Forearm, Wrist, and Hand Reduction

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Chapter 10 Forearm, Wrist, and Hand Reduction

Forearm fractures

Overview

1. Fractures of both bones of the forearm (Figure 10-1) should be reduced anatomically (except in children younger than 12 years) to preserve forearm rotation.

a. Only accept as much deformity as can remodel in 1 year.

b. In children younger than 8 years, bayonet apposition and 20 degrees of angulation is acceptable.

c. In children older than approximately 8 years, length should be restored and angulation of 10 degrees is acceptable.

2. A Monteggia fracture is a combination of a radial head dislocation and a fracture of the ulna. The vast majority of Monteggia fractures should be treated surgically.

a. Anatomic reduction of the ulnar fracture often results in spontaneous reduction of the radiocapitellar dislocation.

b. In children, a greenstick fracture of the ulna may occur or the ulna may plastically deform, and the radial head dislocation is often missed (Figure 10-2).

c. The direction of radial head displacement and ulnar fracture angulation varies and dictates the reduction maneuvers.

3. A Galeazzi fracture is a combination of a radial fracture and a distal radioulnar joint dislocation.

a. The vast majority of Galeazzi fractures should be treated surgically.

b. Anatomic reduction of the radial fracture often results in spontaneous reduction of the distal radioulnar joint dislocation.

4. Nightstick fractures of the diaphyseal ulna can accommodate 10 degrees of angulation and 50% translation.

Figure 10-1

Figure 10-2

Indications for Use

1. Ulnar shaft fractures with or without radial head dislocation

2. Radial shaft fractures with or without distal radioulnar joint dislocation

3. Fractures of both bones of the forearm

Precautions

1. Even if an anatomic reduction is achieved, follow-up should occur within a week of the injury.

2. Do not use an intravenous (IV) stand that is attached to the ceiling unless it is specifically designed to handle large weights.

3. Ensure that the finger trap is secure! Sudden and unanticipated release of traction can result in injury to both the patient and the physician.

Pearls

1. Patient positioning is key to obtaining appropriate traction. Strict positioning of the shoulder to 90 degrees and flexion of the elbow to 90 degrees allows perfectly longitudinal traction to be applied through the fracture site.

2. Be patient! Allow 5 to 10 minutes for traction to result in disimpaction of the fracture.

3. Forewarn patients that their index and long fingers may hurt more than their forearms by virtue of the finger trap.

a. Also inform patients that their fingers will likely turn blue but that this symptom is normal, expected, and will resolve shortly after the finger traps are removed.

b. Performing a digital block of the index and long fingers before traction may be considered in certain patients.

4. To “release traction” while performing the reduction maneuver, it is often easier to simply grasp the hand and allow slack in the fingertrap or traction loop.

Equipment

1. Stockinette: 3 inches wide, 4 feet long

2. Rolled gauze: 2 inches wide

3. IV pole

4. Weights: 10 to 15 lb

5. ABD pad (optional)

Detailed Technique

1. Position the patient:

a. The patient should be supine on the stretcher with his or her shoulder girdle entirely off the side.

b. If a long arm cast will be applied afterward, place a stockinette (see Chapter 13).

2. Begin sedation.

3. Prepare finger traps:

a. Attach a rolled gauze finger trap (Chapter 8) to the index and long fingers using a double-ring construct (Figure 10-5).

b. Abduct the shoulder to 90 degrees and flex the elbow to 90 degrees to create a 90-90 position.

c. Secure the other end of the traction to the IV pole.

4. Set traction, if necessary (Figure 10-6).

a. Cut a 2-foot length of stockinette.

b. Place an ABD inside the stockinette for padding (optional).

c. Cut small holes in each end of the stockinette.

d. Drape the stockinette around the forearm.

e. Hang the traction weights.

f. Allow traction to hang for at least 5 minutes (less than 1 hour is recommended).

5. Obtain traction views (optional). Portable anteroposterior (AP) and lateral radiographs of the forearm, wrist, and elbow can be obtained in traction to evaluate the reduction.

6. Perform a reduction maneuver (Figures 10-7 and 10-8).

a. The direction in which forces are applied depends on the type of fracture.

b. Bring the distal fragment to the proximal fragment.

c. Correct forearm rotation to match proximal fragments, generally as described below:

(1) Proximal fractures of both bones of the forearm: mild supination

(2) Midshaft fractures of both bones of the forearm: neutral

(3) Distal fractures of both bones of the forearm: slight pronation

7. Apply a splint (see Chapter 13) or a cast (see Chapter 13) while maintaining traction.

a. Prepare an interosseous mold (Figure 10-9).

b. Flatten the ulnar border of the cast/splint with your shin (Figure 10-10) or a flat surface (Figure 10-11).

8. Obtain postreduction AP and lateral films of the elbow, forearm, and wrist.

Figure 10-5

Figure 10-6

Figure 10-7

Figure 10-8

Figure 10-9

Figure 10-10

Figure 10-11

Distal radius fracture reduction

Indications for Use

1. Displaced distal radius fractures

2. Carpal fractures

Precautions

1. Do not use an IV stand attached to the ceiling unless it is specifically designed to handle large weights.

2. Ensure that the finger trap is secure! A sudden and unanticipated release of traction can result in injury to both the patient and the physician.

Pearls

2. Be patient! Allow 5 to 10 minutes for traction to result in disimpaction of the fracture.

3. Forewarn patients that their thumb may hurt more than their wrist by virtue of the finger trap.

a. Also inform patients that their thumb will likely turn blue but that this symptom is normal, expected, and will resolve shortly after the finger traps are removed.

b. Performing a digital block of the thumb before traction may be considered in certain patients.

4. To “release traction” while performing the reduction maneuver, it is often easiest to simply grasp the forearm and allow slack on the finger trap or traction loop.

Improvisation

2. If a weight pole is not available, see Chapter 12.

Figure 10-13

Figure 10-14

Figure 10-15

Figure 10-16

Equipment

1. Stockinette: 3 inches wide, 4 feet long

2. Rolled gauze: 2 inches wide

3. IV pole

4. Weights: 10 to 15 lb

5. ABD (optional)

Detailed Technique

1. Position the patient:

a. The patient should be supine on the stretcher with the shoulder girdle entirely off the side.

b. If a long arm cast will be applied afterward, place a stockinette (see Chapter 13).

2. Prepare finger trap:

a. Attach a rolled gauze fingertrap (see Chapter 8) to the thumb using a single-ring construct (Figure 10-17).

b. Abduct the shoulder to 90 degrees and flex the elbow to 90 degrees to create a 90-90 position.

c. Secure the other end of the rolled gauze to the IV pole.

d. Alternatively, commercially available finger traps may be used. However, we have found that commercial finger traps are liable to loosening during traction application.

3. Set traction, if necessary:

a. Cut a 2-foot length of stockinette.

b. Place an ABD inside the stockinette for padding (optional).

c. Cut small holes in each end of the stockinette.

d. Drape the stockinette around the forearm.

e. Hang the traction weights.

f. Allow the traction weights to hang for at least 5 minutes.

4. Obtain traction films (optional). Portable AP and lateral radiographs of the distal radius should be obtained while the patient is in traction.

5. Perform a reduction maneuver.

a. The direction in which forces are applied depends on the type of distal radius fracture.

(1) Because the majority of distal radius fractures are displaced dorsally, the description below applies to a dorsally displaced distal radius fracture.

(2) For volarly displaced fractures, reverse the direction.

b. Grasp the hand, as if arm wrestling, using your right hand.

c. With your left hand, grasp the proximal radius with your thumb on the fracture site dorsally and your fingers curled around the radius proximal to the fracture (see Figure 10-14).

d. Recreate the mechanism by hyperextending the wrist (see Figure 10-15).

e. Release the hanging traction temporarily. Pull up with your right hand.

f. Begin to flex the wrist.

g. Shift your thumb slightly distally so it is over the distal fragment.

h. Using your left thumb, push the fragment volarward and use your fingers to pull dorsalward (see Figure 10-16).

6. Holding your thumb on the fracture site, use your knee to help maintain the wrist in a flexed posture while traction is reapplied. This technique maintains the reduction.

7. Apply a splint or cast (see Chapter 13).

8. Place a three-point mold on the splint, ensuring that the wrist is in slight flexion and moderate ulnar deviation and that the carpals are translated volarly (Figure 10-18).

Figure 10-17

Figure 10-18

Intercarpal dislocation

Overview

Intercarpal dislocations are illustrated in Figures 10-19 and 10-20.

1. Intercarpal dislocations are often missed in the emergency setting.

2. All intercarpal dislocations require urgent operative fixation.

3. Reducing the dislocation by closed means is extremely difficult.

4. Use of general anesthesia or conscious sedation often is helpful in obtaining the reduction.

Figure 10-19

Figure 10-20

Indications for Use

1. Lesser arc injuries (perilunate or lunate dislocations)

2. Greater arc injuries (perilunate or lunate dislocations with associated carpal fractures)

Precautions

1. Do not use an IV stand attached to the ceiling unless it is specifically designed to handle large weights.

2. Ensure that the finger trap is secure! Sudden and unanticipated release of traction can result in injury to both the patient and the physician.

Pearls

1. Patient positioning is key to obtaining appropriate traction. Strict positioning of the shoulder to 90 degrees and flexion of elbow to 90 degrees allows perfectly longitudinal traction to be applied through the fracture site.

2. Be patient! Allow at least 20 minutes for traction to result in exhaustion of countering muscles.

3. Forewarn patients that their fingers may hurt more than their wrist by virtue of the finger trap.

4. Also inform patients that their fingers will likely turn blue but that this symptom is normal, expected, and will resolve shortly after the finger traps are removed.

5. To “release traction” while performing the reduction maneuver, it is often easiest to simply grasp the forearm and allow slack in the rolled gauze.

Improvisation

If a weight pole is not available, see Chapter 8.

Equipment

1. Stockinette: 3 inches wide, 4 feet long

2. Rolled gauze: 2 inches wide

3. IV pole

4. Weights: 10 to 15 lb

5. ABD pad (optional)

Detailed Technique

1. Position the patient supine on the stretcher with his or her shoulder girdle entirely off the side.

3. Set traction, if necessary.

a. Cut a 2-foot length of stockinette.

b. Place an ABD inside the stockinette for padding (optional).

c. Cut small holes in each end of the stockinette.

d. Drape the stockinette around the forearm.

e. Hang the traction weights.

f. Allow the traction weights to hang for at least 20 minutes.

4. Perform a reduction maneuver.

a. Have an assistant stabilize the arm by placing both hands over the brachium.

b. Grasp the patient’s hand with one hand to apply traction.

c. With the other hand, grasp the distal forearm so that your thumb points toward the traction, coming to rest at the distal wrist crease.

d. Extend the wrist while applying pressure on the lunate with your thumb (Figure 10-21).

e. While applying maximal manual traction and maintaining pressure on the lunate with your thumb, bring the wrist back to neutral or slight flexion (Figure 10-22).

5. Obtain postreduction views while the patient is in traction if possible. Portable AP and lateral radiographs of the carpals can be obtained while the patient is in traction.

6. Apply a sugar-tong splint (see Chapter 13) while maintaining the wrist in slight flexion and ulnar deviation.

7. Obtain postreduction films.

Figure 10-21

Figure 10-22

Boxer’s fracture

Overview

Boxer’s fracture is illustrated in Figure 10-23.

1. Fractures of the fifth metacarpal neck are easy to reduce, but maintaining the reduction with closed means is unlikely.

2. Angulation of up to 45 degrees is usually well tolerated.

3. An ulnar nerve block provides complete pain relief of the fifth metacarpal.

Figure 10-23

Indications for Use

1. Fourth or fifth metacarpal shaft fractures

2. Fourth or fifth metacarpal neck fractures

Precautions

The molding required to hold a reduction can lead to pressure necrosis of the dorsal skin and extensor tendons.

Pearls

1. Ensure that rotational alignment is perfect by checking to be certain that no scissoring of the digits occurs when the patient makes a fist.

2. Augment analgesia with a hematoma block when reducing the fourth metacarpal.

3. Immobilizing the proximal interphalangeal (PIP) joints is not necessary if the proximal phalanx is not fractured.

Improvisation

The fracture is usually minimally painful and can await definitive management if supplies are not available.

Equipment

1. Ulnar gutter cast (see Chapter 13)

2. Ulnar gutter splint (see Chapter 13)

Detailed Technique

1. Position the patient so the forearm is vertical.

2. Perform a field block, nerve block, or hematoma block. An ulnar nerve block is reliable for fifth metacarpal fractures, but fourth metacarpal fractures may need a supplemental field or hematoma block.

3. Perform a reduction maneuver (Figure 10-24).

a. With one hand, stabilize the patient’s hand by pinching the metacarpal between your thumb and index fingers.

b. With your other hand, curl the patient’s affected finger and apply a dorsally directed force on the proximal phalanx.

4. Place an ulnar gutter splint or cast (see Chapter 13).

5. Place a mold on the splint/cast (Figure 10-25).

a. Place your left thumb just proximal to or at the apex of the fracture.

b. Grasp all the fingers in your right palm and apply a dorsally directed force while maintaining the metacarpophalangeal (MP) joints flexed and the interphalangeal (IP) joints in an extended position.

6. Obtain postreduction films.

Figure 10-24

Figure 10-25

Digital dislocations

Indications for Use

1. Thumb MP dislocations

2. Thumb IP dislocations

3. Finger MP dislocations

4. Finger PIP dislocations

5. Finger distal IP dislocations

Precautions

Hyperextension of a digit in a dorsal splint can lead to pressure necrosis of the dorsal skin and extensor tendons.

Pearls

1. A good block is essential to permit application of sufficient traction and force to reduce the dislocations.

2. In-line traction is typically sufficient to reduce most dislocations (Figure 10-27).

3. Recreating the mechanism of injury while applying traction can be helpful (Figure 10-28).

4. For thumb MP dislocations, placing the wrist and IP joint in flexion releases tension on the flexor pollicis longus and aids in the reduction (Figure 10-29).

5. If a reduction cannot be achieved, consider the possibility that soft tissue (e.g., volar plate or tendons) is interposed or that the bone is buttonholed between two tendons (Figure 10-30).

6. If the fracture/dislocation or dislocation reduces but then redisplaces even in the splint, it is inherently unstable and requires urgent attention by a hand surgeon.

Figure 10-27

Figure 10-28

Figure 10-29

Figure 10-30

Improvisation

If at first you don’t succeed, try something else.

Equipment

1. Aluminum padded splint

2. ½-inch-wide silk tape

Detailed Technique

1. Position the patient so that you have direct access to his or her fingers.

2. Perform a nerve block.

a. An ulnar nerve block is reliable for the small finger.

b. Median and radial nerve blocks at the wrist are necessary for thumb dislocations.

c. Digital blocks are sufficient for finger dislocations.

d. Wait 10 to 15 minutes for the nerve block to take effect.

3. Precut strips of ½-inch silk tape into 3-inch lengths.

4. Measure the aluminum foam splint and cut it to size (Figure 10-31). Only the involved joint should be splinted.

5. Trim away excess foam (Figure 10-32).

6. Contour the splint with an appropriate bend.

a. Dorsal dislocations (distal bone dislocates dorsally) can be splinted in flexion (Figure 10-33) or extension block splints (Figure 10-34).

b. Volar dislocations (distal bone dislocates volarly) should be splinted in extension (Figure 10-35).

7. Perform reduction maneuver:

a. Finger MP joints:

(1) With one hand, stabilize the patient’s hand.

(2) Pinch the finger with your other hand and apply traction (Figure 10-36).

(3) Exaggerate the deformity if necessary.

b. Thumb MP joints:

(1) With one hand, stabilize the patient’s hand.

(2) Pinch the thumb with your other hand and apply traction (Figure 10-37).

(3) Exaggerate the deformity if necessary.

(4) Flexion of the wrist and IP joint can facilitate reduction (see Figure 10-29).

c. Finger IP joints:

(1) With one hand, stabilize the patient’s hand.

(2) Pinch the finger with your other hand and apply traction (Figure 10-38).

(3) Exaggerate the deformity if necessary.

d. Thumb IP joint:

(1) With one hand, stabilize the patient’s hand.

(2) Pinch the finger with your other hand and apply traction.

(3) Exaggerate the deformity if necessary.

8. Place a padded aluminum splint for IP joint dislocations.

a. Hold the splint in place while applying circumferential tape.

b. Securing the distal end of the splint first is easiest (Figure 10-39).

9. Obtain postreduction films.

Figure 10-31

Figure 10-32

Figure 10-33

Figure 10-34

Figure 10-35

Figure 10-36

Figure 10-37

Figure 10-38

Figure 10-39

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