What is the treatment for a wrist fracture?

Treatment of Wrist Fractures

The initial management of wrist fractures should include radiographic imaging with at least 3 views (posteroanterior, lateral, and oblique) followed by appropriate reduction and immobilization based on fracture characteristics, with surgical intervention reserved for unstable or intra-articular fractures with significant displacement. 1

Diagnosis and Initial Assessment

Imaging

• Initial radiographs: Always indicated as first-line imaging for suspected wrist trauma 1

  • Minimum of 3 views required: posteroanterior (PA), lateral, and 45° semipronated oblique view
  • A fourth projection (semisupinated oblique) may increase diagnostic yield for distal radius fractures 1

• Advanced imaging when initial radiographs are equivocal:

  • CT without IV contrast: Recommended to confirm or exclude suspected wrist fractures 1
    • Particularly useful for evaluating intra-articular extension of distal radius fractures
    • Helpful for preoperative planning for complex articular injuries
  • MRI without IV contrast: Useful when radiographs are normal but clinical suspicion remains high 1
    • Can detect occult fractures and concomitant ligament injuries
    • May change diagnosis in 55% of patients and management in 66% when radiographic findings don't explain symptoms 1

Treatment Algorithm

Non-displaced or Minimally Displaced Fractures

1. Closed reduction and cast immobilization

   • Position of immobilization: Evidence suggests dorsiflexion may provide statistically better range of motion outcomes compared to palmar flexion or neutral position, though the clinical significance is questionable 2
   • Duration: Typically 4-6 weeks (optimal time for pin removal and mobilization remains inconclusive) 1

2. Follow-up radiographs

   • Should be obtained to ensure maintenance of reduction
   • If displacement occurs during follow-up, consider surgical intervention

Displaced Fractures

1. Closed reduction and casting for stable fractures after reduction

   • Consider adjuvant treatment with vitamin C for prevention of disproportionate pain 1
   • Ultrasound and/or ice are options for adjuvant treatment 1

2. Surgical intervention for:

   • Unstable fractures
   • Intra-articular fractures with >2mm step-off (to avoid long-term complications like osteoarthritis) 1
   • Fractures with coronally oriented fracture lines, die-punch depression, or more than three articular fragments 1

Surgical Options

1. External fixation

   • Limit duration of fixation to reduce complications 1
   • Avoid overdistraction of the wrist 1

2. Internal fixation

   • Increasingly used, especially in elderly patients 1
   • Higher cost than non-operative treatment and increased rates of hospitalization 1
   • Goal: restoration of radial length, inclination, and tilt, plus realignment of articular fragments 1

3. Post-surgical rehabilitation

   • Early wrist motion after stable fracture fixation is not necessary 1

Special Considerations

Elderly Patients

• Recovery of grip strength and mobility is slower in patients over 60 years 3
• Wrist fractures in patients over 50 years should prompt investigation for osteoporosis 1, 4
• Systematic investigation of fracture risk is important for prevention of subsequent fractures 1

Complications to Monitor

• Stiffness (most common complication in high-energy injuries) 5
• Median nerve compression (especially in high-energy injuries) 5
• Secondary displacement
• Malunion: Long-term studies show considerable residual displacement can remain after non-surgical treatment (dorsal angulation 13°-18°, radial shortening 2-3mm) 3

Pitfalls to Avoid

1. Inadequate imaging: Using only 2 views is not adequate for detecting wrist fractures 1
2. Missed diagnosis: Distal radius and scaphoid fractures may be radiographically occult initially 1
3. Delayed treatment: In cases of vascular compromise, emergent reduction is necessary 1
4. Underestimating long-term impact: Even non-surgically treated distal radius fractures can lead to hand/wrist impairment a decade after trauma 3
5. Neglecting osteoporosis screening: Wrist fractures increase the risk of subsequent fractures, especially in the first 7 years 4

By following this structured approach to diagnosis and treatment, optimal outcomes can be achieved for patients with wrist fractures, minimizing morbidity and preserving function.