Importance of soft-tissue evaluation in hand and wrist trauma: statistical evaluation

Four radiologists reviewed 197 hand and wrist radiographs to determine the usefulness of routine soft-tissue evaluation in the delineation of bony trauma. Soft-tissue changes at four sites in the lateral view were evaluated. Dorsal-hand fat-plane swelling was associated with second through fifth metacarpal fractures (p less than 0.01). Dorsal-wrist fat-plane swelling was associated with carpal fractures and wrist dislocations (p less than 0.01). Pronator and dorsal radial swelling were both associated with forearm fractures and carpal dislocations (p less than 0.01). Soft-tissue changes at five sites in the posteroanterior view were evaluated. Thenar swelling was associated with thumb metacarpal fractures and dislocations (p less than 0.01). Hypothenar swelling was associated with second through fifth metacarpal fractures and dislocations (p less than 0.01). Navicular fat-pad swelling was associated with carpal fractures (p less than 0.01) and strongly suggested a navicular fracture when present. Pararadial swelling was significantly associated with distal radial fractures (p less than 0.01), while paraulnar swelling was significantly associated with ulnar fractures (p less than 0.01). The lateral view of the hand and wrist is useful in compartmentalizing fractures to the hand, wrist, and forearm. Swelling in any compartment should lead to closer evaluation of all bony structures contained within that compartment. The soft tissues found in the posteroanterior view of the hand and wrist help further localize hand and wrist fractures. Additional views should be considered when significant swelling is present in the absence of an obvious fracture or dislocation. When more than one fat plane is unequivocally disturbed, protective immobilization with reexamination in 10 days is recommended.