Mayfield, Johnson and Kilcoyne described a pattern of carpal injury caused by wrist hyperextension, ulnar deviation and intercarpal supination in 1980. So have the patient make the OK sign and resist as you try to open it! It is a branch of the median nerve and is purely motor, so there will be no sensory deficit or paresthesia! It manifests as loss of pinch strength between the thumb and index finger. >5mm of shortening of the radius relative to the distal ulna.Ī subtle clinical finding often associated with the Galeazzi fracture is anterior interosseus nerve injury. DRUJ injury is radiographically diagnosed by:įracture at the BASE of the ulna styloid process (not the tip)Ī widened DRUJ (a comparison x ray may be necessary), or The radial shaft fracture is usually obvious and can distract the clinician from the less dramatic DRUJ injury. There’s a saying in orthopedics that “the most commonly missed injury is the second injury”. Hughston confirmed this is 1957, reporting that 35/38 cases treated nonoperatively had unsatisfactory outcomes. The Galeazzi fracture is a classic EM boards question, because it is important! It was termed by Campbell as the “fracture of necessity” (modern day translation = “this needs surgery!”) in 1942 because nonoperative management was observed to be associated with recurrent ulna styloid dislocations. Ko to highlight these injuries that are often subtle, yet important because of the comorbidities associated with missing the diagnosis. Injury to this ligament can occur with acute FOOSH injury or be caused by degenerative rupture of the ligament. Scapholunate dissociation is caused by injury to the scapholunate ligament. Once the lunocapitate joint is reduced, the wrist can be extended in traction again for full reduction. Then, with continued traction, the wrist should be gradually flexed so that the capitate falls back into place within the concavity of the lunate. The wrist should be extended while placing palmar pressure on the lunate. Usually, the assistance of our orthopaedic colleagues is warranted. How Would I Reduce These Injuries in the ED? Definitive treatment involves open reduction and internal fixation. If unsuccessful, operative management is indicated. If successful, definitive treatment can occur up to 7 days later. In the ED, closed reduction can be attempted. On an AP film, a break in Gilula’s arc/lines may be used to assess for a perilunate or lunate dislocation (Figure 2). In a perilunate dislocation, the lunate sits in line with the radius/ulna, however the capitate/metatarsal bones are dislocated dorsally. In a lunate dislocation, the lunate itself is physically removed or out of line with the rest of these bones (Figure 1, far right), resulting in the classic “spilled teacup” appearance on x-ray. In a normal lateral x-ray, these bones should all align (Figure 1, far left). The key to distinguishing these injuries on imaging is the alignment between the metacarpal, carpal, and the radius/ulna bones. Lunate and perilunate dislocations can be easily confused or mistaken for each other. The injury can be an isolated injury or associated with forearm fractures and should be tested for with every forearm injury as its presence can alter the disposition and even functionality of the patient. It has significant contributions to the axial load-bearing capabilities of the forearm. The distal radioulnar joint (DRUJ) consists of both the bony radioulnar articulation as well as the soft tissue components, including ligaments. What exactly is the distal radioulnar joint and why is it important? Each of these injuries should be carefully assessed for on physical exam and imaging. If found, these injuries can alter the management and disposition of the patient. Three less common injuries are reviewed here. Many of these injuries are uncomplicated, but an astute clinician can diagnose subtle and uncommon injury patterns. In the emergency department, orthopedic complaints make up a large percentage of presentations, up to 50% in the pediatric population and close to 33% in the adolescent and young adult population. “Can’t Miss” Hand and Wrist Injuries in the ED
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