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Hi, everyone. I'm Doctor Vikash. And today I'm going to be giving a presentation on wrist fractures this as my learning objective. And I hope that by the end of this talk, the students will be able to understand the physical anatomy of the wrist and the hand, try to identify common types of these structures that would be encountered in your day to day practice. Go through the basic denominators regarding the clinical history and examination findings have an idea of some common neurological investigations and some common signs that can be picked up from them and then get a general understanding of the acute management of risk fractures at this. From a student perspective, from the perspective of this overall general management of, I'll be using this outline to give this presentation. First, I'll start with an introduction. I'll go through some relevant anatomy which will be important for understanding some of the bio being discussed. I will then go to the common type of risk fractures. Talk a bit about the clinical features, go through some investigation and then run through the management. The is the part of the musculoskeletal system. It's quite a complex joint and it says there's a bridge between the hand and the forearm because of this function. It it's one of the commonest sites of orthopedic injury. As a gi doctor in orthopedics you will likely encounter is more risk factor. You know, if you on call to understand how risk factors develop, then it's important that you, we understand some of the basic anatomy. It's biomechanics and all of these will add up together when we're talking about clinical features and management. Starting with the relevant anatomy, the bones that make up the rich joint include the distal ends of the radius and ulnar, the eight KPA bones and the proximal portions of the five metacarpal bones. On the right. You can see a diagram that is showing this is at the distal ends of the radius, the distal end of the. And this complex here are the bones a scaphoid ate from bones a here in the center, the ham with his foot and the trapezoid and the trapez here we have the distal ends of the metacarpal bones. All five of them in this slide showing the bones and the articulations and how they all work together to make up uh this joint. Yeah, it is a radiograph showing a radi radiographic anatomy of which joint. What what I already agreed to, we have some common types of wrist fractures that will be going over during this presentation. Basically, all of the bones that we initially discussed about the the, these are ends of the ulnar ranges, the carpal bones and ends of the carpal bones. I'm gonna try to cover some of the com the common types of risk factors in this presentation and then some of the few that should I might be missed because the may be associated with significant complications. So, um some common risk fractures that we see from it, different settings from the emergency department setting in general practice in certain situations in daily present and even in the orthopedic department lead to these fractures, skiway fracture. These most likely will make up the bulk of the majority of presentations for risk factors injuries. That a we have some important facts also that belong to this category that, that you know, we miss because they may be associated with significant problems there. Uh ate any kind of dislocation of any of the Kappa bone classically ate and perate dislocation or dislocation, which I will also discuss about later on moving forward. Generally, the steroid, just fructose remains the com the most common orthopedic injury you encounter, like I already mentioned for a couple of fractures, the most common fracture you would see are fractures. II would also like to mention at this point that it also is one of the some of the most common fractures. It it is important to know how to identify them on the radiograph. But you, when you identify them, you try to avoid using them particularly because all complications. There are other risk factors that increase the risk of evolution that fracture include trauma, osteopenia, and osteoporosis. So you see, you tend to see these fractures in because of the risk of opinion is and we'll also be going over some fractures. There are quite a few of them. Um Although currently, the current teaching is that we are trying to do away with some of the names for common presentations. They are still common. They are still commonly asked exam fracture. So we have the coolest fracture, a Smith's fracture and a Buttons fracture, which are all fractures, affecting the distal and the radius and, and we have box and venous fracture which are fractures that are affecting the metacarpal. We're gonna go over this in a minute. There are some clinical features that uh are commonly nominator amongst the different types of risk of facts. So one of the things you have to pick up on the history would be the mechanism of injury. Classically, it is a fall on an outstretched hand. So it is the commonest mechanism of injury for most risk factors, especially in the elderly pac. These are typically low energy in you had a fall from a standing height, mm with a with the fellow and hand, they try to stretch out their hands and their wrist to break the fall and will sustain a fracture of the wrist. Although this is the commonest presentation, we can also have high energy fractures, particularly in the younger population from road traffic accidents fall, falls from height and in certain other situations. Basically, the fracture pattern can be determined by the degree of or radiation. You can decide which, what type of fracture would they, would it be, would it be do or, or do? Or um molar fractures would be part of the fracture, part of escape and part of es would be effective to the degree of radial. How he what is the weight of the patient? How much risk, risk extension and flexion is occurring at the time of impact? The common symptoms at presentation would be wrist pain, some swelling and an obvious wrist deformity reason you all have to explore for risk factors if you uh seeing this patient. So another patient with history of osteoporosis, osteopenia who is taking medication for this, you begin to suspect that in an examination, usually an inspection, the wrist will be swollen. Sometimes they may have a, there may be an obvious deformity. It, it may be we there may be bruising around the wrist. If you try to over touch, touch the wrist with the on patient, there will be reduced movements due to pain. It's important that you know, patients who present with fractures generally and specific particularly for risk factors in this situation to test for neurovascular integrity of the radial neck. A common neck, the hand w regarding the investigation, plain x rays of the wrist are usually the first line investigation and quite often they are sufficient to make a diagnosis and decide on a management plan going forward. The views usually requested are the ap and lateral views but sometimes some special views like the oblique view or the views may be requested for in Children. These situations where plain x rays are not sufficient to make a diagnosis. So you require further information since you have the risk is usually requested. For, for instance, for preoperative planning, if you want to further assess structure and morphology of the, to decide on the most appropriate technique for surgery, you require a ct of wrist and there are certain situations where the clinic is not enough information they have been in extension, then yeah, may be appropriate to get a, a CT of the and then the complex fractures particularly in high energy fractures where you see here that you need to be better defined the morphology of a fracture and your request for c in entire situations, the pla A plan X ray and T are usually sufficient, sufficient. But in situations may require an MRI especially if you are suspecting that you get a significant soft tissue injury like a a injury which will be quite common. Uh And despite a normal X ray they symptoms. So you may try to look and see if you uh if there are any fractures that can be noted. Principles of management would apply to all types of risk factors. So different elements of this would feature in the risk factors that we're gonna discuss in the specific risk factor we're gonna discuss going forward. The overall and general overarching principle is that we should optimize recovery of the wrist and hand function. So if someone has a fracture, they want to see how much of their function they can get back. So uh in when we are managing these patients, that should be what uh goal, that's what that should be. What we are hoping to achieve to do this once effectively manage the pain, regular assessment, we wanna try to immobilize the limb to reduce or injury and damage. We want to elevate the limb limb to the swelling. I wanna give antibio to prevent infections and to open fractures to prevent tears. And in this place, fractures, fractures will have to be reduced and fixed, uh usually solidly and postsurgery and post intervention and post amputation. They will have, they will need to be adequate rehabilitation, using physical therapy and occupational therapy and other measures to try to get back to that principle of recovery of the wrist, recovery and function. More specific fractures. I start by this causing these fractures. They combinate orthopedic fractures. Generally. Um you will, if you do two on calls, you know, as a junior doctor, you're most likely gonna need at least one or or even more facts. So, like we initially mentioned regarding the clinical features here who injuries where you have a classic vision, it's swollen on all hands. So usually low energy uh it's a higher, it's, it's common in women. About 50. Usually the risk factors of osteopenia in osteoporosis are present in this age group. And what not regarding the biomechanics and not of the wrist is that the radius over about 80% of the A LA L load of wrist. These fractures could be displaced or undisplaced. Show you what I mean. In the next slide, it could be extraarticular or intraarticular fractures and sometimes these three fractures the need some but fs uh all different types of these factors depending on the level of placement which we'll see much later. They are operative and non operative management options for managing risk factors. This slide just shows the three common with the structure. The colon has been fractured. The C fracture is an extra fracture, there is dos ation of the displaced fra fracture fragment. So in this situation here we have here is a fracture fragment in fracture and it is displaced. Do you do the opposite of a col fracture? As often described is it is called a fracture. It's also sometimes called a reverse fracture. So that distal fra that mo distal fragment of the fracture is instead angulated, is displaced and angulated to the hold out side of the forearm underneath. Finally, there is the less common buttons fracture, which is mainly an intra articular fracture. So we have an intra you, you can see the fracture line here extending intraarticularly. It's not extraarticular. And so the but the buttons, there's also a ventral button fracture where these intraarticular affectation of the articular surface of the distal radius. It's on the ventral side in contrast to the classic structure where it's at the side and where's your growth showing and reiterating? What I just discussed here, we have a fracture. Yeah, this is a line that the Verni line joining that is supposed to continue from the distal end of the radiation and ulnar with the car under line with the bones in this, in this direction. So usually if you watch this, it's usually an indication that look there's been displacement of the fracture. It can help you, we can guide you to fing out. If there is in this situation, we see the fracture segment displaced do me and the and those are to the perpendicular line that is that goes across the distal end of the leg and carpal bones. So you can see the fragments here. And this is the classic uh in the image of the right, we can see again this line but instead it's there's a whole a whole in the uh smooth fracture, regardless of the type of fractures, clinical change. They are they, they no, they are broadly divided into non operative methods and method of management but non methods, sometimes we could try to do a close reduction on skin testing. Usually there are certain indications for non operative treatments. There are any medications where you want to opt for a close reduction. How are you doing or in C four? So the indications would be if the, if there is a non fracture. So we have moderate displacement, mild in that is less than five millimeters of ra short of the dos UL is less than five degree. I'd rather just show you this again. In the next slide. What I mean by radio shortening and dorsal angulation in a situation where there is greater and is and uh angulation. A significant placement were for operative management, you know, um external position in certain situations for the some complication of this area of fractures. So it could be where the bone fractures of the bone of the line abnormally, there could be no union where there is no fracture he at all. And there's still a fracture line defect present. You have compartment syndrome developing where and the distal for um there is an increase in compartment fracture with compartment result of bleeding. A result of inflammatory response. There is an increase in the compartment pressure on the forearm which leads to abnormal which makes a compromise of circulation, pain and possible tissue necrosis. If it's not treated or compartment syndrome is a emergency because sometimes with healing of the fracture, we could get nerve entrapment again, we just run around the talk end of ras and all now could be injured and developed. And in this situation, obviously, we we have pro problems with carpal tunnel, the carpal tunnel syndrome. I next would be the Ekho fractures. The scaphoid is the most common couple of bone fracture you will encounter about 60% of couple, couple of fractures would be fractures of the with skway fractures. They tend to require aqua fractures and it may be difficult, especially early on injury, injury with any presentation. So then five fractures and even in those situations, sometimes brain x rays will tell you how much an accident the fracture may have ac. So usually if you use an MRI is often needed for surgical planning, this before fracture, the mechanism of injury classically will also be a follow on and but we have across the high dose pro and risk. So usually I just try to do this on myself. So I try to flex your wrist pronated and on a or you can see that you fall on that. So this this is just slightly above around the anatomical location of the SK for on presentation, we tell you wasn't with circumduction of the risk. Um classically, the standard is around the agra called small. And if you can probably around the in clinically, if you see wasn't a risk pain was a conduction, there is a tendon is around there because it usually it's very highly sensitive to the most likely that it is a fracture. Again, investigation wise a player will usually be requested for it sometimes it's negative. So, clinically, you have a high suspicion of ski fractures, immobilize the for the patients in uh back slab and repeat the X ray and do the week. There are, there's a the non, there's a non operative management. No management management will involve cost mobilization. And this is your indicated for fractures that are quite stable. They are noncomplex and they are non displaced operative management would be for fractures that are displaced, a significant com combination. And you want to try as much as possible to improve function particularly among patients. So you can use percutaneous. And the to the story generally depends on what the surgeon believe would be appropriate. Considering the degree of this placement, complications from scaphoid fractures could include non union and nonunion. Like they mentioned, there could be osteonecrosis where you have the scaphoid has a unique drug of five which unlike all the bones and unlike what is usual in the body, it comes from distal to proximal. So it it is also when in case of fracture, we tend to have a high risk of tissue necrosis due to blood com a compromise of the blood. So we tend to have an increased rate of osteonecrosis. Um These really graphs show a fracture, I'll allow you to just give, give yourself like a moment to try to see if you can identify the fracture lines in the left, the one on the right is or have already been indicated for you. So here you can see the fracture line just here on here in this case. So for is yeah, shaped like a boot. Uh So it's one of the easiest bones identify AAA couple of bones. So we have the line just around here. It's I think this is a big car. So here, so you can see that partial line. Oh So a factor of the three, they are common bone fractures. The usual mechanism of injury is a direct blow to the dosing of the hand. Um Sometimes I fall on a hyperflex twist that you see plastic period, lateral views may not give you um ideal look the top of the of the bone amongst the bone. So sometimes an oblique view may require, it just lies under the PC form and and it may be difficult also to pro clinically because of this position for non displaced fractures of three. Manage for 4 to 6 weeks. We check X ray done to confirm fracture here. Um If if, if there's an unstable factor, the progression, we decision complications of preparing fractures, uh non union and sometimes constant and persistent instability because it has like a very significant position within the boot. So where fractures tend to be persistent, instability of the part you can see here just lying beneath the bone. I think this is a bit clearer if you identify it here. There's just here you can avoid a fracture. It's quite difficult to visualize it for x rays sometimes also require, you may have to de trapezium and detect common structures. The mechanism of injury is a question. But in this situation, that's really close. He run examination wise, there's point tenderness, usually what it is of the tongue, it's quite highly sensitive. So if you're having 10 and a little to usually you either uh fracture or a fracture. And so we could demonstrate quite well. Um uh No management would involve applying uh using a tongue speaker cast. This is basically a cast where it's one of the, it extends uh some part of the cast extends to the tongue. It is usually done for at least six weeks in situations where non operative management either fails or the place of management. What is on the slide is that there could also be complications, factors where we have no I and pneumonia. This is the CT scan showing a fracture. You can see the fracture line is here in this position. I try to get the, this is not quite clear. But if you look quite closely, you see the fracture lines here, it's, it's very, very recent movement. Uh CT next, we'll talk about some epma base of thumb fractures. Um We practice on its own in the film factors involved the metacarpal of these a mechanical injury classically is an axial force as applied to the, to when the tongue is infection, it usually results. In fact of the base of the MOARA. Got you. Come on. You much practice of the film that is Rolando and Bennett with Bennett fracture. There's uh there's an intraarticular and a, a palmar ulnar fragment. A fracture with Rolando, we have a wire t shaped, complete intraarticular fracture. I'll show this again in the next slide. Yeah. Yeah. We have a DD structure. I mean BP for just a straight line in the base of the tongue. Here we have a random factor. Usually why sometimes T shifts completely factor. I was I like it. I'll talk about per limit and fractures or per location. These are, these are quite red um causes of acute injury and acute pain, but they're quite important because the as treated with for neurovascular outcomes if they are not treated alternately properly. Yeah, high and injuries, injuries. So we have accidents blue, blue, the risk that would result in or fractures. So you have a traumatic mechanical injury usually that would. So your risk is really extended and normal to eliminate itself takes and your kids, we have rooted ligament instability. So in the per its location of the itself stays in position for the car. So that's one of the one of the key between a and location. So, you know, in the first situation, the lunar bone itself is arrest. Um it articulates with the radius is what rotates and then dislocates in the, the stays in position. But the rest of the car, the rest of the bone, it's quite an important when you are looking at the X, which I show the next one of the reasons why this is, although it's right, it's important is because it's associated with nerve injury in about 25% of the case. So early on in the injury, he's not offend promptly, he was not released or in the emergency department. There's a very high chance of me getting injury. Despite this, if it's reduced to probably on presentation and splinted, this can be done at least to help relieve or reduce the chance of injury, but it it has quite poor outcomes. So most of the time we still tend to opt for operative management because of the fact that there's a high chance that reduction has been before emg and followed by a planned open reduction and ligament because usually with a lot of that makes the risk quite unstable complications, uh media nerve injury. Um because of lot of there's a chance of skin damage of. So a practice show two x rays demonstrating perinatal this location. So the one on the left where you can see this C bone large, so it's quite easy to I xrays of these shape. Usually you rest just here on the outrageous. Remember again, the that we mentioned earlier, that should be at the center just at the center of the he start and kind of and it cuts across and, and, and it continues with the. So we can see the should be just around here. So this is classical and the X ray on the right, you see the here, the shape, the half moon shaped bone I still have, you can draw a line, you can see that it's still bye these surface of. But the rest of the the rest of the car has been and sit here. This is the key distinction between box fracture. Although it's not really classically a risk factor, it usually discuss the risk fractures is a distal fix, metacarpal fracture. The mechanism of injury is the chroma which the name of a box boxer structure. There is a deformity of those. So we tend to we have an of digits, sorry and not. So the digits tends to be formed. And when you ask, ask the patient to follow or try to make a fist, you see that some of the digits tend to up, up gives you hint of look. Yeah, there it could be a fracture of the uh it's a known immobilization and I got and this is this is usually reserved for non displaced fracture for operating management if they have open fractures, the fact of treatment. And so in this situation, they usually opt for complications. Uh No. And so this x-ray demonstrates a fracture just around here of the distal end of the Hi, this is a classic box of fracture. And then for the, just for your. So, I'd like to thank you for listening to my presentation. If you have any questions, you can just try to contact me and I'll be more than happy to answer them.