Emergency Medicine

296 Orthopaedic Emergencies

INJURIES TO THE WRIST AND HAND

(i) Stable injuries include transverse shaft and greenstick fractures.

(ii) Unstable injuries include oblique shaft and comminuted

fractures, and the fracture–dislocation of the base of the thumb

(Bennett’s fracture).

(iii) Bennett’s fracture

(a) this is an oblique fracture through the base of the thumb

metacarpal involving the joint with the trapezium, with

subluxation of the rest of the thumb radially

(b) look for swelling of the thenar eminence, sometimes with

local palmar bruising

(c) make sure the X-ray includes the base of the thumb to avoid

missing this injury.

MANAGEMENT

1 Splint a stable fracture with a scaphoid plaster and refer the patient to the

next fracture clinic.

2 Refer unstable fractures (including Bennett’s) to the orthopaedic team for

possible open reduction and internal fixation.

Dislocation of the thumb metacarpal

DIAGNOSIS

1 This may occur in motorcycle, skiing and football accidents, from forced

thumb abduction or hyperextension.

2 Request an X-ray to exclude an associated fracture.

MANAGEMENT

1 Reduce under procedural sedation, a Bier’s block or under general anaesthe-

sia, according to departmental practice.

(i) Apply traction to the thumb with pressure over the metacarpal

head. After the manipulation, repeat the X-ray to confirm the

reduction.

(ii) Place the forearm in a scaphoid plaster with plenty of cotton-

wool padding, and refer the patient to the next fracture clinic.

2 Refer the patient immediately to the orthopaedic team if the reduction fails.

(i) The metacarpal head may have ‘button-holed’ through the joint

capsule between tendons, and require open reduction.

RUPTURE OF THE ULNAR COLLATERAL LIGAMENT

DIAGNOSIS

1 This condition (‘gamekeeper’s thumb’, which referred to a chronic lesion) is

caused by forced t humb abduction, t y pica lly in sk iing accidents.