Wrist injuries

Remember analgesia

Undisplaced # of distal radius incl. greenstick #

  • POP backslab and sling. Refer to the Fracture Clinic.(Referral form)

Fractures of the ulnar styloid

  • No active treatment required. 
  • Backslab for comfort, sling
  • Fracture Clinic.(Referral form)

Scaphoid injuries

Scaphoid fractureTerry Thomas sign
  • Most common carpal fracture (70%), followed by triquetral and trapezium
  • FOOSH with hyper-extension of the wrist
  • Initial x-ray (full scaphoid series): Specificity is 100% but Sensitivity is 80%
  • Pre-Test Probability of scaphoid fracture in patient with scaphoid wrist pain and non-diagnostic x-rays is about 25% (17-38% across 4 studies) so:
    • 1 out of 4 people with a negative initial x-ray have a fracture
    • Or 3 out of 4 people going home home in splint don't have a #
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
  • Radiologically confirmed fractures should be treated by scaphoid POP, sling and referral to the Fracture Clinic
  • Refer for ORIF if > 1mm displacement of fragments , angulation of 15%, fracture comminution
  • Cases with an appropriate history of trauma with signs above but negative X-rays, should have a scaphoid POP or splint and reviewed in the Fracture Clinic in 14 days time.(Referral form)
  • 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
  • Manipulate as instructed under Bier's block or GA by disimpaction, flexion, pronation and ulnar deviation
  • 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:

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

These "rules" may not apply in some (elderly e.g.) patients. Please discuss with your ED senior if in doubt.

Smith's fracture

Usually internally fixed and so should be referred to on-call Orthopaedic Team. If not manipulate under LA or GA 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.(Referral form)

Barton's fracture

Bartons Fracture
  • Displaced intra-articular fracture of the distal radius
  • Often requires MUA under Bier's block
  • 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)

Torus fracture

Torus (buckle) fractures distal radius

Torus fracture of the distal radius in children should be splinted rather than PoP. Please ask parents to either attend GP for a check up in 3 weeks or to remove the splint and see if their child is symptom free. If any concerns, please return to the ED/LIU. Parent advice sheet

Other carpal fractures

  • Immobilise in backslab, sling and refer to the Fracture Clinic.(Referral form)
  • 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.(Referral form)

Content by Dr Íomhar O' Sullivan 22/02/2004. Reviewed by Dr ÍOS 28/03/2005, 30/10/2005, 31/01/2007, 29/01/2010. Last review Dr ÍOS 21/06/21.