In the Young and Elderly

2.3 ANCC CONTACT HOURS Wrist in the young and elderly

By Colleen R. Walsh, DNP, MSN, RN, ONP-C, ACNP-BC

Mrs. C, a 72-year-old White female, was outside bandage wrap and transported to her local commu- walking her dog on a leash when it suddenly lunged nity hospital. toward a squirrel in an attempt to chase it. Mrs. C The physical exam in the ED revealed a thin, anx- was pulled forward, tripped on the uneven sidewalk, ious, frail, elderly woman with a “dinner fork” defor- and began to fall, her right side leaning forward. She mity of the right wrist. Her range of motion (ROM) Minstinctively stretched her right arm forward to break of the wrist and fingers was difficult to determine her fall and landed on the heel of her hand. She due to pain. Her hand was warm and pink, and the immediately felt severe pain in her right wrist and right radial pulse amplitude equaled the left radial was unable to get up. A neighbor witnessed the pulse. Mrs. C complained of numbness in her palm fall and ran to assist her. The neighbor noticed that and middle finger. Mrs. C’s wrist looked grossly deformed and called Anteroposterior (AP) radiographs revealed a distal 911. The emergency medical services (EMS) ambu- radius fracture (see AP wrist fracture) and the lateral lance arrived several minutes later. Mrs. C was (L) radiographs revealed dorsal displacement of the alert and oriented to person, time, and place, and distal fragment (see Lateral view right wrist). After the her vital signs were: pulse 112 and regular, respira- orthopedic surgeon evaluated her, Mrs. C was diag- tions 22, and BP 156/90. She complained of severe nosed with a right Colles fracture (see Colles fracture pain and a “pins and needles” sensation in her wrist. of the wrist and hand). Because her past medical history The emergency medical technicians noted that she included hypertension, type 2 diabetes mellitus, and was unable to fully move her fingers and her right moderate chronic obstructive pulmonary disease due radial pulse was diminished when compared to to long-standing asthma, the surgeon attempted a her left. She was placed in a posterior splint with a nonsurgical closed reduction of the fracture in the ED.

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Accurate and timely assessment and communication within perioperative, postoperative, and rehabilitative services can help assure positive outcomes for patients with wrist fractures. fractures

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An I.V. intermittent infusion catheter was placed in and L radiographs of the right wrist. The radiograph Mrs. C’s left hand without difficulty. revealed loss of reduction of the fracture and the sur- After moderate sedation and analgesia with geon decided to proceed with an open reduction midazolam and morphine, the surgeon placed Mrs. with internal fixation (ORIF). Mrs. C was brought C’s fingers into traps that allowed for longitudinal into the OR where the anesthesia provider placed a traction and elevation, and successfully reduced Bier block after the arm was exsanguinated using an the distal radius fracture. The postreduction radio- elastic bandage. A pneumatic tourniquet was placed graphs revealed good alignment with approximately around the mid-humeral portion of the right arm. 5 degrees of dorsal angulation. Her wrist was placed in a volar splint with elastic wrap, and she was Colles fractures of the wrist and admitted to the general orthopedic unit for observa- hand tion and pain management. Mrs. C continued to complain of numbness in her Colles’ fracture palm, and her pain wasn’t well controlled with oral oxycodone/acetaminophen. The nurse obtained orders from the surgeon for morphine sulfate I.V. every 2 hours as needed for pain management. Her pain level decreased from 7/10 to 4/10, but she continued to complain of numbness in her hand. The surgeon evaluated her and told the nurse that he felt the numbness was due to some swelling around the median nerve and that it would resolve once the swelling subsided. Source: The Anatomical Chart Company. Atlas of Pathophysiology, The next morning, the surgeon gave her discharge 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2010. instructions and ordered a predischarge repeat AP

AP wrist fracture Lateral view right wrist

Chapman MW, Szabo RM, Marder RA, et al. Chapman’s Orthopaedic Image courtesy of William Morgan, MD, University of Massachusetts Surgery, 3rd edition. Philadelphia, Lippincott Williams & Wilkins, Medical Center 2001; 1421

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Using a volar incision, the surgeon explored the fracture and Post ORIF AP/Lateral view of right wrist carpal tunnel, noting that the median nerve was compressed. A previously undetected nondisplaced ulnar styloid fracture was also noted. He performed a carpal tunnel release and applied a volar plate with screws to the distal radial fracture (DRF) and pinned the ulnar styloid fracture. The post-ORIF films revealed good reduction and alignment (see Post ORIF AP/lateral view of right wrist), and the posterior splint with elastic bandage wrap was reapplied. Mrs. C was transferred to the postanesthe- Images courtesy of William Morgan, MD. University of Massachusetts Medical Center sia care unit. After an unevent- ful recovery, she was transferred to the orthopedic unit. Volar splint She complained of wrist pain that was well controlled with a patient-controlled analgesia pump. The palm and middle finger numbness resolved, and after a social service consulta- tion, Mrs. C was discharged home in the care of her sister 3 days after her fall. Her primary care provider (PCP) was notified of her hos- pitalization and a dual energy X-ray absorptiometry (DEXA) scan was obtained; it revealed a T score of -2.6, and Mrs. C was diagnosed with osteoporosis. She was started on an oral dose of the bisphosphonate, Images courtesy of William Morgan, MD. University of Massachusetts Medical Center alendronate once per week. An occupational therapy consult was obtained so that a customized volar splint hadn’t impaired her ability to care for herself, could be fabricated after the edema in her hand and she remained independent in all activities and wrist resolved (see Volar splint). Follow-up of daily living. radiographs at 4 and 12 weeks revealed no loss of reduction, and the fractures were healed at Risk factors for wrist fractures 6 months. Since the plate wasn’t causing her The major risk factor for wrist fractures is osteoporo- pain, Mrs. C elected not to have her hardware sis, and there’s mounting evidence that an osteopo- removed. She reported that the wrist fracture rotic wrist fracture can be linked to osteoporotic www.ORNurseJournal.com May OR Nurse 2012 31

fractures in other sites.1 In children and adolescents, Using data from the National Electronic Injury sports injuries and motor vehicle crashes account Surveillance System All Injury Program, Orces and for the majority of wrist fractures.2 Martinez found that the incidence of fall-related DRFs, which are the most common type of wrist wrist and forearm fractures among women fracture in the United States, are estimated to occur increased gradually with age beginning at age 50. at a rate of 150,000 to 200,000 per year.3 DRFs In men, the rate of fractures remained low until have a bimodal distribution. Osteoporotic DRFs typ- much later in life.11 This study demonstrates the ically occur in women in their 60s and 70s, and usu- marked differences between the sexes and sug- ally result from a fall from a standing height, which gests that fall prevention programs may benefit is considered a low-energy fracture.4,5 Adolescents at-risk females, especially those with diminished and young adults often sustain DRFs while in their bone mineral density.11 teens and 20s, usually as a result of high-energy injuries, such as motor vehicle crashes.6 Structure and function of the wrist The most common mechanism of injury for all The wrist is composed of eight carpal bones, the dis- types of wrist fractures is a fall on an outstretched tal ends of the radius and ulna, and the proximal por- hand (FOOSH).5 The wrist is hyperextended and the tions of the five metacarpal bones (see Bony structures point of impact causes energy forces through the dis- of the wrist and hand). Together, these bones form the tal radius that result in various fractures.7,8 Patient wrist, which is considered a gliding joint.12 The wrist weight, degree of deviation of the radius and ulna, has a broad ROM. The radius is shorter than the and the degree of dorsiflexion at the time of impact ulna, and lies on the thumb side of the wrist.13 The determine the fracture pattern.9 In a small group of radius rotates around the ulna, which gives the hand patients, the scaphoid (a carpal bone) may also be the ability to rotate and be flexible.13 The articulation fractured at the time of impact.10 of the distal radius and ulna is called the radioulnar joint. It’s held together Bony structures of the wrist and hand by multiple ligaments, with the primary being the annular, anterior, Distal phalanx and posterior radioulnar ligaments; and the Middle phalanx Phalanges oblique cord ligament.14 The interosse- Proximal phalanx ous membrane, a thin fibrous tissue, connects the radius and ulna at various points and allows for other Metacarpal ligamentous attach- bones ments.14 The eight carpal Hamate Trapezoid bones line up in two rows: the proximal Pisiform Trapezium Carpal Carpal carpal bones are the bones Triquetrum Capitate bones scaphoid, lunate, triquetrum, and the pisi- Lunate Scaphoid form; and the distal carpal bones consist of Ulna Radius the trapezium, trapezoid, capitate, and the Source: Cohen BJ‚ Wood DL. Memmler’s The Human Body in Health and Disease‚ 10th ed. Baltimore, MD: 15,16 Lippincott Williams & Wilkins; 2004. hamate. The carpal bones allow the wrist

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. to move in a wide arc of an individual who’s holding a motion. bat, club, or racket swings No discussion of the wrist is through an arc of motion and complete without examining the hits a stationary object.17 elbow. The proximal radius and • Trapezium fracture is ulna also articulate around the uncommon and occurs with elbow, and they both articulate forced radial deviation of the with the distal humerus to form thumb.17 the elbow joint.13 Many wrist • Trapezoid fracture is very fractures occur with such force uncommon and occurs with that fractures and/or dislocations axial loading during the of the elbow may also occur, FOOSH.17 The mechanism of injury therefore, the surgeon must eval- • Pisiform fracture occurs to can assist the surgeon uate the elbow as well. the small sesamoid bone that with evaluating lies within a tendon (similar to fractures of the wrist. Types of wrist fractures the patella). FOOSH is the usual Fractures of the wrist can be mechanism of injury.17 classified as fractures of the The carpal bones are also carpal bones and fractures of the radius and/or prone to scaphoid–lunate dissociation, and lunate ulna.17 The mechanism of injury can assist the sur- and perilunate dislocations. These result from geon with evaluating fractures of the wrist. There extreme flexion or extension of the wrist and often are many different classification systems used to result in ligamentous instability or rupture.17,20,21 describe various fractures, but those systems are These are potentially serious injuries that often are beyond the scope of this article. Carpal bone frac- missed during initial exam. It’s essential that the sur- tures include the following: geon carefully considers all possible injuries to the • Scaphoid fracture is the most common carpal wrist and supporting structures when evaluating wrist bone fracture.17,18 The mechanism of injury is injuries.22 FOOSH, and incorporates bone and ligament Many fractures of the distal radius have formal integrity, position of the wrist and hand when the names, or eponyms, that describe the location of the fall occurred, the duration of the compression, and fracture and the direction of the displacement of the the direction of forces defining the fracture pat- distal fragment.7 These names usually refer to the tern.18,19 Hyperextension of the wrist causes the physicians who originally described these fractures.23 radial styloid to compress the scaphoid, which Fractures that occur with certain occupations are causes the fracture.18 also included in the nomenclature of fractures.24 • Lunate fracture is relatively uncommon and Radius and/or ulna fractures/dislocations include the occurs with FOOSH.17 following: • Triquetrum fracture is a common carpal bone • Colles: This is a fracture of the distal radius with fracture and is the second-most common fracture dorsal angulation and displacement of the distal in sports injuries.20 Hyperextension and ulnar fragment. This causes the classic “dinner fork” deviation at the time of the fall is the most com- deformity.8,23,24 The wrist is bent upward. mon mechanism of injury and considered a high- • Smith: This is often called a “reverse Colles frac- energy force that will often fracture additional ture” since the distal radius assumes a volar displace- carpal bones.17 ment. The wrist is bent downward, and it’s common • Capitate fracture occurs to the largest carpal among young people with high-velocity trauma.24 bone, which has a limited blood supply.17 A direct • Barton: These are divided into volar and dorsal blow to the dorsum of the wrist along with FOOSH fractures. are the major mechanisms of injury.17 – Volar-type Barton is a fracture-dislocation of • Hamate fracture is uncommon and usually the volar rim of the radius and is more common. results from the wrist being in a dorsiflexed position – Dorsal-type Barton is a fracture-dislocation of with some ulnar deviation. This usually occurs when the dorsal rim of the radius.24 www.ORNurseJournal.com May OR Nurse 2012 33

• Chauffeur: This isolated fracture of the radial the proper anatomical support for the fracture during styloid process, also called a Hutchinson fracture, is the healing process.20,21 The splints are fabricated to often associated with more complex fractures of be fracture specific and also individualized for each the wrist.24 patient. Surgical treatment of wrist fractures includes • Galeazzi: This fracture involves a radial shaft plates and screws, percutaneous pins, cannulated with an associated dislocation of the distal radioul- screws, and external fixation.1,2,4,5,8,17 (See External nar joint. The mechanism of injury is FOOSH, and fixation of the wrist.) these fractures usually require surgery to stabilize Scaphoid fractures represent a challenge for the the wrist.25 surgeon. Unfortunately, these fractures may go • Monteggia: This is a dislocation of the radial undetected and unreduced, which can lead to non- head at the elbow with a fracture, usually along union or avascular necrosis of the scaphoid.30-33 the distal third of the ulna. This is an uncommon Anatomical reduction with possible pin or screw fracture and accounts for less than 5% of all fore- fixation along with splinting is critical for adequate arm fractures.26,27 fracture healing. A thumb spica cast or brace is used to immobilize the thumb and wrist while healing is Treatment of wrist fractures occurring.32 When treating wrist fractures, the goal is to align the fractures anatomically, immobilize the fractures until Treating children healing occurs, and maintain and preserve func- Treating younger patients may represent a challenge, tion.4,5,8,28,29 First, these fractures must be diagnosed as the epiphysis is a critical structure in the bone accurately. Most fractures can be diagnosed with sim- development of children and adolescents. The long ple AP and L radiographs; some fractures, especially bones consist of the epiphysis, which consists of the the carpal bones, may require further imaging with proximal and distal ends of bones; the metaphysis, computed tomography or magnetic resonance imag- which lies between the epiphysis and diaphysis at the ing, especially if ligamentous injury is suspected.17 proximal and distal ends of bones; and diaphysis, or Many fractures can be manually reduced by the shaft, of a long bone (proximal epiphysis, proximal surgeon and splinted; others require surgical inter- metaphysis, diaphysis, distal metaphysis, and distal vention. The splinting is important as the surgeon epiphysis).12 must mold and shape the splint so that it provides The epiphysis consists of spongy bone covered by a thin layer of compact bone. In children, the epiphysis is sepa- External fixator-wrist rated from the metaphysis by a cartilaginous growth plate, also called the epiphyseal plate. Longitudinal bone growth occurs at the growth plate, and the growth plate usually ossifies (hardens) during late puberty. Any injury to the growth plate before it ossifies can adversely affect the bone’s ability to achieve maximum length.34 In children and younger adolescents, DRFs often occur in or near the growth plate. It’s critical for the surgeon to identify those fractures and provide treatment that will preserve the integrity of

Images courtesy of Miki Patterson, PhD, RN. University of Massachusetts-Lowell. the growth plate. Ironically, although the distal radial physis

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. is the most commonly separated physis in children, it Complications of wrist fractures rarely causes disturbances in longitudinal growth of Complications of wrist fractures can be divided into the radius.34 It’s important for the surgeon to reduce early and late, as well as high, medium, and low the fracture anatomically, and percutaneous pinning probability of occurring.41 Median nerve entrapment is performed often to allow for early mobility and is common with Colles fractures, and many surgeons ROM. These fractures in children can also be treat- elect to perform carpal tunnel releases at time of ed with a properly molded cast. ORIF.2,17,21,41 Malunion of fractures occurs early in the course of Preoperative and perioperative care treatment as does stiffness and pain in the hand and Patients undergoing surgical repair of a wrist fracture wrist.41 Nonunions of fractures also can occur, espe- require routine preoperative assessment and man- cially of the scaphoid due to the limited blood sup- agement the same as any other patient; the perioper- ply.17,18 DRFs rarely experience nonunions due to ative nurse should review the Association of periOp- excellent blood supply. Complex regional pain syn- erative Registered Nurses Perioperative Standards and drome (formerly called reflex sympathetic dystro- Recommended Practices, 2012 Edition, for general phy), can occur soon after the fracture.41 guidelines for the perioperative patients.35 Special cir- In elderly patients with osteoporotic wrist frac- cumstances include the polytrauma patient and tures, continued morbidity from osteoporosis often those who have sustained open fractures. occurs.1,3 Patients with one osteoporotic fracture are Communication among the team is essential for twice as likely to sustain another site fracture.1 the planning and execution of a successful proce- Clinicians managing the care of elderly patients with dure. The preoperative assessment and documenta- wrist fractures should obtain a DEXA scan, and insti- tion of the neurovascular function of the hand tute treatment for any identified osteoporosis.42 must be noted.36,37 Confirmation of the operative Vascular injuries represent a serious complication site as outlined by the American Academy of of wrist fracture. The force of the initial impact can Orthopaedic Surgeons and The Joint Commission cause comminution of the bony fragments, causing is part of the perioperative RN’s responsibility as lacerations or compression of the radial or ulnar well as other team members.38 The recommended arteries.17 Rapid recognition of vascular injuries may timing of antibiotic surgical prophylaxis is within prevent loss of the injured hand. 60 minutes prior to skin incision to allow for the Complications from the surgical repair procedure greatest tissue concentration of drug, and the peri- include screws impinging on tendons or ligaments, operative RN needs to ensure that the proper anti- or pins interfering with the blood supply.43,44 biotic is available for the anesthesia provider to Knowledge of the intricate anatomy of the hand administer it.39 and wrist can help prevent some of these surgical Surgical repair of a wrist fracture usually requires complications. the use of a pneumatic tourniquet to establish a bloodless surgical field. As pneumatic tourniquet Case study revisited technology improves, the perioperative RN must Mrs. C was fortunate that a nearby neighbor wit- remain current in knowledge of tourniquet systems nessed her fall and called for help immediately. The and follow the appropriate guidelines for use of the elderly often sustain fractures while in their homes device.40 and are unable to call for help—they may not be Anesthesia is usually accomplished via regional found for several hours or days.45 Quick management blocks, and care must be taken that the extremity of her fracture helped her to have a positive outcome. is well padded, as well as those other areas subject- Mrs. C’s radial artery and median nerve were ed to shearing and pressure forces. The careful compromised when she was initially evaluated, but documentation of the neurovascular bundle exam careful splinting and transport by EMS reversed the findings is essential. The median nerve is often pressure on the radial artery and helped restore an entrapped, and the perioperative RN should antici- adequate blood supply to her hand. The median pate that a carpal tunnel release will most likely be nerve continued to be compromised, and the carpal performed at the time of surgical fixation of the tunnel release at the time of volar plating prevented fracture.41 permanent median nerve damage. www.ORNurseJournal.com May OR Nurse 2012 35

It’s common for a wrist fracture to lose the ana- 3. Rozental TD, Branas CC, Bozentka DJ, et al. Survival among elderly patients after fractures of the distal radius. J Hand Surg Am. tomic reduction after attempts at closed reduction, 2002;27(6):948-952. as was the case with Mrs. C. In her case, the surgical 4. Chen NC, Jupiter JB. Management of distal radial fractures. J Bone plating and pinning allowed her to have earlier Joint Surg Am. 2007;89(9):2051-2062. 5. Ring D, Jupiter JB. Treatment of osteoporotic distal radius fractures. mobility of her hand, preserving more function. Osteoporos Int. 2005;16(suppl 2):S80-S84. Epub 2004 Dec 22. Studies have demonstrated that 6 months after an 6. Price CT. Surgical management of forearm and distal radius fractures unstable DRF, patients treated with closed reduction in children and adolescents. Instr Course Lect. 2008;57:509-14. and casting had similar functional outcomes as those 7. Altizer LL. Colles’ fractures. Orthop Nurs. 2008;27(2):140-145; quiz 146-147. treated aggressively with ORIF.46 Patients with closed 8. Riego de Dios R, Craig WD. Distal radial fracture imaging. 2009. reduction were required to wear casts or splints until http://emedicine.medscape.com/article/398406-overview. healing occurred, while those who had surgery were 9. Byrd GD, Rozental TD. Wrist fracture etiology. ePocrates Online. allowed to begin using the hand sooner. These find- 2011. http://online.epocrates.com/. 10. Rutgers M, Mudgal CS, Shin R. Combined fractures of the distal ings may indicate that more aggressive approaches radius and scaphoid. J Hand Surg Eur Vol. 2008;33(4):478-483. to DRFs, especially in the elderly, may improve the 11. Orces CH, Martinez FJ. Epidemiology of fall related forearm and ability to perform independent activities of daily wrist fractures among adults treated in US hospital emergency depart- ments. Inj Prev. 2010. http://injuryprevention.bmj.com/content/ living in the short term. The occupational therapy early/2010/09/28/ip.2010.026799.abstract. consult early in her recovery period was a wise 12. Crowther-Radulewicz CL. Structure and function of the musculo- move in terms of splinting and exercises. skeletal system. In: McCance KL, Huether SE, Brashers VL, Rote NS, eds. Pathophysiology: The Biological Basis for Disease in Adults and Children. Mrs. C’s PCP also ordered a DEXA scan and 6th ed. St. Louis, MO: Elsevier Mosby; 2010:1540-1567. immediately began treatment for her newly diag- 13. Darling D. Radius. Encyclopedia of Science: Anatomy and Physiology. nosed osteoporosis. Reversing bone loss can help http://www.daviddarling.info/encyclopedia/R/radius_arm.html. prevent further osteoporotic fractures, which could 14. Wheeless CR. Ligaments of the wrist. Wheeless Textbook of Ortho- paedics. 2008. http://www.wheelessonline.com/ortho/ligaments_of_ adversely affect her quality of life. Some studies the_wrist. support waiting for several months after an osteo- 15. Hoynak BC. Carpal bone injuries. 2010. http://emedicine.medscape. porotic fracture to begin bisphosphonate therapy.47 com/article/97565-overview. 16. Moses S. Wrist anatomy. Family Practice Notebook. 2011. http:// Since bisphosphonates inhibit bone formation and www.fpnotebook.com/ortho/exam/WrstAntmy.htm. reabsorption, theoretically, the use of these drugs 17. Hoynak BC, Hopson L. Wrist fracture in emergency medicine. immediately after fractures or surgery for fractures 2010. http://emedicine.medscape.com/article/828746-overview. could lead to nonunion of the fracture. The PCP 18. Boles CA. Scaphoid fracture imaging. 2010. http://emedicine. must carefully review the risks and benefits of medscape.com/article/397230-overview. 19. Ramos-Escalona J, García-Bordes L, Martínez-Galarza P, Yunta-Gallo such treatment, and discuss the risk and benefits A. Ulnar variance and scaphoid fracture. J Hand Surg Eur Vol. with the patient. 2010;35(3):195-197. Epub 2009 Dec 9. 20. Steinberg MD. Acute wrist injuries in the athlete. Ortho Clin N Am. 2002;33(3):535-545. Conclusion 21. Beeson MS. Wrist dislocations in emergency medicine. 2008. Wrist fractures represent a challenge for clinicians. http://emedicine.medscape.com/article/823944-overview. The young and the elderly are at the highest risk, 22. Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in and the perioperative RN must be aware of the the ED: lunate and perilunate injuries. Am J Emerg Med. 2001;19(2):157-162. physiologic differences between these ages when 23. Hanel DP, Jones MD, Trumble TE. Wrist fractures. Orthop Clin planning and providing care for these patients. North Am. 2002;33(1):35-57, vii. Accurate and timely assessment and communication 24. Smithuis R. Wrist: fractures. The Radiology Assistant. 2008. http:// within perioperative, postoperative, and rehabilitative www.radiologyassistant.nl/en/476a23436683b. 25. Ertl JP. Galeazzi fracture. http://emedicine.medscape.com/ services can help assure patients with these fractures article/1239331-overview. will have positive outcomes. OR 26. Putigna F, Ursone RL, Strohmeyer K. Monteggia fracture. http:// emedicine.medscape.com/article/1231438-overview. 27. Simon RR, Sherman SC, Koenigsknecht SJ. Forearm. In: Emergency REFERENCES Orthopedics: The Extremities. 5th ed. McGraw-Hill; 2007:218-231. 1. Schousboe JT, Fink HA, Taylor BC, et al. Association between self- 28. Martineau PA, Malone KJ, Hanel DP. Bridge plating of distal radius reported prior wrist fractures and risk of subsequent hip and radio- fractures. In: Slutsky DJ, Osterman AL, eds. Fractures and Injuries of the graphic vertebral fractures in older women: a prospective study. J Bone Distal Radius and Carpals: The Cutting Edge. Philadelphia, PA: Elsevier Miner Res. 2005;20(1):100-106. Epub 2004 Oct 25. Saunders; 2009:201-208. 2. Nelson DL. Distal fractures of the radius. 2010. http://emedicine. 29. Papp S. Carpal bone fractures. Orthop Clin North Am. 2007;38(2): medscape.com/article/1245884-overview. 251-260, vii.

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 30. Querellou S, Moineau G, Le Duc-Pennec A, et al. Detection of oc- operative practice setting in Association of periOperative Registered cult wrist fractures by quantitative radioscintigraphy: a prospective study Nurses (AORN). Perioperative Standards and Recommended Practices, Den- on selected patients. Nucl Med Commun. 2009;30(11):862-867. ver, CO: 2012. http://aornstandards.org/content/1/SEC12.extract. 31. Pierre-Jerome C, Moncayo V, Albastaki U, Terk MR. Multiple occult 41. Byrd GD, Rozental TD. Wrist fracture complications. ePocrates On- wrist bone injuries and joint effusions: prevalence and distribution on line. 2011. https://online.epocrates.com/noFrame/showPage.do?method MRI. Emerg Radiol. 2010;17(3):179-184. Epub 2009 Aug 7. =diseases&MonographId=392&ActiveSectionId=52. 32. Tu YK, Chen AC, Chou YC, Ueng SW, Ma CH, Yen CY. Treat- 42. Wells GA, Cranney A, Peterson J, et al. Alendronate for the pri- ment for scaphoid fracture and nonunion—the application of 3.0 mm mary and secondary prevention of osteoporotic fractures in postmeno- cannulated screws and pedicle vascularised bone grafts. Injury. pausal women. Cochrane Database Syst Rev. 2008;(1):CD001155. 2008;39(suppl 4):96-106. 43. Bushnell BD, McWilliams AD, Messer TM. Complications in dorsal 33. Smith ML, Bain GI, Chabrel N, Turner P, Carter C, Field J. Using percutaneous cannulated screw fixation of nondisplaced scaphoid waist computed tomography to assist with diagnosis of avascular necrosis fractures. J Hand Surg Am. 2007;32(6):827-833. complicating chronic scaphoid nonunion. J Hand Surg Am. 2009;34(6):1037-1043. Epub 2009 May 15. 44. Bianchi S, van Aaken J, Glauser T, Martinoli C, Beaulieu JY, Della Santa D. Screw impingement on the extensor tendons in distal radius 34. Carroll KL. Alterations of musculoskeletal function in children. In: fractures treated by volar plating: sonographic appearance. AJR Am J McCance KL, Huether SE, Brashers VL, Rote NS, eds. Pathophysiology: Roentgenol. 2008;191(5):W199-W203. The Biological Basis for Disease in Adults and Children. 6th ed. St. Louis, MO: Elsevier Mosby; 2010:1618-1643. 45. Friese G. Breaking bones: Prehospital hip fracture assessment. 2011. 35. Association of periOperative Registered Nurses (AORN). Periopera- http://www.emsworld.com/print/EMS-World/Breaking-Bones/1$3349. tive Standards and Recommended Practices, Denver, CO: 2012. 46. Rozental TD, Blazar PE, Franko OI, et al. Functional outcomes for 36. Kurkowski T. Perioperative considerations for the orthopaedic client. unstable distal radial fractures treated with open reduction and internal In: Maher AB, Salmond SW, Pellino TA, eds. Orthopaedic Nursing. 3rd fixation or closed reduction and percutaneous fixation. A prospective ed. Philadelphia, PA: WB Saunders; 2002:269-301. randomized trial. J Bone Joint Surg Am. 2009;91(8):1837-1846. 37. Barnett S, Strickland L. Perioperative patient care. In: National As- 47. Solomon DH, Hochberg MC, Mogun H, Schneeweiss S. The rela- sociation of Orthopaedic Nurses, ed. National Association of Orthopaedic tion between bisphosphonate use and non-union of fractures of the Nurses Core Curriculum for Orthopaedic Nursing. 6th ed. Boston, MA: humerus in older adults. Osteoporos Int. 2009;20(6):895-901. Epub Pearson Custom Publishing; 2007:99-126. 2008 Oct 9. 38. American Academy of Orthopaedic Surgeons. Joint Commission Guidelines for Implementation of the Universal Protocol for the Pre- Colleen R. Walsh is an associate professor in Graduate Nursing at the vention of Wrong Site, Wrong Procedure and Wrong Person Surgery. University of Southern Indiana College of Nursing and Health Professions, http://www.aaos.org/about/papers/advistmt/1015.asp in Evansville, Ind. 39. Weber WP, Marti WR, Zwahlen M, et al. The timing of surgical antimicrobial prophylaxis. Ann Surg. 2008;247(6):918-926. The author has disclosed no financial relationships related to this article. 40. Association of periOperative Registered Nurses (AORN). Recom- mended practices for the use of the pneumatic tourniquet in the peri- DOI-10.1097/01.ORN.0000414184.11122.69

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INSTRUCTIONS Wrist fractures in the young and elderly TEST INSTRUCTIONS DISCOUNTS and CUSTOMER SERVICE • To take the test online, go to our secure website • Send two or more tests in any nursing journal published by Lippincott at http://www.nursingcenter.com/ORnurse. Williams & Wilkins together and deduct $0.95 from the price of each test. • On the print form, record your answers in the • We also offer CE accounts for hospitals and other health care facilities on test answer section of the CE enrollment form on nursingcenter.com. Call 1-800-787-8985 for details. page 38. Each question has only one correct answer. You may make copies of these forms. PROVIDER ACCREDITATION • Complete the registration information and Lippincott Williams & Wilkins, publisher of ORNurse2012 journal, will award course evaluation. Mail the completed form and 2.3 contact hours for this continuing nursing education activity. Lippincott registration fee of $21.95 to: Lippincott Williams Williams & Wilkins is accredited as a provider of continuing nursing education & Wilkins, CE Group, 74 Brick Blvd., Bldg. 4 by the American Nurses Credentialing Center’s Commission on Accreditation. Suite 206, Brick, NJ 08723. We will mail your Lippincott Williams & Wilkins is also an approved provider of continuing certificate in 4 to 6 weeks. For faster service, nursing education by the District of Columbia and Florida #FBN2454. This include a fax number and we will fax your certif- activity is also provider approved by the California Board of Registered icate within 2 business days of receiving your Nursing, Provider Number CEP 11749 for 2.3 contact hours. enrollment form. Your certificate is valid in all states. • You will receive your CE certificate of earned The ANCC’s accreditation status of Lippincott Williams & Wilkins contact hours and an answer key to review your Department of Continuing Education refers only to its continuing nursing results.There is no minimum passing grade. educational activities and does not imply Commission on Accreditation • Registration deadline is June 30, 2014. approval or endorsement of any commercial product. www.ORNurseJournal.com May OR Nurse 2012 37