Broken Wrist: Plaster or Surgery?

The story I hear most often: a slip on a wet bathroom floor, a missed step on the stairs, a fall off a stool while cleaning the top of a cupboard before Diwali. You put your hand out, and the wrist takes the whole force.

In most adults this breaks the end of the radius, the larger forearm bone, just above the wrist joint — a distal radius fracture.

Two people with “a fracture in the wrist” can be given completely different advice, because what matters is:

• Displacement — whether the broken ends have stayed in line or shifted, tilted or shortened.
• The joint surface — whether the crack runs into the wrist joint and leaves a step in the smooth cartilage.
• Stability — whether the bone is crushed into many pieces, which makes it likely to slip again.
• You — your age, bone strength, which hand is dominant, and what your hands do all day.

A thirty-year-old tailor and a seventy-five-year-old grandmother with the same X-ray may sensibly end up with different treatment. Neither choice is wrong.

A fracture that has not moved, or barely moved, almost always heals well in a plaster or fibreglass cast. Many moderately displaced fractures can also be treated without an operation: I numb the area, gently pull the bone back into position (a closed reduction), and hold it with a moulded plaster.

The catch is that a reduced fracture can slowly slip back over the first week or two, before the bone starts to knit. So a repeat X-ray in the first one to two weeks is not optional. If the position holds, you carry on in the cast. If it slips beyond what is acceptable, that is the moment to discuss surgery, while the bone can still be moved easily.

For older adults, there is an honest point that is not said often enough. In people over about 65 who do not put heavy demands on their wrists, a cast often gives much the same function a year later as an operation, even when the X-ray does not look perfect. The wrist may look a little different, but daily life — cooking, bathing, holding a grandchild — usually goes back to normal.

A cast typically stays on for about five to six weeks for an adult. Children heal faster, and the common “buckle” fracture in a child often needs only a removable splint for a few weeks.

I recommend an operation when it is likely to give you a clearly better wrist than plaster would, usually when:

• The bone is badly displaced, shortened or angled and cannot be held in a good position by a cast.
• The break runs into the joint and leaves a step in the joint surface, which can lead to stiffness and early arthritis if left.
• The fracture slips again in plaster at the one or two week check.
• The bone has broken through the skin (an open fracture).
• Both wrists are broken, or other injuries make weeks in a cast impractical.
• A younger, active person whose work depends on full wrist movement and grip — a mechanic, a cook, a cricketer, a dentist.

The most common operation today uses a small titanium plate and screws on the palm side of the wrist. Most patients can then start gentle wrist movement within the first couple of weeks instead of waiting six weeks in plaster. For simpler breaks, thin wires (K-wires) passed through the skin with a plaster afterwards are an option. Badly crushed fractures sometimes need an external frame for a few weeks.

Earlier movement is an advantage, but surgery is not a shortcut to full recovery. At a year, many people in plaster and many people with plates end up in a similar place.

Go to an emergency department straight away if any of these follow a fall on the wrist:

• A wound over the fracture, or bone visible through the skin.
• Obvious deformity — the wrist bent into a step or “fork” shape.
• Numbness or tingling in the fingers, especially the thumb, index and middle fingers.
• A hand that is cold, pale or blue.
• A fall from a height, a road accident, a head injury, or pain elsewhere — especially the hip in an elderly person. Please read my guide on hip fracture in elderly parents if an older relative cannot stand after the fall.

Once a cast is on, come back the same day if pain keeps getting worse instead of better, the fingers swell badly or change colour, you cannot move your fingers, or numbness and tingling start. These can mean the cast is too tight or pressure is building on a nerve. Do not cut the cast yourself, and do not wait for morning.

One more trap: pain at the base of the thumb after a fall, with a “normal” X-ray. This can be a fracture of the scaphoid, a small wrist bone that often does not show up on the first X-ray. If missed, it can fail to heal, so it is protected in a splint and re-checked with a repeat X-ray or scan.

Whichever treatment you have, the bone itself usually takes around six weeks to become solid enough to come out of the cast. My article on how long a broken bone takes to heal explains why some people take longer.

A typical adult course, though everyone varies:

• First two weeks: swelling and pain settle. Desk work is often possible.
• Around six weeks: the cast comes off, or the wrist is out of its splint after surgery. Expect it to feel stiff and weak at first; this is normal.
• Two to three months: most daily activities, including cooking and typing, are back. Driving resumes once you can grip the wheel firmly and safely.
• Six months to a year: grip strength and the last bit of movement keep improving. Heavy lifting and push-ups come towards the end.

Physiotherapy and your own daily exercises matter more than which treatment you had. Turning the palm up, as you do to receive change or hold a thali, is often the last movement to come back.

Keep the elbow and shoulder moving throughout; a shoulder held still in a sling for weeks can stiffen much like a frozen shoulder. And if you are over 50 and broke your wrist in an ordinary fall, ask about a bone density test (see the questions below).

Patients looking for the best orthopaedic care in Mira Road after a wrist fracture need an honest decision quickly, because the window for correcting a slipped fracture is short. Surgicare Plus is one of the leading joint replacement and arthroscopy practices in Mira Road, with fellowship-trained expertise in trauma reconstruction, and we are trusted by patients across Mira Bhayandar, Vasai-Virar and Thane. I see every patient myself, from first consultation to last follow-up.

At the first visit I examine the hand, check the nerves and circulation, and go through the X-rays with you, including what will happen if the bone slips. Where plaster is reasonable, we start there, and I arrange the repeat X-rays at the right time so nothing is missed. If surgery is genuinely the better option, I explain why, what the operation involves, and give you an honest written estimate.

Wrist fracture surgery is done at our associated hospitals — Wockhardt Hospital, Gurukripa Hospital, Orbit Hospital and Apollo Spectra. Advanced robotic knee replacement (MISSO) is done at Wockhardt Hospital, Mira Road. Follow-up and cast checks continue at the clinic at Shop No. 40-41, Poonam Cluster 2, Mira Road East, open Monday to Saturday, 10 am to 8 pm, and Sundays by appointment.

Already have an X-ray? WhatsApp it to +91 94219 91530 for a first opinion. More about the practice is on the Mira Road clinic page.