Wrist fractures March 2018 | by EMauthor Colles fracture •Fracture within 2.5 cm of articular surface with a combination of deformities (dorsal shift and tilt, radial shift and tilt, and impaction) •Check radial pulse and median nerve function •Minimally displaced fractures oBelow elbow back slab oAnalgesia oFracture clinic follow up oWill need manipulation if articular surface of radius is angulated more than 10 deg or if there is significant shortening •Place in a below elbow back slab with mild flexion and ulnar deviation •Arrange a fracture clinic follow up •Comminuted or unstable fractures, especially in young adults, will need internal fixation, refer to orthopaedics Smith fracture (reverse Colles) •Volar angulation of distal radius •Unstable fracture, will need a buttress plate in many cases •ED manipulation is essentially a reverse of the Colles manipulation finished off with a volar slab in dorsal angulation. Orthopaedic team must review patient in the department (and will usually ambulate them; but they cannot be referred by ED to fracture clinic) Barton fracture •A variant of Smith fracture with involvement of the articular surface •Unstable fractures that need internal fixation •Refer to orthopaedics Scaphoid fracture •Can result from a fall on outstretched hand or kick back injury •Clinically suspected from mechanism of injury and tenderness over the anatomical snuff box and tenderness over dorsal surface of scaphoid (which is more specific ) •Other clinical signs include pain on telescoping the thumb and pain on ulnar deviation of the wrist •Ask for scaphoid views •If obvious fracture identified, then oScaphoid plaster oAnalgesia oFracture clinic follow up •If x-ray negative but clinically suspected then oScaphoid plaster oAnalgesia oED review clinic in 10-14 days with plaster removal on arrival •Beware that fracture of radial styloid and of the base of thumb metacarpal can give ASB tenderness Avulsion fracture of triquetral •Commonly missed •Local tenderness over the triquetral •Look for the avulsed part on lateral view of the wrist •Treat with bandage and mobilisation or back slab if too painful •Refer to fracture clinic Fracture of hook of hamate •Can be a sports injury •Tenderness over the hamate (ulnar side of wrist) •Will need special views, ask for senior help or bring to review clinic if in doubt Key point: triquetal and hook of hamate fractures are rare and are therefore missed more frequently. Have a low threshold for seeking advice Lower radial fracture in children •Undisplaced fractures of the distal radial metaphysis, Greenstick/Buckle fractures. oBelow elbow back slab oAnalgesia oFracture clinic oAngulated fractures of lower radial metaphysis oThose will need manipulation even if greenstick, refer to orthopaedics •Slipped radial epiphysis oUsually of Salter-Harris 2 type oRefer to orthopaedic or discuss with senior as they need prompt manipulation and plaster immobilisation |
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