Background
The wrist represents the region from the distal radius and ulna to the carpometacarpal joints.
It is one of the most complex and dynamic joints in the human body, and yet also one of the most commonly injured regions.
Spectrum of disease varies greatly, ranging from simple sprains to complex fracture/dislocation patterns with associated neurologic compromise.
This provides for a vast array of potential pathology, making the evaluation and diagnosis of injury quite difficult.
Making things even more complex, even subtle injury patterns can have dramatic and longstanding complications if not properly diagnosed and treated at initial presentation.
Consequences from injury and delay in diagnosis include:1
Rising medical costs
Decreased school attendance
Lost work hours
Loss of independence
Chronic pain
Lasting functional disability
A thorough knowledge of anatomy, mechanism of injury, injury patterns, radiographic findings, and appropriate treatment and follow-up are imperative for optimal patient care.
Epidemiology
Wrist injuries are one of the most common presentations in the ED, accounting for 2.5% of all ED visits.2
Incidence appears to be increasing worldwide, likely multifactorial:3
Advancing age and changes in bone metabolism
Increasing sports activity in children
Increasing obesity rates
The most common fracture is the distal radius fracture, which accounts for one-sixth of all fractures seen and treated in US emergency departments.4
Colles fracture is the most common fracture in all persons less than 75 years old
Carpal fractures account for 20% of fractures to wrist and hand.5
Injury patterns tend to be bimodal in distribution, affecting youth and elderly populations primarily.
Younger patients tend to present with higher mechanism injuries.
Motor vehicle accidents
Sports injuries
Elderly patients present after low mechanism falls.
The vast majority of wrist pathology occurs via a fall on outstretched hand (FOOSH) (fall on an outstretched hand) mechanism.
Anatomic Considerations / Pathophysiology
The wrist is composed of the distal radius and ulna, as well as eight carpal bones that are arranged in two transverse rows (Figure 3.1).
Proximal carpal row (radial to ulnar) – scaphoid, lunate, triquetrum, pisiform.
Distal carpal row (radial to ulnar) – trapezium, trapezoid, capitate, hamate.
The carpal rows form three “arcs,” which are key to identifying injury on PA radiograph.
Principle movements of the wrist are flexion, extension, radial deviation, and ulnar deviation.
The radius articulates directly with the proximal carpal row.
Articular surface is both concave and tilted.
Concavity “cups” the scaphoid and lunate
Normal volar tilt of 0–22° (lateral radiograph)
Normal radial tilt (“or radial inclination”) of 15–30° (PA radiograph)
The ulna has no direct bony articulations.
Ulna has a nonosseous fibrocartilage union with the radius, triquetrum, and lunate, called the triangular fibrocartilage complex (TFCC). (Figure 3.2)
The ulna articulates with the radius at the distal radioulnar joint (DRUJ).
Stability of this joint is maintained by the TFCC, interosseous membrane, and both dorsal and volar radioulnar ligaments.
Pronation and supination are accomplished through articulations at the proximal and distal radioulnar joints.
There are two classifications of ligaments in the wrist: extrinsic and intrinsic.
Extrinsic ligaments connect carpal bones to the radius, ulna, or metacarpals.
Intrinsic ligaments connect carpal bones to one another.
Extrinsic ligaments are further characterized as dorsal or volar.
Volar ligaments are relatively stronger than dorsal counterparts, which plays a role in injury pattern and associated carpal instability.
There is dual vascular supply to the wrist with the radial and ulnar arteries.
Radial artery runs lateral (radial) to the flexor carpi radialis.
Ulnar artery is just radial to the flexor carpi ulnaris.
Many of the carpal bones have solitary vascular supply, paradoxically running in a distal to proximal course. This has significant impact on fracture healing, depending on anatomic location of the lesion, which is described later in more detail.
Motor and sensory inputs are from radial, ulnar, and median nerves:
Radial nerve courses dorsally, supplying motor function to wrist extension and finger extension; sensory input is to the dorsum of the hand.
Median nerve runs within the carpal tunnel on the volar aspect of the wrist, supplying motor function to wrist flexion, finger flexion, thumb flexion, extension, and abduction; sensory input is to the volar aspect of the hand for the first three digits.
Ulnar nerve runs parallel to the ulnar artery and passes through Guyon’s canal, consisting of the pisiform and hook of the hamate; it controls hypothenar muscles, interossei, and the fourth and fifth digit lumbricals; sensory input is to the ulnar side of the palm and fourth and fifth digits.
Each of these nerves is susceptible to injury with certain fracture patterns, to be discussed later in the chapter.
Figure 3.1. PA view of the carpal bones. S = Scaphoid, L = Lunate, T = Triquetrum, P = PisiformTr = Trapezium, Td = Trapezoid, C = Capitate, H = Hamate.
Figure 3.2. Triangular Fibrocartilage Complex (TFCC).
Focused History and Physical Examination
History
As with any medical presentation, a good history is paramount.
Key features include:
Mechanism of injury
Timing and duration or pain
Alleviating and aggravating features
Neurovascular changes
History of prior injury or surgery
Baseline motor and sensory function prior to injury
Hand dominance
Special attention to baseline activity and occupation
Physical Examination
Physical examination begins with appearance and comparison to the opposite extremity.
Note swelling, ecchymosis, deformity, and distal perfusion
Point of maximal tenderness, referred pain
Passive and active ROM, noting pain and limitations
Palpable landmarks:
Dorsal (radial to ulnar) (Figure 3.3):
Radial Styloid
Distal end of the radius, easily palpable and usually visible on inspection
Snuff box (Figure 3.4)
Bordered proximally by the radial styloid, radially by the abductor pollicis longus and extensor pollicis brevis, and ulnarly by the extensor pollicis longus tendon
Scaphoid resides within the snuff box, more prominent with ulnar deviation
Depression felt just ulnar to the radial styloid
Landmark for the scapholunate joint
Capitate is palpated just distal with the wrist in neutral position
Lunate is palpable with the wrist in flexion
Ulnar styloid
Bony prominence on the dorsal ulnar aspect, easily visible
Triquetrum
Palpable just distal to the ulnar styloid
Volar (radial to ulnar)(Figure 3.5):
Scaphoid Tubercle
Just distal to the radial styloid, at the thenar muscle base
Pisiform
At the base of the hypothenar muscles, just distal to the ulnar styloid and distal wrist crease
Hook of the hamate
Approximately 1 cm distal and radial to the pisiform
Range of motion:
Test range of motion of the wrist in all directions and compare to the contralateral side.
Range of motion at the wrist includes:
Flexion
Extension
Pronation
Supination
Radial deviation
Ulnar deviation
Special tests:
Finkelstein test (De Quervain’s tenosynovitis) (Figure 3.6)
Patient places the thumb in flexion within the palm, and examiner deviates the wrist ulnarly.
Positive = pain
Tinel’s sign (carpal tunnel syndrome) (Figure 3.7)
Phalen’s test (carpal tunnel syndrome) (Figure 3.8)
Dorsiflexion of the wrist for upwards of 60 seconds
Positive = paresthesias in median nerve distribution
Scaphoid shift test (scapholunate dissociation) (Figure 3.9)
Examiner’s thumb presses on the base of the thenar eminence, over the scaphoid, while the hand wraps around the wrist.
Examiner’s opposite hand holds the patient’s hand at the level of the MCP joints.
The wrist is held in extension and mild ulnar deviation.
While applying thumb pressure over the scaphoid, the wrist is gently flexed and radially deviated.
Positive = if the scaphoid shifts dorsally
While releasing pressure on the scaphoid, examiner or patient may feel or hear a “click” as the scaphoid returns to its normal position.
TFCC compression test (TFCC tear) (Figure 3.10)
Axial load the wrist and then deviate wrist to ulnar side.
Test is positive if it creates a click and reproduces the patient’s pain.
Assesses the stability of the DRUJ.
With the wrist in pronation, volar pressure is placed on the distal ulna.
Test is positive if pain or instability is elicited compared to contralateral side.
Shuck test (Figure 3.11)
Also tests stability of DRUJ
The distal radius is held with one hand, and the distal ulna with the other.
The distal radius is moved dorsally.
This test is positive if it elicits pain or instability compared to the contralateral side.
Neurovascular exam:
Two-point discrimination is the most sensitive test for sensory function of the nerves.
Compare to uninjured hand
Volar
Distinguish two blunt points that are 2–5 mm apart on the fingertips, 7–10 mm at the base of the palm6
Dorsal
Distinguish two blunt points at 7–12 mm
Median nerve
Sensory – sensation to the index fingertip
Motor – thumb abduction
Ulnar nerve
Sensory – sensation to little fingertip
Motor – abduction of fingers, or thumb adduction
Radial nerve
Sensory – sensation to dorsum of thumb/webspace
Motor – extension of wrist and MCPs
Vascular exam:
Radial pulse
Ulnar pulse
Capillary refill
Figure 3.3. Dorsal landmarks of the wrist.
Figure 3.4. Anatomic snuff box landmarks. The radial styloid forms the base, and both the scaphoid and trapezium may be palpated within the snuff box.
Figure 3.5. Volar landmarks of the wrist.
Figure 3.6. Finkelstein test.
Figure 3.7. Tinel’s sign.
Figure 3.8. Phalen’s test.
Figure 3.9. Scaphoid shift test.
Figure 3.10. Triangular fibrocartilage complex (TFCC) compression test.
Figure 3.11. Shuck test.
Radiographic Considerations
Evaluation begins with PA, lateral, and oblique radiographs of the wrist.
PA radiograph provides detailed information for both obvious and subtle injury patterns (Figure 3.12).
Radial length (height) – measurement from the ulnar articular surface to the tip of the radial styloid
Normal is 9–12 mm
Shortening is suggestive of distal radial fracture
Radial tilt (inclination) – measurement of ulnar slant of the radial articular surface
Normal is 15–30°
Decrease is suggestive of fracture or DRUJ disruption
Carpal arcs (Figure 3.13)– three smooth lines drawn between carpal bones
Proximal – proximal border of scaphoid, lunate and triquetrum
Middle – distal border of proximal carpal row
Distal – proximal border of capitate and hamate
Disruption of these lines is suggestive of fracture, dislocation, or both
Carpal distance – the space between each of the carpal bones
Normal is 1–2 mm, equal distance between each bone
Pathologic is greater than 3 mm
Lateral radiograph evaluates the fracture line, volar or dorsal displacement, intra-articular extension, and carpal alignment.
Lateral radiograph should have no more than 2 mm of the ulna projecting beyond the radius
Pronator quadratus fat pad – normal radiolucent linear line just volar to the radius and ulna
Volar displacement, bowing, or loss of fat pad suggests radius or ulna fracture
Volar tilt of radius (Figure 3.14) – the natural angle of the radiocarpal joint
Normal is 0–22° volar angulation
Measured by the angle formed by a line perpendicular to the long axis of the radius and a line along the surface of the distal radius
Fractures with dorsal angulation need to be reduced to neutral or + volar tilt for good functional outcome
Straight line should exist between central axis of the radius, lunate, capitate and the third metacarpal. (Figure 3.15)
Normal variance up to 10°
Disruption is suggestive of fracture or carpal dislocation
Scapholunate angle (Figure 3.16) – angulation between intersecting lines drawn through the central axis of the scaphoid and lunate
Normal is 30–60°
Angulation greater than this suggests rotary subluxation of the scaphoid, or fracture
Capitolunate angle – angulation between central axis lines through capitate and lunate
Normal is 0–30°
Greater than 30° suggests carpal dislocation
Oblique radiograph is best for assessing the most radial carpal bones.
Scaphoid, trapezoid, trapezium more clearly seen in this view compared to the PA
Also helpful for assessing intra-articular extension of distal radius fractures
Dedicated views may be obtained with suspicion for certain injuries.
Scaphoid view – PA radiograph with the wrist held in ulnar deviation
Exposes the scaphoid
Enhances detection of subtle fractures
Carpal tunnel view – wrist is held in hyperextension, radiograph is directed across the volar wrist.
Good for detection of hamate and pisiform fractures
Clenched fist view – AP radiograph with patient clenching the fist forcefully
Accentuates potential scapholunate dissociation
Figure 3.12. Normal radial length and inclination on PA radiograph.
Figure 3.13. Carpal arcs on PA view.
Figure 3.14. Normal volar tilt on lateral radiograph.
Figure 3.15. Straight line through radius, lunate, capitate, and metacarpal.
Figure 3.16. Normal scapholunate angle.
Differential Diagnosis-Emergent and Common Diagnoses
Scaphoid Fractures
General Description
Most common fractured carpal bone, accounting for 62–87% of all carpal fractures7
Scaphoid serves as a link between the carpal rows.
Bulk of it is articular surface
Acts to stabilize the carpal rows
Also one of the most frequently missed carpal fractures
Misdiagnosed as “wrist sprain”
Delay in diagnosis increases chance for poor outcome
High incidence of AVN and nonunion due to poor vascular supply
Blood enters the dorsal cortex near the tubercle waist
Proximal bone has no direct blood supply
Fractures are characterized by anatomic location:
Table 3.1 Emergent and Common Diagnoses in the Emergency Department
| Emergent Diagnoses | Common Diagnoses |
|---|---|
| Perilunate dislocation | Scaphoid fracture |
| Lunate dislocation | Distal radius fracture |
| Displaced distal radius fracture | Carpal tunnel syndrome |
| Any open fracture | De Quevain’s tenosynovitis |
| Any injury associated with neurovascular compromise | Ganglion cyst |
| Any unstable fracture or dislocation |
Mechanism
Injury occurs with forced hyperextension and axial load of the wrist, described as FOOSH
Radial deviation impinges the scaphoid against the radius
Approximately 3% occur with flexion injury10
Presentation
Typically seen in young adults, age 15–30
Rare in children, as the carpus is primarily cartilaginous until adolescent years
Dorsal wrist pain just distal to the radial styloid
Complaint of pain with wrist and thumb movement
Swelling and ecchymosis is variable
Physical Examination
Overall excellent sensitivity, but poor specificity at 74–80%
Tenderness directly over the scaphoid, both volar and dorsal
Tenderness in anatomic snuff box – 90% sensitive, 40% specific
Axial load of thumb in line with first metacarpal
Resisted supination
Flexion and radial deviation
Essential Diagnostics
Standard PA, oblique, and lateral x-ray views will pick up many fractures (Figures 3.17 and 3.18).
Look for displaced scaphoid fat stripe as subtle finding11
If the exam is suggestive of injury, a scaphoid view increases sensitivity.
Despite this, upwards of 30% of fractures will be undetectable in the acute setting.12
CT scan is very sensitive for fracture, but cases of false negatives have been reported.
Wrist MRI has been reported as 100% sensitive in multiple studies, but is not readily available in most EDs.
Figure 3.17. Displaced and angulated scaphoid fracture.
Figure 3.18. Abnormal fat pad in subtle scaphoid fracture.
ED Treatment and Disposition
Based on suspicion for injury and x-ray findings
Clinically Suspected Injury, XR Normal
Splint in short arm thumb spica
Re-examine in seven to ten days, repeat x-ray
If negative but continued clinical suspicion, reapply splint and re-evaluate again in seven to ten days, consider bone scan, CT, or MRI
If positive for nondisplaced fracture, thumb spica cast for six weeks
Nondisplaced Scaphoid Fracture
Thumb spica splint in the ED
Debate over long vs. short arm splints, no clear correct answer
Follow-up with thumb spica casting
Period of immobilization varies depending on anatomic location of fracture; more proximal fracture = longer
Average immobilization is twelve weeks
Displaced Scaphoid Fracture
Thumb spica splint in the ED
Significant displacement, comminution, and/or angulation require hand surgeon consultation and urgent referral
Such injuries require open reduction and internal fixation
Absolute indications: ≥1-mm displacement, ≥ 15-mm angulation
Return to Play
Most athletes will undergo surgical fixation to allow for earlier return to athletic activity.
If screw fixation with satisfactory union is achieved, patients may begin athletics within a few weeks while remaining in cast with appropriate paddling
After the cast has been removed, early ROM and strengthening with physical therapy are essential to restore function.
The wrist should remain in rigid bracing with activity until:
Radiographic evidence of union
Strength and ROM are similar to the uninjured extremity
Pain subsides
Complications
Given the tenuous blood supply, scaphoid fractures have a high rate of nonunion and avascular necrosis (AVN).
Nonunion rates vary according to injury pattern and treatment:
Displaced fractures, 50% rate of nonunion
Nondisplaced and immobilized, 15% nonunion rate15
Proximal > waist > distal > tubercle
Delayed union and nonunion are directly related to premature discontinuation of immobilization.
There is a high incidence of chronic pain and radiocarpal arthritis.
Pediatric Considerations
Low likelihood of carpal injury until adolescence
High incidence in teenage athletes
Pearls and Pitfalls
90% of scaphoid injuries occur in isolation.
If there is suggestion of injury on examination, treat as such despite normal x-rays.
Up to 30% of initial x-rays read as normal
Place in thumb spica and arrange for follow-up within one week
Hesitate to diagnose “wrist sprain,” truly a diagnosis of exclusion.
Any injury to the proximal scaphoid warrants consultation, as some surgeons will elect for operative stabilization vs. conservative therapy.
Triquetrum Fractures
General Description
Second most common carpal fracture
Two general types:
Dorsal chip – most common
Triquetral body
Excellent vascular supply, thus low risk for AVN and nonunion
Mechanism
Dorsal chip – typical mechanism with FOOSH, in ulnar deviation
Hamate forces triquetrum against radius or ulnar styloid
Body – direct impact on dorsal hand, usually high mechanism
Association with perilunate dislocations
Presentation
Variable presentation
Possible pain, swelling, and ecchymosis on dorsum of the hand
Physical Examination
Tenderness and edema to the dorsum of the hand, just distal to the ulnar styloid
Limited ROM with both flexion and extension
Essential Diagnostics
Dorsal chip – best seen on lateral radiograph
Body – standard PA or oblique views
Figure 3.19. Dorsal chip fracture of the triquetrum.
ED Treatment and Disposition
Treat with volar splint in the ED, followed by short arm cast.
Four to six weeks usually results in complete healing.
Return to Play
Athletes can return to sports while casted provided that there is adequate padding.
After cast removal, athletes should remain in a semi-rigid brace until there is no further tenderness.
Complications
Rarely ulnar nerve injury
Limited AVN due to good vascular supply
Pediatric Considerations
None
Pearls and Pitfalls
In patients with perilunate fracture/dislocation, make sure to search for triquetral body fractures.
Lunate Fractures
General Description
Account for 1.4–6% of carpal fractures16, 17
Lunate lies between the radius and the distal capitate
Two general fracture patterns:
Dorsal avulsion
Lunate body
Like the scaphoid, vascular supply runs distal to proximal and predisposes the lunate to AVN
Posttraumatic AVN, referred to as Keinbock’s disease, results from approximately 20% of lunate fractures
Mechanism
Dorsal avulsion fractures usually result from forced hyperextension, FOOSH
Lunate body fractures typically occur from axial loading
Presentation
Pain and swelling on the dorsum of the hand
Physical Examination
Tenderness on the dorsum of the hand, just distal to Lister’s tubercle
Exacerbated by axial load on the third metacarpal
Essential Diagnostics
Standard PA, oblique, and lateral radiographs frequently miss nondisplaced lunate fractures.
Cone-down views may enhance sensitivity, but still frequently miss fractures.
CT and MRI both offer excellent sensitivity, and may be obtained in follow-up for those with high suspicion.
ED Treatment and Disposition
Immobilize in thumb spica splint.
Refer to hand surgeon for casting for roughly six to eight weeks.
Fractures with displacement of more than 1 mm, angulation, or instability warrant urgent orthopedic referral for operative intervention.
Return to Play
Aggressive rehabilitation with ROM and strengthening should be pursued after cast removal.
Rigid bracing should be employed until strength and ROM are similar to the uninjured side, typically at least three months.
Complications
Much like the scaphoid, lunate fractures are prone to AVN and nonunion due to poor vascular supply, especially with proximal injury.
Pediatric Considerations
Lunate fractures generally fair better in adolescents when compared to adults.
Pearls and Pitfalls
Even if x-rays are negative, if clinical suspicion is high for injury, splint the patient and refer to hand surgeon for follow-up and x-rays in seven to ten days.
Isolated lunate fractures are uncommon, necessitating a search for associated distal radius, carpal, or metacarpal injuries.
Capitate Fractures
General Description
Largest of the carpal bones
Centrally located in the distal carpal row
Articulations with proximal scaphoid and lunate, adjacent trapezoid and hamate, and the three middle metacarpals
Given location, rarely fractured
Isolated fractures occur in less than 0.3% of all carpal injuries18
Frequently associated with scaphoid fracture and perilunate dislocation
Fractures are usually transverse in nature
Mechanism
Two general mechanisms:
FOOSH, forced hyperextension
Direct blow to dorsum of the hand
Presentation
Pain and swelling to the dorsum of the hand
Physical Examination
Direct palpation on the dorsum of the hand, over the capitate, reproduces the greatest pain.
Pain with axial loading of the third metacarpal
Swelling and ecchymosis to the dorsum of the hand
Rarely may have associated median neuropathy.
Essential Diagnostics
Standard PA, lateral, and oblique views usually identify fracture
If x-ray is negative and high clinical suspicion, CT is very sensitive.
ED Treatment and Disposition
Nondisplaced fractures
Immobilization in thumb spica splint
Follow-up thumb spica or short arm casting for six to eight weeks
Displaced or associated carpal instability
Splint and urgent hand surgeon referral for operative intervention
Return to Play
Nonsurgical fractures may return to play once casted.
Surgical fractures may not return to play while still in cast for approximately four to six weeks.
Selective return to play with protective splinting for next three months.
May return to play without protective splinting once full range of motion, strength, and function have been restored.
Complications
Like scaphoid fractures, associated with AVN and nonunion, especially if proximal fracture
High incidence of perilunate ligamentous injury and dislocation
Median neuropathy or acute carpal tunnel syndrome
Pediatric Considerations
Rare
Pearls and Pitfalls
Capitate fractures rarely occur in isolation. If found, it is imperative to search for associated pathology.
Distal radius and scaphoid fracture
Perilunate instability
Err on the side of caution and splint if there is clinical concern for fracture.
Hamate Fractures
General Description
Most ulnar of the distal carpal bones
Fractures are uncommon, accounting for 1–4% of carpal fractures
Three general types:
Hook (or hamulus) – most common
Body or proximal articular surface
Distal articular surface
Mechanism
Presentation
Pain and swelling to the hypothenar eminence
Paresthesias in the ulnar distribution
Physical Examination
Tenderness over the hamate, approximately 1 cm distal and radial to the pisiform
Proximal injuries exhibit pain with wrist ROM
Distal injuries with pain on axial load of the fifth metacarpal
Assess for ulnar neuropathy
Essential Diagnostics
PA, oblique, and lateral views will likely pick up significant body fractures (Figure 3.20), but frequently miss factures of the hook.
Carpal tunnel views (Figure 3.21) and reverse oblique radiographs are best for hook fractures.
If mechanism and exam are consistent with injury, CT can be obtained and is reportedly 100% sensitive.19
Figure 3.20. Hamate fracture on oblique radiograph.
Figure 3.21. Hook of hamate on carpal tunnel view P = Pisiform, H = Hamate.
ED Treatment and Disposition
Immobilize in ulnar gutter splint
Nondisplaced fractures managed with routine follow-up in seven to ten days for casting for total of six to eight weeks.
Displaced fractures or ulnar neuropathy: urgent follow-up and likely operative intervention
Return to Play
Nondisplaced body fractures may return to sport immediately with semi-rigid synthetic cast.
After operative repair, may return to sport approximately four to six weeks after function is restored.
Complications
Ulnar neuropathy and nonunion is common with Hook fractures.
Usually require operative excision of the hook
Ulnar artery injury can also occur, as it courses alongside the nerve
Fifth MCP arthritis
Pediatric Considerations
Rare in children.
Pisiform Fractures
General Description
Unique as the only carpal sesamoid bone
Only articulation is with the triquetrum.
Flexor carpi ulnaris attaches to the volar aspect of the pisiform.
Forms part of Guyon’s canal (with hamulus) through which both ulnar artery and nerve pass
Fractures are rare, generally carry a good prognosis
Avulsion
Transverse body
Comminuted
Mechanism
Two general injury patterns
FOOSH or forced hyperextension
Direct blow to hypothenar eminence
Avulsion fractures result from hyperextension/traction on flexor carpi ulnaris
Presentation
Pain and swelling to the hypothenar region
Ulnar paresthesias
Complaint of hand weakness
Physical Examination
Pain and swelling over the pisiform, exacerbated by wrist flexion and ulnar deviation.
Assess for possible ulnar neuropathy
Essential Diagnostics
Standard PA radiograph will sometimes demonstrate fracture.
Reverse oblique and carpal tunnel views are far more sensitive.16
ED Treatment and Disposition
Immobilization in volar splint
Routine follow-up in one week with casting for total of four to six weeks
Cases of ulnar neuropathy require urgent consultation
Nonunion could necessitate operative excision
Return to Play
May return to sport once casted as long as pain free
Complications
Ulnar neuropathy as detailed earlier
Flexor carpi ulnaris injury
Nonunion, although rare
Pediatric Considerations
As with other carpal injuries, pisiform fracture is rare in young children
Pearls and Pitfalls
Ensure complete assessment and documentation of ulnar nerve function and distal perfusion with any pisiform or hamate injury.
If you suspect injury, obtain carpal tunnel or reverse oblique films.
Trapezium Fractures
General Description
Most radial bone of the distal carpal row
Articulates with the scaphoid, trapezoid, and first metacarpal
Fractures are rare, accounting for 1–4% of carpal fractures.
Two general fracture types:
Trapezial ridge – serves as attachment for transverse carpal ligament
Trapezial body – vertical or comminuted fractures
Mechanism
Presentation
Pain and swelling at the thenar eminence, worse with thumb movement.
Physical Examination
Limited ROM in thumb due to pain
Pain with axial load on first metacarpal
Tenderness in distal snuff box
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