ANATOMY
INJURIES
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XRAYS
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100
Name the proximal row of carpal bones?
scaphoid, lunate, triquetrum, and pisiform
100
Your 15 year old patient fell on her outstretched hand while skateboarding and has normal films but persistent tenderness in the snuffbox. What is the correct course of action?
Splint and follow up vs dedicated films vs re-image in a few days. Scaphoid fracture--malunion can cause severe morbidity
100
What are two physical exam findings that are relatively sensitive for scaphoid fracture?
1. Anatomical snuffbox tenderness on examination - highly sensitive 90% indication of scaphoid fracture, but it is nonspecific 40%
2. Tenderness of the scaphoid tubercle: the physician extends the patient’s wrist with one hand and applies pressure to the tuberosity at the proximal wrist crease with the opposite hand. This provides better diagnostic information; sensitivity 87%, specificity 57%
3. Pain with the scaphoid compression test (i.e. axially/longitudinally compressing a patient’s thumb along the line of the first metacarpal)
4. Pain in the snuffbox with pronation of the wrist followed by ulnar deviation (52% percent positive predictive value, 100% percent negative predictive value)
100
SCAPHOID FRACTURE
100
NORMAL
200
what tendon(s) can be injured in a colles fracture?
extensor policus longus--from friction vs lister's tubercle
200
A 30 yo woman describes pain at the radial side of the wrist that is more notable with thumb and wrist movement. There is pain at the radial styloid with active or passive stretch the thumb tendons over the radial styloid in thumb flexion
de Quervain tendinopathy, a self-limited fast-track type disorder. The described test is the Finkelstein maneuver. Some patients may also notice some swelling and tenderness on the radial side of the wrist.
DQT affects both the abductor pollicis longus and the extensor pollicis brevis at the point where they pass through a fibro-osseous tunnel (the first dorsal compartment) from the forearm into the hand.
MGMT: thumb spica, nsaids. possible steroid injection.
200
AUDIO DAILY DOUBLE
Chauffeur's fracture, also known as Hutchinson fracture, is a type of oblique fracture of the radial styloid process in the forearm. The injury is typically caused by compression of the scaphoid bone of the hand against the styloid process of the distal radius. It can be caused by falling onto an outstretched hand.
200
SCAPHOLUNATE DISASSOCIATION
Orthopedic referral is necessary because these injuries require either closed reduction with percutaneous pinning or ORIF and repair of the ligament.
Instability and subsequent early, severe degenerative arthritis can occur if left untreated.
200
30 yom complains s/p foosh c/o pain and swelling on the radial side of the wrist and often a “clicking” sensation with wrist movement.
SCAPHOLUNATE DISLOCATION
SL space >3mm
Treatment: volar splint and f/u
300
WHAT ARE the three bones that form the articulation between the forearm and the wrist?
scaphoid, lunate and radius
300
A guy injures his wrist. What is the treatment?
LUNATE DISLOCATION
The lunate’s articulations with both the radius and capitate are disrupted displacing the lunate volarly creating a “spilled teacup”
Immediate closed reduction and splinting should take place with early operative referral.
300
What is the ER TREATMENT OF SUSPECTED AND CONFIRMED SCAPHOID FX?
SUSPECTED: short arm thumb spica
CONFIRMED: Long arm thumb spica splint in dorsiflexion with radial deviation
300
300
14 yo boy s/p bike accident.
Triquetrum body fracture is rare. Only 3% of all triquetrum fractures. You may not see one.
Treatment is forearm cast for a month.
400
Describe the blood supply to the scaphoid bone
400
Which soft tissue injuries are associated with this fracture?
The pisiform and hook of the hamate form the bony walls of Guyon’s canal that contains the ulnar nerve and artery; therefore, it is important to exclude injury to them. 
400
Name three forearm fractures that typically require immediate orthopedics attention.
1. Galeazzi
2. Monteggia
3. Both bones pediatric fractures that cannot be sufficiently approximated in ED
4. Any open fracture, risk of compartment syndrome, neurovascular compromise
400
MONTEGGIA
400
A 30 year old man attends the Emergency Department after injuring his right wrist. He was playing rugby and landed awkwardly during a tackle with his hand trapped underneath another player. On arrival he is complaining of significant pain in his right wrist with reduced movement in all directions.
POST MANIPULATION IMAGE 
ISOLATED DISTAL RADIUS ULNAR JOINT DISLOCATION
- The mechanism for isolated volar DRUJ dislocation is most commonly due to hyper- supination of the forearm, particularly with the hand in a fixed position.
- The patient presents with wrist pain, swelling and reduced ROM – particularly with pain on pronation.
- The tell-tale sign of a hollow where the prominent ulna styloid normally sits is not always obvious due to patient body habitus and swelling.
500
A spandex wearing cyclist who rides around prospect park in an effort to forestall the aging process develops bilateral hand weakness and muscle atrophy. Which condidtion do you suspect?
ulnar compression neuropathy at the wrist
500
What are the four stages of carpal instability according to the mayfield classification?
1. Scapholunate
2. peri-lunate (capitate)
3. peri-lunate (triquetrum)
4. lunate dislocation
500
Basketball player with wrist pain after an injury.
The trapezium is a saddle-shaped bone that articulates with the thumb metacarpal. Injuries are produced by a direct blow to the thumb or from a dorsiflexion and radial deviation force
500
BARTON'S FRACTURE: intra-articular distal radius fracture, often associated with carpal subluxation.
Unstable fractures involving >50% of the radial articular surface or those with accompanying carpal subluxation require open reduction and internal fixation. Emergent orthopedic consultation is recommended.
500
Intra-articular distal radius fracture with scapholunate dislocation