Wrist fractures

Notes

Definition

Fractures of the distal radius are common orthopaedic injuries.

They exhibit a bimodal distribution, seen the young following high-energy injuries and as fragility fractures in the elderly.

Colles’ fracture

A type of distal radius fracture defined as an extra-articular fracture of the metaphyseal region of the radius with dorsal angulation (of the distal fragment) and impaction. 

Wrist fracture

Smith’s fracture

Often described as a reverse Colles’. Refers to a fracture of the distal radius with palmar angulation of the distal fragment.

Anatomy

The wrist is a synovial joint formed by the distal radius, articular disc and proximal carpal bones.

The radiocarpal (wrist) joint is a synovial joint formed by the distal articular surface of the radius and the articular disc with the scaphoid, lunate and triquetrum. It is a biaxial and ellipsoid joint. The ulna does not form part of the radiocarpal joint.

Whilst held in a neutral position only the scaphoid and lunate are in contact with the radius and articular disc. When the wrist is held in adduction the triquetrum comes into contact with the articular disc.

Wrist anatomy

Radial inclination

Radial inclination, measured in the AP view, represents the angle between a line perpendicular to the long axis of the radius at the corner of the lunate fossa and a line running from the corner of the lunate fossa to the tip of the radial styloid. The average is 23 degrees.

Volar tilt

The articular surface exhibits a ‘volar tilt’ of approximately 11 degrees. Measured in the lateral view it represents the angle between a line perpendicular to the long axis of the radius and a line along the articular surface.

Ulnar variance

Ulnar variance, measured in the AP view refers to the distance between two lines drawn perpendicular to the long axis of the radius at the level of distal ulnar articular surface and the sigmoid notch of the radius. Normally it is between +2mm to -2mm of neutral.

Aetiology

Distal radius fractures most commonly result from a fall onto an outstretched hand (FOOSH).

Fractures of the distal radius may be broadly categorised as high-energy fractures (typically young patients, e.g fall from bike or motorcycle) and fragility fractures (typically elderly, fall from standing height).

Colles’ fracture tend to occur with a fall onto a extended wrist. Smith’s fractures tend to occur with a fall onto a flexed wrist.

Note: In a cohort of patients the fracture will be a symptom of an underlying condition, particularly in the elderly. Always ask yourself why the patient fell! In those whose histories do not support a mechanical fall consider cardiac and neurological causes of falls, loss of consciousness or imbalance.

Clinical features

Fractures of the distal radius are acute injuries, patients will present with pain, swelling and reduced function of the affected joint.

Symptoms

  • Pain
  • Reduced range of movement

Signs

  • Boney tenderness
  • Swelling
  • Dorsal angulation of the hand

Investigations & diagnosis

The diagnosis of a wrist fracture may be made clinically and confirmed by a wrist radiograph.

Bedside

  • Observations
  • Urine dip
  • ECG

Bloods

  • FBC
  • U&Es
  • CRP
  • Bone profile
  • Vitamin D
  • Group & save 
  • Clotting screen

Imaging

  • Wrist X-ray (AP and lateral films)
  • CT: allows accurate delineation of the extent of the fracture and any intra-articular involvement.
  • MRI: allows assessment of soft tissue injuries.

Management

The goal of treatment is to restore normal anatomical alignment to encourage healing and preserve functionality.

Conservative

The majority patients presenting with fractures of the distal radius receive their initial management in ED. For those with extra-articular fractures most will attempt a closed reduction and cast immobilisation under local anaesthetic (e.g. haematoma block). The aim is to restore normal anatomical alignment of the distal radius. Patients are then referred to fracture clinic for further review.

Surgical

Surgical fixation is reserved for patients who are likely to have poor functional outcomes from closed reduction and cast immobilisation alone. 

These include fractures that are intra-articular (and displaced), significantly comminuted or show significant radial shortening. Fractures that are unstable in cast with progressive dorsal angulation and loss of radial height should also be considered for operative intervention. 

Operative options include ORIF (normally volar approach with volar plate), external fixation and percutaneous pinning.

Note: Open fractures should be managed as per the BOAST open fracture guideline.

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