01Approach to the Critical Patient/attcp47

Triage and limb threat

›Immediate priorities

›Open injury

›Visible bone

›Deep laceration over carpus

›Neurovascular compromise

›Pale or cool hand

›Capillary refill > 2 seconds

›Absent radial pulse

›Doppler-only pulse

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive finger extension

›Firm forearm compartments

›High-risk instability

›Suspected perilunate injury

›Gross carpal deformity

Immediate actions and documentation

›Time-critical actions

›Ring and constriction removal

›If unable, urgent ring cutter

›If digital ischemia, immediate removal before imaging

›Pre-immobilization neurovascular status

›Radial pulse

›Ulnar pulse

›Capillary refill

›Median nerve sensation

›Ulnar nerve sensation

02History/hx46

Mechanism and timing

›Injury context

›FOOSH

›Wrist extension angle

›Ulnar deviation at impact

›Direct blow to ulnar palm

›Bat, club, racquet mechanism

›Handlebar impact

›Axial load through metacarpals

›Punch against object

›Fall onto clenched fist

›High-energy trauma

›MVC

›Fall from height

›Time since injury

›< 24 hours

›1-7 days

›> 7 days

Symptoms and red flags

›Symptom pattern

›Radial-sided wrist pain

›Worse with pinch or grip

›Worse with wrist extension

›Ulnar-sided wrist pain

›Worse with ulnar deviation

›Worse with gripping a handle

›Clicking or instability sense

›Painful clunk with motion

03Physical Exam/exam49

Inspection and palpation map

›Regional findings

›Swelling and ecchymosis distribution

›Radial snuffbox swelling

›Volar wrist swelling

›Hypothenar swelling

›Skin integrity

›Laceration depth

›Tent skin blanching

›Puncture near hook of hamate region

›Bony tenderness map

›Anatomic snuffbox tenderness

›Scaphoid tubercle tenderness

›Dorsal triquetrum tenderness

›Hook of hamate tenderness

›Pisiform tenderness

›Trapezium base thumb tenderness

›Joint above and below

›Elbow radial head tenderness

›Metacarpal base tenderness

Functional maneuvers and neurovascular

›Function and stability

›Wrist range limitation

›Pain with extension

›Pain with ulnar deviation

›Grip strength limitation

›Pain-inhibited grip

›True weakness concern

04Differential Diagnosis/ddx41

Carpal fractures and patterns

›Carpal fracture spectrum

›Scaphoid fracture

›ICD-10 S62.0-

›SNOMED CT concept: Fracture of scaphoid bone

›Lunate fracture

›ICD-10 S62.1-

›SNOMED CT concept: Fracture of lunate

›Triquetrum fracture

›ICD-10 S62.14-

›SNOMED CT concept: Fracture of triquetrum

›Pisiform fracture

›ICD-10 S62.16-

›SNOMED CT concept: Fracture of pisiform

›Trapezium fracture

›ICD-10 S62.17-

›SNOMED CT concept: Fracture of trapezium

›Trapezoid fracture

›ICD-10 S62.18-

›SNOMED CT concept: Fracture of trapezoid

›Capitate fracture

›ICD-10 S62.13-

›SNOMED CT concept: Fracture of capitate

›Hamate fracture

›ICD-10 S62.15-

›SNOMED CT concept: Fracture of hamate

Mimics and co-injuries

›Non-fracture diagnoses

05Laboratory Tests/lt20

When labs matter

›Indication-based labs

›Open injury or contamination

›CBC for infection or bleeding concern

›Basic metabolic panel for operative planning

›Significant bleeding or anticoagulation

›INR for warfarin

›Anti-Xa level per local protocol for factor Xa inhibitors

›Procedural sedation plan

›Glucose if altered mental status risk

›Pregnancy test when applicable

›Crush injury or prolonged ischemia concern

›Creatine kinase for rhabdomyolysis concern

›Creatinine for renal risk

Interpretation and pitfalls

›Limitations

›Normal labs do not exclude compartment syndrome

›Diagnosis remains clinical

›Escalation based on exam trajectory

›Coagulation tests may not reflect DOAC effect reliably

›Use local reversal pathways when high-risk bleeding

›Specialist consultation when urgent surgery likely

06Diagnostic Tests/dt74

Scoring Systems

›Fracture and instability classifications

›Herbert classification for scaphoid

›Type A acute stable

›A1 tubercle

›A2 incomplete waist

›Type B acute unstable

›B1 distal oblique

›B2 complete waist

›B3 proximal pole

›B4 trans-scaphoid perilunate

›B5 comminuted

›Type C delayed union

›Persistent fracture line

›Minimal sclerosis

›Type D established nonunion

›Sclerotic margins

›Cystic change

›Humpback deformity or collapse

›Mayfield stages for perilunate instability

›Stage I scapholunate dissociation

›SL interval widening

›Rotary subluxation

›Stage II capitolunate disruption

›Capitate displaces dorsally

›Lunate remains aligned with radius early

›Stage III lunotriquetral disruption

›Complete carpal dissociation progression

07Disposition/dispo30

Discharge criteria

›Outpatient management pathway

›Stable vitals

›No systemic trauma concerns

›Pain controlled with oral meds

›Intact neurovascular status

›Normal capillary refill

›No progressive neurologic symptoms

›Appropriate immobilization applied

›Splint well-fitted

›Post-splint neurovascular documented

›Follow-up arranged

›Hand surgery or orthopedics timeframe set

›Advanced imaging plan when needed

Admission, urgent consult, and transfer

›Escalation triggers

›Open fracture

›IV antibiotics pathway

›Urgent operative evaluation

›Perilunate or lunate dislocation

›Emergent reduction need

›Urgent hand surgery involvement

›Neurovascular compromise

›Persistent median nerve deficit

›Pulseless or cool hand

›Compartment syndrome concern

›Progressive pain despite analgesia

›Pain with passive stretch increasing

08Treatment/t107

Immediate life-saving interventions

›Limb-threatening actions

›If pulseless or cool hand, immediate escalation

›Emergent specialist consult

›Avoid delays for nonessential imaging

›If open injury, antibiotics and tetanus pathway

›Cover wound with sterile dressing

›Minimize repeated wound probing

›If suspected perilunate with median nerve symptoms, urgent reduction pathway

›Analgesia readiness

›Post-reduction neurovascular reassessment

Immobilization and Splinting

›Splint selection by suspected injury

›Scaphoid suspicion

›Thumb spica splint

›Wrist neutral to slight extension

›Nonspecific wrist pain with stable X-ray

›Volar wrist splint

›Removable brace option if low risk

›Perilunate or major instability suspicion

›Sugar tong splint

›Strict immobilization and elevation

›Ulnar palm pain with hamate hook suspicion

›Ulnar gutter or short arm splint

›Avoid gripping activities

›Splint principles

›Swelling-phase avoidance of circumferential cast

›Splinting preferred initially

›Recheck swelling in 2-5 days

›Elevation and edema control

›Hand above heart level

›Finger ROM encouraged if safe

›Post-splint checks

›Median nerve sensation

›Ulnar nerve sensation

›Capillary refill

Reduction

›Reduction indications

›Perilunate or lunate dislocation

›Median nerve compromise

›Severe deformity

›Gross malalignment threatening skin

›Blanching or tenting

›Progressive swelling with tight skin

›Analgesia and anesthesia options

›Local and regional options

›Hematoma block when applicable

›Avoid in open injury

›Aspirate before injection

›Ultrasound-guided regional block when available

›Median nerve block for select procedures

›Ulnar nerve block for ulnar-sided pain

›Procedural sedation pathway when required

›Monitoring and airway readiness

›Continuous pulse oximetry

›ECG monitoring

›Capnography when available

›Medication options

›Ketamine IV 0.5-1 mg/kg

›Additional 0.25-0.5 mg/kg as needed

›Emergence reactions preparedness

›Propofol IV 0.5-1 mg/kg

›Additional 0.25-0.5 mg/kg boluses

›Hypotension risk mitigation

›Fentanyl IV 0.5-1 mcg/kg

›Repeat dosing to effect

›Respiratory depression monitoring

›Reduction technique principles for perilunate patterns

›Longitudinal traction and countertraction

›Finger traps or manual traction

›Sustained traction 1-3 minutes

›Dorsal pressure on displaced capitate region

›Restore lunate-capitate alignment

›Avoid repeated forceful attempts

›Post-reduction stabilization

›Sugar tong or well-molded short arm splint

›Immediate post-reduction radiographs

›Failed reduction pathway

›Persistent malalignment

›Urgent hand surgery evaluation

›CT for injury mapping if stable

›Persistent median nerve deficit

›Emergent specialist escalation

›Consider carpal tunnel decompression per specialist

Open fracture medications and timing

›Antibiotics and tetanus

›Antibiotic timing target

›As early as feasible

›Do not delay for imaging when clearly open

›Typical antibiotic choices by contamination risk

›First-generation cephalosporin for low contamination

›Add gram-negative coverage for high contamination per local protocol

›Penicillin allergy alternative per local protocol

›Tetanus prophylaxis

›Tdap booster when indicated

›Tetanus immune globulin when indicated

›Wound care

›Sterile moist dressing

›Irrigation volume per contamination severity

›Avoid primary closure in ED unless specialist-directed

DVT prophylaxis when relevant

›VTE risk consideration

›Upper extremity isolated carpal fractures

›Routine pharmacologic prophylaxis usually not indicated

›Encourage early ambulation

›High-risk patients with immobilization and additional factors

›Prior VTE history

›Active malignancy

›Prolonged immobility

›Alignment with local protocol

›Document rationale when deviating

›Coordinate with admitting or operative service

09Special Populations/sp33

Pregnancy

›Pregnancy considerations

›Imaging safety

›Extremity radiographs with shielding when feasible

›CT wrist generally low fetal exposure due to distance

›Analgesia considerations

›Acetaminophen as first-line

›NSAID avoidance in later pregnancy per obstetric guidance

›Disposition thresholds

›Lower threshold for evaluation of associated trauma

›Rh status evaluation when significant trauma per obstetric protocol

Geriatric

›Older adult considerations

›Fragility mechanisms

›Low-energy FOOSH common

›Osteoporosis risk counseling

›Complication risk

›Delirium risk with opioids

›Higher risk from prolonged immobilization

›Follow-up urgency

›Lower threshold for early advanced imaging

›Early hand therapy planning

Pediatrics

›Pediatric considerations

›Physeal injury differential

›Distal radius Salter-Harris patterns

›Carpal ossification stage limitations on X-ray

›Exam challenges

10Background/b35

Epidemiology

›Frequency and distribution

›Carpal fracture distribution

›Scaphoid approximately 60-70% of carpal fractures

›Triquetrum approximately 15-20% of carpal fractures

›Remaining carpal bones less common individually

›Typical demographics

›Scaphoid fractures common in adolescents and young adults

›FOOSH as predominant mechanism

›Sport associations

›Hook of hamate in bat and racquet sports

›Trapezium in thumb axial load injuries

Pathophysiology

›Anatomic risk features

›Scaphoid blood supply vulnerability

›Retrograde flow to proximal pole

›Proximal pole AVN risk increased

›Carpal instability mechanisms

›Ligament disruption progression in perilunate injuries

›Median nerve compression in lunate dislocation

›Injury pattern mapping

›FOOSH with extension and radial deviation

›Dorsal triquetrum avulsion with wrist extension

›Hook of hamate fracture with handle impact

Therapeutic Considerations

›Management rationale

›Early immobilization in occult scaphoid suspicion

›Nonunion risk reduction

11Patient Discharge Instructions/pdi27

Copy discharge instructions

›Discharge instructions package

›Immobilization care

›Keep splint clean and dry

›Do not insert objects into splint

›Check fingers for color and swelling several times daily

›Swelling control

›Elevation above heart level

›Ice over splint if tolerated

›Finger motion encouraged if not restricted

›Pain plan

›Acetaminophen per label dosing

›NSAID use if no contraindication and appropriate for patient

›Opioid only if prescribed and shortest duration

›Activity restrictions

›No lifting with injured hand

›No sport or gripping until cleared

›Return to ED immediately

›Increasing pain not controlled

›New numbness or tingling

›Fingers turning pale, blue, or cold

›Increasing swelling with tight splint

›Inability to move fingers

›Fever or drainage from wound

›Follow-up plan

›Hand surgery or orthopedics within 3-7 days for suspected scaphoid or any confirmed carpal fracture

›Earlier follow-up within 24-48 hours for worsening symptoms or neuro complaints

›Advanced imaging appointment if X-ray negative but high suspicion

12References/r14

Clinical guidelines and core sources

›Reference set

›AAOS and specialty society guidance on wrist and hand fractures

›Operative indications for displaced scaphoid fractures

›Follow-up and imaging recommendations for occult scaphoid

›British Society for Surgery of the Hand guidance for scaphoid and carpal injuries

›Immobilization strategies

›Advanced imaging pathways

›ACEP procedural sedation clinical policy and safety recommendations

›Monitoring standards

›Airway preparedness

›ATLS principles for trauma evaluation when high-energy mechanism present

›Secondary survey completion

›Imaging beyond wrist when indicated

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Evidence & Review

Evidence & Review