Carpal Bone Injuries

Causes

Causes include the following:

• Sports-related injuries

• Chronic overuse injuries

• Trauma

Carpal fractures most frequently occur after a fall onto an outstretched hand.[1]

Scaphoid navicular

Other mechanisms of injury have recently come to light in addition to a fall on the outstretched hand with hyperextension. These include forced palmar flexion of the wrist with axial loading of the wrist in a fixed position and hyperpronation.[2]

United States statistics

The frequency of carpal bone injuries cannot be specifically determined because they encompass a range and variety of injuries near and around the wrist joint. Additionally, retrospective analysis by diagnosis category grossly underestimates the number of incidents.

The author's perspective is from a personal observation made one weekend day during a 12-hour shift several years ago in Wildomar, California. Seven fractures or fracture-dislocations of the wrist presented to the emergency department; all were related to roller blades, and all involved children aged 5-16 years.

The rate of chronic overuse injuries and other sports-specific injuries approaches 35-50% of all carpal injuries in the sports world. Fractures of the distal radius account for one sixth of all fractures seen and treated in the emergency department. These injuries are most common in patients aged 6-10 years and those aged 60-69 years.

International statistics

International rates approximate the US rate.

The wrist joint, or carpus, is a complex arrangement between the forearm and the carpal bones, stabilized by strong, ligamentous attachments.[3, 4] The average wrist movement is 80º in flexion, 70º in extension, 30º in ulnar deviation, and 20º in radial deviation. Pronation and supination occur at the radioulnar articulation in the forearm, not at the wrist. The majority of injuries to the wrist occur with the wrist in the flexed position.

The muscles of the hand originate primarily in the forearm and pass over the wrist; the flexor carpi ulnaris inserts into the pisiform bone and is the only muscle that inserts into the wrist. The second and third metacarpals are fixed at the base and are immobile.

Carpal bones

The 8 carpal bones are arranged in 2 rows and are cuboid, with 6 surfaces. Of these 6 carpal surfaces, 4 are covered with cartilage to articulate with the adjacent bones, and 2 are roughened for ligament attachments. The proximal row, which contains the scaphoid, lunate, triquetrum, and pisiform, articulates with the radius and triangular cartilage to form the carpus. The distal row contains the trapezium, trapezoid, capitate, and hamate.

The ulnar nerve runs deep to the flexor carpus ulnaris tendon through the canal of Guyon. The median nerve lies between the flexor carpus radialis and the palmaris longus tendon in the carpal tunnel. Blood is supplied via the radial and ulnar arteries, which form the dorsal palmar arch. The scaphoid bone receives its blood supply from the distal part of this arch, which is prone to injury.

Anatomic considerations

The carpus is composed of the interval between the distal end of the radius and ulna and the proximal end of the metacarpal bones. A complex system of articulations works in unison to provide a global range of motion for the wrist joint. As noted above (see Functional Anatomy, Carpal bones), 8 carpi are arranged in 2 rows to form a compact, powerful unit. The distal row articulates with the proximal surface of the metacarpal bones. The proximal row articulates with the distal end of the radius and the fibrocartilaginous end of the ulna. The ulna does not articulate with the carpus.

The wrist has 5 large joint cavities in addition to the intercarpal joint spaces: (1) radiocarpal joint, (2) distal radioulnar joint, (3) midcarpal joint, (4) large carpometacarpal joint (between the carpus and the second, third, fourth, and fifth metacarpals), and (5) small carpometacarpal joint (between the first metacarpal and trapezium).

Motion at the wrist joint occurs between the radius and carpal bones. The size, position, and relation to the radius and surrounding carpal bones render the wrist joint vulnerable to injury. With dorsiflexion and radial deviation of the wrist, the joint is impinged by the radius; because of its narrow mid portion, the wrist joint is predisposed to injury. Healing depends on blood supply to the area; at this joint, blood enters the bone along the dorsal surface near its mid portion. Thus, the scaphoid is prone to avascular necrosis.

Sport-specific biomechanics focus on the unique characteristics that place the carpal bones at risk for injury during a sporting activity. This can be as obvious as a fall onto an outstretched hand during a roller sport to the hand plant that is involved in a gymnastics move.

Chronic use and movements in racquet sports, golf, and baseball require the carpus to resist torque stress. Depending on the strength of the weakest link, acute or chronic injury can ensue, which can be especially true in the hyperpronation-supination activity that is involved in the modern golf swing. The key to wrist injury prevention is to improve strength and flexibility in all planes of motion.

The prognosis depends on the severity of the injury and whether surgical correction is required. For example, simple, nondisplaced fractures of the distal radius require approximately 6 weeks of immobilization and 4-6 weeks of rehabilitation for a return to the full, premorbid condition. However, fracture-dislocations of the wrist that require open reduction and internal fixation require 8-12 weeks for the initial treatment phase and a similar amount of time for rehabilitation.

The prognosis following wrist fractures is influenced by many variables, including the complexity of the injury. Open fractures with large soft-tissue injuries have a much poorer prognosis. Additionally, timely and appropriate care can improve the prognosis. Appropriate follow-up monitoring and aggressive rehabilitation are essential.

Complications

Most complications from wrist fractures occur when the distal radius is fractured.

Colles fractures may result in radial shortening and angulation deformity, subluxation of inferior radioulnar joint, reflex sympathetic dystrophy, median nerve injury, osteoarthritis, or ulnar impaction syndrome.

Radiocarpal fracture-dislocation may cause entrapment of tendons or the ulnar nerve and/or artery.

A Hutchinson fracture may result in scapholunate dislocation, osteoarthritis, or ligament damage.

A Smith fracture may result in a complication similar to that of a Colles fracture.

Ulnar styloid fractures often result in nonunion.

When a patient is reintroduced to a sporting activity, in order to avoid reinjury and protect the injury site, take into account the patient's overall athletic strength when formulating an approach. For example, a tennis player with a carpus injury must regain full strength before attempting full use of the injured wrist during play. Specific care to the wrist-supporting ligaments and muscles is necessary to prevent overuse injuries during recovery and return of function.

Advise patients that wrist protection with support in the axial plane (with volar and dorsal hard-surface materials) is vital to prevent carpal injures in such sports as inline skating (ie, rollerblading).

For patient education resources, see the Hand, Wrist, Elbow, and Shoulder Center, Arthritis Center, and Breaks, Fractures, and Dislocations Center, as well as Carpal Tunnel Syndrome and Wrist Injury.

Distal radius, scaphoid, and lunate fractures are usually the result of a fall onto an outstretched hand, but they may also be caused by direct trauma (eg, during impact with a football helmet).[5, 6]

Extension fractures of the distal end of the radius

These fractures result from a fall onto a pronated, dorsiflexed hand. Upon striking a hard surface, the hand becomes fixed while the momentum of the body produces 2 forces: (1) a twisting force, which causes excessive supination of the forearm, and (2) a compression force, which acts vertically through the carpus to the radius.

The lunate acts as the apex of a wedge against the articular surface of the radius and causes different injuries, depending on the age of the patient. In very young children, a greenstick fracture of the distal radius occurs, with or without an associated fracture of the distal ulna. In adolescents, separation of the lower epiphysis with dorsal displacement or crushing of the radial epiphysis occurs. In adults, a fracture occurs within 1 in (2.5 cm) of the carpus. The distal fragment is usually proximally and distally displaced. In all age groups, the fracture may be complicated by injury to the median nerve, injury to the sensory branch of the radial nerve, fracture of the scaphoid, and/or dislocation of the lunate.

Although rare, a true Colles fracture is a transverse fracture of the radius, 1.57 in (4 cm) proximal to the wrist joint with backward, upward, and outward displacement of the distal fragment. In current practice, the term Colles fracture is loosely applied to any complete fracture of the distal end of the radius with an associated dorsal displacement of the hand on the forearm.

Colles fractures frequently result in radial-shortening deformities, reflex sympathetic dystrophy, and/or osteoarthritis. Although most Colles fractures can be treated with closed reduction, the majority of Smith fractures require orthopedic surgery (eg, Kirschner wires [K-wires] for anatomic reduction).[7]

Extension fractures of the distal end of the radius (reverse Colles fracture/Smith fracture)

A true Smith fracture is a fracture of the entire thickness of the distal radius, 0.5-1 in (1.3-2.5 cm) above the wrist. The lower end of the radius is proximally and volarly displaced. Smith fractures have come to be known as any fracture of the distal radius with an associated anterior (volar) displacement.[8]  See the images below.

One mechanism of injury is a direct blow to the dorsum of the hand with the hand in the flexed position. More frequently, a Smith fracture is caused by an indirect mechanism, such as when a person falls backward onto an outstretched hand in supination. Upon striking the ground, the hand locks in supination while the body's momentum forces the hand into hyperpronation, resulting in a typical hyperpronation injury.

Median nerve compression in the carpal tunnel is a common complication of a Smith fracture. Loss of this nerve function is manifested by the loss of thumb opposition and decreased sensation to the thumb, index finger, long finger, and radial half of the ring finger. If left untreated, this injury results in reflex sympathetic dystrophy. The majority of Smith fractures require orthopedic surgery (eg, K-wires for anatomic reduction).

Pseudocarpal injuries

The definition of pseudocarpal injuries is limited to injuries that involve the distal end of the radius and ulna (just proximal to the carpus), with clinical signs that mimic carpal bone injuries. Examples include articular disk injuries of the wrist, dislocations of the inferior radioulnar joint, and traumatic dislocation of the distal end of the ulna.

These injuries are rare and require consultation with an orthopedist for definitive management. Recognizing these injuries in the emergency department or on the field is important to avoid misdiagnosis or delay in appropriate management.

Wrist articular injuries

Injury to the articular disk of the wrist occurs from multiple mechanisms. Articular injuries coexist with the other more common injuries, although isolated injuries to the articular disk can occur. The most common pathologic defect is a tearing of the disk from its attachment at the margin of the ulnar notch of the radius. The primary function of the triangular disk of the wrist is to prevent lateral displacement of the ulna.

The most common mechanism of injury is dorsiflexion and pronation of the hand. Less frequently, extreme hyperextension and supination may cause injury. Volar and dorsal dislocation of the radial head may coexist.

Traumatic dislocation of the distal end of the ulna

Dislocation or subluxation of the distal end of the ulna is most often associated with radial fractures. However, acute traumatic dislocation or subluxation of the ulnar head without fracture can occur and is often not immediately recognized.

The ulnar head may be displaced anteriorly or posteriorly, depending on the mechanism of injury. Extreme extension and pronation of the hand produces a dorsal dislocation of the ulnar head. Extreme extension and supination of the hand produces a volar dislocation of the ulnar head.

A Galeazzi fracture is a specific type of radial fracture that is associated with a displaced distal radioulnar subluxation.

Ulnar styloid fractures frequently result in nonunion fractures, which require eventual, definitive surgical repair.

Traumatic dislocation of the distal end of the radius

A Monteggia fracture represents a displaced proximal ulnar fracture with radial dislocation. In most cases, the radial head is displaced anteriorly; radial nerve injuries are common with this type of injury.

Carpal bone dislocation

Carpal bone injuries are common in individuals of all age groups, but they are particularly common in adolescents. A solid knowledge of anatomy is essential for the clinician to comprehend the factors involved in these types of injuries and the rationale for therapy.

The scaphoid is usually fractured secondary to hyperextension of the wrist, often from falls onto the outstretched hand. The scaphoid is wedged between the radius and the surrounding carpal bones, particularly the capitate. Scaphoid fractures are usually associated with other injuries of the wrist, including dislocation of the radiocarpal joint, dislocation between the 2 rows of carpal bones, fracture-dislocation of the distal end of the radius, fracture at the base of the thumb metacarpal, and dislocation of the lunate.

Radiocarpal fracture-dislocation may result in entrapment of the ulnar nerve and artery.

Lunate and perilunate dislocation

These rare injuries may have a poor outcome if they are not recognized in a timely fashion. An exact diagnosis is often difficult to make based on radiographic findings. The 4 specific projections that help when taking comparison x-ray films are the anteroposterior (AP), lateral, 45° of pronation, and 45° of supination views.

Knowledge of the exact injury mechanism can help predict the resulting dislocation. Carpal bone dislocation is usually the result of extreme flexion or extension injuries of the wrist. The type of dislocation or fracture-dislocation produced by these mechanisms depends on the direction and intensity of the acting force or the position of the hand in relation to the forearm at the moment of impact.

The integrity of the lunate-capitate relationship is the most crucial factor in all dislocations of the wrist. The resulting lesions are directly related to the disruption or preservation of this articulation.

Extension injuries

When the hand is forced into extension (eg, during fall onto an outstretched hand), dorsal perilunate dislocation or volar lunate dislocation occurs. Commonly, a scaphoid fracture or scaphoid fracture-dislocation complicates the dorsal perilunate dislocation.

Flexion injuries

Dorsal dislocation of the lunate can occur when the hand and carpus are hyperflexed, such as with a fall onto the back of the hand. The upward force that is generated when the hand contacts the ground and the downward force that acts through the radius forces the capitate to rotate anteriorly, driving the lunate backward into a dorsal position.

Volar perilunate dislocation occurs when the hand and carpus are not hyperflexed. With this injury, the carpus is driven anteriorly toward the lunate. The lunate remains in its normal position, with the radius and the rest of the carpus dislocating anteriorly to the lunate. Volar perilunate dislocation is often associated with scaphoid fractures.

The aforementioned carpus injuries require consultation with a specialist and are usually treated with open reduction and internal fixation.

Lunate fractures

Lunate fractures most often result from a dorsiflexion injury or the impact of the heel of the hand with a hard surface. Patients usually present with weakness of the wrist and pain, which is aggravated with compression along the third digital ray.

Capitate fractures

Capitate fractures occur in approximately 15% of all carpal bone fractures. The size and position of the capitate make it susceptible to injury because it is the largest carpal bone and articulates with 7 bones. The blood supply is from the dorsal segment and is often disrupted, resulting in avascular necrosis, which is intimately related to the axial motion of the third metacarpal.

Capitate fractures usually result from direct blows or falls onto hard surfaces. These injuries most often occur with the hand in dorsiflexion and are often associated with other injuries.

The sports medicine clinician must always differentiate between a wrist fracture and a wrist dislocation.

Wrist dislocation

Pain is usually localized to the dorsum of the wrist over the radioulnar joint. Pronation or supination against resistance causes pain, and occasionally, a click may be heard when the wrist is rotated. X-ray examination findings are usually grossly negative.

With a dorsal dislocation, the patient usually has a history of acute wrist injury. Marked prominence of the ulnar head is present on the dorsum of the wrist with the hand locked in pronation. Attempts to supinate the wrist cause severe pain.

With a volar dislocation, the patient usually has a history of an acute injury to the wrist with loss of the normal prominence of the ulnar head on the dorsum of the wrist. Prominence of the ulnar head on the volar aspect of the wrist occurs with the hand locked in supination. The transverse diameter of the wrist is narrowed; attempts to pronate the hand cause severe pain.

Wrist fracture

Although ecchymosis is not always present, edema and point tenderness around the wrist should alert the clinician to the likelihood of a fracture (thereby preventing the misdiagnosis of a sprain or dislocation). Perform a thorough range-of-motion examination with pronation and supination to access pain and limitation of motion.[9, 10]

With a distal-radius fracture, the patient has point tenderness along the distal radius. Look for acute carpal tunnel syndrome. A median nerve examination is particularly important in patients who have dorsally displaced distal radius fractures, because this injury is associated with acute carpal tunnel syndrome.

With a scaphoid fracture, the patient has point tenderness in the anatomic snuffbox (located between the extensor pollicis longus and extensor pollicis brevis tendons). A study by Mallee et al concluded that anatomical snuff box tenderness was the most sensitive clinical test for scaphoid fractures.[11]

With a lunate fracture, the patient has point tenderness over the lunate fossa (located distal to the radius at the base of the long-finger metacarpal).

Nerve injury

Upon patient presentation and after treatment, the sports medicine practitioner must document the neurovascular status of the patient's affected extremity. Carefully note the ulnar and median nerve function. The ulnar nerve is often injured with closed fractures of the pisiform, triquetrum, hamate, and fourth and fifth metacarpals.

The motor branch of the ulnar nerve is the chief motor nerve of the hand. The sensory branch is rarely affected.

Blunt trauma to the hypothenar eminence may result in contusion to the ulnar nerve, with resulting neuropraxia.

Median nerve injury, including traumatic carpal tunnel syndrome, is manifested by sensory disturbances in the thumb, index, and long fingers and is associated with Colles fractures, perilunate dislocations, and carpal bone injuries.

If a large hematoma is present, it may be aspirated or surgically removed after consultation with the appropriate specialist.

Compression along the volar ligament results in pain and paresthesias along the median nerve. The thenar eminence exhibits muscle atrophy only late in this disorder.

Acute reduction of the displaced fracture is indicated if an acute injury is secondary to a displaced fracture and there is compression of the ulnar or median nerve.

Wrist articular injuries

Management of these injuries must exactly mirror the mechanism of injury. For example, with pronation injuries, treatment involves supinating the hand with the elbow flexed at 90°. With a supination injury, pronation corrects the defect.

No laboratory studies are indicated in cases of isolated wrist injury. However, erythrocyte sedimentation rate analysis can be helpful for monitoring the degree of inflammation involved with a chronic wrist problem.

The majority of wrist fractures can be assessed adequately with good-quality anteroposterior (AP) and lateral radiographic images.[12] The palmar slope of the articular surface of the distal radius is appreciated on a lateral x-ray film of the wrist. A slope of 11 º is normal.

For distal radius fractures, measure the palmar slope to assess the degree of angulation. Determine whether the fracture is intra-articular, and note the presence of any step-off at the articular surface. The ulnar styloid is chipped in approximately 60% of all patients with this fracture.

For scaphoid fractures, the fracture may be at the wrist, tuberosity, or proximal pole. If a scaphoid fracture is strongly suggested, a posteroanterior view of the scaphoid with the wrist in ulnar deviation may distract the fragments and make the fracture more apparent.

A bone scan or magnetic resonance imaging study may be necessary to detect occult fractures that may not be visualized on plain radiographs.[13, 14]

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.[15, 16, 17, 18]

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. See the images below.

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.

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.

Generally, analgesics and anxiolytics are the drugs that are used to treat fractures. In addition, administer proper antibiotics in cases of open fractures.

Class Summary

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.

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.

Propoxyphene/acetaminophen (Darvocet N-100)

Drug combination indicated for mild to moderate pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Indicated for moderate to severe pain.

Codeine/acetaminophen (Tylenol With Codeine)

Indicated for mild to moderate pain.

Class Summary

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.

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.

Return to play recommendations are as follows:

• Distal radius fracture: Uncomplicated fractures require conversion of the splint to a short-arm cast for 6-8 weeks once swelling has abated. An orthopedic specialist should assess the limb for adequate alignment and the need for operative intervention.

• Scaphoid fracture: Treatment in a thumb spica cast for 12 weeks results in healing for 90% of these fractures.

• Lunate fracture: Most lunate fractures heal with placement of a spica cast for 10-12 weeks.