Wrist Fractures

Introduction

FOOSH – “Fall On Out-Stretched Hand” is a common emergency department presentation that can result in a number of different fractures of the bones of the wrist.
 
The majority of fractures involve the distal radius. You should also be mindful of fracture of the scaphoid (often missed), and be wary in children of fractures that only seem to involve one of the radius or ulnar (as they require proper assessment and x-ray of the elbow too).
 
We will also look at wrist fractures that aren’t necessarily caused by a “FOOSH”.
 

Epidemiology

• Account for about ¼ of all limb fractures
• Most common in children and young adults as these are the populations that engage in the risk taking activities
• A second peak incidence is seen in old age, with frail, elderly, osteoporotic patients fall

Anatomy

Knowing the bones of the wrist is useful, but as long as you can point out a scaphoid, and know your ulnar from your radius anything involving the other carpal bones is a bit more specialist.
 
There are two ‘rows’ of carpal bones, with four in each.
 
 
 

Basics of Management

Reduction and Manipulation

Most cases of wrist fracture are suitable for conservative management.

• Until you have an x-ray, try to keep all patients nil by mouth, as they may require sedation for manipulation and reduction. Some sources state 1 hour of NBM is enough, but many places practice a 4 hour rule.
• Usually, sedation is not a general anaestheitc, but conscious sedation. Suitable agents often include ketamine (especially in children) and benzodiazepines in adults (for example midazolam, or perhaps a combination of midazolam and fentanyl). The exact agent, or combination of agents will be decided by the person performing the sedation. It is also possible to perform local anaesthesia, nerve blocks, or haematoma blocks, although conscious sedation is probably the most popular method.
• Sedation carries some (not negligible) risks, particularly related to the airway. Some individuals can have an airway compromise requiring intubation from only mild sedatives.
• Make sure you provide adequate analgesia. In many cases this will require opiates. Bearing in mind the point above, these often shouldn’t be given via the oral route.

Immobilization

• Full casts should be avoided in the first few days due to swelling (and possible compression and subsequent neurovascular compromise) that occurs in the days after the initial injury
• The mainstay of treatment is a back slab (aka volar slab). This is a partial plaster of Paris cast that runs on the volar surface of the wrist and forearm, with crepe bandages to hold it in place. This is then usually reviewed in fracture clinic within a few days. The joint my be re-x-rayed to check the bones have not shifted and then a full cast applied
  • In scaphoid fractures, a spica thumb cast is used instead of a volar slab

Surgery

• If its not possible to get an adequate reduction, or there is a reduction with a dislocation, or there is an open fracture, then its likely surgery will be required. Often there is a pin screws or wires placed to hold the pieces of bone together This is often referred to as ‘open reduction and internal fixation’ or ORIF.

Assessment

All patients who present with a FOOSH and have ongoing pain, tenderness, or neurovascular signs will require an x-ray.
A normal x-ray does not mean there is no fracture. 
In the presence of a normal x-ray, a decision has to be made about the likelihood of an occult scaphoid fracture. If there is anatomical snuffbox tenderness but normal x-ray, you should still apply immobilization and have the patient re-x-rayed and assessed in out patient clinic follow up (usually 2 weeks after the event). 
 
The main points to assess are:

• Is there a fracture?
• Does this person need a cast?
• Does this person need a reduction?
• Is there neurovascular deficit requiring urgent intervention?

Scaphoid fracture

Scaphoid is the most common carpal bone fracture, and usually caused by a  $(function(){ var pertama = $('#herb-dict .herblist li:first-child').attr('class'); $('#herb-dict .herblist li.'+pertama).show(); $('#herb-dict .alphlist li#'+pertama+' a').addClass('active'); $('#herb-dict .alphlist li a').click(function(){ var target = $(this).attr('rel') $('#herb-dict .herblist li').hide(); $('#herb-dict .herblist li.'+target).show(); $('#herb-dict .alphlist li a').removeClass('active'); $(this).addClass('active'); }); });