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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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| | ===Specific Management=== |
| | *Based on fracture location (see individual fracture page for details) |
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| * Mechamism of injury
| | ==See Also== |
| * Hyperextension (FOOSH)
| | *[[Fractures (main)]] |
| * Scaphoid, lunate, triquetrum, or pisiform fractures
| | *[[Carpal dislocations]] |
| * 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 | |
| * Scaphoid
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| * Pain in the snuffbox (especially with ulnar deviation)
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| * Grip strength reduced | |
| * 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== | | ==References== |
| | <references/> |
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| | | [[Category:Orthopedics]] |
| * 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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| * EvaluateZone of vulnerability.pdf
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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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| * 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]] | |
