My brother crash landed while hang gliding and broke his wrist into many tiny pieces. The surgeon spent hours putting it all back together. We watched the video together last night but there wasn’t any real narration. When things are that busted up, how does the surgeon even know where to start?

When trauma causes bones to fracture, split and explode apart, the surgeon is faced with some complex challenges. This is especially true in the wrist and hand where there are many bones intricately fitted together like a jig saw puzzle. One of the biggest challenges is how to separate the broken pieces when they are jammed together and then realign all the fragments.

Traction is often used (suspending the forearm in a vertical position) to pull the bones apart. The surgeon suspends the patient’s forearm in a vertical traction unit. The first part of the procedure may have to be done with the hand suspended in mid-air. The position is definitely awkward for the surgeon.

Once the impacted pieces of bone are pulled apart, the next step is to temporarily place the pieces together. To help guide him (or her), the surgeon uses fluoroscopic (real-time) X-rays. Fluoroscopy allows the surgeon to see inside the joint while performing the procedure.

A special locking plate and wires will do the trick to hold the fracture together. Later the wires will be backed out and more secure, permanent fixation replaces the wires. The surgeon must take the time to fine-tune the reduction by lining each fragment up one at a time. Then it is necessary to go back and firmly attach everything together. And finally, the surgeon takes a look inside the joint for any other soft tissue damage that needs to be repaired.

This may not describe exactly what was done to repair or reconstruct your brother’s wrist but it gives a general idea. The severity of the fracture and specific bones affected dictate how the surgeon approaches each case. Many hours and years of training go into complicated cases like this. They start by working on cadavers (human bodies preserved after death for study) in a laboratory with close supervision.

When they are ready, they observe and assist other more experienced hand surgeons before attempting simple steps (always with guidance and supervision). Even fully trained hand surgeons perform as many wrist fracture fixation procedures (simple and complex) possible arthroscopically. By doing so with the simple surgeries, the more complex become a matter of completing several simple steps one at a time toward the final goal of restoring anatomy, alignment, and function.