Distal-radius and scaphoid fractures

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Distal-radius description includes articular extension, dorsal or volar tilt, radial height and inclination, comminution, ulnar styloid and distal-radioulnar relationship. Treatment considers age, baseline function, bone and displacement rather than radiographs alone. Immediate goals are skin and nerve safety, analgesia and acceptable reduction. Finger, elbow and shoulder movement begin early, and cast fit is reviewed as swelling changes.

Scaphoid injury is diagnosed clinically before it is radiographically obvious. Palpate anatomical snuffbox and tubercle and assess axial thumb load cautiously. MRI can confirm or exclude fracture early and identify other injury. CT defines displacement and union when relevant. The proximal pole's retrograde supply explains its higher nonunion and avascular-necrosis risk. A clear pathway prevents unnecessary prolonged casting while protecting genuine occult fractures.

For distal-radius reduction, establish whether deformity threatens skin or median nerve and select analgesia before manipulation. NICE advises considering intravenous regional anaesthesia in adults when trained staff and monitoring are available. Re-image after a well-moulded splint and record whether radial height, tilt and articular congruity are restored. When surgery is chosen, intra-articular fractures should be treated within 72 hours and extra-articular fractures within 7 days, with earlier intervention for open injury, nerve compromise or irreducible deformity. Re-displacement requires prompt review rather than waiting for routine clinic.

Definitive distal-radius treatment is patient specific. Stable alignment may be casted with early finger movement and subsequent wrist rehabilitation. If a dorsally displaced fracture can be reduced closed to an acceptable joint surface, percutaneous K-wire fixation is considered; inability to restore the joint closed supports open reduction and internal fixation. In selected older adults, moderate residual displacement may be accepted after discussion of functional goals and operative risk. The distal radioulnar joint and ulnar styloid are assessed from stability, not from an isolated fragment label.

A scaphoid pathway distinguishes diagnosis from union. MRI is the supported early diagnostic test for a clinically suspected fracture; CT is more useful for measuring displacement and cortical healing. Distal-pole fractures generally have better perfusion than waist and proximal-pole injuries. Displacement, proximal location, carpal instability and occupational demand increase the value of hand-surgery review and fixation. Smoking cessation is clinically important. Persistent pain after an apparently united fracture warrants assessment for nonunion, osteonecrosis, scapholunate injury or early scaphoid-nonunion advanced collapse.

Older and frail patients need ring removal, cast-pressure surveillance, analgesic review and early return of independence. A fragility distal-radius fracture is a sentinel event for fracture-liaison and falls prevention. Pregnancy does not preclude necessary wrist radiographs or MRI, but medicines and procedural anaesthesia are selected for gestation. Anticoagulants may increase swelling and bruising; new median symptoms still demand immediate examination rather than attribution to medication. At discharge, state which fingers and joints should move, when the cast and wound are reviewed and who owns any MRI result.

Follow-up after distal-radius treatment measures finger flexion, forearm rotation, wrist motion, grip and the ability to perform personal and occupational tasks. Cast removal is not the end of care: swelling, tendon irritation and weakness can persist. New inability to extend the thumb suggests extensor pollicis longus rupture and needs hand review. Ulnar-sided pain may arise from distal-radioulnar instability or altered loading. Disproportionate allodynia and autonomic change raises complex regional pain concern after structural complications are excluded, favouring early desensitisation and multidisciplinary rehabilitation.

Scaphoid follow-up must distinguish tenderness from proven union. Review MRI and CT in the context of fracture site and symptoms, and do not return a manual worker or contact athlete to heavy load solely because pain has improved. Nonunion assessment considers deformity, sclerosis, proximal-pole viability and carpal alignment. Treatment can require fixation and bone graft, with vascularised options for selected perfusion problems. A patient whose MRI excludes fracture should leave immobilisation promptly and receive a diagnosis and rehabilitation plan for the actual wrist injury.

Key points

Remove rings and inspect deformity, wounds and skin; document median, anterior interosseous, ulnar and radial motor and sensory function and perfusion.
Obtain PA and lateral wrist radiographs for distal-radius injury and dedicated scaphoid views when radial-sided tenderness is present.
Reduce severe displacement promptly under adequate analgesia, apply a well-moulded splint and repeat neurovascular examination and radiographs.
NICE advises considering intravenous regional anaesthesia for adult dorsally displaced distal-radius reduction when appropriately trained staff are available.
When surgery is needed, NICE timing is within 72 hours for intra-articular and within 7 days for extra-articular distal-radius fracture, with earlier action for tissue threat.
If closed reduction of a dorsally displaced fracture restores the joint adequately, percutaneous K-wire fixation is considered; open reduction is used when the joint cannot be satisfactorily reduced closed.
For suspected scaphoid fracture after a thorough examination, NICE recommends considering MRI as the first-line imaging investigation.
If immediate MRI is unavailable, immobilise and arrange a defined early imaging pathway; never discharge persistent snuffbox tenderness without ownership.
Scaphoid waist and proximal-pole displacement, nonunion risk and patient demand guide fixation versus cast treatment.
After fragility distal-radius fracture, connect falls and bone-health assessment through the current fracture-liaison service.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Fragility fall

A fall onto an outstretched hand commonly produces a dorsally angulated distal-radius fracture in osteoporotic bone.

High-energy wrist load

Collision or fall from height creates intra-articular comminution, volar displacement, carpal instability and neurovascular or soft-tissue injury.

Scaphoid compression

Force through an extended radially deviated wrist compresses the scaphoid between radius and distal carpus, often fracturing its waist.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Distal-radius malalignment
Loss of radial height, inclination or volar tilt changes radiocarpal and distal-radioulnar mechanics and can impair rotation and grip.
2
Median-nerve compression
Volar displacement, swelling or a tight cast raises carpal-tunnel pressure and can cause progressive sensory and motor deficit.
3
Scaphoid blood supply
Most inflow enters distally and travels retrograde, leaving the proximal pole vulnerable to avascular necrosis after waist or proximal fracture.
4
Occult early fracture
A nondisplaced scaphoid line may be invisible initially, yet continued loading and delayed protection can promote displacement and nonunion.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Dorsal distal-radius fractureRed flag

Dinner-fork deformity, swelling and wrist pain follow a fall on the outstretched hand.

Median-nerve compromiseRed flag

Progressive thumb, index and middle-finger paraesthesia or thenar weakness after swelling or reduction is urgent.

Occult scaphoid fracture

Snuffbox or tubercle tenderness and radial-sided pain persist despite normal initial radiographs.

Perilunate injuryRed flag

High-energy pain, abnormal carpal alignment and median symptoms suggests an unstable carpal dislocation.

Proximal scaphoid risk

Proximal-pole fracture carries greater nonunion and osteonecrosis risk because its blood supply is vulnerable.

Red flags requiring action

Progressive median paraesthesia, thenar weakness, severe volar swelling or increasing pain after reduction suggests acute carpal-tunnel compromise.
An open wound, non-blanching skin, cool hand or irreducible carpal deformity requires immediate hand and vascular escalation.
Snuffbox or scaphoid-tubercle tenderness with negative radiographs remains an occult scaphoid injury until definitive imaging or follow-up excludes it.
High-energy wrist pain with altered carpal arcs or median symptoms may be perilunate dislocation rather than an isolated distal-radius fracture.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
PA and true lateral wrist radiographsFirst step
Why
Define distal-radius displacement, articular extension and carpal alignment.
Interpretation and limitations
Review tilt, height, inclination and distal radioulnar and perilunate relationships, then repeat after reduction.
02
Dedicated scaphoid radiographs
Why
Look for waist, distal or proximal fracture after radial-sided clinical findings.
Interpretation and limitations
A normal early series does not exclude an occult fracture.
03
First-line MRI for suspected scaphoid fractureFirst line
Why
Confirm occult fracture and identify alternative bone or soft-tissue injury early.
Interpretation and limitations
NICE supports considering MRI first line after clinical examination; arrange protected follow-up if immediate access is unavailable.
04
CT for scaphoid geometry or union
Why
Define displacement, cortical bridging and operative anatomy.
Interpretation and limitations
CT complements MRI and is particularly useful when displacement or healing is the question.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Wrist sprain

Diffuse soft-tissue pain may settle quickly, but persistent focal radial-sided bony tenderness requires a structured occult scaphoid assessment pathway.

Perilunate dislocation

High-energy carpal pain, abnormal alignment and median symptoms can be missed unless lateral carpal relationships are reviewed carefully.

Hook of hamate fracture

Ulnar-palmar pain after bat or racquet impact, local tenderness and pain gripping points away from the scaphoid toward hamate injury.

De Quervain tenosynovitis

Radial styloid tendon pain with thumb movement is usually atraumatic and lacks focal snuffbox or tubercle bony tenderness.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Distal-radius emergency careReduce tissue-threatening deformityFirst stepA displaced distal-radius fracture presents with deformity or nerve and skin concern.

1Remove rings, give analgesia and document skin, perfusion and named nerve functions.
2Perform controlled reduction with suitable anaesthesia, apply a moulded splint and repeat examination.
3EscalationObtain post-reduction radiographs and escalate open, irreducible, nerve or unstable articular injury.

02Definitive distal radiusMatch fixation and timing to patternDefinitiveThe reduced fracture requires operative assessment.

1Assess articular reduction, alignment, stability, patient function and bone quality.
2Use K wires when satisfactory closed articular reduction is achievable and open reduction when it is not.
3Meet the 72-hour intra-articular or 7-day extra-articular surgery target unless more urgent tissue factors apply.

03Suspected scaphoidProtect and prove earlyClinical scaphoid findings persist with or without a visible line.

1PreferredImmobilise appropriately and arrange early MRI as the preferred diagnostic route when available.
2Use CT for displacement or union questions and obtain hand-specialist review for proximal, displaced or unstable fracture.
3DefinitiveAlternativeStop immobilisation when definitive imaging excludes fracture and provide an alternative diagnosis and safety net.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Provides baseline analgesia before reduction and through early recovery.

Paracetamol for adult wrist pain

Use an oral adult dose of 500 mg to 1 g when required, separated by 4 hours or longer and capped at four doses during 24 hours.

Reduce the maximum in low body weight or hepatic risk and count all combination preparations.

NICE recommends considering this technique for adult dorsally displaced distal-radius reduction.

Intravenous regional anaesthesia

Use the local weight-based prilocaine or approved local-anaesthetic regimen only in a monitored setting with trained staff, correct tourniquet technique and toxicity rescue.

Follow maximum-dose, vascular-access, tourniquet-time and local-anaesthetic-toxicity protocols; not suitable for every patient or setting.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Distal-radius malunion

Persistent shortening, abnormal tilt or articular incongruity can cause deformity, ulnocarpal loading, reduced forearm rotation and post-traumatic arthritis.

Median neuropathy

Acute pressure or later malunion can cause sensory loss, nocturnal symptoms and thenar weakness requiring decompression or correction.

Scaphoid nonunion

Delayed diagnosis, proximal location, smoking and fracture displacement increase failure of union, persistent wrist pain and progressive carpal collapse.

Avascular necrosis

Proximal scaphoid fragments can lose retrograde perfusion, causing sclerosis, structural collapse, painful nonunion and progressive degenerative wrist change.

Complex regional pain

Disproportionate persistent pain, allodynia, stiffness, swelling and autonomic change can prolong disability after either wrist injury and complicate rehabilitation.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Recheck finger colour, swelling, median symptoms and cast pressure after reduction and as oedema changes.
Confirm maintained distal-radius alignment according to stability and treatment pathway.
Track finger, wrist, elbow and shoulder movement to prevent avoidable stiffness.
Ensure every suspected scaphoid has a completed imaging result and named reviewer.
Monitor scaphoid tenderness and union, especially in proximal, displaced fractures and smokers.
After fragility injury, confirm osteoporosis and falls actions have an accepting service.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Median symptoms can evolve

A normal initial hand examination does not protect against acute carpal-tunnel pressure developing after swelling or reduction.

MRI avoids two errors

Early confirmation prevents both missed occult fracture and unnecessary weeks of immobilisation for a wrist sprain.

Scaphoid supply runs backwards

Distal entry of vessels makes the proximal pole most vulnerable after a waist fracture.

Alignment is functional anatomy

Radial height and tilt affect distal-radioulnar loading, forearm rotation and long-term grip.

11Common pitfallsFrequent interpretation and management errors.

01
Leaving rings on a swelling hand or failing to repeat median-nerve findings after reduction.
02
Accepting a post-reduction film without reviewing carpal and distal-radioulnar alignment.
03
Calling normal initial scaphoid radiographs a definitive exclusion despite focal tenderness.
04
Keeping a patient immobilised indefinitely because no one owns the MRI result.
05
Missing falls and osteoporosis care after a fragility distal-radius fracture.