Wrist Fractures Flashcards
What must be done in any wrist fracture?
the pulse must be felt and the hand examined for circulatory or neural deficit
What is a nightstick fracture?
These fractures are very uncommon and are usually caused by a direct blow to either the radius or an ulna – hence “nightstick” fracture.
Give two reasons why night stick fractures are important to know about
- An associated dislocation may be undiagnosed; if only one bone is broken and there is displacement there must be a dislocation of proximal or distal radioulnar joint.
- Non-union is liable to occur unless it is realized one bone takes as long to consolidate as two
How do you treat an isolated fracture of the ulna
- Forearm brace
- Rigid internal fixation
What are the issues with isolated fracture of the radius?
Prone to rotary displacement due to pull of thumb abductors and pronator quadratus
Give three diferent ways in which isolated fractures of the radius should be positioned, depending on point of fracture
Upper third fractures should be supinated, middle third fractures should be neutral and lower third fractures should be pronated. Internal fixation with compression plate/intramedullary rods preferred.
What is a Monteggia fracture?
Fracture of the Ulna and Dislocation of Radial Head
What is a Galeazzi fracture?
Distal 1/3 Radius fracture and Distal Radio-ulnar dislocation
Who is monteggia fracture most common in?
Most common in children between 4 and 10 years of age.
How does a Monteggia fracture occur?
Fall on the hand and forcible pronation of the elbow. Radial head usually dislocated forwards and the upper third of the ulna fractures and bows forwards.
What do you call a Distal 1/3 Radius fracture and Distal Radio-ulnar dislocation
Galeazzi fracture
Define clinical features of Monteggia fracture
Ulnar deformity usually obvious but radial head dislocation masked by swelling. Pain on lateral side of elbow is the most obvious clue. Wrist and hand should be examined for signs of radial nerve damage.
What do you see on Monteggia x-ray?
Head of the radius is dislocated forwards and there is a fracture of the upper third of the ulnar with forward bowing.
What is the key to treating Monteggia?
Key to treatment is to restore the length of the fractured ulna – only then can radius be fully reduced.
Ulnar fracture reduced through ORIF (open reduction, internal fixation) and bone grafts can be added.
Give three complications of Monteggia?
- Nerve injury
- Malunion
o Unless the ulna has been perfectly reduced the radial head remains dislocated and limits elbow flexion - Non-union
How is Monteggia treated differently in children, and why?
In children may present as greenstick fracture of ulnar – this may not be detected, but must be corrected or the child will have chronic subluxation of the radial head. This can be done through closed reduction.
How does a Galeazzi fracture occur?
The usual cause is a fall on the hand; probably with a superimposed rotation force. The radius fractures in its lower third and the distal radio-ulnar joint dislocates.
What are the clinical features of Galeazzi fracture?
More common the Moteggia fracture. Tenderness over distal ulna is a striking feature, and it may be possible to get “piano key” sign by balloting the distal ulnar. It is also important to rule out an ulnar nerve lesion.
What does Galeazzi x-ray show?
A transverse or short oblique fracture is seen in the lower third of the radius, with angulation or overlap. The distal radio-ulnar joint is dislocated or subluxated.
What is Galeazzi treatment?
Important step is to restore the length of the radius. Closed reduction successful in children, open reduction in adults.
What is the mnemonic for remebering Monteggia vs Galeazzi
GRIMUS
GRIMUS helps to remember which forearm bone is fractured - and whether the distal ("inferior") or proximal ("superior") part of the bone is involved.
• G: Galeazzi
o R: radius
o I: inferior
• M: Monteggia
o U: ulna
o S: superiorWhat is a Colle’s fracture?
A Colle’s fracture is a transverse fracture of the radius just above the wrist, with dorsal displacement of the distal fragment
Who does Colle’s fracture happen in?
It is the most common of all fractures in older people, the high incidence being related to the onset of post-menopausal osteoporosis. Thus the most common patient is an old lady FOOSH.
What is the MOA of Colle’s fracture?
Force is applied in the length of the forearm with the wrist in extension. The bone fractures at the cortico-cancellous junction and distal fragment collapses into extension, dorsal displacement, radial tilt and shortening.
What are the clinical feature of Colle’s?
Dinner fork deformity with prominence on the back of the wrist and a depression on the front. In patients with less deformity there may only be local tenderness and pain on wrist movements.
What are the x-ray features of colle’s?
There is a transverse fracture of the radius at the cortico-cancellous junction, and often the ulnar styloid process is broken off. The radial fragment is impacted into radial and backward tilt. Sometimes there is an intra-articular fracture; sometimes it is severely comminuted.
Give five x-ray features of Colle’s
- Bone fracture at cortico-cancellous junction
- Distal fragment collapses into
o Extension
o Dorsal displacement
o Radial tilt
o Shortening
How do you treat an undisplaced Colle’s?
Simple splint
How do you treat a displaced colle’s?
Displaced Colle’s fractures are manipulated under anaesthetic (haematoma block, bier’s block or axillary block) – the distal fragment is pushed into place by pressing on the dorsum while manipulating the wrist into flexion, ulnar deviation and pronation.
The fracture will then unite in about 6 weeks.
How do you treat a comminuted colle’s?
Fracture can be reduced and held with percutaneous wires, but if impaction is severe even this may not be enough – an external fixatior can then be used. Volar locking plates are being used for Colle’s fractures now, and are applied to front of the radis
What three factors complicate the outcome of Colle’s fracture?
- Shortening >2mm at distal radio-ulnar joint
- Dorsal tilt of >10*
- Dorsal translation of >30%
What are three complications of Colle’s repair?
- Circulatory problems
- Nerve injury (median nerve compression)
- Reflex sympathetic dystrophy (complex regional pain)
What is a Smith’s fracture?
Smith’s fracture is essentially a reverse Colle’s – The distal fragment is displaced anteriorly instead of dorsally and is caused by a fall on the back of the hand.
What do you see on x-ray in Smith’s?
Fracture through the metaphysis of the radius, with anterior displacement.
What is the treatment for Smith’s?
The fracture is reduced by traction, supination and extension of the wrist.
How do children suffer distal forearm fractures?
FOOSH
Give two main types of distal forearm fracturs in children
Physeal fractures
Metaphyseal fractures
What type of Salter-Harris are physeal fractures of distal radius usually?
Almost invariably Salter-Harris Type I or II with the epiphysis shifted and tilted backwards and radially.
Give three complications of distal forearm fractures in children
- Compartment syndrome
- Malunion
- Radio-ulnar discrepancy
Pain in anatomical snuff box
Scaphoid fracture
Scapho lunate injury
Just beyond Lister’s tubercle
Middle of the wrist
Lunate dislocation
Pain beyond head of the ulnar
Triquetral fracture
Pain in base of hypothenar eminence
Hamate fracture
Pain in dorsum of ulno-carpal joint
Triangular fibrocartilage complex
What special techniques do you use for imaging carpal bones?
The imaging of carpal injuries is key to diagnosis and requires three different views – AP, Lateral and an oblique Scaphoid view.
What is the most common type of carpal injury?
Scaphoid fractures account for almost 75% of all carpal fractures, although they are rare in the elderly and in children
How do scaphoid fractures occur?
A FOOSH injury is the most common method of fracturing the scaphoid.
How does avascular necrosis occur in Scaphoid fractures and give chance of it happening for
distal third fracture
middle third fracture
and proximal fractures
Thus 1% of distal third fractures, 20% of middle third fractures and 40% of proximal fractures result in non-union or avascular necrosis of the proximal fragment.
What are the clinical features of scaphoid fractures
Pain and fullness in anatomical snuffbox.
How are scaphoid fractures treated?
Undisplaced fractures need no reduction and are treated in plaster – 90% of waist fractures will heal. Wrist is held dorsiflexed and in the glass holding position.
What are the three complications of scaphoid healing?
Avascular necrosis – Proximal fragment may die, causing wrist collapse and arthritis development. Bone Grafting, as for delayed union, may be successful, but it causes many avoidable difficultied.
Non-union
Osteoarthritis.
What happens in hamate fracture?
Fracture of the hook is common following a direct blow of the palm of the hand. Can damage the ulnar nerve
How is trapezium fractured?
Damaged if shaft of the first metacarpal impacts onto it
How is the lunate fractured?
Follow hyperextension injury to the wrist
How does lunate dislocation occur?
Fall tears into tough ligaments that bind the carpal bones. The lunate usually remains attached to the radius and the rest of the carpus is displaced backwards (peri-lunate dislocation). The hand usually snaps back again but the lunate may be levered out of position and displace anteriorly.
What is a special clinical feature of lunate dislocation?
carpal tunnel symptoms due to involvement of the median nerve.
What does scapho-lunate dissociation present as?
A wrist sprain may be followed by persistent pain and tenderness over the dorsum just distal to Lister’s tubercle.
