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 ?