Can't Miss Hand and Wrist Fractures in the ED

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Written by: Justine Ko, MD (NUEM PGY-3) Edited by: Spenser Lang MD (NUEM Alum ‘18 ) Expert commentary by: Matt Levine, MD

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“Can’t Miss” Hand and Wrist Injuries in the ED

In the emergency department, orthopedic complaints make up a large percentage of presentations, up to 50% in the pediatric population and close to 33% in the adolescent and young adult population. Many of these injuries are uncomplicated, but an astute clinician can diagnose subtle and uncommon injury patterns. Three less common injuries are reviewed here. If found, these injuries can alter the management and disposition of the patient. Each of these injuries should be carefully assessed for on physical exam and imaging. 

DISTAL RADIOULNAR JOINT (DRUJ) INJURIES

What exactly is the distal radioulnar joint and why is it important?

The distal radioulnar joint (DRUJ) consists of both the bony radioulnar articulation as well as the soft tissue components, including ligaments. It has significant contributions to the axial load-bearing capabilities of the forearm. The injury can be an isolated injury or associated with forearm fractures and should be tested for with every forearm injury as its presence can alter the disposition and even functionality of the patient. 

When does it occur?

A DRUJ injury may occur, although rarely, in isolation. This is usually related to a fall on outstretched hand (FOOSH). A DRUJ injury is more often associated with a fracture. Common associations include: 

• Distal radial fracture (DRF)

  • DRF + DRUJ = Galeazzi fracture (pictured to the right)

• Ulnar styloid fracture 

How should I assess for a possible DRUJ injury?

• Routine AP and lateral views are poor for determining a DRUJ injury. This is largely a CLINICAL DIAGNOSIS.

• Piano Key Sign: with the patient’s hand in pronation, push on the dorsal aspect of the ulnar head. Depression and rebound of the ulnar head suggest DRUJ instability

• Table Top Test: have patient place hands on a table and apply force. A DRUJ injury will show dorsal depression of the ulna

• Grind Test: hyperextend the wrist and axial load the forearm. A positive sign elicits pain over the joint 

How does this alter management?

When associated with a fracture, operative management is often indicated and consultation with our orthopedist is warranted. When missed, a DRUJ injury will result in instability of the joint and arthrosis. 

PERILUNATE AND LUNATE DISLOCATIONS

It has been reported that these injuries are missed in up to 25% of ED presentations.

How do these injuries occur?

In perilunate and lunate dislocations, the mechanism is usually hyperextension in the setting of trauma. Patients presents with hand and wrist pain/swelling.

How do I distinguish perilunate from lunate dislocations?

Lunate and perilunate dislocations can be easily confused or mistaken for each other. The key to distinguishing these injuries on imaging is the alignment between the metacarpal, carpal, and the radius/ulna bones.

In a normal lateral x-ray, these bones should all align (Figure 1, far left). In a lunate dislocation, the lunate itself is physically removed or out of line with the rest of these bones (Figure 1, far right), resulting in the classic “spilled teacup” appearance on x-ray. In a perilunate dislocation, the lunate sits in line with the radius/ulna, however the capitate/metatarsal bones are dislocated dorsally. 

On an AP film, a break in Gilula’s arc/lines may be used to assess for a perilunate or lunate dislocation (Figure 2).

How Are These Injuries Treated?

In the ED, closed reduction can be attempted. If successful, definitive treatment can occur up to 7 days later. If unsuccessful, operative management is indicated. Definitive treatment involves open reduction and internal fixation. 

How Would I Reduce These Injuries in the ED?

Usually, the assistance of our orthopaedic colleagues is warranted. Finger traps can be used for traction. The wrist should be extended while placing palmar pressure on the lunate. Then, with continued traction, the wrist should be gradually flexed so that the capitate falls back into place within the concavity of the lunate. Once the lunocapitate joint is reduced, the wrist can be extended in traction again for full reduction.

SCAPHOLUNATE DISSOCIATION

What is a scapholunate dissociation?

Scapholunate dissociation is caused by injury to the scapholunate ligament. Injury to this ligament can occur with acute FOOSH injury or be caused by degenerative rupture of the ligament. 

How do I diagnosis it?

These patients present with radial wrist pain. On imaging, the following signs can aid in diagnosis. 

• Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones 

• Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent. A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability.  

How do I manage it?

In the ED, patients should be placed in a thumb spica cast for stabilization and referred to orthopaedics for follow up. Operative indication includes injury within 3 weeks and associated imaging and physical exam findings. During this time frame, the SL ligament is still viable for repair. 

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Expert Commentary

Great choice by Dr. Ko to highlight these injuries that are often subtle, yet important because of the comorbidities associated with missing the diagnosis. 

The Galeazzi fracture is a classic EM boards question, because it is important!  It was termed by Campbell as the “fracture of necessity” (modern day translation = “this needs surgery!”) in 1942 because nonoperative management was observed to be associated with recurrent ulna styloid dislocations.  Hughston confirmed this is 1957, reporting that 35/38 cases treated nonoperatively had unsatisfactory outcomes.

There’s a saying in orthopedics that “the most commonly missed injury is the second injury”.  The radial shaft fracture is usually obvious and can distract the clinician from the less dramatic DRUJ injury.  DRUJ injury is radiographically diagnosed by:

• Fracture at the BASE of the ulna styloid process (not the tip)

• A widened DRUJ (a comparison x ray may be necessary), or

• >5mm of shortening of the radius relative to the distal ulna.

A subtle clinical finding often associated with the Galeazzi fracture is anterior interosseus nerve injury.  It is a branch of the median nerve and is purely motor, so there will be no sensory deficit or paresthesia!  It manifests as loss of pinch strength between the thumb and index finger.  So have the patient make the OK sign and resist as you try to open it!

Mayfield, Johnson and Kilcoyne described a pattern of carpal injury caused by wrist hyperextension, ulnar deviation and intercarpal supination in 1980. In their original research on cadavers, progressive hyperextension force was applied and resulted in a consistent, sequential, progressively more unstable intercarpal injury pattern known as the four stages of carpal instability:

1. Scapholunate dissociation

2. Perilunate dislocation

3. Perilunate and triquetral dislocation

4. Lunate dislocation

Acute scapholunate dissociation is the most common pattern of carpal instability. It occurs secondary to a tear of the scapholunate interosseus ligament.  Scapholunate dissociation can also be chronic secondary to arthritic changes when there is no history of recent trauma.

X rays in lunate and perilunate dislocations are often not as clear and obvious as the diagrams used to teach these injuries.  The key to realizing that there is a carpal bone dislocation is recognizing that the carpal arcs are disrupted on the AP view. The distal and proximal carpal rows should never overlap on this view.  If you recognize this, you will heighten your suspicion and won’t miss these injuries, even if you cannot immediately tell the exact diagnosis.  

The name perilunate dislocation has always been a pet peeve of mine. There is no perilunate bone, so this nomenclature just introduces confusion.  It should simply be called a capitate dislocation, because that it what it really is.

All of these injuries, and more, are further detailed in our Ortho Teaching Files!

Matthew R. Levine, MD

Assistant Professor

Department of Emergency Medicine

Northwestern University

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How to Cite this Post

[Peer-Reviewed, Web Publication] Ko J, Lang S. (2019, Aug 19). Can't Miss Hand and Wrist Fractures in the ED. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/cant-miss-hand-and-wrist-fractures-in-the-ed/.

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Other Posts You Might Enjoy

To learn more about the diagnosis and management of orthopedic injuries from head to toe, check out our Ortho Teaching Files!

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References

1. Bowen WT, Slaven EM. 2014. “Evidence-based management of acute hand injuries in the emergency department.” Emergency Medicine Practice 16 (12):1-28. 

2. “Distal Radial Ulnar Joint (DRUJ) Injuries - Trauma - Orthobullets.” n.d. Accessed March 7, 2018. https://www.orthobullets.com/trauma/1028/distal-radial-ulnar-joint-druj-injuries.

3. Kardashian G, CHristoforou DC, Lee SK. 2011. “Perilunate dislocations.” Bulletin of the NYU Hospital for Joint Diseases 69 (1):87-96.

4. “Lunate Dislocation (Perilunate Dissociation) - Hand - Orthobullets.” n.d. Accessed March 2, 2018. https://www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation.

5. Pappou, Ioannis P., Jennifer Basel, and D. Nicole Deal. 2013. “Scapholunate Ligament Injuries: A Review of Current Concepts.” Hand (New York, N.Y.) 8 (2): 146–56. https://doi.org/10.1007/s11552-013-9499-4.

6. Reisler T, Therattil PJ, Lee ES. 2015 “Perilunate Dislocation.” Eplasty. 

7. Rodner CM, Weiss APC. “Acute scapholunate and lunotriquetral dissociation.” American Society for Surgery of the Hand. 155-171.

8. Scalcione LR, Gimber LH, Ho AM, Johnston SS, Sheppard JE, Taijanovic MS. 2014. “Spectrum of carpal dislocations and fracture-dislocations: imaging and management.” AJR 203: 541-550.

9. Thomas, Binu P, and Raveendran Sreekanth. 2012. “Distal Radioulnar Joint Injuries.” Indian Journal of Orthopaedics 46 (5): 493–504. https://doi.org/10.4103/0019-5413.101031.

Must Not Miss Fractures in the ED

Written by:  M. Terese Whipple , MD (NUEM PGY-3) Edited by: Ashley Amick, MD (NUEM alum '18) Expert commentary by: Matthew Pirrotte, MD

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Undiagnosed fractures occur frequently in the Emergency Department setting, with a total miss rate of 1-3%.  These missed fractures not only lead to poor patient outcomes, but also account for the second highest cost of litigation against EM docs, behind only MI.1,2  This may not seem relevant if you are lucky enough to have access to a Radiologist 24-7,  however there are several injuries that will be missed if they are not included in the differential diagnosis, because even the best radiologist can’t read a film if it wasn’t ordered. This blog post will cover three ‘must not miss’ injuries to keep in mind when assessing your run-of-the-mill orthopedic injuries namely:  the Maissoneuve fracture, Lisfranc injury, and Galeazzi/Montaggia fracture-dislocations.  Finding these tricky injuries require additional radiographic views beyond those standardly ordered, but keeping them in your differential will mean better outcomes for you and your patients.

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Massonieuve Fracture:

What is it and how will it present?

 A Massonieuve Fracture (which can be as difficult to pronounce as it is to miss) is a spiral fracture of the proximal 1/3 of the fibula with a disruption of the distal tibiofibular syndesmosis, which occurs in 5% of ankle injuries3. The injury occurs with pronation and external rotational forces are applied to a fixed foot, with damage propagating from the stressed tibial bone or deltoid ligament up through the interosseus membrane, causing a fracture to the proximal fibula.4 A twisted ankle in high heels is a classic mechanism for his injury.  In some cases the only apparent deformity is soft tissue swelling, pain, or ecchymosis at the ankle.  Patients may complain only of ankle pain, and because they are unable to bear weight they don’t load the damaged fibula, and therefore do not complain of lateral leg pain.  

Exam:

The patient will likely have pain with palpation over the ankle fracture/injured ligaments. Evaluate the ankle syndesmosis with compression and dorsiflexion eversion testing (will simulating a “high ankle” syndesmotic injury). In addition, make sure to palpate the proximal fibula both directly along the proximal shaft and head, and with gentle squeezing of the proximal leg just below the knee joint (a squeeze test).  Pain with these maneuvers should prompt additional radiographs.  Finally, test peroneal nerve function with ankle dorsiflexion and dorsal foot sensation. It is subject to injury in fibular fracture.

Radiologic Findings:

View you may not think of: Tib-fib or knee XR

Ankle AP:

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Look for fractures of the medial malleolus or posterior margin of the tibia. Also look for avulsion fractures indicating interosseus ligament disruption, such as in this case, with both a fracture of the lateral malleolus and a chip fracture indicated by the white arrow [3,5]. There is obvious widening of the syndesmosis.

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Look for joint space widening (white arrow) or widening of the syndesmosis (black arrow) [6]. If patient can’t stand, you may have to perform manual stress of the joint while the radiographs are taken (as indicated in this AP).

Knee or Tib/fib:

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Proximal fibular fracture {3}

Management and why it matters:

This fracture is considered by many to be among the most unstable ankle injuries [4].  If there is an intact mortise with no joint space widening, the patient can be casted and follow up with orthopedics. If there is joint-space widening at the ankle mortise, surgical intervention is likely required. If undiagnosed, a patient with a Massonieuve fracture may incur a host of bad outcomes including delayed orthopedic intervention, chronic pain, arthritis, and impaired mobility.

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Lisfranc Fracture-Dislocation

What is it and how will it present?

Lisfranc injury broadly refers to disruption of the metatarsals from the tarsus, with emphasis on the second tarsometa-tarsal joint and Lisfranc ligament [7].  The Lisfranc ligament runs obliquely from the medial cuneiform to the base of the second metatarsal (see below image for a refresher on normal foot anatomy). Injuries run the spectrum from sprain to an unstable fracture/dislocation. A dislocation of the tarsometatarsal (Lisfranc) joint is often associated with fractures, most commonly at the base of the second metatarsal or cuboid bone. It is estimated that 20-40% of Lisfranc injuries are missed on initial presentation. It can be caused by diverse mechanisms of injury including direct, high-energy trauma, such as MVCs (45% of injuries), or indirect mechanisms including [8]:

1. Forced flexion of the forefoot with a fixed hind foot (a horseback rider falling with a foot caught in a stirrup)

2. Forced supination/pronation on a plantar flexed foot (a soccer player having their forefoot stepped on and subsequently falling)

3. Axial load on a flexed foot (a drunken cubs fan celebrating the World Series win by jumping from Harry Caray’s statue onto a plantar flexed foot)

Physical Exam:

Pain localizes to the midfoot.  The exam may be subtle, or there may be significant swelling and deformity present. The patient can be ambulatory or unable to bear weight.  Test the joint by stabilizing the hindfoot, any twisting of the forefoot may cause pain. Compression across the forefoot will stress the space between the first and second metatarsals, causing a pain or a palpable click if a Lisfranc injury is present.  The Piano-key test is preformed by stabilizing the hindfood, grasping the metatarsals, and preforming passive dorsiflexion and plantar flexion at the tarsometatarsal joint, looking for pain or subluxation.9  Rarely they can have associated dorsalis Pedis injury as it courses near the joint, so make sure to check pulses. The tibialis anterior nerve can also become interposed and cause the big toe to point upwards, called the “Toe Up Sign.”

Radiologic Findings:

If a Lisfranc injury is suspected, foot radiographs with additional views including WEIGHT BEARING AP, lateral, and oblique are essential.

First a normal foot:

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1. The lateral margin of the 1st metatarsal should be aligned with the lateral margin of the medial cuneiform.

2. The medial aspect of the base of the 2nd metatarsal should align with the medial border of the middle cuneiform.

3. The medial margins of the 4th metatarsal and cuboid should be aligned [10].

 

 

 

Findings suggesting injury:

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AP: Diastasis of >2 mm between the base of the 1st and 2nd metatarsals indicates Lisfranc injury. 90% have associated avulsion fracture of the base of the second metatarsal or medial cuneiform, known as Fleck Sign (pictured at left). The pictured radiograph also demonstrates lateral displacement of all 5 metatarsals [11,12].

Lateral: Allows for identification of any dorsal or plantar dislocation [12]. 

Oblique: Allows for evaluation of the alignment of the 3rd and 4th metatarsals with the cuboid and cuneiform [12]. 

 

 

 

Management and why it matters:

If there is no evidence of widening of the Lisfranc joint space, the patient can be splinted and follow up with orthopedics, however they MUST BE non-weightbearing. Any evidence of fracture-dislocation >2 mm requires orthopedic consultation in the ED for likely operative fixation. Fractures found later have worse outcomes. Delayed ORIF after late recognition is better than no intervention, however most patients still require shoe modification or orthoses [12]. 

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Galeazzi and Monteggia Fracture Dislocations

The radius and ulna are joined by an interosseus membrane. When one is injured the other is likely to be affected as well (just like the tibia/fibula).

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Management and why it matters: 

If either fracture is suspected, consult hand surgery/orthopedics for reduction and definitive management. Both almost always require ORIF or other surgical treatment. Chronic pain and limitation of supination and pronation can occur if not properly treated [13]. 

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Expert Commentary

Drs. Whipple and Amick do a nice job of highlighting several eponymous fractures which can be tricky to diagnose. In general I find that missed extra-axial orthopedic injuries in the emergency department are the result of several factors

1. Failure to “film what hurts.” If a patient feels that their injury was sufficiently serious to warrant a visit to the emergency department, the prudent practitioner maintains a low threshold for imaging. Clinical decision rules for judicious imaging are clearly valid but need to be applied judiciously. When in doubt, get the film.

2. Failure to review films directly. Radiologists, while skilled and vital partners, rarely have the detailed information gleaned from simply pressing on patient’s bones and figuring out where they hurt. Correlation with point tenderness is a critical part of radiographic assessment. Scrutiny of radiographic bony anatomy near the sites of tenderness can lead to discovery of subtle fractures.

3. Failure to consider mechanism. Given the frequency with which we in the ED see serious trauma, it is easy to fall into a trap of being unimpressed with mechanisms that are actually quite severe. Every experienced acute care practitioner has had the chance to be absolutely flabbergasted by the severe polytrauma that can result from “low impact’ mechanisms such as stair falls, falls from standing, and pedestrians struck by vehicles at low speed.

The ramifications of a missed fracture can be significant. A recent analysis of closed legal claims in emergency medicine found that three of the top ten diagnoses in medical malpractice lawsuits were related to fracture care(vertebral, radius/ulna, tibia/fibula) [14]. A similar analysis of pediatric cases demonstrated that in children over the age of 3, fractures remain the most common source of medical malpractice claims [15]. This is to say nothing of the obvious morbidity and potential disability that may result from a missed injury.

The interesting thing about the fractures that discussed by Drs. Whipple and Amick is that, at least in the case of the Maisonneuve and forearm fractures, what tends to be missed is the severity and operative nature of these injuries rather than the fractures themselves.A clinician seeing a patient with an eponymous forearm fracture will likely not misdiagnose them as an elbow sprain. Similarly, few people would interpret the ankle films of a patient with Maisonneuve fracture to be normal, the problem comes in missing the fibular injury. Lisfranc’s fracture is a different entity; it is not uncommon for these patients to be misdiagnosed several times as having a “foot sprain” before the proper diagnosis is made.

One thing you can take to the bank in emergency orthopedics is that if the fracture is named after someone the injury involved can usually find a way to trick even a savvy clinician. Bennett, Rolando, Jefferson, Smith, and Sagond are also names that will you will encounter in your career.  As yet no one has attached their name to the nondisplaced fracture of the distal phalanx of the small toe, but one never knows.

Matthew Pirrotte, MD

Assistant Professor of Emergency Medicine, NUEM

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How to cite this post

[Peer-Reviewed, Web Publication]   Whipple M, Amick A (2018, August 6). Can't Miss Fractures in the ED.  [NUEM Blog. Expert Commentary by Pirotte M]. Retrieved from http://www.nuemblog.com/blog/missed-fractures

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References:

1. Schwartz, D. Ten Most Commonly Missed Radiographic Findings in the ED. Boston Scientific Assembly. Thursday, October 8, 2009. Boston Convention & Exhibition Center.

2. Hallas P and T Ellingsen. Errors in fracture diagnoses in the emergency department – characteristics of patients and diurnal variation. BMC Emergency Medicine. 2006. 6(4). doi:10.1186/1471-227X-6-4.

3. Millen JC and D Lindberg. Maissoneuve Fracture. The Journal of Emergency Medicine. 2011. 41(1): 77–78.

4. Charopoulos I, Kokoroghiannis C, Karagiannis S, Lyritis GP, Papaioannou N. Maisonneuve fracture without deltoid ligament disruption: a rare pattern of injury. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 49(1):86.e11-7

5. Sports Medicine for the Emergency Physician: A Practical Handbook. Ed. A. Waterbrook. Cambridge University Press: NY, NY. 2016. 75-77, 130-131, 248-249, 273.

6. Taweel NR et al. The proximal fibula should be examined in all patients with ankle injury: A case series of missed Maisonneuve fractures. The Journal of Emergency Medicine. 2013. 44(2): 251-255.

7. Wynter S, Grigg C. Lisfranc injuries. Aust Fam Physician. 2017 Mar;46(3):116-119.

8. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int 2006;27(8):653–60.

9. Seybold JD, Coetzee JC. Lisfranc injuries: When to observe, fix, or fuse. Clin Sports Med 2015;34(4):705–23.

10. Sherief TI, Mucci B, Greiss M. Lisfranc injury: How frequently does it get missed? And how can we improve? Injury, Int. J. Care Injured. 2007. 38: 856—860.

11. Gupta, RT et al. Lisfranc injury: Imaging findings for this important, but often missed diagnosis. Curr Probl Diagn Radiol. 2008 May/June. 115-126.

12. van Rijn J et al. Missing the Lisfranc Fracture: A case report and review of the literature. The Journal of Foot & Ankle Surgery. 2012. 51: 270-274.

13. Perron, A et al. Orthopedic pitfalls in the ED: Galeazzi and Monteggia Fracture-Dislocation. Am J Em Med. 2001 May. 19(3): 225-228.

14. Brown, T. W., McCarthy, M. L., Kelen, G. D. and Levy, F. (2010), An Epidemiologic Study of Closed Emergency Department Malpractice Claims in a National Database of Physician Malpractice Insurers. Academic Emergency Medicine, 17: 553–560

15. Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatr Emerg Care. 2005 Mar; 21 (3): 165-169

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