Treatment of Wrist Bone Fractures
Immediate Management and Immobilization
For non-displaced or minimally displaced distal radius fractures, immobilization for as short as 1 week followed by early mobilization is safe and effective, with no clinically significant difference in outcomes compared to traditional 3-5 weeks of casting. 1
Initial Immobilization Strategy
Apply a short arm cast or splint that never obstructs full finger range of motion - this is the most critical technical point to prevent stiffness, which is the most functionally disabling complication 2, 3
For stable, non-displaced fractures: 1 week of cast immobilization is sufficient, followed by gradual wrist mobilization 1
For traditional approach: 3-5 weeks of immobilization remains acceptable but offers no functional advantage over shorter duration 1
Obtain standard 3-view radiographs (posteroanterior, lateral, oblique) as initial imaging for all suspected wrist fractures 2, 3
Critical Early Mobilization Protocol
Begin active finger motion exercises immediately upon diagnosis - this is non-negotiable and should start within the first postoperative days for surgical cases 4, 2, 3
Finger motion does not adversely affect adequately stabilized fractures and prevents the most common preventable complication: finger stiffness 2, 3
Implement a home exercise program for finger motion during the entire immobilization period 2, 3
Early finger motion is essential to prevent edema and stiffness, which are among the most functionally disabling adverse effects 4
Post-Surgical Management
For Operatively Treated Fractures (Volar Plate Fixation)
Early mobilization (2-3 days post-surgery) produces equivalent or superior outcomes compared to 2 weeks of splinting, with better early functional scores 5, 6
Remove splint at 2-3 days post-operatively and begin immediate active wrist and finger exercises 5, 6
At 6 weeks post-surgery, early mobilization shows statistically better functional outcomes (Modified Mayo Wrist Score 65/100 vs 55/100, p=0.025) 6
No increased risk of secondary dislocation with early mobilization - rates remain equivalent at 1.0-1.5% regardless of immobilization duration 1, 6
Exception: Consider Extended Immobilization When
Perform intraoperative fluoroscopic arthrography to identify hidden scapholunate or lunotriquetral ligament injuries - these occur in 62.5% of distal radius fractures 7
If ligamentous injuries are identified, immobilize with plaster splint for extended period 7
If no ligamentous injury, use elastic bandage only and proceed with early mobilization 7
Physiotherapy Considerations
Formal supervised physiotherapy provides minimal additional benefit over home exercise programs for most patients after the initial instruction session 5
One physiotherapy visit for instruction, followed by home exercises, produces equivalent outcomes to multiple supervised sessions 5
The QuickDASH score difference between supervised therapy and home exercises is not clinically significant at any time point (maximum difference of 7 points at 6 weeks, p=0.05) 5
Cost consideration: Each outpatient physiotherapy session costs approximately £40.70, making home programs substantially more cost-effective without compromising outcomes 8
When to Consider Formal Physiotherapy
Patients with multiple comorbidities, frailty, or inability to perform home exercises independently 4
Presence of significant stiffness at 3-week follow-up despite home exercises 3
Follow-Up Protocol
Obtain radiographic follow-up at 3 weeks and at time of immobilization removal to confirm adequate healing and maintenance of alignment 2, 3
Clinical assessment should focus on finger and wrist range of motion, not just radiographic parameters 3
Avoid overly aggressive physical therapy in the early postoperative period as this may increase risk of fixation failure 4
Secondary Prevention for Patients ≥50 Years
All patients aged 50 and older with wrist fractures require systematic osteoporosis evaluation to prevent subsequent fractures 4
Perform DXA scanning of spine and hip 4
Prescribe calcium 1000-1200 mg/day plus vitamin D 800 IU/day - this is standard for all fragility fractures 4
Implement fall prevention strategies and balance training as long-term rehabilitation 4
Consider orthogeriatric co-management for frail elderly patients with multiple comorbidities 4
Common Pitfalls to Avoid
Never immobilize fingers - splints must allow full finger range of motion throughout treatment 2, 3
Do not continue wrist immobilization indefinitely after fracture stability is achieved - prolonged immobilization causes more harm than the fracture itself 3
Avoid restricting above-chest-level activities until fracture healing is evident on radiographs 4
Do not assume all patients require formal physiotherapy - most achieve equivalent outcomes with home exercises after initial instruction 5