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: Dorsal compartment: Flexors pronators Dorsal compartment: Extensor muscles

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)

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? What bones are fractured? 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? 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

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 carpal-metacarpal 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 #? Management of displaced #? 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: 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

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 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 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

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 ?