Common Orthopedic Hand and Wrist Injuries

Almost any hand or wrist injury is potentially devastating depending on the patient's occupation and interests. The authors, both emergency physicians, thoroughly review the musculoskeletal structure and neuroanatomy involved in these injuries and update the clinical management of various dislocations, connective tissue injuries, and fractures.

By Joseph Lang, MD, and Francis Counselman, MD

Hand and wrist injuries are not foreign to primary care and emergency department physicians. Hand injuries alone account for nearly 1.4 million visits to the emergency department annually. Of these, the majority are due to blunt trauma. Because the hands perform so many fundamental and delicate tasks in various professions and in daily life, even a minor injury can have devastating consequences. Thus, no injury should be taken lightly. Often, both the hand and the wrist are injured, and because they are so dependent on one another, they must both be examined thoroughly whenever either one is injured.
 

ANATOMY OF THE HAND

The hand consists of 27 bones, which are made up of 14 phalanges, 5 metacarpals, and the 8 carpal bones of the wrist. The carpal bones are lined up in two rows of four bones each, which are connected by thick ligaments. These ligaments are then covered on the volar (or palmar) side by the flexor retinaculum, through which the median nerve and flexor tendons of the fingers run. The musculature that surrounds the bones in the hand and provides movement can be categorized as the intrinsic and extrinsic muscles. Intrinsic muscles originate in the hand, while the extrinsic muscles originate in the forearm. The intrinsic muscles include the interossei, lumbricals, adductor pollicus, and the muscles of the thenar and hypothenar eminences.

The thenar muscles cover the thumb metacarpal and include the opponens pollicis, the abductor pollicis brevis, and the superficial head of the flexor pollicis brevis. (These muscles are sometimes referred to as the "OAF" muscles—for opponens, abductor, and flexor.) The median nerve innervates these muscles.

The hypothenar muscles are innervated by the ulnar nerve and originate from the flexor retinaculum and insert on the fifth metacarpal and proximal phalanx of the fifth finger. These muscles include the opponens digiti minimi, the abductor digiti minimi, and the flexor digiti minimi.

The lumbricals are the muscles that help with flexion of the metacarpal-phalangeal (MCP) joint and with extension of the interphalangeal joints. They arise from the flexor digitorum profundus tendon in the fingers and run along the radial aspect of each finger, inserting at the MCP joint. The median nerve controls the second and third lumbricals, while the ulnar nerve controls the fourth and fifth lumbricals.

The interossei are divided into the dorsal and palmar groups. The interossei originate from the metacarpals and insert into the extensor components of the second through fifth digits. There are three palmar and four dorsal interossei. The dorsal interossei abduct the fingers from midline, while the palmar interossei adduct the second, fourth, and fifth fingers. These muscles are innervated by the ulnar nerve.

The tendons that control extension of the fingers and wrist run along the dorsal side of the forearm, hand, and fingers. There are nine extensor tendons that pass under the extensor retinaculum and are then separated into six compartments by fibrous bands. The extensor tendons of the second through fifth fingers are joined by another fibrous band, called the juncturae tendinum, which is located on the dorsal aspect of the hand just proximal to the MCP joint. This is important because if an extensor tendon is cut proximal to this band, then an injured finger may still have normal extension because of the attachments to the other intact tendons. When the extensor tendons enter the finger, they form a band called the central slip, which attaches to the middle phalanx. This divides into two lateral bands, which attach to the distal phalanx along with the tendons of the lumbrical and interosseus muscles.

The flexor tendons of the fingers and wrist run along the palmar side of the forearm and hand. There are 12 flexor tendons; of these, nine cross into the hand through the carpal tunnel. The other three, the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus, do not. These three tendons flex and deviate the wrist to the ulnar or radial side. The flexor digitorum superficialis inserts on the palmar aspect of the middle phalanx and flexes all of the joints it passes. The flexor digitorum profundus runs deep to the flexor digitorum superficialis until it splits into two parts at the MCP joint. Both sections then insert onto the base of the distal phalanx, flexing all of the joints it crosses. It is imperative to test the function of these two tendons when evaluating patients with a laceration of the hand or fingers. Also of note is that the flexor tendons are enclosed in synovial sheaths, which makes them prone to infection if a penetrating injury occurs. This is not true for the extensor tendons.
 

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INNERVATION OF THE HAND

Innervation of the hand is through the median, radial, and ulnar nerves. Not only do these nerves control motor function of the hand as described above, but they also control sensory function. The median nerve enters the hand through the carpal tunnel. It then divides into the recurrent median nerve and the common digital branches. The recurrent median nerve innervates the OAF muscles of the thumb, while the common digital branches innervate the lumbricals of the index and middle finger. The median nerve has a purely sensory branch in the hand, known as the palmar cutaneous nerve, which provides sensory function to most of the palm. The median nerve provides sensation for all parts of the palmar side of the hand except for the fifth finger, the ulnar side of the fourth finger, and the ulnar side of the palm. It also provides sensation for the dorsum of the second, third, and part of the fourth fingers from the proximal interphalangeal (PIP) joint distally. Damage to the median nerve not only causes loss of sensation to the areas mentioned, but also causes atrophy of the thenar muscles, resulting in a so-called monkey hand, or flattening of the palm.

The ulnar nerve enters the hand through the ulnar tunnel, also known as Guyon's canal. It innervates the muscles previously discussed and a branch of it innervates the adductor pollicis. The ulnar nerve also provides sensation for both the palmar and dorsal sides of the fifth finger and the ulnar half of the fourth finger, as well as the part of the hand proximal to this area. The dorsal side of the hand is innervated by a branch of the ulnar nerve called the dorsal cutaneous branch. Damage to the ulnar nerve causes anesthesia in the areas discussed, as well as clawing of the fourth and fifth fingers, known as Duchenne's sign.

The radial nerve passes into the hand by way of Lister's tubercule and the radial styloid. The radial nerve is purely sensory to the hand, innervating the dorsal aspect of the thumb and extending distally to the PIP joint of the second, third, and part of the fourth fingers and the areas on the dorsum of the hand proximal to this. Because it does innervate the wrist and finger extensors and the abductor pollicis longus muscle proximal to the hand, injury to this nerve causes wrist drop, anesthesia to the aforementioned areas, and adduction of the thumb.

When examining the hand, the clinician should always check for two-point discrimination on the fingertips. There should be at most six millimeters of separation between the two points on the fingertips, and often as little as two millimeters can be differentiated. For a normal exam, 80% accuracy is needed. Less than 80% accuracy or no sensation at all usually implies a digital nerve injury and may also suggest a digital artery injury, based on the close proximity of these two structures.

The ulnar and radial arteries supply blood to the hand. The radial artery terminates in the hand, forming the deep palmar arch. The ulnar artery gives off a branch to the deep palmar arch and then continues around to form the superficial palmar arch. These two arches have many other anastamoses with each other. The superficial palmar arch sends off two arteries to each finger, which run on the radial and ulnar aspects of each finger.

DISLOCATIONS OF THE DIP AND PIP JOINTS

In an examination of the hand from the most distal site to the most proximal, the distal interphalangeal joint (DIP) is encountered first. The most common dislocation of this joint is a dorsal dislocation. Radiographs are recommended prior to attempted reduction because of the possibility of associated fractures, including avulsion fractures. Once x-rays have been obtained and the decision to reduce is made, a digital block for anesthesia may be used, although in our experience this is generally a quick reduction and painful for only a few seconds. Whether to use anesthesia or not may be left for the patient to decide.

Reduction is achieved using longitudinal traction on the finger and hyperextension. Pressure is then placed on the dorsum of the base of the distal phalanx in a palmar direction. There should not be an audible pop as in a shoulder reduction. If the dislocation cannot be reduced, an orthopedic or hand surgeon consultation is recommended. In the case of an open dislocation, an orthopedic or hand surgeon should always be consulted. The patient should be started on an intravenous (IV) prophylactic antibiotic, such as cefazolin.

Dislocation of the PIP joint is the most common dislocation of the hand. It can occur dorsally or laterally. When a dorsal dislocation occurs, there is a volar plate rupture, which may cause difficulty when attempting to reduce the dislocation. In lateral dislocations, ulnar deviation is more common because the radial collateral ligament is more likely to tear than the ulnar collateral ligament. Radiographs should be obtained prior to reduction to exclude a fracture. Dorsal dislocations are reduced the same way as DIP dislocations, and if reduction is successful, the joint should be splinted at 30 degrees of flexion for three weeks. If the reduction is unsuccessful, in all likelihood the volar plate has become entrapped in the joint space and will require surgery.

With lateral dislocations, reduction is attempted with longitudinal traction as well. If there is an avulsion fracture of more than 33% of the articular surface area, this is an unstable injury and will require surgical repair. Similarly, if there is more than 20 degrees of deformity or instability with passive testing of the flexed joint, this will require surgery too, because this is usually indicative of a complete ligamentous tear.
 

MCP AND CMC JOINT DISLOCATIONS

Metacarpal-phalangeal joint dislocations are uncommon. When they occur, they are usually dorsal dislocations and involve rupture of the volar plate, resulting in most cases from a hyperextension injury. Dislocations of the MCP joint are divided into two classes—simple and complex. Simple dislocations appear worse on initial examination, with up to 60 to 90 degrees of hyperextension, but the articular surfaces are still in communication and the dislocation can usually be reduced in the emergency department. Radiographs should always be obtained to exclude an associated fracture. If an attempt at reduction is going to be made, the wrist should be flexed to release tension on the flexor tendons. Pressure should then be applied in a distal and volar manner on the proximal phalanx. If reduction is accomplished, the joint should be splinted in flexion and a referral to a hand surgeon should be made. Complex dislocations involve the dissociation of the two articular surfaces, with the dorsal plate becoming entrapped in the interspace. These are not reducible and require surgical repair.

Carpal-metacarpal (CMC) joint dislocations are also uncommon, due to the multiple ligaments that surround these bones. These dislocations are usually incurred after closed-fist injuries or high speed trauma, such as a motor vehicle collision. The dislocations are most often dorsal and are usually associated with a fracture. After x-rays are taken, closed reduction may be attempted, but anesthesia is required. Reduction is attempted using traction and flexion with longitudinal pressure on the metacarpal base. Extension of the head of the metacarpal is also needed to provide correct realignment. The hand is then splinted. The patient should be referred to an orthopedic or hand surgeon; operative intervention is still usually necessary to place K wires for stability.
 

THUMB DISLOCATIONS

The thumb has only two phalanges. As a result, only two joints can become dislocated—the interphalangeal (IP) joint or the MCP joint. Dislocation of the IP joint is uncommon due to the strength of the ligaments and the volar plate. When a dislocation does occur, it is often an open wound. Closed dislocations are reduced in the same manner as a DIP dislocation, with splinting afterward with a minor degree of flexion for three weeks.

Dislocations of the MCP joint of the thumb are usually dorsal and often result from a hyperextension injury, with concomitant rupture of the volar plate. Like other MCP joint dislocations, they may be simple or complex. If the dislocation is reducible, according to the same criteria applied to other MCP joint dislocations, a radial block often provides sufficient anesthesia, but at times a median nerve block may also be required. Distal pressure should be exerted on the base of the proximal phalanx, with the metacarpal in an adducted and flexed state. The wrist may also be flexed in more difficult reductions to reduce tension on the joint. Once reduction has been achieved, the joint should be splinted in a thumb spica at 20 degrees of flexion for four weeks. Complex, nonreducible, or unstable dislocations will require surgical intervention.

The CMC joint of the thumb may on rare occasions be dislocated. These dislocations are reduced in the same manner as other CMC dislocations and require a thumb spica splint and orthopedic referral because they are often unstable.

A tear of the ulnar collateral ligament of the thumb is known as a gamekeeper's thumb. This results in radial deviation of the thumb. Today, the most common cause is skiing, but years ago the injury got its name from Scottish hunters or gamekeepers, who would hurt their thumbs while twisting the necks of rabbits. Physical examination will usually demonstrate swelling around the joint, with tenderness to palpation along the ulnar border of the thumb; a weak, pinching grasp of the thumb and index finger may also be present.

Radiographs should be taken to rule out a fracture. Stress testing of the joint should be performed with the thumb in full extension and in 30 degrees of flexion. Either 40 degrees of joint movement or 15 degrees more than the unaffected thumb indicates a complete tear. Partial tears can be treated with a thumb spica splint for four weeks. Complete tears will require surgical repair, which should be done one to three weeks after the injury.

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CARPAL BONE DISLOCATIONS

Dislocations of the carpal bones of the hand are usually the result of a fall on an outstretched hand (FOOSH) injury. These dislocations are actually due to scapholunate or triquetrolunate ligament disruptions. All of these injuries somehow involve the lunate bone. They are staged I through IV, with I being the least severe and IV being the most severe. Stage I is a scapholunate dissociation. These patients have pain on the radial side of the wrist and may also have a click with wrist movement. Radiographs will show the Terry-Thomas sign, which is a widening of the scapholunate joint space by more than three millimeters. (Terry-Thomas was a British comedian with a gap between his two front teeth; the sign was named after him.)

If a carpal bone dislocation is suspected clinically but not seen on routine posteroanterior radiographs, having the patient clench his fist and taking another x-ray may bring the gap into better view. The scaphoid bone may rotate or subluxate in some injuries as well. The scapholunate angle may increase to more than 60 degrees, which is abnormal, and x-rays will show a ring sign as the scaphoid appears shorter and the cortical bone is observed on end.

Stage II injuries are perilunate dislocations, where the lunate bone remains fixed in place but the capitate bone dislocates dorsally. There may be an associated scaphoid fracture with this injury. Stage III injuries are essentially stage II injuries with a triquetrum dislocation that overlaps the lunate or hamate bone. Stage IV injuries are lunate dislocations, which cause the lunate to rotate in a volar direction. On the posteroanterior view, the piece of pie sign is observed, which is a triangular piece of bone seen on the lunate. It is easier to identify on the lateral view as the spilled tea cup sign—that is, as a C or tea cup tilted forward toward the palm.

Stage I injuries are managed with a radial gutter splint and orthopedic referral. Stage II through IV injuries require orthopedic or hand surgery consultation in the emergency department.
 

TENDON INJURIES

Tendons can be broadly divided into two categories—flexor and extensor. Flexor tendon injuries cause less impairment of hand function than extensor tendon injuries. This is mainly due to the redundancy of the flexor tendons in the hand, while there is only one extensor tendon for the second through fifth fingers. Flexor tendon lacerations should always be repaired in the operating room because the synovial sheaths predispose to serious infections. Extensor tendon injuries can be repaired by an emergency department physician, but because the tendons often retract into the hand when they are cut, they can be difficult to repair without surgical intervention.

Flexor tendon injuries are classified into five zones. Zone I is where the flexor digitorum superficialis inserts into the profundus tendon and the base of the distal phalanx. Zone II is from the MCP to the DIP joint of the fingers, an easily damaged area that must be thoroughly assessed for flexor tendon injuries. Zone III extends from the exit of the carpal tunnel to the MCP joint, essentially including the palm. Zone IV includes the wrist and carpal tunnel, which has many tendons in a small area. If there is an open injury, it must be carefully explored. Zone V is the forearm.

Any flexor tendon lacerations should be repaired by a hand surgeon within 12 hours, but they can be splinted with the fingers flexed for delayed repair within four weeks. This is not as favorable, however, as having the tendon repaired within the first 12 hours.

Extensor tendons are classified into eight zones. Zone I is the area over the DIP joint and distal phalanx. Disruption of the tendon will cause mallet finger, which is a DIP that is flexed to 40 degrees at rest. As long as there is less than 25% of the articular surface involved, this can be treated with immobilization and hyperextension for 8 to 10 weeks. If more than 25% of the articular surface is involved as a result of an associated avulsion fracture, surgery is required. The long-term consequence of this injury can be a swan's neck deformity, which is hyperextension of the PIP joint.

Zone II is over the middle phalanx; assessment and treatment are the same as for zone I injuries. Zone III is over the PIP joint. Injury here can result in a boutonniere's deformity, which is hyperextension at the MCP and DIP joints. Treatment consists of splinting the PIP joint only in hyperextension, leaving the MCP and DIP joints free to move. Referral to a hand surgeon is necessary, and if this is an open injury or associated with a displaced avulsion fracture, then surgery is recommended. Zone IV injuries are located on the proximal phalanx and are treated like zone III injuries.

Zone V injuries occur over the MCP joint. All open injuries in this area are presumed to be human bites (secondary to a fist-to-mouth mechanism of injury) until proven otherwise. Patients are often not forthcoming with this history. Primary tendon repair can be performed here using 4-0 nonabsorbable sutures, but rarely does a complete tendon laceration occur. All bites should be treated with an antibiotic with antistaphylococcal and beta-lactamase inhibition properties (for example, amoxicillin or clavulanate potassium) and delayed closure in four to five days.

Zone VI injuries are on the dorsum of the hand. The tendons are very superficial here and can be easily damaged. They can be surgically repaired or splinted in 30 degrees extension at the wrist and a neutral MCP joint for referral to a hand surgeon. Zone VII injuries involve the wrist and multiple tendons; these should be evaluated by a hand surgeon. Zone VIII injuries are in the distal forearm. Injuries in this location often require tendon retrieval for complete lacerations and may need to be performed in the operating room.
 

PHALANX FRACTURES

General principles of orthopedic management apply to fractures of the hand, such as a thorough neurovascular assessment, both proximal and distal to the injury, and radiographic examination. Most closed fractures can be stabilized with splinting in the emergency department and managed on an outpatient basis. Open, intra-articular, or unstable fractures, however, require consultation for probable open reduction in the operating room. All open fractures require antibiotics, such as cefazolin, usually administered intravenously.

Distal phalanx fractures are the most frequently seen fractures of the hand, with the tuft being the most common site. Tuft fractures are often associated with nail bed lacerations, which should be surgically repaired. If only a subungual hematoma is present, then trepanation of the nail may be attempted first. Fractures at the base of the distal phalanx should be closely examined for any intra-articular or avulsion fractures. Generally, these fractures can be splinted in a hairpin or metal splint, without splinting the PIP joint. Analgesia and follow-up are required.

Middle and proximal phalanx fractures are treated in a similar manner. Middle phalanges have two tendon attachments that can exert forces on the bone if it is broken. Fractures of the neck of the middle phalanx result in volar angulation; fractures at the base result in dorsal angulation. Proximal phalanx fractures generally are volar angulated because of the extensor and interosseus muscles. Direct blow injuries may cause transverse or comminuted fractures, while twisting injuries tend to cause spiral or oblique fractures.

Because the digital arteries and nerves run on the sides of the fingers, a careful neurovascular examination is mandatory. Rotational deformities need to be evaluated clinically; it is often difficult to assess them by radiographs alone. Clinically, the plane of the fingernails of the affected hand should be observed with the fingers slightly flexed. With a closed fist, the second through fifth fingers should point to the scaphoid bone. The majority of fractures are closed, stable fractures that simply require buddy taping and follow-up in 7 to 10 days. For displaced fractures, a digital block can be performed and reduction attempted. If reduction is successful, the hand should be splinted in either a radial or ulnar splint, from the DIP joint to the elbow, with the MCP joint in 90 degrees of flexion and the wrist extended at 20 degrees. Irreducible or unstable fractures often require surgical repair.

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METACARPAL FRACTURES

Metacarpal fractures are classified as head, neck, shaft, or base fractures. The second and third metacarpals are fixed and have little to no anteroposterior movement. The fourth and fifth metacarpals have anteroposterior movement. This comes into play when determining the amount of angulation that can be allowed, while still ensuring proper healing and finger and hand function. Fractures of the metacarpal head are usually due to a crush or direct blow injury. Often this results in a comminuted fracture. If it is open, it should be assumed that it is due to a human bite. A hand surgeon should be consulted and appropriate antibiotics should be initiated. If the wound is closed, the hand can be splinted with the wrist extended to 20 degrees, the MCP flexed to 90 degrees, and the PIP and DIP extended. All injuries should be referred to a hand or orthopedic specialist for follow-up.

Neck fractures are usually due to a direct force. A fracture of the neck of the fifth metacarpal is termed a boxer's fracture because of its frequent association with that mechanism of injury. This is a type of fracture in which the degree of angulation is extremely important. If the distal fragment and the fifth finger are angulated less than 40 to 45 degrees, then reduction is unnecessary. The amount of angulation allowed should be less than 35 degrees for the fourth finger but only 15 degrees for the second and third metacarpals. Any more than this requires reduction with splinting in a gutter splint similar to that used for metacarpal head fractures. Once again, early follow-up is necessary.

Shaft fractures are usually from direct blows as well. These fractures tend to shorten and rotate instead of angulate. If angulation does happen, less than 10 degrees is tolerable in the second and third fingers, while up to 20 degrees is acceptable for the fourth and fifth metacarpals. Any rotational deformity, degree of angulation greater than the above mentioned, or open, irreducible, or multiple fractures will require internal fixation. A good general rule to remember is that any shaft fracture that requires manipulation or reduction will need surgical repair. Most of these fractures can be managed initially with a gutter splint (not including the MCP joint) and referral to a hand or orthopedic surgeon.

Base fractures are uncommon, and a careful examination for a carpal fracture should be performed. The ulnar nerve runs near the base of the fourth and fifth metacarpals and an evaluation of its function (both motor and sensory) should be part of the examination.

The thumb (or first) metacarpal is not commonly fractured due to its mobility. When they occur, these fractures are classified as either intra-articular or extra-articular. Extra-articular fractures are more common and usually result from a direct blow or axial loading injury. The mobility of the thumb allows for up to 20 degrees of angulation; more angulation than that will require reduction. A thumb spica should be applied and the patient referred to a hand or orthopedic surgeon.

Intra-articular fractures can be either a Bennett's or Rolando's fracture. A Bennett's fracture is an intra-articular fracture at the base of the thumb, with a dislocation or subluxation of the CMC joint. The ulnar portion of the metacarpal remains in place, and the remainder is displaced radially and dorsally. Reduction is necessary, followed by thumb spica splinting and early referral. A Rolando's fracture is a comminuted fracture at the base of the thumb. Thumb spica splinting and early referral are also necessary with this type of fracture.
 

CARPAL BONE FRACTURES

Fractures of the carpal bones account for up to 10% of hand fractures. The most common is a scaphoid fracture, which usually results from a FOOSH injury. The scaphoid can be fractured in the distal, middle, or proximal area. The blood supply comes from the distal to the proximal aspect, and proximal fractures should be watched closely for avascular necrosis. About 10% of scaphoid fractures are missed on initial x-rays, so a thumb spica should be applied to all suspected fractures, with re-evaluation in 7 to 10 days. If there is more than one millimeter of displacement, orthopedic referral is recommended.

Lunate fractures are not common. They usually occur in association with another fracture and are also seen in people with congenitally short ulnas. They are treated in the same manner as a scaphoid fracture.

Triquetrium fractures are usually the result of direct trauma or a FOOSH injury. Typically, they occur as a result of the ulnar styloid causing a dorsal chip fracture. The triquetrium is covered by many ligaments and in most cases there is no displacement with the fracture. Avascular necrosis has not been reported as a complication. Treatment is a short arm splint for four to six weeks.

The pisiform bone is actually a sesamoid bone in the flexor carpii ulnaris tendon. Because this bone makes up one of the sides of Guyon's canal, where the ulnar artery and nerve run, the examiner must have a high index of suspicion for an injury. A short arm splint for four weeks is the treatment, with ulnar deviation and 30 degrees of flexion. Trapezium fractures are usually due to an injury to the thumb. Nondisplaced fractures are treated with a thumb spica for six weeks, while displaced fractures require outpatient referral for open reduction. Trapezoid fractures are rare and are usually due to an axial load on the metacarpal bone of the index finger. If the fracture is simple, a short arm cast will suffice. If a fracture dislocation is present, close follow-up with an orthopedist is necessary.

Capitate fractures are normally due to a direct blow to the dorsum of the wrist; there is often an associated scaphoid fracture or dislocation. With this bone, like the scaphoid, avascular necrosis may develop. These fractures are managed the same way as a trapezoid fracture. Hamate fractures are rare; when they do occur, the hook is involved. The most common mechanism of injury is an interrupted swing with some type of sports equipment in the affected hand. The hook of the hamate makes up another side of Guyon's canal, and like the pisiform bone, it should be watched closely. A short arm cast with orthopedic follow-up in 7 to 14 days is recommended.

The distal radius and ulna are considered part of the wrist and are frequently injured as well. Colles' fracture is the most common wrist fracture seen in the adult population. The mechanism is usually a FOOSH injury. The fracture occurs at the metaphysis of the distal radius and involves dorsal displacement with angulation. Often, it is associated with an ulnar styloid fracture; this is the dinner fork deformity that is frequently described.

Because the median nerve and vasculature are at risk for injury with this fracture, a careful neurovascular examination should be performed. Any indication of damage to these structures requires emergent orthopedic consultation. If no such damage is found, reduction should be attempted in the emergency department. Most fractures can be reduced and then immobilized. Comminuted fractures and those with more than 20 degrees of dorsal angulation or intra-articular involvement require close follow-up with an orthopedist.

A Smith's fracture, also known as a reverse Colles' fracture, has the same mechanism of injury with similar complications. The difference is that the fracture is volar angulated and displaced and is known as a garden spade deformity. Treatment is the same as for a Colles' fracture, with reduction in the opposite direction.

A Barton's fracture is a dorsal rim or volar rim fracture involving the distal radius. It is an intra-articular fracture, with displacement of the carpus (or hand). The carpus is dislocated in the same direction as the fracture. Most of these require surgical repair. An orthopedist should be consulted. Some minimally displaced fractures may be managed by closed reduction with splinting and early orthopedic follow-up.

A Hutchinson fracture, also known as a chauffeur's fracture, is a fracture of the radial styloid with intra-articular involvement. This is a transverse fracture of the radial metaphysis. Nondisplaced fractures can be treated with a short arm splint for four to six weeks with orthopedic follow-up. However, many ligaments attach to the radial styloid and displacement of as little as three millimeters can have poor results. These fractures are often associated with scapholunate dissociation. This must be surgically corrected, and as with a Barton's fracture, early orthopedic consultation with close follow-up is advised.

An ulnar styloid fracture is often due to either forced dorsiflexion or radial deviation of the wrist. If it is an isolated injury, the patient often complains of a clicking sound in the wrist. However, this fracture often occurs with other fractures, such as Colles' fracture. Splinting in a neutral position with ulnar deviation and orthopedic follow-up is recommended.
 

MANY DIFFERENT INJURIES

Due to the number of bones, tendons, nerves, and vessels in the area, it is easy to understand how many different injuries can occur in the hand and wrist. By following the basic principles of examination, reduction, splinting, and referral, the primary care physician and emergency physician can ensure that their patients receive appropriate care.

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