The radius is the most commonly broken bone in the arm. When the break occurs at the wrist, the injury is known as a distal radius fracture. Some of these fractures are “lucky breaks” in that there is no bone displacement. In such cases, the arm can heal nicely with just a cast to support and immobilize the break. However, when bone is shattered or displaced, surgery will be needed to restore normal function to the arm.
Orthopedist Dr. David Nelson, a hand surgeon with MarinHealth Medical Center, has performed many reparative surgeries on distal radius fractures. Here, he explains what to look for if you are concerned you may have a distal fracture, and whether you can safely wait a day to get an X-ray. Dr. Nelson also discusses why it’s better to delay surgery until the swelling starts to go down, and what to expect from the recovery process.
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Dealing with Distal Fractures
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David Nelson, MD
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Transcription:
Dealing with Distal Fractures
Bill Klaproth (Host): Distal radius fractures are very common. In fact, the radius is the most commonly broken bone in the arm. And here to talk about distal radius fractures is Dr. David Nelson, a hand surgeon with Marin General Hospital. Dr. Nelson, thank you so much for your time today. So let's go over this first for someone listening, what bone is the radius in your arm?
Dr. David Nelson, MD (Guest): Okay, it's good to be here. It's the bone on the thumb side of your forearm. So it's one of the bones that comes up to your wrist, and it's on the thumb side.
Bill: So what is the distal?
Dr. Nelson: What it means is the part that's over by your wrist, not the part over by your elbow. Some people call distal radius fractures, 'wrist fractures.' Doctors tend to call it distal radius.
Bill: Okay, I'm looking at my arm as you're telling us that. So why is this area of the arm so prone to breaking?
Dr. Nelson: I don't think we entirely know. It's interesting. It was first stated in 1814 that when you break your arm, you break it one inch from the joint, and that has held up true ever since then. I'm sure it has to do with the fact that you have thinner bone here. In the middle of the shaft it's quite thick bone, but as the bone transitions to the end, it tends to thin out.
Bill: So with a distal radius fracture, you just mentioned about an inch back. Do they always break the same, or are there different ways that bone can be broken?
Dr. Nelson: That's a great question. If you fall on your palm, and that's the way we usually do because we can get our hand out to catch us, the bone bends backwards towards the hairy side of your hand, uh, and that's the most common. Probably 90% or 95% go that way. But if for instance you're holding something, and you start to fall, you don't want to let go and you don't get your hand out, and you land on the back side of your hand, it bends in the other way.
Um, and there's some other variations. If a young man crashes a motorcycle or falls off a second story of a building, the energy there is higher, and it tends to shatter the bone. But the majority of people, they'll be walking along, and trip and fall, catch themselves, and it bends the normal way, and the name for that is a Colles fracture, and the person who described it in 1814 was Dr. Abraham Colles, the guy who said always look one inch from the joint.
Bill: Wow, that's really interesting. So what's a good sign that you've broken it?
Dr. Nelson: Uh, I don't think there's any good signs, they're all bad signs, and the bad signs are there's a deformity of your arm. Because it should only bend at the wrist, and if it's slightly bent about an inch closer to your elbow than the wrist, that's a sign that it's broken.
Bill: So look for a deformity in the arm, and the person would be in obvious pain. Right?
Dr. Nelson: Absolutely, it'll be painful and swollen. Uh, the degree of pain and swelling, uh, can vary. But if you fall on an outstretched hand and it hurts more than you think just a wrist sprain would hurt, you probably should have it seen by your local favorite orthopedic surgeon, and both physical examination and an x-ray would help make the diagnosis.
Bill: And if you think this is the case, Dr. Nelson, you shouldn't wait. Some people may be like, "I'll just sleep with it overnight, it'll get better." Right? Is it better to go, "You know what? I think this may be broken." Get in as soon as possible?
Dr. Nelson: I don't know if there's an absolute rule on that, because so many times you wait overnight, and it's just a sprain, and it goes away. So it really depends. If there's deformity, you should go in and be seen. If all you have is pain, and it's something that you think you can manage with a little bit of ice, elevation, some Aspirin or Tylenol or something, waiting the next day is not bad.
Treatment sometimes is a cast, more often is a surgery, but generally I would not recommend doing the surgery immediately. I would like to put a person in a splint, keep it elevated, and wait about a week to ten days, and let some of the swelling go down, and that makes it easier and faster to do the surgery.
So this is not something like chest pain or weakness in the leg from a stroke where you really need to go in right away. You could wait a while, even the next day would be fine.
Bill: Well that's a really good distinction, and thank you for explaining that to us. So do you x-ray the arm then generally? Is that how you diagnose this?
Dr. Nelson: Yes. Well, it's always a combination of you listen to the patient, find out how they fell. You examine the arm, see where it's tender, see if there's any deformity. You're also checking for other things to make sure the nerves are working, and that the skin is not broken. But then an x-ray is the way you get an idea of the conformation of the fracture, that's the shape of the fracture, which way did it go? Did the bone bend towards the hairy side of the hand or towards the palm side of the hand? Um, how much is broken up in little pieces? And the angle or how far it's bent, and all of these are factors which the surgeon will take into account on making a recommendation for treatment.
Bill: So speaking of treatment, you mentioned surgery. How often do you have to perform surgery on this? Or in most cases, does just casting it take care of it?
Dr. Nelson: I would say that when someone falls from a, uh, level height, and they're over fifty, um, more commonly they need surgery. The surgery is an outpatient surgery often done at an outpatient surgery center, and the advantage is that if you do the surgery, you can get rid of the splint and the cast right away.
People who have a fracture that is not displaced, uh, can often have just a cast. We'll typically do a splint for about a week to allow the swelling to occur, then to start coming down, and then a cast, and the patient would be in immobilization for approximately six weeks.
So the surgery is not necessarily a bad thing. Certainly you'll get rid of the cast right away after surgery, um, and be able to resume your activities better. And then patient factors, how healthy they are, what their activities are, are they still working, et cetera.
Bill: So generally, return to activity is about six weeks, and then how long for it to fully heal where the person is absolutely back to normal in general?
Dr. Nelson: That's a good question. Let me rephrase it a little bit because cast treatment and operative treatment have different, post-operative restrictions. If you go with a cast, generally you'll be in a cast for a total of six weeks from the time that you fell. After that, you'd probably be going to hand therapy, and you'd be able to be using the hand increasingly. I would probably recommend that you not do things that involve force or risk of falling, such as say playing tennis or playing football, for about three to four months. You would be able to drive right away in the cast, if you feel comfortable, let's say doing so. That’s the key criteria. It's do you feel safe and comfortable doing it?
If you have surgery, the dressing is generally changed in a couple of days. Often my patients get just a Band-Aid at three days, and they'll be driving right away. They'll be able to do more earlier, but I wouldn't want them to do something forceful like swinging a tennis racket or a golf club for about a month or six weeks, and they would be able to return to more vigorous activities slightly earlier than the cast treatment, maybe at three months.
Bill: And Dr. Nelson, do most people fully recover from a distal radius fracture?
Dr. Nelson: That's a great question. The grand majority of people will go back to doing everything they did before, other than if a person wants to do a push-up, which means putting your wrist at ninety degree and putting all your weight on it. You might not be able to do a push-up that way. You might have to, what we call, do a gorilla push-up, where you're pushing up on your knuckles. And um, downward dogs and similar yoga postures often take extreme motions of the wrist, and you may not be able to do a ninety degree extended wrist. However, yoga is more of a mental discipline, and my patients find that they can assume appropriate positions for the contemplation they want to do, even if they're not able to do downward dogs or planks.
Bill: So good to know, and for anyone listening who is a practitioner of yoga, it's very good information. Dr. Nelson, you're a wealth of information. Thank you so much for your time today. For more information, please visit www.MarinGeneral.org. That's www.MarinGeneral.org. This is The Healing Podcast brought to you by Marin General Hospital. I'm Bill Klaproth, thanks for listening.
Dealing with Distal Fractures
Bill Klaproth (Host): Distal radius fractures are very common. In fact, the radius is the most commonly broken bone in the arm. And here to talk about distal radius fractures is Dr. David Nelson, a hand surgeon with Marin General Hospital. Dr. Nelson, thank you so much for your time today. So let's go over this first for someone listening, what bone is the radius in your arm?
Dr. David Nelson, MD (Guest): Okay, it's good to be here. It's the bone on the thumb side of your forearm. So it's one of the bones that comes up to your wrist, and it's on the thumb side.
Bill: So what is the distal?
Dr. Nelson: What it means is the part that's over by your wrist, not the part over by your elbow. Some people call distal radius fractures, 'wrist fractures.' Doctors tend to call it distal radius.
Bill: Okay, I'm looking at my arm as you're telling us that. So why is this area of the arm so prone to breaking?
Dr. Nelson: I don't think we entirely know. It's interesting. It was first stated in 1814 that when you break your arm, you break it one inch from the joint, and that has held up true ever since then. I'm sure it has to do with the fact that you have thinner bone here. In the middle of the shaft it's quite thick bone, but as the bone transitions to the end, it tends to thin out.
Bill: So with a distal radius fracture, you just mentioned about an inch back. Do they always break the same, or are there different ways that bone can be broken?
Dr. Nelson: That's a great question. If you fall on your palm, and that's the way we usually do because we can get our hand out to catch us, the bone bends backwards towards the hairy side of your hand, uh, and that's the most common. Probably 90% or 95% go that way. But if for instance you're holding something, and you start to fall, you don't want to let go and you don't get your hand out, and you land on the back side of your hand, it bends in the other way.
Um, and there's some other variations. If a young man crashes a motorcycle or falls off a second story of a building, the energy there is higher, and it tends to shatter the bone. But the majority of people, they'll be walking along, and trip and fall, catch themselves, and it bends the normal way, and the name for that is a Colles fracture, and the person who described it in 1814 was Dr. Abraham Colles, the guy who said always look one inch from the joint.
Bill: Wow, that's really interesting. So what's a good sign that you've broken it?
Dr. Nelson: Uh, I don't think there's any good signs, they're all bad signs, and the bad signs are there's a deformity of your arm. Because it should only bend at the wrist, and if it's slightly bent about an inch closer to your elbow than the wrist, that's a sign that it's broken.
Bill: So look for a deformity in the arm, and the person would be in obvious pain. Right?
Dr. Nelson: Absolutely, it'll be painful and swollen. Uh, the degree of pain and swelling, uh, can vary. But if you fall on an outstretched hand and it hurts more than you think just a wrist sprain would hurt, you probably should have it seen by your local favorite orthopedic surgeon, and both physical examination and an x-ray would help make the diagnosis.
Bill: And if you think this is the case, Dr. Nelson, you shouldn't wait. Some people may be like, "I'll just sleep with it overnight, it'll get better." Right? Is it better to go, "You know what? I think this may be broken." Get in as soon as possible?
Dr. Nelson: I don't know if there's an absolute rule on that, because so many times you wait overnight, and it's just a sprain, and it goes away. So it really depends. If there's deformity, you should go in and be seen. If all you have is pain, and it's something that you think you can manage with a little bit of ice, elevation, some Aspirin or Tylenol or something, waiting the next day is not bad.
Treatment sometimes is a cast, more often is a surgery, but generally I would not recommend doing the surgery immediately. I would like to put a person in a splint, keep it elevated, and wait about a week to ten days, and let some of the swelling go down, and that makes it easier and faster to do the surgery.
So this is not something like chest pain or weakness in the leg from a stroke where you really need to go in right away. You could wait a while, even the next day would be fine.
Bill: Well that's a really good distinction, and thank you for explaining that to us. So do you x-ray the arm then generally? Is that how you diagnose this?
Dr. Nelson: Yes. Well, it's always a combination of you listen to the patient, find out how they fell. You examine the arm, see where it's tender, see if there's any deformity. You're also checking for other things to make sure the nerves are working, and that the skin is not broken. But then an x-ray is the way you get an idea of the conformation of the fracture, that's the shape of the fracture, which way did it go? Did the bone bend towards the hairy side of the hand or towards the palm side of the hand? Um, how much is broken up in little pieces? And the angle or how far it's bent, and all of these are factors which the surgeon will take into account on making a recommendation for treatment.
Bill: So speaking of treatment, you mentioned surgery. How often do you have to perform surgery on this? Or in most cases, does just casting it take care of it?
Dr. Nelson: I would say that when someone falls from a, uh, level height, and they're over fifty, um, more commonly they need surgery. The surgery is an outpatient surgery often done at an outpatient surgery center, and the advantage is that if you do the surgery, you can get rid of the splint and the cast right away.
People who have a fracture that is not displaced, uh, can often have just a cast. We'll typically do a splint for about a week to allow the swelling to occur, then to start coming down, and then a cast, and the patient would be in immobilization for approximately six weeks.
So the surgery is not necessarily a bad thing. Certainly you'll get rid of the cast right away after surgery, um, and be able to resume your activities better. And then patient factors, how healthy they are, what their activities are, are they still working, et cetera.
Bill: So generally, return to activity is about six weeks, and then how long for it to fully heal where the person is absolutely back to normal in general?
Dr. Nelson: That's a good question. Let me rephrase it a little bit because cast treatment and operative treatment have different, post-operative restrictions. If you go with a cast, generally you'll be in a cast for a total of six weeks from the time that you fell. After that, you'd probably be going to hand therapy, and you'd be able to be using the hand increasingly. I would probably recommend that you not do things that involve force or risk of falling, such as say playing tennis or playing football, for about three to four months. You would be able to drive right away in the cast, if you feel comfortable, let's say doing so. That’s the key criteria. It's do you feel safe and comfortable doing it?
If you have surgery, the dressing is generally changed in a couple of days. Often my patients get just a Band-Aid at three days, and they'll be driving right away. They'll be able to do more earlier, but I wouldn't want them to do something forceful like swinging a tennis racket or a golf club for about a month or six weeks, and they would be able to return to more vigorous activities slightly earlier than the cast treatment, maybe at three months.
Bill: And Dr. Nelson, do most people fully recover from a distal radius fracture?
Dr. Nelson: That's a great question. The grand majority of people will go back to doing everything they did before, other than if a person wants to do a push-up, which means putting your wrist at ninety degree and putting all your weight on it. You might not be able to do a push-up that way. You might have to, what we call, do a gorilla push-up, where you're pushing up on your knuckles. And um, downward dogs and similar yoga postures often take extreme motions of the wrist, and you may not be able to do a ninety degree extended wrist. However, yoga is more of a mental discipline, and my patients find that they can assume appropriate positions for the contemplation they want to do, even if they're not able to do downward dogs or planks.
Bill: So good to know, and for anyone listening who is a practitioner of yoga, it's very good information. Dr. Nelson, you're a wealth of information. Thank you so much for your time today. For more information, please visit www.MarinGeneral.org. That's www.MarinGeneral.org. This is The Healing Podcast brought to you by Marin General Hospital. I'm Bill Klaproth, thanks for listening.