Minor Injuries – Wrist Injuries

Author: Josh Bickley / Editor: Liz Herrieven / Reviewer: Joseph Lok / Codes: SLO1, SLO4, TP7 / Published: 09/04/2019 / Reviewed: 16/06/2026

The wrist plays a vital role in positioning the hand, transmitting load, and enabling the range of movement required for everyday function. As a complex joint made up of the distal radius and ulna, eight carpal bones, and multiple ligamentous structures, it is particularly vulnerable to injury. Even seemingly minor wrist trauma can result in significant long-term pain, instability, stiffness, and functional impairment if injuries are missed or inadequately managed.

Wrist injuries are common presentations to the emergency department and are frequently initially managed by clinicians working in urgent and emergency care settings, including Emergency Clinical Practitioners (ECPs). Accurate assessment and early recognition of significant injury patterns are essential, as prompt diagnosis and appropriate management can reduce the risk of long-term morbidity. The following summary outlines the key principles in assessing and managing common fractures and dislocations involving the distal radius, distal ulna, and carpal bones.

Assessment:

Adequate and timely analgesia should be provided where appropriate, as uncontrolled pain can significantly impair patient participation and limit the accuracy of clinical assessment; reassessment following analgesia is therefore essential.1

The ‘Look, Feel, Move’ assessment, is a simple but effective way structured assessment for limb injuries.2

Look

• Deformity
• Swelling
• Bruising
• Wounds or bleeding
• Scars – previous surgery or trauma
• Skin colour
• Limb position
• Muscle wasting or asymmetry
• Compare with the other side

Feel

• Sensation / neurovascular status distal to injury
• Temperature
• Tenderness: localised or diffuse
• Crepitus
• Bony step or instability
• Soft tissue swelling
• Pulses and capillary refill

Move

• Active movement first, if safe
• Then passive movement if needed and tolerated
• Resisted movement to check for tendon ligament injury
• Range of movement
• Pain on movement
• Restriction
• Joint stability post x-ray – to check for ligament injury
• Ability to weight bear or use the limb functionally

Colles’ Fractures: An ED Staple

Colles’ fractures are among the most common fractures encountered in ED. While seen in all ages, in older patients they are often a marker of osteoporosis following low-energy trauma—typically a FOOSH (fall onto outstretched hand). The distal radius fractures, displacing and angulating dorsally (the “dinner fork” deformity), often with an associated ulnar styloid fracture.

Most EDs reduce these in-house if there are no complications, then placed in a plaster of paris (POP) backslab before referring to fracture clinic.

For more information, please visit our blog on Colles’ fracture.

Smith’s fracture

A Smith’s fracture is often described as a “reverse Colles’ fracture”. In this injury, the distal radius is displaced in a volar direction, typically following a fall onto the dorsal aspect of the wrist. In contrast to Colles’ fractures, Smith’s fractures are less common.

The principles of manipulation are similar to those for a Colles’ fracture, but the deforming forces and reduction manoeuvres are reversed. However, Smith’s fractures have a high rate of re-displacement and often demonstrate instability following reduction. As a result, definitive management is frequently undertaken by the orthopaedic team, either with manipulation or, more commonly, surgical fixation, provided there is no urgent neurovascular compromise.

In many emergency departments, an initial attempt at reduction in the ED is still undertaken, as achieving some degree of reduction and immobilisation in plaster can improve comfort while awaiting orthopaedic review.

Fig.1 via Radiopaedia.org, rID: 66146 

Be mindful and look out for fractures involving the articular surface of the radius, as these should be discussed on the day with the on-call orthopaedic team due to the risk of articular incongruity, instability, and long-term functional impairment if inadequately reduced. Intra-articular involvement increases the likelihood of post-traumatic osteoarthritis, stiffness, and persistent pain, and may require operative management to restore joint alignment.

Carpal injuries

Carpal bone injuries are common presentations to the emergency department, most often occurring following a FOOSH. These injuries range from simple stable fractures to complex fracture-dislocations and ligamentous injuries, with the potential for significant functional impairment if missed or inadequately managed. Careful clinical assessment, appropriate imaging, and an understanding of injury patterns are essential to identify unstable injuries, associated neurovascular compromise, and those requiring early orthopaedic or specialist hand team involvement.

Fig.2 via Radiopaedia.org, rID: 59022

Scaphoid fractures3

The Scaphoid is the most commonly fractured carpal bone. Scaphoid fractures should be suspected in patients presenting with post-traumatic wrist pain, particularly where there is tenderness in the anatomical snuffbox, tenderness over the scaphoid tubercle, or pain on axial loading of the thumb. Plain radiographs are indicated where clinical suspicion exists. In addition to standard wrist views, dedicated scaphoid views should be obtained, typically including oblique views and PA views in ulnar deviation.

Despite these additional views, a significant proportion of scaphoid fractures remain occult on initial imaging. The consequences of a missed scaphoid fracture can be considerable, with risks including non-union, avascular necrosis (particularly of the proximal pole), and the later development of degenerative wrist arthritis. It is therefore important that patients with a clinically suspected scaphoid fracture are managed as though a fracture is present, even if no fracture is visible on the initial X-ray.

These patients should be appropriately immobilised and arranged for clinical follow-up, normally 10-14 days post injury – with repeat imaging if symptoms persist. In some departments, advanced imaging such as MRI may be performed where pain or tenderness persists despite normal initial radiographs, as MRI is the gold standard as it has high sensitivity for detecting occult fractures. Local pathways and protocols should be followed.

Unconfirmed scaphoid fracture should be placed in wrist splint. Confirmed scaphoid fractures are typically immobilised in a below-elbow thumb spica cast or splint, according to local protocol.3

Fig.3 via Radiopaedia.org, rID: 7669

Triquetrum fracture

Another important carpal injury to recognise is a triquetral fracture, most commonly occurring following a FOOSH. The triquetrum is the second most commonly fractured carpal bone after the scaphoid. The most common injury pattern is a dorsal cortical avulsion (“chip”) fracture, which is often best identified on the lateral wrist radiograph, although oblique views may also help demonstrate the injury.

Most dorsal cortical avulsion fractures can be managed in a removable wrist splint or below-elbow cast for comfort (according to local protocol), sling and fracture clinic follow up.

Lateral view

Fig.4 via Radiopaedia.org, rID: 52227

Hamate fractures

If a carpal bone injury is suspected but not clearly visible on standard PA or lateral wrist radiographs, additional or dedicated views should be obtained. Certain carpal fractures can be difficult to identify on standard imaging. For example, fractures of the hook of the hamate are often poorly visualised on routine wrist views and may be better demonstrated on oblique or specialised carpal tunnel views. As with many carpal injuries, delayed or missed diagnosis can result in significant long-term consequences, including persistent pain, reduced grip strength, non-union, and neurovascular or tendon complications.

Fig.5 via Radiopaedia.org, rID: 75703

Carpal dislocation

Lunate and perilunate dislocations are often described together as they are important diagnoses not to miss and are frequently only identified on the lateral wrist radiograph. When assessing a lateral wrist X-ray, the normal alignment is often described as an apple (the capitate) sitting in a teacup (the lunate) sitting on a saucer (the distal radius), with the third metacarpal aligned on top of the capitate. An imaginary line should pass through the centre of all these structures in a normal wrist.

In a lunate dislocation, often following a FOOSH, patients typically present with volar wrist pain and swelling. The lateral X-ray shows the lunate displaced in a volar direction relative to the radius and capitate, producing the classic “spilled teacup” sign. On the AP view, the lunate may appear triangular, often referred to as the “piece of pie” sign. Lunate dislocations carry a high risk of median nerve compression, avascular necrosis, chronic pain, and long-term functional impairment.

Perilunate dislocations are usually higher-energy injuries and are often associated with greater pain and more significant swelling. In these injuries, the lunate remains aligned with the distal radius, but the remainder of the carpus dislocates dorsally in relation to the lunate. Associated Scaphoid fractures are common as part of a greater arc injury pattern. On the lateral radiograph, the capitate and third metacarpal are displaced dorsally relative to the lunate (the “apple behind the teacup” appearance). Median nerve injury is also common, and urgent reduction with specialist hand or orthopaedic input is required. CT imaging is often helpful acutely to assess associated carpal fractures and define the full extent of the injury.

Fig.6 – Perilunate dislocation via Radiopaedia.org, rID: 9893

Fig.7 – Lunate dislocation via Radiopaedia.org, rID: 17209

Urgent same-day referrals include:

• Neurovascular compromise
• Open fracture
• Significant displacement
• Carpal dislocation
• Suspected compartment syndrome
• Irreducible deformity

References

1. National Institute for Health and Care Excellence (NICE). Major trauma: Assessment and initial management. [NG39]. NICE, 2016.
2. Blom A, Warwick D, Whitehouse M, editors. Apley & Solomon’s System of Orthopaedics and Trauma. 10th ed. Boca Raton (FL): CRC Press; 2018.
3. British Society for Surgery of the Hand (BSSH). Scaphoid fractures: standards of care [Internet]. London: BSSH; 2025