By Carmella Fernandez MD, MBA
Fractures of the wrist are one of the most common injuries treated in the emergency department and by orthopedic surgeons.
We typically see wrist fractures in one of two settings and in a bimodal age distribution. Younger patients with normal bone density, typically sustain high energy injuries such as a fall off of a ladder, where as an older individual can sustain a fracture from a low energy injury such as a fall while playing tennis or pickleball. The difference between the two are very important as a low energy injury typically indicates that the bone was not strong enough to withstand the impact. This can indicate a more serious underlying bone deficiency such as osteoporosis. The lifetime risk of sustaining an osteoporotic fracture is 40% in women and 30% in men. Quite often an individual has never had a bone density test, or was told they had a normal bone density at the time of presentation to an orthopedic surgeon.
Below is a list of the most common questions I receive from my patients’ at the time of their initial evaluation for a wrist fracture.
1. I went to the ER and was told I have a wrist fracture? What bones are involved in a wrist fracture?
There are two bones in the forearm that end at the level of the wrist. The larger of these two is the distal end of the radius and the smaller is the ulna. The radius carries approximately 80% of the axial load to the joint surface when one extends their wrist such as when performing a push up. Therefore, when medical providers refer to a “wrist fracture” , they are typically speaking about a break of the distal radius. However, quite often there is a concurrent fracture of the smaller ulna as well in the setting of a distal radius fracture.
2. How quickly should I see an orthopedic upper extremity specialist after my injury?
You should ideally have an evaluation within one week of the date of injury. If by chance surgical intervention is indicated for your fracture it does become more difficult as the time passes and the bones begin to healed in a poor position.
3. What should I do while I wait for my specialist appointment?
The most important thing you can do is refrain from any lifting, pulling, or pushing activities as this will increase your discomfort and can allow the bones to shift into a position that my require future surgical intervention. In addition, if there was no injury to your fingers, elbow, or shoulder you will want to move these joints to prevent stiffness which may require extensive occupational therapy to improve your results. I always tell my patients that their goal should be to make a full fist and have full extension of their fingers within a few days of visiting with me.
4. I was told my wrist is “shattered”, does that mean I need surgery?
No, it does not. There are certain radiographic criteria that are utilized to help decide if surgical intervention will improve someone’s ultimate functional outcome. In addition, to these criteria I also take in mind the activity level of my patients’ in conjunction with their concurrent medical conditions. I always tell my patients’ that I don’t just treat an X-ray, I treat them as a whole individual, and the X-ray is only a component of this decision tree. I enjoy reviewing the X-ray findings and helping my patients’ come to a decision regarding their treatment plan.
5. If I don’t have surgery, what are my other options?
Conservative treatment options for a wrist fracture including casting, splinting, or a combination of the two. I typically following my patients weekly for three weeks following initiation of conservative treatment to assure there is no change in alignment of the fracture. If the bones shift during the first three weeks, then surgical intervention to improve the alignment can be performed prior to healing of the fracture. One can expect to be immobilized in a cast and/or splint for a total of six weeks prior to initiating wrist range of motion. Sometimes at the end of the immobilization period individuals may be referred to an occupational therapy to improve their range of motion, and further down the line improve their grip strength.
6. What does surgery involve for a wrist fracture?
Surgical intervention involves making an incision to access the fracture fragment(s) to improve alignment and restore and stabilize the osseous anatomy. Once the bone fragments are aligned then a combination of different implant devices are inserted to stabilize the bone while it heals. Often these plates and screws are retained indefinitely, however depending on the fracture pattern and bone quality there is a possibility that certain types of plates must be removed once the bone is healed.
7. What should I expect after surgery?
The first office appointment will occur two weeks after the date of surgery, at which time the sutures are removed and depending on the fracture pattern and bone quality, often my patients’ are transferred into a removable splint and may begin wrist and forearm motion. There is an 8-10 week period post-operatively that you must refrain from any lifting, pulling, or pushing with the operative hand. At 12 weeks post op I typically allow my patients to return to all activities gradually with no restrictions.
Carmella Fernandez MD, MBA
Dr. Fernandez is a dual fellowship trained orthopedic surgeon specializing in surgery of the hand, wrist, and elbow. Her clinical interests focus on developing personalized treatment plans to restore pain-free function to her patients through a variety of non-surgical and surgical solutions.
Fernandez Upper Extremity Insitute
730 Goodlette Frank Road N., Suite #204
Naples, Florida 34102