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Emergency and Acute Medicine – Carpal Fractures
Overview
Carpal fractures involve the most frequently injured region of the upper extremity. The scaphoid accounts for approximately 68% of cases, followed by the triquetrum at about 18%. These injuries often coexist with other wrist trauma, including scaphocapitate syndrome (capitate fracture with scaphoid fracture), perilunate dislocations, hamate fractures with fourth and fifth carpometacarpal injuries, and concurrent distal radius fractures.
Mechanisms of Injury
Typical mechanisms include a fall on an outstretched hand with wrist hyperextension or hyperflexion, direct blows, axial loading, and repetitive or chronic use injuries. Hyperflexion commonly results in dorsal avulsion fractures, while hyperextension leads to volar avulsion fractures. Hook of hamate fractures are classically associated with forceful swinging motions, such as with racquets or golf clubs.
Clinical Features
Patients usually report a fall or direct impact. Examination reveals pain, swelling, and reduced wrist motion. Careful palpation of individual carpal bones is possible with proper wrist positioning. Scaphoid fractures often present with snuffbox tenderness, which is sensitive but nonspecific; specificity improves with wrist pronation and ulnar deviation. Axial thumb compression may elicit pain but lacks specificity. Palmar tenderness over the scaphoid tubercle at the distal wrist crease with wrist extension is more specific.
Initial Assessment Priorities
A complete examination of the entire upper extremity and shoulder girdle is required to identify associated injuries. A thorough neurovascular assessment is essential, particularly for hamate fractures, which may involve ulnar nerve or artery injury.
Diagnostic Evaluation
Standard imaging includes anteroposterior, lateral, and oblique views of the wrist and hand. Dedicated views, such as scaphoid views, should be obtained when suspicion remains high. CT scanning provides superior fracture detection, while MRI is useful for identifying occult fractures and ligamentous injuries.
Conditions to Differentiate
Consider metacarpal base fractures, distal radius or ulna fractures, lunate dislocation, perilunate dislocation, and in children, distal radius epiphyseal injuries, as pediatric wrist trauma rarely represents a simple sprain.
Early Management
In the prehospital or early ED setting, protect open wounds, elevate the limb, apply ice, remove constricting jewelry, and immobilize the wrist with padded splints. As with all trauma, assess for life-threatening injuries first.
Definitive Emergency Care
Most isolated carpal fractures are initially treated with immobilization aimed at maintaining alignment. Thumb spica splints are used for scaphoid and trapezium fractures. Sugar-tong splints are appropriate for capitate and lunate fractures, maintaining the wrist in neutral position. Volar splints are suitable for triquetrum, pisiform, trapezoid, and hamate fractures with slight wrist extension. Suspected fractures, especially scaphoid injuries, should be splinted even if initial radiographs are negative. Open fractures require immediate irrigation, IV antibiotics targeting Staphylococcus aureus with additional gram-negative coverage for severe soft tissue injury, tetanus prophylaxis, neurovascular monitoring, and urgent orthopedic consultation.
Pain Control
Analgesia includes NSAIDs, mild oral narcotics, or other oral analgesics. Proper immobilization often provides significant pain relief.
Disposition Planning
Open fractures and unstable or displaced injuries requiring operative intervention warrant admission. Closed, nondisplaced fractures adequately immobilized may be discharged with orthopedic follow-up in 7–10 days.
Follow-Up Strategy
All confirmed fractures require orthopedic referral for casting and definitive care. Missed injuries or inadequate immobilization can result in nonunion, avascular necrosis, chronic pain, and disability. Persistent pain despite negative initial imaging should prompt repeat radiographs or advanced imaging after 7–10 days.
Clinical Pearls and Pitfalls
Carpal fractures are frequently occult on initial imaging and easily missed. All clinically suspected fractures should be immobilized. While most scaphoid fractures occur in isolation, other carpal fractures are commonly associated with additional wrist or hand injuries. Long-term outcomes depend heavily on early recognition, proper splinting in a functional position, and timely orthopedic follow-up.
Overview
Carpal fractures involve the most frequently injured region of the upper extremity. The scaphoid accounts for approximately 68% of cases, followed by the triquetrum at about 18%. These injuries often coexist with other wrist trauma, including scaphocapitate syndrome (capitate fracture with scaphoid fracture), perilunate dislocations, hamate fractures with fourth and fifth carpometacarpal injuries, and concurrent distal radius fractures.
Mechanisms of Injury
Typical mechanisms include a fall on an outstretched hand with wrist hyperextension or hyperflexion, direct blows, axial loading, and repetitive or chronic use injuries. Hyperflexion commonly results in dorsal avulsion fractures, while hyperextension leads to volar avulsion fractures. Hook of hamate fractures are classically associated with forceful swinging motions, such as with racquets or golf clubs.
Clinical Features
Patients usually report a fall or direct impact. Examination reveals pain, swelling, and reduced wrist motion. Careful palpation of individual carpal bones is possible with proper wrist positioning. Scaphoid fractures often present with snuffbox tenderness, which is sensitive but nonspecific; specificity improves with wrist pronation and ulnar deviation. Axial thumb compression may elicit pain but lacks specificity. Palmar tenderness over the scaphoid tubercle at the distal wrist crease with wrist extension is more specific.
Initial Assessment Priorities
A complete examination of the entire upper extremity and shoulder girdle is required to identify associated injuries. A thorough neurovascular assessment is essential, particularly for hamate fractures, which may involve ulnar nerve or artery injury.
Diagnostic Evaluation
Standard imaging includes anteroposterior, lateral, and oblique views of the wrist and hand. Dedicated views, such as scaphoid views, should be obtained when suspicion remains high. CT scanning provides superior fracture detection, while MRI is useful for identifying occult fractures and ligamentous injuries.
Conditions to Differentiate
Consider metacarpal base fractures, distal radius or ulna fractures, lunate dislocation, perilunate dislocation, and in children, distal radius epiphyseal injuries, as pediatric wrist trauma rarely represents a simple sprain.
Early Management
In the prehospital or early ED setting, protect open wounds, elevate the limb, apply ice, remove constricting jewelry, and immobilize the wrist with padded splints. As with all trauma, assess for life-threatening injuries first.
Definitive Emergency Care
Most isolated carpal fractures are initially treated with immobilization aimed at maintaining alignment. Thumb spica splints are used for scaphoid and trapezium fractures. Sugar-tong splints are appropriate for capitate and lunate fractures, maintaining the wrist in neutral position. Volar splints are suitable for triquetrum, pisiform, trapezoid, and hamate fractures with slight wrist extension. Suspected fractures, especially scaphoid injuries, should be splinted even if initial radiographs are negative. Open fractures require immediate irrigation, IV antibiotics targeting Staphylococcus aureus with additional gram-negative coverage for severe soft tissue injury, tetanus prophylaxis, neurovascular monitoring, and urgent orthopedic consultation.
Pain Control
Analgesia includes NSAIDs, mild oral narcotics, or other oral analgesics. Proper immobilization often provides significant pain relief.
Disposition Planning
Open fractures and unstable or displaced injuries requiring operative intervention warrant admission. Closed, nondisplaced fractures adequately immobilized may be discharged with orthopedic follow-up in 7–10 days.
Follow-Up Strategy
All confirmed fractures require orthopedic referral for casting and definitive care. Missed injuries or inadequate immobilization can result in nonunion, avascular necrosis, chronic pain, and disability. Persistent pain despite negative initial imaging should prompt repeat radiographs or advanced imaging after 7–10 days.
Clinical Pearls and Pitfalls
Carpal fractures are frequently occult on initial imaging and easily missed. All clinically suspected fractures should be immobilized. While most scaphoid fractures occur in isolation, other carpal fractures are commonly associated with additional wrist or hand injuries. Long-term outcomes depend heavily on early recognition, proper splinting in a functional position, and timely orthopedic follow-up.
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