Hand and Wrist

Jeffrey J. Peterson

Thomas H. Berquist

▪ FRACTURES/DISLOCATIONS: DISTAL RADIUS/ULNAR FRACTURES—COLLES FRACTURE

KEY FACTS

Fractures of the distal radius are common. In elderly patients, osteopenia results in fracture from minor trauma. In children, incomplete or physeal fractures are common. Fractures of the ulna or ulnar styloid commonly occur with distal radial fractures.
Distal radial fractures have multiple eponyms, such as Colles, Smith, Barton, and Chauffeur’s fractures. Today, most are categorized by the extent of articular involvement. Type A fractures are extra-articular, Type B fractures are partial articular, and Type C fractures involve both the radiocarpal joints and distal radioulnar joint (DRUJ).
Colles fracture is a term applied to fractures to distal radial, with or without articular involvement, and dorsal displacement of the distal fragment.
Mechanism of injury: fall on the outstretched hand.
Anteroposterior (AP) and lateral radiographs are diagnostic. However, computed tomography (CT) is often performed to completely evaluate articular involvement.
Treatment: traction to reduce and reachieve radial length and palmar tilt. Closed reduction is usually successful.
Complications: occur in up to 33% of patients and include
- Compressive neuropathy
- Arthrosis
- Malunion
- Tendon rupture
- Ligament injuries
- Ischemic contractures

FIGURE 8-1. Lateral radiograph of the wrist demonstrates incomplete fractures of the ulna (arrowhead) and a torus (buckle) fracture of the radius (curved arrow).

FIGURE 8-2. Posteroanterior (PA) (A) and lateral (B) radiographs of the wrist show a typical Colles fracture with dorsal impaction of the radius and an ulnar styloid fracture. The fracture extends into the distal radioulnar joint (DRUJ) (Type B).

FIGURE 8-3. Coronal (A) and sagittal (B) computed tomography (CT) images clearly demonstrate the fracture fragments and the extent of articular separation.

FIGURE 8-4. Posteroanterior (PA) radiograph of an old Colles fracture with shortening of the radius and decreased radial inclination (lines). There is degenerative arthritis and an associated fifth metacarpal fracture (arrow).

SUGGESTED READING

Cooney WP, Dobyns JH, Linscheid RL. Complications of Colles’ fractures. J Bone Joint Surg. 1980;62A:613-619.

Orthopedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma. 1996;10:26-30.

▪ FRACTURES/DISLOCATIONS: DISTAL RADIUS/ULNAR FRACTURES—SMITH FRACTURE

KEY FACTS

Smith fracture is a “reverse Colles fracture” with palmar displacement of the distal radial fragment.
Mechanism of injury: fall on a palmar flexed wrist.
Treatment: closed reduction; restore radial length. Internal fixation may be required with significant displacement or articular involvement.
Complications: identical to Colles fracture complications.

FIGURE 8-5. Anteroposterior (AP) (A) and lateral (B) radiographs of a Smith fracture with palmar displacement of the distal radius.

SUGGESTED READING

Thomas FB. Reduction of Smith’s fracture. J Bone Joint Surg. 1957;37B:463-470.

▪ FRACTURES/DISLOCATIONS: DISTAL RADIUS/ULNAR FRACTURES—BARTON FRACTURE

KEY FACTS

A Barton fracture is an intra-articular fracture of the radius involving the dorsal or volar lip of the radial styloid.
Radial styloid fractures are divided into three zones. Zone I fractures may be stable without associated ligament injuries. Zone II fractures commonly have associated ligament injury. Zone III fractures are likely to have ligament injury and joint incongruency (Fig. 8-6).
Mechanism of injury: Palmar fractures occur similar to Smith fractures. Dorsal fractures result from a fall on the outstretched hand with the forearm pronated.
Treatment: closed reduction unless the articular surface cannot be restored. In the latter setting, internal fixation may be required.
Complications: similar to Colles fracture, except subluxation and arthrosis are more common.

FIGURE 8-6. Zones of radial styloid (Barton fracture). Zone I: styloid tip, may be stable with no ligament injury. Zone II: possible ligament injury, may have articular deformity. Zone III: likely to have ligament injury and joint deformity.

FIGURE 8-7. Volar Barton fracture. Anteroposterior (AP) (A) and lateral (B) radiographs of an intra-articular fracture of the lateral aspect of the radius.

SUGGESTED READING

DeOliveira JC. Barton’s fracture. J Bone Joint Surg. 1973;55A:586-594.

Putnam MD. Radial styloid fractures. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore: Williams and Wilkins; 1996:322-329.

▪ FRACTURES/DISLOCATIONS: DISTAL RADIUS/ULNAR FRACTURES—CHAUFFEUR’S FRACTURE

KEY FACTS

A Chauffeur’s fracture is an intra-articular fracture of the distal radius that predominately involves the radial styloid.
The fracture line typically enters the joint at the junction of the scaphoid and lunate fossae.
Mechanism of injury: axial compression transmitted through the scaphoid. Decades ago, the injury was associated with backfires resulting in the automobile starting crank striking the wrist.
AP and lateral radiographs are adequate for diagnosis.
Treatment: cast immobilization if minimally displaced. Percutaneous K-wires may be required to maintain reduction.

FIGURE 8-8. Posteroanterior (PA) radiograph of a Chauffeur’s fracture during reduction with an external fixation.

SUGGESTED READING

Wood MB, Berquist TH. The hand and wrist. In: Berquist TH, ed. Imaging of Orthopedic Trauma, 2nd ed. New York: Raven Press; 1992:749-870.

▪ FRACTURES/DISLOCATIONS: GALEAZZI FRACTURES

KEY FACTS

The Galeazzi fracture is a fracture of the distal radius, usually diaphysis, with associated subluxation or dislocation of the DRUJ.
Mechanism of injury: fall on the outstretched hand with hyperpronation of the forearm.
Treatment: reduction and internal fixation.
Routine radiographs are diagnostic.
Complications: malunion of the fracture and residual subluxation of the DRUJ.

FIGURE 8-9. Posteroanterior (PA) (A) and lateral (B) radiographs show a distal radial fracture with dislocation of the distal radioulnar joint (DRUJ).

FIGURE 8-10. Posteroanterior (PA) radiograph in a patient with a prior Galeazzi fracture after plate and screw fixation of the radial fracture and K-wire fixation of the joint.

SUGGESTED READING

Wood MB, Berquist TH. The hand and wrist. In: Berquist TH, ed. Imaging of Orthopedic Trauma. 2nd ed. New York: Raven Press; 1992:749-870.

▪ FRACTURES/DISLOCATIONS: DISTAL RADIOULNAR JOINT SUBLUXATION/DISLOCATIONS

KEY FACTS

Subluxation or dislocation of the DRUJ may be dorsal (most common) or volar.
Mechanism of injury:
- Dorsal—hyperpronation injury
- Volar—hypersupination injury to the forearm
Routine radiographic findings may be subtle. Axial CT or magnetic resonance imaging (MRI) with the wrist in pronation, neutral, and supinated positions is most useful to confirm the diagnosis.
Treatment: Closed reduction and cast immobilization may be successful. Open repair may be best for long-term results and optimal stability.

FIGURE 8-11. Lateral radiograph shows distal radioulnar joint subluxation with dorsal subluxation of the distal ulna in relation to the distal radius.

SUGGESTED READING

Hamlin C. Traumatic disruption of the distal radioulnar joint. Am J Sports Med. 1977;5:93-96.

Nakamura R, Horie E, Imaeda T, et al. Criteria for diagnosing distal radioulnar joint subluxation by computed tomography. Skeletal Radiol. 1996;25:649-653.

▪ FRACTURES/DISLOCATIONS: SCAPHOID FRACTURES

KEY FACTS

The scaphoid is the most commonly fractured carpal bone in adults, accounting for 70% of all carpal injuries. Scaphoid fractures in children account for only 2.9% of hand and wrist fractures.
Mechanism of injury: fall on the outstretched hand.
Scaphoid fractures may be difficult to detect and treat. Nonunion and avascular necrosis (AVN) are common complications.
Scaphoid fractures are classified by fracture location and orientation of the fracture line. Fractures may involve the (1) tubercle, (2) distal articular surface, (3) fracture of the distal third, (4) waist fracture, or (5) proximal pole fracture (Fig. 8-12).
Imaging of scaphoid fractures requires AP, lateral, and scaphoid views. Displacement or obliteration of the navicular fat stripe is a useful sign for subtle fractures. Radionuclide scans, MRI, or CT may be useful for detecting subtle fractures and evaluating complications.
Treatment: cast immobilization for undisplaced fractures. Displaced fractures (>1 mm step-off or angulation) are treated with internal fixation.
Complications: delayed union (failure to unite in 3 months), nonunion, malunion, AVN (most common with proximal pole fractures), radioscaphoid impingement, and arthrosis.

FIGURE 8-12. (A) Locations of scaphoid fractures: 1, tubercle; 2, distal articular surface; 3, distal third; 4, waist; 5, proximal pole. (B) Oblique fracture. Shearing forces (arrows) lead to instability and displacement. (C) Transverse waist fracture is more stable.

FIGURE 8-13. (A) Subtle scaphoid fracture with absent navicular fat stripe (arrow). (B) Displaced scaphoid waist fracture.

FIGURE 8-14. Humpback deformity. (A) Sagittal proton density-weighted magnetic resonance (MR) image demonstrates fluid (open arrow) in the fracture line and deformity (white lines) caused by dorsal separation of the fracture’s fragments. (B) Sagittal reformatted computed tomography (CT) image demonstrates a similar humpback deformity (lines) with sclerosis of the proximal fragment caused by avascular necrosis (AVN).

FIGURE 8-15. Coronal T1-weighted magnetic resonance (MR) image shows nondisplaced scaphoid fracture, which was radiographically occult.

FIGURE 8-16. Posteroanterior (PA) view of a displaced scaphoid fracture with Herbert screw fixation. The proximal pole is sclerotic because of avascular necrosis (AVN).

SUGGESTED READING

Cooney WP III. Isolated carpal fractures. In: Cooney WP III, Linscheid RL, Dobyns JH, eds. The Wrist: Diagnosis and Operative Treatment. St. Louis: Mosby; 1998:474-487.

Fisk GR. An overview of injuries of the wrist. Clin Orthop. 1980;149:137-144.

▪ FRACTURES/DISLOCATIONS: OTHER CARPAL FRACTURES

KEY FACTS

Other carpal fractures occur less frequently than scaphoid fractures.
The triquetrum is the second most common carpal bone fractured followed by the capitate and lunate.
Mechanism of injury: fall on the outstretched hand; compressive or shearing forces.
Treatment: closed reduction and cast immobilization.
Imaging usually can be accomplished with radiographs. The lateral view is most useful for triquetral avulsion fractures. Subtle injuries may require CT or MRI.
Complications: nonunion, arthrosis, and carpal tunnel syndrome.

FIGURE 8-17. Lateral radiograph shows a triquetral fracture (arrow) seen only on the lateral radiograph.

FIGURE 8-18. Coronal T1-weighted (A) and T2-weighted (B) images of a capitate fracture (arrow) with surrounding edema. Radiographs were normal.

FIGURE 8-19. Sagittal T2-weighted fast spin-echo image with fat suppression demonstrates an undisplaced lunate fracture (arrow).

SUGGESTED READING

Berquist TH. Imaging of Orthopedic Trauma, 2nd ed. New York: Raven Press; 1992:749-870.

▪ FRACTURES/DISLOCATIONS: CARPAL AND CARPOMETACARPAL DISLOCATIONS

KEY FACTS

Dislocations of the carpus are most often associated with perilunate injury.
The transscaphoid perilunate dislocation is most common. The proximal scaphoid maintains its lunate relationship, and the distal scaphoid and remainder of the carpal bones displace dorsally.
Carpometacarpal dislocations are most often associated with distal carpal or metacarpal base fractures.
Mechanism of injury: fall on the outstretched hand.
Imaging may be accomplished with posteroanterior (PA) and lateral radiographs. CT is best for subtle cases, evaluation of osteochondral fractures, treatment planning, and postreduction evaluation.
Treatment: closed reduction if alignment can be restored; otherwise internal fixation.
Complications: arthrosis, AVN, and instability.

FIGURE 8-20. Transscaphoid perilunate dislocation seen on posteroanterior (PA) (A) and lateral (B) radiographs. The PA view shows a fracture of the scaphoid with the lunate and proximal scaphoid in nearly normal position (A). The lateral view shows preservation of radiolunate alignment (line) but dorsal dislocation of the capitate and second carpal row (C). The distal scaphoid fracture fragment (S) remains attached to the capitate and is also displaced dorsally (B).