It’s Christmas Eve, and you walk in to the ED wishing for a silent night. You get settled in, and you see “Clause, Santa- 1746 yo M wrist pain” show up on your board. Apparently, Rudolph found his way into the spiked eggnog, and Santa had some difficulty getting around the world tonight. While you’re waiting for the Xrays to come back, let’s quickly review wrist bone fractures.
Mnemonics for the carpal bones usually go from lateral to medial, proximal to distal. An example: Some Lovers Try Positions That They Cannot Handle à Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, and Hamate.
Can you identify them on Xray?
What injury would you suspect if Santa told you his hand got caught around his reigns and his wrist got twisted forcefully? What kind of splint are you going to use?
Triquetrium avulsion fracture: This is usually caused by hand twisting against resistance
Short arm sugar-tong splint
What injury would you suspect if Santa told you Rudolph hit the brakes abruptly and Santa fell on his outstretched hand?
Read more about scaphoid injuries here: http://blog.clinicalmonster.com/2015/11/fooshing-off-my-board-review/
Lunate and capitate fractures rarely occur in isolation and usually occur with fractures of other wrist bones.
What if Santa fell on his hypothenar eminence area instead?
Pisiform fracture: Volar splint, 30 degrees flexion at the wrist and ulnar deviated
What injury would you suspect if Santa told you he was making the “STOP!” motion with both his hands and Rudolph kicked his wrist?
Trapezium fracture: A blow to the wrist in a dorsiflexed, radially deviated position usually causes this. It can also cause snuffbox tenderness and a weak pinch. You should place wrist in a thumb spica splint.
Let’s say Santa got fed up and swung a bat at Rudolph, and Rudolph kicked the bat causing Santa’s swing to be interrupted. What fracture would you suspect?
Hamate fracture- These fractures usually involve the 4th or 5th metacarpal fracture dislocations.
Place a short arm volar splint with the 4th and 5th metacarpal in flexion
What wrist bone is left?
Trapezoid fractures are extremely rare (less than 1% of carpal fractures). They are usually caused by axial loading on the second metacarpal. The splint of choice would be a thumb spica.
References:
Escarza, Robert, et al.. “Chapter 266. Wrist Injuries.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2011, http://accessmedicine.mhmedical.com.newproxy.downstate.edu/content.aspx?bookid=348&Sectionid=40381757.
Remember, what we do in practice may not always be the right answer on the exam. Frustrating, I know, but don’t cry about it, or you’ll get put on Santa’s naughty list.
Special thanks to Dr. Willis and Dr. deSouza
Karen
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