Wrist Fractures (Colles): Casting, Surgery, and Rehabilitation

Wrist fractures — most commonly a distal radius fracture or “Colles” fracture — are the most common upper-limb fracture in adults. The injury follows a familiar pattern: a fall on the outstretched hand, sudden severe pain in the wrist, swelling, and an obvious deformity. The decision between cast treatment and surgery is one of the most discussed in orthopedic clinic and depends on the fracture pattern, the patient’s age and demands, and how much the bones have shifted out of position. This article explains the modern approach.

Who gets wrist fractures?

Two main groups: children and active young adults (high-energy injuries — sport, falls), and post-menopausal women and older adults (low-energy injuries — fall from standing height, suggesting underlying osteoporosis). The second group is particularly important because a fragility wrist fracture is a marker of future hip and spine fracture risk and warrants a bone-health workup.

The initial assessment

X-rays in two views confirm the diagnosis and characterise the fracture pattern — extra-articular (outside the wrist joint) or intra-articular (involving the joint surface), the amount of displacement, comminution (multiple fragments), and any associated wrist injuries. A CT scan is occasionally needed for complex intra-articular fractures.

The decision: cast or surgery?

Several factors guide the decision:

• Fracture pattern — undisplaced or minimally displaced fractures usually heal well in a cast. Significantly displaced fractures may need reduction and surgical fixation to restore alignment.
• Joint involvement — intra-articular fractures with a step in the joint surface generally need restoration to prevent later arthritis.
• Patient age and demands — younger, active patients with manual occupations or athletic demands have lower tolerance for slight residual deformity. Older sedentary patients often function well even with some malalignment.
• Bone quality — osteoporotic bone holds plates and screws less well; treatment is individualised.

Cast treatment

For displaced fractures requiring reduction, the manipulation is done under local or regional anaesthesia and the position confirmed with X-ray. The cast extends from below the elbow to the knuckles, leaving the thumb and fingers free. Total cast time is typically 5–6 weeks. Follow-up X-rays at 1 and 2 weeks check that the position has been maintained — fractures can re-displace in a cast, and a small minority need surgery after initial conservative treatment.

Surgical options

Modern surgery for displaced wrist fractures most commonly uses a volar locking plate — a small plate applied to the front of the wrist with locking screws that hold the fragments precisely. The operation takes 60–90 minutes under regional or general anaesthesia. Patients begin gentle finger and wrist movement within days, much earlier than after a cast.

Other options include percutaneous pins (less commonly used), external fixation (for severely comminuted fractures), and bridging plates for complex intra-articular patterns.

Recovery

The recovery pathway differs by treatment:

After cast treatment

Hand and elbow movement throughout. Cast removed at 5–6 weeks. Physiotherapy to regain wrist range, grip strength, and dexterity. Light desk work usually possible during casting; full hand use returns over 8–12 weeks.

After surgery

Gentle wrist movement within days under physio guidance. Splint for comfort for 2–4 weeks. Light use of the hand from day 1. Full activity at 8–12 weeks for most patients. The advantage is earlier movement and the disadvantage is the small operative risk profile.

Outcomes

Modern outcomes for both cast and surgical treatment are good, with the right choice for the right patient. Most patients regain near-normal wrist function. Mild residual stiffness in the first 3–6 months is common and improves with consistent rehabilitation. Wrist arthritis is uncommon after well-treated extra-articular fractures and more likely after intra-articular fractures, particularly if reduction was incomplete.

The bone-health conversation

For any patient over 50 with a fragility wrist fracture, we recommend a DEXA scan to assess bone density and screen for osteoporosis. Detecting and treating osteoporosis now can prevent the much more morbid hip and spine fractures that often follow.