During exploration, consider the position of the hand at the time of injury: reproducing th is may reveal injuries otherwise hidden. Therefore, put all mobile structures through their full range of movement. Extensor tendon injuries > 50 % or complete division needs repair (eg 4/0 or 5/0 non-absorb able mono \201 lament using Bunnell or Kessler stitch) by an experienced surgeon. This may be achieved under LA in the ED, depending on facilities and expertise. Follow extensor ten don repair with appropriate immobi- lization (eg volar slab type POP with \201 nger joint s in full extension and slight \202 exion at the MCPJs). Treat <50 % division by splintag e in extension (eg POP slab as above) under the care of the hand surgeon. Flexor tendon injuries Refer immediately for specialist repair. Nerve injuries Complete division of a nerve may cause surprisingly little sensory loss, so take complaints of any altered sensation very seriously. Refer patients with suspected nerv e injuries. Digital nerves can be repaired up to the level of the distal phalangeal joint ( DIPJ), although it may be decided not to attempt to repair injuries which are distal to the PIPJ. Remember that it is functionally important to have intact sensation over the \200 \230edges \200\231 of the hand (the thumb, the radial aspect of the index \201 nger or ul nar aspect of the little \201 nger). Patients sometimes present late after digital nerve injuries \200\224 repair can still be quite successful up to 2 weeks after injury. 435 HAND WOUNDS AND ASSOCIATED INJURIES Reverse \201 ght bites Treat and refer as outlined in b Speci \201 c bites and stings, p .416. Consider transfer of blood-borne infection as discussed in b Needlestick injury, p.41 8. Amputations Refer patients with partial or complete digital amputation with bony loss. Rece nt proximal amputations without crush injury in \201 t young patients may be suitable for re-implantation: others may be treated with \200\230termi- nalization \200\231 or advance ment \202 ap. Let the hand surgeon decide. Meanwhile, dress, bandage and elevate, give IV analgesia, tetanus cover, broad spec- trum antibiotics (eg cephalosporin), and keep fasted . Wrap the amputated part in moist saline swabs and place in a sealed plastic bag, surround ed by ice/water mix at 4 * C. Note: Do not freeze or place the amputated part directly in s olution. Finger pad amputations Skin loss less than 1cm 2 without bony exposure may be allowed to he al with non-adherent dressings. Larger areas of tissue loss (particularly in adults) may re quire skin grafting or advancement \202 ap, but some do heal satisfactorily with simple d ressings. Ring avulsions Refer all circumferential and signi \201 cant degloving injuries. Compound injuries Wounds over dislocations or fractures usually require specialist atten- t ion. Distal compound phalangeal fractures may be treated in the ED with wound cleaning, clo sure, review, and prophylactic antibiotics. Crush injuries Frequently cause \200\230burst \200\231 injury \201 ngertip wounds. Clean the wounds and take into account the likely swelling when considering closure. Elevate, dr ess, give analgesia, and arrange review. Nail bed lacerations Accurate repair (eg 6/0 Vicryl) may prevent nail deformity. Nailfold-l acerations extending towards the nail bed require removal of the nail to allow suture. Cons ider replacing the nail after to act as a temporary dressing. Foreign bodies under nail Splinters and other FBs under \201 ngernails are relatively com mon. Apply a digital block and remove with \201 ne forceps. If the FB cannot be reached e asily, cut away an appropriate piece of nail. Subungual haematomas Blood frequently collects under the nail after a crush injury, causing pain by pressure. If > 50 % of the nail is affected, trephine the nail distal to the lunul a, using a red hot paper clip or battery operated drill. High pressure injection injuries Industrial grease or paint guns may cause small skin wound s, which initially appear trivial, disguising a devastating injury with risk of permanent s tiff- ness and signi \201 cant tissue loss. X-rays may help to identify the extent of fore ign material. Refer all such patients to a hand surgeon for immediate exploration and debri dement. 436 CHAPTER 9 Wounds, fractures, orthopedics Hand fractures and dislocations Distal phalangeal fractures Treat closed fractures of the d istal portion (tuft) of the distal phalanx with analgesia and elevation. Treat compound bur st injuries (from crushing injuries or hammer blows) with meticulous exploration, wound toi let/ repair under LA and arrange follow-up. Give antibiotics (not a substitute for primary surgical treatment). Mallet \201 nger with fracture \200\230Mallet \201 nger \200\231 injury may be associa ted with a small fracture at the base of the distal phalanx at the point of attachment of t he extensor tendon. Treat as for (the more usual) mallet \201 nger injury without fractur e by plastic mallet splint for \211\210 6weeks, advice and follow-up (see details on b Sof t tissue hand injuries, p.440). Refer larger bony fragments ( > 1 / 3 articular surface) wi th mallet deformity or those with subluxation for pos- sible K-wire internal \201 xation. Fig. 9.15 Mallet \201 nger deformity. Fig. 9.16 Mallet \201 nger with avulsion fracture. Proximal and middle phalangeal fractures Treat undisplaced fractures with elevation, neighb or strapping (Fig. 9.17 ), and analgesia. Manipulate angulated proximal and middle phalange al frac- tures under digital or wrist blocks. A useful tip for proximal phalangeal fracture s is to use a needle-holder or pencil placed adjacent to the web space as a fulcrum. Mainta in reduction using neighbor strapping and a volar slab POP or \202 exible padded aluminum (Zimmer) splint, although the latter can be dif \201 cult to secure. If reduction is unsa tisfactory or cannot be maintained, refer for surgical \201 xation. Index, middle, and ring metacarpal fractures Check for displacement or rotational deformity and refer if present. Treat with analgesia, elevation, and protect in a volar slab POP. In ternal \201 xation may be considered for midshaft MC fractures with marked angulation, bu t can be complicated by marked post-operative stiffness. Phalangeal dislocations X-ray all dislocations prior to reduction for presence of associate d fractures. Reduce under digital or metacarpal nerve block ( b p.294) or Entonox by tra ction and gentle manipulation, then check integrity of the collateral ligaments. Con \201 rm reduction on X-ray and immobilize the \201 nger by neighbor strapping. Elevate the han d, provide oral analgesia and arrange follow-up. 437 HAND FRACTURES AND DISLOCATIONS Fig. 9.17 Neighbor (buddy) strapping. Little (5th) metacarpal fractures Common result of punching. Check for rotational deformity by gently \202 exing \201 ngers into the palm (they should point roughly to the thenar emi- nence and touch, but not overlap adjacent \201 ngers on \202 exion). Angulation i s common with neck fractures and rarely requires correction, with even up to 40 * being acc epted. Apply neighbor strapping, elevate and give analgesia. A volar slab POP for 2weeks is sometimes advocated \200\224 follow local protocols. Warn the patient that the 5th knuckl e will be shorter than before. Arrange follow-up and advise hand exercises as soon as possi ble. Refer to orthopedic team if there is rotational deformity or signi \201 cant angulation, p articularly with base and shaft fractures, which may need surgery. Also refer patients with associated wounds, remembering that these may be compound human bites ( \200\230reverse \201 ght-bites \200\231 \200\224 b Speci \201 c bites and stings, p.416). Little (5th) metacarpal dislocations Dislocations at the base of the 5th MC may be associat ed with a fracture. Refer for reduction and internal \201 xation. 438 CHAPTER 9 Wounds, fractures, orthopedics Thumb fractures and dislocations Dislocation at metacarpophalangeal joint After X-rays and LA block, attempt reduction. If successful, assess and document the integrity of the collat eral ligaments (see b Soft tissue hand injuries, p.440), then immobilize in slight ( \211 \210 15 * ) \202 exion in a POP and arrange follow-up in fracture clinic. Reduction may b e unsuccessful due to \200\230button-holing \200\231 \200\224 in this case, refer for ope n reduction. Gamekeeper \200\231s thumb with associated avulsion fracture Most abduction injuries result in ulnar collateral ligament injury without fracture, but occasionally an avulsion fractur e occurs at the point of ligament attachment instead. Treat this in a scaphoid POP and refe r to fracture clinic, unless the bony fragment is displaced by more than 2mm, in which case internal \201 xation will probably be required. MC Fig. 9.18 If undisplaced, treat in scaphoid POP, and refer to fracture clinic, but if displaced, refe r for internal \201 xation. Thumb dislocations Dislocations usually follow falls onto the thumb or hyperextension injur ies. They can occur at any level, including at the interpahalangeal joint (IPJ), MCPJ, and at the carpometacarpal joint. Reduce dislocations by traction and local pressure under comb ined median and radial nerve blocks ( b Nerve blocks at the wrist, p.296). Con \201 rm red uction by X-ray, immobilize in a scaphoid POP, and arrange follow-up. 439 THUMB FRACTURES AND DISLOCATIONS Bennett \200\231s fracture-dislocation ( b p.498) This is a fracture through the base of th e thumb (1st) MC with radial subluxation of the MC, leaving a small proximal fragment still joined to the trapezium (Fig. 9.19 ). The injury results from a fall onto the thumb or fro m a fall/blow onto a \201 st closed around the thumb. Deformity and swelling occur over t he base of the thumb and may be mistaken clinically for a scaphoid injury. This is an unsta ble injury requiring expert attention. If undisplaced, apply a Bennett \200\231s type POP ( similar to a scaphoid POP, but with the thumb abducted). If there is any displacement, refe r for manipu- lation under anesthetic (MUA)/ \201 xation. Maintaining reduction often requ ires the use of screw or Kirschner wire \201 xation. Fig. 9.19 Bennett \200\231s fracture-dislocation. 440 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue hand injuries Gamekeeper \200\231s thumb The thumb \200\231s ulnar collateral l igament is crucial for stability and function. It is typically injured in hyperabduction in juries (eg falls while skiing). Complete rupture usually results in the two parts of the li gament being separated by the adductor aponeurosis (the \200\230Stener lesion \200\231), s o satisfac- tory healing cannot occur. If tender over the ulnar collateral ligament of the thumb MCPJ, obtain X-rays: if these demonstrate a fracture, do not stress the joint, but tr eat appropriately instead ( b Thumb fractures and dislocations, p.438). If no fracture, ass ess stability of the ulnar collateral ligament by gentle abduction of the MCPJ (compare wit h the other hand). Examine the ulnar collateral ligament with the thumb slightly (15 * ) \202 exed. If pain precludes adequate examination, consider Entonox (and/or LA injection ) and repeat the examination. Signi \201 cant ( > 30 * ) laxity implies complete rupture a nd need for operative repair. Treat uncomplicated sprains with analgesia, elevation, and ei ther criss- cross adhesive strapping ( \200\230thumb spica \200\231) or a scaphoid POP if s ymptoms are severe, and arrange follow-up. Refer suspected or demonstrable ulnar collateral ligament rupture to the orthopedic surgeon, to consider primary surgical repair. Mallet \201 nger Injury to the extensor mechanism at the DIPJ is relatively common and results fro m forced \202 exion of the DIPJ or from a blow/fall directly onto the \201 ngertip. In the elderly it can follow minimal trauma. There is loss of full active extension at the DIP joint. Normal \202 exion is preserved. X-ray to exclude associated fracture \200\224 tr eated as outlined on b p.436. In the absence of a large fragment, treat in a plastic (malle t) splint secured with tape for \211\210 6weeks (see b p.436). Ensure that the patient und erstands the importance of wearing the splint at all times and to keep the \201 nger stra ight if the splint is removed for washing (eg hold \201 nger against a \202 at surface until splint replaced). Warn that there may be a small degree of permanent \202 exion def ormity. Arrange initial follow-up at \211\210 7 \200\22310 days, to ensure compliance with treatment and to reassess in case swelling has d and a smaller splint is required. Volar p late injury These are signi \201 cant injuries, often with prolonged morbidity. Hyperexten sion at the PIPJ injures the volar plate at the base of the middle phalanx with or without evidence of bony involvement. Examination shows fusiform swelling of the PIPJ with tenderne ss over the volar aspect. Treat with \200\230buddy strapping \200\231 to adjacent \201 n gers (or \200\230Bedford splint \200\231), elevate, provide analgesia, and begin mobilizat ion immediately. Arrange review to ensure full mobility is regained. A2 pulley injury The \201 nger \202 exor tendon sheath at the PIPJ is thickened and known as the A2 pulley. O ccasionally (especially in rock climbers), the tendon cuts through the A2 pulley, causing c haracteristic bowstringing on \202 exion. There may be associated tendon injury. Treat co nservatively with buddy strapping (or Bedford splint) and elevation. Arrange hand specialis t follow-up. Boutonni re deformity ( b Eponymous fractures, p.498) Characteristic deformit y from untreated rupture/division of central slip \201 nger extensor tendon may follow bl unt or penetrating trauma. 441 OTHER SOFT TISSUE HAND PROBLEMS Other soft tissue hand problems Pulp infections Infection of the pulp space at the \201 n gertip may re \202 ect underlying FB or osteomyelitis, so X-ray to search for these and tr eat accordingly. If X-rays are normal, incise the pointing area under LA digital block. Sen d pus for bacteriology, apply a dressing, commence oral antibiotics (eg \202 ucloxacillin 250 \200\223500mg PO qds), and arrange follow-up. Paronychia Infection of the nailfold adjacent to the nail is common. In the early stages, o ral antibiotics (eg co-amoxiclav or \202 ucloxacillin) may cure. Once pus has developed, drain this under LA digital block by an incision over the \202 uc tuance (usually a small longitudinally-orientated incision adjacent to the proximal nailfol d suf \201 ces, but pus under the nail may require removal of a segment of nail). Antibiot ics are then unnecessary, unless there is spreading infection (in which case, consider co-a moxiclav). Pyogenic \202 exor tenosynovitis Infection of a \201 nger \202 exor tendon sheath may follow penetrating injury. Classical signs (Kanavel \200\231s signs) are: \200 Tendernes s over the \202 exor tendon. \200 Symmetrical swelling of the \201 nger. \200 Finge r held in \202 exion. \200 Extreme pain on passive extension. Ensure tetanus prophylaxi s, then refer urgently for exploration, irrigation, and IV antibiotics. Other infections These include palmar space infections and septic arthritis \200\224 refer immediately for specialist treatment. Locked \201 nger Elderly patients with underlying osteoarthritis (OA) sometimes present w ith locking at a \201 nger MCPJ. A \201 xed \202 exion deformity is present, such tha t the patient can \202 ex, but not fully extend at the MCPJ. There is usually no particul ar history of trauma \200\224 the underlying cause is entrapment of the palmar plate on an osteophyte. Refer for an early hand surgeon opinion: surgery may be required. Trigger \201 nger/thumb This is relatively common, but not particularly related to trauma . Most cases are satisfactorily treated by steroid injection into the \202 exor tendon sh eath, but leave this to a specialist. 442 CHAPTER 9 Wounds, fractures, orthopedics Carpal bone fractures and dislocations Scaphoid fractures Assess and document whether there is tenderness over the scaphoid in all wrist injuries. Scaphoid fractures occur from falli ng onto an outstretched hand or from \200\230kick-back \200\231 injuries (eg from a steeri ng wheel in a car crash or football goalkeeper making a save). Pain and swelling over the w rist \200\231s radial aspect may be accompanied by dif \201 culty gripping. Look for \200 Tenderness in anatomical snuffbox: compare both sides. \200 Tenderness ov er palmar aspect of scaphoid (scaphoid tubercle). \200 Scaphoid pain on compressing the t humb longitudinally. \200 Scaphoid pain on gentle \202 exion and ulnar deviation of the wrist. \200 Tenderness over dorsum of scaphoid. X-rays Request specialized scaphoid (not wrist) views. Four views are usually taken (AP, lateral, right, and left obliques). Rememb er that scaphoid fractures may not be visible on initial X-rays. The scaphoid mostly fractu res through the waist, but sometimes through the tubercle (the latter does not give rise to signi \201 cant complications). Treatment If there is clinical or radiological evidence of fracture, apply a scaphoid POP o r splint, and arrange review in 10 \200\22314 days. Treat minimal snuffbox tenderness witho ut radiologically visible fracture with analgesia, and a wrist splint and arrange review as above. Complications Include non-union, avascular necrosis, and OA. Follow-up of clinically suspected scaphoid fractures (but normal X-rays) is often undertake n in ED clinic. Review at 10 \200\22314 days after injury, when if there is no clinical evi dence of fracture, patients may be discharged. If, however, there is continuing pain and/or scaphoid tenderness, repeat the X-rays: treat visible fractures in POP; but if X-rays are still normal, treat in splint or POP, and arrange MRI (or bone scan for those with claustro phobia or other contraindication to MRI) to de \201 nitively answer whether there is a fra cture or signi \201 cant carpal ligament injury. Lunate dislocations These injuries are rare, but often missed (Fig. 9.22 ). They follow fal ls onto the outstretched wrist, and result in pain and swelling anteriorly over the wrist. Median nerve paraesthesia may be a clue to the diagnosis. X-ray shows dislocation and rotat ion of the lunate so that it is shifted in front of the carpus and its concave surface face s towards the palm instead of distally. The AP view may look relatively normal, so carefull y scrutinize lateral views. Refer for immediate MUA. Complications Median nerve injury, avascular necrosis, Sudeck \200\231s atrophy. Other carpal dislocations Isolated dislocations of other carpal bones occur, but often inju ries are more complicated and involve dislocations (and fractures) of one row of carpal bon es (eg trans-scaphoid perilunate dislocation; Fig. 9.21 ). Surprisingly, perhaps, given alm ost inevitable signi \201 cant swelling, these injuries can be missed. Give analgesia and refer for reduction by the orthopedic team. 443 CARPAL BONE FRACTURES AND DISLOCATIONS Flake avulsion carpal fractures Small avulsions from the dorsum of the carpus are often fro m the triquetrum. Treat with immobilization in a POP backslab or wrist support splint, anal gesia, and refer to fracture clinic. Fractured hook of hamate Local palmar tenderness may give rise to suspicion of a fracture o f the hook of the hamate. Diagnosis can be dif \201 cult: specialized X-rays or CT may be required to demonstrate the fracture. Immobilize in POP and refer to fracture clinic. Radius Lunate Capitate Ulna Scaphoid Fig. 9.20 Wrist: normal lateral. Capitate Lunate Fig. 9.21 Perilunate dislocation. Fig. 9.22 Lunate dislocation. 444 CHAPTER 9 Wounds, fractures, orthopedics Colles \200\231 fracture Presentation This fracture affects the radius within 2.5cm of the wrist, such that the distal fragment is angulated to point dorsally. It usually results fro m a fall onto an outstretched hand. Osteoporosis contributes to i frequency in post-menopau sal women. Colles \200\231 fractures produce characteristic clinical deformity (sometimes l ikened to a \200\230dinnerfork \200\231). Check for scaphoid tenderness, distal sensation, and pulses in all cases. Radiological features X-ray appearances include one or more of the following: \200 Poster ior and radial displacement (translation) of the distal fragment. \200 Angulation of the distal fragment to point dorsally (the articular surface of the distal radius normally has a 5 * forward tilt on the lateral wrist X-ray). Angulation of the distal fragment to point more radially (the articular surface of the dist al radius is normally tilted 22 * towards the ulnar side on AP wrist X-ray). Impaction, leading to shortening of the radius in relation to the ulna. Fig. 9.23 Colles fracture Treatment Provide analgesia, immobilize in a backslab POP, and elevate with a sling. Discha rge those with undisplaced fractures (if they will manage at home) and arrange fracture cli nic follow-up. Advise the patient to keep moving \201 ngers, thumb, elbow, and shoulder. Deciding if MUA is indicated MUA is required for: \200 Grossly displaced fractures. \200 Loss of normal forward radial articular surface tilt on lateral wrist X-ray. Neutral or m inimal tilt may be acceptable in the very young or very old (particularly in the non-domina nt limb). Seek senior advice if unsure. Timing of MUA Patients with compound fractures and/or symptoms of nerve compression require urgent MUA. For many other patients, the timing of the procedure is less important. Many E Ds undertake closed manipulation of Colles \200\231 fractures in adult patients at the time of initial presentation, whilst others arrange for the patient to return for the procedure within 1 \200\2232days to a speci \201 c theater list as a day case. 445 COLLES \200\231 FRACTURE MUA procedure for Colles \200\231 fractures Consent Discuss the risks and bene \201 ts of the procedure. In particular, explain that, if left untreated, an angulated Colles \200\231 fracture may result in long-term stiffness and a signi \201 cantly weaker grip. The princ ipal risks of manipulation are: \200 Tears to the skin on the dorsum of the wrist (especi ally in those with thin skin (eg on steroids) and/or signi \201 cant swelling (eg on warfa rin). Late slippage of the bones requiring a further procedure. \200 Risks of the anesthetic em ployed. Choice of anesthetic The anesthetic options available include: haematoma block ( b p.289), intravenous regional anesthesia ( b Bier \200\231s block, p.290), IV sedation ( b p .308), GA ( b p.310). The choice of anesthetic will depend upon local protocols, as well as patient related factors, such as the type of fracture and extent of fasting. For example, a minimally angulated fracture in an elderly individual may be satisfactorily managed using a haematoma block, whereas a more dramatically angulated and displaced fracture may not. E vidence suggests that Bier \200\231s block is superior to haematoma block (see www.bestbets .org ). Technique Different individuals may employ different techniques, but the aim is to attempt to return the anatomy to its previous position. In particular, it is important to correct t he dorsal angulation ( \200\230restore the volar cortex \200\231). Many descriptions of red uction techniques involve initial traction and \200\230dis- impaction \200\231 of the frag ments, followed by wrist \202 exion and pronation with pressure over the distal radial fr agment(s). Some operators focus more upon gentle direct manipulation of the distal fragment , rather than indirect measures (traction, wrist \202 exion, etc.). Following manipulatio n, apply a backslab POP, whilst maintaining the reduction, with the wrist slightly \202 e xed and pronated (avoid excessive \202 exion as this can cause additional long-term probl ems). Satisfactory reduction can be con \201 rmed by image intensi \201 er/X-ray. If the reduction is not satisfactory, repeat the manipulation procedure. Medium and long-term complications of Colles \200\231 fracture Patients may present to the ED with later complications following Colles \200\231 fracture (and the treatment provided for it), including the following: \200 Stiffness of wrist and adjacent limb joints : refe r for physiotherapy. \200 Malununion and cosmetic problems : refer to GP/orthopedic team. \200 Re \202 ex sympathetic dystrophy (Sudeck \200\231s atrophy) : refer for physiother apy and GP/orthopedic follow-up. Carpal tunnel syndrome may occur after Colles \200\231 fracture, but also re \202 ect other problems (eg lunate dislocation): check original X-rays. Extensor pollicis longus rupture may occur some weeks after fractures with minimal displace ment: see b Soft tissue wrist injuries/problems, p.447. 446 CHAPTER 9 Wounds, fractures, orthopedics Other wrist fractures Smith \200\231s fracture This is an unstable distal radius fracture ( sometimes referred to as a \200\230reverse Colles \200\231 fracture \200\231) where the di stal fragment is impacted, tilted to point anteriorly and often displaced anteriorly (Fig. 9.24 ). It usually follows a fall onto a \202 exed wrist. Give analgesia, immobilize in a backslab POP and refer for MUA (often dif \201 cult to hold in position after reduction) or ORIF using a buttress plate (preferred in some orthopedic centers). Fig. 9.24 Smith \200\231s fracture (lateral view). Barton \200\231s and reverse Barton \200\231s fracture ( b p.498) An intra-articular fractu re involving only the dorsal or volar portion of the distal radius is called a Barton \200 \231s fracture and reverse Barton \200\231s fracture (Fig. 9.25 ), respectively. The result ant fragment tends to slip, so the fracture is inherently unstable. Provide analgesia, immo bilize in a POP backslab and refer. Most patients require ORIF and plating. Isolated radial styloid fracture Fig. 9.25 Lateral view of a reverse Barton \200\231s fracture. Caused by similar mechanisms of injury as scaphoid fractures (ie falls onto an outstretched hand or kickback injuries). It is sometimes referred to as a Hutchinson fracture ( b Epony mous fractures, p.500). Treat with anal- gesia, backslab POP, elevation sling and fracture clinic. Internal \201 xation is occasionally required. 447 SOFT TISSUE WRIST INJURIES/PROBLEMS Soft tissue wrist injuries/problems Wrist sprain Exclude scaphoid or other fracture (or dis location) before considering the diagnosis of a \200\230simple wrist sprain \200\231. Rela tively minor damage to ligaments around the wrist can occur following hyperextension or \202 exion of the wrist, causing swelling and tenderness around the joint. Treat with a wri st splint or tubigrip support, analgesia, or NSAIDs, and progressive exercise. Continuing p ain and problems arouse suspicions of more signi \201 cant injury (possibly involving othe r structures, such as the scapholunate ligament or triangular \201 brocartilage complex). Refer for specialist investigation. TFCC injury The triangular \201 brocartilage complex at the distal end of the ulna may be injured with associated structures. Often, these injuries only become apparent later, when what was diagnosed as a \200\230simple wrist sprain \200\231 fails to settle \200\224 pa in and tenderness persists over the TFCC. Arrange specialist follow-up for further investig ation (eg MRI) and treatment. Rupture of wrist/hand tendons Rupture of tendons may occur without penetrating trauma. The most common rupture involves extensor pollicis longus a few weeks after (usually undisplace d) fracture of the distal radius. Rupture of other extensor (and occasionally \202 exor) tendons occurs in association with OA, rheumatoid arthritis (RA), scaphoid non-union, chron ic renal failure (CRF), systemic lupus erythromatosus (SLE). Refer to a hand surgeon. Radial tenosynovitis ( \200\230intersection syndrome \200\231) Typically follows unaccustom ed repetitive activity, such as gardening, DIY, or decorating. Over hours to days, a painfu l fusiform swelling develops over the radial aspect of the distal forearm. Movement of the wrist pro- duces pain and palpable (occasionally audible) crepitus. Immobilize in a simple adjustable wrist splint and unless contraindicated, prescribe NSAID for 7 \200\22310days. A fter this, allow gradual mobilization of the wrist and educate about eliminating the cause. Immobilize severe cases in a forearm POP for 2 weeks before beginning mobilization. De Quervain \200\231s tenosynovitis Affects the tendon sheaths of abductor pollicis longus and extensor pol- licis brevis. Pain, swelling, and crepitus occur over the lateral (dorso- radial) aspect of the radial styloid. Symptoms can be reproduced by thumb or wrist movement . Finkelstein described grasping the patient \200\231s thumb and rapidly \200\230abducting the hand ulnarward \200\231, but probably more useful is pain on ulnar movement of the wri st with the thumb clenched in a \201 st. Treat with NSAID and splintage for 7 \200\22310 days. A removable fabric wrist splint (including the thumb) may suf \201 ce, but consider a scaphoid type POP for severe pain. Persistent symptoms may respond to steroid injection o f the tendon sheath using an aseptic technique. 448 CHAPTER 9 Wounds, fractures, orthopedics Forearm fractures and related injury If one forearm bone is fractured, look for a fracture or dislocation of the other. Obvious deformity in an adult forearm indicates fracture of the radial and ulna shafts. Ini tially treat with: \200 Analgesia (eg increments of IV morphine + anti-emetic until pain relieved). Immobilization in backslab POP. \200 If one or both fractures are compound, give IV antib iotics ( b p.422), tetanus cover, and dress the wound. Always check distal pulses and sensation, and examine for associated injuries at the wrist and elbow. Only once this has been done and the patient is comfortable, can he/she be sent for X-ray. Ensure X-rays demonstrate the whole lengths of the radius and ulna, including se parate views of both the elbow and wrist joints. Fractures of both radius and ulna shafts Adult fractures, unlike those in children, may be markedly displaced with little or no bony contact between the fragments. Rotational deformi ty is common. Check carefully for clinical evidence of neurovascular injury. Closed reducti on is dif \201 cult, and often fails or is complicated by late slippage. Treat fractures w ith analgesia/immobilization as above and refer for ORIF. Isolated ulna shaft fracture These usually occur from a direct blow to the outer edge of th e forearm (it is typically seen as a defense injury) or from a fall striking the ulna shaft . X-ray the whole ulna and radius to exclude associated fracture or disloca- tion of the ra dial head (see below). If undisplaced, treat in an above elbow POP with the elbow \202 ex ed to 90 * and the forearm in mid-supination. Refer all displaced or angulated fractures fo r ORIF. Galeazzi fracture-dislocation (see b p.499) De \201 ned as a fracture of the radiu s associated with dislocation of the distal radio-ulnar joint at the wrist (Fig. 9.26 ). Al ways look for subluxation of the ulna in radial fractures. Treat with analgesia and immobil ization in a temporary POP backslab. Refer for ORIF. Dislocation of radio-ulnar joint Fracture of radius Fig. 9.26 449 FOREARM FRACTURES AND RELATED INJURY Monteggia fracture-dislocation (see b p.501) De \201 ned as a fracture of the ulna associa ted with dislocation of the radial head. Occurs from forced pronation of the forearm (eg fa ll onto an out- stretched, fully pronated forearm). Can also occur by a direct blow or fall onto the proximal ulna, displacing the head of the radius. Treat with analgesia and immobi lization in a temporary above-elbow POP backslab. Refer to the orthopedic team for ORIF (or sometimes in children, for treatment with MUA and POP). A related injury is the Hume fract ure ( b Eponymous fractures, p.500) in which anterior dislocation of the radial head is com bined with an olecranon fracture. Refer for ORIF. Note: Monteggia fracture-dislocations are not infrequently missed at initial presentation, due to attention being distracted by the ulna fracture (Fig. 9.27 ). To avoid this: \200 Request elbow and wrist X-rays in any patient with forearm shaft fracture. Check all elbow X-rays carefully to ensure that the radial shaft is normally aligned and that the radial head abuts the capitellum. Dislocated radial head Fracture of the ulna Fig. 9.27 Monteggia fracture-dislocation. Isolated radial shaft fracture These are very uncommon. Always treat and assume that there is some associated damage to the distal radio-ulnar joint at the wrist. 450 CHAPTER 9 Wounds, fractures, orthopedics Elbow injuries In any injured elbow look speci \201 cally for: \200 Elbow effusion (felt as a tense, bulging swelling halfway between the lateral epicondyle and the point of the olecranon). The normal relationship between the olecranon and the lateral and medial epicondyles: all s hould form an equilateral triangle with the elbow \202 exed. Range of movement: X-ray patients who cannot fully extend the elbow and \202 ex to touch the shoulder tip. Olecranon fractures Follow falls onto the point of the elbow. The olecranon fragment may di s- place proximally due to pull of triceps. Swelling, tenderness, or crepitus are present o n examination. In the young, the olecranon epiphysis may cause con- fusion on X-rays. Treat undisplaced or hairline fractures in an above elbow backslab POP at 90 * , provide analges ia and arrange fracture clinic follow-up. Refer fractures that are displaced or involve the elbow joint for ORIF. Radial head/neck fractures Follow falls onto outstretched wrist (the radial head impacts against the capitellum) or direct trauma to the elbow. They sometimes occur in combination with a wrist fracture. Examine movements \200\224 extension and \202 exion are usually limited, but supination and pronation may be relatively normal. Look for an elbow effusion and palpate for tenderness over the radial head while supinating/pro nating the elbow. X-ray con \201 rms elbow effusion, but fractures may be dif \201 cult t o see. Treat undisplaced fractures with analgesia, and a collar and cuff sling. If very pai nful, immobilize in an above elbow POP backslab at 90 * . Arrange fracture clinic review. R efer comminuted or displaced fractures as they may require MUA, internal \201 xation or o ccasionally excision/replacement of the radial head. Elbow effusion, no visible fracture Al ways assume that a radial head/neck fracture is present: provide analgesia, a collar and cu ff sling, and arrange review to ensure that full movement is regained. Extra symptomatic re lief may be achieved by aspiration of the elbow joint (via a point midway between the olecr anon and lateral epicondyle) under aseptic conditions. Elbow fat pad sign Elevated anterior fat pad Fractured radial head Posterior fat pad Fig. 9.28 Elbow fat pad sign. 451 ELBOW INJURIES Dislocated elbow Examination reveals loss of the normal triangular relationship between the olecranon and epicondyles. Check distal pulses and sensation as brachial artery, median an d ulnar nerves may be damaged. Elbow dislocations may be classi \201 ed according to the d irection of dislocation and the presence of associated fractures (eg fractured coronoid). T he most frequent injury is postero-lateral dislocation (ie movement of the distal part in a postero- lateral direction). After analgesia and X-ray, most dislocations may be reduced in the ED under IV sedation wit h full monitoring ( b Sedation, p.308). However, GA is sometimes required. Reduction Choose between the following techniques for reduction of postero-lateral dislocat ions: \200 Flex the elbow to 60 * with countertraction on the upper arm. Pull on the full y pronated forearm at this angle. Slight \202 exion at the elbow may be necessary. Alternatively, lever the olecranon forward with both thumbs while holding the elbow \202 exed and while an assistant provides traction on the forearm. Reduction is con \201 rmed by a \200\230clunk \200\231 and restoration of the normal tria ngular relationship of the elbow landmarks. Once reduced, recheck pulses and sensation, imm obilize in an above elbow POP backslab at 90 * and X-ray again (looking for associated frac tures). Consider admission for analgesia and observation for possible signi \201 cant limb swelling. If unable to reduce, refer for reduction under GA. Supracondylar fractures (see b p.722) Fractures of the distal third of the humerus usually occur from falls onto the out stretched hand. They are most common in children (b p.722), but also occur in adults. The e lbow may be grossly swollen and deformed, but the normal triangular relationship of the ole cranon and epicondyles is characteristically preserved. Check distal pulses and sensation c arefully as the brachial artery, ulnar, median, and radial nerves can all be damaged. Immob ilize in an above elbow backslab POP and give analgesia. Refer to the orthopedic surgeon as MUA/ORIF are usually required. Fractures of the capitellum occasionally occur in isolation. If undisplaced, treat conserva tively with analgesia and POP. Refer those with displaced fractures for specialist treatmen t (possibly ORIF). Medial collateral ligament injury Instability on stress testing of the medial (ulnar collat eral) ligament implies a signi \201 cant injury. Treat in backslab POP with the elbow \202 exed to 90 * and supported in a sling. Arrange fracture clinic follow-up. Other elbow injuries Elbow injuries are relatively common in children. Speci \201 c injuri es in children are considered as follows: \200 Supracondylar fracture ( b Pediatric upper limb injuries, p.722). \200 Lateral and medial condylar injury \200\224 ( b p.724). \200 Pulled elbow \200\224 ( b Pediatric upper limb injuries, p.724). 452 CHAPTER 9 Wounds, fractures, orthopedics Soft tissue elbow problems Injuries to biceps and brachialis In \202 ammation of biceps an d/or brachialis at the site of attachment at the elbow can cause persistent symptoms: treat with rest and NSAID. Biceps brachii can rupture either at its long head in the bicipital g roove or near the elbow insertion. Long head ruptures typically affect the elderly and resu lt in a characteristic abnormal shape and low biceps position on attempted elbow \202 exi on against resistance: unless the patient is young, \201 t, and active, surgical repair i s rarely indicated. Distal ruptures are some- times treated conservatively, but some may be ne \201 t from repair: arrange orthopedic review to consider this. Lateral epicondylitis This is commonly called \200\230tennis elbow \200\231. It follows re petitive or exces- sive stress to the origin of the forearm and hand extensor muscles at th e lateral epicondyle. It can occur spontaneously, but usually follows repetitive lifting, p ulling, or sports (eg as a result of an incorrect backhand technique in tennis). In \202 a mmation, oedema, and microtears occur within the extensor insertion. Look for localized swelling, warmth or tenderness over the lateral epicondyle and immediate ly distal to it. Examine movements: dorsi \202 exion of the pronated wrist against resistance will reproduc e symptoms.