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. 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. 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. 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. 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. 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.

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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.

1Perilunar, 2 Periscapholunar, 3 Trans-scapho perilunar, 4 Scaphoid dislocation 5 Lunate dislocation 6 Scaphoid and lunate7 Lunate and part of scaphoid

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.

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.

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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.

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.

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.

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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. 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. 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.

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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%).

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 #.

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.

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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.

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 #.

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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.

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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.

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.

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.

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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.

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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. 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. 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. 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.

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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.

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.

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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).

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.

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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.

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.

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 #.

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.

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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.

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.

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.

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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.

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.

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.

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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.

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.

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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.

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. 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.

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.

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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.

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.

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).

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.

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.

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Second : By increasing the deformity and applying pressure directly over distal fragment while maintaining traction, reduction may be achieved.

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.

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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.

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.

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