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Carpal Fractures, Emergency Medicine

Basics

Description

- FOOSH or direct blow - Hyperflexion в†’ dorsal avulsion fracture - Hyperextension в†’ volar avulsion fracture

- 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

- 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

- 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)

  • Most commonly injured region of upper extremityMost 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 dislocationsHamate fractures associated with injuries to 4th and 5th CMC and metacarpals concurrent with distal radius fractures

Etiology

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

Diagnosis

Signs and Symptoms

History

  • FOOSH or direct blowHyperflexion в†’ dorsal avulsion fractureHyperextension в†’ volar avulsion fracture
  • Hook of hamate fractures:Associated with a forceful swing of a racquet or club

Physical Exam

  • 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 specificSpecificity improved with pronation and ulnar deviation of wristScaphoid compression test (axial loading thumb causes pain) is also not very specificTenderness of tubercle on palmar aspect at distal wrist crease with wrist in extensionMore specific than snuffbox tenderness

Essential Workup

  • 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

Diagnosis Tests & Interpretation

Imaging

  • 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

Differential Diagnosis

  • 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. пїЅ

Treatment

Pre-Hospital

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

Initial Stabilization/Therapy

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

Ed Treatment/Procedures

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

Medication

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

Follow-Up

Disposition

Admission Criteria

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

Discharge Criteria

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

Follow-Up Recommendations

  • 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 necrosisSplinting is crucial for long-term function and mobilityImmobilize any injury with significant pain and refer for repeat radiographs in 7-10 days or more advanced imaging (CT or MRI)

Pearls and Pitfalls

  • 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

Additional Reading

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

Codes

ICD9

  • 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
  • 814.07 Closed fracture of capitate bone [os magnum] of wrist
  • 814.02 Closed fracture of lunate [semilunar] bone of wrist
  • 814.04 Closed fracture of pisiform bone of wrist
  • 814.05 Closed fracture of trapezium bone [larger multangular] of wrist
  • 814.06 Closed fracture of trapezoid bone [smaller multangular] of wrist
  • 814.08 Closed fracture of hamate [unciform] bone of wrist
  • 814.09 Closed fracture of other bone of wrist
  • 814.0 Closed fractures of carpal bones

ICD10

  • S62.009A Unsp fracture of navicular bone of unsp wrist, init
  • S62.109A Fracture of unsp carpal bone, unsp wrist, init for clos fx
  • S62.116A Nondisp fx of triquetrum bone, unsp wrist, init for clos fx
  • S62.133A Disp fx of capitate bone, unsp wrist, init for clos fx
  • S62.123A Disp fx of lunate, unsp wrist, init for clos fx
  • S62.143A Disp fx of body of hamate bone, unsp wrist, init for clos fx
  • S62.156A Nondisp fx of hook process of hamate bone, unsp wrist, init
  • S62.163A Disp fx of pisiform, unsp wrist, init for clos fx
  • S62.173A Disp fx of trapezium, unsp wrist, init for clos fx
  • S62.186A Nondisp fx of trapezoid, unsp wrist, init for clos fx

SNOMED

  • 82065001 fracture of carpal bone (disorder)
  • 31975004 Fracture of navicular bone of wrist (disorder)
  • 7585008 Fracture of triquetral bone of wrist (disorder)
  • 73316002 Fracture of capitate bone of wrist (disorder)
  • 14916000 Fracture of trapezoidal bone of wrist (disorder)
  • 2012002 Fracture of lunate bone of wrist (disorder)
  • 74465000 Fracture of trapezium of wrist (disorder)
  • 84030002 Fracture of pisiform bone of wrist (disorder)
  • 85922006 Fracture of hamate bone of wrist (disorder)