Wrist and Forearm Injuries

Rebecca Burton-MacLeod

R2, Emergency Medicine

July 29, 2004

Anatomy of the wrist

Anatomy of the wrist

Thanks Trevor…

Anatomy of the forearm

• Volar compartment:– Flexors

– pronators

•Dorsal compartment:

–Extensor muscles

History and physical

• History– Mechanism

– Point of maximal pain

• Physical– Inspection

– Palpation (Lister’s tubercle, snuffbox, ulnar styloid)

– ROM

– Neurovascular (document presence of radial/ulnar/brachial pulses and radial/median/ulnar nerves)

Case

• 19y.o. male presents to ED after partying all night. Fell down stairs, can’t quite remember how he landed. But c/o pain “in the wrist”. O/E right wrist is swollen and diffusely tender over dorsum distal radius and lunate. Otherwise normal exam. – You decide to order xrays and xray tech wants

to know what views you want?

Xrays

• 3 main views:– PA– Lateral– Oblique

Case cont’d

• You get your xrays back, what is your approach to reading this film?– Radial length measurement

9-12mm

– Ulnar slant of distal radius 15-25 degrees

– Approx 2mm between each of carpal bones

– 3 smooth curves along carpal articular surfaces

Carpal bone arcs

Case cont’d

• How do you approach reading a lateral film?– Volar tilt of radius 10-25

degrees– 3 concentric cups of radius,

lunate, capitate– Normal straight alignment

<10 degrees– Scapholunate angle 30-60

degrees– Capitolunate angle 0-30

degrees– Soft tissue displacement

Case

• 27y.o. M was hit with hockey stick across right arm and has swollen mid forearm. Tender over entire length of ulna.

• What views do you want?– AP and lat

• Anything else you want to make sure is included in xrays?– Joint above and below #

Case cont’d

• How would you determine if proximal radius is appropriately aligned?– Line through prox

radial shaft and head should intersect capitellum

Carpal injuries

Scaphoid #

• Makes up 60% of carpal bone #

• MoI: FOOSH

• # through waist of scaphoid most common

• Risks of AVN due to distal source of blood supply (3%)

• 17% of pts have associated # in wrist/forearm

Scaphoid complications

Scaphoid complications

• Nonunion, arthritis, AVN, collapse of pole, settling of capitate into proximal row

• Post-surgical proximal carpectomy

Case

• 27y.o. M presents to ED after falling off mountain bike. Swelling and pain in left wrist. On exam, how would you identify scaphoid #?– Tenderness over snuffbox, tenderness over

scaphoid tubercle, pain with axial compression of MC jt, pain with resisted supination

Case cont’d

• Anything noticeable on xray?

Case cont’d

• What if xray were completely normal, but worrisome exam?– 15% of scaphoid # do not show up on xray– If clinically suspicious then cast immobilization

and rpt xray in 10-14 days– If rpt xray still negative but suspicious exam,

then CT may show #

Scaphoid #

• What type of cast:

• Acute nondisplaced stable scaphoid #?– Below elbow thumb spica cast x 12 wks

• Delayed nondisplaced stable scaphoid #?– Long arm thumb spica cast x 6 wks, then short

arm thumb spica cast for remainder (time to union is 3 mos faster)

Case

• 42y.o. F sustained FOOSH to right hand. O/E tender over dorsal aspect of wrist distal to ulnar styloid, decreased wrist ROM.– What xrays do you want to order?

Case cont’d

• Interpretation of xray?– Small dorsal chip

fragment

– Triquetral #

Case cont’d

• Management of triquetral #?– Immobilize in short arm cast x 4-6 wks

• Similar treatment recommended for pisiform #, trapezium #, capitate #, trapezoid #

Case

• Xray interpretation?– Trapezium #

Case

• What type of xray is this?– Carpal tunnel view

• What bones are fractured?– Trapezium and hamate

Hamate #

• Hook of hamate is most common site of #

• Treatment is immobilization in short arm cast, with ortho f/u in 1-2wks

• Complications:– Ulnar nerve injury– nonunion

• May require surgical excision of hook

Case

• 35y.o. M who is right-handed and presents with remote hx of being hit in dorsiflexed right hand with jack hammer while at work 2 yrs ago. Since c/o gradually worsening tender wrist. No other recent trauma

• You do xrays and see…

Case cont’d

• Interpretation?– Sclerotic lunate

fragment

• What is the name of this condition?– Kienbock’s disease

– AVN of lunate following traumatic #

– Treatment--ortho

Lunate #

• Because of risk of Kienbock’s disease, all suspected lunate # should be immobilized in short arm cast

• Should receive ortho f/u in 1-2wks

Carpal # general rules

• All displaced carpal bone #, carpal dislocation, or # involving carpal-metacarpal jt should be referred to ortho for ORIF

Carpal instability

• Stage 1—scapholunate failure

• Stage 2—capitolunate failure

• Stage 3—triquetrolunate failure

• Stage 4—lunate dislocation

Carpal instability

• Stage 1:– Fall on extended wrist is usual cause– Frequently c/o pain in wrist with activity followed by

aching– Scaphoid test and catch-up clunk

• 4 fingers on dorsum or radius and thumb over scaphoid tuberosity, move hand from ulnar deviation to radial deviation and apply pressure with thumb—pain as scaphoid is moved dorsally if unstable

• Move wrist from radial to ulnar deviation and will hear clunk as lunate catches up with alignment of scaphoid

Carpal instability

• Stage 1:– Terry Thomas sign

(2mm between scaphoid and lunate)

• Gap increases with clenched fist AP view

– Signet ring sign

Carpal instability

• Stage 2:– Fall on extended wrist

Carpal instability

• Stage 2:– Best seen on lat view

– Capitate is dorsally dislocated

– Lunate in normal position

Carpal instability

• Stage 3:– Axial loading on hyperextended pronated wrist– Pain and laxity on ulnar side of wrist– Xray show triquetrum displaced proximally on

AP view; may be exaggerated with ulnar deviation

Carpal instability

• Stage 4:– Major complication is

acute compression of median nerve

– xray shows triangular lunate, and on lat view spilled teacup and dorsal displacement of capitate

Carpal instability

• All carpal dislocation injuries need ortho referral for reduction/stabilization

• Complications include median nerve palsy, chronic carpal instability, degenerative arthritis

Distal radius / ulna injuries

Quiz

• What # is associated with “dinner fork” deformity?– Colles #

• What is the other name for a “reverse Colles #”?– Smith’s #

• Which type of # gives classical “chauffeurs #”?– Hutchinson #

Case

• 56y.o. F fell onto dorsum of right wrist. Now painful, swollen wrist. What type of # is this?– Smith’s #– Volar displacement

and angulation of metaphysis of distal radius

Case cont’d

• What would your management be of this #?– Attempt closed reduction, if unsuccessful then

ORIF necessary– Cast x 6-8 wks

Colles’ #

• Most common wrist # in adults

• Dorsal displacement and angulation of distal radial metaphysis

• Often associated # of ulnar styloid

Colles’ #

• Management:– Prompt closed reduction– If marked dorsal comminution, intraarticular

extension of #, displacement >20 degrees dorsal angulation, then require ortho f/u

– If open #, neurovasc compromise, or failed attempt at reduction then immediate ortho referral

Acceptable measurements for healing of distal radius #

• Xray criteria:• Radiulnar length

• Radial inclination• Radial tilt

• Articular incongruity

• Measurements:• <5mm radial

shortening• >= 15 degrees• 15 degree dorsal tilt

and 30 degree volar• <= 2mm at radiocarpal

joint

Case

• 33y.o. M construction worker was tightening a crank pulley when he lost grip and crank hit him in back of right wrist.

• Xray interpretation?– Transverse # of radial

metaphysis with extension into radiocarpal joint

• Type of #?– Hutchinson #

Case cont’d

• Management of nondisplaced #?– Short arm cast x 4-6 wks

• Management of displaced #?– ORIF

Barton’s #

• Oblique intraarticular # of rim of distal radius with displacement of carpal and # fragment

• Usually volar subluxation– “volar Barton’s #”

• Use lat xray for determination of degree of articular surface involvement and displacement

• Require ortho ORIF

DRUJ

• Dislocation of radioulnar joint• Often associated with distal radius or Galeazzi’s #• Clinical high suspicion for diagnosis• May either be dorsal or volar dislocation of ulna• Disruption of triangular fibrocartilage complex,

avulsion # of ulna styloid common

DRUJ

• With dorsal dislocation:– Prominent ulnar styloid– Pain and limitation with supination

• With volar dislocation:– Loss of normal ulnar styloid prominence– Pain and limitation with pronation

DRUJ

• Xrays may be normal

• If DRUJ suspected, CT is recommended of the wrist

• Require ortho consult for reduction/stabilization

• Long arm cast x 6 wks

Forearm injuries

Case

• 41y.o. M minding his own business when assaulted near Cecil Hotel. Hit on left forearm with baseball bat.

• Describe the xray• Any other xray images

you want?

Case cont’d

• Management of this #?– Short arm cast x 6-8 wks

• If the # were in mid or proximal third of ulna, what would your management be?– Long arm cast– Q1wk f/u to ensure no displacement

When to refer…

• If >10 degrees of angulation

• # with >50% displacement of diameter of ulna

Interventions for isolated diaphyseal fractures of ulna in adults.

Handoll, HH. Cochrane Database. Jan 2004.

• 3 articles about management of isolated ulnar #• Short arm prefabricated braces with long arm casts

—no difference in # healing, pts were more functional and “happier” with braces

• Wrap bandages, short arm casts, and long arm casts—pts with wrap bandages had more pain

• 2 types of plates—no significant difference in # healing (doesn’t matter to us!)

• Overall—not great trials, need better data to indicate appropriate method of treatment

Radius and ulna shaft #

• Usually requires significant force so often displacement as well

• As you can see….

ORIF required for displacement

If undisplaced then long arm cast x 8 wks (ortho f/u in 1wk to ensure no displacement)

Which one is which?

Galeazzi’s # Monteggia’s #

Monteggia’s #

• # of proximal ulna and dislocation of radial head• Delayed diagnosis of radial head dislocation in ¼

of cases• MoI: forced pronation of forearm during FOOSH• Often damage to deep branch of radial nerve

(wkness or paralysis on extension of fingers and thumb)

• Requires immediate ortho referral for ORIF

Monteggia’s #

Monteggia’s #

• Type 1—ant dislocation and angulation

• Type 2—post dislocation and angulation

• Type 3—lat dislocation and angulation

• Type 4—# of radial and ulna shafts with radial head dislocation

Galeazzi’s #

• 3-7% of all forearm # seen• Distal radius # and

dislocation of DRUJ• MoI: wrist in extension,

forearm pronated, and FOOSH

• “fracture of necessity”…I.e. surgery is necessity for good outcome!

• Require ortho referral as unstable # for ORIF

Pediatric injuries

Pediatric injuries

• Or as I like to call it…is anything wrong with this arm?

Pediatric fractures

• 3 main types:– Buckle—treat in short arm cast and ortho f/u– Greenstick– complete

Xray…

• What type of # is this?– buckle

Greenstick #

• By definition, they are displaced #

• Thus, require long-arm cast x 6-8 wks and ortho f/u to ensure no further displacement

• When to reduce (I.e. how much displacement is too much? ) ?– Angulation >10 degrees

Xray…

Complete #

• Complete # through both cortices of radius, often associated ulna # as well

• Require reduction

• If reduction not adequate, then possible ORIF

• Long arm cast x 7-8wks

Reduction versus remodelling in pediatric distal forearm fractures: a preliminary cost

analysis.Do, TT. J Ped Ortho. Mar 2003.

• N=34 pts with wrist metaphyseal fractures who were reduced and lost reduction on f/u

• Pts with <15 degrees angulation, <1cm shortening, open physis—heal within cast in 6wks; remodel in 7.5 months

• Pts with no reduction—saved 2h ED time, saved 50% of costs (US$270 vs. US$536)

• No significant clinical deformities or residual functional deficits

Position of immobilization for pediatric forearm fractures.

Boyer, BA. J Ped Ortho. Mar 2002. • N=99; distal-third forearm fractures• Closed reduction and casting in neutral,

pronated or supinated positions• Initial angulation—20 degrees; post-

reduction angulation—3 degrees; angulation at union—7 degrees

• No significant difference between casting positions with regards to forearm angulation

Growth plate #

• Usually Salter I or II of distal radius

• Salter I—treat with short arm cast/splint, with ortho f/u

• Salter II—if displaced, require ortho for reduction; immobilize in long-arm cast, with ortho f/u

Plastic deformation

• Unique to children• Bowing of bone without

obvious #• May be associated with #

in other forearm bone…so be careful not to miss it!

• Contralateral arm xrays may be useful

• Refer to ortho for reduction and long arm cast and f/u

References

• Rosen’s• Canale: Campbell’s Operative Orthopedics. 10th ed. Mosby , Inc. 2003• Perron, AD. Evaluation and management of high-risk orthopedic

emergencies. Emerg Med Clin NA. Feb 2003. 21(1):159-204.• Overly, F. Common pediatric fractures and dislocations. CPEM. June

2002. 3:106-117.• Do, TT. Reduction versus remodeling in pediatric distal forearm

fractures: a preliminary cost analysis. J Ped Ortho B. Mar 2003. 12(2):109-115.

• Handall, HH. Interventions for isolated diaphyseal fractures of ulna in adults. Cochrane database. Jan 2004.

• Boyer, BA. Position of immobilization for pediatric forearm fractures. J Ped Ortho. Mar 2002. 22(2):185-187.

Questions ?