Rosen & Barkin's 5-Minute Emergency Medicine Consult (135 page)

CODES

674.54 Peripartum cardiomyopathy, postpartum condition or complication

BASICS

• Most commonly injured region of upper extremity
  
  • Most commonly fractured carpals are the scaphoid (68%) and triquetrum (18%)
    
• Carpal bone fractures commonly occur with other wrist injuries:
  
  • Capitate fractures along with scaphoid (scaphocapitate syndrome) sometimes occur with perilunate dislocations
    
  • Hamate fractures associated with injuries to 4th and 5th CMC and metacarpals concurrent with distal radius fractures
    

• Fall on outstretched hand (FOOSH) with a hyperextended or hyperflexed wrist
  
• Direct blow
  
• Axial loading
  
• Chronic use injury
  

DIAGNOSIS

• FOOSH or direct blow
  
  • Hyperflexion → dorsal avulsion fracture
    
  • Hyperextension → volar avulsion fracture
    
• Hook of hamate fractures:
  
  • Associated with a forceful swing of a racquet or club
    

• Pain, swelling, decreased range of motion
  
• Individual palpation of each carpal bone is possible with correct positioning of wrist
  
• Scaphoid fractures:
  
  • Snuffbox tenderness is sensitive but not very specific
    
  • Specificity improved with pronation and ulnar deviation of wrist
    
  • Scaphoid compression test (axial loading thumb causes pain) is also not very specific
    
  • Tenderness of tubercle on palmar aspect at distal wrist crease with wrist in extension
    
  • More specific than snuffbox tenderness
    

• A complete physical exam of the entire upper extremity and shoulder girdle:
  
  • Evaluate for associated injuries
    
• Neurovascular exam is essential
  
• Hamate fractures may be associated with ulnar nerve or artery injuries
  

• Anterior–posterior, lateral, oblique views of the hand and wrist
  
• Special views (e.g., scaphoid views) may be obtained for most of the carpals if physical exam is suspicious
  
• CT scan has superior sensitivity for fractures
  
• MRI can diagnose ligamentous injuries
  

• Metacarpal base fractures
  
• Distal radius or ulna fractures
  
• Lunate or perilunate dislocations
  

Be wary of epiphyseal injuries of the distal radius: Children rarely get simple sprains or fractures of the wrist.

TREATMENT

• Prevent contamination of any lacerations overlying the area
  
• Patients with swelling or significant pain at the wrist or hand:
  
  • Elevate extremity and apply ice
    
  • Remove jewelry, watches
    
  • Immobilize extremity with padded board splints to reduce further injury
    

As in any trauma, assess for other more serious injuries.

• Isolated carpal bone fractures can be initially managed with splinting
  
  • Goal to obtain and maintain normal alignment
    
• Thumb spica:
  
  • Scaphoid and trapezium fractures
    
  • Wrist held in slight extension
    
• Sugar tong splint:
  
  • Capitate and lunate fractures
    
  • Extends from MCP joint on dorsal side of hand, wrapping around the elbow, ending at midpalmar crease
    
  • Wrist neutral
    
• Volar splint:
  
  • Triquetrum, pisiform, trapezoid, hamate fractures
    
  • Extends from midpalmar crease to below the elbow
    
  • Wrist in slight extension
    
  • Splint suspected fractures (especially scaphoid) based on physical exam despite negative radiographs
    
• Open carpal fractures:
  
  • Requires extensive, high-pressure irrigation
    
  • Parenteral antibiotics against
    Staphylococcus aureus
    , with gram-negative coverage in Grade III (involving significant soft tissue damage) open fractures
    
  • Monitor neurovascular status
    
  • Tetanus prophylaxis
    
  • Immediate orthopedic consultation
    

• Mild oral analgesics, oral narcotics, NSAIDs for patient comfort
  
• Proper splinting will relieve most of the pain for these injuries
  

FOLLOW-UP

• Open fractures are admitted for early operative irrigation and débridement
  
• Patients with injuries requiring surgical management (open reduction, unstable displaced fractures) sometimes are admitted for early intervention
  

Closed, nondisplaced carpal fractures treated with adequate splinting may be discharged to have orthopedic follow-up in 7–10 days.

• Confirmed fractures are referred to orthopedics for definitive casting and further management
  
• Missed fractures or improper splinting can lead to long-term complications and disability:
  
  • Untreated scaphoid, capitate, and lunate fractures lead to high rates of nonunion and avascular necrosis
    
  • Splinting is crucial for long-term function and mobility
    
  • Immobilize any injury with significant pain and refer for repeat radiographs in 7–10 days or more advanced imaging (CT or MRI)
    

• Carpal fractures may not be apparent on initial radiographs and may lead to long-term disability if not treated appropriately
  
• Splint all suspected fractures and refer for repeat radiographs or consider CT scanning in ED or outpatient setting
  
• Most (90%) scaphoid fractures are isolated injuries:
  
  • All other carpal fractures are more often associated with other wrist or hand injuries
    
• Adequate treatment involves splinting in position of function and referral for definitive casting and management
  

• Goddard N. Carpal fractures in children.
  Clin Orthop Relat Res
  . 2005;432:73–76.
  
• Kouris GJ, Schenck RR. (2011, Feb 3). Carpal fractures. eMedicine. Retrieved 5/13/2013 from
  http://emedicine.medscape.com/article/1238278-overview
  .
  
• Papp S. Carpal bone fractures.
  Orthop Clin North Am
  . 2007;38(2):251–260.
  
• Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures.
  Am Fam Physician
  . 2004;70:879–884.
  
• Simon R, Sherman S, Koenigsknecht S, eds. Carpal fractures.
  Emergency Orthopedics: The Extremities
  . 5th ed. New York, NY: McGraw-Hill, 2007.
  

CODES

• 814.00 Closed fracture of carpal bone, unspecified
  
• 814.01 Closed fracture of navicular [scaphoid] bone of wrist
  
• 814.03 Closed fracture of triquetral [cuneiform] bone of wrist