Distal radius fractures, or broken wrists, are one of the most common musculoskeletal injuries seen by surgeons. They range from simple, stable breaks to highly complex fractures that shatter the joint surface. Deciding on the best treatment is a nuanced process that goes far beyond the X-ray, requiring a surgeon to balance the fracture pattern with the patient’s bone quality, functional demands, and long-term goals.

Classifying the Fracture Pattern

The first step in management is understanding the nature of the break, which typically falls into one of several categories:

• Extra-articular Fractures: These breaks occur outside the wrist joint (the radiocarpal joint). They are often “fragility fractures” caused by low-energy falls in patients with osteoporosis, but can also result from high-energy trauma in younger patients.
• Intra-articular Fractures: These are more complex injuries where the fracture line extends into the joint surface.
• Comminuted Fractures: These are among the most challenging, as the bone is broken into multiple fragments.
• Volar Marginal Fragments: A specific and challenging pattern where a small piece of the joint breaks off, which can lead to persistent instability if not properly identified and fixed.
• Radiocarpal Fracture-Dislocations: These are severe, high-energy injuries involving both a fracture and a dislocation of the wrist joint. They are often associated with significant soft tissue and ligament damage and require prompt surgical intervention.

Surgical Goals and Strategies

While stable, non-displaced extra-articular fractures can often be treated non-operatively with a cast, most complex fractures require surgery. The primary goal of surgery is to restore stable, anatomic alignment and a smooth joint surface to prevent long-term arthritis.

For complex and comminuted fractures, a CT scan is often necessary to fully visualize the fragments and plan the operation. Surgical techniques may involve:

• Open Reduction and Internal Fixation (ORIF): Using advanced volar locking plates and screws to rebuild the bone.
• Fragment-Specific Fixation: Using smaller, targeted plates or wires to secure specific fragments, such as the volar marginal fragment.
• Arthroscopic-Assisted Fixation: Using a camera inside the joint to ensure the articular surface is perfectly recreated.

Addressing Associated Injuries

High-energy fractures can cause significant swelling, leading to associated conditions like acute carpal tunnel syndrome. In such cases, patients may experience numbness or tingling in their fingers. When surgery is performed to fix the fracture, the surgeon can also perform an endoscopic carpal tunnel release through a small, minimally invasive incision to relieve pressure on the nerve and reduce postoperative pain.