Carpal Tunnel Syndrome Compression of median nerve Risk Factors • Obesity • Female gender • Coexisting conditions (diabetes, pregnancy, rheumatoid arthritis, hypothyroidism, connective tissue diseases) • Genetic predisposition • Aromatase inhibitor Treatment • Glucocorticoid injections • Splinting • Surgical decompression #CarpalTunnel #Syndrome #Diagnosis #MedianNerve

Boxer's Fracture - ED Management Be sure to assess for wounds in patients with fractures of the 4th and/or 5th metacarpal neck(s) and clarify if these wounds were sustained as "fight bites" as this will guide prophylactic antibiotic treatment. Here's a quick summary. • Most common type of metacarpal fracture • Fracture of the 4th or 5th metacarpal neck with volar displacement Of the metacarpal head • Mechanism: Closed fist blow against a person or hard surface • Exam: Swelling and tenderness over dorsal surface of affected metacarpal(s) • Possible associated injuries: lacerations (if present, need to clarify what was punched as this will guide antibiotic coverage) • ED Management: Pain control, reduce if needed (using hematoma block or ulnar nerve block), immobilize; if open wound, must update tetanus and give appropriate antibiotics (Augmentin if "fight bite", Keflex if hard object) as well as provide wound care (copious irrigation but no closure if "fight bite", irrigation with closure if hard object) • Splint: Ulnar gutter with MCP flexed 70-900 • Ortho consult: No (unless open, severely comminuted, any malrotation, unacceptable angulation) • Disposition: Discharge home with orthopedic follow-up within I MH/CCF/CWRU EM Res @MetroHealth_EM #Boxers #Fracture #Thumb #Metacarpal #Radiology #XRay #Diagnosis #Management #Hand #Orthopedics #MSK

What is a Boxer’s fracture?? Fracture of the 4th or 5th metacarpal neck - Common in younger males - Usually secondary to the following injuries: punching a wall, direct blunt/force trauma, falls onto the hand Symptoms/exam findings concerning for Boxer’s fracture? - Pain along ulnar aspect of the hand - Swelling along dorsum or ulnar part of hand - Focal tenderness or step off over fractured metacarpal - Always check for skin integrity, intact strength/sensation, and pulses!! - Don’t miss – compartment syndrome! Management: - Immobilize with ulnar gutter splint – usually for 4 weeks Urgent orthopedics referral: - Neurovascular compromise - Certain radiologic findings: - Comminuted - Displaced or evidence of malrotation - Compromise of growth plate or articular space - Multiple fractures - Overlying wounds or signs of open fracture Hand consult recommended if injury of dominant hand or occupation/hobbies significantly affected! #Boxers #Fracture #Hand #Metacarpal #Diagnosis #Management #Referral #Orthopedics

Scaphoid Fractures The scaphoid is the most commonly fractured carpal bone. Remember, if a fracture is suspected (tenderness to the anatomic snuffbox) but not seen on x-ray, the patient still needs to be sent home in a thumb spica splint. Here's a quick summary. • Most common carpal bone fracture • Complications • Avascular necrosis: most commonly affects proximal portion as a result of arterial supply to the scaphoid entering distally • Nonunion or malunion: associated with missed fractures that are inadequately immobilized • Both lead to carpal instability and osteoarthritis • Mechanism: Fall onto outstretched hand • Exam: Tenderness to anatomic snuffbox, pain with supination • Possible associated injuries: Scapholunate dissociation, perilunate dislocation • ED Management: Pain control, immobilize • Splint: Thumb spica • Ortho consult: No (unless displaced mm, proximal pole fracture, associated scapholunate dissociation) • Disposition: Discharge — if known fracture, follow-up with Orthopedics within 1 week; if suspected fracture, follow-up with PCP or orthopedics in 2 weeks for repeat x-rays MH/CCF/CWRU EM Res @MetroHealth_EM #Scaphoid #Fracture #Wrist #Carpal #Radiology #XRay #Diagnosis #Management #Orthopedics #Sports #MSK

Perilunate Dislocation On lateral wrist XR, the capitate ("apple") should sit in the lunate ("tea cup") which should articulate with the distal radius ("saucer"). In perilunate dislocation, the capitate is dislocated dorsally and no longer sitting in the lunate. Here's quick summary: • Dorsal dislocation of the capitate • Lunate articulates with the distal radius "saucer" but capitate "apple" does not sit in lunate "tea cup" • Mechanism: Fall onto outstretched hand • Exam: tenderness and swelling to dorsal wrist, pain with wrist extension • Possible associated injuries: Carpal fracture (scaphoid most commonly, 60%; also trapezium, capitate, triquetrum), radial styloid fracture, median nerve injury • ED Management: Pain control, sedation and emergent reduction • Splint: Sugar tong • Ortho consult: Yes • Disposition: Pending orthopedic recommendations; ill ultimately need operative repair MH/CCF/CWRU EM Res @MetroHealth_EM #Perilunate #Dislocation #Wrist #Carpal #Radiology #XRay #Diagnosis #Management #Orthopedics #Sports #MSK