What is the assessment and treatment for a broken wrist?

Assessment and Treatment of Broken Wrist

Initial Assessment

Begin with standard 4-view radiographs (posteroanterior, lateral, 45° semipronated oblique, and scaphoid view) as the first-line imaging for all suspected wrist fractures. 1

Clinical Evaluation Priorities

• Document mechanism of injury to assess for high-energy trauma patterns that may indicate perilunate fracture-dislocations 2
• Examine for radial-sided tenderness, scaphoid snuffbox pain, and carpal alignment abnormalities on physical examination 1
• Assess finger range of motion immediately as finger stiffness is one of the most functionally disabling complications 3
• Evaluate for median nerve involvement, particularly in high-energy injuries or suspected perilunate dislocations 2

Radiographic Protocol

• Two views are inadequate and miss important pathology; minimum 3-view series is required, with 4-view series (adding scaphoid view) increasing diagnostic yield 1
• Assess for carpal instability patterns: scapholunate diastasis >4 mm, dorsal lunate tilt >10°, or lunotriquetral diastasis with abnormal carpal angles 3

Management Based on Initial Radiographs

When Fracture is Confirmed on X-ray

Determine if operative fixation is indicated based on fracture characteristics:

• Intra-articular involvement >1/3 of articular surface requires operative fixation 3
• Palmar displacement or interfragmentary gap >3 mm indicates need for surgery 3
• Complex articular injuries benefit from CT without IV contrast for preoperative planning using 3D reconstructions 3

For stable fractures managed non-operatively:

• Immobilize appropriately and instruct active finger motion exercises immediately to prevent finger stiffness 3
• Early wrist motion is not routinely necessary after stable fracture fixation 3
• Consider vitamin C supplementation for prevention of disproportionate pain (complex regional pain syndrome) 3

When Initial Radiographs are Negative or Equivocal

Two management pathways exist:

Option 1 (Conservative approach):

• Place patient in short arm cast and repeat radiographs at 10-14 days 3, 1
• Downside: delays diagnosis and may lead to functional impairment 3

Option 2 (Advanced imaging):

• CT without IV contrast to exclude or confirm suspected fractures, particularly useful for carpometacarpal joint fracture-dislocations 3
• MRI without IV contrast if high clinical suspicion persists, though it does not predict need for treatment better than physical examination plus radiography and shows no difference in outcomes compared to radiography alone 3

When Fracture is Present with Suspected Ligament Injury

If conventional radiographs show fracture but carpal malalignment is suspected:

• CT arthrography is the most accurate imaging modality with nearly 100% sensitivity, specificity, and accuracy for scapholunate ligament tears and approximately 100% sensitivity for lunotriquetral ligament tears 3
• CT arthrography detects partial ligament tears and articular cartilage defects more accurately than MR arthrography with greater interobserver agreement 3
• MRI or MR arthrography are alternatives but have lower sensitivity (70% for scapholunate, poor for lunotriquetral tears at 1.5T) 3

Critical Treatment Principles

Immediate Interventions

• Instruct active finger motion exercises at first encounter regardless of treatment method to prevent finger stiffness, which is extremely difficult to treat after fracture healing 3
• Do not use MRI or CT with IV contrast as there is no evidence supporting their use in acute wrist trauma 3
• Avoid ultrasound for fracture detection as it has only 47% sensitivity and 61% specificity for scaphoid fractures 3
• Bone scan is not indicated in acute wrist trauma 3

Special Considerations for Complex Injuries

Perilunate fracture-dislocations require:

• Open reduction and internal fixation for accurate alignment with both dorsal and palmar surgical approaches often indicated 2
• Lunate must be reduced first and stabilized, followed by scaphoid, capitate, and triquetrum reduction with K-wires 2
• Median nerve exploration and release is recommended in most patients along with palmar ligament repair 2

Long-term Management

• Recognize that many patients report persistent pain and functional limitations up to 18 months after wrist fracture 4
• Home exercise programs are comparable to physical therapist-led therapy with small effect sizes for rehabilitation 4
• Screen for osteoporosis in fragility fractures (women ≥40 years, men ≥50 years) as these patients are at higher risk for subsequent hip fracture 5

Common Pitfalls to Avoid

• Do not rely on 2-view radiographs alone as they miss significant pathology 1
• Do not obtain immediate MRI for surgical decision-making as it has little added value for determining which patients require surgery 3
• Do not delay finger motion exercises as finger stiffness is the most functionally disabling complication and extremely difficult to treat later 3
• Do not overlook median nerve injury in high-energy wrist trauma or perilunate dislocations 2