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

ReferencesAhn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears: a review. Bull NYU Hosp Jt Dis 2006; 64:114.

Carpenter CR, et al. Adult scaphoid fracture. Acad Emerg Med 2014; 21:102.

Daniels JM 2nd, Zook EG, Lynch JM. Hand and wrist injuries: Part I. Nonemergent evaluation. Am Fam Physician 2004;69:1941.

Dobyns JH, Beckerbaugh RD, Bryan RS, et al. Fractures of the hand and wrist. In: Hand Surgery, 3rd, Flynn JE (d), Williams & Wilkins, Philadelphia 1982.

Geissler W, Slade JF. Fractures of the carpal bones. In: Operative Hand Surgery, 6th, Green DP (Ed), Churchill Livingstone, Philadelphia 2011. p.639.

Kozin "Perilunate injuries: diagnosis and treatment" J. Am. Acad. Ortho. Surg., Mar 1998; 6: 114 - 120.

Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg Am 1981; 6:515.

Seitz WH Jr, Papandrea RF. Fractures and dislocations of the wrist. In: Rockwood and Green's Fractures in Adults, 5th, Bucholz RW, Heckman JD (Eds), Lippincott Williams & Wilkins, Philadelphia 2002.

Topper SM, Wood MB, Ruby LK. Ulnar styloid impaction syndrome. J Hand Surg Am 1997; 22:699.

Van Tassel DC, Owens BD, Wolf JM. Incidence estimates and demographics of scaphoid fracture in the U.S. population. J Hand Surg Am 2010; 35:1242.

Webb BG, Rettig LA. Gymnastic wrist injuries. Curr Sports Med Rep 2008; 7:289.