When a person sustains a fall, the first reaction is to stretch out his arms to break the fall. This makes the wrist the first line of impact and takes most of the blow. Most injuries are minor sprains, but it important to figure the ones that are not. Some fractures and some ligament tears in the wrist may be dismissed as sprains by the injured or even by the examiner. Pain may persist for weeks and weeks before further evaluation is sought.
The wrist is made up of the far end of two large bones, the radius and the ulna, and several other smaller bones. A broken wrist may refer to any one of them. The most common fractures are those of the radius, ulna, and scaphoid.
Distal Radius Fracture
The radius is the larger of the two bones of the forearm and lies on the thumb side. The distal radius is the end toward the wrist and is a very common site for fractures. Distal radius fractures can happen in the young (commonly called buckle fractures), and in elderly (commonly called Colle’s fractures). When they occur in elderly, especially with minor injuries and falls, they may be a sign of osteoporosis and are considered fragility fractures. Distal radius fractures often occur together with distal ulna fracture.
The break (fracture) can occur in different ways. It is often bent backwards, the pieces may have displaced, and the fracture line may go through the joint. The tip of the broken bone may go through the skin. There may be more than two pieces. All of those findings as well as the health and functional requirements of the patient are considered before a treatment recommendation is offered.
There are many ways to treat distal radius fractures. The first step is to decide whether the pieces are in acceptable alignment. If so, then treatment consists of protecting them from displacing, and close monitoring. To protect the fracture, I may apply a cast or a Velcro splint. You are not supposed to remove either one but you may adjust the Velcro straps to fit as the tissue swelling goes down. I usually start with weekly x-rays to watch for any change in the alignment. If such a change happens, we may have to go to plan B.
If the alignment of the bone is not acceptable, I may offer you to correct the deformity. If the fracture is only a few days old, and if the pieces are adequate for closed reduction (manipulation), I could do it on the spot under local anesthesia. I will then apply a cast and repeat the x-ray to check whether the new alignment is acceptable.
Sometimes, the position of the bone is not permissive for closed reduction, we may agree to do it in the operating room. This is usually the case when the pieces require internal support to stay in place in the form of a pins or plates and screws.
Distal Ulnar Fracture
The scaphoid is one of the small bones in the wrist. It looks like a cashew nut. It is located on the thumb side of the wrist. A scaphoid fracture is usually caused by a fall on an outstretched hand. Scaphoid fractures may not be obvious and may be mistaken for a sprain, even by emergency room providers. One source of confusion is that x-rays may not show the fracture at the time of injury, and it may take two weeks for a fracture line to show on x-rays. When suspected, the wrist should be protected with a splint until further evaluation. When in doubt, A CT scan or an MRI may help visualize the fracture line that does not show x-ray.
Treatment of scaphoid fractures depends on the location of the fracture, whether the two pieces has separated, and on the functional demands of the patient. If the pieces have not shifted or separated at all, immobilization with a cast for a few weeks is a good option. Periodic evaluation with x-ray is important to confirm healing and positioning of the fragments until healing is confirmed.
For patients who cannot tolerate a cast for a prolonged period, which may be 12 or more weeks long, or for whose daily activity can be seriously affected by cast immobilization I may offer the patient to fix it with a screw through a small cut in the skin without disturbing the fracture itself. The screw will then immobilize the fracture on the inside and lower the time needed for immobilization. If the pieces are not well aligned, it may be necessary to reduce them and then fix the fracture with a screw. No matter what treatment option is selected, it is important to monitor for healing as the scaphoid bone is known for being difficult to heal. It may also lose blood supply to one of the fragments, which may turn into a dead bone (avascular necrosis). In both cases, surgery becomes necessary to avoid wrist arthritis in the future. Surgery for these conditions usually include bone grafting, which may or may not be vascularized.