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| == Background == | | ==Background== |
| | | [[File:Carpal bones.png|thumb|Carpal bones]] |
| *Scaphoid fractures account for 70% of all carpal fractures | | [[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 | | *Ulnar nerve damage associated with fractures of hamate or pisiform |
| *50% of pisiform fx associated with injury to distal radius or other carpal bone | | *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 fx | | *If bone fragment seen posterior to carpus on lateral, very likely triquetrum fracture |
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| <br>
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| == Diagnosis ==
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| *'''Mechamism of injury'''
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| **Hyperextension (FOOSH)
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| ***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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| See [[Wrist Bones]]
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| *Checklist
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| #Palmar tilt of the radius is present on the lateral view
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| #Radial articular surface lies distal to the ulna
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| #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")
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| ***Scaphoid fx
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| **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 ==
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| *Scaphoid Fx
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| **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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| <br>
| | ==Fracture Types== |
| | {{Carpal fractures}} |
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| *Lunate/perilunate dislocation
| | ==Evaluation== |
| **Consult hand surgeon for immediate reduction(very difficult to reduce) | | [[Image:Wrist_-_Lateral.jpg|thumb|Lateral view]] |
| | *Evaluate Zone of Vulnerability (see picture) |
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| == Source == | | ==Management== |
| | {{General Fracture Management}} |
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| UpToDate, Accident & Emergency Radiology, Harwood-Nuss
| | ===Specific Management=== |
| | *Based on fracture location (see individual fracture page for details) |
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| == See Also == | | ==See Also== |
| | *[[Fractures (main)]] |
| | *[[Carpal dislocations]] |
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| [[Wrist Bones]]
| | ==References== |
| | <references/> |
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| [[Category:Ortho]] | | [[Category:Orthopedics]] |
