2 Anatomy Can you name all these bones? Use skeleton to run through bony anatomyThink about other structures vessels, nerves
3 Clinical Case 1 85 year old woman Falls over and lands on outstretched armPain in wristTender over base of thumb and wristWhat are possible injuries?
4 X-ray of wrist This shows fracture of distal radius Why are elderly women more likely to break bones after simple fall?
5 Distal Radial Fracture Colles Fracture Most common injury of wristDistal radius is displaced away from palm
6 Colles fracture of wrist How is this injury treated?What long term complications may the patient experience?What can be offered to help reduce these complications?Treated in A and ERegional anaesthetic/ nerve blockManual reduction , then 4-6 weeks in plasterComplications:Pain, stiffness, reduced strength, reduced movementAll of which can be v disabling esp if dominant handPhysiotherapy is essentialSome dept run special hand clinics with physio, occupational therapy etc
7 Post manipulation x-ray Aim to align the bones as near to normal anatomical positionThis reduces subsequent complications
8 Wrist fractures3 typesDepends on what position the hand is forced into by the fallDepends on displacement of distal radius and whether the wrist joint is involved
9 Smiths fractureOpposite to Colles I.e. distal radius is displaced towards the palmLess common, but can be more seriousMore likely to damage vessels and nerves as they run along the palmar side of the wristOften surgical reduction under GA
10 Barton’s fractureLike Smith I.e fracture of distal radius with displacement towards the palm, but also fragments displaced proximallyThis is a more complicated injury and requires surgical reduction and internal fixation with wires to keep the bony fragments togetherHelen Taylor’s sister has just sustained this injury after she fell at a kids roller skating partyShe was in hospital for 4 days, can’t drive for 6 weeks and as it is her dominant hand can’t do simple tasks e.g brushing teeth, filing kettle.You have been warned!
11 Clinical case 2 8 year old child Falls onto outstretched arm whilst skateboardingNot using armTender over wrist on examinationWhat is most likely injury?
12 Greenstick fracture of distal radius Why does this x-ray look different? Because not all of the bones are yet ossified.Why do children get these types of fractures rather than breaking the bone? Because their bones are more flexible and less brittleHow are these treated? Wrist Support or plaster
13 Clinical case 3 25 year old man Falls over handlebars whilst mountain bikingAttends A and ETender over base of thumb and wrist
14 Scaphoid views on x-ray Fracture through waist of scaphoidDistal radius okCan be subtle on initial xray
16 Scaphoid fracture Fall on outstretched hand Tender in anatomical snuffboxUsually fractures through the waist of ScaphoidComplications???
17 Blood supply to Scaphoid Radial ArteryBranch enters Scaphoid distallyFracture through waist can interrupt the arterial supply, leading to ischaemia of the bone, which is called avascular necrosis
18 Avascular necrosis of scaphoid Affects proximal pole of scaphoidBone may fragmentCauses secondary degenerative pain
19 What if X-ray normal? If clinically suspect scaphoid fracture Treat as fracture and repeat x-ray in fourteen days time when fracture maybe more apparentImage wrist with MRI as will show subtle fractures, bone oedema, and ligamentous injury
20 MRI of Scaphoid fracture T1 weighted T2 weighted fat sat showing oedema in distal scaphoid
21 Wrist and hand In Summary, we have looked at Anatomy Common injuries Complications of injury