Hand and Wrist Trauma: Fractures, Dislocations, and Soft-Tissue Injury
Translating the radiograph into a decision
Distal radius. Volar locking plates dominate dorsally displaced adult fractures. Decision points are articular congruity (accept under 2 mm of step in young patients), DRUJ stability, and the ulnar styloid. Document median nerve status before and after reduction.
Scaphoid. The proximal pole has a retrograde blood supply, so proximal fractures carry the highest nonunion and AVN risk. Snuffbox tenderness with negative films means immobilize and repeat imaging or obtain CT/MRI. A proximal fracture needs a wrist-inclusive thumb spica, not a short forearm cast.
Thumb base. Bennett (two-part intra-articular) and Rolando (comminuted Y) fractures need anatomic reduction; CMC incongruity produces early arthritis.
Metacarpal and phalangeal fractures. Radiographs underestimate rotation. Test the composite fist: about 10 degrees of malrotation produces roughly 2 cm of fingertip overlap and mandates fixation. Dorsal angulation of the small finger metacarpal neck up to 40 degrees may remodel, but malrotation at any age does not.
Carpal dislocation. Check Gilula's arcs. In perilunate dislocation the lunate stays in its fossa while the capitate is dorsal; in lunate dislocation the lunate is volar ('spilled teacup'). A scaphoid fracture with perilunate injury is the trans-scaphoid perilunate pattern.
Soft tissue. Tuft fracture with nail bed laceration requires nail bed repair and splinting. Gamekeeper's thumb with a Stener lesion needs surgery.
Rule of thumb: treat the hand, not the film - rotation and the composite fist are clinical diagnoses.