Wrist Case #4

History and Physical67 yo F presents

after losing control of her walker and falling forward onto her outstretched, extended right hand. Pt complains of 10/10 pain in the wrist and inability to move her wrist. Denies any other injuries

T 98.4 P 87 BP 156/88 O2 97%

Gen: age approp female in obv pain but NAD

MSK: profound swelling of right wrist, no laceration, 2+ distal pulses. TTP over right wrist and prox right metacarpals.

Neuro- limited flexion/extension of right wrist, otherwise 5/5 strength, nl sensation

Radiographs

Diagnosis: Perilunate Dislocation

Posterior dislocation of capitate and distal carpal row with lunate in nl position

Pain ManagementReduction of carpal dislocation with

longitudinal traction and dorsal pressureOrtho consultation needed as often

associated carpal fx present and significant ligamentous injury requiring open repair

ED Management

Often missed due to inadequate radiographsImportant to get good lateral view to see

dislocationHigh frequency of associated carpal

fractures, usually scaphoid or radial styloidMust be cautious of median nerve palsy; can

have an acute carpal tunnel syndromeImmediate ortho consultation preferred

Pearls

More Images

http://www.wheelessonline.com/ortho/perilunate_dislocation

http://radiopaedia.org/articles/perilunate-dislocationhttp://www.eorif.com/WristHand/

perilunatedislocation.htmlhttp://www.ispub.com/journal/

the_internet_journal_of_orthopedic_surgery/volume_8_number_1_8/article/concomitant_elbow_and_perilunate_dislocation_floating_forearm.html

http://www.feinberg.northwestern.edu/emergencymed/residency/ortho-teaching/wrist/case67/case67background.html

References