What is the treatment for suspected carpal bone tenting?

Treatment of Suspected Carpal Bone Tenting

Immediate surgical consultation is indicated for carpal bone tenting, as this represents a displaced fracture with impending skin perforation that requires urgent operative intervention to prevent skin necrosis, infection, and long-term functional impairment.

Initial Management

Immediate Actions

• Do not attempt to reduce or straighten the deformity 1
• Activate emergency medical services immediately if the extremity shows signs of vascular compromise (blue or extremely pale appearance) 1
• Cover any open wounds with a sterile dressing 1
• Immobilize the wrist in the position found using a well-padded splint if transport to definitive care will be delayed 1

Critical Assessment Points

• Evaluate for neurovascular compromise (check capillary refill, sensation, and motor function)
• Document the presence of skin blanching or tenting, which indicates urgent need for reduction 1
• Assess for open fracture, which would require immediate antibiotics and tetanus prophylaxis

Diagnostic Imaging

Initial Radiographic Evaluation

• Obtain standard 3-view wrist radiographs (posteroanterior, lateral, and 45° semipronated oblique views) 2
• These views are essential to identify the specific fracture pattern and degree of displacement 2

Advanced Imaging Considerations

• CT without IV contrast is indicated when radiographs are equivocal or when detailed preoperative planning is needed for complex articular injuries 1, 2
• Three-dimensional CT reconstructions are particularly valuable for surgical planning in cases with significant displacement or intra-articular involvement 1, 2
• MRI without IV contrast may be considered if there is concern for associated ligamentous injuries (scapholunate or lunotriquetral ligament tears), though this should not delay urgent surgical intervention 1

Definitive Treatment

Surgical Intervention

• Operative fixation is the standard of care for displaced fractures with skin tenting 1, 2
• Surgery should be performed urgently (within hours) to prevent skin necrosis and reduce infection risk
• Arthroscopic evaluation during surgery is an option to assess for intra-articular involvement and associated ligament injuries 1
• Surgical treatment of associated ligament injuries (scapholunate, lunotriquetral, or TFCC tears) at the time of fracture fixation is an option 1

Post-Reduction Management

• Following reduction and fixation, cast immobilization is preferred over removable splints for displaced fractures 1
• Serial radiographic evaluation should be performed for 3 weeks and at cessation of immobilization to monitor for loss of reduction 1

Common Pitfalls to Avoid

• Never attempt closed reduction in the field or emergency department without surgical backup, as this may cause further soft tissue damage or convert a closed fracture to an open one
• Do not delay surgical consultation while waiting for advanced imaging if skin tenting is present
• Avoid applying ice directly to tented skin, as this may cause additional tissue damage; if cooling is needed, place a barrier between the cold source and skin 1
• Do not assume that successful closed reduction eliminates the need for surgical evaluation, as ligamentous injuries may still require operative treatment 1