Wrist injuries
Snuffbox tenderness means splint and follow-up, even if the X-ray is normal. Check the median nerve before and after any reduction.
Two patients after a fall on the outstretched hand.
First: a 65-year-old woman slipped in her bathroom. Her right wrist looks like a "dinner fork" from the side, swollen, with tingling in her thumb and index finger. Rings still on.
Second: a 20-year-old man fell off his motorbike. He has tenderness in the anatomical snuffbox and pain when you push his thumb towards the wrist. His wrist X-ray is reported as normal.
What injury does each have, what do you do now, and how do you avoid missing the second one?
- Remove rings nowBefore the hand swells.
- Median nerve and circulationSensation over index finger and thumb, capillary refill, radial pulse. Before and after any manipulation.
- Feel systematicallyDistal radius, ulnar styloid, snuffbox, scaphoid tubercle, base of thumb, elbow.
- X-rayAP and lateral wrist. Add scaphoid views if any scaphoid sign.
- Displaced distal radiusReduce under haematoma block or sedation, back slab, re-X-ray.
- Suspected scaphoid, normal X-raySplint and arrange MRI, or repeat X-ray at 10–14 days.
- ElevateSling, finger exercises.
- Fracture clinicWithin a week. Older women: bone health assessment.
- Median nerve symptoms (tingling or numb thumb, index and middle fingers)
- Open fracture
- Severe displacement or skin tenting
- Circulation problems
- Perilunate or lunate dislocation
- Unstable or intra-articular fracture
- Scaphoid fracture with a normal first X-ray
- Acute carpal tunnel syndrome
- Perilunate or lunate dislocation
- Distal radioulnar joint injury (Galeazzi)
- Elbow injury from the same fall
- Osteoporosis in older women
| Paracetamol | 1 g 4 times daily |
| Ibuprofen | 400 mg 3 times daily with food |
| Haematoma block | Lidocaine 1% up to 10 mL into the fracture haematoma (max 3 mg/kg plain) |
| Acceptable distal radius position (guide) | Dorsal tilt under about 10°, radial shortening under 3 mm, step in the joint under 2 mm (varies with age and function) |
| Scaphoid follow-up | MRI within days, or repeat X-ray at 10–14 days |
| Scaphoid risks | Avascular necrosis and non-union of the proximal pole |
Check every dose against a current drug reference and your hospital protocol.
On this page
The injury by age
A fall on the outstretched hand (FOOSH) causes different injuries at different ages:
- Children: buckle (torus) and greenstick fractures of the distal radius, growth plate (Salter-Harris) injuries.
- Young adults: scaphoid fractures, high-energy distal radius fractures, carpal dislocations.
- Older adults, especially women with osteoporosis: distal radius (Colles) fractures.
History
- How did they fall? Onto the palm (FOOSH) or the back of the hand? Height, speed (motorbike)?
- Dominant hand, job, hobbies (decides how perfect the result must be).
- Tingling or numbness in the fingers.
- Previous wrist injuries, osteoporosis, steroids.
- In children: does the story fit? Any other injuries?
Examination
- LookDeformity (dinner fork = Colles), swelling, bruising, wounds.
- FeelDistal radius, ulnar styloid, anatomical snuffbox, scaphoid tubercle, base of thumb, carpal bones, then the elbow.
- Scaphoid testsSnuffbox tenderness, scaphoid tubercle tenderness, pain on thumb axial compression, pain on ulnar deviation.
- NervesMedian (index fingertip), ulnar (little fingertip), radial (back of the thumb web).
- CirculationCapillary refill, radial and ulnar pulses.
Distal radius fractures
| Type | Displacement | Mechanism | Notes |
|---|---|---|---|
| Colles | Distal fragment tilted and displaced dorsally (back of hand) | Fall on outstretched hand | "Dinner fork"; commonest in older women |
| Smith | Distal fragment tilted toward the palm | Fall on a flexed wrist | "Reverse Colles"; often unstable |
| Barton | Intra-articular rim fracture with carpal subluxation | Higher energy | Usually needs surgery |
| Buckle (torus) | Cortex bulges, no break through | Children | Splint for 3 weeks; no follow-up X-ray usually |
| Greenstick | One cortex broken | Children | May need reduction if angulated |
- Analgesia and consentExplain the procedure.
- Haematoma blockClean skin, aspirate fracture blood, inject lidocaine 1% up to 10 mL (within 3 mg/kg). Wait 10 minutes.
- ReduceTraction to disimpact, then correct the tilt (for Colles: flex and ulnar-deviate the distal fragment).
- Back slabBelow-elbow, moulded, leaving fingers and thumb free.
- CheckRe-X-ray, median nerve, circulation, sling, elevate. Fracture clinic in a week.
Suspected scaphoid fracture
The scaphoid gets its blood supply from the distal end. A fracture through the waist or proximal pole can cut off the blood to the proximal part, causing avascular necrosis, non-union and early arthritis. Up to a fifth of scaphoid fractures don't show on the first X-ray.
- Cast or scaphoid splint
- fracture clinic
- displaced or proximal pole: surgery
- Splint
- MRI within days (or CT)
- or repeat X-ray at 10–14 days
- Sprain management
- return if not better in 2 weeks
Carpal dislocations
Perilunate and lunate dislocations follow high-energy falls. Severe swelling, median nerve symptoms, and on the lateral X-ray the lunate no longer sits in line with the radius and capitate ("spilled teacup" sign). Urgent orthopaedics: these are easily missed and need early reduction.
Acute carpal tunnel syndrome
Increasing numbness in the median nerve distribution after a wrist fracture or reduction, with pain. Release the cast to the skin, elevate, and call orthopaedics urgently: it may need surgical decompression.
Treatment doses
Common mistakes
- Leaving rings on a swelling hand.
- Calling a wrist "sprained" without examining the scaphoid.
- Discharging a suspected scaphoid fracture with a normal X-ray and no follow-up.
- Not checking the median nerve before and after reduction.
- Missing a carpal dislocation on the lateral X-ray.
- Forgetting the elbow in a FOOSH injury.
- Not starting a bone health assessment in an older woman.
Come back if
- Fingers numb, cold, pale or blue.
- Plaster too tight, or pain getting much worse.
- A "sprain" not better after 2 weeks.
Frequently asked questions
What should be done if a scaphoid fracture is suspected but the X-ray is normal?
Splint the wrist and arrange an MRI (or CT), or repeat the X-ray at 10–14 days. A missed scaphoid fracture can lead to avascular necrosis.
What is a Colles fracture?
A distal radius fracture with the distal fragment displaced and tilted towards the back of the hand, usually from a fall on an outstretched hand, giving a "dinner fork" deformity.
What is the difference between Colles and Smith fractures?
Both are distal radius fractures. In Colles the fragment tilts towards the back of the hand; in Smith it tilts towards the palm.
How is a haematoma block done?
Under clean conditions, a needle is passed into the fracture, blood is aspirated to confirm position, and up to 10 mL of 1% lidocaine (within the maximum dose) is injected. Wait about 10 minutes before reducing.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A woman fell on an outstretched hand. The distal radius fragment is angled dorsally. What fracture is this?
Answer: Colles fracture. Colles: dorsal angulation, "dinner fork" deformity.
- Barton fracture: Rim fracture with subluxation.
- Smith fracture: Volar angulation.
- Scaphoid fracture: Different bone.
- Galeazzi fracture: Shaft fracture with DRUJ injury.
2. A young man has anatomical snuffbox tenderness after a fall, but scaphoid X-rays are normal. What is the best plan?
Answer: Splint and arrange MRI. Suspected scaphoid fracture: immobilise and image again (MRI or repeat X-ray).
- Steroid injection: No.
- Surgery now: Not without confirmation.
- Crepe bandage only: Not enough.
- Discharge without follow-up: Missed fractures cause avascular necrosis.
3. Why is a missed scaphoid fracture dangerous?
Answer: Risk of avascular necrosis. Retrograde blood supply to the proximal pole makes non-union and avascular necrosis likely.
- Risk of nerve cut: No.
- Risk of compartment syndrome: Uncommon.
- Risk of DVT: No.
- Risk of sepsis: No.
4. A 70-year-old woman falls on her outstretched hand and has a ‘dinner fork’ wrist deformity. X-ray shows a distal radius fracture with dorsal angulation. What is it?
Answer: Colles fracture. Colles fracture: distal radius within 2.5 cm of the wrist with dorsal displacement/angulation (dinner fork), commonly in osteoporotic women after FOOSH. Smith (reverse Colles): volar displacement from fall on flexed wrist. Barton: intra-articular fracture-dislocation of the radial rim. Treat by closed reduction and cast, or ORIF if unstable. Complications: malunion, median nerve compression, EPL rupture, complex regional pain syndrome. Check bone density.
- Smith fracture: Smith fracture has volar displacement.
- Barton fracture: Barton fracture is an intra-articular rim fracture.
- Monteggia fracture: Monteggia is an ulna fracture with radial head dislocation.
5. After falling onto the back of a flexed wrist, a woman’s X-ray shows a distal radius fracture with volar (palmar) displacement of the distal fragment (‘garden spade’ deformity). What is it?
Answer: Smith fracture. Distal radius fractures: Colles — extra-articular, dorsal displacement/angulation (‘dinner fork’), FOOSH, osteoporotic women; Smith (reverse Colles) — volar displacement, fall on flexed wrist, unstable — usually needs ORIF (volar plate); Barton — intra-articular fracture of dorsal or volar rim with radiocarpal subluxation; chauffeur — radial styloid. Complications: malunion, median nerve injury/carpal tunnel, EPL rupture (Colles, late), CRPS.
- Colles fracture: Colles fracture has dorsal displacement.
- Barton fracture: Barton fracture is an intra-articular rim fracture.
- Chauffeur fracture: Chauffeur fracture involves the radial styloid.
6. After a fall on the outstretched hand, a young man has tenderness in the anatomical snuffbox, but the X-ray looks normal. Which bone is likely injured, and what is the main risk?
Answer: Scaphoid; avascular necrosis. The scaphoid is the most commonly fractured carpal bone. Its blood supply enters distally, so a waist fracture can cut off the proximal pole, causing avascular necrosis and non-union. Early X-rays may miss it, so the wrist is immobilised and imaged again (or MRI is done). The radial artery runs in the floor of the snuffbox.
- Lunate; carpal tunnel syndrome: Lunate dislocation can compress the median nerve, but snuffbox tenderness points to scaphoid.
- Distal radius; malunion: Colles' fracture; tender over distal radius.
- Hamate; ulnar nerve injury: Hook of hamate fracture affects the ulnar nerve.
- Trapezium; thumb base arthritis: Not the usual injury.
7. After a supracondylar fracture of the humerus, a child cannot flex the index finger when making a fist (pointing index, 'hand of benediction') and the thenar muscles are weak. Which nerve is injured?
Answer: Median nerve at the elbow. A median nerve injury at the elbow paralyses the forearm flexors it supplies (FDS, lateral FDP, FPL) and thenar muscles. On making a fist, the index (and middle) finger stays straight. Injury at the wrist (carpal tunnel) spares forearm flexors, causing only thenar weakness and sensory loss. Supracondylar fractures also risk the brachial artery (Volkmann's contracture).
- Ulnar nerve at the elbow: Clawing of ring and little fingers.
- Radial nerve in the spiral groove: Wrist drop.
- Median nerve at the wrist only: Spares the long finger flexors.
- Musculocutaneous nerve: Weak elbow flexion.
References and dose sources
- NICE NG38 — Fractures (non-complex): assessment and management
- BOAST — Distal radius fractures
- Lidocaine (lignocaine) dosing: Drugs.com: Lidocaine dosage (see also our lidocaine (lignocaine) dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.