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 carpalmetacarpal 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; postreduction 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 ?