Carpal fractures: Difference between revisions

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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
 
==  ==
 
 
 
 
 
{| width="300" border="1" cellpadding="1" cellspacing="1"
|-
! scope="col" | Carpal Bone
! scope="col" | Mechanism of Injury
! scope="col" | Examination
! scope="col" | ED Management<br>
|-
| Scaphoid
| FOOSH
| Snuffbox tenderness;<br>pain w/ radial deviation/flexion
| Short arm, thumb spica, in dorsiflexion w/ radial deviation
|-
| Triquetrum
|
1. Avulsion fracture: twisting of hand against resistance or hyperextension
 
2.&nbsp;Body fracture: direct trauma
 
| Tenderness at dorsum of the wrist, distal to the ulnar styloid
| Short arm, sugar tong splint
|-
| Lunate
| FOOSH
| Tenderness at shallow indentation of the mid-dorsum of wrist, ulnar and distal to Lister tubercle
| Short arm, thumb spica splint
|-
| Trapezium
| Direct blow to thumb; force to wrist while dorsiflexed and radially deviated
| Painful thumb movement and weak pinch strength; snuffbox tenderness
| Short arm thumb spica splint
|-
| Pisiform
| Fall directed on hypothenar eminence
| Tender pisiform, prominent at the base of hypothenar eminence
| Short arm, volar splint in 30 degrees flexion and ulnar deviation
|-
| Hamate
| Interrupted swing of golf club, bat, or racquet
| Tenderness at hook of hamate, just distal and radial to the pisiform
| Short arm, volar wrist splint with 4th and 5th metacarpal joints in flexion
|-
| Capitate
| Forceful dorsiflexion of the hand with radial impact
| Tenderness over capitate just proximal to the third metacarpal
| Short arm, volar wrist splint
|-
| Trapezoid
|
| Tenderness over radial aspect of base of index metacarpal
| Short arm thumb spica splint
|}
 
 
 
 
 
== Diagnosis  ==
 
=== Mechamism of injury ===
 
*Hyperextension (FOOSH)
**Scaphoid, lunate, triquetrum, or pisiform fractures
**Consider oblique views
*Hyperflexion
**Triquetrum fracture  
*Axial loading
**of the wrist: scaphoid fx, scapholunate dissociation
**thumb: trapezium fx
**index: trapezoid fx
*Direct blow to palmar surface
**Pisiform or hamate fractures
 
=== Specific Bone Fx ===
 
*Scaphoid
**Pain in the snuffbox (especially with ulnar deviation)
**Grip strength reduced
**Often associated with perilunate dislocation
*Lunate
**Pain aggravated by wrist motion or gripping
**Pain with axial loading of the 3rd digit
**Often associated with other injuries
*Triquetrum
**TTP just distal to the ulnar styloid
**Pain on the ulnar aspect of the wrist
*Pisiform
**Pain/swelling at the palmar and ulnar aspects of the wrist
**TTP over the hypothenar eminence
*Hamate
**Sudden wrist pain when a swinging motion has been interrupted
**TTP over hypothenar eminence
**4th, 5th digit paresthesia if fx involves ulnar nerve
*Capitate
**Pain/swelling on dorsum of hand
**Rarely fractured in isolation
*Trapezoid
**Point tenderness just proximal to 2nd metacarpal base
*Trapezium
**Pain/weakness with making "OK" sign or touching thumb to tip of 5th digit
**Significant discomfort
**Minimal swelling
 
== Imaging  ==
 
*See [[Wrist Bones]]
*Checklist
 
#Radial articular surface lies distal to the ulna
#Dorsal surface of the distal radius is smooth
#Waist of the scaphoid is intact
#Intercarpal joints are no more than 2mm wide; adjacent surfaces are parallel
#Capitate sits in the concavity of the lunate
#Palmar tilt of the radius is present
 
*PA
**Evaluate [[Media:Zone_of_Vulnerability.jpg|Zone of Vulnerability]]
*Lateral
**Evaluate scapholunate angle (should be between 40-60deg)
*Oblique
*Also consider:
**PA with maximal ulnar deviation ("Scaphoid View")
***Scaphoid fx
**Carpal tunnel view
***Hamate hook fx
***Trapezium fx
***Pisiform Fx
**PA clenched fist view
***Consider for scapholunate instability (space &gt;2mm suggests ligamentous disruption)
**CT
***Trapezoid fx
 
== Treatment  ==
 
*Scaphoid Fx
**Thumb-spica spint (or preferably a cast) until repeat xrays performed at 10 days
*Lunate Fx
**Double sugar tong or long-arm thumb spica splint
**May lead to osteonecrosis if not recognized and treated
*Triquetrum Fx
**Volar splint w/ wrist in slight dorsiflexion and the MCP free
*Pisiform Fx
**Volar or dorsal splint
*Hamate Fx
**Volar splint
*Capitate Fx
**Sugar-tong or short arm thumb spica splint
*Trapezoid Fx
**Volar splint
*Trapezium Fx
**Short arm thumb-spica
*Dislocations
**Scapholunate
***Volar splint, referral within 1 week
**Lunate/perilunate
***Volar spint, immediate reduction


== Disposition  ==
==Fracture Types==
{{Carpal fractures}}


*Scaphoid Fx
==Evaluation==
**Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
[[Image:Wrist_-_Lateral.jpg|thumb|Lateral view]]
*Lunate Fx
*Evaluate Zone of Vulnerability (see picture)
**Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
*Triquetrum Fx
**Refer for displacment &gt;1mm
*Pisiform Fx
**Tend to do well with casting; refer for casting if unable to obtain in the ED
*Hamate Fx
**Refer for dislocation, pts who need to return to actvitiy ASAP
*Capitate Fx
**Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
*Trapezoid Fx
**Refer for comminution or dislocation
*Trapezium Fx
**Refer for displacement &gt;2mm, intraarticular fx w/ &gt;1mm incongruity, comminuted fx


== Source  ==
==Management==
{{General Fracture Management}}


*UpToDate
===Specific Management===
*Accident &amp; Emergency Radiology
*Based on fracture location (see individual fracture page for details)


== See Also ==
==See Also==
*[[Fractures (main)]]
*[[Carpal dislocations]]


*[[Wrist Bones]]
==References==
<references/>


[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 22:12, 27 March 2024

Background

Carpal bones
Zone of Vulnerability
  • 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

Fracture Types

Carpal fractures

AP view

Evaluation

Lateral view
  • Evaluate Zone of Vulnerability (see picture)

Management

General Fracture Management

Specific Management

  • Based on fracture location (see individual fracture page for details)

See Also

References

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