Is My Wrist Broken or Sprained? A Hand Surgeon Explains

It happens in a fraction of a second. A foot slips on ice, a bike wheel catches, a skateboard stops and the rider does not, and a hand goes out to break the fall. The palm takes the weight, the wrist bends back, and within a few minutes it is sore, swollen and hard to use. The question that follows is almost always the same: is the wrist broken, or is it just sprained?

A fall onto an outstretched hand is the classic cause of both injuries, which is part of why they are so easy to confuse. A sprain is an injury to the ligaments that hold the wrist bones together; a fracture is a break in one of the bones. Both can swell, bruise and hurt to move, and both can look surprisingly ordinary in the first hours. The difference matters because some of the injuries that feel like a mild sprain — a small break in the scaphoid bone, or a torn ligament deep in the wrist — do best when they are found early and can cause lasting problems when they are not.

Xavier Simcock, MD, a hand, wrist and elbow surgeon at Midwest Orthopaedics at Rush, explains the signs that separate a wrist sprain from a fracture, two injuries that can be dismissed as a simple sprain, why a normal X-ray does not always settle the question, and when a sore, swollen wrist is worth an examination.

What a Fall on an Outstretched Hand Does to the Wrist

The wrist is not a single joint. It is formed by the ends of the two forearm bones — the radius on the thumb side and the ulna on the small-finger side — and eight small carpal bones arranged in two rows at the base of the hand. A web of ligaments links these bones and keeps them lined up as the wrist bends, straightens and turns.

When you land on an open hand, the force travels up through the palm into the carpal bones and the end of the radius, usually with the wrist bent sharply backward. Where that force ends up depends on the angle of the fall, the speed, and the strength of the bone. If the ligaments give way first, the result is a sprain. If a bone gives way first, it is a fracture — most often of the end of the radius, a distal radius fracture, which accounts for about one in every six broken bones treated in U.S. emergency rooms, or of the scaphoid, one of the carpal bones on the thumb side. The same fall can also do both at once.

Sprains are graded by how badly the ligament is injured. In a mild (grade 1) sprain the ligament is stretched but not torn; in a moderate (grade 2) sprain it is partly torn; in a severe (grade 3) sprain it is torn completely or pulled off the bone, sometimes taking a small chip of bone with it.

Wrist Sprain vs. Fracture: The Signs That Point Each Way

No single sign settles the question at home, and some fractures and serious ligament tears look no different from a mild sprain at first. Still, several features of a wrist injury lean one way or the other, and they are the same things a hand surgeon asks about first.

The shape of the wrist. A sprained wrist looks swollen but keeps its normal outline. A wrist that looks bent, angled or out of place points strongly to a fracture, most often of the distal radius. The reverse is not true: many fractures, including many scaphoid fractures, cause no visible deformity.

Where it hurts. Pain and tenderness concentrated at one spot on a bone matter more than a general ache across the wrist. The small hollow on the thumb side of the back of the wrist — the area known as the anatomic snuffbox — is where a scaphoid fracture is typically most tender. Pain on the thumb side that is worse with gripping, pinching, pushing or pulling is worth taking seriously even when the wrist looks normal.

How the pain behaves. A distal radius fracture usually hurts immediately. A mild sprain hurts too, but is expected to improve with rest, ice and elevation. Pain that is not easing, or that is getting worse, is a reason to be examined. The American Academy of Orthopaedic Surgeons (AAOS) advises seeing a doctor when the pain and swelling of a wrist sprain last more than 48 hours, and advises seeing a doctor for wrist pain that does not go away within a day of the injury, because it can be a sign of a scaphoid fracture.

Swelling and bruising. Both injuries swell and bruise, so a swollen wrist on its own does not tell them apart. Swelling and bruising that appear quickly after a hard fall, together with sharp tenderness over the bone, can point toward a fracture.

Whether the wrist still moves. One common piece of reassurance does not hold up: being able to move the wrist does not rule out a break. Movement tells you more about pain than about the bone.

Numbness, tingling or a pale hand. Fingers that are numb or tingling, or a hand that looks pale, after a wrist injury suggest that a nerve or blood vessel is involved. AAOS advises going to an emergency room right away when the fingers feel numb after a wrist injury.

A feeling of popping or clicking. A sensation of popping or tearing inside the wrist at the moment of injury can come with a sprain. Clicking or a sense that the wrist is shifting when it moves in the weeks afterward is one of the signs of a significant ligament tear, discussed below.

Sprained or Broken Wrist, Side by Side

The Fracture Most Often Mistaken for a Sprain: The Scaphoid

The scaphoid is a small, curved bone at the base of the thumb that links the two rows of carpal bones. It breaks in the same kind of fall that sprains a wrist, and it is the injury that AAOS names as the most common example of a fracture mistaken for a mild or moderate sprain. Unless the wrist is deformed, a broken scaphoid may not be obvious; the pain is sometimes mild, there may be little swelling, and the wrist can still be used.

Two features make the scaphoid worth singling out. The first is that a scaphoid fracture does not always show up on an X-ray taken right after the injury. When a surgeon suspects one and the first X-ray looks normal, a common approach is to protect the wrist in a splint or cast for two to three weeks and repeat the X-ray, by which time the fracture line often becomes visible. An MRI or CT scan can sometimes show the fracture sooner.

The second is the bone's blood supply, which is poor and runs in an unusual direction — from the thumb end of the bone back toward the forearm. A fracture can disrupt it further, so healing problems are more common with the scaphoid fracture than with many other fractures. A scaphoid that fails to heal (a nonunion), or a fragment that loses its blood supply (avascular necrosis), can lead over time to arthritis of the wrist. Prompt treatment may help avoid these complications, which is why thumb-side wrist pain after a fall is not something to wait out for weeks.

The Sprain That Is Not Minor: A Torn Scapholunate Ligament

Among the wrist problems Dr. Simcock treats with ligament surgery is one that starts with a fall in which no fracture or break was seen on X-ray, followed by swelling, pain, clicking or a sense that the joint is moving when it should not. One reason this happens is that X-rays show bone, not ligament. A wrist can have a serious ligament injury and an X-ray in which every bone is intact.

The ligament most associated with this problem is the scapholunate ligament, which binds the scaphoid to the lunate, its neighbor in the first row of carpal bones. AAOS notes that even a wrist injury that seems mild, with little swelling, could still involve a torn ligament that may need surgery to avoid long-term problems. Signs of a scapholunate ligament tear include pain and swelling on the thumb side of the wrist, difficulty gripping or lifting, a clicking or popping sensation as the wrist moves, and a feeling of weakness or instability.

An X-ray can still help. When the ligament is torn, the scaphoid and lunate may sit farther apart than they should or fall out of their normal alignment, and a surgeon may compare the injured wrist with the other side or take additional views. When the X-ray is normal but the examination suggests a ligament injury, an MRI, CT scan or arthrogram — an imaging study after dye is injected into the joint — can show more, and wrist arthroscopy allows the surgeon to look at the ligament directly.

Timing matters here. According to AAOS, whether surgery can fully restore wrist function after a severe ligament tear depends in part on the time between the injury and the operation, and some people with severe tears that are not treated, or not treated successfully, develop arthritis of the wrist over several years. Left untreated, a complete scapholunate tear can lead to a pattern of progressive arthritis called scapholunate advanced collapse (SLAC wrist).

When the Wrist Is Broken: Distal Radius Fractures

A break at the end of the radius is what most people mean by a broken wrist. It usually causes immediate pain, swelling, bruising and tenderness, and the wrist may look bent or out of place. In younger people these fractures typically follow a high-energy injury such as a fall from a height, a bike crash or a car accident; in older adults, particularly those with osteoporosis, a simple fall from standing height can be enough.

That last point is worth knowing on its own. A wrist that breaks in an ordinary fall can be the first sign of weakened bones, and after this kind of fracture a doctor may recommend testing bone density, especially when there are other risk factors for osteoporosis.

Not every broken wrist needs surgery. A fracture in good position is often treated in a splint and then a cast; one that has shifted may be gently realigned without an incision first; and one that cannot be put back or held in position may be fixed with a plate and screws, pins or an external frame. Which of these fits depends on the fracture, the person's age and activity level, and the surgeon's examination — the options are described on the distal radius fracture treatment page.

What People Commonly Try First

For a wrist that keeps its normal shape, is sore and swollen but not severely painful, and has normal feeling in the fingers, the measures a clinician typically recommends first are the familiar ones for a sprain: rest from the activity that caused it, ice wrapped in a cloth for about 20 minutes at a time, an elastic compression wrap that is not too tight, and keeping the wrist raised above the level of the heart. If it is appropriate for your health history, a clinician may also suggest an over-the-counter anti-inflammatory medicine. AAOS notes that when a wrist injury is not very painful and does not look out of place, it may be reasonable to wait until the next day to see a doctor, with the wrist protected in a splint, iced and elevated in the meantime.

Those measures suit a mild sprain. They do not tell you whether the injury is a mild sprain, and a wrap or brace that makes a wrist feel better can make it easy to keep putting off an examination. Pain and swelling that have not clearly improved after about two days, or any of the warning signs below, are a reason to have the wrist examined rather than strapped up for longer.

When to Have a Wrist Injury Checked

A wrist that was twisted and is steadily getting better rarely needs an appointment. The following are reasons to be seen:

• The wrist looks bent, angled or out of place — go to an urgent care center or emergency room right away
• Numbness, tingling or pale fingers after the injury — go to an emergency room right away
• Severe pain, or pain that is getting worse instead of better
• Pain and swelling that have not improved after about 48 hours
• Tenderness on the thumb side of the wrist, especially in the snuffbox, or pain with pinching and gripping
• Clicking, popping, or a feeling that the wrist is weak or shifting when it moves
• A wrist that was X-rayed as normal but still hurts or swells a week or two later

For the rest, a hand surgeon or an orthopedic fracture specialist who can examine the wrist and review X-rays at the same visit is usually a more direct route than waiting to see whether it settles.

How a Hand Surgeon Tells the Difference

The examination starts with the story: how the fall happened, which way the wrist bent, what was felt at the moment of injury, and how the pain and swelling have behaved since. The surgeon then looks at the shape of the wrist, presses along each bone and over the main ligaments to find exactly where it is tender, checks the snuffbox, tests grip and the movement of the wrist and thumb, checks sensation and circulation in the fingers, and compares the injured side with the other wrist.

X-rays come next, usually several views of the wrist. They show whether a bone is broken and whether the pieces have moved, and they can show the changes in spacing and alignment between the carpal bones that suggest a torn ligament. When the X-rays are normal but the examination points to a scaphoid fracture or ligament tear, the surgeon may protect the wrist in a splint and repeat the X-rays in two to three weeks, or order an MRI or CT scan; for a suspected ligament injury, an arthrogram or wrist arthroscopy can add more detail.

Treatment then follows the diagnosis. A mild sprain usually needs only home care and time, often recovering fully over several weeks; a moderate sprain may be protected in a splint, with stretching or therapy afterward to restore motion. A complete ligament tear may need surgery to repair or reconstruct the ligament. A fracture is splinted, cast or fixed depending on which bone is broken and whether it is in position, and a scaphoid fracture can take longer to heal than most other breaks. Because stiffness is common after wrist fractures, many patients work with a certified hand therapist once the wrist is ready to move. Which of these applies, and whether any procedure is needed, is a decision made with the surgeon after the examination and imaging.

Frequently Asked Questions

Can you move your wrist if it is broken?

Sometimes, yes. Some wrist fractures, and scaphoid fractures in particular, still allow the wrist to move, sometimes with only moderate pain. Being able to move the wrist does not rule out a break; deformity, pinpoint tenderness over a bone and pain on the thumb side are more useful signs, and imaging, starting with an X-ray, is needed to see the bone.

How long does a sprained wrist take to heal?

It depends on the grade. According to AAOS, mild wrist sprains often recover fully over several weeks, moderate sprains can take longer, and after surgery for a severe tear the ligament usually heals in 8 to 12 weeks, with full recovery taking 6 to 12 months. A wrist that is not improving as expected should be examined rather than given more time.

Why is my wrist still swollen weeks after a fall?

Some swelling can linger after a more significant sprain. But a wrist that is still swollen and painful weeks after a fall, especially with pain on the thumb side, weakness or clicking, can mean the injury was more than a sprain — an unrecognized scaphoid fracture or a ligament tear — and is worth an examination, even if an earlier X-ray was normal.

Should I get an X-ray for a sprained wrist?

Not every sore wrist needs one. An X-ray is worthwhile when the wrist looks deformed, when pain is severe or worsening, when pain and swelling have not improved after a day or two, when there is tenderness on the thumb side of the wrist, or when the fingers are numb or tingling.

Can an X-ray miss a broken wrist?

It can miss some. A scaphoid fracture does not always show on an X-ray taken right after the injury, and ligament tears do not show directly on X-ray at all. When the examination suggests one of these injuries, a surgeon may splint the wrist and repeat the X-ray in two to three weeks, or use MRI or CT.

Can a wrist be sprained and broken at the same time?

Yes. The same fall can break a bone and tear a ligament, and a severe sprain can pull a small chip of bone away with the ligament, which is technically a fracture. Ligament injuries can also accompany distal radius fractures, which is one reason surgeons look at the whole wrist and not only the obvious break.

Many wrists that are twisted or jarred in a fall turn out to be sprains that recover with time and simple care. The ones that do not tend to announce themselves in particular ways — a wrist that is out of shape, pain on the thumb side that will not settle, numbness, or clicking and weakness after an X-ray that looked normal — and those are the injuries the hand and wrist specialists at Midwest Orthopaedics at Rush would rather see early than late. An examination and the right imaging can usually settle the question.

This article is for general information and is not a substitute for medical advice. Please consult a physician about your individual situation.

Header image: "Colles' Fracture of Radius" by Lucien Monfils, via Wikimedia Commons, CC BY-SA 4.0, cropped.

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A wrist that is still sore, swollen or clicking after a fall deserves a closer look. Our fellowship-trained hand, wrist and elbow surgeons treat wrist fractures and ligament injuries, and the first job is finding out which one you are dealing with.