WristTriage.com

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The content focuses on triaging orthopaedic injuries and conditions and was reviewed by site owner, Canadian Physiotherapist Terry Kane.  If you have any comments or suggestions to improve the content, please contact Terry at terry@terrykane.ca.

Triaging Wrist Injuries

Introduction

Wrist injuries are among the most common orthopedic concerns in emergency and clinical settings. The wrist is a highly complex joint that allows for a wide range of motion while providing stability for hand function. Due to its role in daily activities, sports, and work-related tasks, wrist injuries can significantly impact quality of life and productivity.

Effective triage of wrist injuries is crucial for early diagnosis, appropriate management, and prevention of long-term complications. This article provides a detailed guide to triaging wrist injuries, covering anatomy, mechanisms of injury, assessment techniques, classification systems, imaging modalities, and treatment strategies.

1. Understanding Wrist Anatomy and Injury Mechanisms

Wrist Anatomy

The wrist consists of multiple bones, ligaments, tendons, and nerves that provide mobility and strength.

  • Bones:
    • The radius and ulna form the forearm and articulate with the wrist.
    • The carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate) connect the forearm to the hand.
    • The metacarpal bones extend from the carpals to the fingers.
  • Ligaments and Soft Tissue:
    • Radiocarpal Ligaments: Provide wrist stability.
    • Triangular Fibrocartilage Complex (TFCC): Supports the distal radioulnar joint and absorbs impact.
    • Flexor and Extensor Tendons: Control finger and wrist movement.
  • Neurovascular Structures:
    • Median nerve: Runs through the carpal tunnel and controls thumb movement.
    • Ulnar nerve: Affects grip strength and sensation in the ring and little fingers.
    • Radial nerve: Supplies sensation to the back of the hand.

Mechanisms of Wrist Injuries

Wrist injuries occur through various mechanisms:

  • Falls: A fall on an outstretched hand (FOOSH injury) is the most common cause of wrist fractures and sprains.
  • Direct Trauma: Blunt force, such as from sports injuries or industrial accidents.
  • Repetitive Stress: Overuse injuries, such as tendinitis or carpal tunnel syndrome, are common in athletes and manual laborers.
  • High-Energy Trauma: Motor vehicle accidents may cause complex fractures or ligament disruptions.
  • Twisting or Hyperextension: Can lead to ligament sprains or dislocations.

2. Initial Triage and Assessment

Primary Survey: Identifying Life-Threatening Conditions

Following the Advanced Trauma Life Support (ATLS) protocol, use the ABCDE approach:

  1. Airway and Cervical Spine Control: If the injury resulted from high-energy trauma, assess for associated cervical spine injuries.
  2. Breathing and Oxygenation: Rule out chest injuries in cases of multiple trauma.
  3. Circulation and Hemorrhage Control: Assess for signs of compartment syndrome in cases of swelling or vascular compromise.
  4. Disability and Neurological Examination: Assess for nerve involvement and functional deficits.
  5. Exposure and Environmental Control: Inspect the wrist for swelling, deformities, and open wounds.

If a wrist injury is suspected, immobilization should be prioritized to prevent further damage.

Secondary Survey: Focused Wrist Examination

Once stabilized, perform a detailed wrist assessment:

  • Inspection:
    • Look for swelling, bruising, deformities, or open wounds.
    • Check for obvious displacement, indicating a fracture or dislocation.
    • Assess wrist position (e.g., dorsal displacement in Colles’ fracture).
  • Palpation:
    • Identify points of tenderness over the distal radius, scaphoid, and lunate.
    • Assess the snuffbox for pain (scaphoid fractures).
    • Check for crepitus, which may indicate fractures.
  • Range of Motion (ROM):
    • Active and passive movements of the wrist, hand, and fingers.
    • Pain or restriction suggests ligamentous or bony injury.
  • Neurological Examination:
    • Median nerve: Sensation in the thumb, index, and middle fingers.
    • Ulnar nerve: Sensation in the ring and little fingers.
    • Radial nerve: Sensation on the dorsum of the hand.
  • Vascular Examination:
    • Check radial and ulnar pulses to assess circulation.
    • Capillary refill should be under 2 seconds.
    • Assess for compartment syndrome (severe pain, swelling, pallor).

Red Flags for Severe Wrist Injuries:

  • Significant deformity (suggesting fracture or dislocation).
  • Loss of sensation or weakness in the hand.
  • Absent pulses or cold hand (vascular injury).
  • Severe swelling and tightness (compartment syndrome).

3. Classification of Wrist Injuries

1. Fractures

  • Distal Radius Fractures:
    • Colles’ Fracture: Dorsally displaced fracture, common in FOOSH injuries.
    • Smith’s Fracture: Volar displacement, often from a fall on a flexed wrist.
    • Barton’s Fracture: Involves the radiocarpal joint.
  • Scaphoid Fractures:
    • Common in young adults after FOOSH injuries.
    • Risk of avascular necrosis due to poor blood supply.
  • Ulnar Styloid Fractures: Often accompany distal radius fractures.

2. Dislocations

  • Lunate Dislocation: “Spilled teacup” sign on X-ray.
  • Perilunate Dislocation: Carpal bones displaced but lunate remains aligned.
  • Distal Radioulnar Joint (DRUJ) Dislocation: May occur with TFCC injury.

3. Ligamentous Injuries

  • Scapholunate Ligament Tear: Leads to instability and degenerative changes.
  • TFCC Tear: Causes ulnar-sided wrist pain and instability.

4. Tendon Injuries

  • De Quervain’s Tenosynovitis: Inflammation of the thumb tendons.
  • Flexor/Extensor Tendon Lacerations: Require surgical repair.

5. Nerve Compression Syndromes

  • Carpal Tunnel Syndrome: Median nerve compression causing numbness and weakness.
  • Guyon’s Canal Syndrome: Ulnar nerve compression affecting grip strength.

4. Imaging and Diagnostic Modalities

1. X-ray (First-Line Imaging)

  • AP and lateral views are essential.
  • Scaphoid view for suspected scaphoid fractures.
  • Clenched fist view for scapholunate instability.

2. CT Scan (For Complex Fractures)

  • Provides detailed images of intra-articular fractures and dislocations.

3. MRI (For Soft Tissue and Ligament Injuries)

  • Best for TFCC tears, ligament sprains, and occult fractures.

4. Ultrasound

  • Quick bedside assessment for tendon injuries and fluid collections.

5. Management Strategies

1. Immediate Stabilization

  • Immobilization: Use a splint or cast for fractures and sprains.
  • Pain Control: NSAIDs, opioids, or intra-articular lidocaine for severe pain.
  • Reduction Techniques: Performed for dislocations under sedation.
  • DVT Prophylaxis: Consider in high-risk immobilized patients.

2. Non-Surgical Management

  • Indications: Stable fractures, mild sprains.
  • Treatment:
    • Physical therapy for ROM and strength.
    • Bracing or splints for support.
    • Corticosteroid injections for chronic inflammation.

3. Surgical Management

  • Indications:
    • Unstable fractures (displaced scaphoid fractures).
    • Ligament tears with instability.
    • Chronic instability requiring repair.
  • Procedures:
    • ORIF (Open Reduction and Internal Fixation)
    • Ligament reconstruction
    • Tendon repair

Conclusion

Triaging wrist injuries requires a structured approach emphasizing early recognition, stabilization, and appropriate imaging.

Identifying red flag symptoms is crucial to prevent complications.

Timely intervention ensures the best outcomes for individuals with wrist injuries, enhancing functional recovery and long-term joint health.