A wrist fracture is a break in one or more of the bones that make up the wrist joint — including the distal radius, distal ulna, and the eight small carpal bones. Wrist fractures are among the most frequently treated orthopedic injuries, ranging from straightforward distal radius fractures to subtle scaphoid fractures that are easily missed on X-ray.
MRI plays a critical role in wrist fracture evaluation — particularly for scaphoid fractures and other carpal bone injuries that are not visible on initial X-rays but carry significant risk of complications if missed. Undiagnosed scaphoid fractures can progress to nonunion and avascular necrosis, a pattern similar to that seen in Kienböck's disease. Wrist fractures are also frequently associated with soft tissue injuries — including TFCC tears and scapholunate ligament disruption — that require separate evaluation and treatment.
Causes
- Fall on an outstretched hand (FOOSH): The most common mechanism — particularly in older adults and athletes. Force transmitted through the extended wrist at impact is the leading cause of both distal radius and scaphoid fractures.
- High-energy trauma: Motor vehicle accidents, falls from height, and sports collisions can cause severe wrist fractures, often with multiple fracture lines and associated soft tissue injuries.
- Sports injuries: Skiing, snowboarding, skateboarding, cycling, inline skating, and contact sports carry significant wrist fracture risk.
- Osteoporosis: Decreased bone density — particularly in postmenopausal women — makes the distal radius susceptible to fracture from relatively minor falls. Distal radius fractures are among the most common osteoporotic fractures.
- Repetitive stress: Stress fractures can develop from repetitive loading, particularly in gymnasts and overhead athletes.
- Direct blow: A direct impact to the wrist from an object or during contact sports can cause fracture.
- Pathologic fracture: Fractures through areas of weakened bone due to tumors, infection, or metabolic bone disease can occur with minimal or no trauma.
Symptoms
- Pain: Immediate, often severe pain at the injury site, worsened by movement or attempted use of the hand.
- Swelling: Rapid swelling around the wrist and hand following injury.
- Bruising: Discoloration extending into the hand and forearm due to bleeding under the skin.
- Deformity: Visible deformity with displaced fractures — the classic "dinner fork deformity" of a Colles' fracture appears as the wrist bent upward.
- Tenderness: Significant tenderness at the fracture site; focal tenderness in the anatomic snuffbox is the hallmark of scaphoid fracture.
- Limited range of motion: Inability or unwillingness to move the wrist or fingers due to pain.
- Numbness or tingling: Injury to the median nerve can cause numbness or tingling in the fingers — a sign requiring urgent attention.
- Weakness: Decreased grip strength or inability to hold objects.
- Crepitus: A grating sensation with wrist movement caused by bone fragments.
Diagnosis
Physical examination includes inspection for deformity, swelling, and open wounds; palpation for tenderness; range of motion assessment; and careful neurovascular examination of the hand. Focal tenderness in the anatomic snuffbox (between the thumb tendons at the wrist) is the key clinical sign of scaphoid fracture and warrants further imaging even when X-rays appear normal.
X-rays are the first-line imaging study, identifying most fractures and assessing alignment and displacement. However, X-rays miss a significant proportion of scaphoid and other carpal bone fractures, particularly in the first 1–2 weeks after injury. A dedicated wrist MRI is the most accurate tool for identifying occult fractures not visible on X-ray, detecting bone marrow edema (the earliest sign of fracture), evaluating associated soft tissue injuries including TFCC tears and scapholunate ligament disruption, and assessing for early avascular necrosis. CT is used when detailed three-dimensional bone anatomy is needed for surgical planning, particularly for complex intra-articular distal radius fractures and carpal fractures.
Classification
Wrist fractures are classified based on the bone involved, fracture pattern, displacement, and joint involvement:
- Distal radius fractures — the most common wrist fracture, with several named subtypes:
- Colles' fracture: Extension-type fracture with dorsal displacement — the classic "dinner fork" deformity.
- Smith's fracture: Flexion-type fracture with palmar (volar) displacement.
- Barton's fracture: Intra-articular fracture-dislocation of the distal radius.
- Chauffeur's fracture: Fracture of the radial styloid.
- Scaphoid fracture: The most common carpal bone fracture, particularly in young adults. High risk of nonunion and avascular necrosis due to tenuous blood supply — early MRI diagnosis is critical.
- Other carpal fractures: Fractures of the lunate, triquetrum, hamate, capitate, trapezium, trapezoid, or pisiform — often missed on X-ray and best identified on MRI.
- Open vs. closed: Open fractures involve a break in the skin and require urgent treatment.
- Displaced vs. non-displaced: Whether bone fragments have moved from normal alignment — a key determinant of treatment.
- Comminuted: Fracture with multiple bone fragments.
- Intra-articular vs. extra-articular: Whether the fracture extends into the joint surface.
Treatments
Treatment depends on fracture type and severity, patient age, activity level, and hand dominance.
Initial management: Splint immobilization to prevent further injury, ice and elevation to reduce swelling, and appropriate pain management with acetaminophen, NSAIDs, or prescription analgesics as needed.
Non-surgical treatment: Non-displaced or successfully reduced fractures are treated with cast immobilization, typically for 4–8 weeks depending on fracture type and healing progress. Closed reduction — manipulation of the bones back into alignment under local anesthesia — is performed for displaced fractures amenable to non-surgical management. Regular follow-up X-rays confirm maintained alignment during healing.
Surgical treatment in displaced, unstable, or complex fractures
Surgery is indicated for unstable fractures, displaced intra-articular fractures, open fractures, fractures with neurovascular injury, and fractures that cannot be successfully reduced closed. Options include:
- Open reduction and internal fixation (ORIF): Realignment and stabilization with plates, screws, or pins — the most common surgical approach for displaced distal radius fractures.
- Percutaneous pinning: Pins placed through the skin to stabilize the fracture, used for certain distal radius and scaphoid fractures.
- External fixation: A frame applied outside the skin with pins anchored into bone, used for severely comminuted fractures or those with significant soft tissue injury.
- Bone grafting: Required for fractures with bone loss or for treating established nonunion.
Scaphoid fracture considerations
Non-displaced scaphoid fractures may be treated with prolonged cast immobilization (8–12 weeks or longer). Displaced or proximal pole fractures typically require surgical fixation due to high risk of nonunion and avascular necrosis. Early MRI diagnosis is essential — a missed scaphoid fracture treated as a sprain can lead to permanent wrist damage.
Rehabilitation and recovery
Hand therapy begins after appropriate healing, focusing on restoring range of motion, grip strength, and functional use. Most patients regain good function, though full recovery may take several months. Potential complications include malunion, nonunion, post-traumatic arthritis, stiffness, median nerve injury, tendon rupture, and complex regional pain syndrome — all of which are best detected and monitored with follow-up imaging.
Get an MRI to Confirm Your Diagnosis
Before surgical planning or starting treatment, a clear MRI diagnosis ensures the right path forward. First Look MRI offers self-pay Wrist MRI scans — no doctor's order or insurance required — at our locations in Georgia, Texas, and Colorado.