Treatment Show
Prehospital CareThe injured extremity should be splinted gently from above the elbow to the hand to prevent additional injury from inadvertent manipulation. As with all trauma, address the possibility of additional injuries. Attend to ABCs, and use spine precautions if indicated by history and mechanism. Urgent reduction of fractures may be necessary when neurovascular status has been compromised. This should be completed in the prehospital setting only when estimated ED arrival is more than 6 hours after the time of injury.  Emergency Department CareIn the ED, obtain a thorough history. Exclude additional injuries, and, if warranted, provide a full trauma evaluation. Maintain gentle, temporary splinting when not directly examining the injured wrist. Wrist fractures are managed by reduction and immobilization following administration of adequate anesthesia and analgesia. Such reductions are typically performed by emergency physicians or orthopedic surgeons. [22] Prior to closed reduction and fixation but after a careful neurovascular examination, administer proper sedation/anesthesia for the following 2 reasons: (1) to reduce or eliminate discomfort to the patient and (2) to reduce muscle spasm and splinting, which allow easier reduction and stabilization. Options for analgesia or anesthesia prior to closed reduction include parenteral narcotics, conscious sedation, local/regional blocks, and hematoma blocks. Oral analgesics are suitable only for those injuries that do not require manipulation. Conscious sedation increasingly is becoming the method of choice as more emergency physicians become skilled in its use. Properly performed, conscious sedation provides excellent anesthesia and muscle relaxation and leaves the patient with little or no recall of the event. Hematoma block is performed by inserting a needle into the area of the fracture, aspirating blood to confirm placement, and injecting local anesthetic. The skin should be well prepared to avoid introduction of bacteria into the fracture site. For either hematoma or regional blocks, 0.5% bupivacaine (Marcaine) is ideal because of its low toxicity and long duration of action. For hematoma blocks, 10 mL of 0.5% bupivacaine is injected into the hematoma and another 5 mL is injected around the site. Allow 10-15 minutes prior to attempting manipulation. Brachial block, while providing excellent anesthesia, is best left to those skilled in its use. Reduction and immobilizationAlways assess and document neurovascular status before starting reduction. Accurate reduction of the fracture is essential to obtaining good functional results. Early reduction lessens morbidity and improves patient comfort. Anatomic reduction is obtained by manipulation and plaster fixation and confirmed by repeat radiographs, portable fluoroscopy, or bedside ultrasonography. Anatomic reduction of distal radius fractures, both Colles and Smith fractures, are difficult to judge clinically. Ang et al adds ultrasonography to the traditional approach and offers the clinician a noninvasive way to identify proper alignment prior to post reduction radiographs. [23] The method of immobilization varies with the specific injury involved. Colles fractureThe 2 keys to successful reduction of the typical Colles fracture are as follows:
ED treatment includes application of a plaster sugar-tong splint with the wrist held in slight flexion, with slight ulnar deviation and pronation of the forearm. Obtain postreduction radiographs; assess and document neurovascular status of the extremity after reduction. Document function of the median nerve and the sensory branch of the radial nerve. Smith fractureFor proper reduction of a Smith fracture, the forearm must be supinated fully while the elbow is fixed by an assistant or with the aid of the Weinberg traction device. Extend the wrist to 90° and fully supinate the forearm. Then, recreate the position of the hand at injury to relax the periosteal attachments. Move the hand into the hyperflexed position and reduce the fracture segment with traction at approximately negative 60° while moving the fragments into alignment along the volar aspect of the wrist, pushing the fragment upwards and backwards with the thumbs. The wrist is forced into ulnar deviation and dorsiflexion for reduction. This position is held until a plaster sugar-tong splint is placed. These fractures are very difficult to hold in position, especially if dorsiflexion and ulnar deviation is lost during application of the plaster. Postreduction radiographs and documentation of the neurovascular status of the extremity is the standard of care. Volar and dorsal dislocationsFor volar dislocations, the hand is hyperpronated. For dorsal dislocations, it is hypersupinated. A sugar-tong splint is then placed. For volar dislocations, the hand is splinted fully pronated, whereas for dorsal dislocations, the hand is splinted in supination. Appropriate consultation by an orthopedist must follow within the next 48 hours. Scaphoid fracturesThe diagnosis of scaphoid fracture is often made on clinical suspicion alone. Immobilize the wrist in all patients with documented or suspected fractures. Place the injured extremity in either a short- or long-arm thumb spica case with the distal interphalangeal (DIP) joint of the thumb included. The length of the cast remains controversial; however, the long-arm thumb spica has been demonstrated to improve rotational stability. Orthopedic follow-up is required. Other carpal fracturesLunate fractures require a short-arm spica cast or splint with thumb immobilization. Emergency treatment of capitate, trapezium, and trapezoid fractures consists of position of function and orthopedic consultation. The isolated triquetral avulsion fracture can be treated with splint immobilization for 3-6 weeks. Midcarpal and ulnar side wrist instability must be ruled out before assuming that this is the correct treatment. The clinical examination should include a lunate-triquetral shear test to rule out lunotriquetral interosseous ligament tears, [24] and midcarpal instability should be evaluated with an axial compression and ulnar deviation test. [25] If ligamentous instability is suspected, an MRI is indicated for further evaluation. Fractures of the pisiform can be immobilized with a volar splint. Injuries to the triquetrum are best treated with a sugar-tong splint. Treatment of a hamate fracture involves a short-arm cast with the fourth and fifth MCP joints held in flexion. Pronation and supination injuriesManagement of wrist articular injuries exactly mirrors the mechanism of injury. For example, with pronation injuries, the hand is supinated with the elbow held flexed at 90°. With a supination injury, pronation corrects the defect. Nerve injuryUpon presentation and after treatment, the ED physician must evaluate the neurovascular status of the extremity. Careful note must be taken of ulnar and median nerve function. The ulnar nerve is often injured with closed fractures of the pisiform, triquetrum, hamate, and fourth and fifth metacarpals. The motor branch of the ulnar nerve is the chief motor nerve of the hand. The sensory branch rarely is affected. Blunt trauma to the hypothenar eminence may result in contusion to the ulnar nerve, with resulting neurapraxia. If a large hematoma is present, it may be aspirated or surgically removed after appropriate consultation. Median nerve injury, including traumatic carpal tunnel syndrome, is manifested by sensory disturbances in the thumb and index and long fingers. Median nerve injury is associated with Colles fractures, Smith fractures, perilunate dislocations, and carpal bone injuries. Compression along the volar ligament results in pain and paresthesias along the median nerve. Only late in this disorder does the thenar eminence exhibit muscle atrophy. Recognition of the injury and referral for consultation is the aim of the ED physician. If an acute injury is secondary to a displaced fracture, and physical signs indicate compression of the nerve, acute reduction of the displaced fracture is indicated. Medical CareOral analgesics should be provided forpain relief. To reduce pain and edema, apply ice to the injured region for the first 48 hours. Open fracture and/or joint capsule injury require the following treatments:
In cases of distal radius fracture, look for acute carpal tunnel syndrome. Distal radius fractureOnce swelling has subsided, uncomplicated fractures require conversion from a splint to a short-arm cast for 6-8 weeks. An orthopedic specialist should provide follow-up to assess for adequate alignment and the need for operative intervention. Patient may require physical therapy to regain baseline range of motion. Scaphoid fractureTreatment in a spica cast for 12 weeks results in healing in 90% of these fractures. Scaphoid union is evaluated through consecutive imaging and clinical follow-up over this period. A CT scan will definitively identify union. Return to normal activity is contingent on fracture type and patient condition. Protocol suggests that patients wait for at least 50% union before returning to normal activity. Contact sports should be avoided for 2-3 months after treatment, owing to the increased risk of refracture. [26] Lunate fractureMost heal in a spica cast for 10-12 weeks.
Author Bryan C Hoynak, MD, FACEP, FAAEM Associate Clinical Professor of Emergency Medicine, University of California at Irvine School of Medicine; Director of Emergency Services, Chairman of Division of Emergency Medicine, Placentia-Linda Hospital; Faculty, Idaho College of Osteopathic Medicine Bryan C Hoynak, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Burn Association, American College of Emergency Physicians, American College of Surgeons, American Heart Association Disclosure: Nothing to disclose. Coauthor(s) Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Chief Editor Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians Disclosure: Nothing to disclose. Acknowledgements Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Which immobilization device is best for a patient with an unstable wrist?Following the diagnosis of an unstable injury, a splint may be the best treatment option and is loosely defined as an external device used to immobilize an injury or joint and is most often made out of plaster.
Why is immobilization the preferred way to manage fractured limbs?In cases of traumatic fracture or luxation, temporary limb immobilization improves patient comfort, controls regional soft tissue swelling, provides a protective covering for open wounds, and can prevent closed fractures from becoming open fractures via skin penetration by sharp fracture fragments.
What is bone immobilization?Immobilization refers to the process of holding a joint or bone in place with a splint, cast, or brace. This is done to prevent an injured area from moving while it heals.
When splinting a fracture straighten or reposition the fractured limb as necessary?Severely deformed fractured limbs should be straightened by a doctor if sensation or pulses are impaired prior to splinting. The process of straightening should not worsen the injury. A basic rule of splinting is that the joint above and below the broken bone should be immobilized to protect the fracture site.
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Which immobilization device is best for a patient with an unstable wrist fracture
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