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Evaluating acute hand and wrist injuries

Larry Collins, MPAS, PA-C, ATC, DFAAPA

Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine Disclosures

• I have no real or apparent conflicts of interest to report History

• What was the cause? • What were the symptoms at the time of injury, did they occur later, were they localized or diffuse? • Was there swelling and discoloration? • What treatment was given and how does it feel now? Observation

• Deformity • Swelling • Skin defect • Range of motion • Pain w/motion Palpation

• Point of injury • Proximal and distal – Tenderness – Deformity – Edema – Crepitus – Changes in skin temperature – ‘false joint’ Neurovascular Status

• Motor and sensory function – Median, radial, and ulnar nerves • Circulation – Radial pulse – Capillary refill Distal Radius Fractures

• Common fracture in upper extremity • Majority occur as isolated injuries – Youths  sports  high-energy falls – Seniors  low-energy falls Presentation

• Audible pop or crack followed by moderate to severe pain, swelling, and disability • Proximal third radius fracture may result in abduction deformity due pull of pronator teres • Edema, ecchymosis w/ possible crepitus • Forward displacement of radius causing visible deformity (dinner fork deformity) • When no deformity is present, injury can be passed off as bad sprain • Tendons may be torn/avulsed and there may be median nerve damage Radiographs

• Loss of normal anatomy – Displacement – Angulation –  radial height • Involvement of radiocarpal or distal radioulnar joint • Articular surface – Step-off – Separation • Significant comminution Management – Adult

• RICE • Splint • Emergent orthopedic referral – Open fractures – Compression neuropathy – Compartment syndrome – Vascular compromise Surgical vs. Non-Surgical

• Patient needs – Bone quality – Comorbidities – Functional demand Management – Peds

Urgent Referral • Open fractures • Neurovascular compromise • Displaced radius with intact ulna • Associated wrist or elbow dislocation • Supracondylar fracture • Radius fracture with dislocation of distal ulna (Galeazzi ) Non-displaced Extra-articular Fractures

• Stable • Well-molded sugar-tong, or double sugar-tong splint – Transition to cast 1-2 weeks • Elevation • Range of motion for shoulder and fingers • Opioids as needed Sugar-tong Splints Referral

• Articular step-off • Intraarticular displacement • Displacement > 2/3 of radial shaft • Comminution with radial shortening Management – Peds

• Refer displaced I or II and all III, IV, V Management – Peds

• Torus (buckle) fracture – Stable – Immobilization with splint or short-arm cast • Non-displaced Salter-Harris I or II fractures – Stable – Immobilization with short arm splint x 3-4 weeks – Volar splint for I; sugar-tong for II – Sling for support • Greenstick fracture – Immobilization with cast x 6-8 weeks – Distal  short arm cast – Proximal  long arm cast x 3 then short arm Wrist Sprains

• Etiology – Most common wrist injury – Arises from any abnormal, forced movement – Falling on hyperextended wrist, violent flexion or torsion • Signs and Symptoms – Pain, swelling and difficulty w/ movement Wrist Sprains

• Management – RICE – Splint – NSAIDs – ROM – Begin strengthening soon Triangular Fibrocartilage Complex (TFCC) Injury • Etiology – Occurs through forced hyperextension, falling on outstretched hand – Violent twist or torque of the wrist • Signs and Symptoms – Pain along ulnar side of wrist, difficulty w/ wrist extension, possible clicking – Swelling is possible, not much initially – Pain increases with rotation and ulnar deviation of the wrist Triangular Fibrocartilage Complex (TFCC) Injury Examination

• Recreate symptoms with ulnar deviation and extension • Axial loading with ulnar deviation • “Push-off” test – Getting out of chair with armrests Management

• NSIADs • Thumb spica splint or short arm cast x 4-6 weeks • Surgical referral may be indicated Scaphoid Fracture

• Common • Often initially missed • May fail to heal 2°poor blood supply – Non-union

https://www.orthobullets.com/hand/6034/scaphoid-fracture. Accessed 12/08/2018. Scaphoid Fracture

• Signs and Symptoms – Swelling – Pain in anatomic snuff box – Presents like wrist sprain – Pain w/ radial flexion Scaphoid Fracture

• Management – High index of suspicion – Consider MRI – Splint • Thumb spica – Immobilization lasts 6 weeks – Wrist requires protection against impact loading for 3 additional months Indications For Surgical Referral

• Open • Neurovascular compromise • Proximal pole • Displaced • Patient preference • Delayed presentation • Scapholunate disruption • Evidence of non-union or osteonecrosis Scaphoid Fractures Usefulness of MRI Metacarpal Shaft Fractures

• Direct axial or compressive force • 5th metacarpal fractures  punch – Boxer’s fracture • Signs and Symptoms – Pain – Swelling – Crepitus – Angular or rotational deformity Rotational Deformity

https://www.merckmanuals.com/Content/Images/no-copy.png. Accessed 12/11/2017. Indications For Referral

• Open • Intra-articular • Rotational malalignment • Significant displacement • Multiple Metacarpal Fracture

• Management – Splint (include digits) • MCP in 70-90° flexion – Cast after 1-2 weeks (leave PIP free) – 6 weeks in cast • ? Transition to splint 5th Metacarpal Fracture

• Management – Stable – Splint for pain – Consider cast or splint 1st Metacarpal Fracture

• Bennett Fracture • Base of 1st metacarpal • Result of an axial and abduction force to the thumb • Signs and Symptoms – Pain – Swelling – Inability to grip/pinch Radiographs

• Intra-articular 1st Metacarpal Fracture

• High incidence OA • Unstable • Surgical referral – Displacement • Casting is option for non-displaced Phalangeal Fractures

• Occurs from direct trauma or twist • Spiral or angulated • Signs and Symptoms – Pain and swelling – Possible deformity Indications for Referral

• Open • Neurovascular injury • Intra-articular • Rotated • Shortened • Comminuted Management

• RICE and analgesics • Non-displaced • Transverse, oblique, or avulsion • Buddy tape • Consider gutter splint for function Questions?

Evaluating acute hand and wrist injuries

Larry Collins, MPAS, PA-C, ATC, DFAAPA

Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine [email protected]