Wrist Fractures and Dislocations Workup
- Author: Michael Morhart, MD, MSc, FRCSC; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...
Radiographic examination is essential for diagnosis, and classification of all carpal fractures and dislocations. All diagnosed fractures should be carefully examined for evidence of contaminant fractures and for dislocations that are less obvious than the primary injury. Improper positioning of the wrist for radiographs is a common cause of failure to make the correct diagnosis; thus, proper radiographic technique is crucial. All wrist injuries should include 4 views, posteroanterior (PA), lateral, and supinated and pronated obliques. In addition, all wrist injuries should have scaphoid/navicular views because of the relative frequency of scaphoid fracture.
The 4 essential views (ie, PA, lateral, supinated and pronated obliques) identify 97% of fractures. The lateral view is used to assess the degree of scaphoid fracture angulation. On PA views, radial displacement of a fractured scaphoid usually obliterates the linearity of the radial radiolucent soft tissue pad known as the navicular fat stripe sign.
The scaphoid view or navicular view is recommended. This is a PA radiograph with the wrist extended 30° and deviated ulnarly 20°. This view helps to stretch out the scaphoid and is also used for assessing the degree of scaphoid fracture angulation.
A clenched-fist radiograph has also been useful for visualization of the scaphoid waist. This may also assist in demonstrating dynamic scapholunate instability.
Initially, the fracture is not recognizable on a radiograph. Treatment is initiated with immobilization in a thumb spica cast for 2 weeks (allowing for resorption at the fracture site) and then evaluation with repeat radiography.
Bone scan, CT scan, ultrasound, and MRI
In addition to radiographs, bone scan, CT scan, and ultrasonograms have also been reliable in the early (< 24 h) detection of occult nondisplaced scaphoid fractures.
In emergent management, the bone scan is useful to help detect high-probability fractures not visible on standard radiographs (see image below).
CT scans are particularly useful for identifying malalignments within the carpus and in the diagnosis of more obscure distal osteocartilaginous fractures.
MRI has emerged as a useful adjunct in the detection of occult scaphoid fractures as well as nonunions. Dorsay has found that MRI performed in patients with high degree of suspicion reduced the time interval for casting and allowed an earlier return to function. MRI with gadolinium enhancement remains the criterion standard in the diagnosis of scaphoid nonunions with or without avascular necrosis.
See Lunate fracture in the Pathophysiology section for classification based on radiographic findings. Fractures of the lunate are difficult to diagnose with radiographs; thus, additional CT scan and MRI studies are recommended. Radiography is perhaps more useful after deterioration to Kienböck disease.
The 4 routine views of the wrist are recommended; also include carpal tunnel views. The initial lunate fracture is often difficult to diagnose based on radiographic findings. Fracture lines and fragmentation become evident only weeks later.
During stage IIIB, the collapsing carpus undergoes scapholunate dissociation, which results in flexion of the scaphoid and a ring sign often also seen with progressive perilunate instability, which is discussed further below.
MRI (T1- and T2-weighted images)
Avascular necrosis of the lunate shows the hallmark signal reduction of the lunate.
This is useful in the early stages when initial radiographic findings are normal but clinical findings are suggestive (stage 1).
CT scan studies are useful for all stages of disease, particularly in the acute fracture setting.
These may show early changes, but the findings are nonspecific and lead to false-positive and false-negative results.
In addition to the 4 basic views, PA traction views can also aid in diagnosis and classification. Clenched-fist anteroposterior (AP) views have been shown to help diagnose the more dynamic scapholunate dissociation. Approximately 20% of perilunate injuries are misinterpreted on initial radiographs.
The ring sign may be seen with PA/AP views. In scapholunate dissociation (stage I), ligament instability results in permanent flexion of the scaphoid and a foreshortened appearance on AP/PA cross-section. This end-on projection of the distal pole of the scaphoid produces the classic signet ring sign (also observed in stage IIIB Kienböck disease).
The Terry-Thomas sign may be seen on AP/PA views. Pathognomonic for perilunate instability, this radiologic sign means a gap is present between the lunate and scaphoid, which is considered abnormal if larger than 3 mm on the radiograph.
The spilled-teacup sign may be seen on the lateral view. Normally, the kidney-shaped lunate holds the head of the capitate with its concave surface and articulates with the distal radius with its proximal convex surface. With lunate dislocation (stage IV), the lunate usually flips volarly on its volar radiolunate ligament hinge so that its concavity faces the carpal tunnel. This provides the appearance of a cup turned downward and is referred to as the spilled-teacup sign on lateral-view radiographs.
CT scan, bone scan, MRI: These are useful in the setting of subtle acute, delayed, late, or dynamic carpal instability presentations.
Perilunate Fracture Dislocation
Standard PA (for fracture pattern) and lateral radiographs (for identifying displacement of the carpus)
Typically, these views are sufficient. Traction radiographs also are often helpful.
A delay in diagnosis is not unusual, especially in persons with polytrauma in whom the injury is overlooked.
Poorly taken initial radiographs are usually to blame; radiographs are often misinterpreted, and the fracture is treated as a Colles fracture.
This is recommended for late diagnosis and when routine films are difficult to interpret.
Very late presentation after many years includes carpal tunnel syndrome and ruptures of the flexor tendons.
Isolated Carpal Fractures (Excluding Scaphoid and Lunate)
AP, lateral, radial, and ulnar deviation views are used for carpal fractures.
Trapezium, trapezoid, pisiform, and hamate fractures benefit from the addition of carpal tunnel views.
Moreover, the trapezium, trapezoid, pisiform, and hamate fractures also may benefit from the addition of a CT scan.
Isolated Carpal Dislocations
With lateral and AP views, projections are minimal. Possible trapezoidal, trapezium, and pisiform dislocations should have oblique views.
This is indicated for all complicated presentations.
Fracture Dislocation and Axial Dislocation
AP views allow assessment of the type of axial dislocation (radial vs ulnar).
Lateral radiographs allow a determination of the direction of dislocation.
Additional traction views and CT scan
These may be necessary for a full assessment of the intercarpal ligamentous and carpal articulative derangements.
Dennis HH, Sze AC, Murphy D. Prevalence of carpal fracture in Singapore. J Hand Surg Am. 2011 Feb. 36(2):278-83. [Medline].
Rhee PC, Jones DB, Moran SL, et al. The Effect of Lunate Morphology in Kienbock Disease. J Hand Surg Am. 2015 Feb 18. [Medline].
Cooney WP, Linscheid RL, Dobyns JH, eds. The Wrist: Diagnosis and Operative Treatment. St. Louis, Mo: Mosby-Year Book; 1998. 32-46, 62-70, 73-104, 106-22, 385-8, 393-6,403-10, 417, 421-5, 431-45.
Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg [Am]. 1980 May. 5(3):226-41. [Medline].
Garcia-Elias M, Dobyns JH, Cooney WP 3rd, Linscheid RL. Traumatic axial dislocations of the carpus. J Hand Surg [Am]. 1989 May. 14(3):446-57. [Medline].
Berger RA. A method of defining palpable landmarks for the ligament-splitting dorsal wrist capsulotomy. J Hand Surg [Am]. 2007 Oct. 32(8):1291-5. [Medline].
Gelberman RH, Bauman TD, Menon J, Akeson WH. The vascularity of the lunate bone and Kienböck's disease. J Hand Surg [Am]. 1980 May. 5(3):272-8. [Medline].
Dorsay TA, Major NM, Helms CA. Cost-effectiveness of immediate MR imaging versus traditional follow-up for revealing radiographically occult scaphoid fractures. AJR Am J Roentgenol. 2001 Dec. 177(6):1257-63. [Medline].
Bishop AT, Beckenbaugh RD. Fracture of the hamate hook. J Hand Surg [Am]. 1988 Jan. 13(1):135-9. [Medline].
Bae DS, Gholson JJ, Zurakowski D, et al. Functional Outcomes After Treatment of Scaphoid Fractures in Children and Adolescents. J Pediatr Orthop. 2015 Feb 26. [Medline].
Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res. 1982 Apr. 199-207. [Medline].
Adler JB, Shaftan GW. Fractures of the capitate. J Bone Joint Surg Am. 1962 Dec. 44-A:1537-47. [Medline].
Alexander AH, Lichtman DM. Kienböck's disease. Orthop Clin North Am. 1986 Jul. 17(3):461-72. [Medline].
Alnot JY, Bellan N, Oberlin C, et al. Fractures and non unions of the proximal pole of the carpal scaphoid bone. Internal fixation by a proximal to distal screw. Ann Chir Main. 1988. 7(2):101-8. [Medline].
Amadio PC, Berquist TH, Smith DK, et al. Scaphoid malunion. J Hand Surg [Am]. 1989 Jul. 14(4):679-87. [Medline].
Baird DB, Friedenberg ZB. Delayed ulnar-nerve palsy following a fracture of the hamate. J Bone Joint Surg Am. 1968 Apr. 50(3):570-2. [Medline].
Beckenbaugh RD, Shives TC, Dobyns JH, et al. Kienböck's disease: the natural history of Kienböck's disease and consideration of lunate fractures. Clin Orthop Relat Res. 1980 Jun. 98-106. [Medline].
Bilos ZJ, Hui PW. Dorsal dislocation of the lunate with carpal collapse. Report of two cases. J Bone Joint Surg Am. 1981 Dec. 63(9):1484-6. [Medline].
Boulas HJ, Milek MA. Hook of the hamate fractures. Diagnosis, treatment, and complications. Orthop Rev. 1990 Jun. 19(6):518-29. [Medline].
Buchler U. Lunate revascularization. Orlando, Fla: Paper presented at: The Wrist Investigators Workshop; October 2-3, 1991.
Burton RI, Eaton RG. Common hand injuries in the athlete. Orthop Clin North Am. 1973 Jul. 4(3):809-38. [Medline].
Campbell RD Jr, Lance EM, Yeoh CB. Lunate and perilunar dislocations. J Bone Joint Surg Br. 1964 Feb. 46:55-72. [Medline].
Campbell RD Jr, Thompson TC, Lance EM, et al. Indications for open reduction of lunate and perilunate dislocations of the carpal bones. J Bone Joint Surg Am. 1965 Jul. 47:915-37. [Medline].
Carter PR. Common Hand Injuries and Infections. Philadelphia, Pa: WB Saunders; 1983. 123-41.
Chow SP. Moulding press injury of the hand. Ann Acad Med Singapore. 1979 Oct. 8(4):493-6. [Medline].
Chow SP, So YC, Pun WK, et al. Thenar crush injuries. J Bone Joint Surg Br. 1988 Jan. 70(1):135-9. [Medline].
Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg [Am]. 2001 Sep. 26(5):908-15. [Medline].
Codman EA, Chase HM. The diagnosis and treatment of fracture of the carpal scaphoid and dislocation of the semilunar bone, with a report of thirty cases. Ann Surg. 1905. Part II, 41:863.
Cooney WP, Bussey R, Dobyns JH, et al. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res. 1987 Jan. 136-47. [Medline].
Corfitsen M, Christensen SE, Cetti R. The anatomical fat pad and the radiological "scaphoid fat stripe". J Hand Surg [Br]. 1989 Aug. 14(3):326-8. [Medline].
Destot EAJ. Injuries of the wrist: a radiological study. Atkinson FRB, translator. New York, NY: Paul Hoeber; 1926.
Dobyns JH, Linscheid RL. Fractures and dislocations of the wrist. Rockwood CA Jr, Green DP, eds. Fractures and Dislocations. 2nd ed. Philadelphia, Pa: JB Lippincott; 1975. Vol 1:
Dobyns JH, Linscheid RL, Chao EYS, et al. Traumatic instability of the wrist. Instr Course Lect. 1975. 24:182-99.
Dunn AW. Fractures and dislocations of the carpus. Surg Clin North Am. 1972 Dec. 52(6):1513-38. [Medline].
Ferenz CC. Acute perilunate dislocations. Orthop Rev. 1986 Apr. 15(4):213-7. [Medline].
Foster RJ, Hastings H 2nd. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop. 1987 Jan. (214):121-9. [Medline].
Foucher G, Saffar P. Revascularization of the necrosed lunate, stage I and II, with a dorsal intermetacarpal arteriovenous pedicle. Chir Main. 1982. 1:259.
Foucher G, Schuind F, Merle M, Brunelli F. Fractures of the hook of the hamate. J Hand Surg [Br]. 1985 Jun. 10(2):205-10. [Medline].
Frankel VH. The Terry-Thomas sign. Clin Orthop. 1977 Nov-Dec. (129):321-2. [Medline].
Friedman L, Yong-Hing K, Johnston GH. The use of coronal computed tomography in the evaluation of Kienbock's disease. Clin Radiol. 1991 Jul. 44(1):56-9. [Medline].
Friedman SL, Short WH, Werner FW, et al. The effect of grip on ulnar variance. Paper presented at: Annual Meeting of the American Society for Surgery of the Hand; October 28, 1995. Orlando, Fla.
Garcia-Elias M, Abanco J, Salvador E, Sanchez R. Crush injury of the carpus. J Bone Joint Surg Br. 1985 Mar. 67(2):286-9. [Medline].
Garcia-Elias M, Irisarri C, Henriquez A, et al. Perilunar dislocation of the carpus. A diagnosis still often missed. Ann Chir Main. 1986. 5(4):281-7. [Medline].
Gellman H, Caputo RJ, Carter V, et al. Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid. J Bone Joint Surg Am. 1989 Mar. 71(3):354-7. [Medline].
Gilula LA. Carpal injuries: analytic approach and case exercises. AJR Am J Roentgenol. 1979 Sep. 133(3):503-17. [Medline].
Green DP, O'Brien ET. Classification and management of carpal dislocations. Clin Orthop Relat Res. 1980 Jun. 55-72. [Medline].
Green DP, O'Brien ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg [Am]. 1978 May. 3(3):250-65. [Medline].
Green DP, Rowland SA. Fractures and dislocations in the hand. Rockwood CA Jr, Green DP, eds. Fractures and Dislocations. 2nd ed. Philadelphia, Pa: JB Lippincott; 1975. Vol 1:
Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984 Jan. 66(1):114-23. [Medline].
Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg [Am]. 1993 Sep. 18(5):768-79. [Medline].
Hindman BW, Kulik WJ, Lee G, et al. Occult fractures of the carpals and metacarpals: demonstration by CT. AJR Am J Roentgenol. 1989 Sep. 153(3):529-32. [Medline].
Jones WA, Ghorbal MS. Fractures of the trapezium. A report on three cases. J Hand Surg [Br]. 1985 Jun. 10(2):227-30. [Medline].
Jonsson K. Nonunion of a fractured scaphoid tubercle. J Hand Surg [Am]. 1990 Mar. 15(2):283-5. [Medline].
Jonsson K, Jonsson A, Sloth M, et al. CT of the wrist in suspected scaphoid fracture. Acta Radiol. 1992 Sep. 33(5):500-1. [Medline].
Kashiwagi D, Fukiwara A, Inoue T, et al. An experimental and clinical study on lunatomalacia (abstr). Orthop Trans. 1977. 1:7.
Kerluke L, McCabe SJ. Nonunion of the scaphoid: a critical analysis of recent natural history studies. J Hand Surg [Am]. 1993 Jan. 18(1):1-3. [Medline].
King AB. Kienböck’s disease (abstr). J Bone Joint Surg [Br]. 1964. 46:570.
Kozin SH, Berlet AC. Injuries to the perilunar carpus. Orthop Rev. 1992 Apr. 21(4):435-48. [Medline].
Linscheid RL. Kienböck's disease. J Hand Surg [Am]. 1985 Jan. 10(1):1-3. [Medline].
Mayfield JK. Mechanism of carpal injuries. Clin Orthop. 1980 Jun. (149):45-54. [Medline].
Mayfield JK. Patterns of injury to carpal ligaments. A spectrum. Clin Orthop. 1984 Jul-Aug. (187):36-42. [Medline].
Monahan PR, Galasko CS. The scapho-capitate fracture syndrome. A mechanism of injury. J Bone Joint Surg Br. 1972 Feb. 54(1):122-4. [Medline].
Norbeck DE Jr, Larson B, Blair SJ, Demos TC. Traumatic longitudinal disruption of the carpus. J Hand Surg [Am]. 1987 Jul. 12(4):509-14. [Medline].
Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg [Am]. 1982 Jul. 7(4):376-9. [Medline].
Parker RD, Berkowitz MS, Brahms MA, Bohl WR. Hook of the hamate fractures in athletes. Am J Sports Med. 1986 Nov-Dec. 14(6):517-23. [Medline].
Pisano SM, Peimer CA, Wheeler DR, Sherwin F. Scaphocapitate intercarpal arthrodesis. J Hand Surg [Am]. 1991 Mar. 16(2):328-33. [Medline].
Polivy KD, Millender LH, Newberg A, Phillips CA. Fractures of the hook of the hamate--a failure of clinical diagnosis. J Hand Surg [Am]. 1985 Jan. 10(1):101-4. [Medline].
Posner MA. Injuries to the hand and wrist in athletes. Orthop Clin North Am. 1977 Jul. 8(3):593-618. [Medline].
Primiano GA, Reef TC. Disruption of the proximal carpal arch of the hand. J Bone Joint Surg Am. 1974 Mar. 56(2):328-32. [Medline].
Roach JJ. Compound incomplete dislocation of the trapezium and compound fractured hamate hook. J Natl Med Assoc. 1978 Nov. 70(11):841-2. [Medline].
Saunier J, Chamay A. Volar perilunar dislocation of the wrist. Clin Orthop. 1981 Jun. (157):139-42. [Medline].
Siegert JJ, Frassica FJ, Amadio PC. Treatment of chronic perilunate dislocations. J Hand Surg [Am]. 1988 Mar. 13(2):206-12. [Medline].
Slade III JF, Merrell G. Percutaneous Scaphoid Fixation via a Dorsal Technique. Capo JT, Tan V. Atlas of minimally invasive hand and wrist surgery. first. New York: Infoma; 2008. 4: 89-94/12. [Full Text].
Teisen H, Hjarbaek J. Classification of fresh fractures of the lunate. J Hand Surg [Br]. 1988 Nov. 13(4):458-62. [Medline].
Teisen H, Hjarbaek J, Jensen EK. Follow-up investigation of fresh lunate bone fracture. Handchir Mikrochir Plast Chir. 1990 Jan. 22(1):20-2. [Medline].
Tiel-van Buul MM, van Beek EJ, Broekhuizen AH, et al. Radiography and scintigraphy of suspected scaphoid fracture. A long- term study in 160 patients. J Bone Joint Surg Br. 1993 Jan. 75(1):61-5. [Medline].
Torisu T. Fracture of the hook of the hamate by a golfswing. Clin Orthop. 1972 Mar-Apr. 83:91-4. [Medline].
Viegas SF, Amparo E. Magnetic resonance imaging in the assessment of revascularization in Kienbock's disease. A preliminary report. Orthop Rev. 1989 Dec. 18(12):1285-8. [Medline].
Watson-Jones R. Fractures and Joint Injuries. 4th ed. Baltimore, Md: Williams & Wilkins; 1955. Vol 2:
Weber ER, Chao EY. An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg [Am]. 1978 Mar. 3(2):142-8. [Medline].
Weseley MS, Barenfeld PA. Trans-scaphoid, transcapitate, transtriquetral, perilunate fracture- dislocation of the wrist. A case report. J Bone Joint Surg Am. 1972 Jul. 54(5):1073-8. [Medline].
White RE Jr, Omer GE Jr. Transient vascular compromise of the lunate after fracture-dislocation or dislocation of the carpus. J Hand Surg [Am]. 1984 Mar. 9(2):181-4. [Medline].
Young TB. An unusual combination of rare hand and wrist injuries. Injury. 1986 Nov. 17(6):415-6. [Medline].
Zimmerman NB, Mass DP. A pisiform fracture. Orthopedics. 1987 May. 10(5):817-20. [Medline].