Emergency Medicine

290 Orthopaedic Emergencies

INJURIES TO THE WRIST AND HAND

(ii) Disimpact the fracture by firm traction on the thumb and fingers,

and by hyperextending the wrist in the direction of deformity. An

assistant should provide countertraction to the upper arm, with

the elbow kept flexed at 90°.

(iii) Next, extend the elbow and then use your thenar eminence to

reduce the dorsal displacement and to rotate back the dorsal

angulation, with the heel of your other hand acting as a fulcrum.

(iv) Alter your grip to push the distal fragment towards the ulna to

correct radial displacement.

(v) Finally, hold the hand pronated in full ulnar deviation with the

wrist slightly flexed. Pad the forearm with cotton-wool and apply

the backslab to the radial side of the forearm (see Fig. 9.2c). Hold

the backslab in place with a crêpe bandage.

(vi) Take a check X-ray to assess the adequacy of the reduction before

terminating the anaesthetic:

(a) reduction should be near perfect in a young person

(b) up to 10° of residual dorsal angulation can be accepted, i.e.

neutral position in an elderly person.

6 Give the patient a sling, with instructions to keep the shoulder and fingers

moving, and review in the next fracture clinic.

7 Remember to check that an elderly patient will still be able to manage at

home, particularly if they already rely on a walking frame. Social services

help may be needed. Inform the GP by fax and letter.

Smith’s fracture

DIAGNOSIS

1 This fracture is caused by a fall on to the dorsum of the hand, a hyperf lexion

or a hypersupination injury. It results in a distal radial fracture with volar

displacement. It is often termed a reversed Colles’ fracture.

2 Examine for localized swelling and a classical ‘garden spade’ deformity. The

patient is unable to extend the wrist and has pain on supination and pronation.

(i) Assess for damage to the median nerve causing loss of sensation

in the radial three-and-a-half digits and weakness of abductor

pollicis.

MANAGEMENT

1 Reduce the fracture under procedural sedation, Bier’s block, axillary block

or general anaesthetic, according to departmental policy.

2 Smith’s reduction and immobilization

(i) Disimpact the fracture by firm traction to the forearm in

supination, with an assistant providing countertraction to the

upper arm.