EMed

Wrist injuries

Remember analgesia

Undisplaced # of distal radius incl. greenstick #

  • Splint or backslab & sling. In CUH VFAC (green) follow up

Fractures of the ulnar styloid

  • No active treatment required
  • Splint for comfort, sling
  • In CUH VFAC (green) referral

Scaphoid injuries

  • Commonest (70%) carpal # (then triquetral & trapezium)
  • FOOSH with hyper-extension of the wrist
  • Initial x-ray (full scaphoid series):
    • Specificity is 100%, Sensitivity is 80%
  • 1 of 4 people with a negative initial x-ray have a #
  • In CUH: refer to ANP clinic in the ED (@10/7). If still symptomatic but x-rays negative on review at 10 days: refer to VFAC
Sign Pos LR [95%CI] Neg LR [95% CI]
Clamp sign * 8.6 [0.51-147] 0.54 [0.14-1.18]
Resisted supination pain ** 6.1 [0.04-10.86] 0.09 [0.00-11.9]
Thumb compression pain 2.0 [1.1-3.5] 0.24 [0.06-0.99]
Scaphoid tubercle 1.7 [1.3-2.1] 0.23 [0.09-0.56]
Snuff box tenderness 1.5 [1.1-2.1] 0.15 [0.05-0.43]
Ulnar deviation pain 1.4 [0.8-2.4] 0.53 [0.13->1]
* Clamp sign : ask patient "exactly where does it hurt?". The patient will form a clamp with the opposite thumb and index finger on both sides of the thumb.
** Pain with resisted supination: Hold the injured hand with forearm in neutral position. Patient attempts supination = pain when examiner resists
Scaphoid fracture
# scaphoid waist
Terry Thomas sign
Beware scapholunate lig #
(Terry Thomas sign)

In CUH

  • Radiologically confirmed scaphoid #s should be treated by scaphoid POP, sling & # clinic
  • Refer to ortho for ORIF if > 1mm displacement of fragments, angulation ≥15%, # comminution
  • Check x-rays for signs of ruptured scapholunate ligament. (Terry Thomas sign)
  • If seen, confirm again no evidence of carpal dislocation and treat as a scaphoid fracture

Colles' fracture

  • Refer to senior ED staff for anaesthetic technique if manipulation required
  • Manipulate as instructed under Bier's block or analgesia and sedation. Remember traction (often forgotten), flexion, pronation and ulnar deviation makes your job (and result) much easier
  • Apply POP backslab and sling
  • Obtain check X-rays. Refer to the Fracture Clinic(Referral form)

Indications for manipulation rather then backslab (& # clinic referral) include:

  • > 10° dorsal angulation (tilt)
  • Radial shortening > 3 mm (important)
  • Radial shift more than 2 mm
  • Dorsal displacement more than 2 mm

"Rules" may not apply in some (elderly e.g.). Please discuss with your EM senior if in doubt.

Smith's fracture

  • Usually require internal fixation (refer to on-call orthopaedic team)
  • If not, manipulate under LA/sedation by disimpaction, supination, extension and ulnar deviation and apply ventral POP slab. Obtain check X-rays. Extend slab anterolaterally over the upper arm to form an above elbow slab and keep forearm supinated. Provide sling and refer to the Fracture Clinic

Barton's fracture

  • Displaced intra-articular fracture of the distal radius
  • Often requires MUA
  • Beware neurovascular compromise - always check median nerve function and advise immediate return if symptoms
  • If reduction not ideal - refer to on-call Orthopaedic Team.(Referral form)
Bartons Fracture

Torus (buckle) fractures distal radius

  • Torus # of the distal radius in children should be splinted
  • In CUH please refer to "VFAC Green"
  • Please ask parents to remove the splint in a few days & see if their child is symptom free
  • If concerns, please return to the ED/LIU. advice sheet
Torus fracture

Other carpal fractures

  • Immobilise in backslab, sling and refer to the VFAC
  • Commonest is flake triquetral fracture seen on dorsum carpus lateral view:
    • Triquetral complication : deep branch ulnar nerve : beware early ulnar motor signs

Wrist or carpal dislocations

  • Check neurovascular status (particularly median nerve)
  • Refer to the on-call Orthopaedic team

Content by Dr Íomhar O' Sullivan. Last review Dr Kanti Dasari, Dr ÍOS 1/10/23.