Wrist and Hand Fractures
D. Nicole Deal
A. Bobby Chhabra
EPIDEMIOLOGY
Wrist and hand injuries account for 25% of athletic injuries (3).
Gymnasts have the highest level of wrist and hand injuries, with up to 43% suffering chronic injuries. In one series, 88% of elite male gymnasts complained of wrist pain and 58% required nonsteroidal anti-inflammatory drug (NSAID) therapy to continue competing (47).
DISTAL RADIUS FRACTURES
Distal radius fractures account for 10% of all bony injuries, up to 75% of all fractures to the forearm, and 16% of all fractures treated in the emergency room (2,41,55).
Injury often occurs during running or contact sports when the hand is planted on the ground, the wrist hyperextends, and the arm rotates. In addition to a fracture of the distal radius, injury to the triangular fibrocartilage complex (TFCC) and distal radioulnar joint (DRUJ) can result.
On physical examination, examine for deformity (classic silver fork as described by Colles) (19), swelling, pain, and limited range of motion (ROM). Check the DRUJ for tenderness, dislocation, or subluxation, and examine for any loss of pronation or supination.
Carpal tunnel symptoms may be present in up to 15% of patients, but controversy exists concerning acute versus delayed (48-72 hours) release (25,30).
Clinical symptoms of DRUJ disruption, including pain and instability, have been found in 5%-15% of fractures (46).
The TFCC is the major stabilizer of the DRUJ. Disruption of the TFCC and other carpal ligaments, including the scapholunate ligament, has been identified at time of arthroscopy in 45%-70% of cases (29,51). Most TFCC tears are in the central or radial portion of the complex and are treated with debridement (65).
Anatomic reduction of intra-articular distal radius fractures is required. Two millimeters of articular step-off increases the risk for subsequent degenerative arthritis (43).
Radiographic Evaluation
True posteroanterior (PA) and lateral views required. Oblique and fossa lateral views, traction views, and magnetic resonance imaging (MRI), computed tomography (CT) scan, bone scan, and fluoroscopy may provide critical information regarding the nature of the fracture and associated injuries when planning for fracture management (7,14,24).
Management of Distal Radius Fractures
Most stable fractures can be treated with closed reduction and casting, whereas unstable fractures, suggested by (a) excessive fracture comminution, (b) fracture displacement, (c) radial articular surface angulation greater than 20 degrees, (d) articular surface separation or step-off greater than 2 mm, and (e) comminution of both volar and dorsal cortices, often require surgical intervention.
Extra-articular fractures: Stable fracture treatment generally consists of closed reduction and placement of a well-fitted long-arm cast with a good 3-point mold and the forearm in neutral or supination to help stabilize the DRUJ and improve recovery of supination following fracture healing (52,69). Casting should be performed after acute swelling subsides. Close radiographic follow-up is required every 1-2 weeks to assure that loss of reduction and shortening does not occur. Unstable extra-articular fractures may require percutaneous pin fixation in conjunction with cast or external fixation for support.
Noncomminuted intra-articular fractures: Barton fractures are the result of shear forces across either the volar or dorsal lip of the distal radius, resulting in two large fragments that extend into the joint (5). Closed reduction is usually obtained by reversal of the deformity, but maintenance of reduction usually requires surgical stabilization (42).
Comminuted or complex intra-articular fractures: Highly comminuted articular fractures with dorsal comminution and subchondral bone defects frequently collapse and shorten thus requiring close radiographic observation and remanipulation if nonoperative management is chosen. Fractures with articular displacement > 2 mm often require external or internal fixation. Accuracy of reduction may be assessed with either open or arthroscopic visualization of the articular surface to ensure anatomic restoration of the
surface. Bone grafting may be required to fill bony defects especially in the subchondral region (6,29,74).
Complications
Nonunion following distal radius fracture is a rare occurrence, whereas malunion — most commonly shortening and loss of volar tilt — is a common complication (20,35). Correction of malunion should be undertaken when there is persistent pain and loss of the functional wrist arc of motion, most commonly loss of flexion and supination.
Return to Sports
Stable fractures treated with splint or cast immobilization should be maintained in a reduced position until fracture healing is evident (4-8 weeks). The athlete may then begin to rehabilitate the wrist using a removable thermoplastic splint for the next 4-6 weeks until full pain-free ROM and strength have been achieved. Return to sports without protection is usually not allowed until 3 months from the time of injury. Fractures treated with rigid internal fixation can be protected by a thermoplastic splint with early ROM exercises. Once radiographic evidence of healing is present, progressive strengthening exercises may be begun, but full return to sport is not permitted before 3 months. Unstable intraarticular fractures are often immobilized for 6-12 weeks, and full return to sports is discouraged until motion and strength have been restored (18,53).
SCAPHOID FRACTURES
Scaphoid fractures are the most common carpal bone fracture (1 in 100 college football players per year) and often the result of apparently minor trauma (75).
Fracture mechanism is forced hyperextension with ulnar deviation.
Extraosseous vascular supply enters the scaphoid at the middle and distal poles while the proximal pole relies on retrograde flow. This results in a high rate of avascular necrosis and nonunion with proximal pole fractures.
Patient presents with pain in the anatomic snuff box.
Radiographs include PA, lateral, navicular, and closed fist views.
Bone scan and MRI are useful in identifying nondisplaced fractures.
Treatment: Nondisplaced fractures (< 1 mm of displacement) may be treated nonoperatively with immobilization versus open reduction and internal fixation (ORIF) (23,73).
Options for immobilization include a long-arm thumb spica cast with the wrist in slight palmar flexion and radial deviation for 6 weeks followed by short-arm thumb spica cast until healing is evident on radiographs, usually within 3 months (31), versus short-arm thumb spica versus short-arm casting (73).
If there is no evidence of healing by 3-4 months, then consider the use of bone grafting or electrical stimulation to enhance healing.
Early operative intervention for nondisplaced fractures with percutaneous compression screw fixation is controversial but may allow the athlete to return earlier to sports and provide a lower risk of fracture displacement and rehabilitation time (28,44,66).
Athletes with snuffbox pain and negative radiographs should be immobilized in thumb spica cast and reassessed at 1- to 2-week intervals until the pain resolves or the diagnosis is made radiographically with x-rays or MRI (28).
Treatment: Displaced fractures most often requires ORIF to restore anatomic alignment and facilitate accurate reduction with compression screws.
Compression screw fixation techniques have improved and permit minimal immobilization of 2-3 weeks followed by early restorative therapy and return to activities (37); however, with athletes susceptible to reinjury, a 3- to 4-month period of healing and rehabilitation may allow a safer return to sports (64).
Return to Sports
Athletes may participate in sport with immobilization; plastic, synthetic, and silastic casts have been used effectively in contact sports (62).
Splint protection is continued for strenuous activities for an additional 2-3 months following radiographic healing until strength and motion approach those of the contralateral side (49).
HAMATE FRACTURES
Hook or body of the hamate fractures is present in 2%-4% of carpal bone fractures (63).
Hook of the Hamate Fractures
Injury commonly occurs from direct force of bat, club, or racket.
Diagnosis is often missed; chronic fractures are associated with flexor tendon rupture and ulnar nerve neuropathy.
Pain is localized over the hamate in the hypothenar eminence.
Carpal tunnel view and CT scans aid in diagnosis.
Body of the Hamate Fractures
Less common than hook fractures; often associated with dislocation of fourth and fifth metacarpals (48).
Oblique radiographs of the carpus and CT scans can assist in defining the fracture.
Nondisplaced fractures are treated with cast immobilization for 4-6 weeks.
Displaced fractures are treated with open reduction, Kirschner wire or screw fixation, and immobilization for 4-6 weeks.
Return to Sports
Athletes with fractures treated by conservative measures may return to sport immediately with protection until pain free (49).
Athletes treated with excision of the hamate hook may return to sport as tolerated; they will often have hypothenar tenderness for several months and will require the use of well-padded gloves for return to sport (28).
Athletes with surgically treated fractures are restricted from sport until after healing is evident (4-6 weeks). Participation may resume with splint or cast protection until normal strength and ROM return (49).
CAPITATE FRACTURES
The capitate is centered within the carpus, is well protected from injury, and accounts for only 1%-2% of all carpal fractures (28).
Fractures often occur from either a direct blow to the dorsum of the wrist or from forced dorsiflexion or volar flexion. Capitate fractures are often associated with scaphoid fractures and perilunate dislocations (61).
Radiographic assessment is performed with PA and lateral views, CT scan, or MRI.
Nondisplaced fractures are treated with immobilization in short-arm cast for 6-8 weeks.
Capitate fractures are associated with poor outcomes because the fractures are inherently unstable, and delayed union, nonunion, and avascular necrosis are common complications (61).
Displaced fractures (2 mm of displacement) are treated with ORIF with Kirschner wires or screw fixation and immobilized in a short-arm cast for 6 weeks.
Return to Sports
Athletes with nonoperative fractures may return to sport immediately with protective casting (49). Close follow-up must be maintained to assure that fracture displacement does not occur, obligating operative intervention.
Athletes with surgically treated fractures are restricted from sport until after healing is evident (4-6 weeks). Participation may resume with splint or cast protection for an additional 3 months or until normal strength and ROM return (49).
PISIFORM FRACTURES
Pisiform fractures are rare and usually occur from direct blow to the palm and account for 1%-3% of all carpal bone fractures (28).
Patients tend to have tenderness over the hypothenar region.
Fractures are best visualized on 30-degree oblique anteroposterior (AP) view or carpal tunnel view.
Acute nondisplaced fractures are managed by immobilization in a short-arm cast for 3-6 weeks.
Comminuted fractures and symptomatic nonunions are managed by excision, with care to preserve the flexor carpi ulnaris tendon, with little or no functional impairment (4).
TRIQUETRUM FRACTURES
Triquetrum fractures are common carpal bone fractures in sports accounting for 3%-4% of all carpal bone injuries (15).
Fractures commonly consist of avulsion of the dorsal cortex following hyperextension injury causing impingement with the distal ulna.
Treatment of this dorsal marginal fracture consists of immobilization in short-arm cast for 3-4 weeks (28,64).
Isolated fractures through the body of the triquetrum are rare injuries and are often associated with scapholunate ligamentous disruption, which must be clinically assessed (28Related posts:
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