Upper extremity injuries

by  Meltem Songur Kodik

Injuries of Shoulder

Case Presentation

A 50-year-old male was brought to the emergency department after he fell onto his outstretched arm while working in a construction pit. He complained of severe pain, instability and weakness on his right shoulder. His vital signs were normal. On the physical examination, the arm was in abduction and external rotation. Normal contour of the deltoid and acromion was lost. The patient was leaning away from the injured side and cannot adduct or internally rotate the shoulder even slightly without severe pain. His humeral head was palpable anteriorly, and all movements were limited and painful. Additionally, there was palpable fullness below the coracoid process, towards the axilla. The neurovascular examination was normal. Initial anteroposterior (AP) radiogram showed an anterior glenohumeral dislocation. The dislocation was reduced in the emergency room.

Critical Bedside and General Approach

Preserving function, preventing infection and assuring perfusion of the limb should be the goals. Proper diagnosis and treatment are essential for establishing these goals.

• Check vital signs
• Learn mechanism of injury
• Take medical history
• Make an orderly and thorough examination
• Order necessary imaging and labs.
• Noncritical orthopedic injuries should be treated only after more threatening injuries have been addressed.

Differential Diagnosis

• Fractures: Proximal end of the humerus (the most frequently injured bone of the shoulder) [Figure 1] , clavicle (80 % being middle-third fractures) [Figure 2], scapula [Figure 3].

• Dislocations: Glenohumeral (mostly anterior, rarely posterior, inferior and superior) [Figure 4], followed by acromioclavicular, sternoclavicular.

• Soft tissue injuries: Impingement syndrome (Subacromial tendinitis and bursitis with rotator cuff tears, tendinitis of the long head of the biceps tendon)

History and Physical Examination Hints

• Combination of pain, instability, stiffness and loss of power are the main complaints. The complaints usually start after trauma with acute pain. Shoulder instability may be subtle or obvious subluxation or dislocation.
• The young athletes usually sustain anterior glenohumeral dislocation during athletic activities with rapid movements. The avulsion of the anteroinferior glenohumeral ligament is frequent. Characteristically, capsulolabral detachment occurs. (Bankart’s lesion) In the elderly, a fall onto the outstretched arm is a more common mechanism of injury.
• With an anterior glenohumeral dislocation, the patients hold their arms in slight abduction with external rotation with the help of their opposite hand. The patients with an acute acromioclavicular sprain usually have a step-off at the joint and hold their arms to their side.
• Patients seeking medical care for their shoulder symptoms usually have a previous shoulder pathology. For patients with an obscure history of shoulder trauma, the patients’ pain is usually misreferred to as cardiac, biliary or abdominal pathology.

Emergency Diagnostic Tests and Interpretation

• For traumatic injuries, AP (45-degree lateral), transscapular lateral (“Y” view)[Figure 5], and axillary lateral views are helpful. The true AP view provides a glenohumeral joint image without bony overshadow, so it is preferable over the standard AP view. The axillary lateral view is beneficial to evaluate the fractures of the glenoid fossa and the acromion or coracoid process.

• The CT views are especially useful in determining scapular injuries. 3D reconstruction from chest CT provides requested soft tissue data details as well.
• Bedside ultrasonography is particularly useful in clavicular fractures.

Emergency Treatment Options

1. Initial Stabilization: Please refer to “Critical Bedside And General Approach” part. The incidence of neurovascular complications increases with time. Therefore, the reduction of dislocation should be performed immediately. Before performing the reduction, the type of dislocation and any accompanying bone fractures should be shown radiographically.
2. Medications: For all reduction techniques, adequate sedation/ analgesia or anesthesia is required. For many reductions, sedation with IV fentanyl (50 to 100 mcg) and IV midazolam (1 to 3 mg) is sufficient. Deep sedation with propofol or etomidate is required for some patients. Rarely, general anesthesia may be necessary. Injection of a local anesthetic intraarticularly is another good alternative and facilitates the reduction.
   
3. Analgesia:
   • For children: Ibuprofen; Infants and Children <50 kg: Limited data available in infants <6 months: 4 to 10 mg/kg/dose every 6 to 8 hours; maximum single dose: 400 mg; maximum daily dose: 40 mg/kg/day. Children ≥12 years: Refer to adult dosing.
   • For pregnant patients: Paracetamol is still considered safe in pregnancy and should remain the first-line treatment for pain and fever. Dose: 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours.
   • For elderly: patients Acetaminophen 325 to 650 mg every 4 to 6 hours or 1000 mg every 6 to 8 hours.
4. Procedures:
   
   • Shoulder Dislocations: Glenohumeral. Various techniques such as traction, leverage, or scapular manipulation can be used in combination for reduction. Some methods such as Hippocrates and Kocher maneuvers must not be used because of their high incidence of complications (axillary nerve injury, humeral shaft and neck fractures, and capsular damage).
     One of the most frequently used adequate leverage technique is Leidelmeyer’s external rotation method. While the patient is in supine position, the arm is gently adducted and the elbow is flexed to 90 degrees and gentle external rotation is applied until the reduction provided. The rate of success of this method is 80-90 %. There are other techniques such as Cunningham and scapular rotation techniques which requires almost no analgesia or sedation with high success rate.
   • Fractures:
     • Clavicle: After closed reduction of the fracture, clavicular (figure-of-eight splint) splint should be applied.
       
     • Scapula: To support the ipsilateral upper extremity, a sling immobilization is used.
     • Proximal Humerus: A sling and swathe device is necessary for immobilization.

Pediatric, Geriatric, Pregnant Patient, and Other Considerations

Pediatric considerations

In the pediatric age group, closed reduction is similar to the adults. Under 10 years of age, shoulder dislocations are rare. Because of concomitant physeal (i.e., growth plate) fractures, an orthopedic consultation is recommended before reduction.

Elderly considerations

In the elderly, anterior shoulder dislocation is more common; of those, 20% suffer redislocation and 60% have a cuff tear. To stabilize the shoulder the torn cuff should be repaired; patients with multiple redislocations usually require both procedures.

Pregnant considerations

Procedural sedation in pregnant women provides relief from significant pain, distress or fear, and exposure to the medications used in procedural sedation is short and are relatively low. Such features of this method provide no adverse pregnancy outcomes.

Disposition Decisions

Admission Criteria

If the closed reduction of shoulder dislocation fails, or when the patients have a neurovascular compromise, the patient may need admission for reduction under general anesthesia or open reduction.

Discharge Criteria

After the reduction is accomplished, the shoulder is immobilized with velpeau bandage and the patient is discharged.
The patient is referred to an orthopedic surgeon within one week.
The patient should be informed if there is redislocation.

Referral

Accompanying fractures of shoulder dislocations are Hill Sachs deformities (cortical depression in the humeral head created by the glenoid rim during dislocation), Bankart lesions and fractures of greater tuberosity. In such circumstances, orthopedic referral is required.

Injuries of Elbow

Case Presentation

An 8-year-old boy fell onto his left outstretched arm with a hyperextended elbow, while he was riding his bike to school. When he arrived at the ED, his left elbow was tender and swollen, and he was unable to move the forearm. His vital signs were normal. On physical examination, he was holding the upper extremity immobile in extension to the side. The elbow appeared angulated and the upper extremity shortened. The neurovascular examination was normal. Radiogram, including anteroposterior (AP) and lateral films, revealed a supracondylar extension fracture. The prominence of the olecranon attached to the posteriorly displaced distal fragment is similar to that seen with posterior dislocation of the elbow. The fracture was stable after reduction and immobilized with a splint; elbow in a flexed position.

Critical Bedside and General Approach

These steps are the same as those mentioned above in the topic “shoulder.”

Differential Diagnosis

Fractures

1. Fractures of the distal humerus:
   • Supracondylar fractures [Figure 6]; Extension type (mostly) and Flexion type
     • Type 1: Minimal or no displacement
     • Type 2: Slightly displaced
     • Type 3: Totally displaced
   • Transcondylar, intercondylar, lateral condyle, and medial condyle fractures
   • Articular surface fractures: Capitellum, Trochlea, Epicondyle, Little Leaguer’ s Elbow, Olecranon
   • Radial head and neck fractures
2. Dislocation and Subluxation:
   • Elbow: Posterior (Mostly) [Figure 7], medial, lateral, anterior (Rarely)
   • Radial head (nursemaid’ s elbow)
3. Soft tissue disorders: Epicondylitis (Tennis Elbow), Olecranon bursitis, biceps tendon rupture.

History and Physical Examination Hints

• Indirect trauma transmitted through the bones of forearm causes many of the elbow injuries. (e.g., FOOSH= Fall on outstretched hand )
• Very few fractures or dislocations occur by direct blows.
• Numbness or weakness distal to the injury should indicate the possibility of neurovascular injury.
• Extension type supracondylar fracture has a characteristic S-shaped configuration of the arm held at the side. On the other site, flexion type supracondylar fractures leads the supporting of the forearm with the opposite hand where the elbow is flexed at 90°. When the prominence of olecranon is increased, it suggests posterior dislocation of the elbow or extension supracondylar fracture. Anterior dislocation or flexion supracondylar fracture leads to the loss of normal olecranon prominence.
• When the prominence of olecranon is increased, it suggests posterior dislocation of the elbow or extension supracondylar fracture. Anterior dislocation or flexion supracondylar fracture leads to the loss of regular olecranon prominence.
• Gradual onset of dull ache at the elbow happens with epicondylitis. This pain increases with grasping and twisting of the elbow.
• With the elbow in a 90° flexion, the radial head, tip of the olecranon and the lateral epicondyle normally form an equilateral triangle. Fracture of the radial head, olecranon or the lateral epicondyle alters this relationship.
• A complete neurovascular examination should be made for the elbow and distal extremity. This examination should include: sensation and strength tests of the median, radial, ulnar, and musculocutaneous nerves, deep tendon reflexes of the biceps (C5), brachioradialis (C6), and triceps (C7), palpation of the brachial, radial, and ulnar pulses, the range of motion and strength of the elbow should be examined.

Emergency Diagnostic Tests and Interpretation

• Plain radiographs should be obtained in three views of plain x-rays – AP, lateral, and lateral oblique are necessary. AP view shows the epicondyles (medial and lateral) and the articular surfaces. (radiocapitellar and ulnotrochlear) The lateral view provides the relation of the bones of the distal humerus and proximal forearm. The radiocapitellar joint, medial epicondyle, radioulnar joint, and coronoid process view with the lateral oblique.
• Fat pad sign: With a history of known or suspected trauma of the elbow, if there is an abnormal fat pad sign this should be considered as an indication of an occult fracture. Wide anterior fat pad, also, known as ‘’sail sign’’ indicates an occult fracture. Posterior fat pad sign in an adult indicates radial head fracture; in children indicates supracondylar fracture. Watch this video.

• X-rays of the uninjured elbow help distinguish fractures from the normal epiphyses and ossification centers. To identify fractures, physeal injuries and dislocations ultrasound is a useful tool. Children with lateral condyle fractures may benefit from an MRI.

Emergency Treatment Options

• Initial Stabilization:
  • Before taking radiographs, to prevent further injury, immobilization should be performed. Please refer to “Critical Bedside And General Approach” part in the topic “shoulder.”
• Medications: Please refer to the topic “shoulder.’’
• Procedures:
  • Supracondylar fractures:
    • Nondisplaced fractures of children do not require immediate orthopedic evaluation. These patients may be referred for follow up within a week after splinting. The family should be informed to return if an unmanageable pain or compartment syndrome happens.
    • Displaced supracondylar fractures generally require open or closed reduction and percutaneous pinning for monitoring of pulses, never function and forearm compartments; the patient should be hospitalized. The patient is discharged with a splint or cast with percutaneous pins.
  • Transcondylar, intercondylar, condylar, epicondylar fractures, articular surface fractures: orthopedic consultation is necessary for all these.
  • Elbow dislocations: to avoid vascular damage, reduce immediately, flex to 90° and place a posterior splint.
  • Radial head fracture: for all fractures for 24 to 48 hours a sling or posterior splint and cold application, analgesic etc. applied, and the patient should be referred to an orthopedic surgeon.
  • Radial head subluxation: for reduction of RHS, there are two techniques – supination/flexion and hyperpronation. The latter is more successful for the reduction and may be less painful.

• Epicondylitis: Once a clinical diagnosis of epicondylitis is made, the initial treatment consists of activity modification, counter force bracing, nonsteroidal anti-inflammatory drugs (NSAIDs) (if not contraindicated) and physical therapy. Severe cases can be splinted.

Pediatric, Geriatric, Pregnant Patient, and Other Considerations

Pediatric: In children younger than ten years of age, posterior elbow dislocation is the most common. Due to the different stages of ossification and predominance of cartilage, there is difficulty in interpretation of pediatric elbow X-rays. In the pediatric elbow, the six ossification centers are shown numbered in the order of appearance: Capitellum, radial head, internal (medial) epicondyle, trochlea, olecranon, external (lateral) epicondyle (mnemonic: CRITOE).

Disposition Decisions

Admission Criteria

• Open fractures accompanying vascular injuries
• When an operative reduction or internal fixation is indicated
• All the patients with gross swelling and ecchymosis should be hospitalized for observation to monitor and decrease the risk for compartment syndrome.

Discharge Criteria

• Reduced dislocations and stable fractures with none of the above features
• Splinted patients with an arrangement of orthopedic follow up in 24-48 hour
• Simple soft tissue injuries

Referral

For a close follow-up, all fractures discharged from ED should be referred to an orthopedic surgeon.

Injuries of Wrist

Case Presentation

A 63-year-old woman fell on her outstretched hand while she was replacing a bulb at home. She presented to the ED with tenderness, severe pain, swelling, numbness, and coldness in the region of the wrist. On physical examination, she had swelling and ‘’dinner-fork’’ deformity. The neurovascular examination was normal. On the PA and lateral views of the wrist, a distal radius fracture, called Colles’ fracture is evident. The emergency physician performed an early anatomic reduction with the restoration of radial length and correction of the dorsal angulation to a neutral position.

Differential Diagnosis

1. Distal radius and ulna injuries:
   • Colles’ Fracture (the most frequent): Transverse fracture of the distal radial metaphysis, which is dorsally displaced and angulated. [Figure 8]
   • Smith’s Fracture (Reverse Colles’ Fracture): Transverse fracture of the distal radial metaphysis with associated volar displacement and angulation.
   • Barton’s Fracture: Oblique intra-articular fracture of the rim of the distal radius with associated displacement of the distal radial fragment.
   • Hutchinson’s Fracture (Chauffeur’s fracture): Intra-articular fracture of the radial styloid.
   • Distal radioulnar joint disruption
   • Pediatric fractures of the distal radius: Torus [Figure 9], Greenstick, complete fractures [Figure 10]
2. Carpal injuries:
   • Fractures: Scaphoid [Figure 11], lunate, triquetral, pisiform, hamate, trapezium, capitate, trapezoid
   • Clinical features: Carpal instability, midcarpal and intercalated segment instability, radiocarpal instability
3. Soft tissue injuries: Carpal tunnel syndrome (due to distal radius fractures and repetitive strain), de Quervain’ s Disease and intersection syndrome

History and Physical Examination Hints

• Falling on an Out-Stretched Hand (FOOSH) is the most common mechanism of wrist injuries, with the wrist in extension.
• Immature, weaker epiphyseal plate or metaphysis of the radius in children are more likely to sustain injuries, sparing the still-cartilaginous carpal bones.
• Young adults with active lifestyles are more likely to be injured with greater forces.
• In the elderly, especially in women with some degree of osteoporosis, distal radial metaphysis is more fragile resulting in Colles fracture.
• “Anatomic snuffbox’’ on the dorsum of the wrist is an important landmark. Because the scaphoid is palpable with its triangle by styloid, extensor pollicis brevis tendon and the extensor pollicis longus tendon. Tenderness in this area may indicate a scaphoid fracture.
• The examination should include assessment of neurovascular status motor and sensory function of the median, radial and ulnar nerves. Because acute median nerve compression is a common occurrence, the sensation of thumb and index fingers is important, especially with severely displaced fractures. In all injuries to the wrist, radial and ulnar pulses should be evaluated.

Emergency Diagnostic Tests and Interpretation

Standard views of the wrist include posteroanterior (PA), lateral, and oblique views. MRI and CT provide the diagnosis of the radiographically occult fractures.

Emergency Treatment Options

• Initial Stabilization: Please refer to “Critical Bedside And General Approach” part in the topic “shoulder.”
• Medications: Please refer to the topic “shoulder.’’
• Procedures:
  • Distal radius and ulna fractures:
    • Colles’ and Smith’s fractures: Closed reduction and immobilization in a sugar-tong splint. Because the Smith’ s fracture, unlike Colles’ fracture, is more unstable, it requires operative intervention and splint reduction.
    • Barton’ s Fracture: Since those fractures do not benefit close reduction, they should be referred to an orthopedic surgeon immediately.
    • Hutchinson’ s Fracture: If the fracture is non-displaced, a sugar-tong splint immobilization is sufficient. In such cases, a short arm cast is a definitive treatment. On the other hand, displaced fractures accompanied with a scapholunate ligament injury, open or closed reduction and fixation is necessary. Since many ligaments of the wrist are attached to the styloid process, it should be reduced accurately for wrist function.
  • Distal radioulnar joint disruption: A long arm cast is applied after closed reduction
  • Pediatric fractures of the distal radius: A short arm splint is required for immobilization.
  • Carpal injuries: A short arm splint with a thumb spica is required for immobilization.
  • Carpal tunnel syndrome: The wrist is splinted in a neutral position and cortisone injections are given additionally into the carpal tunnel.
  • De Quervain’s Disease: for mild and moderate forms conservative measurements such as rest of the arm in elevated position, splinting, NSAIDs and corticosteroid injections into dorsal extensor compartment of the wrist may be sufficient.

Pediatric, Geriatric, Pregnant Patient, and Other Considerations

Pediatric

The most common fractures in children and adolescents are the distal radial fractures (44). Commonly growth plate injuries occur with the distal radius fractures leading to physeal injuries (45). The most important aspect of these physeal fractures is premature closure and growth arrest of the injury site.

Geriatric

Distal radius fractures in older patients should be screened for osteoporosis. Also, distal radius fractures in an senior man is an early and sensitive marker of skeletal fragility (47). Subsequent fractures are prevalent and treatment of underlying osteoporosis in this population group is required.

Disposition Decisions

Admission Criteria

• Open fractures
• Fractures with compartment syndrome or neurovascular compromise
• Fractures needing immediate operative management or general anesthesia for reduction
• Fractures associated with soft tissue complications
• Fractures associated with circulatory deterioration in the hand

Discharge Criteria

• Appropriate reduction and immobilization
• Orthopedic follow-up should be arranged
• Pain control measures should be taken adequately
• Cast or splint care instructions should be given at discharge and should be assured the patient understands them.
• After ED treatment, the documentation of intact neurovascular function is performed.

Referral

For a close follow-up, all fractures discharged from ED should be referred to an orthopedic surgeon.

References and Further Reading

• Emergency Medicine: Clinical Essentials, 2nd Edition James G. ADAMS. Chap 87. Injuries to the shoulder Girdle and Humerus .M. Scott Linscott. P 763-775
• Rosen’s Emergency Medicine – Concepts and Clinical Practice 8nd Edition. Chapter 53. Shoulder. Mohamud R.Daya and Rachel R. Bengtzen P 618-642
• http://www.uptodate.com/contents/physical-examination-of-the-shoulder#H11044332
• Cole PA: Scapular fractures. Orthop Clin North Am 2002; 33:1.
• Lapner PC, Uhthoff HK, Papp S: Scapula fractures. Orthop Clin North Am 2008; 39:459.
• Tadros AM, Lunsjo K, Czechowski J, Corr P, Abu-Zidan FM: Usefulness of different imaging modalities in the assessment of scapular fractures caused by blunt trauma. Acta Radiol 2007; 1:71.
• Yeh GL, Williams GR: Conservative management of sternoclavicular injuries. Orthop Clin North Am 2000; 31:189.
• Cross KP, Warkentine FH, Kim IK, Gracely E, Paul RI: Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. Acad Emerg Med 2010; 17:687.
• Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev 2009;2:CD007121.
• https://5minuteconsult.com/collectioncontent/6-186893/drugs/ibuprofen
• http://emedicine.medscape.com/article/2172401-overview
• de Fays L,Van Malderen K  Use of paracetamol during pregnancyand child neurological development. Dev Med Child Neurol.2015 Aug;57(8):718-24. doi: 10.1111/dmcn.12745. Epub 2015 Apr 7 
• http://www.drugs.com/dosage/acetaminophen.html#Usual_Adult_Dose_for_Pain
• Ufberg JW, Vilke GM, Chan TC, Harrigan RA: Anterior shoulder dislocations: Beyond traction-countertraction. J Emerg Med 2004; 27:301.
• Sayegh FE, et al: Reduction of acute anterior dislocations: A prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am 2009; 91:2775.
• Bowen RE, Mah JY, Otsuka NY: Midshaft clavicle fractures associated with atlantoaxial rotatory displacement: A report of two cases. J Orthop Trauma 2003; 17:444.
• Malik S, Chiampas G, Leonard H: Emergent evaluation of injuries to the shoulder, clavicle and humerus. Emerg Med Clin North Am 2010; 28:739.
• Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res 2005; :41.
• S. Gumina, F. Postacchini. Anterior dislocation of the shoulder in elderly patients.J Bone Joint Surg Br.1997 Jul;79(4):540-3.
• Neuman G,Koren G. Safety of procedural sedation in pregnancy. J Obstet Gynaecol Can.2013 Feb;35(2):168-73.
• Blake R, Hoffman J. Emergency department evaluation and treatment of the shoulder and humerus. Emerg Med Clin North Am 1999; 17:859.
• Cleeman E, Flatow EL. Shoulder dislocations in the young patient. Orthop Clin North Am 2000; 31:217.    
• Rosen’s Emergency Medicine – Concepts and Clinical Practice 8nd Edition. Chapter 52. Humerus and Elbow. Thom A. Mayer P 596-617
• http://www.uptodate.com/contents/elbow-injuries-in-the-child-or-adolescent-athlete#H7
• Posner MA. Compressive neuropathies of the median and radial nerves at the elbow. Clin Sports Med 1990; 9:343.
• Bachman D, Santora S. Orthopedic trauma. In: Textbook of Pediatric Emergency Medicine, Fleisher GR, Ludwig S, et al. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p. 1538.
• Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am 2006; 53:41.
• Bachman D, Santora S. Orthopedic trauma. In: Textbook of Pediatric Emergency Medicine, Fleisher GR, Ludwig S, et al. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p. 1538.
• Davidson RS, Markowitz RI, Dormans J, Drummond DS. Ultrasonographic evaluation of the elbow in infants and young children after suspected trauma. J Bone Joint Surg Am 1994; 76:1804.
• Zuazo I, Bonnefoy O, Tauzin C, et al. Acute elbow trauma in children: role of ultrasonography. Pediatr Radiol 2008; 38:982.
• Horn BD, Herman MJ, Crisci K, et al. Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability. J Pediatr Orthop 2002; 22:8.
• Pudas T, Hurme T, Mattila K, Svedström E. Magnetic resonance imaging in pediatric elbow fractures. Acta Radiol 2005; 46:636.
• Baratz M, Micucci C, Sangimino M. Pediatric supracondylar humerus fractures. Hand Clin 2006; 22:69.
• Unsworth-White J, Koka R, Churchill M, et al. The non-operative management of radial head fractures: a randomized trial of three treatments. Injury 1994; 25:165.
• Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 1998; 102:e10
•  Rettig AC, Patel DV. Epidemiology of elbow, forearm, and wrist injuries in the athlete. Clin Sports Med 1995; 14:289.
•  Villarin LA Jr, Belk KE, Freid R. Emergency department evaluation and treatment of elbow and forearm injuries. Emerg Med Clin North Am 1999; 17:843.
• Rosen’s Emergency Medicine – Concepts and Clinical Practice 8nd Edition. Chapter 51. Wrist and Forearm David T. Williams and Hyung T. Kim P 596-617
• Ritchie JV, Munter DW: Emergency department evaluation and treatment of wrist injuries. Emerg Med Clin North Am 17: 823, 1999. [PMID: 10584104]
• Breitenheiser MJ, Gaebler C: Trauma of the wrist.Eur J Radiol 25: 129, 1997. 
• Basu A, Lomnassey LM, Demos TC, et al: Diagnosis: scaphoid fracture. Orthopedics 28: 177, 2005.
• Duckworth AD, Ring D, McQueen MM: Assessment of the suspected fracture of the scaphoid. J Bone Joint Surg Br 2011; 93:713-719
• Germann CA, Perron AD: Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic injuries. Emerg Med Clin North Am 2010; 28:969.
•  Pizzutillo PD. Pediatric orthopaedics. In: Essentials of Musculoskeletal Care, 3rd, Griffin YL. (Ed), American Academy of Orthopaedic Surgeons, Rosemont 2005. p.863.
• Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am 2006; 53:41.
• Waters PM, Bae DS. Fractures of the distal radius and ulna. In: Rockwood and Wilkin’s Fractures in Children, 7th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.292.
• Haentjens P, Johnell O, Kanis JA, et al. Evidence from data searches and life-table analyses for gender-related differences in absolute risk of hip fracture after Colles’ or spine fracture: Colles’ fracture as an early and sensitive marker of skeletal fragility in white men. J Bone Miner Res 2004; 19:1933.