Fractures of the hand, wrist and forearm are most common as a result of a fall on to an outstretched arm as you attempt to soften your landing. These injuries typically occur following slips/trips but mostly in sport with around 25% of all sports-related injuries involve the wrist or hand.
Depending on the exact mechanism and area of pain, there are several fracture sites that are seen more commonly. However, in most cases the typical symptoms include:
For ease & clarity, the most common fractures and their presentation will be explained in separate sections.
A break in one of the 5 metacarpal bones (long bones between the wrist & fingers) which can occur at the head, neck, shaft and/or base and usually results from direct impact or a fall. These fractures are most common in contact sports such as boxing, martial arts, rugby etc. and, work-related accidents involving a fall on to the hand. Fractures specifically at the fourth or fifth metacarpals are alternatively referred to as a ‘Boxer’s fracture’.
Metacarpal neck fractures are typically sustained following a punch impact. Shaft fractures usually take place with compression, torsion or direct impact and the fracture can be classified based on the fracture pattern which is ubiquitous with all long bone breaks. Lastly, metacarpal base fractures – which are far less common, do not present as severe. Of these, the 5th metacarpal is the most susceptible.
Metacarpal fractures are seen more frequently in:
These injuries require a thorough physical assessment coupled with imaging to establish the extent of the injury, helping dictate treatment & management. In less severe injuries – where there is little to no displacement at the fracture site, they will be managed conservatively. This will involve wearing a splint/cast to allow bone healing to occur, coupled with an individualised and progressive self-management and home exercise plan to restore full movement and function, and, to build strength.
In cases where there is a displacement, misalignment or loss of stability, surgery will be likely however this will be discussed in detail at your consultation with an Orthopaedic specialist.
This is a fracture of the base of the thumb, usually occurring when the thumb is forced outwards, away from the hand (thumbs up position). This mechanism leads to displacement of the joint and a fracture at the base of the first metacarpal, making it complex and unstable.
Along with the typical presentation of a fracture previously described, the patient will present with focal pain around the injury site with a ‘pinching’ action of the thumb being very painful. Reduced dexterity will occur, leading to inhibited function.
An X-ray is commonly performed for diagnosis and it is common for a CT scan to take place so that the degree of soft tissue damage can be established. If there is instability and displacement, surgery is required to fixate the joint and allow the bones to fuse and heal. In the absence of displacement and where stability is maintained, a thumb spica splint can be used for immobilisation.
It is important to have a clear and progressive rehabilitation plan in place to restore movement and functionality, alongside increasing strength of the local muscles and tendons. Your Physiotherapist can help create a plan, working with you. Your clinician may also use treatment techniques such as deep tissue massage and joint mobilisations to help support your recovery.
This is a fracture to the end of the radius (forearm bone) near the wrist joint – on the thumb side. When looking at the forearm with it parallel to the floor, an upwards displacement of the distal radius occurs, producing a noticeable deformity referred to as ‘dinner fork’. A Colles fracture is commonly sustained from a fall on an outstretched hand.
Colles fractures are most prevalent in young adults and the elderly with a higher percentage of cases being female. This injury is the common fracture which occurs at this region of the radius and most patients will have Osteoporosis – frequently observed in mature females when placing their hand out to break a fall. In incidences of this fracture in younger patients, the injury typically results from high impact as more energy is needed to break the stronger bone. Common activities include horse riding, skiing, motorbike accidents, falling from a height and contact sports.
This fracture similarly presents with pain, change in sensation (tingling/numbness), bruising or redness, coupled with the ‘dinner fork’ abnormality outlined & pictured above. The pain is typically located at and around the fracture site in the wrist. Colles fractures can also be graded using the Frykman classification as illustrated in the accompanying picture (Kleinlugtenbelt et al., 2017).
Patients typically recover with no issues however in more severe injuries when there has been a bony displacement and subsequent reduction (put back in place, either anatomically or surgically with fixation) imaging is advisable to review healing and to check for complications which could arise including malunion (bones do not fuse correctly), movement in the wrist bones (carpals), shortening of the radius and wrist & forearm stiffness.
An un-displaced and stable fracture is usually managed conservatively with a cast. In more severe cases, surgery may be indicated to restore normal anatomy and stabilise the fracture site which is achieved with external- or internal fixation and the use of pins. A splint or cast will then be worn immobilise the wrist and forearm, allowing for healing to occur.
Initial care comprises of swelling, pain control and gradually restoring wrist mobility and soft tissue flexibility. Rehabilitation usually begins at 7-8 weeks post-fracture if managed conservatively. If surgery was performed in the form of internal fixation, movement can begin as early as 1-week post-operation however, this is the perfect time to consult with a Physiotherapist so that the correct guidance and management plan can be created. Your Physiotherapist may also provide guidance on how to care for any scar tissue to minimise soft tissue restriction. As range of motion returns, the focus shifts to strengthening wrist and forearm movements including gripping, bending and extending the wrist and pronating/supinating (rotating) the forearm. Stretching can also be introduced gradually at this stage. Finally, weight-bearing and high-level function and sporting actions can be implemented, based on individual requirements.
This type of wrist fracture also known as reverse Colles fracture as the distal fracture fragment of the radius moves to your palmar side and blocks the bending of the wrist upwards when palm facing the ceiling.
There are 3 types of Smith’s fracture depending on which part of the bone is affected:
You can also use Frykman’s fracture classification in Smith’s fracture, with the only nuance being the direction in which the distal radius is displaced.
You can expect comparative fracture complications after Colles and Smith’s fractures:
Management again is almost similar to the management of Colle’s fracture. Surgery is an option where an Orthopaedic surgeon will stabilize the fracture site with plate and screws. Post-operative and conservative Physiotherapy management will be similar to Colle’s fracture management as outlined above.
The scaphoid is the largest carpal bone – there are 8 in the wrist, which is synonymous with a ‘broken wrist’; typically sustained during a fall on to an outstretched hand. Patients usually complain of a mild ache deep in the thumb side of the wrist and pinching/gripping actions tend to exacerbate symptoms. A small amount of bruising and swelling may be observed in the anatomical snuff box (pictured). As this fracture presents with relatively mild symptoms, it can be difficult to diagnose accurately and early. This can increase the potential for complications to arise including insufficient & delayed healing, reduced function & strength, degenerative changes, and most significantly, avascular necrosis (bone tissue death due to inhibited blood supply).
Scaphoid fractures are primarily seen in young adults, with a larger prevalence in males and make up 15% of acute wrist injuries. X-ray may be necessary to assist diagnosis and management. The most significant physical clinical feature for scaphoid fracture is anatomical snuffbox pain which is highly sensitive (able to rule out fracture) but with poor specificity (to correctly identify a fracture) (Phillips, Reibach & Slomiany, 2004). Compression through the base of the thumb may also reproduce symptoms and may assist diagnosis further (Sarwark, 2010).
If a fracture is suspected despite a lack of evidence on X-ray, it is common practice for a thumb spica to be worn for 2 weeks before reviewing. Immobilisation is vital to allow the fracture to heal and the damage may worsen and impact blood supply if not rested sufficiently. If pain and swelling persists after 2 weeks of rest then your specialist at a fracture clinic may consider 4-6 weeks of immobilisation in a plaster cast. After review at 6 weeks, they may also organize another X-ray to check healing. If satisfactory, Physiotherapy management can begin based on simple range of movement before progressing to strengthening & weight bearing exercises.
If your scaphoid fracture is not responding to conservative management, the specialist may consider surgical stabilisation, they may also deliberate this option if the fracture fragments are more than 1mm apart during the initial X-ray.
Another carpal bone which articulates with the radius in the wrist. A direct blow to the wrist can cause a fracture to this bone but most common is microfracture due to repetitive strain to the radial aspect of the wrist (e.g. heavy drilling), this microfracture can eventually lead to avascular necrosis of the bone and then to arthritis of the wrist. This avascular necrosis also known as Kienbock’s disease.
Management includes immobilisation of the joint, removal of the Lunate – in severe cases, and reducing repetitive stress to the joint.
When your palms facing up, the Ulna is the bone lies closer to the body and the Radius runs almost parallel on the outside. The main movement that occurs at the forearm is rotation – pronation and supination (twisting the forearm and wrist to turn the hand over). This will be the main movement affected when one or both forearm bones are fractured.
Forearm bones can break anywhere between elbow and wrist but the following description excludes elbow and wrist fractures and only explains shaft fractures of forearm bones.
The fractures are broadly categorised as open and closed. Occasionally the bone will break through the skin (open fracture) and requires urgent medical care due to increased risk of infection. There will be no open wound in a closed fracture. Both fracture types can occur in isolation or a combination and one or both bone can break.
Simple observation of your forearm movement may be enough to indicate a fracture. Often an X-ray will help a clinician to rule in/out a fracture of the forearm.
Treatment & Management
If only one bone is fractured and it is not displaced, a plaster cast for 6-8 weeks will allow the bone to fuse and heal. A Physiotherapist will help you with progressive strengthening soon after your immobilisation period.
Surgical intervention is required to restore normal anatomy and stability in more severe cases where there has been displacement of the bones. Surgery will consist of the insertion of plates and screws to fixate the fracture site. Bear in mind that you will need extensive Physiotherapy input after this to get back to your routine activities. Exercise rehabilitation can often start 2 -3 weeks post-surgery with simple wrist and elbow movements which will progressively be progressed by your Physiotherapist, guided by the advice of the surgeon.
The main difference and consideration for the bones of children and adolescents is ‘growth plates’ which are softer regions of most long bones which is where they lengthen during growth and development.
Treatment & Management
This depends on what type of fracture. If the fracture site is stable and unmoved this will be treated non-surgically but in rare cases – if the child presents with an open fracture and displaced fracture fragments, then the specialist may opt for a surgical fixation.
Black, W. S., & Becker, J. A. (2009). Common forearm fractures in adults. American family physician, 80(10), 1096-1102.
Calder, P. R., Achan, P., & Barry, M. (2003). Diaphyseal forearm fractures in children treated with intramedullary fixation: outcome of K-wire versus elastic stable intramedullary nail. Injury, 34(4), 278-282.
Kleinlugtenbelt, Y.V., Groen, S.R., Ham, S.J., Kloen, P., Haverlag, R., Simons, M.P., Scholtes, V.A., Bhandari, M., Goslings, J.C. and Poolman, R.W. (2017). Classification systems for distal radius fractures: Does the reliability improve using additional computed tomography?. Acta orthopaedica, 88(6), pp.681-687.
Phillips, T. G., Reibach, A., & Slomiany, W. P. (2004). Diagnosis and management of scaphoid fractures. American family physician, 70(5), 879-884.
Sarwark, J. F. (2010). Essentials of musculoskeletal care. American Academy of Orthopedic Surgeons.