Assessment and Management of Wrist and Forearm Injuries

WRIST
ANATOMY
Describe the anatomy within the scope as an NP, including: Bones, ligaments, tendons and soft tissues of the wrist Neurovascular anatomy
HISTORY
Undertake a full history Understanding the importance of MOI, hand dominance, occupation and hobbies.
EXAMINATION
Demonstrates a full wrist assessment. (with special consideration for assessment of scaphoid injury)
Understands the indications is able to demonstrate special tests to assess function or injury (examples include): Finkelstein Phalens Tinels Froments
INVESTIGATIONS
Demonstrate understanding of indications and contraindications for X-ray.
Interpret wrist Xray. (Understanding own limitations and when to request advice/review.)
MANAGEMENT
Can discuss different types of presentations and their management including: • Fractures • Tendon/ligamentous injury • Dislocations • Carpel tunnel • Soft tissue injury/infection Knows where to find local guidance for management and advice of specific injuries.









Signed competence at applying: • High arm sling • Wrist splint +/- thumb addition for ? scaphoid # • Below elbow backslab • Ulnar gutter slab • Volar slab • Soft cast






Understands the importance of appropriate advice and follow up, demonstrating safe discharge.

Executive Summary

This document provides a comprehensive clinical briefing for the assessment and management of wrist and forearm injuries, tailored for Emergency Department (ED) practitioners. Hand and wrist injuries account for up to 20% of all ED attendances in the UK, and their anatomical complexity necessitates a structured and thorough approach to prevent significant long-term morbidity [1, 2].

Critical Takeaways:

Forearm Complexity: Seemingly simple forearm fractures can conceal complex instability. Always obtain imaging that includes the elbow and wrist joints to exclude associated dislocations, such as Monteggia (proximal ulna fracture with radial head dislocation) or Galeazzi (distal radius fracture with distal radioulnar joint [DRUJ] dislocation) patterns [3].
Paediatric Nuances: Children exhibit distinct injury patterns due to open physes and more pliable bone. The Salter-Harris classification is essential for determining prognosis. Torus (buckle) fractures are stable and require minimal intervention, whereas any fracture involving the growth plate requires careful management to mitigate risks of growth arrest [3].
The Occult Scaphoid Fracture: A significant percentage (up to 40%) of acute scaphoid fractures are not visible on initial radiographs [4]. A "clinical scaphoid fracture," defined by anatomical snuffbox tenderness and pain on axial loading of the thumb, must be treated as a confirmed fracture with immobilisation and appropriate follow-up to prevent the debilitating complications of avascular necrosis and non-union [3, 4].
Rotational Deformity: Malrotation in metacarpal or phalangeal fractures is not acceptable. The "scissoring" of fingers upon flexion is a critical sign that necessitates reduction and likely fixation to preserve hand function [2].
BOAST Guidelines for Distal Radius Fractures: Displaced distal radius fractures in adults require timely reduction, often under haematoma or Bier's block, to restore critical anatomical parameters such as radial height, radial inclination, and volar tilt [3, 5]. Articular step-off greater than 2mm, significant radial shortening, or severe angulation are indications for surgical referral [3].

1. Clinically Relevant Anatomy

A detailed understanding of the wrist's intricate anatomy is fundamental to accurate diagnosis and effective management. The wrist serves as the crucial link between the forearm and hand, facilitating a wide range of motion through a complex interplay of bones, ligaments, and neurovascular structures [6].

1.1. Bones and Articulations

The wrist comprises the distal radius and ulna, eight carpal bones, and the proximal metacarpals [6].

Radius & Ulna: These bones are connected by the interosseous membrane, a vital structure for load transmission and stability. The distal radioulnar joint (DRUJ) is a pivot joint critical for forearm pronation and supination [3, 6]. The distal radius normally extends beyond the ulna and has a volar tilt of approximately 11 degrees [3, 5].
Carpal Bones: The eight carpal bones are arranged in two rows. They form a proximal transverse arch that helps distribute forces across the structure [6].
- Proximal Row: Scaphoid, Lunate, Triquetrum, Pisiform. This row is an "intercalated segment," meaning its motion is dictated by surrounding forces rather than direct tendon attachments [4].
- Distal Row: Trapezium, Trapezoid, Capitate, Hamate. This row is more rigidly bound and articulates with the metacarpals [4].
- Mnemonic: Some Lovers Try Positions That They Can't Handle (Scaphoid, Lunate, Triquetrum, Pisiform; Trapezium, Trapezoid, Capitate, Hamate) [2].
Major Articulations: Key joints include the radiocarpal joint (distal radius articulating with scaphoid and lunate), the midcarpal joint (between the two carpal rows), and the carpometacarpal (CMC) joints [6]. The 2nd and 3rd CMC joints are rigid pillars, while the 4th and 5th are mobile to allow for grip formation [2].

1.2. Ligaments and Triangular Fibrocartilage Complex (TFCC)

The stability of the wrist is conferred by a complex network of extrinsic (connecting forearm to carpus) and intrinsic (interconnecting carpal bones) ligaments [4, 6].

Scapholunate (SL) Ligament: The most commonly injured wrist ligament, disruption of which leads to scapholunate dissociation and long-term instability [7].
Lunotriquetral (LT) Ligament: The ulnar equivalent of the SL ligament; injury can lead to volar intercalated segment instability (VISI) [8].
Triangular Fibrocartilage Complex (TFCC): This is a critical stabilising structure on the ulnar side of the wrist, analogous to the meniscus of the knee. It is formed by the triangular fibrocartilage discus, radioulnar ligaments, and ulnocarpal ligaments [6].
- Functions: The TFCC is the primary stabiliser of the DRUJ. It also absorbs compressive forces and transmits approximately 20% of the axial load across the wrist in neutral ulnar variance [6].
- Injury: The TFCC is at high risk for injury from falls onto an outstretched hand (FOOSH), particularly with wrist extension and pronation, or from powerful rotational forces [6].

1.3. Tendons and Compartments

While there are no intrinsic wrist muscles, numerous tendons from forearm muscles cross the joint to act on the hand [6].

Extensor Compartments: The extensor tendons are organised into six fibro-osseous tunnels on the dorsal aspect of the wrist, held in place by the extensor retinaculum [6]. | Compartment | Tendons Contained | | :---------- | :---------------- | | 1 | Abductor Pollicis Longus (APL), Extensor Pollicis Brevis (EPB) | | 2 | Extensor Carpi Radialis Longus (ECRL), Extensor Carpi Radialis Brevis (ECRB) | | 3 | Extensor Pollicis Longus (EPL) | | 4 | Extensor Digitorum (ED), Extensor Indicis (EI) | | 5 | Extensor Digiti Minimi (EDM) | | 6 | Extensor Carpi Ulnaris (ECU) |
Flexor Tendons & Carpal Tunnel: Nine flexor tendons (four Flexor Digitorum Superficialis, four Flexor Digitorum Profundus, and one Flexor Pollicis Longus) pass through the carpal tunnel along with the median nerve. The tunnel's floor is formed by the carpal arch and its roof by the flexor retinaculum (transverse carpal ligament) [2, 6].

1.4. Neurovascular Anatomy

Nerves:
- Median Nerve: Enters the hand through the carpal tunnel. It provides motor function to the thenar muscles ("precision grip") and sensation to the volar thumb, index, middle, and radial half of the ring finger. Compression within the carpal tunnel is a common complication of distal radius fractures [2, 3, 6].
- Ulnar Nerve: Enters the hand via Guyon's canal, running between the pisiform and hamate. It provides motor function to most intrinsic hand muscles ("power grip") and sensation to the little finger and ulnar half of the ring finger [2, 6].
- Radial Nerve: The superficial branch provides sensation to the first dorsal web space and the dorsum of the hand. Its motor branches innervate the wrist and finger extensors more proximally in the forearm [2, 6].
Blood Supply: The wrist is supplied by branches of the radial and ulnar arteries, which form extensive dorsal and palmar anastomotic arches [6].
- Vulnerable Supply: The scaphoid and lunate have tenuous, retrograde blood supplies. The scaphoid is primarily supplied by vessels entering its distal pole and waist; a waist fracture can disrupt blood flow to the proximal pole, leading to a high risk of avascular necrosis (AVN). Similarly, the lunate's variable blood supply makes it susceptible to AVN (Kienböck's disease) following trauma [4, 6].

2. Paediatric vs. Adult Injury Patterns

Children have fundamentally different bone biomechanics, leading to unique fracture patterns and management principles. The physis (growth plate) is the weakest point in the paediatric skeleton [3].

Feature	Paediatric	Adult
Bone Quality	Porous and pliable with a thick periosteum. Tends to fail in compression (buckle) or bending (greenstick) [3].	Brittle and cortical. Tends to fail in shear or with comminution [3].
Weakest Point	Physis (Growth Plate). Ligaments are often stronger than the physis [3].	Ligaments and Metaphysis. Ligaments frequently tear before the bone breaks [3].
Common Patterns	Torus (Buckle): Stable compression failure. <br> Greenstick: Incomplete fracture with plastic deformation. <br> Salter-Harris: Physeal involvement [3].	Comminuted fractures. <br> Intra-articular fractures extending into the joint surface [3].
Remodelling Potential	High. Significant angulation (up to 20-30° in the plane of motion) can be accepted in young children [3, 9].	Low to none. Anatomical restoration is critical, often requiring surgical fixation [3].
Management	Often conservative with casts or splints. Unstable reductions may require K-wires [3].	Often requires Open Reduction Internal Fixation (ORIF) with plates and screws for unstable or intra-articular fractures [3].

The Salter-Harris Classification (Paediatric Physeal Injuries)

This classification is crucial for predicting the risk of growth arrest [3].

Mnemonic: SALTER
- S (I) - Straight across the physis. Good prognosis.
- A (II) - Above the physis (through physis and metaphysis). Most common type, good prognosis.
- L (III) - Lower or Lateral to the physis (through physis and epiphysis). Intra-articular, risk of arthritis.
- T (IV) - Through or Transverse (through metaphysis, physis, and epiphysis). High risk of growth arrest.
- E (V) - Erasure or Rammed (crush injury of the physis). Poor prognosis, high risk of growth arrest.

3. Clinical Assessment

A systematic approach to clinical assessment is paramount. Seemingly minor injuries can mask severe underlying pathology [2].

3.1. History

Hand Dominance & Vocation/Recreation: Essential for understanding the functional impact of the injury and guiding rehabilitation goals [2].
Mechanism of Injury (MOI):
- FOOSH (Fall on an Outstretched Hand): The classic mechanism for distal radius (Colles'), scaphoid, and scapholunate ligament injuries [3, 5].
- Fall onto a Flexed Wrist: Associated with Smith's fractures [4, 10].
- Direct Blow: An isolated ulnar shaft fracture ("nightstick fracture") is a classic defensive injury [3].
- High-Energy Trauma (e.g., fall from height, RTA): Suspect complex, comminuted, or intra-articular fractures and always assess for concomitant injuries to the elbow, shoulder, and spine [3, 5].
- High-Pressure Injection: A surgical emergency. The small entry wound belies extensive internal chemical necrosis and risk of compartment syndrome [2, 11].
- Punching Injury ("Fight Bite"): Any laceration over a metacarpophalangeal (MCP) joint is a human bite until proven otherwise. These have a high risk of septic arthritis from oral flora (e.g., Eikenella corrodens) and require aggressive washout and antibiotics [2, 12, 13].
Paediatric Considerations: If the reported mechanism is incongruent with the injury pattern (e.g., a spiral fracture in a non-ambulatory child), non-accidental injury (NAI) must be considered [3].
Tetanus Status: Must be verified for all open injuries [2].

3.2. Physical Examination

The examination should be methodical: Look, Feel, Move, Special Tests, and Neurovascular Assessment. Always compare with the uninjured side.

Look (Inspection)

Deformity:
- "Dinner Fork" Deformity: Dorsal displacement and angulation characteristic of a Colles' fracture [3, 5].
- "Garden Spade" Deformity: Volar displacement and angulation seen in a Smith's fracture [3, 10].
Resting Posture & Cascade: At rest, the fingers should adopt a progressively flexed posture from the index to the little finger. Disruption of this natural cascade suggests a flexor tendon injury [1, 2].
Rotational Deformity: Unacceptable in any finger fracture. Best assessed by asking the patient to make a loose fist; all fingers should point towards the scaphoid tubercle, and there should be no "scissoring" or overlap [2, 14].
Swelling & Ecchymosis: Note the location and extent. Global hand swelling can be a sign of compartment syndrome, deep space infection, or high-energy crush injury [1].
Wounds: Document location, size, contamination, and any skin loss. Explore every wound thoroughly [1].

Feel (Palpation)

Bony Tenderness:
- Palpate the entire length of the radius and ulna, including the radial head at the elbow and the ulnar styloid [3].
- Anatomical Snuffbox: Tenderness here is a key sign of scaphoid fracture [9].
- Lister's Tubercle: A dorsal landmark on the distal radius. The lunate and capitate lie just distal to it [6].
- Ulnar-sided pain: Tenderness just distal to the ulnar styloid can indicate a triquetral fracture or TFCC injury [8, 15].
DRUJ Instability: A prominent ulnar head that can be depressed but springs back up is known as the "piano key" sign [3].

Move (Range of Motion)

Active vs. Passive: A discrepancy where passive ROM exceeds active ROM suggests tendon or nerve pathology [2].
Pronation/Supination: This movement primarily occurs at the proximal and distal radioulnar joints. Pain or loss of this motion often indicates pathology at the radial head or DRUJ, or a malaligned forearm fracture [3, 6].
Flexion/Extension & Deviation: Assess and compare the total arc of motion to the contralateral wrist [6].

Special Tests

Scaphoid Fracture Tests:
- Anatomical Snuffbox Tenderness: High sensitivity (96%) but low specificity (36%) (LR- 0.15) [9].
- Scaphoid Tubercle Tenderness: Palpation of the volar scaphoid tubercle. Sensitivity ~90%, Specificity ~50% (LR- 0.24) [9].
- Scaphoid Compression Test: Axial loading of the thumb metacarpal towards the scaphoid. Sensitivity ~80%, Specificity ~60% (LR- 0.24) [9].
- Pain on Resisted Supination: Sensitivity ~95%, Specificity ~75% [9].
- Clinical Guideline: A combination of snuffbox tenderness and pain on axial loading should be treated as a scaphoid fracture pending definitive imaging [3].
Ligamentous Instability Tests:
- Scaphoid Shift Test (Watson's Test): To assess for scapholunate ligament injury. With the wrist in ulnar deviation, the examiner applies pressure to the volar scaphoid tubercle and passively moves the wrist into radial deviation. A painful "clunk" as the scaphoid subluxes dorsally is a positive test [16].
- DRUJ Ballottement Test: The examiner stabilises the distal radius and translates the ulnar head in a volar/dorsal direction. Increased laxity or pain compared to the uninjured side suggests instability [3].
Allen's Test: Assesses the patency and collateral circulation of the radial and ulnar arteries. Its routine use in the ED is not essential as the hand has significant vascular redundancy [1].

Neurovascular Assessment

Vascular: Check radial and ulnar pulses. Assess capillary refill time (<2 seconds is normal) and temperature of the digits [2].
Neurological: Perform a systematic check of the median, ulnar, and radial nerves. | Nerve | Motor Test (Simplified) | Autonomous Sensory Zone | | :--- | :--- | :--- | | Median | "OK" sign (tests Anterior Interosseous Nerve branch), Thumb opposition | Volar tip of the index finger | | Ulnar | Finger abduction/adduction (crossing fingers) | Volar tip of the little finger | | Radial | "Thumbs up" (wrist/finger extension, tests Posterior Interosseous Nerve branch) | First dorsal web space |
- Digital Nerves: The gold standard for assessing digital nerve integrity is two-point discrimination. Normal is <6mm. Always compare with the uninjured side or an adjacent digit. A simple pinprick test can be used for screening [2, 17].

4. Investigations and Interpretation

4.1. Radiography (X-Ray)

Required Views:
- Wrist: Posteroanterior (PA), true lateral, and oblique views are standard [5].
- Forearm: Anteroposterior (AP) and lateral views that must include the wrist and elbow joints are mandatory to rule out associated dislocations (Galeazzi, Monteggia) [3].
- Scaphoid Series: If a scaphoid fracture is suspected, this includes PA, lateral, oblique, and a PA view with ulnar deviation to elongate the scaphoid [4, 9].
- Clenched Fist View: May accentuate widening of the scapholunate space in ligamentous injuries [16].
Radiographic Analysis (The "ABCs"):
- A - Alignment:
  - Gilula's Arcs: On the PA view, three smooth arcs should be traceable along the proximal and distal surfaces of the proximal carpal row and the proximal surfaces of the capitate and hamate. A break in any arc signifies carpal dislocation or subluxation [16, 18].
  - Collinearity: On a true lateral view, the radius, lunate, and capitate should align in a straight line, resembling "apples in a cup" [5, 16].
- B - Bones: Trace the cortex of each bone, looking for fracture lines, lucencies, or impaction.
- C - Cartilage/Joint Spaces:
  - Scapholunate Interval: Should be <3-4 mm on a PA view. Widening (>4 mm) is the "Terry Thomas" or "David Letterman" sign, pathognomonic for scapholunate dissociation [9, 16].
Key Measurements on Distal Radius Films: | Measurement | Normal Value | Significance of Abnormality | | :--- | :--- | :--- | | Radial Inclination (PA view) | 20-25° | Loss indicates impaction and collapse [5]. | | Radial Height (PA view) | 10-13 mm | Shortening >5 mm leads to poor functional outcomes and DRUJ issues [3, 5]. | | Volar (Palmar) Tilt (Lat view) | 10-25° | Loss of volar tilt or dorsal angulation >20° compromises wrist function [3, 5]. | | Ulnar Variance (PA view) | Neutral (0 to -2 mm) | Positive variance (ulna is long) can cause ulnar impaction syndrome [5, 6]. |

4.2. Common Fracture Patterns and Eponyms

Eponym	Description	Key Features / Risks
Colles'	Extra-articular distal radius fracture with dorsal displacement and angulation [3].	Most common type. FOOSH mechanism. Risk of median nerve compression, EPL tendon rupture [3, 5].
Smith's	Extra-articular distal radius fracture with volar (palmar) displacement and angulation ("reverse Colles'") [3, 10].	Unstable. Caused by fall on a flexed wrist. High risk of median nerve injury [3, 4].
Barton's	Intra-articular shear fracture of the distal radius with associated carpal subluxation. Can be dorsal or volar [3].	Inherently unstable. High risk of post-traumatic arthritis. Almost always requires surgical fixation (ORIF) [3, 5].
Chauffeur's (Hutchinson's)	Intra-articular fracture of the radial styloid [3].	Caused by direct blow or avulsion. Often associated with scapholunate ligament injury [3, 5].
Die-Punch	An intra-articular depression fracture of the lunate fossa of the distal radius from axial load [5, 9].	Requires anatomical reduction to prevent arthritis.
Galeazzi	Fracture of the distal third of the radius with associated DRUJ dislocation [3].	An unstable "fracture of necessity" in adults, requiring ORIF.
Monteggia	Fracture of the proximal third of the ulna with associated radial head dislocation [3].	A frequently missed injury; failure to diagnose the dislocation leads to permanent disability.
Mnemonic: MUGR (Monteggia = Ulna #, Galeazzi = Radius #) or GRUesome MURder (Galeazzi = Radius fracture/Ulna dislocation; Monteggia = Ulna fracture/Radial dislocation) [3].

4.3. Advanced Imaging

Computed Tomography (CT): Excellent for characterising complex intra-articular fractures, assessing displacement and comminution, and for surgical planning. More sensitive than plain films for detecting occult fractures [9].
Magnetic Resonance Imaging (MRI): The gold standard for diagnosing occult scaphoid fractures within 24 hours of injury and for assessing soft tissue structures like the TFCC and intrinsic ligaments [4, 9].
Point-of-Care Ultrasound (POCUS): Can be a useful adjunct for diagnosing distal radius fractures with reported sensitivity and specificity between 95-100%. The primary finding is cortical disruption [5].

5. Management Strategy

5.1. Initial Management and Analgesia

Haemostasis: For open injuries, use direct pressure and elevation. Avoid blindly clamping vessels, as digital nerves run in close proximity [1].
Analgesia:
- Haematoma Block: An effective and simple technique for distal radius fracture reduction. After sterile prep, inject 5-8 mL of 1% lidocaine without adrenaline directly into the fracture haematoma [5].
- Intravenous Regional Anaesthesia (Bier's Block): Provides excellent anaesthesia for reduction but requires specific equipment and monitoring [3, 5].
- Nerve Blocks: Ultrasound-guided peripheral nerve blocks may provide superior analgesia compared to haematoma blocks [5].

5.2. Fracture Reduction and Immobilisation

Indications for Reduction: Any neurovascular compromise, significant displacement, or angulation exceeding acceptable limits. In adults with high functional demands, criteria for an acceptable post-reduction position include [5]:
- No dorsal tilt (neutral to normal volar tilt).
- Radial shortening <5 mm.
- Intra-articular step-off <2 mm.
Reduction Technique (for Colles' Fracture): Apply longitudinal traction (finger traps can be useful), disimpact the fracture by exaggerating the deformity, then apply volar pressure and ulnar deviation to restore length and alignment [5, 9].
Immobilisation:
- Acute Phase: Use a backslab or splint, not a full circumferential cast, to accommodate swelling. The cast should be split to the skin [3, 5].
- Sugar-Tong Splint: Ideal for acute forearm and wrist fractures as it effectively prevents pronation and supination [3, 5].
- Thumb Spica Splint: For all confirmed or suspected scaphoid fractures, and fractures of the thumb metacarpal or trapezium [4, 14].
- Position of Safety: For hand immobilisation, the wrist should be in slight extension (20-30°), MCP joints flexed to 70-90°, and interphalangeal (IP) joints in full extension. This position keeps collateral ligaments at maximal length, preventing stiffness [1, 14]. Avoid the "Cotton-Loder" position (extreme flexion and ulnar deviation) for distal radius fractures, as it significantly increases pressure on the median nerve [3].

5.3. Management of Specific Injuries

Injury	ED Management	Orthopaedic Referral
Undisplaced Distal Radius Fx	Sugar-tong or dorsal backslab splint [3].	Routine outpatient follow-up.
Displaced Distal Radius Fx	Closed reduction under appropriate analgesia. Immobilise in a well-moulded sugar-tong splint [3, 5].	Urgent referral for any open fracture, neurovascular compromise, or failed reduction. Otherwise, next-day fracture clinic follow-up.
Adult Forearm Shaft Fx (Both Bones)	Above-elbow backslab. Requires admission for ORIF [3].	Immediate admission.
Galeazzi / Monteggia Fx	Above-elbow backslab. These are orthopaedic emergencies [3].	Immediate consultation and admission.
Suspected Scaphoid Fx (Occult)	Thumb spica splint. Provide clear follow-up instructions for repeat imaging (MRI pathway or X-ray in 10-14 days) [3, 4].	Urgent fracture clinic follow-up.
Confirmed Scaphoid Fx	Thumb spica cast/splint. Displaced fractures (>1mm) require ORIF [9].	Urgent referral for displaced fractures. Routine follow-up for undisplaced.
Other Carpal Fx (e.g., Triquetral chip)	Volar slab for comfort. Most can be treated symptomatically [9, 15].	Routine outpatient follow-up.
Lunate/Perilunate Dislocation	This is a surgical emergency. Attempt closed reduction if competent and able. Immobilise and elevate [16].	Immediate, urgent surgical consultation.
Scapholunate Dissociation	Thumb spica or volar splint [7, 16].	Urgent outpatient referral for likely surgical repair.
Paediatric Torus (Buckle) Fx	Removable wrist splint. Many trusts advocate for discharge with home management leaflets and no routine follow-up [3, 9].	No routine referral needed per local guidelines.
Paediatric Greenstick/Displaced Fx	Requires manipulation if angulation >15°. Above-elbow cast may be needed to control rotation [3].	Follow-up in fracture clinic.

6. Complications

6.1. Immediate and Early Complications (Hours to Days)

Compartment Syndrome: A limb-threatening emergency.
- Signs: Severe pain out of proportion to the injury, pain on passive extension of the fingers, a tense or "woody" feeling forearm, and paraesthesia. Pulselessness is a very late and ominous sign [3, 5].
- Management: Immediate and complete removal of all circumferential dressings/casts down to the skin. Urgent surgical consultation for fasciotomy is required. Compartment pressures >30 mmHg are an indication for surgery [5].
Acute Carpal Tunnel Syndrome: Occurs due to swelling or direct compression of the median nerve by fracture fragments.
- Signs: Progressive paraesthesia in the median nerve distribution, weakness of thumb abduction (abductor pollicis brevis). Worsening pain after reduction is a red flag [3, 5].
- Management: Emergency release of cast/splint. If symptoms persist or progress, urgent surgical decompression is necessary [5].
Vascular Injury: Rare in closed fractures but can occur in high-energy injuries. If perfusion does not improve with reduction, an emergency vascular surgery evaluation is needed [5].
Loss of Reduction: Common in unstable fracture patterns. Risk factors include severe initial displacement, dorsal comminution, osteoporosis, and an associated ulnar fracture [9].

6.2. Delayed and Late Complications (Weeks to Months)

Malunion: The fracture heals in an unacceptable position (e.g., radial shortening, dorsal angulation). This is the most common complication and can lead to chronic pain, weakness, and ulnar impaction syndrome [3, 5].
Non-union: The fracture fails to heal. This is a significant risk with displaced scaphoid waist and proximal pole fractures (up to 25% and 60% respectively) due to the tenuous blood supply [9].
Avascular Necrosis (AVN): Death of bone due to loss of blood supply. A major concern for the proximal pole of the scaphoid and the lunate (Kienböck's disease) [4, 6].
Tendon Rupture: Delayed rupture of the Extensor Pollicis Longus (EPL) tendon is a classic complication, occurring weeks to months after a minimally displaced Colles' fracture [3, 5]. The patient presents with a sudden inability to extend the thumb IP joint.
Post-Traumatic Osteoarthritis: Inevitable with residual intra-articular step-off >2 mm. A step-off of just 1 mm predisposes to arthritis [5].
Stiffness: The most common complication of any hand or wrist injury. Prevention is key through judicious immobilisation in the "position of safety" and early mobilisation of unaffected joints (fingers, elbow, shoulder) [1, 2].
Complex Regional Pain Syndrome (CRPS): A debilitating condition of chronic pain, swelling, and autonomic dysfunction. Vitamin C 500mg daily for 50 days post-distal radius fracture may reduce the risk [2, 9].

7. References

Helman A, Sayal A, Distefano M. Episode 178 Hand Injuries – Pitfalls in Assessment and Management. Emergency Medicine Cases. January 2023.
Competencies required for Hand Examination and Assessment.pdf.
Wrist & Forearm Competencies.pdf.
Abramson T, Messina M, Ahlzadeh G, Campagne D, Johnson W, Swadron S, et al. Carpal Fracture. In: CorePendium [Internet]. Burbank (CA): CorePendium, LLC; 2022 Dec 19.
Petron DJ. Distal radius fractures in adults. In: UpToDate [Internet]. Waltham (MA): UpToDate Inc.
Boggess BR. Anatomy and basic biomechanics of the wrist. In: UpToDate [Internet]. Waltham (MA): UpToDate Inc.
Swartz J, Donaldson R, Gentiluomo J, Young N, Chiu S, Ostermayer D, et al. Scapholunate dissociation. In: WikEM [Internet].
Swartz J, Holtz M, Donaldson R, Ostermayer D, Claire, Young N. Lunotriquetral ligament instability. In: WikEM [Internet].
Distal Forearm Fractures The Emergency Medicine Manual.pdf.
Donaldson R, Lee J, Fan T, Ye T, Young N, Snyder J, et al. Smith's fracture. In: WikEM [Internet].
Abramson T, Messina M, Ahlzadeh G, Campagne D, Johnson W, Swadron S, et al. High-Pressure Injection Injuries. In: CorePendium [Internet]. Burbank (CA): CorePendium, LLC; 2024 Oct 9.
Abramson T. Closed Fist Injuries (Fight Bites). In: CorePendium [Internet]. Burbank (CA): CorePendium, LLC; 2024 Mar 29.
Kennedy CD, Lauder AS, Pribaz JR, Kennedy SA. Differentiation between pyogenic flexor tenosynovitis and other finger infections. Hand (N Y). 2017;12(6):585-590.
Abramson T, Ross K, McCue J, Campagne D, Johnson W, Swadron S, et al. Metacarpal Fractures. In: CorePendium [Internet]. Burbank (CA): CorePendium, LLC; 2024 Oct 31.
Donaldson R, Swartz J, Fan T, Chiu S, Snyder J, Holtz M, et al. Triquetrum fracture. In: WikEM [Internet].
Brown JV. Wrist Dislocations. In: CorePendium [Internet]. Burbank (CA): CorePendium, LLC; 2025 Jun 17.
Swartz J, Donaldson R, Young N, Lin P, Ostermayer D, Holtz M, et al. Hand exam. In: WikEM [Internet].
Wrist Dislocations The Emergency Medicine Manual.pdf.

8. Example EPIC EHR Documentation Structure

Chief Complaint: Wrist/Forearm Injury

HPI: [Patient details, mechanism of injury, location of pain, associated symptoms]

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Paediatric Context (if applicable):

[ ] Handedness: {Right/Left}
[ ] Parent/Guardian present: {Yes/No}
[ ] Mechanism congruent with injury? {Yes/No - ?NAI}

Physical Exam:

Inspection:
- [ ] No Deformity
- [ ] Deformity present: {Dinner Fork / Garden Spade / Angulation / Rotational Deformity}
- [ ] Swelling/Ecchymosis noted at {location}
- [ ] Skin: {Intact / Open wound / Skin tenting}
Palpation:
- [ ] Radius: {Distal Tender / Shaft Tender / Head Tender}
- [ ] Ulna: {Styloid Tender / Shaft Tender}
- [ ] Anatomical Snuffbox Tender: {Yes/No}
- [ ] Scaphoid Tubercle Tender: {Yes/No}
- [ ] DRUJ: {Stable / Unstable (Piano key sign) / Painful on stressing}
Range of Motion:
- Wrist: Flexion/Extension {degrees/limited by pain}, Ulnar/Radial Deviation {degrees/limited by pain}
- Forearm: Pronation/Supination {degrees/limited by pain}
Neurovascular Status:
- Pulses: Radial {2+, palpable}, Ulnar {2+, palpable}
- Capillary Refill: {<2s / >2s} in all digits
- Sensation:
  - Median N: {Intact / Decreased / Absent} at volar index tip. 2PD {<6mm}.
  - Ulnar N: {Intact / Decreased / Absent} at volar little finger tip. 2PD {<6mm}.
  - Radial N: {Intact / Decreased / Absent} at first dorsal web space.
- Motor:
  - Median N (AIN): {Intact - "OK" sign}
  - Ulnar N: {Intact - Finger abduction/adduction}
  - Radial N (PIN): {Intact - "Thumbs up"/wrist extension}

Imaging & Medical Decision Making:

X-Ray(s) Interpreted: {Wrist / Forearm / Scaphoid series}
- Findings: {No acute fracture or dislocation / Fracture of [bone] / Dislocation of [joint]}
- Fracture Description: {Location: e.g., Distal radius}, {Pattern: e.g., Transverse, Comminuted}, {Intra-articular extension: Yes/No}, {Displacement/Angulation: [details]}
- Eponym: {Colles' / Smith's / Galeazzi / etc.}
- Paediatric Specifics: Salter-Harris Class: {I/II/III/IV/V}. Angulation acceptable for age? {Yes/No}.
- Joints above and below visualised and appear normal.
Impression: [Diagnosis]
Plan:
- [ ] Analgesia provided: [details]
- [ ] Reduction performed (see separate procedure note for details: {Haematoma block / IVRA / Procedural Sedation}). Post-reduction films confirm acceptable alignment.
- [ ] Immobilisation applied: {Sugar-tong backslab / Volar backslab / Thumb spica splint / Above-elbow backslab}.
- [ ] Tetanus prophylaxis updated.
- [ ] Antibiotics administered for open fracture: [details].
- [ ] Orthopaedic team consulted (Dr. [Name]): Plan is for {admission for ORIF / urgent fracture clinic follow-up in [timeframe]}.
- [ ] Discharge with strict advice given regarding cast/splint care, elevation, and clear safety netting for signs of compartment syndrome or neurovascular compromise. Virtual Fracture Clinic leaflet provided.

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