eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Wrist: Differential Diagnoses & Workup

Author: Bryan C Hoynak, MD, FACEP, FAAEM, Associate Clinical Professor of Emergency Medicine, University of California at Irvine School of Medicine; Director of Emergency Services, Chairman of Division of Emergency Medicine, Placentia-Linda Hospital
Coauthor(s): Laura Hopson, MD, Staff Physician, Department of Emergency Medicine, University of Michigan
Contributor Information and Disclosures

Updated: Aug 13, 2009

Differential Diagnoses

Dislocations, Wrist
Fractures, Forearm
Fractures, Hand
Tendonitis
Tenosynovitis

Other Problems to Be Considered

Falls in older persons

Workup

Laboratory Studies

  • No laboratory studies are indicated in patients with isolated wrist injury.

Imaging Studies

  • Radiography
    • Routine radiographs of the wrist include AP, lateral, and oblique views. These are adequate to identify most fractures. Look for evidence of displacement of carpal bone fractures because this often indicates the need for operative intervention.
    • When evaluating a fracture of the distal radius or ulna, carefully check the normal anatomic alignments. The radiocarpal joint viewed on the lateral film normally has 11° of palmar angulation with a range of 1-23°. Ulnar angulation on the AP film is normally 15-30°. The radial length, which is the distance between the ulnar aspect of the distal radius and the tip of the radial styloid, normally measures 11-12 mm.
    • Look for an associated ulnar styloid fracture and involvement of the radiocarpal joint or DRUJ. If the radius appears to be angulated and/or displaced significantly, maintain a high degree of suspicion for a concomitant fracture of the ulna.
    • Scaphoid fractures often are not seen on routine radiographs. Scaphoid views taken with the wrist deviated toward the ulna and slightly supinated may help to demonstrate a fracture. The approximately 10-15% of fractures that are occult may be apparent on plain films after 10-14 days as bony reabsorption occurs at the fracture site. While not appropriate for ED workups, CT scans and bone scans as early as 3 days after injury may aid in the diagnosis.
    • Injuries to the hamate and trapezium can be visualized best with a carpal tunnel view.
    • Like scaphoid injuries, injuries to the lunate and capitate may not be well visualized on plain films, and CT scan may be required.
  • Bone scan or MRI may be necessary to detect occult fractures not visualized on plain radiographs.

More on Fracture, Wrist

Overview: Fracture, Wrist
Differential Diagnoses & Workup: Fracture, Wrist
Treatment & Medication: Fracture, Wrist
Follow-up: Fracture, Wrist
Multimedia: Fracture, Wrist
References
Further Reading
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References

  1. Okazaki M, Tazaki K, Nakamura T, Toyama Y, Sato K. Tendon Entrapment in Distal Radius Fractures. J Hand Surg Eur Vol. Mar 25 2009;[Medline].

  2. Caillit R. Hand Pain and Impairment. FA Davis and Company; 1975.

  3. DePalma. Management of Fractures and Dislocations. WB Saunders and Company; 1970.

  4. Hoppenfeld S. Physical Examination of the Spine and Extremities. Appleton-Century-Croft Publishing; 1976.

  5. Papp S. Carpal bone fractures. Orthop Clin North Am. Apr 2007;38(2):251-60, vii. [Medline].

  6. Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. Mar 2006;117(3):691-7. [Medline].

  7. Resnick D, Kang H. Internal Derangement of Joints. WB Saunders and Co; 1997.

  8. Rockwood C, Green D. Fractures in Adults. Lippincott and Co: 1996.

  9. Simon R, Coenigskecht S. Orthopedics in Emergency Medicine. Appleton-Century and Kross Publishing; 1982.

  10. Tintinalli J, Ruiz E, Krome R. Emergency Medicine: A Comprehensive Study Guide, 4th ed. McGraw-Hill Publishing; 1996.

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Further Reading

Clinical guidelines
Rubin DA, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Jacobson JA, Morrison WB, Resnik CS, Roberts CC, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® acute hand and wrist trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 9 p.

Work Loss Data Institute. Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2008. 128 p.

Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic wrist pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p.

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Keywords

fractured wrist, wrist fracture, wrist fractures, broken wrist, carpal bone fracture, distal radius fractures, ulna fractures, ulnar fractures, scaphoid fracture, lunate fracture, triquetrum fracture, capitate fracture, hamate fracture, trapezium fracture, trapezoid fracture, pisiform fracture, lunate and perilunate dislocation, extension injuries, flexion injuries, fractures of the distal radius and/or ulna, extension fractures of the distal radius, Colles fracture, pseudocarpal injuries, wrist articular injuries, Barton fracture, push-off fracture, radial styloid fracture, Hutchinson fracture

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Contributor Information and Disclosures

Author

Bryan C Hoynak, MD, FACEP, FAAEM, Associate Clinical Professor of Emergency Medicine, University of California at Irvine School of Medicine; Director of Emergency Services, Chairman of Division of Emergency Medicine, Placentia-Linda Hospital
Bryan C Hoynak, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Burn Association, American College of Emergency Physicians, American College of Surgeons, and American Heart Association
Disclosure: Nothing to disclose.

Coauthor(s)

Laura Hopson, MD, Staff Physician, Department of Emergency Medicine, University of Michigan
Laura Hopson, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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