Wrist Fracture

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What is a wrist fracture?

Any break that involves end of the 2 long bones of the forearm (radius and ulna) are considered as wrist fractures. They can be a simple break or more complex involving the articular surface of the joint and areas of ligament attachments.

Causes

A heavy impact on the wrist caused by a simple fall or road traffic accident can lead to most of the body weight transferring to the wrist and result in the fracture.

Symptoms

  • Immediate severe pain in the affected wrist
  • Swelling and deformity of the wrist.

Clinical examination

In presence of deformity, distal radial fracture is very easy to identify. Clinical examination will include assessment of the;

  • Sensation of the hand (displaced fractures can press on the median nerve and lead to carpal tunnel type symptoms such as tingling and numbness in the thumb, index and middle finger
  • Circulation of the hand
  • Tendon injuries
  • Elbow or shoulder fracture (20% of patients with wrist fractures can have missed elbow or shoulder injuries)

Investigations

Plain radiographs are the mainstay of investigations. A CT scan may be required for more complex fractures that involve the joint surface. This provides more detailed information about the fracture and helps with operative planning.

Treatments

Non-operative treatment in Plaster

Un-displaced simple fractures of the wrist can be treated in well molded cast. Displaced fractures which are relocated to a good position under haematoma block (injection of the local anaesthetic to the fracture site) can also be treated in a well applied cast.

Weekly Xrays will be taken for 2 weeks to make sure the fracture does not displace in the cast. The plaster stays in place for 6 weeks. At this point the fracture will be removed and the wrist is allowed to move with the aid of physiotherapist.

Heavy activity should be avoided for 6 weeks following cast removal.

  • Driving can commence after removal of plaster only if the patient is able to have full control over the car and the strength to maneuver the gear and hand break.
  • Return to work depends on the level of activity. Heavy resisted activity and lifting should be avoided for 8 weeks after fracture.
  • Complications include displacement of the fracture in the plaster, pressure ulcers from plaster (patient should ask for change of plaster), finger swellings, CRPS.

 

Operative treatment

If the fracture is found to be displace, unstable, involving the joint surface or if one of the 2 bones has become shorter than the other, surgery is advisable to restore the anatomy for better function.

Surgery involves a general anaesthetic procedure with use of tourniquet (pressure cuff on top of the arm to reduce the bleeding during the procedure) and x-ray machine. Depending on the type of fracture a metal plate and screws are inserted on the back, front or either side of the wrist to hold the broken bone fragments together.

      

Fracture fixation and stability will be checked under x-ray before the soft tissues and the skin is sutured back.

A heavy dressing will be applied to protect the wound for a week.

  • Rehabilitation and after care

After the dressing have been removed at 5-7 days, the wrist is free to be mobilized with the aid of physiotherapist. Strengthening exercises start at 6-8 weeks after surgery.

  • Driving

If the procedure has been performed on the writ wrist, driving can commence about 2 weeks after surgery. If the procedure has been performed on the left wrist, driving can commence about 4 weeks after surgery when the wrist is strong enough to move the gear and hand break in the car.

  • Time off work

Most patients are able to return to work 10-14 days after surgery however manual activity and lifting should be avoided for 8 weeks after surgery.

  • Risks of surgery
    • Infection
    • Injury to median nerve, blood vessels and tendons
    • Scar sensitivity (Scar desensitisation exercises after removal of stitches help to improve scar sensitivity however this can last up to 6 months after surgery)
    • Non-union (failure of the bone to heal, very rare)
    • Delayed union (fracture taking longer than average to heal)
    • Malunion (fracture displacement after surgery, in intra-articular and osteoporotic fractures)
    • Irritation of tendons or tendon rupture from prominent plate/screws
    • Further surgery (in event of a complication)
    • Reduced grip strength
    • CRPS (chronic pain syndrome: A small percentage of patients will develop a severe reaction after hand surgery, with lifelong permanent pain and stiffness which requires extensive physiotherapy and pain medication)

Scar desensitisation exercises

  • Circular motion massages to the scar, from the palm moving towards the wrist using a simple moisturising cream. This must be carried out for 10 minutes, at least 3 times a day.
  • Rubbing the scar on different textured materials to improve skin sensitivity.
  • Submerging the hand under the cold and warm water to improve the temperature sensitivity.