Carpal fractures
Background
- Scaphoid fractures account for 70% of all carpal fractures
- Ulnar nerve damage associated with fractures of hamate or pisiform
- 50% of pisiform fx associated with injury to distal radius or other carpal bone
- If bone fragment seen posterior to carpus on lateral, very likely triquetrum fx
Specific Fractures
Overview
| Carpal Bone | Mechanism of Injury | Examination | ED Management |
|---|---|---|---|
| Scaphoid | FOOSH | Snuffbox tenderness; pain w/ radial deviation/flexion |
Short arm, thumb spica, in dorsiflexion w/ radial deviation |
| Triquetrum |
1. Avulsion fracture: twisting of hand against resistance or hyperextension 2. Body fracture: direct trauma |
Tenderness at dorsum of the wrist, distal to the ulnar styloid | Short arm, sugar tong splint |
| Lunate | FOOSH | Tenderness at shallow indentation of the mid-dorsum of wrist, ulnar and distal to Lister tubercle | Short arm, thumb spica splint |
| Trapezium | Direct blow to thumb; force to wrist while dorsiflexed and radially deviated | Painful thumb movement and weak pinch strength; snuffbox tenderness | Short arm thumb spica splint |
| Pisiform | Fall directed on hypothenar eminence | Tender pisiform, prominent at the base of hypothenar eminence | Short arm, volar splint in 30 degrees flexion and ulnar deviation |
| Hamate | Interrupted swing of golf club, bat, or racquet | Tenderness at hook of hamate, just distal and radial to the pisiform | Short arm, volar wrist splint with 4th and 5th metacarpal joints in flexion |
| Capitate | Forceful dorsiflexion of the hand with radial impact | Tenderness over capitate just proximal to the third metacarpal | Short arm, volar wrist splint |
| Trapezoid | Tenderness over radial aspect of base of index metacarpal | Short arm thumb spica splint |
Imaging
- See Wrist Bones
- Evaluate Zone of Vulnerability
Disposition
- Scaphoid Fx
- Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
- Lunate Fx
- Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
- Triquetrum Fx
- Refer for displacment >1mm
- Pisiform Fx
- Tend to do well with casting; refer for casting if unable to obtain in the ED
- Hamate Fx
- Refer for dislocation, pts who need to return to actvitiy ASAP
- Capitate Fx
- Always refer to a hand surgeon b/c may lead to osteonecrosis if not recognized/treated
- Trapezoid Fx
- Refer for comminution or dislocation
- Trapezium Fx
- Refer for displacement >2mm, intraarticular fx w/ >1mm incongruity, comminuted fx
Source
- UpToDate
- Accident & Emergency Radiology
- Tintinalli