FOOSH It sounded like a fun thing at the time! 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 Edema, ecchymosis w/ possible crepitus Dorsal displacement of radius causing visible deformity (dinner fork deformity)
Presentation When no deformity is present, injury can be passed off as bad sprain Soft tissue injuries may also be present Tendon tear/avulsion Nerve injury
Radiographs Loss of normal anatomy Displacement Angulation radial height Involvement of radiocarpal or distal radioulnar joint Articular surface Step-off Separation Significant comminution
Radiographs Loss of normal anatomy
Radiographs Loss of normal anatomy Displacement
Radiographs Loss of normal anatomy Angulation
Radiographs Loss of normal anatomy radial height
Radiographs Involvement of radiocarpal or distal radioulnar joint Articular surface Step-off Separation
Radiographs Significant comminution
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 Associated wrist or elbow dislocation Supracondylar fracture
Management Peds Sail Sign
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 Sugar-tong Double sugar-tong
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
Management Peds Non-displaced Salter-Harris I or II fractures
Management Peds Non-displaced Salter-Harris I or II fractures Stable Immobilization with short arm splint x 3-4 weeks Volar splint for SH1 Sugar-tong for SH2 Sling for support
Management Peds Greenstick fracture Immobilization with cast x 6-8 weeks Distal short arm cast Proximal long arm cast x 3wks 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 Gupta R, Bozentka DJ, Osterman AL: Wrist Arthroscopy: Principles and Clinical Applications. J. Am Acad. Orthop 2001;9:200-209.
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 Fractures
Usefulness of MRI
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
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
5 th Metacarpal Fracture Management Stable Splint for pain Consider cast or splint
1st Metacarpal Fracture Bennett Fracture Base of 1 st 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 lcollins@health.usf.edu