Wrist and Scaphoid Index case term 1

Anatomy Can you name all these bones? Use skeleton to run through bony anatomy Think about other structures vessels, nerves

Clinical Case 1 85 year old woman Falls over and lands on outstretched arm Pain in wrist Tender over base of thumb and wrist What are possible injuries?

X-ray of wrist This shows fracture of distal radius Why are elderly women more likely to break bones after simple fall?

Distal Radial Fracture Colles Fracture Most common injury of wrist Distal radius is displaced away from palm

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 E Regional anaesthetic/ nerve block Manual reduction , then 4-6 weeks in plaster Complications: Pain, stiffness, reduced strength, reduced movement All of which can be v disabling esp if dominant hand Physiotherapy is essential Some dept run special hand clinics with physio, occupational therapy etc

Post manipulation x-ray Aim to align the bones as near to normal anatomical position This reduces subsequent complications

Wrist fractures 3 types Depends on what position the hand is forced into by the fall Depends on displacement of distal radius and whether the wrist joint is involved

Smiths fracture Opposite to Colles I.e. distal radius is displaced towards the palm Less common, but can be more serious More likely to damage vessels and nerves as they run along the palmar side of the wrist Often surgical reduction under GA

Barton’s fracture Like Smith I.e fracture of distal radius with displacement towards the palm, but also fragments displaced proximally This is a more complicated injury and requires surgical reduction and internal fixation with wires to keep the bony fragments together Helen Taylor’s sister has just sustained this injury after she fell at a kids roller skating party She 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!

Clinical case 2 8 year old child Falls onto outstretched arm whilst skateboarding Not using arm Tender over wrist on examination What is most likely injury?

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 brittle How are these treated? Wrist Support or plaster

Clinical case 3 25 year old man Falls over handlebars whilst mountain biking Attends A and E Tender over base of thumb and wrist

Scaphoid views on x-ray Fracture through waist of scaphoid Distal radius ok Can be subtle on initial xray

Scaphoid Fracture

Scaphoid fracture Fall on outstretched hand Tender in anatomical snuffbox Usually fractures through the waist of Scaphoid Complications???

Blood supply to Scaphoid Radial Artery Branch enters Scaphoid distally Fracture through waist can interrupt the arterial supply, leading to ischaemia of the bone, which is called avascular necrosis

Avascular necrosis of scaphoid Affects proximal pole of scaphoid Bone may fragment Causes secondary degenerative pain

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 apparent Image wrist with MRI as will show subtle fractures, bone oedema, and ligamentous injury

MRI of Scaphoid fracture T1 weighted T2 weighted fat sat showing oedema in distal scaphoid

Wrist and hand In Summary, we have looked at Anatomy Common injuries Complications of injury