Enumerate injuries sustained due to FOOSH

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Injuries from FOOSH (Fall On OutStretched Hand)

FOOSH transmits a compressive axial load up the upper limb while the wrist is in dorsiflexion. The pattern of injury depends on age, bone density, wrist angle at impact, and the magnitude of force. Injuries occur at multiple levels simultaneously and should all be considered.

By Anatomical Level (Distal to Proximal)

1. Wrist / Distal Forearm

Injury	Key Features
Colles' Fracture	Fracture of the distal radius metaphysis with dorsal displacement and volar angulation; most common wrist fracture in adults, especially older women; produces the classic "dinner fork" deformity; often accompanied by ulnar styloid fracture
Smith's Fracture	Reverse Colles' - distal radius fractures with volar displacement; occurs with wrist in palmar flexion at impact
Barton's Fracture	Intra-articular fracture of the dorsal rim of distal radius with radiocarpal subluxation
Volar (Reverse) Barton's	Intra-articular fracture of the volar rim; wrist is in volar flexion at impact; rarer
Chauffeur's Fracture	Isolated radial styloid fracture; caused by deviation and supination forces
Greenstick/Torus fracture	Buckle fracture of distal radius; typical in children due to pliable bone
Galeazzi Fracture-Dislocation	Fracture of the distal radial shaft with disruption of the distal radioulnar joint

(ROSEN's Emergency Medicine; Tintinalli's Emergency Medicine)

2. Carpal Bones

Injury	Key Features
Scaphoid Fracture	Most common carpal fracture (60-70% of all carpal fractures); waist fractures predominate (2/3 of cases); snuffbox tenderness; high risk of AVN with proximal pole fractures; X-rays may be negative initially
Lunate Fracture / Kienbock Disease	Axial load to lunate; can lead to avascular necrosis
Triquetrum Fracture	Second most common carpal fracture; usually a dorsal avulsion chip
Hamate Fracture	Hook fracture from direct palm strike or outstretched hand; associated with ulnar nerve/artery injury
Pisiform Fracture	Direct impact; base of hypothenar
Trapezium Fracture	Axial load along thumb metacarpal
Lunate/Perilunate Dislocation	High-energy FOOSH; perilunate dislocation precedes lunate dislocation on a spectrum of carpal instability
Carpal Instability (DISI/VISI)	Scapholunate or lunotriquetral ligament tears causing intercalated segment instability

(Tintinalli's Emergency Medicine; ROSEN's Emergency Medicine)

3. Forearm Shafts

Injury	Key Features
Radial Shaft Fracture	Isolated or combined; from direct violence or indirect FOOSH
Ulnar Shaft Fracture	Can occur with forearm in forced pronation
Both-Bone Forearm Fracture	Combined radius and ulna fractures; higher energy
Monteggia Fracture-Dislocation	Proximal ulna fracture + anterior dislocation of radial head; FOOSH with forced forearm pronation

(Pye's Surgical Handicraft; Imaging Anatomy, Bones & Joints)

4. Elbow

Injury	Key Features
Radial Head / Neck Fracture	Most common elbow fracture in adults (33-50% of elbow fractures); axial loading forces; classified by Mason system; associated with Essex-Lopresti injury (disruption of interosseous membrane + DRUJ)
Olecranon Fracture	Can occur with indirect FOOSH mechanism; more complex fracture-dislocation patterns
Coronoid Process Fracture	Often associated with elbow dislocation
Supracondylar Fracture of Humerus	Most common elbow fracture in children; FOOSH with elbow in full extension; extension type (95-98%); high risk of anterior interosseous nerve injury and Volkmann's ischemic contracture
Posterior Elbow Dislocation	Most common type (>90%); FOOSH causing hyperextension with valgus stress; associated with brachial artery injury (5-15%) and median nerve injury; frequently accompanied by radial head, coronoid, or distal humerus fractures ("terrible triad")
Capitellum Fracture	Shear force at capitellum; diagnosed on lateral X-ray
Medial Epicondyle Avulsion	Associated with elbow dislocation in children

(ROSEN's Emergency Medicine; Tintinalli's Emergency Medicine; Rockwood & Green's Fractures in Adults 10th ed)

5. Humerus

Injury	Key Features
Proximal Humeral Fracture	FOOSH with shoulder in flexion, abduction, and internal rotation; humeral head forced into valgus; common in osteoporotic elderly; Neer classification
Humeral Shaft Fracture	Less commonly from FOOSH; more often direct blow; risk of radial nerve injury

(Rockwood & Green's Fractures in Adults 10th ed)

6. Shoulder Girdle

Injury	Key Features
Clavicle Fracture	Force transmitted through outstretched arm to clavicle; middle third most common (80%); can also result from direct blow to shoulder
Acromioclavicular Joint Injury	Force transmitted from arm through acromion to clavicle
Glenohumeral Dislocation	Anterior dislocation most common; force applied along abducted, externally rotated arm
Glenoid Fracture	Impaction of humeral head on glenoid rim from FOOSH

(Pye's Surgical Handicraft; Schwartz's Principles of Surgery; Rockwood & Green's)

Age-Based Patterns

Age Group	Typical Injury
Children	Torus/greenstick distal radius, supracondylar fracture, lateral condyle fracture, medial epicondyle avulsion
Young Adults	Scaphoid fracture, carpal dislocations, radial head fracture
Older Adults (osteoporotic)	Colles' fracture, proximal humeral fracture, radial head fracture

Associated Neurovascular Injuries to Exclude

Anterior interosseous nerve - supracondylar fractures (inability to flex thumb IP and index DIP)
Radial nerve - humeral shaft fractures (wrist drop)
Median nerve - elbow dislocations
Ulnar nerve/artery - hamate hook fractures
Brachial artery - elbow dislocations (5-15%), supracondylar fractures
Volkmann's ischemic contracture - compartment syndrome following supracondylar fracture

Sources: ROSEN's Emergency Medicine (Concepts and Clinical Practice); Tintinalli's Emergency Medicine (Comprehensive Study Guide); Rockwood and Green's Fractures in Adults 10th ed; Bailey and Love's Short Practice of Surgery 28th ed; Pye's Surgical Handicraft 22nd ed; Swanson's Family Medicine Review.

Mention injuries around wrist joint

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Here is a comprehensive, structured account of all injuries around the wrist joint, drawn directly from the textbooks.

Injuries Around the Wrist Joint

The wrist extends from the distal radius and ulna proximally to the carpometacarpal joints distally. It accounts for 2.5% of all ED visits annually and up to 25% of sports injuries. Injuries are grouped into four categories: distal radius/ulna fractures, carpal bone fractures, ligamentous/instability injuries, and soft tissue injuries.

Normal wrist PA X-ray anatomy for reference:

Normal wrist PA X-ray showing Gilula lines and carpal bones labeled

S = scaphoid; L = lunate; Tq = triquetrum; P = pisiform; C = capitate; H = hamate; Tm = trapezium; Tz = trapezoid. The three Gilula lines (arcs 1, 2, 3) should be smooth - disruption implies fracture, dislocation, or subluxation.

A. Distal Radius and Ulna Fractures

These are the most common wrist fractures and occur at the weakest point - the distal radial metaphysis.

1. Colles' Fracture

Fracture of the distal radial metaphysis with dorsal displacement and volar angulation
Classic mechanism: FOOSH with wrist in dorsiflexion
"Dinner fork" deformity on lateral view; "bayonet" deformity on AP
Most common in elderly osteoporotic women
Often accompanied by an ulnar styloid fracture
Requires closed reduction and cast immobilization; may need surgical fixation if intra-articular or unstable

2. Smith's Fracture ("Reverse Colles'")

Distal radius fracture with volar displacement
Mechanism: FOOSH with wrist in palmar flexion, or direct blow to dorsum of wrist
"Garden spade" deformity
Inherently unstable - often requires surgical fixation

3. Barton's Fracture

Intra-articular fracture of the dorsal rim of the distal radius with radiocarpal subluxation
Results from high-velocity impact across the wrist in dorsiflexion
Unstable; usually requires ORIF

4. Volar (Reverse) Barton's Fracture

Intra-articular fracture of the volar rim of the radius with volar radiocarpal dislocation
Wrist is in palmar flexion at time of impact
Rarer than dorsal Barton's

5. Chauffeur's Fracture (Radial Styloid Fracture)

Isolated transverse or oblique fracture of the radial styloid, extending from the scaphoid fossa to the radial metaphysis
Named for chauffeurs who suffered violent backfire of hand cranks
Force directed along the radial side of the wrist; produced by ulnar deviation and supination

6. Greenstick / Torus (Buckle) Fracture

Seen in children due to pliable immature bone
Torus: cortical buckling on the compression side without complete fracture
Greenstick: fracture through one cortex, bowing of the other

7. Galeazzi Fracture-Dislocation

Fracture of the distal radial shaft combined with disruption of the distal radioulnar joint (DRUJ)
Wrist pain + forearm deformity; ulna head prominent on dorsum
Requires ORIF of radius + DRUJ stabilization

8. Distal Radioulnar Joint (DRUJ) Injury

Piano key sign positive (ulnar head springs back when depressed)
Pain with pronation/supination
Often associated with TFCC tear

B. Carpal Bone Fractures

Carpal fractures are the most commonly missed wrist injuries. Impact on the thenar eminence tends to injure the scaphoid; impact on the hypothenar eminence tends to injure the triquetrum and pisiform.

1. Scaphoid Fracture (Most common carpal fracture - 60-70%)

Mechanism: FOOSH on dorsiflexed hand, or axial load along thumb metacarpal
Anatomic snuffbox tenderness (sensitivity 90%), scaphoid tubercle tenderness (sensitivity 87%)
Waist = 2/3 of fractures; proximal pole = 16-28%; distal pole = 10%
X-rays may be negative for up to 2 weeks - MRI is the gold standard if high clinical suspicion
Complication: Avascular necrosis of the proximal fragment (risk up to 80% in proximal pole fractures) due to the retrograde blood supply entering distally
Non-union and post-traumatic arthritis (SNAC wrist) if untreated

2. Triquetrum Fracture (Second most common)

Usually a dorsal chip avulsion fracture (dorsal radiocarpal or intercarpal ligament avulsion)
Best seen on lateral X-ray
Often associated with lunotriquetral (LT) ligament injury

3. Lunate Fracture

Rare as an isolated injury
Associated with perilunate dislocation
Avascular necrosis of the lunate = Kienbock's disease (osteonecrosis from repetitive microtrauma or acute fracture)

4. Capitate Fracture

Often occurs in combination with scaphoid fracture (scaphocapitate syndrome)
Proximal pole at risk for osteonecrosis due to retrograde blood supply
May be part of perilunate injury spectrum

5. Hamate Fracture

Hook of hamate fracture: fall on outstretched hand or direct palm strike; common in racquet sports, golf, baseball
Best seen on carpal tunnel radiographic view or CT
Associated with ulnar nerve/artery injury in Guyon's canal (ring/small finger weakness, pain)
Chronic non-union can cause flexor tendon rupture (ring/small finger FDP)

6. Pisiform Fracture

Direct impact to hypothenar region
Treated with immobilization; excision if symptomatic non-union

7. Trapezium Fracture

Axial load along the thumb metacarpal; radial styloid impaction
Often associated with 1st CMC dislocation

8. Trapezoid Fracture

Extremely rare due to protected position

C. Ligamentous Injuries and Carpal Instability

Ligamentous injuries are centered on the lunate, and form a spectrum of progressive severity based on force applied (Mayfield stages I-IV).

Scapholunate dissociation X-ray findings

A. SL dissociation: >3mm gap (black arrow) + "cortical ring sign" of scaphoid rotation (white arrow). B. Grip view enhancing the gap. C. DISI pattern on lateral view.

1. Scapholunate (SL) Ligament Tear - Most common wrist ligament injury

FOOSH on thenar eminence
Dorsal wrist pain, "clicking" with movement, tenderness distal to Lister's tubercle
Radiographic findings:
- Terry Thomas sign (SL gap >3 mm on PA view; >8 mm on clenched fist view)
- Cortical ring sign (scaphoid foreshortening due to palmar rotation)
- DISI (Dorsal Intercalated Segment Instability) on lateral: SL angle >60°, lunate tilts dorsally
Watson shift test: painful clunk with radial deviation while pressure applied over scaphoid tubercle
Gold standard diagnosis: wrist arthroscopy (Geissler classification)

2. Lunotriquetral (LT) Ligament Tear

FOOSH on hypothenar eminence
Ulnar-sided wrist pain; LT ballottement test positive
VISI (Volar Intercalated Segment Instability): lunate tilts volarly
Less common and subtler than SL injury

3. Perilunate Dislocation (Mayfield Stage II-III)

High-energy FOOSH; dorsal dislocation of all carpal bones relative to the lunate
Lunate maintains its relationship with the radius
Disruption through the space of Poirier (weak volar capsule between the two palmar arcades)
On lateral X-ray: capitate lies dorsal to the lunate

4. Lunate Dislocation (Mayfield Stage IV - highest energy)

Lunate dislocates volarly as remaining carpus relocates back under the radius
PA view: "piece of pie" sign (triangular shape of dislocated lunate)
Lateral view: "spilled teacup" sign (lunate tilted into palm)
Median nerve compression (acute carpal tunnel syndrome) is a recognized complication - a surgical emergency

5. Triangular Fibrocartilage Complex (TFCC) Tear

The TFCC is the main stabilizer of the DRUJ and ulnar wrist
Mechanism: axial load with forearm rotation, or FOOSH
Ulnar-sided wrist pain; positive ulnocarpal stress test (pain on compression in ulnar deviation)
Classified as traumatic (Palmer Type 1) or degenerative (Type 2)
MRI or arthroscopy for diagnosis

D. Other / Soft Tissue Injuries

Injury	Notes
Wrist sprain	Partial or complete ligament tear without instability; diagnosis of exclusion - always image first
DRUJ instability	Isolated or combined with distal radius fractures
Extensor tendon injury	May accompany dorsal fractures
Flexor tendon injury	Can follow hook of hamate non-union (FDP ring/small finger)
Median nerve injury	Acute carpal tunnel syndrome with lunate dislocation or distal radius fracture

Age-Based Pattern Summary

Patient	Most Likely Injury
Child	Torus/greenstick distal radius (physeal injury spares cartilaginous carpals)
Young active adult	Scaphoid fracture, SL ligament tear, perilunate dislocation
Elderly / osteoporotic	Colles' fracture (often intra-articular); proximal humerus is a close second

Sources: Tintinalli's Emergency Medicine, Comprehensive Study Guide - Wrist Injuries chapter; Miller's Review of Orthopaedics 9th ed; Pye's Surgical Handicraft 22nd ed; ROSEN's Emergency Medicine.

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