Forearm and Wrist Fractures

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

Fractures of the forearm and wrist are among the most common injuries treated by orthopaedic surgeons. The forearm contains two bones – the radius and the ulna – and a break can occur anywhere along their length or near the wrist. The distal radius fracture (a break of the radius just above the wrist) is the single most frequent fracture, typically caused by a fall onto an outstretched hand.

Types of injury

The forearm and wrist can be broken in several patterns, which influence treatment:

●      Distal radius fracture – the most common, at the wrist end of the radius; may be simple or extend into the wrist joint.

●      Both-bone forearm fracture – both the radius and ulna are broken along the shaft, which in adults usually requires surgery to restore alignment and forearm rotation.

●      Galeazzi and Monteggia injuries – a fracture of one forearm bone combined with a dislocation of the joint at the other end (the wrist or elbow), which need to be recognised and usually require surgery.

●      Isolated ulna fractures and wrist fractures – including injuries to the small carpal bones such as the scaphoid, which have their own healing considerations.

Assessment

After examination, x-rays are used to determine the fracture pattern, whether the bone has moved out of position (displacement), and whether the fracture extends into a joint. This information, together with your age, hand dominance and activity level, guides treatment.

Treatment

Many stable fractures, or those that can be satisfactorily realigned, are treated without surgery in a plaster cast or splint, with regular x-rays to ensure the position is maintained during healing (usually around six weeks). Surgery is recommended when a fracture is unstable, significantly displaced, involves the joint surface, or cannot be held acceptably in a cast. The most common operation for a distal radius fracture is fixation with a volar locking plate and screws, which allows early movement; other patterns are treated with plates, screws or wires as appropriate.

Outcomes and what the evidence shows

The best treatment depends heavily on the individual. In older patients, high-quality evidence shows that while surgical fixation of a displaced distal radius fracture can produce modest improvements in some functional measures and grip strength, the differences are often small and not always clinically meaningful compared with non-operative treatment. A network meta-analysis found that volar plating had the lowest rate of minor complications but one of the higher rates of major complications. Treatment is therefore individualised, weighing the fracture pattern against the patient’s functional demands and general health.

Complications

Most forearm and wrist fractures heal well, but complications can occur with both cast and surgical treatment:

●      Malunion – healing in an imperfect position, which can affect grip, appearance and wrist or forearm rotation and occasionally needs corrective surgery.

●      Stiffness – of the wrist, forearm or fingers, particularly after a period in a cast; hand therapy is important to regain movement.

●      Tendon irritation or rupture – tendons run close to the bone and plates; the extensor pollicis longus tendon to the thumb can occasionally rupture, either from the original fracture or from irritation by a plate.

●      Nerve problems – median nerve compression (carpal tunnel syndrome) can develop, particularly with swelling or a malunited fracture, and may need release.

●      Complex regional pain syndrome (CRPS) – an uncommon but troublesome condition of persistent pain, swelling and stiffness that requires specific hand-therapy management.

●      Delayed or non-union – slow or failed healing, more relevant to certain bones such as the scaphoid.

●      Hardware irritation and infection – prominent plates or screws may need removal, and wound infection can occur after surgery.

Summary

Forearm and wrist fractures vary widely, from simple wrist breaks managed in a cast to complex injuries requiring surgery. Treatment is tailored to the fracture pattern and the individual, and hand therapy is a key part of recovery. Dr Spelman will explain the specific pattern of your injury and the recommended treatment.