Wrist injuries
Remember analgesia
# clavicle
- Check distal neurovascular status (+/- respiratory exam)
- Treat with sling (or collar & cuff [BestBets] and refer to the CUH Fracture Clinic(Referral form)
- Admit (for ORIF) if concern re overlying skin necrosis
# scapula
- Treat with sling and refer to the CUH Fracture Clinic(Referral form)
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
- The Mary's ready reckoner (template right) is available as a transparency in each Cork Emergency Department. Please use in cases of 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 anteriorally 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
- 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)
Undisplaced # of distal radius including 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)
Wrist injuries
Fractures of the scaphoid
- Radiologically confirmed fractures should be treated by scaphoid POP, sling and referral to the Fracture Clinic.
- Hyperextension wrist e.g. FOOSH
- Refer for ORIF if > 1mm displacement of fragments , angulation of 15%, fracture comminution Ref
- Absolute indications for internal fixation include displacement of 1 mm or 150 of angulation. Geissler WB. Carpal fractures in athletes. Clin Sports Med 2001; 20(1):167.
- Cases with an appropriate history of trauma and tenderness in the anatomical snuffbox but negative X-rays, should have a scaphoid POP 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.
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)
References & Links
Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures .Am Fam Physician 2004; 70(5):879 Back
Freeland P. Scaphoid tubercle tenderness: A better indicator of scaphoid fractures? Arch Emerg Med 1989; 6(1):46. Back
Chen SC. The scaphoid compression test. J Hand Surg Br) 1989; 14(3):323. Back
Powell JM, Lloyd GJ, Rintoul RF. New clinical test for fracture of the scaphoid. Can J Surg 1988; 31 (4):237. Back
Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. J Am Acad Orthop Surg 2000; 8(4):225. Back
