Wrist / Hand Fractures

Distal radius/ulna, carpal, and hand injuries seen in urgent care/GP practice. See Fracture Immobilisation & Casting for splinting technique. Distal radius fractures are the most common long-bone fracture in adults and the leading cause of acute carpal tunnel syndrome — always document a neurovascular exam before and after splinting.

Systematic wrist X-ray review

Worth reviewing every trauma wrist film the same way — this is exactly where significant injuries get missed:

• PA view: distal radius/ulna should be touching (a gap suggests a DRUJ injury); carpal joint spaces should all be <2mm and similar in size to each other (a scapholunate gap >3–4mm — the “Terry Thomas” sign — suggests scapholunate ligament disruption).
• Oblique view: the “window to the thumb” — best for base-of-thumb injuries (trapezium, first CMC joint).
• Lateral view: check alignment through distal radius → lunate → capitate → 3rd metacarpal, and for DRUJ injuries.

Scapholunate dissociation (gap >3–4mm on PA view, FOOSH or degenerative rupture) needs orthopaedic review within ~5 days — acute injuries need ligament repair. Splint in a thumb spica in the interim.

Perilunate dislocation is a high-energy injury with usually-obvious wrist deformity — refer as an emergency, not routine ortho follow-up.

Clinical pearl: if there’s significant pain/bruising/deformity but no fracture is seen on X-ray (especially with pain on ulnar deviation, which suggests a TFCC injury on the ulnar side of the DRUJ), don’t discharge as a “sprain” — immobilise (splint) and refer, since MRI a few days later not infrequently shows an occult intra-articular fracture or ligamentous injury that the initial film missed.

Distal radius / distal ulna fracture

The most common long-bone fracture in the US, bimodal (paediatric and >65yo). Ulnar styloid fractures accompany distal radius fractures ~58% of the time.

Pattern	Mechanism	Notes
Colles (most common)	FOOSH with the wrist extended	Dorsal displacement/angulation of the fragment
Smith (reverse Colles)	Fall onto a flexed, pronated wrist, or direct dorsal blow	Volar displacement — high risk of acute carpal tunnel syndrome
Barton	Fall with the wrist in extension+pronation (dorsal) or flexion+supination (volar)	Oblique intra-articular fracture with carpal subluxation — always involves the joint
Hutchinson / “chauffeur”	Direct blow, or FOOSH with the wrist deviated/supinated	Oblique intra-articular fracture through the radial styloid
Die-punch	Axial load driving the lunate into the radius	Intra-articular compression fracture

Reduction targets (for a closed reduction before splinting/referral): <2mm radial shortening, radial inclination >15° (normal 15–25°), <10° dorsal tilt/toward 10–25° volar tilt, ulnar variance <2mm. Splint in a sugar-tong splint in as close to neutral as tolerated (avoid hyperflexion/extension, which can worsen nerve compression).

Refer: any intra-articular fracture, any fracture requiring reduction that isn’t stable/reducible, and all open fractures. Most simple, minimally displaced extra-articular distal radius fractures can be splinted and followed up with routine ortho/hand therapy.

Scaphoid fracture

The most commonly fractured carpal bone (60–70% of carpal fractures, 11% of hand fractures, 2% of all fractures). Typically a young male (15–25yo) FOOSH, usually sports-related. Two-thirds of fractures occur at the waist (mostly non-displaced), 25% distally, and 5–10% at the proximal pole — proximal fractures carry a higher non-union risk, since 70–80% of the scaphoid’s blood supply enters via a single dorsal branch of the radial artery, supplying the proximal pole retrogradely (i.e. a proximal fracture can cut off the pole’s only blood supply).

Clinical examination: anatomical snuffbox tenderness, scaphoid tubercle tenderness, and pain on axial thumb compression (“thumb telescoping”) — each individually near-100% sensitive, and 87–100% sensitive/74% specific when all three are positive within 24 hours of injury (axial thumb compression is the weakest of the three and shouldn’t be relied on alone).

Imaging: plain X-ray sensitivity is only ~70% even with dedicated scaphoid views — a normal X-ray does not exclude a fracture. Traditional practice was blanket immobilisation with repeat X-ray at 2 weeks, but this substantially over-treats (only 4–20% of these patients actually have a fracture). If initial X-rays are negative but clinical suspicion remains, get an MRI (or CT if MRI isn’t available) within 3–5 days — MRI sensitivity 99–100%, CT 93–95%.

Management, by fracture type and displacement:

• Non-displaced/minimally displaced (≤0.5mm) waist fracture — thumb spica cast; ~90% union at 6 weeks.
• Moderately displaced (0.5–1.5mm) waist fracture — conservative management possible, but needs prolonged immobilisation (~8–10 weeks).
• Displaced waist fracture (>1.5mm) — refer for internal fixation.
• Distal fractures — generally managed conservatively; most heal within 4–6 weeks.
• Proximal fractures — generally treated with internal fixation, given the higher non-union risk.

All suspected scaphoid fractures should be immobilised in a thumb spica splint and referred for orthopaedic/hand-surgery follow-up in 10–14 days, even with a normal initial X-ray. Non-union (“SNAC wrist” — scaphoid non-union advanced collapse) causes progressive degenerative change and carpal collapse in these typically young, active patients.

Other carpal fractures (brief)

Scaphoid aside, carpal fractures are individually uncommon and easily missed on plain films — have a low threshold to splint (thumb spica or ulnar gutter) and refer if there’s focal carpal tenderness with a normal X-ray.

• Triquetrum — the 2nd most common carpal fracture (~18%). Usually a dorsal cortical “chip” avulsion from a fall on an ulnarly-deviated, extended wrist — look for it on the lateral view. Volar splint, routine ortho follow-up.
• Hamate (hook) — classic in racquet/bat/club sports (the hook sits in the hypothenar space, origin of the transverse carpal ligament). Often presents subacutely, weeks after the injury, with ulnar-sided wrist pain ± ulnar nerve paresthesia. Hook-of-hamate test: pain with resisted flexion of the 4th/5th DIP joints in ulnar deviation. Easily missed on routine views (carpal tunnel view or CT needed) — refer to a hand surgeon.
• Trapezium — associated with 1st metacarpal fracture/dislocation (Bennett’s/Rolando’s) — suspect with base-of-thumb pain after a fall onto an adducted thumb.
• Lunate — central carpal bone; can progress to avascular necrosis (Kienböck disease) in the 15–20% of people with only a volar blood supply — persistent dorsal wrist pain/stiffness after a “normal” wrist X-ray warrants review if it doesn’t settle as expected.
• Pisiform — direct blow to the hypothenar eminence; ~50% have an associated distal radius or other carpal fracture; check ulnar nerve (Guyon’s canal runs alongside it).

Hand fractures

Boxer’s fracture (4th/5th metacarpal neck fracture) — punching injury. Check for rotational malalignment (have the patient make a fist — the fingers should all point toward the scaphoid, with no overlap/scissoring; this is more functionally important than the angulation itself).

Acceptable angulation on the lateral view (beyond which refer for reduction): 5th finger up to 40°, 4th finger up to 30°, 2nd/3rd finger only 10–20° (these fingers have far less compensatory CMC mobility).

Treatment: ulnar gutter splint in the position of safe immobilisation (POSI) — wrist ~15° extension, MCP joints 70–90° flexion, IP joints ~10° flexion — from just distal to the 5th DIP joint to the proximal forearm. Refer if rotational deformity, significant angulation beyond the thresholds above, or an intra-articular component.

For dislocations of the finger and thumb joints, volar plate injury and thumb ulnar collateral ligament tears, see Finger & Thumb Joint Injuries. For subungual haematoma, nail bed laceration, tuft/Seymour fractures and fingertip amputation, see Fingertip & Nail Bed Injuries.

Mallet finger vs jersey finger

Easily confused but opposite injuries — both may have a normal X-ray (soft-tissue/tendon injury, sometimes with only a small bony avulsion fragment) and both are commonly missed if the exam isn’t specific.

	Mallet finger	Jersey finger
Mechanism	Finger jammed/jarred (ball sports)	Finger caught/grabbed (grabbing a jersey — rugby/football)
Injury	Extensor tendon (or its bony insertion) avulsed from the distal phalanx	Flexor digitorum profundus (FDP) tendon avulsed from the distal phalanx
Deficit	Can’t actively extend the DIP joint — it droops	Can’t actively flex the DIP joint
Management	Splint the DIP in extension continuously for 6 weeks	Needs surgical repair — flexor tendons retract into the palm/forearm and won’t heal splinted; splint in slight flexion (e.g. a Zimmer splint) and refer promptly

The urgency differs: mallet finger can be splinted definitively in urgent care, but jersey finger needs prompt hand surgery referral — delayed repair has a worse outcome once the tendon has retracted and scarred down. For a lacerated (rather than avulsed) flexor or extensor tendon, and for digital nerve injury, see Hand Tendon & Nerve Lacerations.