Wrist Dislocation in Emergency Medicine

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Carpal dislocations represent a continuum of wrist injury that can lead to lunate or perilunate dislocation. The lunate cup commonly is directed in a volar direction in dislocation because of the mechanism of the injury. Perilunate dislocations result from dislocation of the distal carpal row. ^[1] The capitate normally rests within the lunate cup, as seen on a lateral view. With perilunate dislocations, the capitate is seen most commonly as dorsal, but it also may be volar to the lunate on lateral x-ray evaluation. As a result of the stresses involved, scaphoid fractures often accompany perilunate dislocation. ^{[2, 3]} Carpal instability may take many forms and represents a spectrum of injury including scapholunate dissociation, lunate and perilunate dislocations, scaphoid fracture, and other intercarpal instabilities. A lunate dislocation is shown in the radiograph below.

For more information, see Medscape’s Orthopaedics Resource Center.

The mechanism of injury is usually a fall onto an outstretched hand with hand rotation, which may lead to a variety of injuries. These injuries range from scapholunate strain to carpal dislocation, with scaphoid fracture at the end of the spectrum. Unfortunately, most of these injuries are not diagnosed in the ED. The injury may lead to chronic pain and instability of the wrist. ^{[4, 5, 6]}

United States

Incidence of wrist injuries is estimated as 2.5% of ED visits. Wrist dislocations represent a very small portion of these visits. Because of this small proportion of wrist dislocations, they can be easily missed on initial presentation to the ED.

The morbidity of wrist dislocations is tied to the frequently missed diagnosis of lunate or perilunate dislocation in the ED. ^[7] Often, patients are not diagnosed with these injuries until weeks following the initial injury.

Many patients with undiagnosed wrist dislocation have chronic pain.

Carpal instability, including radiocarpal instability, is a frequent complication.

Avascular necrosis of the lunate, Kienbock disease, is a potential complication of lunate dislocation.

Hayden SR. A case of peri-lunate dislocation. J Emerg Med. 1995 Mar-Apr. 13(2):241. [Medline].

Laporte M, Michot A, Choughri H, Abi-Chahla ML, Pelissier P. [Perilunate dislocations and fracture-dislocations of the wrist, a review of 17 cases]. Chir Main. 2012 Apr. 31(2):62-70. [Medline].

Cowell GW, Ng CY, Tiemessen CH, Phillips JE. Transscaphoid perilunate dislocation–a tale of two carpals?. BMJ Case Rep. 2011 Aug 24. 2011:[Medline]. [Full Text].

Carter PR. Fractures and dislocations of the wrist. Common Hand Injuries and Infections. 1983. 123-141.

Mital RC, Beeson M. The Wrist and Forearm. Emergency Radiology. 1999. 47- 75.

Rockwood CA, Jr, Green DP, Bucholz RW. Fractures and dislocations of the wrist. Fractures in Adults. Lippincott Williams & Wilkins Publishers; 1996. 745-867.

Sochart DH, Birdsall PD, Paul AS. Perilunate fracture-dislocation: a continually missed injury. J Accid Emerg Med. 1996 May. 13(3):213-6. [Medline].

Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the ED: lunate and perilunate injuries. Am J Emerg Med. 2001 Mar. 19(2):157-62. [Medline].

Kannikeswaran N, Sethuraman U. Lunate and perilunate dislocations. Pediatr Emerg Care. 2010 Dec. 26(12):921-4. [Medline].

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children’s Hospital of Orange County at Mission

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, California Medical Association

Disclosure: Nothing to disclose.

Wrist Dislocation in Emergency Medicine

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