1. Wrist and Scaphoid
Index case term 1

2. Anatomy Can you name all these bones?
Use skeleton to run through bony anatomy
Think about other structures vessels, nerves

3. Clinical Case 1 85 year old woman
Falls over and lands on outstretched arm
Pain in wrist
Tender over base of thumb and wrist
What are possible injuries?

4. X-ray of wrist This shows fracture of distal radius
Why are elderly women more likely to break bones after simple fall?

5. Distal Radial Fracture Colles Fracture
Most common injury of wrist
Distal radius is displaced away from palm

6. Colles fracture of wrist
How is this injury treated?
What long term complications may the patient experience?
What can be offered to help reduce these complications?
Treated in A and E
Regional anaesthetic/ nerve block
Manual reduction , then 4-6 weeks in plaster
Complications:
Pain, stiffness, reduced strength, reduced movement
All of which can be v disabling esp if dominant hand
Physiotherapy is essential
Some dept run special hand clinics with physio, occupational therapy etc

7. Post manipulation x-ray
Aim to align the bones as near to normal anatomical position
This reduces subsequent complications

8. Wrist fractures
3 types
Depends on what position the hand is forced into by the fall
Depends on displacement of distal radius and whether the wrist joint is involved

9. Smiths fracture
Opposite to Colles I.e. distal radius is displaced towards the palm
Less common, but can be more serious
More likely to damage vessels and nerves as they run along the palmar side of the wrist
Often surgical reduction under GA

10. Barton’s fracture
Like Smith I.e fracture of distal radius with displacement towards the palm, but also fragments displaced proximally
This is a more complicated injury and requires surgical reduction and internal fixation with wires to keep the bony fragments together
Helen Taylor’s sister has just sustained this injury after she fell at a kids roller skating party
She was in hospital for 4 days, can’t drive for 6 weeks and as it is her dominant hand can’t do simple tasks e.g brushing teeth, filing kettle.You have been warned!

11. Clinical case 2 8 year old child
Falls onto outstretched arm whilst skateboarding
Not using arm
Tender over wrist on examination
What is most likely injury?

12. Greenstick fracture of distal radius
Why does this x-ray look different? Because not all of the bones are yet ossified.
Why do children get these types of fractures rather than breaking the bone? Because their bones are more flexible and less brittle
How are these treated? Wrist Support or plaster

13. Clinical case 3 25 year old man
Falls over handlebars whilst mountain biking
Attends A and E
Tender over base of thumb and wrist

14. Scaphoid views on x-ray
Fracture through waist of scaphoid
Distal radius ok
Can be subtle on initial xray

15. Scaphoid Fracture

16. Scaphoid fracture Fall on outstretched hand
Tender in anatomical snuffbox
Usually fractures through the waist of Scaphoid
Complications???

17. Blood supply to Scaphoid
Radial Artery
Branch enters Scaphoid distally
Fracture through waist can interrupt the arterial supply, leading to ischaemia of the bone, which is called avascular necrosis

18. Avascular necrosis of scaphoid
Affects proximal pole of scaphoid
Bone may fragment
Causes secondary degenerative pain

19. What if X-ray normal? If clinically suspect scaphoid fracture
Treat as fracture and repeat x-ray in fourteen days time when fracture maybe more apparent
Image wrist with MRI as will show subtle fractures, bone oedema, and ligamentous injury

20. MRI of Scaphoid fracture T1 weighted T2 weighted fat sat showing oedema in distal scaphoid

21. Wrist and hand In Summary, we have looked at Anatomy Common injuries
Complications of injury