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The Wrist

3/5/2018

0 Comments

 
Authored by Dr. Javier Andrade
  • With any orthopedic injury, it is important to understand the normal bony anatomy of the injured area you are examining:
    • The Wrist is a complex area with multiples bones and joint.
    • It is composed of the more proximal ulna and radius which anchor the wrist and help create the supination and pronation needed for complex hand movements
    • The distal portion of the wrist is made up of the 8 carpal bones arranged in two rows.
Picture
Picture
  • Now that we now what bones make up the wrist, we can talk a bit more about the alignment and tricks we can use to see if there is an injury to the wrist.
    • One such trick we can use for the PA view are Gilula’s Line. It is a technique which uses 3 curved lines to check the alignment of the carpal bone rows.
      • Proximal row, proximal portion (pink)
      • Proximal row, distal portion (blue)
      • Distal row, proximal portion (red)
Picture
  • Also, as with any ortho injury, remember to assess that the patient is neurovascularly intact!
    • Vascular: Can use the doppler probe to assess
      • Ulnar artery
      • Radial Artery
      • Palmar arch
    • Nerves:
      • Radial n: Test the extensor pollicus longus using “thumbs up”
      • Median n: Test using the “OK sign”
        • Make sure patient flexes at the DIP joint
      • Ulnar n: Test using pinky abduction
  • Pathology:
    • Scaphoid Fx
      • Most commonly injured carpal bone and can be easily missed. If you have clinical exam findings but no radiologic findings, treat this as a fracture!
      • Tx: Thumb spica cast and reimage in 12 days.
    • Lunate and Perilunate dislocation
      • Associated with high-energy mechanism of injury as it has to tear through multiple ligaments that hold the hand together. Be on the lookout for other injuries in the wrist.
        • Associated with median n injury in 25% of patients
      • Notice the anatomy on the normal image (left). We can use the lines on the lateral XR view to assess for injury
Picture
Picture
  • Hamate fracture:
    • Body: Clenched fist against solid object
      • Typically requires surgical intervention
    • Hook: Associated with injuries that require swinging equipment (baseball, tennis, etc.)
      • Can cause ulnar n. injury or impingement
  • Distal Radius Fractures:
    • Colle’s: Fx with posterior displacement
    • Smith’s: Fx with anterior displacement
  • Distal Radial-Ulnar joint (DRUJ) injuries
    • Normally, the ulna sits on a small groove on the distal radius known as the sigmoid notch.
      • Any spacing here is abnormal
Picture
  • Management:
    • If purely ligamentous closed immobilization and outpatient follow-up
    • If associated with fracture then operative repair is necessary
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction