eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Wrist: Treatment & Medication
Updated: Oct 20, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Prehospital care includes assessment for other injuries that may accompany the wrist injury.
- If no other injuries are identified, splint the wrist.
- Patients may be transported in their private vehicles, but the prehospital provider must emphasize the potential seriousness of the injury.
- Under no circumstances should a prehospital provider attempt a reduction of a suspected wrist dislocation. It may be a distal radius fracture, which requires significant care to reduce.
Emergency Department Care
- Patients with wrist injuries have an entire spectrum of possible injuries that represent potential disability.
- Although no specific fracture or dislocation may be seen on x-ray, carpal instability still may be present.
- Therefore, splint with plaster even if no injury is found on x-ray.
- Carefully splint with AP splints to the fingers until a hand specialist can evaluate the injury.
Consultations
- Patients in whom a wrist dislocation has been identified require referral to a hand specialist who is either an orthopedic or plastic surgeon, depending on local custom.
- Wrist dislocations may be reduced by emergency physicians, but only after consulting with the hand specialist.
- The patient's own primary care physician may follow up, but it is important to stress to the primary care physician the need for hand specialist referral.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit these patients.
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderately severe pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may decrease toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not use in children (<16 y) who have flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Nonsteroidal anti-inflammatory agents (NSAIDs)
These agents are used most commonly for the relief of mild to moderately severe pain. Although the effects of NSAIDs tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for treatment of mild to moderately severe pain if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT carefully and instruct patients to watch for signs of bleeding)
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small body size, elderly persons, and those with renal or liver disease. Doses higher than 75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe patient.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 14 years: 0.1–1 mg/kg PO q6-8h
>14 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT carefully and instruct patients to watch for signs of bleeding)
Flurbiprofen (Ansaid)
Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.
Adult
500 mg initial dose followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose; not to exceed 10 mg/kg/d
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
More on Dislocation, Wrist |
| Overview: Dislocation, Wrist |
| Differential Diagnoses & Workup: Dislocation, Wrist |
 Treatment & Medication: Dislocation, Wrist |
| Follow-up: Dislocation, Wrist |
| Multimedia: Dislocation, Wrist |
| References |
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References
Carter PR. Fractures and dislocations of the wrist. In: Common Hand Injuries and Infections. 1983:123-141.
Hayden SR. A case of peri-lunate dislocation. J Emerg Med. Mar-Apr 1995;13(2):241. [Medline].
Mital RC, Beeson M. The Wrist and Forearm. Emergency Radiology. 1999;47- 75.
Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the ED: lunate and perilunate injuries. Am J Emerg Med. Mar 2001;19(2):157-62. [Medline].
Rockwood CA, Jr, Green DP, Bucholz RW. Fractures and dislocations of the wrist. In: 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. May 1996;13(3):213-6. [Medline].
Further Reading
Keywords
wrist dislocation, carpal dislocations, lunate dislocations, perilunate dislocations, scaphoid fractures, wrist injuries, carpal instability, radiocarpal instability
