Carpal bones fracturesMANAGEMENT

FOREARM, WRIST & HAND · 12 SECTIONS

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523 items

☷ Legend

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

›Radial nerve sensation

›Median nerve motor

›Ulnar nerve motor

›Radial nerve motor

›Immobilization before definitive imaging when unstable

›Significant deformity

›Severe pain with motion

›Post-immobilization neurovascular status

›Same domains as pre-immobilization

›Pain trend after splint

Perilunate and dislocation escalation

›Perilunate emergency pathway

›Median nerve compression features

›Thenar numbness

›Thumb-index-middle paresthesia

›Thenar weakness

›Radiographic suspicion

›Lateral view malalignment

›Disrupted Gilula arcs

›If suspected perilunate or lunate dislocation, urgent hand surgery or orthopedics

›Closed reduction attempt only if neurovascular compromise and immediate specialist delay

›Post-reduction imaging required

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

›Weak grip

›Neuro symptoms

›Median distribution paresthesia

›Ulnar distribution paresthesia

›Skin integrity concern

›Laceration over carpus

›Contamination or foreign body

Patient factors and baseline

›Risk modifiers

›Hand dominance

›Dominant-hand injury functional impact

›Occupation or sport demands

›Prior wrist injury

›Prior scaphoid fracture

›Prior carpal surgery

›Tobacco or nicotine use

›Nonunion risk counseling trigger

›Follow-up urgency increased

›Anticoagulants

›Hematoma risk

›Low threshold for compartment evaluation

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

›Median nerve function

›Thumb opposition strength

›Thenar sensation

›Ulnar nerve function

›Finger abduction strength

›Small finger sensation

›Radial nerve function

›Thumb extension strength

›Dorsal first webspace sensation

›Perfusion

›Capillary refill

›Radial pulse

›Skin temperature symmetry

PITFALLS

›High-risk misses

›Normal initial radiographs in scaphoid fracture

›Persistent snuffbox tenderness pathway

›Immobilize and arrange advanced imaging

›Missed perilunate injury

›Lateral view not obtained or not true lateral

›Subtle malalignment ignored

›Hook of hamate missed without dedicated views

›Carpal tunnel view omission

›CT requirement in athletes with ulnar palm pain

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

›Scapholunate ligament injury

›Watson shift pain or clunk

›Widened SL interval on radiographs

›TFCC injury

›Ulnar-sided pain with rotation

›DRUJ tenderness

›Distal radius fracture

›Colles pattern

›Intra-articular extension

›Perilunate or lunate dislocation

›Median nerve symptoms

›Lateral view carpal malalignment

›Extensor carpi ulnaris tendinopathy

›Ulnar-sided pain without bony tenderness

›Pain with resisted extension and ulnar deviation

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

›Increased instability

›Stage IV lunate dislocation

›Lunate volar rotation

›Median nerve compression risk

Radiographs

›X-ray strategy

›Standard wrist series

›PA

›Lateral true lateral

›Oblique

›Scaphoid views when suspected

›Ulnar deviation scaphoid view

›PA with clenched fist for SL injury suspicion

›Hamate hook views when suspected

›Carpal tunnel view

›Supinated oblique view

›Alignment checks

›Gilula arcs continuity on PA

›Lunate-capitate-radius colinearity on lateral

›Post-reduction films when reduction performed

›Confirm alignment

›Document improvement

MRI

›MRI indications and performance

›Occult scaphoid fracture pathway

›High clinical suspicion with negative X-ray

›Early MRI within days to reduce unnecessary immobilization

›Avascular necrosis evaluation

›Proximal pole scaphoid concern

›Lunate ischemia concern

›Ligament injury assessment

›Scapholunate ligament tear

›Lunotriquetral ligament tear

›Contraindications and limitations

›Ferromagnetic implant risk

›Motion artifact in severe pain

›CT indications and planning

›Hook of hamate fracture confirmation

›Persistent hypothenar pain with negative X-ray

›Athlete or bat-sport mechanism

›Scaphoid displacement assessment

›Surgical planning for displaced waist fracture

›Assessment of comminution

›Complex carpal fracture-dislocation

›Trans-scaphoid perilunate fracture-dislocation

›Multibone carpal injury mapping

›Technique considerations

›Thin-slice CT for carpal detail

›Coronal and sagittal reconstructions

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

›Unstable fracture pattern

›Displaced scaphoid fracture

›Capitate fracture with rotation

›Carpal fracture-dislocation

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

›Pain-limited localization

›Behavioral barriers to neuro exam

›Immobilization approach

›Thumb spica for scaphoid suspicion in adolescents

›Reassessment within 5-7 days when X-ray negative

›Nonaccidental trauma consideration when appropriate

›Inconsistent history

›Multiple injuries or delayed presentation

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

›Pain control and protection

›Displacement thresholds and surgery

›Displaced scaphoid waist fractures often operative candidates

›Proximal pole fractures higher nonunion and AVN risk

›Perilunate injuries as time-sensitive

›Reduction urgency to protect median nerve

›Definitive fixation often required

›Evidence framing

›Advanced imaging to confirm occult scaphoid fracture supported by improved diagnostic accuracy and reduced unnecessary immobilization

›Procedural sedation safety practices align with ACEP procedural sedation policy principles (ACEP Level B or C depending on element)

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

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.