Overview
The radius and ulna rotate around each other to turn the palm, and the radius widens at the wrist to carry most of the load from the hand. A wrist fracture is usually a break of that widened end, the distal radius; an adult forearm fracture usually breaks both shafts. The problem in each is alignment: a distal radius that heals tilted or short gives a weak, painful wrist, and a forearm that heals with even a small bend permanently loses rotation.
Open reduction and internal fixation (ORIF) restores length, alignment and rotation and holds them with plates and screws rigid enough that the fingers move immediately and the wrist within days. It is done as an outpatient at Bayside Surgery Center in Coconut Grove.
Who It's For
Distal radius fractures are fixed when the joint surface is stepped by more than about 2 mm, the fragment is tilted backward beyond what a cast can hold, the radius has shortened, or a fracture set in a cast slips on the follow-up X-ray. Age and demands matter: the same X-ray in a 30-year-old sailor and an 85-year-old leads to different advice, because an older wrist tolerates malalignment better than surgery. Adult both-bone forearm fractures are generally fixed, because a cast cannot control rotation of two broken shafts.
Undisplaced wrist fractures, and fractures in older patients that sit acceptably after being set, are treated in a cast with weekly X-rays for three weeks. Children's forearm fractures remodel and are usually cast rather than plated.
A fracture on an X-ray is not by itself the reason to plate it. Dr. O'Donnell recommends fixation when the measured displacement, tilt or joint step on imaging, the patient's age and demands, and the position held in a cast on follow-up X-rays together favor surgery; many wrist fractures heal well in a cast. The wrist fracture and forearm fracture pages explain how alignment is measured.
What the Procedure Involves
Surgery is performed under a regional nerve block with general anesthesia or sedation and takes about an hour for a distal radius, up to two hours for both forearm bones. For the wrist Dr. O'Donnell uses an incision of about 6 cm on the palm side of the forearm, between the flexor carpi radialis tendon and the radial artery. The fragments are levered back into place under X-ray guidance and a contoured volar locking plate is fixed to the radius with screws that support the joint surface from below. The plate sits under muscle rather than tendon, so it rarely needs removal.
For both-bone fractures the radius is approached from the front and the ulna through a separate incision along its border under the skin. Each shaft is reduced so its bow matches the other side, because the curve of the radius is what lets it rotate around the ulna, and fixed with a compression plate. Rotation is checked through a full arc before closure. A padded splint goes on and you go home the same day.
Risks & How They Are Minimized
Finger stiffness is the most common problem after any wrist fracture and the one that most affects function, which is why full finger motion is required from day one. Tendon irritation is the specific risk of distal radius fixation: a plate set too far toward the wrist or a screw that is too long can rub the tendons. Plate position and screw lengths are checked on X-ray in the operating room, and a plate that causes symptoms is removed after healing.
Numbness in the thumb and index finger from swelling around the median nerve is common early and usually settles; a carpal tunnel release is added at surgery when there were nerve symptoms beforehand. In forearm fractures the risk that matters is nonunion, because the shafts have a modest blood supply and can take three months or more to unite; stable plating, preserving the tissue around the bone, and no loading until X-rays show healing are the safeguards. Complex regional pain syndrome, a disproportionate pain and stiffness response, is uncommon and reduced by early motion and good pain control. Infection is covered by antibiotics before the incision; blood clots are rare.
Recovery & Rehabilitation
Both protocols share one rule: fingers, elbow and shoulder move fully from day one, the wrist and forearm move gently within one to two weeks, and strengthening waits until X-rays show the bone has healed, about six weeks for a distal radius and often ten to twelve weeks or more for the forearm.
| Phase | Timing | What happens |
|---|---|---|
| Digit & early motion | Weeks 0–2 | Removable splint between exercises. Full active finger, thumb, elbow and shoulder motion; tendon gliding; gentle active wrist and forearm motion as directed. No gripping loads or weight through the arm. |
| Wrist & forearm motion | Weeks 2–6 | Progressive active wrist and forearm motion toward full; gentle stretching; scar mobilization. No strengthening or lifting; X-rays checked for healing. |
| Strengthening | Weeks 6–12 | Begins once Dr. O'Donnell confirms healing, later for forearm fractures. Progressive grip, wrist and rotation strengthening; work-conditioning as needed. |
| Return to activity | Months 3–6 | Progressive strengthening and sport- or job-specific loading. Heavy loading and contact wait for confirmed union, three to four months for forearm fractures. |
Desk work is possible within the first week with the splint on; driving at two to four weeks, once you are off narcotic pain medication and can turn the wheel. Lifting and manual work return with strengthening; contact sport and heavy loading follow union, three to six months depending on the fracture.
Protocol summary
Both protocols call for a splint initially, no lifting or weight bearing through the arm until union is confirmed (about six weeks for the distal radius, often ten to twelve weeks or more for the forearm), and full finger motion at all times. The forearm protocol adds no resisted rotation early and no heavy loading or contact until union.
Phases advance on criteria: full digit motion with controlled swelling to leave Phase I, improving motion with radiographs showing healing to leave Phase II, radiographic union with improving strength to leave Phase III, and functional strength with surgeon clearance for full loading and contact to finish. Dr. O'Donnell paces the program from the fixation achieved at surgery and follow-up X-rays.
Physical Therapy Protocols
Distal Radius Fracture — Open Reduction & Internal PDF ↗Both-Bone Forearm Fracture — Open Reduction & PDF ↗Frequently Asked Questions
Do I need surgery for a broken wrist?
Not always. A fracture that is undisplaced, or sits acceptably after being set, is treated in a cast with weekly X-rays to make sure it holds. Surgery is advised when the joint surface is stepped, the fracture is tilted or shortened beyond what a cast can hold, or it slips in the cast. Age and activity shape the decision.
How long does a plated wrist fracture take to heal?
The bone usually unites in about six weeks, confirmed on X-rays, and that is when strengthening and lifting begin. Motion starts much earlier, fingers on day one and the wrist within one to two weeks, because the plate holds the fracture while it heals. Sport and heavy work return at three to six months per the distal radius protocol.
Why do forearm fractures take longer to heal than wrist fractures?
The shafts of the radius and ulna have a thinner blood supply than the wide end of the radius at the wrist, so they unite more slowly, often ten to twelve weeks or more. Loading before union risks the plate failing, so strengthening and lifting wait until X-rays confirm healing, per the forearm protocol.
Will the plate need to be removed?
Usually not. A volar plate on the distal radius sits under muscle and rarely causes symptoms; forearm plates are left in unless prominent. Removal is considered if a plate irritates a tendon, which shows as pain or crepitus with wrist motion, and only after the bone has fully healed, generally a year or more later.
When can I drive after wrist fracture surgery?
Usually two to four weeks, once you are off narcotic pain medication and can grip and turn the wheel comfortably with the splint off. Patients with a plated forearm are often a little later, because turning the wheel needs the forearm rotation that is slowest to return.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.