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Carpal Bone Injuries Treatment & Management

  • Author: Bryan C Hoynak, MD, FACEP, FAAEM; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Jan 11, 2016
 

Acute Phase

Rehabilitation Program

Physical Therapy

During prehospital care, stabilize the area of the possible fracture at the wrist and elbow because tension on the radius or ulna may further displace fracture fragments. Urgent reduction of the fracture may be necessary if the neurovascular status of the limb has been compromised. Perform the reduction in the prehospital setting if the time of injury is longer than 6 hours from the estimated time of definitive care.

Surgical Intervention

Open fractures and joint-capsule injuries require extensive irrigation (2-3 L), administration of antibiotics such as cephalexin and gentamicin (gentamicin is preferred, especially in cases where open fractures occur in locations around farm animals), emergent operative treatment, and hospital admission.

Other Treatment

Accurate and timely fracture reduction is essential to obtaining good functional results. Early reduction lessens morbidity and improves patient comfort. Obtain anatomic reduction by manipulation and plaster fixation.[14, 15, 16, 17]

Administer proper anesthesia before performing closed reduction and fixation (1) to reduce or eliminate patient discomfort and (2) to reduce muscle spasm and splitting, which allows easier reduction and stabilization.

Anesthesia can involve local infiltration, hematoma block, or brachial block. For these methods, bupivacaine at 0.5% is ideal because of its low toxicity and long duration of action. Local anesthesia is obtained by performing a hematoma block. Introduce the needle into the fracture hematoma and aspirate the blood. Then, inject bupivacaine (10 mL of 5% solution) into the hematoma site. Inject another 5 mL around the site. Allow 10-15 minutes before attempting manipulation. Although a brachial block provides excellent anesthesia, it is best left to those who are skilled in its use.

Two key procedures to successful reduction of the typical Colles fracture are as follows:

  • Recreate the position of injury in the hand and wrist, and then pronate the forearm to correct the supination twist of the distal fractured segment. This reduction can be performed with the aid of the Weinberg finger traction apparatus or by use of an assistant to fix the arm at the elbow. Relax the periosteal ligaments and allow for easier fracture reduction by recreating the mechanism of injury and position of the bony fragments at injury.
  • Extend the wrist back to 90° with the elbow fixed and forearm supinated. Pull the distal segment back, up, and out, at approximately 120°. Then, use both thumbs to push the distal fragment into alignment as the arm is pronated. The initial treatment includes the application of a plaster sugar-tong splint, with the fracture held in slight flexion, the ulna held in deviation, and the forearm held in pronation. Obtain postreduction x-ray films, and assess and document the prereduction and postreduction neurovascular status of the extremity. Document function of the median nerve and sensory branch of the radial nerve.

For proper reduction of a Smith fracture, the forearm must be fully supinated while the elbow is fixed by an assistant or with the aid of the Weinberg traction device. The garden-spade deformity of the Smith fracture is the direct opposite of the dinner-fork deformity of the Colles fracture.

  • Extend the wrist to 90° and fully supinate the forearm. Recreate the position of the hand at injury to relax the periosteal attachments. Then, hyperflex the hand and reduce the fracture segment with traction at approximately 60° while the thumbs move the fragments into alignment along the volar aspect of the wrist, pushing the fragment upward and backward. Force the wrist into ulnar deviation and dorsiflexion for the reduction. Hold this position until a plaster sugar-tong splint is placed. These fractures are difficult to hold into position, especially if dorsiflexion and ulnar deviation are lost during the application of the plaster.
  • Postreduction x-ray films and documentation of the neurovascular status of the extremity are considered part of the standard care.

For volar dislocations, hyperpronate the hand. For dorsal dislocations, hypersupinate the hand. Apply a sugar-tong plaster splint to hold the reduction. For volar dislocations, splint the hand in the fully pronated position; for dorsal dislocations, splint the hand in supination. There must be an appropriate consultation with an orthopedist within the next 48 hours.

Scaphoid fracture treatment requires consultation with an orthopedic surgeon. However, this does not mean the sports medicine physician can initially ignore this injury, which may lead to avascular necrosis if not properly protected and splinted. Emergency department and sports medicine standards of care require the application of a thumb spica splint for any possible injury to the scaphoid (clinically defined as any pain in the area of the anatomic snuffbox). The splint also protects the ulnar collateral ligament of the thumb from further injury.

Initial treatment of lunate fractures consists of a short-arm spica cast or splint with thumb immobilization.

Initial treatment of capitate fractures consists of plaster splinting in a position of function and consultation with an orthopedic surgeon.

Next

Recovery Phase

Rehabilitation Program

Physical Therapy

Under Acute Phase, see Other Treatment for specific casting recommendations. The patient may require physical therapy to regain his/her baseline range of motion.

Consultations

Obtain immediate consultations with a hand specialist or orthopedic surgeon for fractures that are open, are unstable, or require fixation. All other fractures require adequate follow-up monitoring by an orthopedist to ensure proper wrist function.

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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 Surgeons, American Heart Association, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

References
  1. Hoppenfeld S. Physical Examination of the Spine and Extremities. Norwalk, Conn: Appleton & Lange; 1976.

  2. Simon RR, Koenigsknecht SJ. Orthopaedics in Emergency Medicine. 2nd ed. New York, NY: Appleton-Century-Crofts; 1982.

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

  4. Lohan D, Cronin C, Meehan C, et al. Injuries to the carpal bones revisited. Curr Probl Diagn Radiol. 2007 Jul-Aug. 36(4):164-75. [Medline].

  5. Ezquerro F, Jiménez S, Pérez A, et al. The influence of wire positioning upon the initial stability of scaphoid fractures fixed using Kirschner wires A finite element study. Med Eng Phys. 2007 Jul. 29(6):652-60. [Medline].

  6. Vigler M, Aviles A, Lee SK. Carpal fractures excluding the scaphoid. Hand Clin. 2006 Nov. 22(4):501-16; abstract vii. [Medline].

  7. Beeres FJ, Hogervorst M, Den Hollander P, Rhemrev SJ. Diagnostic strategy for suspected scaphoid fractures in the presence of other fractures in the carpal region. J Hand Surg [Br]. 2006 Aug. 31(4):416-8. [Medline].

  8. Steinmann SP, Adams JE. Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci. 2006 Jul. 11(4):424-31. [Medline].

  9. Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am. 2014 Sep. 39 (9):1683-1691.e2. [Medline].

  10. Yin ZG, Zhang JB, Kan SL, Wang P. Treatment of acute scaphoid fractures: systematic review and meta-analysis. Clin Orthop Relat Res. 2007 Jul. 460:142-51. [Medline].

  11. De Filippo M, Sudberry JJ, Lombardo E, et al. Pathogenesis and evolution of carpal instability: imaging and topography. Acta Biomed. 2006 Dec. 77(3):168-80. [Medline]. [Full Text].

  12. Nanno M, Patterson RM, Viegas SF. Three-dimensional imaging of the carpal ligaments. Hand Clin. 2006 Nov. 22(4):399-412; abstract v. [Medline].

  13. You JS, Chung SP, Chung HS, et al. The usefulness of CT for patients with carpal bone fractures in the emergency department. Emerg Med J. 2007 Apr. 24(4):248-50. [Medline].

  14. DePalma AF. The Management of Fractures and Dislocations. 2nd ed. Philadelphia, Pa: WB Saunders; 1970.

  15. Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: a Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill; 1996.

  16. Rosen P, Barkin RM, Braen GR, et al, eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998.

  17. 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. 2006 Mar. 117(3):691-7. [Medline]. [Full Text].

 
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