Distal Radius and Wrist Fractures (Adult)

1. Clinical Overview

Summary

Distal radius fractures (DRF) are the most common fractures in adults, accounting for approximately 18% of all fractures presenting to emergency departments, with an annual incidence of 195 per 100,000 population. [1] These injuries typically result from a fall onto an outstretched hand (FOOSH mechanism) and exhibit a bimodal age distribution: young adults sustaining high-energy injuries and older adults (particularly postmenopausal women) experiencing low-energy fragility fractures secondary to osteoporosis. [2]

The term "wrist fracture" encompasses a spectrum of injuries including fractures of the distal radius, distal ulna, and carpal bones (most commonly the scaphoid). The distal radius is defined as the portion of the radius within 3 cm of the radiocarpal joint. The clinical presentation, classification, and management vary significantly based on fracture pattern, patient age, functional demands, and bone quality.

Optimal management remains controversial despite extensive research. Recent systematic reviews demonstrate that while operative fixation with volar locking plates has become increasingly popular, functional outcomes between operative and conservative management are comparable in many patient groups, particularly the elderly. [3,4] The key clinical challenge lies in identifying which fractures require surgical intervention versus conservative management, balancing anatomical restoration against surgical risks.

Key Facts

Clinical Pearls

"FOOSH mechanism + wrist deformity = fracture until proven otherwise"
Classic presentation requires radiographic confirmation. Always assess neurovascular status immediately.

"Anatomical snuffbox tenderness = scaphoid fracture until proven otherwise"
Initial radiographs are negative in 15-20% of scaphoid fractures. Immobilize and re-image at 10-14 days or use MRI/CT for early diagnosis. [7]

"Dinner fork deformity = Colles; garden spade deformity = Smith"
Colles fractures have dorsal angulation and displacement; Smith fractures have volar angulation. This distinction affects reduction technique and stability.

"Age > 65 + DRF = assess for osteoporosis"
DRF is a sentinel fracture indicating future hip/vertebral fracture risk (2-4x increased). Initiate osteoporosis assessment and management. [8]

"Acceptable alignment varies by patient age and activity"
Young active patients: anatomical reduction essential. Elderly low-demand: can accept 10-15° dorsal angulation, 2mm radial shortening, 2mm articular step-off. [9]

Why This Matters Clinically

Distal radius fractures represent a significant public health burden with direct treatment costs exceeding £100 million annually in the UK alone. Beyond acute management, these fractures serve as sentinel events indicating underlying osteoporosis and elevated future fracture risk. Approximately 30-40% of displaced fractures treated conservatively will re-displace, necessitating surgical intervention. [5] Furthermore, inadequate treatment leads to long-term complications including post-traumatic arthritis (15-20% of intra-articular fractures), chronic pain, reduced grip strength, and functional limitation. [10] Evidence-based management optimizes outcomes while minimizing unnecessary surgical intervention and associated risks.

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2. Epidemiology

Incidence & Prevalence

A comprehensive Swedish national registry study of 23,394 distal radius fractures in adults demonstrated: [1]

• Overall annual incidence: 195 per 100,000 population
• Female incidence: 279 per 100,000
• Male incidence: 108 per 100,000
• Peak female incidence: Age 70-79 years (500+ per 100,000)
• Peak male incidence: Age 20-29 years (150 per 100,000) and > 80 years (200 per 100,000)

Similar patterns emerge globally, with incidence ranging from 150-280 per 100,000 across North America, Europe, and Australia. [28] The dramatic female predominance after menopause reflects declining estrogen levels and accelerated bone loss, with postmenopausal women experiencing 3-4 times the fracture rate of age-matched men. [29]

Scaphoid fractures account for 2-7% of all fractures and 60-70% of carpal bone fractures, predominantly affecting young males (mean age 25-30 years). [11] In contrast to distal radius fractures, scaphoid injuries show male predominance (4:1) and peak incidence in the second to third decades, correlating with higher sports participation and occupational exposure in young men. [30]

Demographics

Risk Factors

Non-Modifiable:

• Age > 50 years: 5-10x increased risk in postmenopausal women [8]
• Female sex: 3-4x increased risk overall [1]
• Previous fragility fracture: 2-3x increased DRF risk [8]
• Genetic factors: Family history of osteoporosis

Modifiable:

Mechanism of Injury

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3. Aetiology & Pathophysiology

Anatomical Considerations

Distal Radius Anatomy:

• Articular surface: Radiocarpal and distal radioulnar joints (DRUJ)
• Normal alignment parameters:
  • "Radial inclination: 22-23° (range 15-30°)"
  • "Volar tilt: 11-12° (range 0-20°)"
  • "Radial height: 11-12 mm"
  • "Ulnar variance: 0-2 mm (neutral to slightly positive)"

Vulnerable regions:

• Metaphyseal-diaphyseal junction: Transition from cancellous to cortical bone (3 cm proximal to articular surface)
• Scaphoid waist: Watershed vascular supply (dorsal and volar branches of radial artery) [7]

The distal radius transitions from dense cortical bone in the diaphysis to highly trabecular metaphyseal bone distally. This region has inherent mechanical weakness, particularly in osteoporosis where trabecular bone quality deteriorates preferentially. [31] The thin dorsal cortex (2-3 mm) provides minimal resistance to dorsal displacement forces, explaining the high incidence of Colles-pattern fractures with dorsal angulation. [32]

Scaphoid vascularity is critical to healing outcomes. The scaphoid receives 70-80% of its blood supply via dorsal carpal branch vessels entering at the distal pole, with retrograde perfusion to the proximal pole. [33] This explains the significantly higher nonunion rate for proximal pole fractures (30-40%) compared to distal pole fractures (less than 5%), as displaced proximal fractures may completely devascularize the proximal fragment. [7,34]

Fracture Biomechanics

Energy of injury determines pattern:

1. Low-energy (elderly, osteoporotic): Simple metaphyseal fractures, extraarticular
2. Moderate-energy: Intra-articular extension, partial comminution
3. High-energy: Comminuted, intra-articular, associated carpal injuries

FOOSH mechanism (wrist extended > 40°, forearm pronated):

• Force transmission: Through scaphoid → lunate → radius
• Dorsal cortex fails in tension → Colles fracture
• Volar cortex compression → comminution

Reverse FOOSH (wrist flexed):

• Volar cortex fails in tension → Smith fracture
• Dorsal cortex compression

Classification Systems

AO/OTA Classification (Most Comprehensive) [1,14]

Type A: Extra-articular

• A1: Ulnar fracture, radius intact
• A2: Simple radius fracture (impacted, non-impacted)
• A3: Multifragmentary radius fracture

Type B: Partial articular (part of articular surface remains attached to diaphysis)

• B1: Sagittal fracture (radial or intermediate)
• B2: Dorsal rim (Barton)
• B3: Volar rim (reverse Barton, die-punch)

Type C: Complete articular (articular surface separated from diaphysis)

• C1: Simple articular, simple metaphyseal
• C2: Simple articular, complex metaphyseal
• C3: Complex articular, complex metaphyseal

Clinical utility: Predicts stability and guides treatment. Type C fractures require surgical fixation in most cases. [1]

Eponymous Fracture Patterns (Exam Favorite)

Exam Detail: Frykman Classification (Historical): Grades I-VIII based on intra-articular involvement and ulnar styloid fracture. Less commonly used now but may appear in older literature and exam questions. Higher grades (V-VIII) indicate radiocarpal and DRUJ involvement.

Fernandez Classification (Mechanism-based):

1. Type I: Metaphyseal bending fractures
2. Type II: Shearing fractures (Barton, radial styloid)
3. Type III: Compression of articular surface (die-punch)
4. Type IV: Avulsion fractures (radial/ulnar styloid)
5. Type V: Combined injury with soft tissue damage

Reliability: AO classification has moderate inter-observer reliability (κ = 0.50-0.65 for types A/B/C, lower for subtypes). [14]

Scaphoid Fracture Classification

Herbert Classification (most commonly used): [7]

• Type A: Stable acute fractures (A1: tubercle, A2: incomplete waist)
• Type B: Unstable acute fractures (B1: distal oblique, B2: complete waist, B3: proximal pole, B4: trans-scaphoid perilunate fracture-dislocation)
• Type C: Delayed union (> 6 weeks)
• Type D: Nonunion (D1: fibrous, D2: sclerotic)

Clinical significance: Type B fractures require surgical fixation. Proximal pole fractures (B3) have highest nonunion risk (30-40%) due to retrograde blood supply. [7]

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4. Clinical Presentation

Symptoms: The Patient's Story

Acute Presentation (Distal Radius Fracture):

• Pain: Immediate, severe wrist pain (8-10/10), exacerbated by movement
• Deformity: Visible deformity if displaced ("dinner fork" in Colles; "garden spade" in Smith)
• Swelling: Rapid onset within 30-60 minutes
• Functional loss: Unable to use hand/wrist, difficulty gripping
• Neurological symptoms: Paraesthesia in median nerve distribution (30% of cases) [15]
• Mechanism: History of fall, usually onto outstretched hand

Scaphoid Fracture Presentation:

• Pain: Radial-sided wrist pain, often less dramatic than DRF
• Swelling: Minimal initially, may be subtle
• Mechanism: FOOSH with wrist extended and radially deviated
• Delayed presentation: May present days later with persistent pain

Red Flag History:

• High-energy mechanism: Suggests associated injuries (carpal fractures, ligament disruption, forearm fractures)
• Progressive paraesthesia/weakness: Acute carpal tunnel syndrome or compartment syndrome
• Pale, cold hand: Vascular injury (rare but critical)

Physical Examination

Inspection:

• Deformity:
  • Colles: "Dinner fork" (dorsal displacement/angulation, radial deviation)
  • Smith: "Garden spade" (volar displacement)
• Swelling: Circumferential wrist swelling (compare to contralateral)
• Bruising: May be immediate or delayed (48-72 hours)
• Skin integrity: Check for open fracture (Gustilo classification if present)
• Attitude: Hand held in protected position

Palpation:

Neurovascular Examination (CRITICAL):

Special Tests:

Systematic Examination:

• Look: Deformity, swelling, bruising, skin integrity
• Feel: Bony tenderness, crepitus, soft tissue tension
• Move: Document range of motion (if tolerable), but avoid if obvious fracture
• Neurovascular: Always assess and document before and after reduction

Red Flags — Immediate Escalation Required

[!CAUTION] Surgical Emergency (within 2-6 hours):

• Open fracture: Requires urgent debridement, antibiotics, tetanus prophylaxis (Gustilo-Anderson classification)
• Compartment syndrome: Clinical diagnosis (5 P's: Pain out of proportion, Pain on passive stretch, Paraesthesia, Pallor, Pulselessness). Requires urgent fasciotomy.
• Vascular injury: Absent pulses, cool/pale hand. Requires vascular surgery review and possible exploration.

[!WARNING]
Urgent Assessment (within 2-4 hours):

• Acute carpal tunnel syndrome: Progressive median nerve symptoms. May require urgent carpal tunnel decompression.
• Severe displacement with skin tenting: Risk of skin necrosis. Requires urgent reduction.
• Associated carpal dislocation: Perilunate/lunate dislocation requires urgent reduction.

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5. Investigations

First-Line Investigations

1. Plain Radiographs (ESSENTIAL) [17]

Standard views:

• PA (posteroanterior): Assess radial height, inclination, articular congruity, ulnar variance
• Lateral: Assess volar/dorsal tilt, displacement, intra-articular step-off
• Oblique: May help visualize radial styloid, articular surface

Scaphoid-specific views (if scaphoid suspected):

• PA, lateral, oblique, scaphoid view (PA with wrist in ulnar deviation, beam angled 20° proximally)

Key radiographic measurements:

Interpreting radiographs:

• Extra-articular vs intra-articular: Follow articular line on PA/lateral
• Comminution: Dorsal cortical comminution (> 50% dorsal cortex) predicts instability
• Associated injuries: Ulnar styloid (30-60%), scaphoid, DRUJ
• Displacement direction: Dorsal (Colles) vs volar (Smith) on lateral view

2. CT Scan (SELECTIVE) [17]

Indications:

• Complex intra-articular fractures (preoperative planning)
• Suspected scaphoid fracture with negative radiographs (if MRI unavailable)
• Assessment of articular congruity and fragment position
• Die-punch (lunate fossa) fractures
• Delayed/nonunion assessment

Advantages:

• Detailed bony anatomy, 3D reconstruction
• Quantifies articular step-off, gap, fragment size
• Guides fixation strategy

Protocol: Thin-slice (1-2 mm) with multiplanar reconstruction (coronal, sagittal along scaphoid axis)

3. MRI (SELECTIVE) [7]

Indications:

• Suspected scaphoid fracture with negative radiographs (GOLD STANDARD for occult scaphoid fractures)
• Assessment of scaphoid viability (AVN) in nonunion
• Soft tissue injuries (scapholunate ligament, TFCC)
• Unexplained persistent wrist pain post-trauma

Findings:

• Scaphoid fracture: Bone marrow edema (T1 low, T2/STIR high signal)
• Occult DRF: Bone bruising, microtrabecular fractures
• Sensitivity/specificity for scaphoid: 95-100% / 85-90% [7]

Timing: Optimal 3-5 days post-injury (allows marrow edema to develop)

Diagnostic Criteria

Clinical Diagnosis of DRF:

• History of trauma (FOOSH) + wrist pain + tenderness ± deformity + radiographic confirmation

Scaphoid Fracture (Clinical Suspicion):

• Anatomical snuffbox tenderness + scaphoid tubercle tenderness + painful wrist movement
• Manage as fracture if radiographs negative: Immobilize in scaphoid cast, repeat radiographs at 10-14 days OR early MRI/CT [7]

Classification on Imaging:

1. Extra-articular vs intra-articular (lateral view primarily)
2. Simple vs comminuted (fragment count)
3. Displacement (translation, angulation, shortening)
4. Associated injuries (ulnar styloid, scaphoid, DRUJ instability)

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6. Classification & Stability Assessment

Fracture Stability Criteria

Lafontaine Criteria (Predicts Instability) — ≥3 factors = unstable: [5]

1. Dorsal angulation > 20°
2. Dorsal comminution
3. Intra-articular extension
4. Associated ulnar fracture
5. Age > 60 years
6. Radial shortening > 5 mm

Additional instability predictors:

• Metaphyseal comminution > 50% of cortex
• Initial displacement > 1 cm
• High-energy mechanism
• Osteoporosis (T-score < -2.5)

Stable fracture characteristics:

• Non-displaced or minimally displaced (less than 5° angulation, less than 2 mm shortening)
• No/minimal comminution
• Extra-articular
• Intact volar cortex

Clinical implication: Unstable fractures have 30-40% re-displacement rate with conservative management. [5]

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7. Management

Management Algorithm

SUSPECTED WRIST FRACTURE
(FOOSH + wrist pain ± deformity)
           ↓
┌──────────────────────────────────────┐
│   IMMEDIATE ASSESSMENT               │
│   • ABCDE (if polytrauma)            │
│   • Neurovascular examination        │
│   • Document median nerve function   │
│   • Analgesia (paracetamol, NSAIDs)  │
│   • Temporary splint, elevation      │
└──────────────────────────────────────┘
           ↓
┌──────────────────────────────────────┐
│   IMAGING                            │
│   • PA, lateral ± oblique X-rays     │
│   • Scaphoid views if snuffbox tender│
└──────────────────────────────────────┘
           ↓
┌──────────────────────────────────────┐
│   ASSESS FOR EMERGENCIES             │
├──────────────────────────────────────┤
│ OPEN FRACTURE → Antibiotics, tetanus,│
│                 urgent surgery        │
│ COMPARTMENT SYNDROME → Fasciotomy    │
│ VASCULAR INJURY → Vascular surgery   │
│ ACUTE CARPAL TUNNEL → Consider       │
│                       decompression   │
│ NONE → Proceed to treatment          │
└──────────────────────────────────────┘
           ↓
┌──────────────────────────────────────┐
│   CLASSIFY FRACTURE                  │
│   • Extra-articular vs intra-articular│
│   • Displaced vs non-displaced       │
│   • Stable vs unstable (Lafontaine)  │
│   • AO/OTA type                      │
└──────────────────────────────────────┘
           ↓
┌──────────────────────────────────────────┐
│   TREATMENT DECISION                     │
├──────────────────────────────────────────┤
│ NON-DISPLACED/MINIMALLY DISPLACED        │
│ (extra-articular, less than 5° angulation,        │
│  less than 2mm shortening)                        │
│ → Immobilization (below-elbow cast)      │
│ → Review 1 week (check position)         │
│                                          │
│ DISPLACED BUT REDUCIBLE + STABLE         │
│ → Closed reduction + immobilization      │
│ → Review 1-2 weeks (check position)      │
│                                          │
│ DISPLACED + UNSTABLE (≥3 Lafontaine)     │
│ → Consider surgery vs conservative       │
│ → Factors: age, activity, comorbidities │
│                                          │
│ INTRA-ARTICULAR (> 2mm step/gap)          │
│ → ORIF (volar locking plate)             │
│                                          │
│ SPECIFIC PATTERNS                        │
│ • Smith fracture → ORIF (volar plate)    │
│ • Barton → ORIF (buttress plate)         │
│ • Comminuted C3 → ORIF ± bone graft      │
│ • Scaphoid (displaced/proximal) → ORIF   │
└──────────────────────────────────────────┘
           ↓
┌──────────────────────────────────────┐
│   IMMOBILIZATION (if conservative)   │
│   • Below-elbow cast preferred       │
│   • Duration: 4-6 weeks (DRF)        │
│   •          6-12 weeks (scaphoid)   │
│   • Early mobilization if stable ORIF│
└──────────────────────────────────────┘
           ↓
┌──────────────────────────────────────┐
│   FOLLOW-UP                          │
│   • Week 1-2: Check position (X-ray) │
│   • Week 4-6: Assess union (X-ray)   │
│   • Remove cast when healed          │
│   • Physiotherapy for stiffness      │
│   • Osteoporosis assessment (age > 50)│
└──────────────────────────────────────┘

Acute Management (First 2 Hours)

1. Assessment & Analgesia

• ABCDE approach if polytrauma
• Neurovascular examination (document median nerve function)
• Analgesia:
  • Paracetamol 1g PO (or IV if unable to swallow)
  • Ibuprofen 400mg PO (if no contraindications)
  • Morphine 5-10mg IV (titrate to pain) for severe pain
  • Regional anesthesia (hematoma block, Bier's block) for reduction

2. Temporary Immobilization

• Volar slab or Futuro splint (backslab if significant swelling)
• Elevation: Hand above heart level (reduces swelling, pain)
• Ice: If available (20 minutes on, 20 minutes off)

3. Imaging

• Standard wrist radiographs: PA, lateral, oblique
• Scaphoid series if anatomical snuffbox tenderness

4. Emergency Management (if applicable)

Closed Reduction Technique (Displaced DRF)

Indications for reduction (ED/fracture clinic):

• Displaced extra-articular fractures
• Angulation > 10-15° (dorsal or volar)
• Radial shortening > 5 mm
• Unacceptable alignment for conservative management

Anesthesia options:

• Hematoma block: 5-10ml 1% lidocaine into fracture hematoma (most common in ED)
• Bier's block: IV regional anesthesia (requires two operators, monitoring)
• Conscious sedation: Midazolam + fentanyl
• General anesthesia: Theatre setting

Reduction technique (Colles fracture):

1. Anesthesia: Wait 10 minutes for hematoma block to work
2. Assistant: Stabilizes upper arm/elbow
3. Traction: Apply longitudinal traction with wrist in slight extension (disimpaction)
4. Manipulation:
   • Increase dorsal angulation briefly (unlocks fragments)
   • Apply volar and ulnar pressure to distal fragment
   • Flex wrist slightly while maintaining traction
   • Pronate forearm (reduces displacement)
5. Immobilization: Apply well-molded below-elbow cast while maintaining position
   • Wrist in slight flexion (0-10°), ulnar deviation (10°), pronation
   • Mold three-point pressure: volar proximal, dorsal distal, volar distal
6. Check radiographs: Immediate post-reduction PA and lateral
7. Reassess neurovascular status

Smith fracture reduction: Reverse technique (dorsal pressure, wrist extension)

Acceptable post-reduction alignment: [9]

• Young active (less than 60 years): Anatomical alignment preferred
• Elderly low-demand (> 65 years):
  • Dorsal angulation less than 10-15°
  • Radial shortening less than 5 mm
  • Radial inclination > 15°
  • Intra-articular step less than 2 mm (controversial)

These "acceptable" parameters derive from biomechanical studies demonstrating that dorsal angulation beyond 20° significantly increases radiocarpal contact pressures and predicts symptomatic arthritis in active patients. [35] However, tolerance for malalignment increases with age and lower functional demands. Multiple studies confirm that elderly patients (greater than 65 years) with dorsal angulation 10-20° maintain acceptable function and report satisfaction rates exceeding 70%. [3,36] The key clinical judgment is matching anatomical goals to patient functional requirements, avoiding unnecessary surgical intervention in low-demand patients while ensuring optimal outcomes for young, active individuals.

Conservative Management

Indications:

• Non-displaced/minimally displaced stable fractures
• Displaced fractures with acceptable post-reduction alignment
• Elderly, low-demand patients with acceptable malunion parameters
• Medically unfit for surgery

Immobilization:

Below-elbow vs above-elbow: Recent meta-analysis shows no difference in outcomes for most DRF. Below-elbow preferred (comfort, function). [19]

Follow-up protocol:

• Week 1-2: Clinical review + radiographs (assess for re-displacement)
  • "If acceptable: Continue cast"
  • "If unacceptable: Discuss surgical options"
• Week 4-6: Radiographs to assess union
  • "If uniting: Remove cast, physiotherapy"
  • "If delayed union: Continue immobilization 2-4 more weeks"
• Week 10-12: Final review (if needed)

Re-displacement risk: 30-40% of initially reduced unstable fractures re-displace in first 2 weeks. [5]

Surgical Management

Indications for Surgery [3,20]

Absolute indications:

• Open fracture
• Intra-articular fracture with > 2 mm articular step-off or gap
• Irreducible fracture
• Smith fracture (highly unstable)
• Barton fracture (fracture-dislocation)
• Failed conservative management (unacceptable re-displacement)

Relative indications (patient factors considered):

• Unstable fracture pattern (≥3 Lafontaine criteria) in active patient
• Young, high-demand patient
• Bilateral fractures
• Polytrauma patient (facilitates early mobilization)
• Patient preference after informed consent

Controversial: Elderly, low-demand patients with displaced fractures. JAMA meta-analysis 2020 showed no functional difference operative vs conservative at 1 year in patients > 60 years. [3]

Surgical Techniques

1. Volar Locking Plate (MOST COMMON) [21]

Indications:

• Most extra-articular and intra-articular DRF
• Smith fracture (buttresses volar cortex)
• Die-punch fractures (elevate and support articular surface)

Technique:

• Henry approach (between FCR and radial artery)
• Reduce fracture under direct vision or fluoroscopy
• Plate positioned on volar surface (watershed line)
• Proximal screws bicortical, distal screws locking (subchondral support)
• Check pronator quadratus coverage (reduces tendon irritation)

Advantages:

• Strong fixation, allows early mobilization
• Buttresses volar cortex (prevents collapse)
• Lower profile than dorsal plates

Disadvantages/Complications:

• Flexor tendon irritation (2-10%) [21]
• Carpal tunnel syndrome (5-10%)
• Screw penetration (5%) — check lateral fluoroscopy carefully
• Hardware removal rate 5-10%

Post-op protocol:

• Volar slab for comfort 1-2 weeks OR immediate mobilization
• Early active ROM exercises (recent evidence favors early mobilization) [6]

2. Kirschner Wire (K-wire) Fixation

Indications:

• Extra-articular fractures in lower-demand patients
• Adjunct to external fixation
• Resource-limited settings

Technique:

• Percutaneous insertion of 2-3 K-wires (1.6-2.0 mm)
• Kapandji technique (intra-focal leverage) or trans-styloid
• Immobilization in cast 6 weeks
• Wire removal 6 weeks

Advantages:

• Minimally invasive
• Cost-effective
• Useful for elderly with thin soft tissues

Disadvantages:

• Pin site infection (5-10%)
• Wire migration
• Requires prolonged immobilization (6 weeks)
• Less stable than plate fixation

Evidence: DRAFFT trial (2014) showed no functional difference between K-wires and volar locking plates at 1 year in dorsally displaced DRF, but higher complication/re-operation rate with K-wires. [22]

3. External Fixation

Indications:

• Open fractures (temporizing or definitive)
• Severe comminution (especially volar comminution)
• Polytrauma (damage control)
• Severe soft tissue injury

Types:

• Bridging: Spanning radiocarpal joint (ligamentotaxis maintains length)
• Non-bridging: Fixes radius without crossing joint (allows wrist movement)

Technique:

• Pins in radial shaft and 2nd metacarpal (bridging) or distal radius fragments (non-bridging)
• Ligamentotaxis restores length, alignment
• Supplementary K-wires for articular fragments

Disadvantages:

• Pin site infection (10-30%)
• Stiffness (bridging fixators)
• Radial shortening can recur
• Requires 6-8 weeks fixation

Evidence: Meta-analysis shows volar plates superior to external fixation for functional outcomes and complication rates. [23]

4. Dorsal Plate Fixation

Indications (RARE now):

• Dorsal Barton fracture
• Specific fracture patterns with dorsal comminution requiring buttress

Problems:

• High extensor tendon irritation/rupture rates (20-30%)
• Usually replaced by volar plating or fragment-specific fixation

Scaphoid Fracture Surgery [7]

Indications:

• Displaced fractures (> 1 mm displacement or step-off)
• Proximal pole fractures (high nonunion risk)
• Unstable patterns (Herbert Type B)
• Nonunion
• Patient preference (athletes, early return to activity)

Technique:

• Percutaneous screw fixation (volar or dorsal approach, Herbert/Acutrak screw)
• Open reduction if displaced or nonunion (volar approach for waist/distal, dorsal for proximal)
• Bone graft for nonunion (vascularized or non-vascularized)

Outcomes:

• Union rate: 95-98% (acute fractures with screw fixation) [7]
• Return to sport: 6-8 weeks (vs 10-12 weeks conservative)

Dual screw fixation: Emerging technique for unstable patterns (increased rotational stability, reduced nonunion risk). [24]

Special Considerations

Elderly Patients (> 65 years):

• Functional outcomes similar with conservative vs surgical management in low-demand patients [3]
• Higher surgical complication rate in elderly
• Accept more deformity (within limits): 10-15° dorsal angulation, 5mm shortening
• Bone quality affects fixation (may need bone graft/substitute)
• CRITICAL: Initiate osteoporosis treatment (sentinel fracture) [8]

The concept of "physiologic age" is increasingly important. A healthy, active 70-year-old may warrant anatomical reduction and fixation, while a frail 60-year-old with multiple comorbidities may be better served by conservative management. [37] Bone quality assessment through radiographic trabecular scoring or DEXA (if available) helps predict fixation stability and re-displacement risk. [38] In severe osteoporosis (T-score less than -3.0), consider augmentation strategies including calcium phosphate cement, locked plating with wider screw purchase, or dual plating for complex fractures. [39] Secondary fracture prevention is paramount: patients sustaining fragility DRF have 2-4 times increased risk of subsequent hip or vertebral fracture within 5 years. [40]

Young, High-Demand Patients (less than 40 years):

• Anatomical restoration essential (future arthritis risk)
• ORIF preferred for displaced/unstable fractures
• Early mobilization critical (prevent stiffness)

Young patients have decades of wrist use ahead, making anatomical restoration paramount. Biomechanical studies demonstrate that even 2mm articular step-off increases contact stress by 20-30%, accelerating cartilage degeneration. [41] Long-term follow-up (10-20 years) confirms post-traumatic arthritis rates of 40-60% in young patients with residual articular incongruity greater than 2mm, compared to less than 10% with anatomical reduction. [42] High-demand occupations (manual laborers, athletes, musicians) amplify the functional impact of malunion. For these patients, aggressive surgical management including fragment-specific fixation, arthroscopic-assisted reduction, and bone grafting may be warranted to optimize outcomes. [43]

Bilateral Fractures:

• Surgical fixation facilitates independence (at least one side)
• Staged surgery if both require ORIF

Polytrauma:

• Early fixation allows mobilization
• Consider external fixation as temporizing measure

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8. Complications

Immediate (Days to 2 Weeks)

Early (2 Weeks to 3 Months)

1. Loss of Reduction / Re-displacement (30-40% unstable fractures) [5]

Mechanism:

• Inadequate initial reduction
• Unstable fracture pattern (Lafontaine ≥3 criteria)
• Premature mobilization
• Poor cast technique (inadequate molding)

Presentation: Week 1-2 radiographs show progressive angulation, shortening

Management:

• Within 2 weeks: Consider re-manipulation (success lower than primary reduction)
• After 2 weeks: Difficult to re-reduce (early callus); consider surgery vs accept position
• Unacceptable alignment: ORIF recommended

Prevention:

• Identify unstable fractures (Lafontaine criteria)
• Consider primary ORIF for unstable patterns
• Well-molded cast with three-point pressure
• Close radiographic follow-up (week 1-2)

2. Cast Complications

• Cast tightness: Compartment syndrome risk (rare); loosen immediately if pain/swelling
• Pressure sores: 2-5% (bony prominences); check cast padding, inspect skin at removal
• Thermal injury: From cast application (hot water, exothermic reaction); use lukewarm water

3. Delayed Union (Scaphoid > DRF)

Definition: Lack of radiographic union by expected time (6 weeks DRF, 8-12 weeks scaphoid)

Incidence:

• DRF: 5% (uncommon)
• Scaphoid waist: 5-10% [7]

Risk factors: Smoking, diabetes, displacement, inadequate immobilization

Management:

• Continue immobilization 4-6 more weeks
• Consider bone stimulation (pulsed ultrasound, electrical stimulation) — weak evidence
• If persistent nonunion: Surgery (see below)

Late (3 Months to Years)

1. Malunion (10-30% conservatively managed DRF) [25]

Definition: Healed fracture in non-anatomical position

Deformity types:

• Dorsal angulation (most common in Colles): Loss of volar tilt, ± dorsal tilt
• Radial shortening: Positive ulnar variance
• Articular incongruity: Step-off/gap

Symptomatic malunion (20-40% of all malunions):

• Pain: Wrist pain, especially with loading
• Stiffness: Reduced flexion/extension (avg 20-30% loss)
• Reduced grip strength: 10-30% compared to contralateral
• Ulnar-sided pain: If positive ulnar variance (DRUJ arthritis, TFCC tear)
• Median nerve symptoms: Late carpal tunnel from altered carpal alignment

Management:

• Conservative: Analgesia, physiotherapy, activity modification (many tolerate well)
• Surgical (corrective osteotomy): If symptomatic and unacceptable deformity
  • "Indications: Dorsal angulation > 25°, radial shortening > 5mm, young active patient"
  • "Technique: Opening wedge osteotomy + bone graft + volar plate"
  • "Outcomes: 70-80% good/excellent if performed within 1 year [25]"

Prevention:

• Identify unstable fractures early
• Consider primary ORIF
• Close radiographic follow-up

2. Nonunion (Scaphoid >> DRF)

Incidence:

• Scaphoid waist (conservative): 5-12% [7]
• Scaphoid proximal pole: 30-40% [7]
• DRF: less than 1% (very rare)

Presentation: Persistent pain, especially with grip/radial deviation; may be painless initially

Diagnosis:

• Radiographs: Persistent fracture line, sclerosis, cyst formation
• CT: Gold standard (assesses union, AVN, bone stock)

Classification (Herbert D):

• D1: Fibrous nonunion (vascularized)
• D2: Sclerotic nonunion (AVN)

Management:

• Surgery recommended for all symptomatic scaphoid nonunions [7]
  • "Non-vascularized bone graft + screw fixation: For fibrous nonunion with good vascularity"
  • "Vascularized bone graft: For AVN (proximal pole), sclerotic nonunion"
  • "Source: Iliac crest (cancellous), vascularized radial artery pedicle graft"
• Union rate post-surgery: 80-95% [7]
• If untreated: Scaphoid nonunion advanced collapse (SNAC wrist) → arthritis

3. Post-Traumatic Arthritis (5-20% intra-articular DRF) [10]

Risk factors:

• Intra-articular fracture with residual step-off > 2 mm (controversial threshold)
• Articular comminution
• Radiocarpal or DRUJ instability
• Age > 50 years

Presentation: Progressive pain, stiffness, reduced grip strength (typically years post-injury)

Management:

• Conservative: Analgesia (NSAIDs, intra-articular steroid injection), splinting
• Surgical (late salvage):
  • "Proximal row carpectomy: For isolated radiocarpal arthritis"
  • "Partial wrist fusion: Radiolunate fusion"
  • "Total wrist fusion: Severe pan-arthritis (relieves pain, sacrifices motion)"
  • "Wrist denervation: Pain relief without sacrificing motion"

4. Stiffness and Functional Limitation (30-50% DRF) [10]

Expected motion loss (average):

• Flexion/extension: 20-30% compared to contralateral
• Pronation/supination: 10-20%
• Grip strength: 10-30%

Risk factors:

• Prolonged immobilization (> 6 weeks)
• Intra-articular fracture
• Comminution
• Associated soft tissue injury
• Age > 60 years
• Poor compliance with physiotherapy

Management:

• Physiotherapy: Essential (active ROM, strengthening)
• Duration: 3-6 months for maximal recovery
• Prognosis: Most regain 80-90% function by 1 year

5. Complex Regional Pain Syndrome (CRPS) (2-10%) [10]

Presentation:

• Disproportionate pain, allodynia
• Vasomotor changes (color, temperature)
• Sudomotor changes (swelling, sweating)
• Motor/trophic changes (weakness, nail/hair changes)

Diagnosis: Budapest criteria (clinical diagnosis)

Management:

• Early mobilization (prevention)
• Physiotherapy/occupational therapy: Graded exposure, desensitization
• Pharmacological: NSAIDs, neuropathic agents (gabapentin, amitriptyline)
• Interventional: Sympathetic blocks (if refractory)
• Prognosis: Most resolve 6-12 months; 10-20% chronic

6. Tendon Complications (Post-Surgical)

7. Hardware Complications (Post-ORIF)

• Screw prominence/penetration: 5-10% [21]; check intra-op fluoroscopy (skyline view)
• Plate irritation: 5-15%; may require removal once healed (typically 12-18 months)
• Infection: 1-2% (superficial), less than 1% (deep); manage with antibiotics ± washout ± removal

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9. Prognosis & Outcomes

Natural History (Untreated)

Distal Radius Fractures:

• Non-displaced: Generally heal well (union > 95%) but may develop late stiffness
• Displaced: Heal in malunion (virtually 100%), with residual deformity and functional limitation
  • "Symptomatic malunion: 20-40%"
  • "Reduced grip strength: 20-40%"
  • "Wrist stiffness: 30-50% motion loss"

Scaphoid Fractures:

• Non-displaced waist: 90-95% union with conservative management [7]
• Displaced/proximal: 30-70% nonunion risk [7]
• Untreated nonunion: Progression to SNAC wrist arthritis (5-10 years)

Outcomes with Treatment

Conservative Management (DRF)

Union rate: > 95% (including malunion)

Functional outcomes (at 1 year):

• DASH score: Mean 10-20 (0=no disability)
• Grip strength: 70-90% of contralateral
• ROM: 70-90% of contralateral
• Satisfaction: 70-80% satisfied

Re-displacement rate: 30-40% if unstable [5]

Surgical Management (ORIF DRF)

Union rate: > 98%

Functional outcomes (at 1 year): [3,20]

• DASH score: Mean 8-15
• Grip strength: 80-95% of contralateral
• ROM: 80-95% of contralateral
• Satisfaction: 75-85% satisfied

Complication rate: 10-20% (minor), 2-5% (major requiring reoperation) [21]

Operative vs Conservative (Meta-analysis 2020): [3]

• Patients > 60 years: No significant functional difference at 1 year
• Patients less than 60 years: ORIF shows slight advantage in ROM and grip strength (clinically small)
• Unstable fractures: ORIF reduces malunion rate (15% vs 35%)

Scaphoid Outcomes

Conservative (non-displaced):

• Union rate: 90-95%
• Time to union: 8-12 weeks
• Return to activity: 10-12 weeks

Surgical (screw fixation):

• Union rate: 95-98% [7]
• Time to union: 8-12 weeks
• Return to activity: 6-8 weeks
• Complication rate: 5-10% (hardware irritation, nonunion)

The decision between conservative and surgical management for non-displaced scaphoid waist fractures remains debated. While union rates are similar (90-95% conservative vs 95-98% surgical), surgical fixation accelerates return to work and sport by 4-6 weeks. [44] Cost-effectiveness analyses suggest surgery is economically favorable for employed patients due to reduced time off work, but conservative management remains appropriate for elderly or low-demand individuals. [45] Patient preference should be central to decision-making after informed discussion of risks, benefits, and time course.

Prognostic Factors

Factors associated with BETTER outcomes:

Factors associated with WORSE outcomes:

Long-Term Outcomes (5-10 Years)

DRF (treated appropriately):

• Arthritis rate: 5-10% (extra-articular), 15-20% (intra-articular) [10]
• Persistent symptoms: 20-30% report occasional pain/stiffness
• Functional limitation: 10-20% report some limitation in heavy activities
• Quality of life: Most return to pre-injury function

Scaphoid (union achieved):

• Arthritis rate: less than 5% if anatomical union
• Persistent symptoms: 10-15% mild pain with heavy grip
• Functional limitation: Minimal if united

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10. Prevention & Screening

Primary Prevention

Osteoporosis prevention (elderly): [8]

• Calcium supplementation: 1000-1200 mg/day
• Vitamin D: 800-1000 IU/day (target serum 25-OH vitamin D > 50 nmol/L)
• Weight-bearing exercise: Reduces falls, maintains bone density
• Fall prevention: Home hazard assessment, balance training, medication review
• Smoking cessation: Reduces bone loss

Trauma prevention (young adults):

• Sports protective equipment: Wrist guards (snowboarding, skating) reduce DRF risk by 50% [27]
• Workplace safety: Training, ergonomics

Secondary Prevention (Post-Fracture)

Osteoporosis assessment and treatment (ESSENTIAL for all patients > 50 years): [8]

Indications for DEXA scan:

• All patients > 50 years with DRF (fragility fracture)
• Postmenopausal women
• Men > 50 years with risk factors

Treatment thresholds (per NOGG/NICE guidelines):

• T-score < -2.5: Osteoporosis — treat with bisphosphonate
• T-score -1.0 to -2.5: Osteopenia — assess 10-year fracture risk (FRAX), treat if high risk
• Prior fragility fracture: Consider treatment regardless of DEXA (clinical diagnosis)

Pharmacological treatment:

• First-line: Oral bisphosphonate (alendronate 70mg weekly, risedronate 35mg weekly)
• Alternatives: IV bisphosphonate (zoledronic acid 5mg yearly), denosumab, teriparatide (severe)
• Duration: 3-5 years initially, reassess

Efficacy: Bisphosphonates reduce future fracture risk by 40-50% [8]

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11. Evidence & Guidelines

Key Guidelines

1. British Orthopaedic Association / British Society for Surgery of the Hand (BOA/BSSH) — Distal Radius Fracture Management (2018)

Key Recommendations:

• Radiographic assessment essential (PA, lateral views)
• Reduction indicated if: dorsal angulation > 10-15°, radial shortening > 3-5mm, intra-articular step > 2mm
• Acceptable alignment in elderly (> 65 years): dorsal angulation less than 15°, radial shortening less than 5mm
• ORIF indicated for unstable fractures in active patients
• Evidence Level: 1A (high-quality RCTs)

2. European Federation of Societies for Surgery of the Hand (EFSSH) — Acute Scaphoid Fracture Guidelines (2020) [7]

Key Recommendations:

• MRI or CT for suspected scaphoid fracture with negative radiographs (within 3-5 days)
• Non-displaced scaphoid waist fractures: conservative management (6-8 weeks immobilization) OR surgical fixation (patient preference, early return to activity)
• Displaced scaphoid fractures (> 1mm): surgical fixation recommended
• Proximal pole fractures: surgical fixation recommended (high nonunion risk)
• Evidence Level: 1A (guidelines), 1B (treatment recommendations)

3. American Academy of Orthopaedic Surgeons (AAOS) — Distal Radius Fractures (2021)

Key Recommendations:

• Reduction recommended if: > 10° dorsal angulation, > 5mm radial shortening, > 2mm articular step-off (in young/active patients)
• No strong evidence favoring surgery vs conservative in elderly patients with acceptable reduction
• Early mobilization (4-6 weeks) preferable to prolonged immobilization
• Evidence Level: Moderate (based on systematic reviews and RCTs)

Landmark Trials & Meta-Analyses

1. DRAFFT Trial (Costa et al. 2014 — Lancet) [22]

Study: RCT comparing volar locking plate vs K-wire fixation in dorsally displaced DRF (n=461)

Results (at 12 months):

• PRWE score: No significant difference (plate 13.3, K-wire 14.0)
• Complications: Higher in K-wire group (reoperation 6% vs 3%)
• Conclusion: No functional benefit of plates over K-wires, but higher reoperation rate with K-wires

Clinical impact: Supports K-wire fixation as cost-effective alternative in appropriate patients

2. Ochen et al. Meta-Analysis (JAMA Network Open 2020) [3]

Study: Systematic review and meta-analysis of operative vs nonoperative treatment of DRF in adults (n=1,543 patients)

Results:

• Function (DASH): No significant difference at 12 months (WMD -1.4, 95% CI -3.8 to 1.0)
• ROM: Slight improvement with surgery (wrist extension WMD 5.6°, p=0.01)
• Complications: Higher with surgery (RR 4.1, 95% CI 1.4-12.1)
• Subgroup (age > 60): No benefit of surgery

Conclusion: In adults, especially > 60 years, functional outcomes similar with surgery vs conservative management

Clinical impact: Supports selective surgical management based on patient factors, not radiographic appearance alone

3. Gouk et al. Meta-Analysis (J Hand Surg Eur 2018) [23]

Study: Meta-analysis of volar locking plate vs external fixation (n=780 patients, 9 RCTs)

Results:

• DASH score: Significantly better with volar plate (WMD -6.2, pless than 0.001)
• Grip strength: Better with volar plate (WMD 4.6 kg, p=0.02)
• Complications: Lower with volar plate (infection 2% vs 16%, pless than 0.001)

Conclusion: Volar locking plates superior to external fixation

Clinical impact: Volar plating preferred over external fixation for most surgical DRF

4. Clementson et al. Scaphoid Guidelines (EFORT Open Reviews 2020) [7]

Study: Evidence-based guideline for acute scaphoid fracture diagnosis and treatment

Key findings:

• MRI sensitivity 95-100%, specificity 85-90% for occult fractures
• Non-displaced waist fractures: 90% union with conservative management (6-8 weeks)
• Displaced fractures (> 1mm): surgical fixation reduces nonunion from 12% to 2%
• Proximal pole fractures: 30-40% nonunion risk with conservative; recommend surgery

Clinical impact: Standardizes diagnostic approach and treatment algorithms

Evidence Strength Summary

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12. Viva & Exam Preparation

Opening Statement (Viva)

"Distal radius fractures are the most common fractures in adults, with an annual incidence of approximately 195 per 100,000. They exhibit a bimodal age distribution, affecting young adults from high-energy trauma and elderly patients as fragility fractures. The most common mechanism is a fall onto an outstretched hand. Classification systems include the AO/OTA system and eponymous patterns such as Colles, Smith, and Barton fractures. Management depends on fracture stability, patient age, and functional demands, ranging from conservative immobilization to operative fixation with volar locking plates. Key complications include malunion, median nerve injury, and post-traumatic arthritis. These fractures represent sentinel events for osteoporosis, requiring secondary prevention strategies."

Common Viva Questions & Model Answers

Q1: "Describe the key features of a Colles fracture and how you would manage it in a 70-year-old woman."

Model Answer: "A Colles fracture is a distal radius fracture with dorsal displacement and angulation, typically resulting from a fall onto an outstretched hand in an elderly patient. Clinically, it presents with the classic 'dinner fork' deformity.

My assessment would include:

• Neurovascular examination, particularly median nerve function
• Radiographs (PA and lateral) to assess displacement, comminution, and intra-articular involvement
• Classification using AO system and assessment of stability using Lafontaine criteria

In a 70-year-old low-demand patient, my management approach would be:

1. If non-displaced or minimally displaced: Below-elbow cast for 4-6 weeks
2. If displaced: Closed reduction under hematoma block, aiming for acceptable alignment (dorsal angulation less than 10-15°, radial shortening less than 5mm)
3. Post-reduction radiographs and close follow-up at 1-2 weeks to check for re-displacement

If the fracture is unstable with ≥3 Lafontaine criteria, I would discuss surgical options, though recent evidence (JAMA 2020) shows no functional difference between conservative and surgical management in elderly patients at 1 year. I would also initiate osteoporosis assessment as this is a sentinel fragility fracture indicating elevated future fracture risk."

Q2: "What are the indications for operative fixation of a distal radius fracture?"

Model Answer: "Indications for surgery can be divided into absolute and relative.

Absolute indications:

• Open fracture requiring debridement
• Intra-articular fracture with > 2mm articular step-off or gap (though this threshold is debated)
• Irreducible fracture or unstable fracture-dislocation (Barton, Smith)
• Failed conservative management with unacceptable re-displacement

Relative indications (patient factors considered):

• Unstable fracture pattern (≥3 Lafontaine criteria) in an active, high-demand patient
• Young patient requiring anatomical restoration
• Bilateral fractures (affects independence)
• Polytrauma patient (facilitates early mobilization)

The decision should be individualized. Recent meta-analysis evidence shows that in patients over 60 years with low functional demands, conservative management achieves similar functional outcomes to surgery with lower complication rates. However, in young, active patients, anatomical reduction and stable fixation optimize outcomes and reduce long-term arthritis risk."

Q3: "How would you manage a suspected scaphoid fracture with negative initial radiographs?"

Model Answer: "Suspected scaphoid fracture with negative radiographs is a common clinical scenario, as 15-20% of scaphoid fractures are not visible on initial X-rays.

My management would be:

1. Immobilization: Apply a scaphoid cast (below-elbow with thumb interphalangeal joint free) to protect the suspected fracture
2. Early imaging:
   • Preferred: MRI within 3-5 days (sensitivity 95-100%, specificity 85-90%)
   • Alternative: CT if MRI unavailable (sensitivity 85-95%)
3. If MRI/CT confirms fracture: Continue immobilization for 6-8 weeks (waist fracture), longer for proximal pole
4. If MRI/CT negative: Remove cast, reassure patient, early mobilization
5. If imaging unavailable: Traditional approach is to continue immobilization and repeat radiographs at 10-14 days (bone resorption at fracture line makes it visible)

This approach prevents nonunion from inadequate treatment while avoiding unnecessary prolonged immobilization. According to EFORT guidelines 2020, early MRI is the gold standard for occult scaphoid fractures and is cost-effective when considering lost work productivity from unnecessary immobilization."

Q4: "What are the complications of distal radius fractures and how would you prevent them?"

Model Answer: "Complications can be categorized by timing:

Immediate (days to 2 weeks):

• Compartment syndrome (less than 1%): Clinical diagnosis with 5 P's. Prevented by avoiding tight casts and elevation. Treatment is urgent fasciotomy.
• Acute carpal tunnel syndrome (5-10%): Progressive median nerve symptoms. Prevented by gentle reduction and avoiding excessive wrist flexion in cast. May require carpal tunnel release.
• Vascular injury (less than 1%): Assess radial pulse pre- and post-reduction. Requires vascular surgery if persistent ischemia.

Early (2 weeks to 3 months):

• Re-displacement (30-40% of unstable fractures): Prevented by identifying instability (Lafontaine criteria ≥3) and considering primary ORIF, well-molded cast, and close radiographic follow-up.
• Delayed union: More common with scaphoid. Prevented by adequate immobilization, smoking cessation.

Late (3 months to years):

• Malunion (10-30%): Prevented by appropriate reduction and surgical fixation when indicated. Symptomatic malunion may require corrective osteotomy.
• Post-traumatic arthritis (5-20% of intra-articular fractures): Prevented by anatomical reduction of articular surface, though even less than 2mm step-off doesn't guarantee prevention.
• Stiffness (30-50%): Prevented by early mobilization (4-6 weeks immobilization maximum if stable) and physiotherapy.
• CRPS (2-10%): Prevented by early mobilization, adequate analgesia, and physiotherapy.

Scaphoid-specific:

• Nonunion (5-12% conservative, 1-3% surgical): Higher risk with proximal pole fractures (30-40%). Prevented by appropriate immobilization duration and surgical fixation for displaced/proximal fractures."

Common Mistakes (What Fails Candidates)

❌ Failure to assess neurovascular status before AND after reduction

• Always document median nerve function (sensation thumb/index, thenar opposition)
• Check radial pulse, capillary refill

❌ Missing scaphoid fracture in patient with "wrist fracture"

• Always palpate anatomical snuffbox
• Low threshold for scaphoid immobilization/imaging

❌ Inappropriately aggressive surgery in elderly patients

• Know the JAMA 2020 evidence: no functional benefit of surgery in > 60 years low-demand
• Accept reasonable malunion parameters in elderly

❌ Not initiating osteoporosis assessment post-DRF in patients > 50 years

• DRF is a sentinel fracture
• DEXA scan and osteoporosis treatment reduces future fracture risk by 40-50%

❌ Quoting outdated "acceptable reduction" parameters without context

• Acceptable alignment varies by age, activity, bone quality
• Young patients: anatomical; elderly: can accept 10-15° dorsal angulation, 5mm shortening

❌ Confusing classification systems

• Know AO/OTA (A/B/C types)
• Know eponymous patterns (Colles, Smith, Barton) and stability

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13. Patient/Layperson Explanation

What is a Distal Radius or Wrist Fracture?

A wrist fracture means you have broken one of the bones in your wrist area. The most common bone to break is the radius, which is the larger of the two bones in your forearm, just above your wrist. This is called a "distal radius fracture." The word "distal" simply means the end of the bone nearest to your hand.

Another bone that can break is the scaphoid, a small bone in your wrist on the thumb side. Scaphoid fractures are less obvious but need careful treatment because they can be slow to heal.

In simple terms: You've broken a bone near your wrist, usually from falling onto your hand.

Why Does It Matter?

Wrist fractures are very common—they're the most common broken bone in adults. They usually happen when you fall and put your hand out to protect yourself. With the right treatment, most people recover well and regain normal use of their wrist and hand.

However, if not treated properly, the bone can heal in the wrong position (called "malunion"), which can cause long-term pain, stiffness, and difficulty with daily activities like gripping, lifting, or turning a doorknob.

In older adults, a wrist fracture is often a sign of weak bones (osteoporosis), which means you're at higher risk of breaking other bones, like your hip or spine. This is why your doctor may want to check your bone strength and possibly start treatment to prevent future fractures.

How is it Treated?

1. Assessment:

• Your doctor will examine your wrist and hand, checking for nerve function and blood flow
• You'll have an X-ray to confirm the fracture and see how much the bones have moved

2. If the Bones Haven't Moved Much (Non-Displaced Fracture):

• Cast or splint: Your wrist will be put in a cast or splint to keep it still while it heals
• Duration: Usually 4-6 weeks (longer for scaphoid fractures, 6-12 weeks)
• Healing: The bone will heal naturally during this time

3. If the Bones Have Moved (Displaced Fracture):

• Reduction: Your doctor will need to move the bones back into the right position (you'll get pain relief or anesthesia for this)
• Cast: After the bones are back in place, you'll wear a cast for 4-6 weeks
• Follow-up: You'll have repeat X-rays to make sure the bones stay in the right position

4. If Surgery is Needed: Some fractures are too unstable to heal properly in a cast alone. Signs you might need surgery include:

• The bones keep moving out of position despite a cast
• The fracture involves the joint surface
• You're young and need your wrist to work perfectly for your job or hobbies

Surgery involves:

• Metal plate and screws: The most common method is to put a small metal plate on the bone, held in place with screws, to keep everything stable while it heals
• Recovery: You may start moving your wrist earlier than with a cast (1-2 weeks), but full healing still takes 6-12 weeks
• Hardware: The plate and screws usually stay in permanently, but sometimes they're removed after 1-2 years if they cause irritation

What to Expect

Week 1-2:

• Pain: Pain is usually worst in the first few days, then gradually improves
• Swelling: Swelling is normal—keep your hand elevated above your heart level to reduce it
• Follow-up: You'll see your doctor to check the position with another X-ray

Week 4-6:

• Cast removal: If healing well, the cast will be removed
• Stiffness: Your wrist will feel stiff—this is normal after being in a cast
• Physiotherapy: You'll start exercises to regain movement and strength

Month 3-6:

• Gradual improvement: Your wrist will gradually get stronger and more flexible
• Activities: You can return to most normal activities, but heavy lifting may take longer
• Full recovery: Most people regain 80-90% of their strength and movement by 6 months to 1 year

When to Seek Help

See a doctor immediately if:

• You fall and have wrist pain, swelling, or obvious deformity
• You can't move your wrist or fingers properly
• You have numbness or tingling in your hand

Call 999 (emergency) if:

• Your hand becomes pale, cold, or numb after injury (sign of poor blood flow)
• You have severe pain that's getting worse, not better (sign of complications)

After treatment, see your doctor if:

• Your cast becomes too tight (fingers swelling, pain, numbness)
• Your pain suddenly gets much worse
• You develop new numbness or weakness in your hand
• You have concerns about your recovery

Remember: Most wrist fractures heal well with proper treatment. Follow your doctor's advice about immobilization and physiotherapy, and you'll have the best chance of a full recovery.

If you're over 50 and this was a low-energy injury (simple fall), your doctor will likely want to check your bone strength (DEXA scan) and may recommend medication to strengthen your bones and prevent future fractures.

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Last Reviewed: 2026-01-17 | MedVellum Editorial Team

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