Did you fall on your hand and now have a painful, swollen or deformed wrist?
If you have fallen on an outstretched hand and your wrist is painful, swollen or visibly deformed, you may have a distal radius fracture, commonly known as a Colles' fracture.
A wrist fracture does not automatically mean that you need surgery.
The important questions are:
How is the fracture aligned? Is it stable? Does it involve the wrist joint? And which treatment is most likely to restore useful function of your hand and wrist?
Key Takeaway
Not every distal radius fracture requires surgery. Treatment depends on the fracture pattern, alignment, stability, joint involvement, bone quality, and the individual's functional requirements.
What Is a Distal Radius Fracture?
The radius is one of the two bones of the forearm and lies on the thumb side. A distal radius fracture occurs when the lower end of this bone breaks close to the wrist.
The term Colles' fracture traditionally describes a distal radius fracture in which the broken fragment is displaced and tilted towards the back (dorsally) relative to the shaft of the radius.
It was first described by Irish surgeon and anatomist Abraham Colles in 1814.
Today, distal radius fractures are recognized as a wide range of injuries. Some are simple and stable, while others may be significantly displaced, fragmented, or extend into the wrist joint. This difference is important because the treatment should be tailored to the individual fracture.
How Does a Distal Radius Fracture Happen?
The most common cause is a fall on an outstretched hand (FOOSH).
When a person slips or trips, the natural reflex is to put the hand out to protect against the fall. The force transmitted through the wrist can cause the distal radius to break.
In older adults
A simple fall from standing height can sometimes cause a fracture when the bone has become weaker because of osteoporosis or reduced bone strength.
A wrist fracture after a relatively minor fall may therefore be an early indication that bone health should also be assessed.
In younger adults
Fractures are more commonly associated with higher-energy injuries, such as:
- Road traffic accidents
- Sports injuries
- Falls from a height
- Significant direct trauma
What Are the Symptoms?
A distal radius fracture may cause:
- Pain around the wrist
- Swelling and bruising
- Tenderness
- Difficulty or pain when moving the wrist
- Weak grip
- Difficulty using the hand
- Visible deformity in a displaced fracture
A classic displaced Colles' fracture can produce a "dinner-fork" deformity, caused by backward displacement of the fractured fragment.
What about numbness or tingling?
Numbness or tingling, particularly involving the thumb, index and middle fingers, may indicate median nerve compression or Acute carpal tunnel syndrome.
Progressive or severe numbness after a wrist fracture requires prompt medical assessment.
What Should You Do Immediately After the Injury?
Until the wrist is assessed:
- Remove rings, bracelets, and watches from the injured hand before swelling increases.
- Keep the hand elevated above heart level where possible.
- Avoid trying to straighten or manipulate the wrist yourself.
- Immobilize the wrist if appropriate.
- A cold pack wrapped in cloth may help with swelling and discomfort.
- Arrange medical assessment and appropriate X-rays.
Seek urgent medical attention if:
- The fingers become blue, pale or unusually cold.
- There is increasing numbness or inability to move the fingers.
- The swelling is severe or rapidly increasing.
- There is an open wound over the fracture.
- The wrist is markedly deformed.
- Pain is severe or progressively worsening.
How Is a Distal Radius Fracture Diagnosed?
The diagnosis is usually confirmed with X-rays of the distal end of the radius, generally including posteroanterior and lateral views. A forearm angulated upward by 20degrees enhances accuracy of interpretation.
The X-rays help assess:
- Whether the fracture is displaced
- Loss of radial height
- Dorsal or volar tilt
- Whether the fracture extends into the wrist joint
- The degree of fragmentation or comminution
- Associated injuries
In some complex fractures, particularly those involving the joint surface, a CT scan may provide additional information for treatment planning.
Why Is the X-ray So Important?
Two patients may both be told that they have a "wrist fracture" but have very different injuries requiring different treatment.
The important questions are:
1. Is the fracture displaced?
A fracture may remain reasonably well aligned or may have shifted significantly.
2. Is the fracture stable?
Some fractures remain in a satisfactory position in a cast. Others can gradually collapse or shift during the healing period. The important finding on the X-ray is to assess the extent of bone crushing (comminution).
3. Does the fracture involve the joint?
When the fracture extends into the wrist joint, restoration of the joint surface becomes particularly important.
4. What are the patient's functional requirements?
The appropriate treatment can also depend on age, occupation, hand dominance, activity level, bone quality and other individual factors.
The fracture should therefore be treated as an individual injury, not simply according to a label such as "Colles' fracture."
Does Every Colles' Fracture Need Surgery?
No.
Some distal radius fractures can be treated successfully without an operation.
A fracture that is undisplaced or can be satisfactorily reduced and is likely to remain stable may be treated with immobilization and careful follow-up.
Other fractures may be unstable, significantly displaced, involve the joint surface or lose their alignment despite initial treatment. In these situations, surgical fixation may be considered.
The decision should be based on the fracture pattern, alignment, stability, joint involvement, bone quality and functional needs of the patient, not simply on age or the fact that the fracture is displaced.
Non-Surgical Treatment
Non-surgical treatment may be appropriate for fractures that are stable or can be satisfactorily reduced and maintained in a good position.
Closed reduction
If the fracture is displaced, the broken bone fragments may be realigned without surgery. This is called closed reduction.
Appropriate local, regional, or general anesthesia may be used depending on the circumstances. This may create apprehension in certain patients, and it is best discussed with the patient at length to allay the fear.
Immobilization
The wrist is then immobilized in a cast or splint for several weeks while the fracture heals.
Follow-up X-rays
Follow-up X-rays are important, particularly during the first six weeks of the healing.
A fracture may look well aligned immediately after reduction but subsequently shift or collapse during healing.
For this reason, follow-up and serial X-rays are an important part of non-surgical treatment.
When Is Surgery Considered?
Surgery may be recommended when:
- Satisfactory alignment cannot be achieved
- The fracture is unstable
- The fracture loses its position during follow-up
- There is significant joint involvement
- There is substantial fragmentation or collapse or comminuted.
- The fracture pattern is unlikely to remain adequately aligned in a cast.
The objective of surgery is not simply to insert a plate.
The aim is to restore appropriate anatomy, provide sufficient stability for healing, and allow rehabilitation at the appropriate time.
Surgical Treatment Options
Volar Locking Plate Fixation
A volar locking plate is commonly used for many unstable distal radius fractures.
The plate is often placed on the palm side of the wrist and secured to the bone with screws. In appropriately selected fractures, stable fixation may allow earlier controlled movement of the wrist. Sometimes the plate may be applied on the dorsal aspect.
However, a volar plate is not automatically required for every distal radius fracture. The fracture pattern determines whether it is appropriate.
The plates are available both in stainless steel and Titanium. They are pre-contoured and available in various sizes and shapes.
K-Wire Fixation
Kirschner wires (K-wires) may be used in selected fracture patterns, either alone or together with other methods of fixation.
External Fixation
External fixation has a role in selected complex fractures, although it is used less frequently than in the past.
The best method of fixation depends on the individual fracture rather than a one-size-fits-all approach.
Cast or Surgery: How Is the Decision Made?
Cast treatment
Surgical fixation
*Suitable for selected stable fractures
Considered for selected unstable fractures
*No surgical incision
Requires an operation
*Alignment is monitored during healing
Provides internal stability
*Follow-up X-rays required.
May permit earlier controlled movement in suitable cases
*Unstable fractures may subsequently displace
Carries surgical risks, including infection, tendon, nerve and hardware-related problems, though minimal .
The choice should be made after assessing the individual fracture and the patient's needs.
Recovery and Rehabilitation
Treatment does not end when the fracture is placed in a cast or fixed with a plate.
The ultimate objective is to restore the best possible movement, strength, and useful function of the hand and wrist, while minimizing pain and long-term disability.
Control Swelling Early
Keeping the hand elevated above heart level is an important part of early recovery.
A sling can sometimes leave the hand hanging below heart level for prolonged periods and may increase dependent swelling.
Keep the Fingers Moving
Unless specifically restricted, finger movement should begin early, even while the wrist is immobilized.
Movement of the elbow and shoulder is also important to prevent unnecessary stiffness.
Hand Therapy
Once the fracture has healed sufficiently and immobilization is discontinued, appropriate exercises and, when required, specialist hand therapy can help restore:
- Wrist movement
- Forearm rotation
- Grip strength
- Hand function
Remember: X-ray healing and functional recovery are not the same thing.
The bone may unite before the wrist feels completely normal.
Recovery of movement, strength, coordination and confidence in using the hand can take considerably longer.
Possible Complications
Most distal radius fractures heal satisfactorily with appropriate treatment, but complications can occur.
Acute Carpal Tunnel Syndrome
Swelling around the wrist can compress the median nerve, causing numbness, tingling or altered sensation, particularly in the thumb, index and middle fingers.
Progressive or severe nerve symptoms require urgent assessment.
Extensor Pollicis Longus (EPL) Tendon Rupture
A delayed rupture of the EPL tendon can occasionally occur after a distal radius fracture, resulting in difficulty or inability to extend the thumb.
Complex Regional Pain Syndrome (CRPS)
Some patients develop disproportionate pain, swelling, stiffness, sensitivity or changes in the appearance or temperature of the hand.
Early recognition and appropriate treatment are important.
Malunion
If the fracture heals in an unsatisfactory position, it may result in:
- Reduced wrist movement
- Restricted forearm rotation
- Altered wrist mechanics
- Reduced grip strength
- Persistent pain or functional difficulty
This is one reason why appropriate assessment of fracture alignment and stability is important from the beginning.
What Happens During a Hand Surgeon Consultation?
During an assessment, the hand surgeon will consider more than the X-ray alone.
The wrist and hand may be examined for:
- Swelling and deformity
- Finger and wrist movement
- Circulation
- Nerve function
- Tendon function
- Areas of tenderness
The X-rays are then reviewed to understand the fracture pattern, alignment, stability and involvement of the wrist joint.
Based on these findings, the appropriate treatment options can be discussed, including the advantages and limitations of both non-surgical and surgical treatment.
Frequently Asked Questions
Can a distal radius fracture heal without surgery?
Yes. Stable fractures, and some fractures that can be satisfactorily reduced and maintained in good alignment, can often be treated with immobilization and follow-up.
How long does a Colles' fracture take to heal?
Bone healing commonly takes several weeks, often around 6 weeks, but recovery of wrist movement, grip strength and full function can take considerably longer.
When does a wrist fracture need surgery?
Surgery may be considered when satisfactory alignment cannot be obtained or maintained, or when the fracture is significantly unstable, substantially displaced or involves the joint in a way that makes restoration of alignment important.
Can I move my fingers after a wrist fracture?
In most cases, finger movement is encouraged unless specifically restricted by the treating surgeon. Early finger movement can help reduce stiffness and swelling.
Why are repeat X-rays necessary?
Some fractures can lose their alignment during the early healing period even after an initially successful reduction. Follow-up X-rays help detect this.
Can a wrist fracture cause carpal tunnel syndrome?
Yes. Swelling associated with the fracture can compress the median nerve and cause numbness or tingling in the hand.
Can a wrist fracture be a sign of osteoporosis?
In an older adult, a distal radius fracture following a relatively minor fall can sometimes indicate reduced bone strength. Assessment for osteoporosis may therefore be appropriate.
Will my wrist be completely normal after the fracture heals?
Not necessarily immediately. Bone healing, restoration of movement, recovery of strength and return to demanding activities occur at different rates. Appropriate rehabilitation is an important part of recovery.
The Most Important Thing to Remember
A wrist fracture is not simply a broken bone that needs to be immobilized or plated.
The fracture pattern, alignment, stability and involvement of the wrist joint determine the treatment.
For some patients, a carefully monitored cast is all that is required. For others, surgical fixation may provide a better opportunity to restore alignment and allow appropriate rehabilitation.
The goal is not merely to make the X-ray look better. The goal is to restore the best possible function of the wrist and hand.
If You Have Injured Your Wrist
If you or a family member has sustained a wrist injury, particularly after a fall, road accident or sports injury, an early assessment can help determine the nature and stability of the fracture and whether further treatment is required.
Do not assume that every wrist fracture needs surgery, or that every wrist fracture will heal well in a cast.
An individualized assessment by a hand surgeon can help you understand your X-rays, treatment options and expected recovery.
Consult Dr. Jindal, Specialist Hand Surgeon, Pune, for assessment and treatment of distal radius and other hand and wrist injuries.
Related reading:
- Bennett fracture, a thumb-base fracture that is easy to miss
- Gamekeeper's thumb, a thumb ligament injury after a fall
- Hand trauma & fractures, the full treatment area