Wrist and Forearm Injuries

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Wrist and Forearm Injuries

• Rebecca Burton-MacLeod
• R2, Emergency Medicine
• July 29, 2004

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Anatomy of the wrist
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Anatomy of the wrist
Thanks Trevor
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Anatomy of the forearm

• Volar compartment
• Flexors
• pronators

• Dorsal compartment
• Extensor muscles

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History and physical

• History
• Mechanism
• Point of maximal pain

• Physical
• Inspection
• Palpation (Listers tubercle, snuffbox, ulnar
  styloid)
• ROM
• Neurovascular (document presence of
  radial/ulnar/brachial pulses and
  radial/median/ulnar nerves)

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Case

• 19y.o. male presents to ED after partying all
  night. Fell down stairs, cant 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?

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Xrays

• 3 main views
• PA
• Lateral
• Oblique

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Case contd

• 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

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Carpal bone arcs
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Case contd

• 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 lt10 degrees
• Scapholunate angle 30-60 degrees
• Capitolunate angle 0-30 degrees
• Soft tissue displacement

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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

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Case contd

• How would you determine if proximal radius is
  appropriately aligned?
• Line through prox radial shaft and head should
  intersect capitellum

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Carpal injuries
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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

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Scaphoid complications
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Scaphoid complications

• Nonunion, arthritis, AVN, collapse of pole,
  settling of capitate into proximal row
• Post-surgical proximal carpectomy

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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

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Case contd

• Anything noticeable on xray?

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Case contd

• 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

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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)

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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?

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Case contd

• Interpretation of xray?
• Small dorsal chip fragment
• Triquetral

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Case contd

• Management of triquetral ?
• Immobilize in short arm cast x 4-6 wks
• Similar treatment recommended for pisiform ,
  trapezium , capitate , trapezoid

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Case

• Xray interpretation?
• Trapezium

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Case

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

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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

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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

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Case contd

• Interpretation?
• Sclerotic lunate fragment
• What is the name of this condition?
• Kienbocks disease
• AVN of lunate following traumatic
• Treatment--ortho

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Lunate

• Because of risk of Kienbocks disease, all
  suspected lunate should be immobilized in short
  arm cast
• Should receive ortho f/u in 1-2wks

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Carpal general rules

• All displaced carpal bone , carpal dislocation,
  or involving carpal-metacarpal jt should be
  referred to ortho for ORIF

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Carpal instability

• Stage 1scapholunate failure
• Stage 2capitolunate failure
• Stage 3triquetrolunate failure
• Stage 4lunate dislocation

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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 thumbpain 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

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Carpal instability

• Stage 1
• Terry Thomas sign (2mm between scaphoid and
  lunate)
• Gap increases with clenched fist AP view
• Signet ring sign

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Carpal instability

• Stage 2
• Fall on extended wrist

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Carpal instability

• Stage 2
• Best seen on lat view
• Capitate is dorsally dislocated
• Lunate in normal position

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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

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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

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Carpal instability

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

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Distal radius / ulna injuries
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Quiz

• What is associated with dinner fork
  deformity?
• Colles
• What is the other name for a reverse Colles ?
• Smiths
• Which type of gives classical chauffeurs ?
• Hutchinson

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Case

• 56y.o. F fell onto dorsum of right wrist. Now
  painful, swollen wrist. What type of is this?
• Smiths
• Volar displacement and angulation of metaphysis
  of distal radius

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Case contd

• What would your management be of this ?
• Attempt closed reduction, if unsuccessful then
  ORIF necessary
• Cast x 6-8 wks

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Colles

• Most common wrist in adults
• Dorsal displacement and angulation of distal
  radial metaphysis
• Often associated of ulnar styloid

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Colles

• Management
• Prompt closed reduction
• If marked dorsal comminution, intraarticular
  extension of , displacement gt20 degrees dorsal
  angulation, then require ortho f/u
• If open , neurovasc compromise, or failed
  attempt at reduction then immediate ortho referral

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Acceptable measurements for healing of distal
radius

• Xray criteria
• Radiulnar length
• Radial inclination
• Radial tilt
• Articular incongruity

• Measurements
• lt5mm radial shortening
• gt 15 degrees
• 15 degree dorsal tilt and 30 degree volar
• lt 2mm at radiocarpal joint

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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

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Case contd

• Management of nondisplaced ?
• Short arm cast x 4-6 wks
• Management of displaced ?
• ORIF

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Bartons

• Oblique intraarticular of rim of distal radius
  with displacement of carpal and fragment
• Usually volar subluxation
• volar Bartons
• Use lat xray for determination of degree of
  articular surface involvement and displacement
• Require ortho ORIF

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DRUJ

• Dislocation of radioulnar joint
• Often associated with distal radius or Galeazzis
  
• Clinical high suspicion for diagnosis
• May either be dorsal or volar dislocation of ulna
• Disruption of triangular fibrocartilage complex,
  avulsion of ulna styloid common

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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

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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

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Forearm injuries
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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?

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Case contd

• 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

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When to refer

• If gt10 degrees of angulation
• with gt50 displacement of diameter of ulna

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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
  castsno difference in healing, pts were more
  functional and happier with braces
• Wrap bandages, short arm casts, and long arm
  castspts with wrap bandages had more pain
• 2 types of platesno significant difference in
  healing (doesnt matter to us!)
• Overallnot great trials, need better data to
  indicate appropriate method of treatment

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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)

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Which one is which?
Galeazzis
Monteggias
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Monteggias

• 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

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Monteggias
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Monteggias

• Type 1ant dislocation and angulation
• Type 2post dislocation and angulation
• Type 3lat dislocation and angulation
• Type 4 of radial and ulna shafts with radial
  head dislocation

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Galeazzis

• 3-7 of all forearm seen
• Distal radius and dislocation of DRUJ
• MoI wrist in extension, forearm pronated, and
  FOOSH
• fracture of necessityI.e. surgery is necessity
  for good outcome!
• Require ortho referral as unstable for ORIF

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Pediatric injuries
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Pediatric injuries

• Or as I like to call itis anything wrong with
  this arm?

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Pediatric fractures

• 3 main types
• Buckletreat in short arm cast and ortho f/u
• Greenstick
• complete

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Xray

• What type of is this?
• buckle

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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 gt10 degrees

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Xray
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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

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Reduction versus remodelling in pediatric distal
forearm fractures a preliminary cost
analysis.Do, TT. J Ped Ortho. Mar 2003.

• N34 pts with wrist metaphyseal fractures who
  were reduced and lost reduction on f/u
• Pts with lt15 degrees angulation, lt1cm shortening,
  open physisheal within cast in 6wks remodel in
  7.5 months
• Pts with no reductionsaved 2h ED time, saved 50
  of costs (US270 vs. US536)
• No significant clinical deformities or residual
  functional deficits

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Position of immobilization for pediatric forearm
fractures.Boyer, BA. J Ped Ortho. Mar 2002.

• N99 distal-third forearm fractures
• Closed reduction and casting in neutral, pronated
  or supinated positions
• Initial angulation20 degrees post-reduction
  angulation3 degrees angulation at union7
  degrees
• No significant difference between casting
  positions with regards to forearm angulation

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Growth plate

• Usually Salter I or II of distal radius
• Salter Itreat with short arm cast/splint, with
  ortho f/u
• Salter IIif displaced, require ortho for
  reduction immobilize in long-arm cast, with
  ortho f/u

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Plastic deformation

• Unique to children
• Bowing of bone without obvious
• May be associated with in other forearm boneso
  be careful not to miss it!
• Contralateral arm xrays may be useful
• Refer to ortho for reduction and long arm cast
  and f/u

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References

• Rosens
• Canale Campbells 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. 3106-117.
• 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.

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Questions ?