Carpal fractures

Background

Carpal Bone	Mechanism of Injury	Examination	ED Management
Scaphoid	FOOSH	Snuffbox tenderness; 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. 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

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

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

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

Scaphoid Fx
- Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
Lunate Fx
- Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
Triquetrum Fx
- Refer for displacment >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 >2mm, intraarticular fx w/ >1mm incongruity, comminuted fx