Scaphoid fracture

  • MC carpal bone fracture, articulates with multiple bones in hand, forms lateral border of carpal tunnel

  • Poor vascular supply to proximal part ➔ ↑ risk of avascular necrosis or nonunion

  • Anatomical snuffbox tenderness/wrist pain

  • X-ray (PA, lateral, oblique, schaphoid views) repeated in 10d if negative

  • TX with thumb spica x6wks (distal fx ➔ short arm; proximal fx ➔ long arm)

    • > 1 mm of displacement or proximal pole fractures ➔ need ortho (operative fixation)

Thumb Spica

Lunate Dislocation

  • Associated with acute carpal tunnel (median nerve)

  • DX: lateral view ➔ palmar displacement of lunate (spilled cup)

  • Requires emergent closed reduction, sugar tong, then ORIF

Scapholunate dissociation

  • Scapholunate ligament injury ➔ wide scaphoid-lunate space

  • DX: > 3mm between scaphoid and lunate

  • Requires radial gutter and hand surgeon

Metacarpal Fracture

  • Surgery if neurovascular injury, open, severe angulation

  • Punched teeth (hx) & abrasions (PE) ➔ augmentin

  • Shaft

    • Transverse fracture MC from punching something (4th-5th MC - boxer's fracture)

    • Gutter splint non-displaced metacarpal shaft fractures

  • Base

    • Dorsal AND volar forearm splint‎. Wrist at ~30° of extension with MCPs free

    • 5th (MC base) fracture usually requires surgery

  • Head

    • Ulnar gutter or short arm to PIP

  • Neck

    • Reduction and radial or ulnar gutter (likely needs to see hand)

Ulnar Gutter

4th/5th metacarpal shaft fracture

Radial Gutter

2nd/3rd metacarpal shaft fracture

Jersey Finger

  • Forced extension of DIP ➔ ruptured flexor digitorum profundus tendon

  • SSX: unable to fully flex - can't fist pump on Jersey shore

  • Always surgical repair (splint in flexion and send to hand)

Mallet Finger

  • Forced flexion of DIP ➔ ruptured extensor digitorum tendon

  • SSX: unable to extend

  • Get xray to r/o avulsion fracture of distal phalanx

  • Splint DIP in hyperextension for 6wks, (don't splint PIP), surgery if angulated > 45°

Non-infectious Tenosynovitis

  • SSX: Pain with passive extension, affected finger is slightly flexed at rest

  • DeQuervian: Excessive/repetitive thumb abduction & extension

    • SSX: Pain (may radiate to radial styloid/thumb/elbow) ↑ with grasping

    • DX: Finkelstein - pull traction on thumb across palm

  • Stenosing tenosynovitis: Metaplasia ➔ ↓smoothness of finger flexion

    • SSX: Finger locks when flexed then pops back (trigger finger)

  • TX non-infectious tenosynovitis with NSAIDs, splinting for 6 wks, tendon sheath GCS injection

Infectious Tenosynovitis

  • Penetrating trauma (IVDA, thorns ➔ fungal, bites), spread of systemic infxn (TB, gonorrhoeae)

  • Can have fever, leukocytosis

  • TX infectious tenosynovitis with debridement and broad spectrum IV abx