What is the appropriate management for a patient with a wrist fracture?

Management of Wrist Fractures

Initial Imaging

Standard 3-view radiography (posteroanterior, lateral, and oblique) is the mandatory first-line imaging for all suspected wrist fractures. 1, 2

Acute Fracture Management Algorithm

If Radiographs Show Fracture

Immobilization Strategy:

• Apply a short arm cast for initial stabilization 1, 2
• Immediately initiate active finger motion exercises through complete range of motion to prevent stiffness, which is the most functionally disabling complication 2, 3
• Finger motion does not adversely affect adequately stabilized fractures 2

Follow-up Protocol:

• Obtain repeat radiographs at approximately 3 weeks to monitor alignment 2, 3
• Obtain final radiographs at time of immobilization cessation to confirm healing 2

If Initial Radiographs Are Negative or Equivocal

You have two evidence-based options:

Option 1 (Traditional Approach):

• Place patient in short arm cast and repeat radiographs at 10-14 days 1
• Downside: delays diagnosis and may lead to functional impairment 1

Option 2 (Advanced Imaging - Preferred):

• Order CT without IV contrast as the next study for suspected occult wrist fractures 1
• CT shows intra-articular extension more frequently than radiography and is useful for preoperative planning 1
• CT cannot evaluate ligamentous injuries (unlike MRI) 1

MRI without IV contrast is an alternative if:

• High clinical suspicion persists despite negative radiographs 1
• One study showed MRI changed diagnosis in 55% and management in 66% of patients with unexplained symptoms 1
• However, another study found MRI did not predict need for treatment better than physical exam plus radiography, with no difference in outcomes 1
• MRI's main advantage over CT is detection of concomitant ligament injuries (scapholunate tears), which may affect surgical planning 1

Do NOT order:

• CT with IV contrast (no evidence supports this) 1
• MRI with IV contrast (not indicated in acute trauma) 1
• Ultrasound (47% sensitivity, 61% specificity for scaphoid fractures - inadequate) 1
• Bone scan (not indicated in acute setting) 1

Surgical Indications

Operative fixation is required when:

• Articular surface involvement exceeds one-third 1
• Palmar displacement of distal fragment present 1
• Interfragmentary gap >3 mm 1

Critical Pitfalls to Avoid

The single most important error is failing to prescribe immediate finger motion exercises during immobilization:

• Finger stiffness is extremely difficult to treat after fracture healing 3
• Stiffness results from prolonged immobilization, pain, swelling, or patient apprehension 2
• Implement a home exercise program for finger motion during the entire immobilization period 2

Do not delay advanced imaging if clinical suspicion is high:

• The traditional "cast and wait" approach delays diagnosis and worsens functional outcomes 1
• CT or MRI should be obtained promptly when radiographs are equivocal 1

Special Populations

For patients >50 years with fragility fractures:

• Implement orthogeriatric and multidisciplinary approach 1
• Systematically investigate fracture risk for secondary prevention 1
• Consider anti-osteoporotic treatment, especially in elderly patients with limited mobility 1

For pediatric Salter-Harris type 2 fractures:

• Same principles apply: short arm cast with immediate finger motion exercises 2
• Follow-up radiographs at 3 weeks and at immobilization cessation 2