neurovascular compromise, warranting urgent treatment; therefore appropriate initial assessment and management are essential.2 Orthopaedic surgeons will decide if surgery is required, depending on the direction of any displacement, the fracture pattern and the co-morbid status of the patient.


Types of Wrist Fractures

There are 3 key fractures of the distal radius to be aware of:

  • Colles’ fracture (most common) – an extra-articular fracture with dorsal displacement (“dinner fork deformity”)
  • Smith’s fracture – an extra-articular fracture with volar displacement
  • Barton’s fracture – an intra-articular fracture with associated dislocation of the radiocarpal joint

Causes and Risk Factors

Fractures of the distal radius are most common in two main groups of patients:3

  • Young patients who participate in sport or are involved in trauma
  • Elderly patients with osteoporosis and low energy trauma

The most common mechanism of injury is a fall onto an outstretched hand (FOOSH). If atraumatic, a pathological fracture should be suspected, and further workup should investigate for malignancy (e.g. blood tests including FBC, serum calcium, alkaline phosphatase and an isotope bone scan.)

Risk factors can, therefore, be thought of in terms of those which increase the risk of osteoporosis and those which increase the risk of falling (Table 1).

Table 1. An overview of risk factors for fractures of the distal radius

Risk factors for osteoporosis Risk factors for falling
  • Post-menopausal women
  • Advanced age
  • Long-term steroid use
  • Low body weight
  • Smoking
  • Excessive alcohol consumption
  • Inactivity
  • Abnormal gait/balance
  • Muscle weakness
  • Poor visual acuity
  • Neurological disease (e.g. Parkinson’s, disease, stroke)
  • Alcohol
  • Polypharmacy

History and Examination

A thorough history and examination of the injury should be performed for patients who present with a suspected distal radius fracture. The mechanism of injury and clinical findings, including skin integrity, assessment of circulation and sensation, should be documented at presentation.2

History

Presenting Complaint

Patients with a suspected fracture of their distal radius will primarily complain of pain, swelling and an inability to use the affected wrist.

History of Presenting Complaint

The events surrounding the fall are very important when taking a history from these patients. You should try and establish:

  • Whether it was a mechanical fall (they tripped or slipped) or if there was a syncopal/blackout episode (suggesting an underlying medical cause)
  • If they suffered a head injury or loss of consciousness
  • If they have had previous falls

The most common associated findings for fractures of the distal radius include:

  • Sudden and severe pain around the wrist
  • Hearing a cracking noise
  • Difficulty or an inability to use the wrist

Although less common, it is important to ask about symptoms which may suggest neurovascular injury including the 3P’s.

  • Paraesthesia – Tingling, pins and needles or loss of sensation in the hand (suggesting nerve injury)
  • Pain – Disproportionate to the injury (suggesting compartment syndrome)
  • Pallor – Paleness or duskiness of the hand (suggesting vascular injury)

Past Medical History

  • Previous fractures, especially if concerned it may be a fragility or pathological fracture
  • Medical co-morbidities (will inform the decision for surgical management)
  • Previous operations

Medications and Allergies

It is important to ask about any medications which may give you a clue as to the cause of the fracture (e.g. antihypertensives causing postural hypotension, bisphosphonates for osteoporosis), as well as medications for the patient’s co-morbidities.

Family History

A family history of fragility fractures, especially parental hip fractures, is a risk factor for osteoporosis.

Social History

  • Smoking – known to delay bone healing and is a risk factor for osteoporosis
  • Alcohol intake – a risk factor for falling and osteoporosis
  • Occupation – this may be a factor in deciding if surgical management is required (e.g. a retired patient versus a world-class violin player)

Ideas, Concerns, Expectations (ICE)

It is important to establish what the patient thinks has happened to them, whether they have any concerns and what treatment they are expecting. This can help to manage patient expectations and educate patients on what care they are likely to receive.

Examination

A thorough orthopaedic examination of the hand and wrist, along with a neurological examination of the upper limb should be performed, in order to assess functional capacity and neurovascular deficits. See the Geeky Medics guide on hand and wrist examination here.

Most common findings:

  • Obvious deformity of the wrist
  • Swelling and/or bruising at the wrist
  • Tenderness on palpation of the distal radius

Less common findings:

  • Open wound and/or the bone protruding through the skin (open fractures require different management due to the risk of infection)
  • Loss of sensation or movement distal to the fracture (suggesting nerve injury)
  • Pulselessness and/or pallor of the hand (suggesting vascular compromise)

A thorough neurological examination of the upper limb should be conducted as well. Please see the Geeky Medics guide here. However, specifically for suspected distal radius fractures, the neurological examination should also include assessment of the median, ulnar and radial nerves (Figure 1).

Median nerve

  • Motor – grip strength and OK sign
  • Sensory – tip of the 2nd digit (digital cutaneous branch) and thenar eminence (palmar cutaneous branch)

Ulnar nerve

  • Motor – finger abduction/adduction
  • Sensory – the tip of the little finger

Radial nerve

  • Motor – finger and wrist extension
  • Sensory – dorsal 1st webspace
Dermatomes of the hand
Figure 1. The sensory distribution in the hand of the radial, ulnar and median nerves. 4

Differential Diagnosis

The clinical presentation of fractures of the distal radius is similar to several other fractures of the wrist:

  • Scaphoid fracture – commonly caused by a FOOSH as well. However, the main complaint is typically localised pain and tenderness over the anatomical snuffbox (triangular depression over lateral, dorsal hand).
  • Ulnar styloid fracture – fracture of the ulnar styloid may be associated with distal radius fractures. It typically presents with local tenderness over the ulnar styloid.
  • Fracture of the radial shaft – less common than distal radius fractures. Range of motion of the wrist is typically pain-free .5

Investigations

Bedside Investigations

  • Electrocardiogram (ECG) – if there is suspicion of cardiac involvement in the fall
  • Urine dipstick – if there is suspicion of a UTI causing confusion as a reason for the fall
  • Blood sugar monitoring (BM) – if there is suspicion of a hypoglycaemic episode as a reason for the fall

Laboratory Investigations

  • Baseline blood tests (FBC, U&E, LFTs)
  • Bone profile if suspecting osteoporosis (Vitamin D, serum calcium, ALP)

Imaging 6

  • X-rays (AP and lateral views of the wrist)
  • CT may be required if you suspect intra-articular involvement or for pre-operative planning
  • MRI may be required if you suspect soft tissue injuries
colles fracture
Figure 2. X-ray showing a Colle’s fracture (dorsal displacement)7

Special Circumstances

A wrist fracture is the most common fragility fracture in perimenopausal and young postmenopausal women.1 If the fracture is thought to be a fragility fracture due to osteoporosis, the FRAX® risk assessment tool8 should be used to assess whether osteoporosis treatment should be started (bisphosphonates) or if a DEXA scan (dual-energy x-ray absorptiometry) is indicated.


Management

According to the British Orthopaedic Associations’ standards for practice, the aim of treatment is to optimise functional recovery rather than achieving specific radiological parameters.9 Management of distal radius fractures can be structured according to their immediate management (usually done in the ED) followed by the definitive management (usually decided upon in fracture clinic).

Immediate Management9

Regardless of the specific type of fracture, the initial management remains the same:

  • ABCDE assessment
  • Analgesia
  • Assessment of skin integrity and neurovascular status (capillary refill time, movements and sensations in the hand)
  • Removal of any rings or jewellery on the affected hand
  • Reduction of displaced fractures under intravenous regional anaesthesia (IVRA) or haematoma block, followed by repeat x-ray
  • Immediate immobilisation (e.g. back slab cast)
  • Elevation

*All patients should be referred to the fracture clinic service and assessed within 72 hours.9

Definitive Management6,9

Table 2. Overview of definitive management strategies for types of wrist fractures

Type of Fracture Definitive Management
Stable, undisplaced fracture
  • Below elbow cast for 4-6 weeks
  • Repeat x-ray at 1 week to ensure fracture remains undisplaced

If patients are unable to tolerate cast, or in those with an incomplete fracture, a forearm splint holding the wrist in neutral can be used.

Colle’s fracture (dorsal displacement) For patients with simple fracture patterns and/or poor co-morbid status:

  • Non-operative treatment = manipulation under anaesthetic (MUA) and below elbow cast for 4-6 weeks

For patients with complex fracture patterns and good co-morbid status:

  • Closed reduction and K-wiring
  • If cannot be reduced, open reduction & internal fixation (ORIF) with plate and screws
Smith’s fracture (volar displacement) Any volar displacement is always unstable and will, therefore, need surgical fixation (unless surgery is unsuitable due to co-morbidities):

  • ORIF with plate and screws
Barton’s fracture The chance of successful reduction is low, therefore ORIF is usually required.

  • If it is a volar Barton’s fracture, these (like Smith’s) are always unstable and require surgical fixation

Follow-Up

All patients should receive information regarding expected functional recovery and rehabilitation, including advice about the return to normal activities such as work, education and driving. Patients should be able to self-refer to the fracture service if progress is not as anticipated and hospitals should provide this mechanism.9

Rehabilitation6

Whether the patient is being treated in a cast or splint or is awaiting surgical fixation, it is critical to have them begin rehabilitation of the hand at the earliest opportunity.

  • Elevation of the limb
  • Early finger motion
  • Occupational therapy programme (graduated range of motion programme) as fracture unites

Cast Care Advice

Patients should be educated on cast care, as well as safety-netted about when to return to the ED. Most casts are removed after 4-6 weeks.

Cast Care

  • Keep plaster dry
  • Do not scratch underneath the plaster
  • Keep elevated for the first week to help reduce the swelling
  • Keep fingers moving to improve circulation and reduce stiffness

Patients should be advised to return to the ED if they suffer from any of the following ‘red flags’:

  • Increasing pain in the area
  • Numbness in the fingers
  • Increasing swelling in the fingers
  • Change of colour in the fingers
  • The plaster becomes wet or damaged

Complications

Surgical Complications

  • Infection
  • Bleeding
  • Neurovascular injury
  • Pain

Specific Complications

  • Malunion (most common complication)
  • Stiffness/decreased range of movement
  • Acute median and/or ulnar nerve damage (~10% of low energy fractures and 30% of high energy fractures)3
  • Osteoarthritis
  • Extensor pollicis longus rupture – patient will be unable to lift their thumb off the table (3-5%)10
  • Non-union
  • Sensitive scar
  • Chronic regional pain syndrome

Key Take-Home Points

  • There are 3 key types of wrist fractures; Colle’s fractures, Smith’s fractures and Barton’s fractures.
  • Colles’ fractures are the most common type of wrist fracture (~15% of the population).11
  • Elderly patients with osteoporosis who FOOSH are likely to suffer fractures of the distal radius.
  • The most common clinical findings are pain, swelling and deformity of the wrist.
  • Neurovascular status should be checked distally to any fracture.
  • Immediate management involves administering analgesia, reducing displaced fractures and immobilisation of the wrist.
  • Definitive management depends on the direction of any displacement of the fracture. Volar displaced fractures always require surgical fixation.

References

  1. Patient.info. Wrist Fractures. Last edited in 2016. [LINK]
  2. British Society for Surgery of the Hand (BSSH). Management of distal radius fractures. Last edited in 2020.[LINK]
  3. Leah Ahn, Mark Vitale, Orrin Franko. Distal Radius Fractures. Last updated in 2020. [LINK]
  4. Geeky Medics. Created in March 2020.
  5. Derek Dombroski, Christian Veillette. Radial shaft fractures. Last updated in 2008. [LINK]
  6. BMJ Best Practice. Wrist fractures. [LINK]
  7. Lucien Monfils. X-ray of Colle’s fracture. [CC BY-SA] [Link]
  8. Centre for Metabolic Bone Diseases, University of Sheffield. FRAX Risk Assessment Tool. [LINK]
  9. British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs). Published in 2017. The management of distal radial fractures. [LINK]
  10. Kevin C. Chung, Alexandra L. Mathews. Management of complications of distal radius fractures. Published in 2015. [LINK]
  11. WG Blakeney. Stabilisation and treatment of Colle’s fracture in elderly patients. Published in 2010. [LINK]

Reviewer

Miss Nicola MacKay

Trauma and Orthopaedics Registrar


Editor

Hannah Thomas


Print Friendly, PDF & Email