1. Wrist and Forearm Injuries
Rebecca Burton-MacLeod
R2, Emergency Medicine
July 29, 2004

2. Anatomy of the wrist

3. Anatomy of the wrist
Thanks Trevor…

4. Anatomy of the forearm Volar compartment: Dorsal compartment: Flexors
pronators
Dorsal compartment:
Extensor muscles

5. History and physical History Physical Mechanism Point of maximal pain
Inspection
Palpation (Lister’s tubercle, snuffbox, ulnar styloid)
ROM
Neurovascular (document presence of radial/ulnar/brachial pulses and radial/median/ulnar nerves)

6. 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?

7. Xrays
3 main views: PA
Lateral
Oblique

8. 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 degrees
Approx 2mm between each of carpal bones
3 smooth curves along carpal articular surfaces

9. Carpal bone arcs

10. Case cont’d How do you approach reading a lateral film?
Volar tilt of radius degrees
3 concentric cups of radius, lunate, capitate
Normal straight alignment <10 degrees
Scapholunate angle degrees
Capitolunate angle 0-30 degrees
Soft tissue displacement

11. 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 #

12. Case cont’d
How would you determine if proximal radius is appropriately aligned?
Line through prox radial shaft and head should intersect capitellum

13. Carpal injuries

14. 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

15. Scaphoid complications

16. Scaphoid complications
Nonunion, arthritis, AVN, collapse of pole, settling of capitate into proximal row
Post-surgical proximal carpectomy

17. 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

18. Case cont’d
Anything noticeable on xray?

19. 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 days
If rpt xray still negative but suspicious exam, then CT may show #

20. 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)

21. 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?

22. Case cont’d Interpretation of xray? Small dorsal chip fragment
Triquetral #

23. Case cont’d Management of triquetral #?
Immobilize in short arm cast x 4-6 wks
Similar treatment recommended for pisiform #, trapezium #, capitate #, trapezoid #

24. Case
Xray interpretation?
Trapezium #

25. Case What type of xray is this? What bones are fractured?
Carpal tunnel view
What bones are fractured?
Trapezium and hamate

26. 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

27. 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…

28. Case cont’d Interpretation? What is the name of this condition?
Sclerotic lunate fragment
What is the name of this condition?
Kienbock’s disease
AVN of lunate following traumatic #
Treatment--ortho

29. 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

30. Carpal # general rules
All displaced carpal bone #, carpal dislocation, or # involving carpal-metacarpal jt should be referred to ortho for ORIF

31. Carpal instability Stage 1—scapholunate failure
Stage 2—capitolunate failure
Stage 3—triquetrolunate failure
Stage 4—lunate dislocation

32. 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

33. Carpal instability Stage 1:
Terry Thomas sign (2mm between scaphoid and lunate)
Gap increases with clenched fist AP view
Signet ring sign

34. Carpal instability
Stage 2:
Fall on extended wrist

35. Carpal instability Stage 2: Best seen on lat view
Capitate is dorsally dislocated
Lunate in normal position

36. 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

37. 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

38. Carpal instability
All carpal dislocation injuries need ortho referral for reduction/stabilization
Complications include median nerve palsy, chronic carpal instability, degenerative arthritis

39. Distal radius / ulna injuries

40. 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 #

41. 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

42. Case cont’d What would your management be of this #?
Attempt closed reduction, if unsuccessful then ORIF necessary
Cast x 6-8 wks

43. Colles’ # Most common wrist # in adults
Dorsal displacement and angulation of distal radial metaphysis
Often associated # of ulnar styloid

44. 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

45. 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

46. 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 #

47. Case cont’d Management of nondisplaced #? Management of displaced #?
Short arm cast x 4-6 wks
Management of displaced #?
ORIF

48. 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

49. 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

50. DRUJ With dorsal dislocation: With volar dislocation:
Prominent ulnar styloid
Pain and limitation with supination
With volar dislocation:
Loss of normal ulnar styloid prominence
Pain and limitation with pronation

51. 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

52. Forearm injuries

53. 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?

54. 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

55. When to refer… If >10 degrees of angulation
# with >50% displacement of diameter of ulna

56. Interventions for isolated diaphyseal fractures of ulna in adults
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

57. 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)

58. Which one is which?
Galeazzi’s #
Monteggia’s #

59. 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

60. Monteggia’s #

61. 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

62. 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

63. Pediatric injuries

64. Pediatric injuries
Or as I like to call it…is anything wrong with this arm?

65. Pediatric fractures 3 main types:
Buckle—treat in short arm cast and ortho f/u
Greenstick
complete

66. Xray…
What type of # is this?
buckle

67. 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

68. Xray…

69. 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

70. 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

71. Position of immobilization for pediatric forearm fractures. Boyer, BA
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

72. 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

73. 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

74. 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 (1):
Overly, F. Common pediatric fractures and dislocations. CPEM. June :
Do, TT. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Ped Ortho B. Mar (2):
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 (2):

75. Questions ?