Wrist Fracture

The wrist is the joint where the two bones of your forearm, the radius on the thumb side and the ulna on the pinky side, meet a constellation of eight small bones called the carpus. Most "wrist fractures" are actually fractures of the radius right at its end (the distal radius); a smaller but more consequential subset involve the carpal bones, the scaphoid most often. Each behaves differently and is treated differently, which is why "broken wrist" can mean a six-week cast or a ten-week thumb-spica cast or a same-week operation, depending on which bone broke and how.

A distal radius fracture happens when you fall onto an outstretched hand (FOOSH) and the radius takes the body's weight at the wrist. The classic Colles fracture has the broken end angled backward, like a dinner fork; the reverse pattern (Smith fracture) happens with falls onto a flexed wrist. Distal radius fractures are by far the most common adult fracture treated in U.S. emergency rooms. They're the "broken wrist" most people picture when they hear the phrase.

A scaphoid fracture happens through the same FOOSH mechanism, but the energy travels through the small boat-shaped bone in the snuffbox at the base of your thumb. The scaphoid is small, but it matters because its blood supply enters from one end: break the bone the wrong way and the far piece can lose its blood supply entirely, leading to avascular necrosis (bone death from loss of blood supply), a fracture that fails to heal, or wrist arthritis years later. A "wrist sprain" that hasn't gotten better in a week is a scaphoid fracture until proven otherwise, which is why we err on the side of imaging and immobilizing rather than reassuring.

The ulnar styloid (the bony bump on the pinky side of the wrist) often breaks alongside a distal radius. Most ulnar styloid fragments don't need fixing on their own. The operation that addresses the radius takes care of them. Beyond these three, the wrist also includes less common fractures of the other carpal bones (lunate, triquetrum, hamate) and combined injuries to the ligaments holding the carpus together (scapholunate ligament injury is the most common of these). The decisive question on a wrist X-ray is which bone broke and whether the alignment will hold while it heals.

Each of these has its own dedicated page with mechanism, diagnosis, and treatment specific to that bone:

• Scapholunate ligament injuryA ligament tear that can accompany a wrist fracture and is missed regularly

The story is usually obvious: a fall onto the hand, a sharp pain at the wrist, immediate swelling, and an inability to grip. Within the first few hours, swelling and bruising spread across the back of the wrist; in displaced distal radius fractures, the wrist takes on the angled-back "dinner-fork" deformity that's all the diagnosis you usually need. Pain localizes well: point tenderness directly over the radius distal to the wrist crease is classic for a distal radius fracture.

The signal that matters most is snuffbox tenderness, point tenderness in the small hollow at the base of your thumb when you spread your fingers, on the side closer to your forearm. Snuffbox tenderness in someone with a FOOSH mechanism is a scaphoid fracture until proven otherwise, even when the X-rays look normal. It can feel like a sprain that should be getting better but is not. Waiting weeks to be seen gives the scaphoid time to start failing to heal, so it is worth having it checked.

What is not typical: numbness or tingling in the thumb and the first few fingers. That can mean a displaced fracture is pressing on the median nerve (an acute carpal tunnel), and the wrist needs to be reset quickly. The same goes for severe pain out of proportion to the injury, a tense and shiny forearm, or any break that has come through the skin (an open fracture). Those are urgent rather than next-week problems.

Evaluation begins with a focused physical exam of the wrist and hand. The surgeon checks where the wrist is tender, inspects the skin, and confirms that the nerves and circulation to the hand are working. Plain X-rays confirm most distal radius fractures and show how far the bone has shifted and whether the break runs into the joint surface. For a suspected scaphoid injury, an added X-ray view brings that small bone into clearer focus. A CT scan helps plan surgery when the fracture runs into the joint surface or is broken into several pieces. An MRI can pick up a scaphoid fracture that is there but does not yet show on a plain X-ray.

When the X-rays are negative but the snuffbox is tender, the wrist is splinted in a thumb-spica position and the patient is brought back for repeat X-rays. By then a fracture line that was invisible at first will often have widened enough to see. If the patient can't afford the wait, MRI gets the answer in a single visit. Both paths are accepted; the cost-benefit drives the choice.

1. Cast or Removable Splint

   Stable, well-aligned distal radius fractures heal reliably in a short-arm cast. Scaphoid fractures that have not shifted heal in a thumb-spica cast (one that includes the thumb), which is typically worn considerably longer because of the scaphoid's limited blood supply; your surgeon will give you a specific timeframe. Buckle-type fractures in children, where the bone bends and cracks rather than breaking all the way through, often heal in a removable splint without a full cast.

2. Closed Reduction

   Distal radius fractures that have angled but are not broken into many pieces can sometimes be reset with the skin still closed, using numbing medicine, and held in a cast. This avoids surgery if the alignment holds. Resetting the bone restores its normal length and angle so the wrist can heal in good position.

3. Serial Imaging

   Out-of-cast films taken at intervals confirm the bones haven't drifted. A late shift in alignment is the most common reason a fracture that started non-operative ends up in the OR, which is why the follow-ups aren't optional.

4. Protected Weight-Bearing

   Even after the cast comes off, you don't go straight to push-ups. The bone is biologically healed but still remodeling for months. Patients with both a distal radius fracture and a scaphoid fracture, or with osteoporotic bone, are kept off load longer.

Surgery is offered when alignment can't be reliably held in a cast, when the fracture extends into the wrist joint surface and the surface can't be left misaligned, when a scaphoid fracture has shifted out of position or sits at the end where the blood supply is worst (where a cast will not reliably heal it), when the median nerve is being compressed and does not ease after the bone is reset, or when the patient needs a faster return to function and the fracture pattern allows operative fixation.

The two operations done most often are wrist fracture fixation, usually a metal plate and screws that hold the radius in place, and scaphoid fixation, usually a single screw placed through a small incision. Both are outpatient operations. Both let the wrist start moving early, which matters because a stiff wrist is a hard wrist to rehabilitate.

If non-operative care is not enough, these procedures are offered by the OSI team for this condition:

• Distal radius fracture fixationHand & Wrist

Providers Who Treat Wrist Fracture

Michael S. Vrana, M.D.

David B. Templin, M.D.

Trent Twitero, M.D.

External patient-education references and related OSI pages for additional background:

• AAOS OrthoInfo, patient education library
• OSI glossary, orthopedic terminology in plain language