I Have A Broken Wrist and I Need Surgery. A Deep Dive On Distal Radius Fractures

Have you recently had an injury and been told by a doctor that you have a wrist fracture or a ‘distal radius’ fracture? If so, you are likely on your way to see a hand surgeon.

I know you want to get back to being you as soon as you possibly can. Below is your introductory guide to help you understand the basics of a distal radius fracture of the wrist.

Figure 1 - The left picture is known as an AP (anterior-posterior) X-ray in which we view the wrist from back to front, as if your palm were flat on the table. On the AP, the larger forearm bone at the bottom left is the radius, and the smaller one bottom right is the ulna. The right picture is a lateral view, meaning we look at the wrist from the side, like a ‘karate chop.’ In this view, the radius and ulna bones overlap.

What is a distal radius fracture?

A wrist fracture is a loose term to describe the general anatomic area of your wrist. While you certainly can break any of the small bones of your wrist, by far the most common ‘wrist fracture’ is an injury to the radius bone.

While the radius is actually a forearm bone (see Figure 1), it commonly breaks near the junction between the forearm and wrist. We call this the ‘distal’ end of the bone (opposite of ‘proximal,’ near your elbow) — this is where the term distal radius fracture comes from.

Why did I break my wrist?

Typically, a distal radius fracture happens after falling and landing on an outstretched hand. However, there are many other causes of wrist fractures, including car accidents or injuries during recreational activities.

As we age and our bones become more fragile, the risk of a distal radius fracture increases. See my wrist fracture patient education page for more about the specific risk factors and characteristics of this fracture.

Is a distal radius fracture common?

For better or worse, a distal radius fracture is the most common surgical fracture we treat. If you find yourself with this injury, you can rest assured of how frequently we perform this surgery.

While there are many subtypes of distal radius fractures — some that need surgery and many that don’t — this article will focus on the ‘garden-variety’ surgical fracture that we encounter. In this specific instance, the radius breaks and moves out of place, necessitating surgery to restore wrist alignment and function.

The most common scenario we see is a patient who sustains a wrist injury, seeks care at an urgent care or emergency room, and then is diagnosed with a wrist fracture and instructed to follow up with a hand surgeon.

As the patient, it is crucial to understand the time sensitivity of this whole process. This wrist fracture is much easier to fix surgically if completed within about 10 days following the injury, which ultimately leads to better outcomes for your wrist after surgery.

After 10-14 days, the bone starts to heal, and the soft tissues contract around the fracture. These factors negatively affect the rate of success following wrist surgery.

“This type of wrist fracture is much easier to fix surgically if completed within about 10 days following the injury”

Ideally, you will see a hand surgeon within the first 2-3 days following the injury, allowing time for planning and scheduling your surgery appropriately. Always remember to bring your records and a CD copy of your X-rays to your first appointment.

Why do I need distal radius surgery?

You may be wondering more about why this fracture requires surgery. In the typical case where the distal radius breaks, the end of the bone nearest your wrist joint will actually move or angle ‘backward’ towards the back of your hand (see Figures 2-4).

Figure 2 - Notice the radius bone has broken and tilted backward on the lateral X-ray (compare the yellow arrow in the Figure 4 broken radius with the yellow arrow in the Figure 5 normal radius). It has also shortened noticeably on the AP xray (compare the height of the green arrow and angle of the red lines in the Figure 4 broken radius with those in the Figure 5 normal radius.)

Figure 3 - Yellow outline of the two separate radius fracture fragments. Notice the yellow fragment on top (more distal) has tilted backward and shortened.

Regardless of the angulation, the bone will still heal, but it will heal in the displaced position. If the angulation is severe enough, the wrist will heal in a shortened position relative to its original length.

This results in two long-term issues for the health of your wrist:

• The first is a loss of range of motion. You can imagine if your wrist heals ‘tipped back’ (in extension), it will be difficult to bend your wrist forward (wrist flexion) as far as normal.

• Second, the shortening of your wrist changes the native tension on the tendons that help you make a fist. A shortened wrist decreases tendon tension, resulting in decreased grip strength.

Figure 4 - A distal radius fracture demonstrating shortening (compare green arrow and the angle between the two red lines to Figure 5) on the AP x-ray. The lateral x-ray demonstrated the backward or ‘dorsal’ tilt of the fractured distal radius fragment.

Figure 5 - A normal wrist AP and lateral set of x-rays for comparison to Figure 4.

While the reasons for surgery are often much more nuanced than I can address in a single article, a final reason you may need surgery involves whether your fracture pattern disrupted the wrist joint surface.

The joint is the smooth end of the bone that glides against the other bones in your wrist when you flex and extend. Imagine the smooth glistening surface of a cue ball in billiards.

If the fracture enters the joint and shifts the bone fragments out of place, you will have lost the smooth contours of the space. The cue ball has shattered. Oftentimes, the best way to restore this is with surgery.

Unfortunately, sustaining this type of fracture will put your wrist at a lifetime increased risk of arthritis. That risk increases significantly if the joint surface isn’t restored to normal (or close to normal) with surgery. Be sure to discuss the anatomy of your particular fracture with your surgeon to best decide on a non-surgical (often with a cast) versus a surgical personalized treatment plan.

What is the surgery for a broken wrist?

Many of my patients ask how I fix the bone in surgery. The goals of fracture surgery are simple:

• First, restore the alignment of the bone fragments to normal, or as close to normal as possible.

• Second, hold that alignment with some sort of internal implant.

While the techniques and options for implants are numerous, by far the most common method is with a plate and screws placed through a 2-3 inch incision on the ‘palm’ side of your wrist. We call this a volar-locked plate. After moving your tendons, vessels, and nerves safely out of the way, the bone fragments are realigned and the plate and screws are applied to secure the alignment (see Figure 6 and 7).

Figure 6 - AP and lateral x-ray of a distal radius fracture after a volar-locked plate has been used to surgically fix the fracture.

Figure 7 - Compare the yellow, green, and red annotations to Figures 4 and 5. The angulation (yellow arrow) and height (green arrow & angle between the red lines) of the distal radius fracture have been restored to the normal anatomic range.

How long does a fracture take to heal?

After this, there is nothing a surgeon can do to affect the speed at which your bone heals. Bone healing is a biological process that your body has to accomplish, typically progressing over 6 to 8 weeks. My job is to hold the bones in place while your body does the healing.

Will my plate and screws set off metal detectors?

The plate and screws we typically use for this fracture are designed to be low-profile and have smooth contours. This means the implant is designed to remain in your wrist forever. It will not set off metal detector alarms at the airport (this is by far the most common question I’m asked!).

Will my plate and screws stay forever?

A small percentage of patients develop irritation over the plate after the bone heals. In the rarest circumstances, this can actually lead to rupture of the tendons that flex your fingers or thumb into a fist.

If you were to develop early signs of plate irritation, you would require a future surgery for implant removal. In all other circumstances, the plate will remain in your wrist permanently. 

What if my broken bone doesn’t heal?

A final thing to understand about fracture surgery relates back to bone healing.

As I indicated above, my job in surgery is to secure the fragments in an appropriately aligned position. Over the following 6 to 8 weeks, your body will fill in the fracture gaps with bony healing. Imagine the grout that fills in and secures tiles. Or the superglue between pieces of a broken vase.

If this biological process fails to happen for any reason, we call this a ‘nonunion.’ Risk factors for developing a nonunion include tobacco use, some chronic diseases, and diabetes.

In the unlikely event that you develop a nonunion, you will need much larger repeat surgery to facilitate bone healing. The most easily modifiable risk factor that you can control is to stop smoking immediately if you have a distal radius fracture (or any other fracture). 

“The most easily modifiable risk factor that you can control is to stop smoking immediately if you have a distal radius fracture (or any other fracture). ”

Distal radius fracture surgery - Surgery Day

The last question I typically get from patients is, ‘what will the surgery day look like?’ Every medical practice and surgical setting is different, so I can only share my own experience.

In my practice, this fracture typically takes about 60-90 minutes total time in the operating room to fix.

You would come into the surgery center on the morning of surgery and receive a nerve block from our anesthesiologist. This block makes your arm completely numb for an average of 16 to 24 hours.

You then receive gentle sedation, similar to what you would receive for a colonoscopy or wisdom tooth extraction. Many people refer to this as ‘twilight’ sedation.

Following surgery, you will then recover in the postoperative area for 30 to 60 minutes before going home with a family member or friend who can drive you home. 

Pain after distal radius fracture surgery

Pain from the surgery site typically is most pronounced for the first 3 to 5 days. This pain is often controlled sufficiently by taking a combination of both ibuprofen and acetaminophen.

Some degree of pain is to be expected. But we do try to prevent uncontrolled, severe pain. If a combination of ibuprofen and acetaminophen isn’t strong enough for pain control, a narcotic medication may be used for a short period of time.

How long is recovery after distal radius fracture wrist surgery?

You will be in a protective splint after surgery for approximately one week. At the one-week mark, your first appointment will be with one of our trained certified hand therapists. At that visit, the therapist will mold you a custom removable cast that can be taken on and off for hygiene. 

You will also begin some gentle wrist range of motion exercises at that time. While you will not be able to lift anything greater than 2 pounds with the injured arm for at least six weeks, you will receive progressive range of motion exercises over this time while your bone is healing.

If the fracture is sufficiently healed and you have regained the appropriate wrist range of motion by six weeks, I typically let my patients resume some light lifting activities that progress thereafter. 

Most patients report to me that they feel 90% of their former selves about 3 months after surgery. Continuous improvement in strength, range of motion, and the return of a wrist that feels ‘normal’ is expected over the first 12 months from the injury date.

That completes our deeper-than-usual dive into an extremely common wrist injury. This injury does not do well if treatment is delayed, so please seek care right away if you think you’ve experienced a distal radius fracture.