Wrist dislocation

 Pure dislocation of wrist is very rare.

 DRU : DRU is a pivot joint as opposed to PRU which is a
swivel joint. Radius rotates 150 º about a fixed ulna.
 DRU has 3 ligaments.
 Strong UCL from ulnar styloid to ulnar carpals by 2 fasciculi.
 2nd is a thin loose capsule that attaches to the margins of the
ulnar notch of radius to the ulnar side of ulna.
 3rd is TFCC which attaches by its wide base to distal ulnar
margin of radius and apex to the root of ulnar styloid.
Wrist dislocation
 Mechanical axis of forearm is a line drawn
from center of the head of radius to center
of head of ulna. Both PRU & DRU joints
move in paired synchrony. Normal range of
motion is 150º and additional intercarpal
movements create illusion of 180º rotation
of forearm.
Wrist dislocation
 Subluxation : Capsular ligaments are sprained but
yet in continuity, so that clinically no deformity is
apparent.
 Dislocation : Not only capsular ligaments are torn
but also TFCC is avulsed sometimes with the
ulnar styloid thus permitting diastases between
radius and ulna so that ulnar head becomes
prominent either on dorsal or volar aspect of wrist.
Wrist dislocation
 Clinically if dislocation is dorsal, there is
marked dorsal prominence of distal ulna
and hand is held in pronation. Wrist appears
narrower than normal and supination is
painful and resistant. Of dislocation is volar,
the normal dorsal prominence of ulnar head
is lost, hand is held in supination, wrist is
narrower than normal and pronation is
painful and resistant.
Wrist dislocation
 Acute injury is associated with rapid and
marked swelling around wrist that obscures
bony landmarks so painful inability to
supinate or pronate should arouse
suspicion of RU dislocation.
 X-rays show overlap of radius and ulna in
AP view and in lateral view ulnar head is
either anterior or posterior depending upon
the dislocation.
Wrist dislocation
 Treatment includes reduction by pressure
against ulna while placing forearm in full
supination or pronation as the case may be
and immobilizing the forearm in the AE
POP cast for 4 to 6 weeks.
 In chronic recurring dislocations repair of
the ligaments though occasionally
successful and resection of the distal end of
ulna is indicated.
Injuries to carpals
 Dislocation of the carpals result from fall on out stretched
hand and are comparatively uncommon. Two main groups.
 First : MC DRC and part of PRC dislocate dorsally.
Occasionally one of the carpal bone fractures part remaining
in alignment and part displacing with the distal row. For e.g.
perilunar, periscapholunar and trans-scaphoperilunar.
 Second : Distal row re-aligns with the radius and part of the
proximal row is extruded. For e.g. dislocation of scaphoid or
lunate, dislocation of lunate and scaphoid and dislocation of
lunate and part of scaphoid which is fractured.
Dislocation of lunate
 Commonest of all carpal dislocations.
 Fall on out stretched hand.
 Frequently overlooked due to failure to interpret the
x-rays.
 Normally pisiform bone stands out to a varying
degree but shape of dislocated lunate is quite
different. Concave surface in which capitate usually
sits is rotated anteriorly so that crescent moon
shape is obvious.
 In AP view, lunate is sector shaped.
 Median nerve involvement is very suggestive.
Dislocation of lunate
 Treatment : Reduction under G/A by traction to
supinated wrist, extending wrist, and applying
pressure with thumb over lunate. Flex the wrist as
soon as you feel the lunate slip into position.
 Reduction checked with x-rays as failure is an
indication for open reduction.
 POP cast in wrist flexion is applied for 2 weeks
F/B cast in neutral position of wrist for further 2
weeks.
Dislocation of lunate
 Complications :-
 Late diagnosis : Manipulative reduction is difficult
and after a week it is impossible. Open reduction
is inevitable with risk of AVN.
 Median N palsy : Prompt reduction is F/B early
complete recovery but in late reduction recovery
may be incomplete.
 Sudeck’s atrophy : Common and treated
accordingly.
Dislocation of lunate
 AVN : Leads to collapse of lunate and secondary
OA. All cases must have monthly x-rays for 6
months to allow early detection. Excision with or
without prosthetic replacement prevent
progressive OA. At later stages arthrodesis of
wrist. Repeated trauma to wrist may lead to
similar condition called Keinbock’s disease found
in manual workers like carpenters, cobblers and
pneumatic drill operators etc.
Dislocation & subluxation of scaphoid
 Uncommon injury, diagnosed radio logically. AP in
both radial and ulnar deviation helpful. Widening
of space between scaphoid and lunate.
 Treatment : If displacement is anterior and
complete, reduce as for lunate. In many cases it
is incomplete, proximal pole being tilted
posteriorly and distal pole anteriorly. Such injuries
have often a toggle like instability within the
dorsiflexion / palmarflexion range and stable
position within this phase must be found with trial
and error during reduction.
Dislocation & subluxation of scaphoid
 Reduction may be achieved by pressure over
the dorsal pole. Wrist should be kept in POP
cast in stable position with added radial
deviation for 6 weeks. Check films are
mandatory. Slight residual displacement
should be accepted as the late results are
usually excellent. Gross displacements should
be reduced through posterior approach with
reefing of posterior (scapholunate) capsule.
Dislocation of lunate and half
scaphoid
 Treated initially by closed reduction
thereafter however scaphoid # dominates
the picture and the treatment should follow
the treatment for the # scaphoid. If after
reduction there is gross carpal instability
internal fixation of the scaphoid is
considered.
Trans-scaphoid Peri-lunar dislocation
 Same as dislocation of lunate and half of
the scaphoid. Commonest of the first group
of carpal dislocations. In some cases there
may be associated # of the styloid
processes of the radius and ulna.
 Treatment : Reduction by traction is usually
easy. Thereafter the management is that of
the # of scaphoid.
Perilunar dislocation
 Corresponds to isolated dislocation of the
lunate.
 Treatment : Reduce by traction, apply
plaster with wrist in flexion for 1-2 weeks
before changing plaster with wrist in neutral
position for further 2 weeks. Thereafter
physiotherapy for wrist mobilization.
Other carpal injuries
 Dislocation of both lunate and scaphoid Treated
as for dislocation of the lunate.
 Peri scapholunar dislocation of carpus:
Treated in the same way as perilunar dislocation.
 Dislocation of trapezium, trapezoid or hamate are
rare. Closed reduction always attempted but open
reduction is frequently required. If there is
instability tansfixation with k-wires may be helpful.
Other carpal injuries
 Fractures through the bodies of any of the
carpal bones other than scaphoid are rare
and treated symptomatically by 6 weeks of
Colles's or scaphoid plaster depending on
the injury. Fractures of the hamate and
pisiform may be complicated by ulnar nerve
palsy which should be treated.
Other carpal injuries
 Small chip # of the carpus are common and result
from hyperextension or hyper flexion injuries of the
wrist. Direct violence is sometimes responsible. The
bone of origin is in doubt. Treated by POP for 3
weeks is all that is required and full recovery of
function is the rule.
 # of hook of hamate occasionally occur in sportsman
especially golfers and may be visualized by carpal
tunnel views. They are best treated by excision.
Scaphoid fracture
 Results from kickback when using starting handles
on IC generators, pumps, compressors and
inboard marine engines.
 Common is fall on outstretched hand.
 Diagnosis : Pain on lateral side of wrist following
injury. Marked and rapid swelling of hand and
wrist. Tenderness in the anatomical snuff box.
 Many wrist sprains without #, Bennett’s # and # of
radial styloid also present similarly.
Scaphoid fracture
 In a true scaphoid #, tenderness will also be
elicited on pressure over dorsal and volar aspect
of scaphoid.
 X-rays : Ask for scaphoid and not wrist so that at
least 3 views of scaphoid are obtained.
 AP, LAT and one or two oblique views must.
 # is often hairline and hard to see, so in all
suspected but unconfirmed cases, repeat x-rays
after 10-14 days are must.
 Decalcification at the # site should render any #
visible.
Anatomical features
 Scaphoid plays a key role in wrist and
carpal functions, taking part in the RC joint,
and in joint between PCR and DCR.
 It articulates with the radius, trapezium,
trapezoid, capitate and lunate.
 Commonest site of # is waist(50%),
proximal half(38%) and distal half(12%).
Anatomical features
 Number of abnormalities in ossification may be
confused with #.
 The os centrale may be small, large, or double.
 Os radiale externum lies in the region of the
tubercle and may represent old, un united #.
 Bipartite scaphoid is now generally regarded as
being due to this, but rounded edges differentiate
these from #.
Anatomical features
 Blood supply of scaphoid is through small
vessels which enter the ligamentous ridge
lying between the two main articular
surfaces. When these vessels are well
scattered ischemia following a # is
uncommon. If all the vessels enter the
distal part of the ridge, # of waist and
proximal poles may be followed by AVN.
Anatomical features
 AVN is of immediate onset but 1-2 months
may elapse before increased density betrays
its presence on x-rays.
 There is usually slow but progressive bony
collapse and RC OA.
 Leads to worsening pain and stiffness in the
wrist.
 AVN occurs in about 30% of # of proximal
pole of scaphoid.
Anatomical features
 Movement of fragments is difficult to control,
and non union may occur in waist #. Cystic
changes at the # site are F/B marginal
sclerosis. The edges may round off and
form a symptom less pseudo arthrosis or
OA may supervene.
 Non union can occur without AVN.
 Most # with AVN are united.
Prognostic features
 Prognosis is good in stable # like # of
tubercle and hair line # of the waist.
 Is poor in unstable # like oblique # of the
distal 3rd, displaced # of the waist, proximal
pole #, # associated with carpal
dislocations and comminuted #.
Treatment of suspected #
 Apply a scaphoid POP cast and sling.
 Remove the plaster and re-X-ray at 2 weeks.
Absorption of bone at the site of any hair line # will
then reveal it. If # is confirmed, apply a fresh cast
and treat it as a frank #.
 If x-ray are negative, pt is presumed to have
suffered a sprain and is treated accordingly.
 But if symptoms persists re-examine and x-ray
after another 2 weeks.
# of tuberosity
 AVN never occurs in these # and non union
is not symptomatic. Symptomatic treatment
i.e. crepe bandage or plaster depending on
pain.
Un displaced # of body
 Scaphoid plaster : Position of hand is quite
important and make it quite clear to the pt.
 Wrist should be fully pronated, radially deviated,
moderately dorsally flexed and thumb should be
in mid abduction.
 Common faults : Plaster including MP joints of
fingers restricting flexion, DP joint of thumb
included preventing IP joint flexion, plaster too
short or plaster too long restricting flexion of the
elbow.
After care
 Sling for first few days till swelling subsides,
analgesics initially and patient is reviewed
at 2 weeks.
 Plaster removed at 6 weeks and scaphoid
assessed clinically and with x-rays. If there
is no tenderness over dorsal surface or
anatomical snuff box and # appears united
on x-rays, the wrist should be left free.
After care
 If # line shows clearly or if x-rays shows
union but there is marked local tenderness
or there is some uncertainty, these all
possibilities suggest a delayed union and a
further 6 weeks of plaster is desirable.
 At 12 weeks, there may be evidence of
AVN (note density of proximal half) but the
# has united, then there is no advantage in
continuing with plaster.
After care
 At 12 weeks if there is no evidence of union
or there is established non union, internal
fixation should be considered using a
Herbert’s screw.
 Local bone grafting may also be required.
 If surgery is refused, plaster should be
discarded.
Displaced # of scaphoid
 Careful analysis of x-ray to exclude a carpal
dislocation.
 Markedly displaced # of the scaphoid
should be primarily fixed and this is
certainly indicated if conservative treatment
has been attempted and check x-rays
through plaster shows persistent
displacement.
Complications
 Sudeck’s atrophy.
 AVN : Surgery should be carried out before
secondary changes occur in wrist. Initially
scaphoid collapses without any OA but further
delay would lead to OA. Scaphoid should be
excised with or without insertion of a silastic
spacer.
 Non-union : May remain symptom free and active
treatment is then inadvisable. If symptoms are
marked, internal screw fixation and BG done.
Complications
 If early impingement OA threatens excision of radial
styloid is done but mid carpal joint is unaffected by
this.
 Advanced OA : Sequel to AVN or non union. In heavy
manual labors wrist (RC) fusion is most reliable in
which pronation and supination are retained but all
other wrist movements are lost. Where some wrist
movement is essential, excision of PCR may be
considered but results are a little unpredictable.
Ganglion
 Cystic swelling overlying a joint or a tendon sheath. Found
most frequently about the wrist but it may appear adjacent to
any joint or tendon sheath.
 Etiology : 2 main theories.
 Mucinous degeneration of connective tissue : Dense
collagenous tissue undergoes degeneration with formation of
multiple small cysts containing mucin. Several small cysts
coalesce into one large cyst. The probable cause is traumatic
obliterative endarteritis causing nutritional deficiency of
connective tissue.
Ganglion
 Facts against this theory are that collagen is
universally distributed and trauma is non selective
yet a ganglion favors only certain locations and it
is rare in elderly in whom degenerative processes
are pronounced.
 Defect in capsule or tendon sheath : Such defect
permits protrusion of synovial tissue. The
communicating channel is obliterated and often
exists as a non patent pedicle or adhesion.
Ganglion
 However defect persists and recurrence
with formation of multiple cysts is common.
Evidence favoring this theory are favored
location which strongly suggests
developmental or traumatic deficiency of
the capsule or tendon sheath. Resection
and closure of capsule or sheath stops
recurrence.
Pathology
 One large main cyst develops and is either unilocular or
multilocular. Multiple small accessory cysts lie adjacent to the
large cyst. Wall is dense fibrous capsule with a smooth
shining surface. Collagen fibers appear to be stringy and
spread apart and contain vacuolated cells but no
inflammatory cells. No definite synovial lining. Fluid is thick,
sticky, clear, colorless and of soft jelly consistency. No
communication with the joint or tendon sheath is apparent but
invariably the cyst is bound to these structures by dense
tissue (which may represent reactive fibrosis about the site of
perforation).
Clinical picture
 History of injury is often elicited.
 Women are predisposed.
 From teens to 50 years of age.
 Swelling may appear gradually or suddenly, may
diminish in size, may disappear completely only to
recur.
 Tense, cystic, tender and fixed to the deep tissues
but never to the overlying skin.
 Smooth rounded contour, more apparent by tensing
the tissues.
Clinical picture
 Pain is continuous, aching and aggravated by joint motion.
 If the cyst is connected with a tendon sheath, a sense of
weakness in finger.
 Most common is dorsum of wrist between the EPL and EDL
of index finger, but on volar aspect appears between BR and
FCR.
 In palm of hand it develops from deep pulley of finger flexor
over MC head and less commonly over middle of PP where it
is small, tense and often thought to be a fibroma.
 Other less common sites are dorsum of tarsal area of foot,
lateral joint interval of knee in front of biceps and
anterolateral aspect of ankle.
Treatment
 Non-operative : Cyst may be aspirated and
injected with prednisolone acetate or a sclerosing
agent like 5% sodium morrhuate. Rupturing cyst
by external force is often practiced. Swelling may
subside under the influence of radiation.
 Non-operative procedures are frequently
unsuccessful.
 Surgical excision is seldom F/B recurrence.
Treatment
 Operative : Transverse incision, cyst is
dissected free and traced to its connection
with capsule or tendon sheath. Elliptical
transversely directed excision of a portion
of capsule or sheath is performed and cyst
removed.
 Postoperatively plaster splint immobilizes
the joint in relaxed position for 3 weeks.
Colles’s #
 # of radius within 2.5 cm of wrist with a
characteristic deformity.
 Commonest of all #.
 Seen mainly in middle aged and elderly
women.
 Osteoporosis is a frequent contributing factor.
 Generally results from a fall on out stretched
hand.
Displacement
 Six characteristic features. Dorsal and
radial displacement are most striking.
 Impact of fall fractures the radius through
cancellous bone of metaphysis. With
greater violence the anterior periosteum
tears and distal fragment tilts into anterior
angulation with loss of normal 5º volar tilt of
the joint surface.
Displacement
 With greater violence there is dorsal
displacement of the distal fragment and
shaft of radius is driven into distal fragment
leading to impaction.
 Altered contour of wrist is typical and
striking, referred to as dinner fork deformity
when viewed from the side.
Displacement
 As the distal fragment is attached to the ulnar
styloid by the triangular fibro cartilage, lateral
(radial) displacement of the distal fragment leads
to tear of ulnar styloid process.
 Sometimes the TFC is torn, in either case there is
disruption of IRU joint.
 Lateral angulation and displacement, dorsal
angulation and displacement, impaction and
rotational or torsional deformity are the six
classical deformities.
Diagnosis
 Pain in wrist, tenderness over distal end of radius
after a fall.
 When there is marked displacement, the clinical
appearance is characteristic.
 X-rays : # is easily identified. May be missed
because impaction has rendered # line
inconspicuous. If in doubt, look at the angle
between the distal end of radius and the shaft in
Lat view. Decrease to less than 0º is suggestive
of # (but enquire about previous injury).
Diagnosis
 Minimally displaced # will also reveal itself in Lat view
by an increase in posterior radial concavity often with
local kinking or by a separate or accompanying break
in the smooth curve of anterior surface of radius.
 In AP view look for any irregularity in the smooth
lateral aspect of radius.
 Although other injuries in association are uncommon,
clinically scaphoid, elbow and shoulder should be
examined and x-ray taken whenever in doubt.
Treatment
 If # is un displaced no manipulation is needed. If #
is grossly displaced, it should be reduced.
 If there is readily appreciated naked eye deformity
manipulation should be carried out (but
distinguish between swelling and deformity)
 If there is displacement of ulnar styloid this
indicates serious disruption of IRU joint. (Acute
ulnar angulation of the distal fragment is also
evidence of this). This # should be corrected
irrespective of other appearances.
Treatment
 If the joint line in the lateral view is tilted 10º
or more posteriorly rather than anteriorly,
the # should be reduced.
 Under anesthesia disimpact the distal
fragment. Elbow is flexed 90º and arm held
by the interlocked fingers of an assistant
and traction is then applied in the line of the
forearm.
Treatment
 Traction need only to be applied for few seconds
and disimpaction confirmed by holding the distal
fragment between thumb and index. It should be
easy to move anteriorly and posteriorly.
 Elbow is now extended, heel of one hand should
be placed over dorsal surface of distal radial
fragment and fingers curled round the patient’s
wrist and palm. This grip alllows traction to be
reapplied to the disimpacted #.
Treatment
 Now by using the heel of the other hand as a fulcrum
firm pressure directed anteriorly corrects all
remaining deformity normally visible on lateral x-rays.
 Still maintaining traction, alter the position of grip so
that heel of right hand is able to push the distal
fragment ulnar wards and correct the radial
displacement. Ulnar angulation & other deformity
seen in AP view is corrected by placing the hand in
full ulnar deviation at wrist.
Treatment
 Change the grip to allow free application of plaster.
One hand holds the thumb fully extended and other
hand holds three fingers to avoid cupping of hand
and maintaining slight traction. Limb should be in full
pronation, full ulnar deviation at wrist and slight
palmar flexion.
 A collar and cuff sling should be applied. Make sure
there is no constriction at elbow or wrist and flex the
elbow at right angle so that forearm is not dependant.
Treatment
 Check x-rays should always be taken on
table and if severe persisting deformity is
there in AP view, remanipulation should be
undertaken. If position is acceptable,
patient is shown finger exercises and
advised regarding normal plaster care.
After care
 Patient seen next day, fingers examined for
circulation and swelling.
 Palm, fingers, thumb and elbow are checked for
constriction and adjustment made.
 After 2 -5 days elbow, fingers and shoulder
exercises started. If there is no swelling, sling is
discarded.
 At 2 weeks, plaster is checked for slackening
(replace), softening (reinforce) and technical
faults. X-rays at this stage might show slight
slipping but if it is marked remanipulation is tried.
After care
 Positional errors : commonest fault is lack of ulnar
deviation. Sadly accepted if discovered at 2
weeks but re plastered in correct position if
discovered earlier because it increases the risk of
late problems arising from disruption of DRU joint,
nonunion of ulnar styloid is common, with
restriction of pronation and supination.
 Excessive wrist flexion leads to difficulty in
recovering dorsiflexion and a useful grip.
After care
 Plaster faults : The distal edge of plaster
does not follow the normal oblique line of
MP joints and restricts finger movements.
The plaster should be trimmed accordingly.
The thumb is restricted by a few turns of
plaster bandage, again the plaster should
be trimmed to permit free thumb
movement.
After care
 Plaster is removed at 5 weeks (6 weeks in badly
displaced # in the elderly) and # is assessed for
union. If there is marked persisting tenderness, a
fresh plaster is applied and union re-assessed
after 2 weeks.
 If tenderness is minimal or absent crepe bandage
is applied and wrist and finger exercises started
frequently and vigorously.
 Review the patient again after 2 weeks.
Complications
 Persistent deformity or mal-union : Radial
drift of distal radius results in prominence of
distal radius, radial tilting and bony
absorption at # site lead to prominent distal
ulna and tilting of plane of wrist as seen in
AP. These deformities may be symptom
free and surgery on purely cosmetic basis
is seldom indicated.
Complications
 In some cases there may be marked pain in DRU
joint due to severe disorganization. Marked local
tenderness and supination is restricted. Grip
strengthening and supination pronation exercises
started. If symptoms remain severe, excision of
distal end of ulna may be considered.
 Uncomplicated persistence of dinner fork
deformity with some loss of palmar flexion, but no
functional disturbance is generally accepted.
Complications
 Delayed rupture of EPL : Due to attrition of
tendon by roughness at the # site or by
sloughing from interference with its blood
supply. Spontaneous recovery may occur
and there is no urgency in treatment. In
elderly this may be accepted or treated
expectantly. In young, EIP tendon transfer
is advocated.
Complications
 Sudeck’s atrophy : Fingers are swollen and
flexion restricted. Hand and wrist are warm,
tender and painful. X-rays shows diffuse
osteoporosis. Mainstay of treatment is
intensive and prolonged physiotherapy. If
pain is severe, further 2-3 weeks rest of wrist
in plaster may give sufficient relief. If MP
joints are stiff in extension and making no
headway, manipulation under GA is done.
Complications
 Carpal tunnel syndrome : Paraesthesia in the
median N is main presenting symptom. Surgical
decompression is advocated at an early stage.
 Comminution of radial fragment : Small vertical
crack through radial fragment or # may run
horizontally and scaphoid or lunate may separate
the fragments. In both types, physiotherapy is
must after union and in latter marked permanent
restriction of movements is the rule.
Complications
 Persisting stiffness : after prolonged physiotherapy
is not uncommon but seldom severe enough to
impair limb function.
 Associated scaphoid # : Manipulation of Colles’s #
and application of scaphoid plaster. After Colles’s #
has united further immobilization may be required
for scaphoid #. Alternately, scaphoid # may be fixed
with screw and Colles’s # manipulated and fixation
discontinued as soon as the latter # has united.
Related fractures
 Undisplaced greenstick # of radius : In its
most minor form it may be overlooked, the
only sign may be slight local buckling. Level
of # is variable, may be situated slightly
proximally. Treated like Undisplaced
Colles’s # by plaster cast for 3 weeks.
Related fractures
 Angulated greenstick # of radius :
Manipulation, plaster cast and after care is
required as for Colles’s #. Plaster fixation
may be reduced to 3-4 weeks depending
on the age of child.
Related fractures
 Overlapping radial # : In children radius
often # close to wrist, with off ending of
fragments. On ulnar side there may be
detachment of TFC, separation of ulnar
epiphysis, # displacement and angulation of
distal ulna i.e. # of both bones of forearm
and dislocation of ulna (Galeazzi #-
dislocation).
Related fractures
 Overlapping radial # : If # line is transverse
reduction is straightforward by traction and
local pressure. If there is oblique # running
distally form front to back, reduction is often
impossible due to integrity of dorsal
periosteum and overlapping bony spikes.
Related fractures
 First : apply maximum traction and press
forcibly on the distal fragment and use
other hand to apply counter pressure.
Reduction is achieved by shearing off one
of the bone spikes.
 Second : By increasing the deformity and
applying pressure directly over distal
fragment while maintaining traction,
reduction may be achieved.
Related fractures
 If shortening is marked and closed methods
fail, open reduction may be considered. If
persisting overlap is accepted, a good
result from remodeling is the usual outcome
provided any angulation is corrected.
Slipped radial epiphysis
 Common in adolescence.
 Displaced distal radial epiphysis is usually
associated with a small # of metaphysis (Salter-
Harris type 2 injury).
 Unless displacement is minimal, manipulation F/B
plaster fixation as for Colles’s # is indicated.
 Growth disturbance is rare, but reduction should
be done promptly as it is often difficult to reduce
after 2 days.
# of radial styloid
 Caused by engine starting handle kickback
as well as by fall on outstretched hand.
 Displacement is usually slight.
 Manipulation unlikely of any value.
 Plaster cast as for Colles’s #.
 Physiotherapy is often required.
 Many of these # are complicated by
Sudeck’s atrophy.
Smith’s #
 Results from fall on back of hand.
 Distal radial fragment is tilted anteriorly (posterior angulation)
and may be displaced anteriorly.
 # is usually impacted.
 Frequently referred as reverse Colles’s # as deformities when
viewed from side clinically and radio logically are in opposite
direction to those seen in Colles’s #.
 Comminuted smith’s # may involve the articular of radius.
 Greenstick # are common.
Smith’s #
 To reduce these #, traction is applied to arm in supination
until disimpaction is achieved, then pressure may be applied
with the heels of the hands to force the distal fragment
dorsally.
 Reduction is difficult to hold and a long arm plaster cast is
required.
 Forearm is in full supination and wrist in dorsiflexion.
 X-rays taken every week for 3 weeks to detect any significant
slipping.
 6 weeks plaster is usually required with physiotherapy after
plaster removal.
Barton’s #
 Form of smith # in which anterior portion
only of radius is involved (Intra articular #).
 Closed reduction as for smith’s # tried.
 If this fails, with the carpals wedging the
fragments apart, ORIF is indicated
particularly in younger patients by
cancellous screw or an Ellis buttress plate.
Related fractures
 Forcible palmar flexion may result in minor
avulsion # of carpus at ligamentous
insertion.
 If the wrist is forcibly palmar flexed or
dorsally flexed, the carpus impinging on the
distal end of radius may produce a marginal
chip # of the radius.
 Symptomatic treatment with 2-3 weeks in
posterior plaster slab is enough.