Most common carpal fracture.

Accounts for more than 70% of carpal fractures.

Scaphoid bridges proximal and distal carpal rows and serves key stabilizing role in wrist.

Unique blood supply feeding from distal end results in slower healing in mid- and proximal fractures.

Three main types: distal or tuberosity, waist, proximal pole.

Pain in anatomic snuffbox after appropriate mechanism.

Pain with extension of wrist and firm grip.

Swelling and occasionally bruising is seen.

Marked tenderness to palpation in anatomic snuffbox.

Pain with extremes of extension, flexion, and ulnar deviation.

de Quervain’s tenosynovitis (see 8.6); carpal or carpal-metacarpal DJD; instabilities (see 8.10).

Initial x-ray often negative. Repeat image in 2 w may demonstrate fracture.

Three-phase bone scan will demonstrate occult fracture 72 hr after injury.

MRI can demonstrate fracture earlier.

Protection, bracing or splinting

Rest, relative rest from offending activities

Ice, for pain management and to reduce swelling

Compression, to reduce swelling

Elevation, to control swelling

Medications, NSAIDs and/or narcotics

Modalities, through physical therapy for pain management and to control swelling.

Most commonly fractured at the hook, which may lead to ulnar nerve injury.

Fracture of the body can occur in conjunction with dorsal metacarpal dislocation.

Pain, swelling, and bruising at hypothenar eminence.

May have numbness along 5th digit (deep branch of ulnar nerve).

Radiographs usually diagnostic. Carpal tunnel view for hook fractures, oblique wrist films for body.

CT or tomograms may be useful if not visualized on plain radiographs.

Hook fractures often require surgical extraction of hook.

Nondisplaced body fractures treated with short arm cast for 4-6 w. Displaced fractures require wire fixation.

Usually can play with appropriate cast as symptoms allow.

Bracing and physical therapy following casting.

Tender at dorsal hand over triquetrum.

Pain with active extension or passive flexion.

Symptoms typically resolve with short arm casting.

Nonunion of chip fracture is relatively common but seldom symptomatic.

Short arm cast for 3-4 w usually adequate.

Persistent symptoms may require excision of fragment.

Usually can play with appropriate cast as symptoms allow.

Bracing and physical therapy following casting.

Associated with repetitive compressive forces (gymnastics, cheerleading).

Typically in younger athletes.

Micro stress fractures with subsequent loss of blood supply leads to AVN.

Associated with ulnar minus wrist, which increases compressive forces on lunate.

Stahl classifications:

Stage 1: acute (normal x-ray, MRI positive)

Stage 2: sclerotic changes

Stage 3: lunate collapse

Stage 4: pancarpal arthrosis/instability

Initially present with vague aching pain, which increases in severity.

Complain of stiffness.

Usually no history of substantial trauma.

Tenderness at lunate.

Nonspecific painful range of motion.

Initial films are normal or may show nonspecific sclerosis or degenerative cysts. Eventually show progressing sclerosis and collapse of the lunate.

MRI is study of choice for early diagnosis.

Should be immobilized and referred to a hand specialist for evaluation.

Falling on an outstretched hand most common.

Also direct trauma or forced wrist extension.

Account for >15% of fractures seen in the emergency room.

Common in snowboarders, skating, roller sports, and collision sports.

Extra-articular fractures from relatively low energy trauma generally results in fracture to metaphysis (Colle’s fracture).

Intra-articular fractures are more common in athletes and arise from high-energy axial load. Results in 4-part comminution in predictable pattern involving:

The majority of these comminuted intra-articular fractures are unstable and will require specialty consultation.

Pain, swelling, bruising, deformity at radial wrist.

Numbness, tingling, or dysesthesias may occur.

Tenderness about the distal radius, swelling, bruising, deformity at radial wrist.

Neurologic and vascular exam may demonstrate compromise.

Stable fractures heal in 4-6 w with cast immobilization.

Unstable fractures usually require surgical fixation.

Assess degree of angulation and displacement of metaphyseal fractures.

AP, lat, oblique generally sufficient to demonstrate intra-articular fractures.

Tomograms are useful to evaluate die-punch lesions of articular radius.

Stable metaphyseal fractures without angulation can be managed with cast immobilization for 6 w. Some prefer a long arm for initial 2-3 w. Serial radiographs should be obtained weekly for the first 3 w to ensure no change in alignment.

Angulated metaphyseal fractures tend to be unstable after reduction. These can be treated with a well-molded long arm cast for 4 w followed by short arm for an additional 2 w. These fractures must be followed closely for loss of reduction. Surgical fixation is usual preferred method of treatment.

Intra-articular fractures are usually unstable and should be seen by an orthopedic surgeon for treatment.

Usually can play with appropriate cast as symptoms allow.

Bracing and physical therapy following casting.

Tenosynovitis of the extensor pollicis brevis or abductor pollicis longus.

Both tendons occupy the 1st dorsal wrist compartment and are generally both involved.

Pain and swelling along the radial wrist.

Pain with gripping and rotational motions (removing the lid from a jar).

Tenderness along extensor thumb, radial wrist, and forearm.

Pain with resisted thumb abduction or extension.

Finklestein’s test: Thumb is passively flexed beneath the flexed fingers and wrist is passively flexed to the ulnar side. A positive test produces pain in the 1st dorsal wrist compartment (Figure 8.1).