wrist injuries
DESCRIPTION
A review of common wrist injuries and their management.TRANSCRIPT
Wrist InjuriesBradley WallacePGY-2, Emergency Medicine4/14/2015
Bradley WallacePGY-2, Emergency Medicine4/14/15
FOOSH FTL
Disclosures
I have no financial disclosures whatsoever.
None.
Seriously.
Objectives
Review basic wrist anatomy
Introduce algorithm for assessing wrist injuries by location
Treatment for most common wrist injuries
Quick and dirty approach for evaluating wrist injuries by age, mechanism, and exam
Keep you awake
BreakdownDorsal
Distal radius fracturesColles’ (dorsal)
Smith’s (volar)
Perilunate and lunate dislocations
Lunate fx
UlnarTriquetral fracture
RadialScaphoid fracture
Trapezium fracture
De Quervain’s tenosynovitis
VolarHook of hamate fracture
Pisiform fracture
Age
Mechanism
Exam
Ulnar
Radia
l
Volar
Dorsal
Dorsal
Four Regions
Dorsal
Radial
Ulnar
Volar
Dorsal Region
Case 128 yo M skiing downhill becomes distracted when he remembers that there were a handful of incomplete notes from his last shift in Blue Zone before he left for vacation.
A. Smith’s fracture
B. Colles’ fracture
C. Hutchinson fracture
D. Barton’s fracture
E. Lagavulin fracture
Distal Radius Fractures
Colles’ FractureDistal radius with dorsal displacement of distal fragment
FOOSH’ing
Distal Radius Fractures
Smith’s FractureDistal radius with volar displacement of distal fragment
Colles’
Reduction Techniques
Hematoma block
Finger traps
Reduction Techniques
Traction, counter-traction
Supinate forearm, dorsally flex– accentuating fracture pattern
Pronate forearm/wrist
Post-Reduction
Place in sugar tong or double sugar tong splint for 2-3 weeks
Will need follow up within the week (ideally) for further radiography to assess post-reduction movement or continued deformity
Fracture DislocationsHutchinson’s fracture
Fracture of radial styloid process
Fracture DislocationsBarton’s fracture
Radiocarpal ligaments avulse radial fragment, displacing either dorsally or palmarly
Distal radius fragment maintains articulation with carpus
Unstable Distal Radius Fractures
Fracture dislocations (Hutchinson, Barton)
Smith’s fracture
Articular stepoff >2mm
Large ulnar styloid fracture (i.e., most/all of the styloid)
When associated with scaphoid fracture or scapholunate ligamentous injury
Advanced OA
A. Smith’s fracture
B. Colles’ fracture
C. Hutchinson fracture
D. Barton’s fracture
A. Smith’s fracture
B. Colles’ fracture
C. Hutchinson fracture
D. Barton’s fracture
A. Stable
B. Unstable
A. Stable
B. Unstable
Case 2
23 yo M wipes out while attempting what would have been a totally gnarly goofy foot fakey 360 cowboy air to roast beef sack tap to dark 50-50 grind 540 frontside pop shove it. He ends up falling back onto an outstretched hand with wrist extended.
ExamTTP at dorsal wrist (shocking)
Paresthesias to thumb, index finger, long finger, and the radial aspect of the ring finger
A. Perilunate dislocation
B. Lunate dislocation
C. Scapholunate ligament injury
D. Periscaphoid dislocation
E. Periscapholunohamate dislocation
Carpal Ligament Disruptions
Spectrum of Awfulness
Scapholunate ligament injury
Perilunate dislocation
Lunate dislocation
Scapholunate Ligament Injury
Most common ligamentous injury to wrist
Commonly associated with scaphoid, lunate, and/or radial fractures
Scapholunate Ligament Injury
Radial gutter or volar splint
Prompt referral to ortho, especially in setting of concomitant radial fracture
Perilunate Dislocation
Between Bozo and Pennywise in FOOSH progression
2/3 of patients with perilunate dislocations will have associated fracture (most commonly scaphoid)
Lateral film most helpful
Lunate Dislocation
Most severe form
Lunate no longer articulates with radial head
Encroaches on carpal tunnel which can lead to median nerve palsies
Treatment
Closed reduction almost always fails
Sugar tong splint until follow up with ortho
Almost always need ORIF
Sugar tong
A. Perilunate dislocation
B. Lunate dislocation
C. Scapholunate ligament injury
D. Periscaphoid dislocation
E. Periscapholunohamate dislocation
A. Perilunate dislocation
B. Lunate dislocation
C. Scapholunate ligament injury
D. Periscaphoid dislocation
E. Periscapholunohamate dislocation
Lunate Fracture
Fall on extended wrist
0.5-6.5% of all carpal fractures
Wrist pain aggravated with wrist motion or gripping
Minimal swelling
Specific Tests
Grasp long finger then push in-line towards wrist
Wrist is fully palmar flexed while examiner palpates dorsal wrist depression. As lunate is exposed, pain is elicited.
Diagnosis
Four view wrist XR
Difficult to see on plain radiographs– if high index of suspicion, consider CT or MRI
If any fracture present, warrants surgical referral
Kienböck's Disease
Lunate received blood supply from volar and dorsal aspects
20% of lunate has single blood source
Undiagnosed trauma can lead to AVN of part of lunate
Dorsal
Distal radius fracturesColles’ (dorsal)
Smith’s (volar)
Lunate fx Kienbock’s disease of the lunate
Perilunate and lunate dislocations
Radial Region
Scaphoid fracture
Trapezium fracture
De Quervain’s tenosynovitis
Case 3
When attempting to execute his nigh-unstoppable knucklepuck, Russ Tyler is checked on the open ice, falling onto an outstretched hand. He is forced to leave the game with worsening wrist pain.
Exam
TTP on radial aspect of wrist, worst in anatomic snuff box
Tenderness on axial loading of the thumb and on forced supination
Faint swelling to dorsoradial aspect of wrist
Slightly reduced grip strength
Negative radiographs
Scaphoid FractureOccult scaphoid fracture present in approx 25% of patients with negative radiographs
Management often is placing in thumb spica for 7-10 days then re-imaging
Other imaging modalities–CT: 83% sensitive, 97% specific
MRI: 97.7% sensitive, 99.8% specific
Bone scintigraphy: 91% sensitive, 86% specific
Scaphoid FractureThumb spica and rpt XR in two weeks
90-98% union rates achieved when non-displaced scaphoid fractures appropriately splinted
Refer to surgery if:Fracture to proximal pole
Fracture displaced >1mm
Delayed presentation (>3 weeks)
Fractures with scapholunate ligament rupture
Scaphoid Fracture
Increased discomfort with resisting supination
Pain with circumscribing arcs with thumb
Pain with ulnar wrist deviation
Axial load on thumb
Case 4
A 30 year old female patient presents with worsening pain to the radial aspect of the wrist radiating to her thumb as well as decreased grip strength. No definite trauma but has a 6 month old at home.
Exam
TTP at distal aspect of radial styloid
Pain on resisting thumb extension
Most intense pain when passively stretching thumb tendons while thumb held in flexion
Mild snuffbox tenderness
A. Trapezium fracture
B. Scaphoid fracture
C. De Quervain’s tenosynovitis
D. Triquetral fracture
Trapezium Fracture
Rare
Axial load injury to thumb
Pain and weakness with pinching movements
Place in thumb spica x4-6 weeks unless open or more than 2mm displacement
de Quervain’s Tenosynovitis
Results from chronic overuse (most common in women with a 6-12 month old)
Tendon sheath inflammation
Pain control via icing, velco thumb spica splint
Surgical intervention if multiple steroid injections fail
Finkelstein’s Test
A. Trapezium fracture
B. Scaphoid fracture
C. De Quervain’s tenosynovitis
D. Triquetral fracture
A. Trapezium fracture
B. Scaphoid fracture
C. De Quervain’s tenosynovitis
D. Triquetral fracture
Radial Region
de Quervain’s tenosynovitis
Trapezium fracture
Scaphoid fracture
Volar Region
Case 5
Betty White is walking. She falls over. She falls onto an outstretched hand. It was her own outstretched hand.
Exam
You Fail
You send Betty White home with NSAIDs because you didn’t pay attention to this lecture
She presents again with worsening pain over the hypothenar region
Now with paresthesias to pinky and ring finger
What did you miss?
Hook of Hamate Fracture
Typically from FOOSH
Swelling may be minimal/absent
Sometimes misdiagnosed as a wrist sprain
Hamulus Fracture
Carpal tunnel view
If displaced, place in volar splint and arrange prompt f/u with hand surgeon
If non-displaced, can place in intrinsic plus for 4-6 weeks
Case 6
A battle-hardened war veteran named Cameron Poe goes to a bar with his wife after returning from a tour of duty and a group of drunken men begin to taunt them. After being attacked, Cameron Poe does that thing that people do in movies where they use their palm to shove a bad guy’s nose up into his brain to kill him instantly. While in prison on a murder charge Cameron Poe has continued pain in the palm of his murder-hand.
Pisiform Fracture
FOOSH or when hand used to strike an object like a hammer
Exam typically shows no deformity and no loss of motion at the wrist
If fracture identified, place in volar splint– typically heal within 3-6 weeks of immobilization
Volar Region
Hook of hamate fracture
Pisiform fracture
Ulnar Region
Triquetral fracture
Ulnar styloid impaction syndrome
Extensor carpi ulnaris tendinopathy and subluxation
Case 6
In one of the final matches of the Kumite, Frank Dux attempts a Dim Mak but one of the final flourishes is blocked forcing his hand into extreme dorsiflexion. Though he completes the match, he has lingering pain on the ulnar aspect of his wrist.
Triquetral Fracture
Hyperextension of wrist when in ulnar deviation
Exam with TTP along ulnar aspect of wrist 1-2cm distal to ulna; pain worse on wrist extension
Place in volar splint rpt XR in 2-3 weeks
Ulnar Region
Triquetral fracture
Ulnar styloid impaction syndrome
Extensor carpi ulnaris tendinopathy and subluxation
BreakdownDorsal
Distal radius fracturesColles’ (dorsal)
Smith’s (volar)
Perilunate and lunate dislocations
Lunate fx Kienbock’s disease of the lunate
UlnarTriquetral fracture
RadialScaphoid fracture
Trapezium fracture
De Quervain’s tenosynovitis
VolarHook of hamate fracture
Pisiform fracture
Quick and Dirty
Age
Mechanism
Exam
Age
Mechanism
Exam
Bonus Case
Questions?
Thanks to…
Sierra Beck
Patrick Thomas
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