Fractures of the Distal Radius (Wrist Fractures)

geekymedics.com/fractures-of-the-distal-radius-wrist-fractures/

Hannah Blades

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

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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 Abnormal gait/balance

Advanced age Muscle weakness
Long-term steroid use Poor visual acuity
Low body weight Neurological disease (e.g. Parkinson’s,
Smoking disease, stroke)
Excessive alcohol Alcohol
consumption Polypharmacy
Inactivity

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:

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 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.
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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 2 nd 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

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:
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 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

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 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
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 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, Below elbow cast for 4-6 weeks

undisplaced Repeat x-ray at 1 week to ensure fracture remains
fracture 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 For patients with simple fracture patterns and/or poor co-morbid
(dorsal status:
displacement) 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 Any volar displacement is always unstable and will, therefore,
(volar need surgical fixation (unless surgery is unsuitable due to co-
displacement) 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
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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

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 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]

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 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

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