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Wrist Fractures

1Introduction

2 Epidemiology

3 Anatomy

4 Basics of Management

4.1Reduction andManipulation 4.2 Immobilization

4.3 Surgery

Contents|rude)

5 Assessment

6 Scaphoid fracture

6.1Investigation

6.2 Treatment

6.3Complications

7 Greenstick Fracture

8 Torus Fracture (aka Buckle Fracture )

8.1Management

9 Colies Fracture 9.1History andExamination

9.2 Management

9.3Complications

9.4 Smiths Fracture ( aka Revere CollesFracture )

9.5 Management and Complications

10 Bartons Fracture

11Chauffer's Fracture

12 Related Entries

Introduction

FOOSH - Fall On Out - Stretched Hand' Is a common emergency department presentation that canresult In anumber of

different fracturesof the bones of the wrist.

The majority of fractures involve the distal radius. You should also be mindfulof fracture of the scaphoid (often missed ) , and be wary in children of fractures that only seem to involve one of the radius or ulnar (as they require proper

assessment and x-ray of theelbow

too ) .

We will also look at wrist fractures

that aren ' t necessarily caused by

a' FOOSH '

.

Epidemiology

Account for about V *

Most common In children and youngadults as these are the populations that engage In the risk taking activities

A second peak Incidence Isseen In old age .with frail , elderly, osteoporotic patients fall

of all limb fractures

Anatomy

Knowing the bones of the wrist is useful, but as long as you can point out a scaphoid, and know your

radius anythinginvolvingthe other carpal bones Isa bit morespecialist.

Thereare two ' rows ' of carpal bones, with

Basicsof Management

four in each.

Reduction and Manipulation

ulnar from your

Most casesof wrist fracture are suitable for conservative management.

Until you have an x-ray . try to keep all patients nil by mouth, as they may require sedation for manipulation and reduction.Some sourcesstate 1hour of NBM is enough, but many places practice a 4 hour rule. Usually, sedation Is not a general anaestheltc.but conscioussedation.Suitable agents often Include ketamine

(especially in children) and benzodiazepines in adults (for example midazolam, or perhaps a combinationof

midazolam and fentanyl). Theexact agent, or combination of agents will be decided by the person performing the

sedation. It is also possible to perform local anaesthesia, nerve blocks, or haematoma blocks, although conscious sedation is probably the most popular method. Sedation carries some ( not negligible) risks, particularlyrelated to the airway. Some individuals can have an airway compromise requiring intubation from only mild sedatives.

Make sure you provide adequate analgesia.In many cases this will require opiates.Bearing in mind the point above, these often shouldnt be given via the oral route.

Immobilization

Full casts should be avoided in the first few days due to swelling(and possible compression and subsequent

neurovascular compromise ) that occurs in thedays after the initial injury The mainstay of treatment is a back slab ( aka volar slab). This is a partial plaster of Paris cast that runs on the volar surfaceof the wrist and forearm , with crepe bandages to hold it In place .This Is then usually reviewed In fracture clinic withina few days . TheJoint my be re x - rayed to check the bones have not shifted and then a fullcast applied In scaphoid fractures , a splca thumb cast Isused Instead of a volar slab

Surgery

If its not possible to get an adequate reduction, or there is a reduction with a dislocation, or there is an open fracture, then Its likely surgery will be required.Often there is a pin screws or wires placed to hold the pieces of bone together This Is often referred to as 'open reduction and Internal fixationor ORIF.

Assessment

All patients who present with aFOOSH andhave ongoingpain, tenderness , or neurovascular signs will require an x - ray .

A normal x - ray does not mean there is no fracture .

In the presence of a normal x-ray .a decision has to be made about the likelihood of an occult scaphoid fracture. If there is anatomical snuffbox tenderness but normal x-ray . you should still apply immobilization and have the patient re-x-rayed and assessedin out patient clinic follow up (usually 2 weeks after the event ) .

The main points to assess.

Is there afracture? Does thisperson need a cast? Does this person need areduction? Is there neurovascular deficit requiring urgent Intervention?

Scaphoid fracture

Scaphoid is the most common carpal bone fracture, and usually caused by a FOOSH.

They account for about 80% of all carpal fractures, and tend to occur in young men aged 20-30.10% of the time there is

another associated fracture.

Investigation

When requesting the x-ray . make sure you mention '?scaphoid fracture ' on the request form, as specific scaphoid views

are taken. X-ray is only about 80-90% sensitive for scaphoid fracture.

Treatment

You shoulddiscuss all scaphoid fractures with the orthopaedic registrar on call.Simple fractures are treated with immobilization.More complex fractures may require surgery.The most common form of surgery for scaphoid fracture is

the Herbert Screw, which is a screwalmost the length of the scaphoid that holds it together in one piece.

Immobilization if:

Non - displaced

Non-complex (eg. no other local fractures , not open

fracture etc )

There isn ' t a visible fractureon x-ray, but there is anatomical

snuffbox tenderness

Immobilization Is usually In the form of a splca thumb cast.Great Instructions on how to apply this cast are available

courtesy of Life in the fast lane.And try to avoid doing this.

The length of time to take for healing is correlated to the locationof the fracture.More proximal fractures usually take longer, and moredistal fractures arequicker to heal. Typical healingtime for adistal fracture Is 4 -6 weeks, but a proximal fracturecan take up to 23 weeks!

Complications

Non - union / delayed union

The fragments of the scaphoid bone fail to heal and remain separated . Typically occursIn late presenting fractures. May

resolve with continued Immobilization (patients may require longer than the typical 6- 12 weeks). Sometimes may be

treated with surgery, particularly in instances where there are functional issues as a result of the complication (e.g. pain,

reduced movement etc)

Malunion

The fragmentsof the scaphoid Join and heal Incorrectly, often In a misaligned position.This Is likely to lead to pain and

reducedROM. May require surgery .

Avascular necrosis Typically associated with fractures at the proximal end and the 'waist' of the scaphoid, as this is the site of the entrance of the blood supply, and the supply may be disrupted if fractureoccurs around here.

Longterm complications

Reduced grip strength

Increased risk of osteoarthritis of wrist Joint

Occult Fracture About 10%of scaphoid fractures don't show up on x-ray. The traditional approach in all patients with FOOSH and a normal x-ray is to check for tenderness of the anatomical snuffbox, and.if present, to immobilize the wrist (user with a Spica thumb cast ) and thento review them again in 2 weeks at fractureclinic.If they still have anormal x-ray with tenderness, an MRI or isotope bone scan can be performed to assess for fracture.CT is less senstivie.

Greenstick Fracture

Greenstick fracturesoccur in children to due the bendy nature of their bones.The name derives from the way a fresh 'green stick or tree branch bens and snaps, with one side often completely disrupted whilst the other remains Intact.

In a greenstick fracture, the periosteum remains intact.

The treatment for these fractures dependson the degree of angulation and/ or displacement.

Most casesare suitable for conservative management. Managed with a split or simple cast if:

Child aged under 10.AND

< 15 - 20 ° angulation

- OR <10 ° angulation with or without lateralshift < 2mm and shortening < 2mm

In reality all thesecases will likely be discussed with the orthopaedics registrar on call to confirm the management. They

should be followed up in fracture clinic within a few days.

Require closed Reduction

Any displacement >20 ° angulation

Closed reductionIs usually performed under sedation In the emergency department or ( /and ) by theorthopaedics registrar .

Pressure should be applied to the deformity for 5-7 minutes.The purpose of the pressure Is to deliberately break

through the undamaged cortex to cause a full fracture, then a full arm cast applied .If there Isa large degree of angulation

and a reduction is not performed, the angulation canbecome worse whilst In the cast.

Reassure parents that any minor deformities will reduce andremodel over time.

Patients should kepp the cast on for 4-6 weeks, and advise them to avoid any activity that might result in a similar injury

(monkey bars, contact sports. trampolines) for a further 4 weeks.

TorusFracture (aka BuckleFracture)

Seenin children, this Is lesssevere than agreenstick fracture, andIs noted by a buckle( Tori = latin = protuberance) In the distal end of the radius and ulnar.

Be wary of any child that has a buckle in only one of the two bones, as they will require assessment and x-ray of the elbow

too.

The fracture Is a result of compression, and the outer margin of the bone 'buckles'. They almost never Involve a

displacement .

Management

Treatment is with a splint or a cast, for 3 weeks. Splint seems to be Just as good as cast, and requires less follow -up (no FU

appointment to remove the cast at the end of the three weeks is required. Refer patients to fracture clinic if you have

seen them in ED.

Very rarely there may be some angulation that requires reduction.

Usually avolar slab Is used.I Ife in the fast Lane has a good explanation of how to apply one.

Colle sFracture

Initially when described by Colie. this referred to a fracture of the distal radius, approximately 4cm from the articular surface. Now however, it tends to refer to any fracture of thedistal radius with dorsal displacement that does not involve the articular surface. They tend to occur in older patients with osteoporosis, although they do still occur in younger individuals too.

Usually managed conservatively.Operative management tends to give abetter radiological outcome but the same

functional outcome.

History and Examination

History of FOOSH

Characteristic dorsal displacement and deformity. Sometimes called 'dinner fork deformity ' due to the shapeof the

wrist on lateral x-ray

Check the ulnar styloid for tenderness, and also examine the elbow, as there may be co-existing radial head fracture Remember to check neurovascular function

Management

Needs to be reduced in the emergency department

This will be done under sedation (as discussed above) and will usually involve longitudinal traction (puling the wrist)

and dorsal pressure.

Once an adequateexternal reduction is seen, apply a back slab, and re-x-ray to check bone alignment. You may need

to repeat the procedure if bone alignment is not adequate

Severely displaced, or open fracture will require surgical (open) reduction and possibly internal fixation

Healingtime : 6-8 weeks

Complications

» Median and ulnar nerve damage. There may be an acute carpal tunnel syndrome

Compartment syndrome

Malunion / non-union

Long term - deformity / loss of function , osteoarthritis

Smith s Fracture(aka RevereColie'sFracture)

Often results from a fall onto a flexedwrist ( as opposed to Colle's falling onto an extended wrist ) .

A fractureof the distal radius that results in volar displacement.

Thereare three types:

Type I - extraarticular Typell - lntraartlcular

Type III - fracture dislocation ( aka Barton's Fracture )

Management andComplications

Essentially the sameas for a Colle's

BartonsFracture

A fracture of the distal radius with dislocation. The same thing as a Smith ' s type III in the case of a volar displacement.

Can be reduced and enlocated in the emergency department like a Collesor a Smiths but this is much less likely to be

effective.Surgical outcomes are very good.

Be wary of nerve, vein or artery entrapment.

Chauffer sFracture

A fracture of the radial styloid process, usually as a result of direct trauma.

Acquired this name around the turn of the 20 tri Century apparently after an increased incidence of this fracture due to

misfiringof early automobiles whilst they were being ' cranked ' as they were started. This resulted in the crank shaft

causing direct trauma to the forearm of would-be patients.