50 year old vet fell off his bike.
What do you see?
What would you do in the emergency room for this?
Remember to use a system for reading your xrays. Read this post if you haven’t yet: System for reading wrist xrays
Updates with answers coming later this week! Please comment below to weigh in and get the best out of the learning process!
Update:
Fracture Description
This is an AP and lateral of the left wrist in a skeletally mature individual with a ring finger comminuted metacarpal shaft fracture and a lunate dislocation.
Remember that you want to say what views, the maturity of bone, and what the most straightforward descriptions of the pathology.
Here is the lunate outlined in the images:
Photo Credit: Nina Suh@NinaSuh9
It is especially easy to miss lunate and other carpal bone fractures especially if there is a distal radius fracture. That is why it is good to develop a system for ready xrays that you do consistently so you decrease the chances of missing something. You can’t trust the radiologist to read your images. You must be responsible.
ED Management
Good neurovascular exam
Carpal tunnel syndrome is a risk (the lunate in this case has been pushed into where you would expect the carpal tunnel to be)
Closed reduction with traction may be worth a try, but this is debated as it can increase swelling
I might want to try finger traps and just see if it would reduce after a while hanging with gravity
Volar slab or sugar tong splint
Just for comfort, no reduction or specific mold necessary
Get a CT
helpful to rule out other fractures that may not be visible on xray
Surgical Overview
There is some debate about approach and what people would do. Some would try percutaneous fixation with pins. Some would do a carpal tunnel release with repair of the capsule and ligaments with a dorsal and volar approach.
The metacarpal fracture looks like it can be treated non-op right now based on angulation <30 degrees and less than 2-5mm of shortening.
Metacarpal fractures acceptable angulation
Metacarpal Shaft Operative Indications (ORIF vs. CRPP) – according to Orthobullets
Open fractures
Unacceptable angulation
Multiple fractures
Any malrotation
When flexing fingers to the palm all fingers should point towards the scaphoid if there is malrotation that finger may not be pointing towards the scaphoid.
Some attendings may decide to pin that in place to avoid displacement later on. The important part of sharing this case is mainly to get used to recognizing that the Lunate is dislocated and to systematically go through your images.
