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WRIST

Wrist Anatomy

The wrist is a bio-mechanically complex joint allowing the wrist to move in extension (up), flexion (down), radial deviation (towards the thumb), ulnar deviation (towards the small finger) and minimal degrees of rotation. view 

Wrist Contusion

Trauma is the term used to describe injury. Trauma is classified by its severity depending on the amount of force used to cause the injury. view 

Wrist Fractures

Wrist Fractures or breaks in the wrist are the most frequent fractures seen in the emergency room. view 

Distal Ulnar Fractures and Traumatic Injuries

The distal end of the ulna is rarely fractured(broken) in isolation except when direct trauma like a gunshot wound or a direct blow to the ulna occurs when the arm is elevated to protect the face. view 

Scaphoid Fractures

The scaphoid is the most frequently fractured (broken) carpal bone in the wrist. view

Wrist Dislocations / Fracture Dislocation

Dislocations of the wrist are rare injuries frequently associated with high energy trauma like a fall from a height, a motor vehicle collision or a high impact sporting event. view

Wrist Open Wounds

Open wrist wounds indicate the skin is breached, the wound contaminated and exposure with potential injury of deeper structures is a possibility. view

Wrist Amputations

An amputation is the severing of a body part. Amputations are classified as partial and complete and if the amputation was a clean cut, a crushing amputation or an avulsion amputation where the amputated limb is pulled right off of the body. view

Wrist Arthritis

The primary vessels or channels that supply blood to the hand while traveling across the wrist are the Radial and Ulnar Arteries. view

Carpal Tunnel Syndrome

Carpal tunnel syndrome is the most frequent cause of nerve compression in the human body. It is caused by compression of the median nerve at the level of the wrist. view

Ulnar Tunnel Syndrome

Ulnar Tunnel Syndrome is the compression of the ulnar nerve at the level of the wrist. Similar to the median nerve, this nerve can be compressed at more proximal locations and can occur in combination with other nerves. view

Wrist Tendonitis

Tendonitis is swelling or inflammation of the tendon or tendon lining called tenosynovium. Tendons at the wrist are normally confined to tunnels they travel through. view

Stiff Wrist

After injury, patients can develop decrease range of motion as a consequence of swelling, pain, and scar formation occurring with significant adhesions that bind various tissue layers. view

Wrist Infections

Infections about the wrist are diseases caused by micro-organisms that invade tissue and cause destruction with the consequent loss of function. view

Wrist Tumors

The most frequent cause of swelling or masses found at the wrist level is ganglion cysts. More frequently found in women, ganglions are like a little balloon made out of the joint capsule, filled with a clear, colorless, gelatinous fluid that comes from the joint itself. view

WRIST FRACTURES

Pathology

Wrist Fractures, or breaks in the wrist, are the most frequent fractures seen in the emergency room. Distal Radius Fractures with and without a distal ulnar fracture is second only to hip fractures in frequency.

Wrist fractures have a bimodal distribution, with peak ages between 6-10 years and between 60-69 years old, often occurring after a fall at ground level.

Higher energy injuries occur more frequently with a fall from a height, a sports injury or a motor vehicle accident.

Over 50 % of distal radius fractures extend into the joint surface (intra-articular), involving the radio-carpal joint or the radio-ulnar joint.

This type of fracture requires the anatomic restoration of the joint surface.

Fractures not involving the joint surfaces (extra-articular) are frequently unstable, despite an acceptable initial reduction and casting. This is because of the poor bone quality or high level of fragmentation occurring in elderly individuals.

Treatment

Many distal radius fractures, particularly in the elderly, have been undertreated because of the poor results initially achieved with an open reduction and internal fixation (ORIF).

However, with more rigorous scrutiny of the personality of the fracture, the trend is now leaning towards fixing many of the fractures previously treated in a cast.

Nonsurgical Fractures are:

  • Not separated (displaced)
  • Significantly shortened or angulated
  • Able to be reduced to an acceptable position with a high likelihood of maintaining the position

These kinds of fractures can often be treated initially with a splint that includes the elbow, called a sugartong splint. This is followed by a short arm cast 3 weeks later, and early controlled motion exercises when the cast is removed around 6 weeks after injury, if x-rays demonstrate sufficient healing has occurred.

The consultation of a therapist will assist in preventing the wrist and hand from becoming stiff and will guide the therapy protocol until the best level of activity is achieved.

Surgical Fractures are:

  • Separated
  • Significantly shortened
  • Angulated
  • Extend into the joint
  • There are multiple small fragments (comminution)

These findings alone or in combination can result in an unstable fracture which means if the fracture is reduced and casted, the likelihood of holding position until healed is unlikely.

In this instance, surgery is indicated. Different Methods of Fracture Fixation

  • Pins
  • Headless screws
  • External fixation
  • Plates & screws

Recently, distal radius fracture fixation has had improved results due to newer plates and screws that lock to each other, consequently providing an improved hold on the fragments until the fracture heals.

This newer plate and screw systems are placed on the palmar side of the wrist where there is improved padding due to the muscles on this side of the forearm. This causes less plate prominence, often eliminating the need for their removal in the future after the fracture has healed.

The locking plates increase the rigidity of the fixation, which allows earlier motion of the wrist and digits even if poor bone quality exists. In turn, this minimizes the stiffness often associated with these injuries and delivers improved and earlier return of normal function.

Severe fractures often have associated conditions like acute carpal tunnel syndrome (compression of the median nerve due to severe swelling about the wrist) demanding release of the nerve on same surgical setting.

Ligament injures associated with distal radius fractures must also be considered.

Injury to the distal radial ulnar joint as occurs when an ulnar styloid fracture is present.

After fracture fixation, the patient can start immediate active motion of the fingers and wrist to prevent stiffness.

A removable wrist splint is used during the perioperative period to provide psychological confidence for elderly patients concerned about losing their balance.

The patients are evaluated 1 week after surgery for an initial wound check and for the initiation of formal therapy. The patient is given a protective brace that is removable for hygiene and wrist and hand exercises.

It takes up to 3- 4 months to obtain about 75% functionality. It may take a full year to obtain maximal improvement. The timeframe depends on the severity of the fracture, associated injuries and the age of the patient.