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Wrist Injuries Emergency Imaging And Management

While wrist injuries are common, they can hardly be described as routine. True, most of us can identify a radius fracture when we see one, and we can usually recognize a carpal fracture. We also know that navicular tenderness suggests an occult fracture, which requires follow-up with an orthopedist.

However, wrist injuries are often quite complex. They comprise a continuum of bony, muscle, and ligamentous damage. Physical exam and radiographic findings are rarely conclusive. Moreover, both recognized and occult injuries can lead to significant long-term sequelae. Because patients rely on their hands for careers and day-to-day activities of all kinds, complete recoveries are usually a…

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  Not Your Typical Wrist Pain

Lunate dislocation will commonly present with volar swelling of the wrist and decreased 2-point discrimination to the median nerve distribution. Approximately 25% of patients will display sensory and/or other median nerve symptoms.

 All in the Wrist

Wrist injuries may be among the most unfamiliar and commonly missed orthopedic injuries among emergency physicians. The anatomy alone is daunting. The injuries can be subtle and when missed can have debilitating repercussions. Many carpal injuries are missed because they are associated with a concurrent fracture pattern. Studies suggest between seven and twenty percent of all distal radius fractures will have an accompanying carpal injury.

 Can't Miss Hand and Wrist Fractures in the ED

Many of these injuries are uncomplicated, but an astute clinician can diagnose subtle and uncommon injury patterns. Three less common injuries are reviewed here. If found, these injuries can alter the management and disposition of the patient. Each of these injuries should be carefully assessed for on physical exam and imaging.

 Carpal Bone Injuries – The Big 4

The most commonly missed occult fracture involving the wrist is the distal radius (not the scaphoid)

 Wrist Trauma: More Than Bones

Acute and subacute wrist trauma predominantly consist of fractures of the distal radius in elderly patients and most frequently carpal fractures (scaphoid, followed by triquetrum and hamatum) and avulsion fractures of the ulnar styloid in younger patients, especially in sports-related injuries but also in work activities. The initial radiographs may miss the fractures and result when untreated in complications as nonunion, osteonecrosis, and degenerative osteoarthritis. Fractures of the distal radius and of the scaphoid may be associated with ligament injuries, most frequently the scapholunate complex, which are often overlooked at the emergency department.

Articles of Interest

Carpal dislocations

While injuries to the carpal bones and ligaments are uncommon, recognizing and properly treating them is important to prevent pain and degenerative changes. Due to the complex nature of the carpal bones and ligaments, carpal ligamentous injuries, carpal dislocations and even fractures are often missed during initial presentation

Carpal Fractures

90% of scaphoid fractures are isolated, while a significant proportion of all other carpal bone fractures involve multiple carpal bones.

Commonly Missed and Mismanaged Wrist Injuries

You might be thinking that wrist injuries are also pretty straight forward. But there are many nuances in diagnosis and management that significantly effect outcomes.

EMRad: Can’t Miss Adult Wrist Injuries

25% of all sports related injuries involve the hand or wrist. Approximately 1.5% of all emergency department visits involve the hand and forearm. Missed wrist injuries can be highly morbid if injuries are missed. Missed wrist injuries are a common area of litigation.

FOOSH: The Most Common Hand Injuries Seen in the ER https://www.advanceer.com/resources/blog/2019/july/foosh-the-most-common-hand-injuries-seen-in-the-/ FOOSH is an acronym for fall on an outstretched hand. This really describes the mechanism of injury. The injury can involve anything that includes the hand, wrist, elbow or shoulder. One common type of Foosh injury is the Colle’s fracture of the wrist

FOOSH is an acronym for fall on an outstretched hand. This really describes the mechanism of injury. The injury can involve anything that includes the hand, wrist, elbow or shoulder. One common type of Foosh injury is the Colle’s fracture of the wrist.

Hand and Wrist Injuries

Note: Oehmke MJ et al have suggested that the blood supply to the scaphoid was more diffuse and complicated than traditionally taught. So the idea that the AVN all comes from disruption of the distal blood supply is likely a bit of a simplistic explanation.

Lunate Dislocation (Perilunate dissociation)

Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes.

Scaphoid Fractures

Non-displaced Patients should be placed in a short-arm thumb spica splint with the hand in “wine glass position” (slight dorsiflexion at wrist, digits in slight flexion) Follow-up with an orthopedist in 14 days for repeat x-rays and possible transition to cast

Scaphoid Fractures – Emergency Management

Scaphoid fractures are much more common in adolescents than younger children. Approximately 75% of the arterial supply is from branches of the radial artery through vascular perforations on the dorsal surface near the tubercle and waist.

The Wrist: Few Bones—Huge Impact

One of the most vulnerable joints in the human body is the wrist. A wrist has eight small bones (carpal bones) connected to the two long forearm bones. Such a small area of the body can make a large impact on wrist or hand fractures, falls, or a condition such as carpal tunnel syndrome.

Wrist and Distal Forearm Injuries: Pearls & Pitfalls

Accounting for 70-80%, the scaphoid is the most commonly fractured carpal bone.5 The mechanism is a FOOSH in extension... Occult fracture of the scaphoid is common, with 20% of initial radiographs being read as negative

Resources

Radiopaedia

Carpal bone fractures comprise a range of different fractures which carry varying outcomes. They can involve one or a combination of carpal bones and also be part of fracture-dislocations.