Recommendations
Key Recommendations
Assess the patient using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.[30]
Perform a thorough history and comprehensive clinical examination. Look for the key signs and symptoms of fractures: pain, swelling, impaired function of the arm or hand, and guarding against movement.[31] Deformity indicates a displaced fracture.[31]
Assess and document neurological and vascular status.[17][32][33][34] Repeat the assessment after the initial management, such as reduction manoeuvres or applying a splint.[34]
Signs indicating a vascular injury include:
Check for other injuries, including significant head injury. If you suspect a head injury, arrange imaging as appropriate and inform the appropriate subspecialty team. See Assessment of acute traumatic brain injury.
Assess the patient’s pain regularly. Use a pain assessment scale suitable for the person's age, developmental stage, and cognitive function. Continue to regularly assess the pain using the same scale.[31]
Order plain x-rays in all patients.[17][32][33] Order an MRI if you suspect a scaphoid fracture.[31]
Assess the patient for compartment syndrome. Key indicators include pain out of proportion to the associated injury and pain on passive movement of the muscles of the involved compartments.[36] See Compartment syndrome of extremities.
Assess and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[31]
Document the mechanism of injury at presentation.[17][32] A history of trauma is almost always present. A fall on the outstretched hand (FOOSH) is often the cause and may occur from a simple slip or trip. This mechanism is more common in older people.[15] In such patients, consider osteoporosis as a predisposing factor for fractures. In a younger patient, there is often a history of a fall on the outstretched hand during a sporting activity, or a history of a vehicular trauma.[12][15]
Ask about pain. Assess the patient’s pain regularly. Use a pain assessment scale suitable for the person's age, developmental stage, and cognitive function. Continue to regularly assess the pain using the same scale.[31]
Assess and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[31]
Examine the limb on presentation and document your clinical findings.[17][32] Look for the key signs and symptoms of fractures: pain, swelling, impaired function of the arm or hand, and guarding against movement.[31]
Non-displaced fractures: look for localised swelling but no deformity. Tenderness over the distal radius is the hallmark.
Displaced fractures: look for obvious deformity, such as the classic ‘dinner fork’ deformity with dorsal angulation at the fracture site associated with Colles’ fracture (resulting from dorsal displacement from falling on a pronated hand). With displaced fractures, the wrist is tender and range of motion limited by pain.
Carefully palpate the carpus, especially the scaphoid, in the anatomical snuff-box distal to the distal radius. Tenderness in this area suggests a scaphoid fracture, either as an isolated injury or associated with concomitant fractures of the distal radius.[2]
Palpate the area around the fracture site and assess the elbow, carpal bones, and hand for associated injuries.
Assess the status of the radial pulse and digital capillary refill time.[17][32][33][34]
Signs indicating a vascular injury include:
Assess the individual function of the radial, median, and ulnar nerves.[17][32][33][34] Document the neurological examination as a timed entry in all patients with extremity trauma. Assume that nerve injury is present until proven otherwise.[37] Re-assess the nerves following any intervention, such as application of a cast or a manipulation.
Practical tip
Concomitant fractures of both the radius and the ulna are usually the result of high-energy trauma from a blow, fall, or motor vehicle accident. Pain and swelling at the fracture site are often accompanied by deformity. Injury to the radial, median, or ulnar nerves may occur, along with vascular injury.
Examine the fracture site for skin tenting or lacerations. Fractures of the distal radius can sometimes be associated with open wounds. Irrespective of age, an open wound usually suggests a high-energy injury.[9] In these fractures, patients may experience numbness affecting the radial three digits, suggesting acute median nerve compression (carpal tunnel syndrome).[9] Numbness of the ulnar two digits, suggesting ulnar nerve compression, is less common.
Check for other injuries, including significant head injury. If you suspect a head injury, arrange imaging as appropriate and inform the appropriate subspecialty team. See Assessment of acute traumatic brain injury.
Assess the patient for compartment syndrome.This occurs more commonly in patients with fractures of the forearm or high-energy wrist fractures than in most other fracture types, though is rare overall.[36] Clearly document:[36]
The time and mechanism of injury
Time of evaluation
Level of pain
Level of consciousness
Response to analgesia and whether a regional anaesthetic has been given.
Key findings indicating compartment syndrome include pain out of proportion to the associated injury and pain on passive movement of the muscles of the involved compartments.[36] Pulses are normally present in compartment syndrome. Absent pulses are usually due to systemic hypotension, arterial occlusion, or vascular injury.[36] See Compartment syndrome of extremities.
Limb ischaemia is a late sign of compartment syndrome and may develop as compartment pressure rises. The classic signs of an ischaemic limb (the ‘5 Ps’) are:
Loss of distal pulses
Pallor
Increased pain with passive stretch of tissues distal to fracture site
Paraesthesias
Poikilothermia.
Symptoms may evolve over time, so repeat the physical examinations and continue to monitor at-risk patients for compartment syndrome.
X-rays
Order plain radiographs in all patients to make a conclusive diagnosis.[17][32][33] For a suspected distal radius fracture, obtain posteroanterior and lateral views centred at the wrist.[17][32] Ensure that the entire radius, along with the wrist and elbow joints, are clearly visualised.[32] In children, orthogonal x-rays should be available to allow proper diagnosis and planning.[33]
Fractures may be minimal cracks, extra-articular fractures, or intra-articular fractures.
Practical tip
Ensure the patient is comfortable for radiography, with sufficient analgesia.
Radiographs also suggest the degree of osteopenia, and may offer some information about the degree of articular involvement or comminution.
Combined injuries of the distal radius and scaphoid are possible but uncommon.
Scaphoid fractures can be missed on x-ray and so x-rays must be carefully examined for these fractures.[2] Consider an MRI as first-line imaging if you suspect a scaphoid fracture.[31][38] In practice, it may be that an x-ray is performed in the emergency department, with an MRI arranged if the patient’s symptoms have not resolved after 7 to 10 days. Consider a clinical diagnosis of a scaphoid fracture in patients where there is pain or tenderness in the anatomical snuff-box. Have a high index of suspicion for this injury and arrange an MRI if the patient has pain despite a normal x-ray.[38][39]
For fractures of the distal radius, radiographic features that suggest the need for surgical treatment include:[40]
Post-reduction radial shortening of >3 mm
Dorsal tilt of >10º
Intra-articular step-off of >2 mm.
Angulation apex-volar of >20º
[Figure caption and citation for the preceding image starts]: (a) Posteroanterior view, (b) lateral view, and (c) posteroanterior oblique view of a normal right wristBMJ 2014;349:g5758; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Labelled version of previous figure. (a) 1=scaphoid; 2=lunate; 3=triquetral; 4-- =pisiform; 5a=body of hamate; 5b=hook of hamate; 6=capitate; 7=trapezoid; 8=trapezium; 1st→5th=respective metacarpal bases; r=radial styloid; u=ulnar styloid; (b) 1--=scaphoid; 2--=lunate; 6--=capitate; dr--=distal radius (note the distal ulna projected through this); t=dorsal tubercle of the radius; (c) as for a, except 5=hamate. *You can use the mnemonic “so long to pinky, here comes the thumb.” -- Object labelled within the dashed lineBMJ 2014;349:g5758; used with permission [Citation ends].
Computed tomography scan
Use computed tomography (CT) for assessing fracture morphology or displacement, union, and deformity, and for preoperative planning.
In patients where surgical fixation is considered, a CT scan of the distal radius or scaphoid may be beneficial for analysing extra- and intra-articular fracture geometry and preoperative planning.[41] A CT scan may also reveal any occult fractures around the carpus.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is useful for evaluating soft tissue injury and bone oedema suggestive of acute injuries.
Use MRI (without contrast) if you suspect an occult fracture of the scaphoid.[31] It may also be used to define associated ligamentous injuries.[42][43]
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