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| ==Background== | | ==Background== |
| | [[File:Carpal bones.png|thumb|Carpal bones]] |
| | [[File:Zone_of_Vulnerability.jpg|thumb|Zone of Vulnerability]] |
| | *[[Scaphoid fracture|Scaphoid fractures]] account for 70% of all carpal fractures |
| | *Ulnar nerve damage associated with fractures of hamate or pisiform |
| | *50% of pisiform fracture associated with injury to distal radius or other carpal bone |
| | *If bone fragment seen posterior to carpus on lateral, very likely triquetrum fracture |
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| | ==Fracture Types== |
| | {{Carpal fractures}} |
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| * Scaphoid fractures account for 70% of all carpal fractures
| | ==Evaluation== |
| * Ulnar nerve damage associated with fractures of hamate or pisiform
| | [[Image:Wrist_-_Lateral.jpg|thumb|Lateral view]] |
| * 50% of pisiform fx associated with injury to distal radius or other carpal bone | | *Evaluate Zone of Vulnerability (see picture) |
| * If bone fragment seen posterior to carpus on lateral, very likely triquetrum fx
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| ==Diagnosis== | | ==Management== |
| | {{General Fracture Management}} |
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| * Mechamism of injury
| | ===Specific Management=== |
| ** Hyperextension (FOOSH) | | *Based on fracture location (see individual fracture page for details) |
| *** Scaphoid, lunate, triquetrum, or pisiform fractures
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| *** Consider oblique views
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| ** Hyperflexion
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| *** Triquetrum fracture
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| ** Axial loading
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| *** of the wrist: scaphoid fx, scapholunate dissociation
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| *** thumb: trapezium fx
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| *** index: trapezoid fx
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| ** Direct blow to palmar surface
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| *** Pisiform or hamate fractures
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| * Specific Bone Fx
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| ** Scaphoid
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| *** Pain in the snuffbox (especially with ulnar deviation)
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| *** Grip strength reduced
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| *** Often associated with perilunate dislocation
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| ** Lunate
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| *** Pain aggravated by wrist motion or gripping
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| *** Pain with axial loading of the 3rd digit
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| *** Often associated with other injuries
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| ** Triquetrum
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| *** TTP just distal to the ulnar styloidPain on the ulnar aspect of the wrist
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| ** Pisiform
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| *** Pain/swelling at the palmar and ulnar aspects of the wrist
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| *** TTP over the hypothenar eminence
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| ** Hamate
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| *** Sudden wrist pain when a swinging motion has been interrupted
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| *** TTP over hypothenar eminence
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| *** 4th, 5th digit paresthesia if fx involves ulnar nerve
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| ** Capitate
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| *** Pain/swelling on dorsum of hand
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| *** Rarely fractured in isolation
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| ** Trapezoid
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| *** Point tenderness just proximal to 2nd metacarpal base
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| ** Trapezium
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| *** Pain/weakness with making "OK" sign or touching thumb to tip of 5th digit
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| *** Significant discomfort
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| *** Minimal swelling
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| ==Imaging==
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| * Checklist
| | ==See Also== |
| #Palmar tilt of the radius is present on the lateral view
| | *[[Fractures (main)]] |
| #Radial articular surface lies distal to the ulna
| | *[[Carpal dislocations]] |
| #Dorsal surface of the distal radius is smooth
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| #Waist of the scaphoid is intact
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| #Capitate sits in the concavity of the lunate
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| #Intercarpal joints are no more than 2mm wide; adjacent surfaces are parallel
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| * PA
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| ** Evaluate zone of vulnerability
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| * Lateral
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| ** Evaluate scapholunate angle (should be between 40o and 60o)
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| * Oblique
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| * Also consider:
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| ** PA with maximal ulnar deviation ("Scaphoid View") | |
| *** Scaphoid fx | |
| ** Carpal tunnel view
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| *** Hamate hook fx
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| *** Trapezium fx
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| *** Pisiform Fx
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| ** PA clenched fist view
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| *** Consider for scapholunate instability (space >2mm suggests ligamentous disruption)
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| ** CT
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| *** Trapezoid fx
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| ==Treatment== | | ==References== |
| | <references/> |
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| * Scaphoid Fx
| | [[Category:Orthopedics]] |
| ** Thumb-spica spint (or preferably a cast) until repeat xrays performed at 10 days
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| * Lunate Fx
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| ** Double sugar tong or long-arm thumb spica splint
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| ** May lead to osteonecrosis if not recognized and treated
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| * Triquetrum Fx
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| ** Volar splint w/ wrist in slight dorsiflexion and the MCP free
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| * Pisiform Fx
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| ** Volar or dorsal splint
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| * Hamate Fx
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| ** Volar splint
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| * Capitate Fx
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| ** Sugar-tong or short arm thumb spica splint
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| * Trapezoid Fx
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| ** Volar splint
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| * Trapezium Fx
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| ** Short arm thumb-spica
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| * Dislocations
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| ** Scapholunate
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| *** Volar splint, referral within 1 week
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| ** Lunate/perilunate
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| *** Volar spint, immediate reduction
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| ==Disposition==
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| * Scaphoid Fx
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| ** Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
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| * Lunate Fx
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| ** Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
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| * Triquetrum Fx
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| ** Refer for displacment >1mm
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| * Pisiform Fx
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| ** Tend to do well with casting; refer for casting if unable to obtain in the ED
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| * Hamate Fx
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| ** Refer for dislocation, pts who need to return to actvitiy ASAP
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| * Capitate Fx
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| ** Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
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| * Trapezoid Fx
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| ** Refer for comminution or dislocation
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| * Trapezium Fx
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| ** Refer for displacement >2mm, intraarticular fx w/ >1mm incongruity, comminuted fx
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| * Lunate/perilunate dislocation
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| ** Consult hand surgeon for immediate reduction(very difficult to reduce)
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| ==Source==
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| UpToDate, Accident & Emergency Radiology, Harwood-Nuss
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| [[Category:Ortho]] | |
