Fractures of the Wrist by Mr G J Packer, Orthopaedic Surgeon in Essex, UK.

Full Presentation of Fractures of the Wrist

Fractures of the wrist are very common injuries.   Around one quarter of all patients in a Fracture Clinic will have suffered a fracture of the wrist.

Fractures of the wrist are commonly given names after the Doctors who first described them.  The commonest type is a COLLES’ fracture but you may also hear terms such as SMITH’S and BARTON’S fracture.  These days, Orthopaedic surgeons tend not to use these terms but to classify these fractures according to their prognosis, that is how severe the injury to the bone and wrist joint is.

There are many classifications for fractures of the distal radius.  One of the commonest is that according to FRYCKMANN who is a Swedish Orthopaedic Surgeon who described a fracture classification system based upon the parts of the joint that were involved.  What he says, and this has been borne out by experiments since this time, is that the more parts of the joint surface that are involved, the more likely the fracture was to result in a poor outcome.

The usual cause of a fracture of the wrist is a fall.  The person falling tries to break their fall by putting their hand out to save themselves and in doing so, the wrist is forced backwards (figure one).

Figure one: A fall onto the outstreched hand is the usual cause of fractures of the wrist joint. Click here to view a larger version.
Figure one: A fall onto the outstreched hand is the usual cause of fractures of the wrist joint. Click here to view a larger version.

The break or fracture usually occurs about 2.5cm from the wrist joint at the point where the radius (the largest of the two bones of the forearm) starts to narrow to form the broad and relatively soft (concellous) bone forming the joint to the hard (cortical) bone in the shaft of the radius (figure two).

Figure two: How and why wrist fractures occur. Click here to view a larger version.
Figure two: How and why wrist fractures occur. Click here to view a larger version.

With more severe force the fracture may extend into either or both of the main joints which allow the wrist to move.  These joints are the radio-carpal joint and the distal radio-ulnar joint (figure three).  When fractures involve joints (what is known as an intra-articular fracture) they can cause stiffness of the joint and if the surface of the joint becomes uneven, this may result in arthritis of the joint.  There is another problem associated with wrist fractures which is that there are two bones that make up the wrist joint, the radius and the ulna.  In most people these bones are approximately the same length (figure three).

Figure three: Tracing of a normal wrist seen from the front to show normal features and the site of fracture. Click here to view a larger version.
Figure three: Tracing of a normal wrist seen from the front to show normal features and the site of fracture. Click here to view a larger version.

When a fracture of the wrist occurs the commonest scenario is that the radius will become short when compared to the ulna.  This is because the dorsal comminution (see figure two) results in a space into which the radius can settle back as the fracture heals.  This results in shortening of the radius in comparison to the ulna and the ulna may then effectively become longer so that when the wrist moves it causes pain and restriction of movement.

The commonest form of fracture of the wrist causes the radius to bend away from the palm.  The patient may therefore notice a change in the shape of the wrist which is called the “dinner fork” deformity after its shape.  This is a deformity of the COLLES’ fracture (figure four).

Figure four: Wrist fracture (X-ray) seen from the side view to show "dinner fork" deformity of Colle’s fracture. Click here to view a larger version.
Figure four: Wrist fracture (X-ray) seen from the side view to show "dinner fork" deformity of Colle’s fracture. Click here to view a larger version.

It is usually obvious to the patient following a fall once a fracture of the wrist has occurred, the wrist joint is usually very painful and swollen and it may of course be deformed.  Immediate treatment consists of resting the painful part (for example in a sling).  The use of something cold will help control swelling, ice or frozen peas are suitable but they should always be wrapped in something (e.g. a towel) and NEVER applied directly to the skin.  This is because direct contact with ice may cause skin damage to occur.

Medical advice should be sought immediately and it is important to remember that the patient may require an anaesthetic for treatment of these fractures and it is therefore important to avoid food and drink until a Doctor or other Medical Practitioner has seen the injury so as to avoid a delay in treatment.

Almost always an X-ray (radiograph) of the wrist is required to make an accurate diagnosis of wrist fractures and to decide upon the correct treatment. Figure four shows the typical appearance of a wrist fracture (in this case a COLLES’ fracture). This X-ray shows that the radius has both bent and moved away from the palm.  It is this movement (what Orthopaedic surgeons call angulation and displacement) which causes the dinner fork deformity.

Figure four: Wrist fracture (X-ray) seen from the side view to show "dinner fork" deformity of Colle’s fracture. Click here to view a larger version.
Figure four: Wrist fracture (X-ray) seen from the side view to show "dinner fork" deformity of Colle’s fracture. Click here to view a larger version.

Leaving the fracture in this position (figure five) will almost certainly result in the problems mentioned above, particularly if the radius remains short compared to the ulna. For this reason, this fracture will almost certainly require further treatment.

Figure five: X-ray of Colle’s fracture seen from the front to show that the radius becomes shortened. Click here to view a larger version.
Figure five: X-ray of Colle’s fracture seen from the front to show that the radius becomes shortened. Click here to view a larger version.

There are three parts to the treatment of a fracture of this sort, firstly to reduce the fracture, that is to put the two parts of the fracture back to their original position. Once the fracture is reduced, it needs to be kept in the correct position until the bones have a chance to heal, this on average takes about six weeks. The third part of fracture treatment is to ensure that the soft tissues of the arm are kept mobile until the arm can get back to its original use.

There are many methods of treatment for fractures of the wrist and it is true to say that Orthopaedic surgeons are undecided as which method of treatment is best. The particular method of treatment will depend both upon the preference and experience of the surgeon and will also depend upon the nature of the fracture. Most surgeons will use a variety of methods to treat fractures of the wrist. It is also worth saying that traditionally treatment of these fractures has been guided by the statement of COLLES in his original paper  who said that people with these fractures do well even if the fracture isn’t reduced. This has meant that these fractures have tended to be under treated in the past although most Orthopaedic surgeons now realise that treatment of these fractures is important if later problems are to be avoided.  This is particularly true these days when patients place greater demands upon their wrists and are less willing to accept limitations of movement and/or pain.  Experimental studies which have looked at these fractures have demonstrated that approximately 97% of fractures are of the COLLES’ type i.e. the deformity is away from the palm and about 3% are towards the palm, that is the SMITH’S type of fracture.

Reduction of the fracture may be achieved by manipulation of the fracture, that is pulling on the hand to pull the bones back into place. This is commonly performed in the Anaesthetic Department or Emergency Room and whilst general anaesthesia may be used for this, it is more common to do it by some means of local anaesthetic block or by injection of local anaesthetic into the fracture site (what is known as a haematoma block). Once the fracture has been reduced, it is often maintained by use of a plaster applied to the arm, a so called COLLES’ plaster. Instead of a full plaster, a backslab is often used in the early stages after injury, that is a plaster which as its name suggests consists of a slab of plaster which does not completely encircle the limb and so, although it protects the injured area and maintains the reduction, allows the arm to swell as it is likely to do in the early stages.

If  your Orthopaedic surgeon decides that plaster treatment alone is suitable for your fracture, it is important particularly in the early stages to elevate the limb but more importantly, to get the affected limb mobilized, not just the fingers and thumb but also the elbow and shoulder as these will often give problems in the long term.

If however the treating surgeon feels that plaster treatment will not control the fracture then he or she may decide that operative treatment is appropriate. The options which may be considered include:

1. Fixing the fracture in position with stainless steel wires ("K" wires).
2. Using an external fixator in which pins are drilled into the bone either side of the fracture and connects to a stabilising device outside of the body.
3. Opening the fracture and fixing it in place with screws and plates.  These screws and plates may be made of metals such as stainless steel or titanium or materials which the body is able to absorb (so called reabsorbable plates).
4. Intra-medullary devices.  These are devices which are inserted into the inside of the bone through a small opening in the radius (the main bone of the arm) which are then fixed in place with screws to prevent the fracture from moving.

Whichever method is chosen, because the bone tends to splinter at this site (what Orthopaedic surgeons call comminution), any of the methods mentioned above may be combined with filling the space that becomes apparent when the fracture is reduced i.e. moved back into position, traditionally this was achieved by using bone taken from the pelvis (bone graft) or by sterilised bone from other materials or other sources of bone mineral e.g. coral. These days it is more common to use bone substitutes, these consist of the mineral content of bone which is made into a form which allows it to be injected into the fracture site.

More recently, if internal fixation is used i.e. insertion of plates and screws into bone, they are often what is known as angularly stable i.e. unlike earlier versions of plates, the screws are fixed into the plate (usually this is achieved by a thread in the screw which screws into the plate itself).  This makes the plate and screws what is known as “angularly stable”.  The benefit of this is that it prevents the lining of the joint or articular surface falling back into the space and more importantly, may often these days mean that bone graft is not required.

There are advantages and disadvantages to each of the methods mentioned above, but it is increasingly recognised that it is this splintering of the bone which occurs on the top of the wrist (dorsal comminution) which is the key to preventing the fracture re-displacing (that is returning to its fractured/broken position) whilst the bone heals. The advantages and disadvantages of each method are indicated in the table below:

Advantages and Disadvantages

Method Plaster/brace
Advantages Easy to apply

Operation not required


Movement of the hand may result in loss of position of the fracture especially as swelling goes down

Plaster needs to be kept on for six weeks and so wrist and hand stiffness may result

Plaster cannot control dorsal comminution

Method "K" wires
Advantages Technically simple operation

Because "K" wires are smooth they are not good at preventing loss of fracture position

A plaster is still required and stiffness of the wrist may result

As the pins are often left out of the skin infection is a common complication

Insertion of wires may result in damage to the tendons around the wrist joint

Method External fixation

Fracture is reduced by pulling onto the wrist ligaments (what is knows as ligamentotaxis) without opening up the fracture

Certain types of fixator include hinges which allow the wrist to move (and hence help to prevent stiffness) with the fixator on whilst keeping the fracture in place


Fixators are often bulky and unsightly

The nature of the wrist ligaments means that to keep the fracture in place wires, screws or bone graft may also be needed in addition to the fixator

If the fixator is applied with too much pull (traction) the wrist or hand may become stiff

The pins which attach the fixator to bone may become infected (pin site infection)

Method Bone Grafting

Use of bone which includes the strong outer layer of the bone (the cortex) means that this method is strong enough to hold the fracture in place and prevent loss of position due to dorsal comminution (see above)

Combining this with the softer inner bone (cancellous bone) stimulates the fracture to heal very quickly


Other methods such as K wires or screws or even plates may be needed to hold the graft in place

Bone from the cortex can usually only be obtained from the pelvis, this is the main problem as the site from which the bone is taken may be very painful and result in difficulty in walking for several weeks

Method Internal fixation (use of plates and screws)

The greatest advantages of metal plates and screws is that they are strong enough to fix the fracture in position and this allows the wrist to be mobilized quickly and often a plaster is not required

Since the advent of angularly stable implants which hold the articular surface or lining of the joint in its correct position, there is less chance of the fracture sinking back into the space behind the joint and the need to add other parts to the operation such as using bone graft or bone substitutes (as described above) is less likely unless the fracture is extremely unstable  

There are now several different ways in which the wrist may be plated and these are described below including bioabsorbable plates.


Plating of the wrist is a technically difficult operation and inevitably there is a scar on the wrist

The tendons (leaders) around the wrist joint are close to the site of the fracture and when metal plates are used these tendons may become irritated by the plates (what is known as synovitis) or they may even rupture

The presence of plates around the wrist may result in discomfort for the patient in the long term and therefore another operation may be required to remove the plate itself. 

Method Intra-medullary devices
Advantages The scars are smaller than with traditional open reduction and internal fixation

Intra-medullary devices are most suitable to extra-articular fractures i.e. those where the joint surfaces are not involved and this represents a relatively small proportion of distal radial fractures    

These devices have not been used long enough to demonstrate that they offer advantages over the current methods  

At Southend Hospital we have been using bioabsorbable plates (Figures six and seven) over the last seven years. These plates offer the advantages of metal plates in that they are strong enough to fix the fracture well enough to allow immediate mobilization but unlike metal plates they are broken down by the body after about three months and so will help to avoid the problems with the tendons which occur with metal plates. These plates are combined with bone substitutes. We have now published the results of our use of bioabsorbable plates in a peer-reviewed Journal, the Journal of Hand Surgery, and we have also published other papers which demonstrate the technique in terms of the approach to the wrist which we use.

Figure six: Reunite reabsorbable plate on plastic bone model; note that these plates are not visible on X-ray. Click here to view a larger version.
Figure six: Reunite reabsorbable plate on plastic bone model; note that these plates are not visible on X-ray. Click here to view a larger version.

Figure seven. Reunite plate and Biobon in a fracture of the wrist (The plate is not visible on X-ray but the holes for the screw are). Click here to view a larger version.
Figure seven. Reunite plate and Biobon in a fracture of the wrist (The plate is not visible on X-ray but the holes for the screw are). Click here to view a larger version.

Over the last four or five years it has become more popular to approach the wrist from the volar surface, that is the palmar surface of the wrist.  The advantage of this approach is that it avoids some of the problems associated with having a plate on the back of the wrist.  Since these angularly stable plates have been available, this approach from the palmar side of the wrist has become much more popular.  Whilst this method offers advantages in terms of the fact that there is less chance of tendons being irritated due to the fact the plate is applied to the volar side of the wrist, that is the palmar side where there are far fewer tendons, because the screws which are used have to come through to the dorsal or top side of the wrist there is still the potential for irritation of tendons.  For patients where there is involvement of the joint surfaces it is sometimes difficult to see and reduce (that is put back into place) the joint surfaces from the volar side which limits the use of this approach.

There are now also special plates which can be applied to the specific parts of the wrist which are broken, what is called a column approach.  This means that smaller plates may be applied to specific fragments within the wrist and these can be very useful for particular fracture patterns.

From what has been said above it will be obvious that there is no one best method for the treatment of fractures of the wrist. Each fracture needs to be judged upon its merits and there may be a variety of treatment methods which are available depending upon the type of fracture and the demands placed upon the wrist by hand dominance, occupation or leisure interest. It is also important to realise that each Orthopaedic surgeon will have a method or methods of treatment which they are familiar with and which will work for them.

If you are unlucky enough to suffer a fracture of the wrist, the most important thing in treatment is to find a surgeon who understands and has an interest in wrist fractures and who takes an interest not just in the bones or soft tissues but also in the after care and what your demands upon the wrist are likely to be. You might consider asking your surgeon the following:

1. What arrangements are there for aftercare once the operation has been performed or the plaster removed?
2. If an operation is suggested, who is going to perform it and what is their experience with the method suggested.
3. If an operation is proposed will it allow me to mobilise (move) the wrist more quickly than if I opt for plaster treatment.
4. What can go wrong with this treatment method and what can be done to correct it should this happen.

The commonest problem following fractures of the wrist is mal-union, that is when the radius heals in the wrong position. As indicated above this is usually due to the fact that the broken part of the radius falls back into the hole on the back of the wrist left by the dorsal comminution. This often results in the radius being shorter than the ulna and is often combined with tilting backwards of the wrist. This results in both deformity (the wrist appears misshapen) and pain due to the ulna catching on the bones of the wrist (the carpal bones). If this occurs it is possible to correct this by means of surgery.

There are a number of methods used to achieve this but in general terms they involve either re-breaking the radius and returning it to its original shape or changing the ulna to make it fit the new shape of the radius. Re-breaking the radius (known as an osteotomy) will usually involve the use of a bone graft to hold the bone in position until it heals and this is then supported by either a plate or an external fixator. Since however angularly stable devices have become available the use of bone graft is becoming less common and it is my practice now to try and avoid bone graft as these angularly stable implants are strong enough to allow use of the plate alone without bone grafting.  This is obviously decided at the time of operation.  The alternative to this is to make the ulna shorter by removing a piece of bone and putting a plate on it to hold the ulna in place until such time as it heals or it may be matched to the size of the radius by trimming it to fit (a matched ulna procedure). As can be imagined this is a specialised part of Orthopaedic or Hand surgery and your surgeon may decide to send you to a surgeon who has a specialist interest or experience in this field.

One other important part of wrist fracture surgery is that fractures of the wrist are often associated with injuries to the ligaments of the wrist.  This can be quite difficult to diagnose in the initial stages and either immediately after the fracture or at some time later if there is the suggestion that the ligaments of the wrist are involved, it may be necessary to further investigate this.  There are a variety of methods available to investigate wrist problems further including further X-rays although these do not show soft tissues or MRI and CT scanning.  It is more common these days that wrist surgeons will want to examine the wrist surface itself and a common way to achieve this is by use of wrist arthroscopy when a small device is inserted into the wrist using keyhole surgery to examine the surface of the wrist joint and to assess the nature of any damage to the joint surfaces and to the ligaments or to another structure known as the triangular fibro cartilage complex (TTCC) which has a similar structure to the cartilage of the knee and may be damaged in a similar way.  Wrist arthroscopy is a specialist form of wrist surgery.  It is however becoming a more commonly performed operation these days.  It is traditionally performed using a rigid arthroscope.  However, at Southend Hospital over the last two years we have been pioneering the use of a flexible scope which is much smaller than the current scope (approximately half the size) and to give an idea of the sizes involved, the current scope used is 1.2mm in diameter which is approximately the thickness of a 5 pence piece.  Our initial results with this procedure have been presented at International Meetings including the International Federation of Surgery for the Hand Meeting in Sydney, Australia in March of 2007. The other advantage is that this method can be performed under local anaesthesia if the patient does not wish to have a general anaesthetic.

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This page was last updated on 30/Nov/2009