eMedicine Specialties > Sports Medicine > Wrist and Hand
Carpal Bone Injuries: Treatment & Medication
Updated: Aug 28, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
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.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.
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.
Medication
Generally, analgesics and anxiolytics are the drugs that are used to treat fractures. In addition, administer proper antibiotics in cases of open fractures.
Analgesics
Pain control is essential to quality patient care because it ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have sustained traumatic injuries.
Fentanyl (Duragesic, Sublimaze)
Short duration (30-60 min) makes titration easy. Excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.
Adult
2-3 mcg/kg IV/IM; not to exceed 50 mcg
Pediatric
1-2 mcg/kg/dose IV/IM q30-60min; not to exceed 3 mcg/kg/h
Phenothiazines may antagonize analgesic effects of opiate agonists; adverse effects may be potentiated when used concurrently with TCAs
Documented hypersensitivity; patients diagnosed with hypotension or potentially compromised airway, in whom establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid use in patients diagnosed with hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; idiosyncratic reaction (chest wall rigidity syndrome) may require neuromuscular blockade to improve ventilation.
Morphine sulfate (Duramorph, Astramorph, MS Contin)
DOC for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. The IV form may be dosed in a number of ways and is commonly titrated until the desired effect is obtained.
Adult
Initial dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg IV/IM/SC q4h
Relatively hypovolemic patients: 2 mg IV/IM/SC initially and then reassess hemodynamic effects of dose
Pediatric
Neonates: 0.05-0.2 mg/kg IV prn; not to exceed 15 mg/dose
Children: 0.1-0.2 mg/kg IV q2-4h prn; not to exceed 15 mg/dose (IV)
Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs, MAOIs, and other CNS depressants may potentiate the adverse effects of morphine when used concurrently.
Documented hypersensitivity; those diagnosed with hypotension; potentially compromised airway in those in whom rapidly establishing airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid use in patients diagnosed with hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; exercise caution in patients who have been diagnosed with atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Propoxyphene and acetaminophen (Darvocet N-100)
Drug combination indicated for mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d
Pediatric
Not established
May increase serum concentrations of carbamazepine, phenobarbital, MAOIs, TCAs, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
Acetaminophen and codeine (Tylenol With Codeine )
Indicated for mild to moderate pain.
Adult
Based on codeine content: 30-60 mg/dose PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
Based on codeine: 0.5-1 mg/kg/dose PO
Based on acetaminophen: 10-15 mg/kg/dose PO q4h; not to exceed 2.6 g/d
Toxicity is increased when administered concurrently with CNS depressants or TCAs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal syndrome; caution in patients with severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose PO, based on acetaminophen, q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: Administer dose based on 650 mg acetaminophen PO q4h (1 tab); single dose not to exceed 10 mg hydrocodone bitartrate; not to exceed 5 doses in 24 h
Phenothiazines may decrease analgesic effects; toxicity increases when administered concurrently with CNS depressants or TCAs
Documented hypersensitivity elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Tabs contain metabisulfate, which may cause allergic reactions; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
Anxiolytics
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect as a higher dose would.
Lorazepam (Ativan)
A sedative hypnotic in the benzodiazepine class. Has a short onset of effect and a relatively long half-life. May depress all levels of the CNS, including limbic and reticular formation, by increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain.
Adult
1-10 mg/d PO/IV/IM divided bid/tid
Start 0.1 mg/kg IV over 2 min, titrate dose to effect
Pediatric
0.05-0.1 mg/kg IV slowly over 2-5 min; may repeat dose of 0.5 mg/kg IV slowly
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS hypotension, depression, and narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with diagnosed renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Midazolam (Versed)
DOC for acute anxiety and sedation to aid in reduction of fractures or dislocations. Provides antegrade amnesia with dose within 1-2 h.
Adult
0.15 mg/kg IV/IM, onset of action within 2 min
Titrate IV dose to achieve effect in increments of 0.02 mg/kg
0.1 mg/kg IM, onset of action 10-15 min
Pediatric
0.1-0.15 mg/kg IM
Initial dose: 0.05-0.1 mg/kg IV; not to exceed 0.6 mg/kg
Decreased effects with concurrent administration of carbamazepine and disulfiram; toxicity increases when administered concurrently with cimetidine, lithium, contraceptives, and CNS depressants (including alcohol)
Documented hypersensitivity; patients with respiratory depression, narrow-angle glaucoma, or preexisting hypotension
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Respiratory depression, apnea, hypotension
More on Carpal Bone Injuries |
| Overview: Carpal Bone Injuries |
| Differential Diagnoses & Workup: Carpal Bone Injuries |
 Treatment & Medication: Carpal Bone Injuries |
| Follow-up: Carpal Bone Injuries |
| References |
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References
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Further Reading
Keywords
wrist bone injuries, wrist injuries, wrist sprain, broken wrist, sprained wrist, wrist fracture, fractured wrist, forearm injury, carpus injuries, wrist dislocation, carpus dislocation, wrist joint, greenstick fracture, Colles fracture, Smith fracture, reverse Colles fracture, pseudocarpal injury, pseudo carpal injury, Galeazzi fracture, Monteggia fracture, dorsal dislocation, volar dislocation, distal radius fracture, scaphoid fracture, lunate fracture, traumatic carpal tunnel syndrome, CTS, carpal tunnel syndrome, perilunate dislocation, Hutchinson fracture
