Distal-radius and scaphoid fractures — Rapid

Synopsis

Assess distal-radius deformity and median-nerve risk, detect occult scaphoid injury, use timely reduction and appropriate MRI or fixation pathways, and prevent collapse, nonunion and stiffness.

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.

Key red flags

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.

Dorsal distal-radius fracture

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

Median-nerve compromise

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

Perilunate injury

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

Investigation priorities

PA and true lateral wrist radiographsFirst step

Define distal-radius displacement, articular extension and carpal alignment.

First-line MRI for suspected scaphoid fractureFirst line

Confirm occult fracture and identify alternative bone or soft-tissue injury early.

Management branches

Distal-radius emergency careReduce tissue-threatening deformity

A displaced distal-radius fracture presents with deformity or nerve and skin concern.

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

Key medicines

Paracetamol for adult wrist painUse 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.

Intravenous regional anaesthesiaUse 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.

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