eMedicine Specialties > Sports Medicine > Wrist and Hand
Wrist Dislocation: Treatment & Medication
Updated: Aug 21, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The rehabilitation of wrist injuries can be divided into 5 phases, as follows5 :
- Phase I: Control inflammation and edema by using rest, ice, compression, and elevation (RICE).
- Phase II: Restore the normal soft-tissue environment by using modalities such as scar massage, whirlpool therapy, and elastomer application.
- Phase III: Increase range of motion (ROM).
- Phase IV: Increase strength.
- Phase V: Work on hardening and/or conditioning.
Proper pain control and anti-inflammatory medication are the cornerstone of all phases of rehabilitation.
Related eMedicine topics:
Skin, Tissue Expansion
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Occupational Therapy
Occupational therapy can be an essential part of rehabilitation, depending on the expertise of the therapist and the motivation of the patient.
Medical Issues/Complications
An expected outcome of surgical reduction of a wrist dislocation is some loss of motion (see Treatment, Acute Phase, Surgical Intervention). The goal of surgery and rehabilitation is to minimize the loss of motion in the athlete (see Maintenance Phase, Rehabilitation Program).
Surgical Intervention
Closed reduction of the wrist dislocation can be attempted after a complete neurovascular examination is performed and proper radiographs are obtained. The patient should be adequately anesthetized by means of an axillary block or general anesthesia. Closed reduction may be difficult if not impossible; the patient should be advised that open reduction may be needed.
For a perilunate dislocation, initial dorsiflexion is followed by gradual volar flexion. Pronation is then used to reduce the capitate back into the lunate.5
For a lunate dislocation, the steps of perilunate reduction are followed by the operators stabilizing the lunate with their thumb as the capitate is brought into palmar flexion. The initial stages of reduction reproduce the perilunate dislocation before the final reduction.
With a scapholunate dislocation, the wrist is dorsiflexed and radially deviated.
Once closed reduction is attempted, PA and lateral radiographic images are obtained to confirm adequate reduction. The carpal bones are then pinned with Kirschner (K) wires because closed reduction is rarely effective by itself. If closed reduction is not successful, the surgeon must attempt open reduction. The wrist is then placed in a cast for 4-6 weeks.
Early diagnosis and anatomic reduction was noted to be essential in a report by Martinage et al13 ; they can also provide satisfactory functional results. Thus, emergency surgical treatment is required. The investigators preferred a dorsal approach and did not perform primary closed reductions.13
Related eMedicine topics:
Anesthesia, General
Hand, Anesthesia: Blocks
Local Anesthesia and Regional Nerve Block Anesthesia
Related Medscape topics:
Resource Center Vascular Surgery
Specialty Site Neurology & Neurosurgery
Specialty Site Orthopaedics
Specialty Site Radiology
Specialty Site Surgery
Consultations
Promptly consult an orthopedic specialist.
Other Treatment
Most complications can be avoided with prompt diagnosis and treatment.
Recovery Phase
Rehabilitation Program
Physical Therapy
The type of physical therapy depends on the needs of the individual patient. Therapeutic modalities may be continued throughout the recovery phase, in addition to ROM and strengthening activities as needed.
Maintenance Phase
Rehabilitation Program
Physical Therapy
The goal of the maintenance phase is for the patient to regain full strength and ROM of the wrist to enable him or her to complete functional daily activities and to gradually return to sports participation or work. The patient independently functions in a work-hardening or sport-specific training program during this phase to continue strengthening to the affected upper extremity.
Medication
Pain control is essential in providing quality patient care to those with wrist dislocations. Pain control ensures patient comfort and aids physical therapy regimens.
Related eMedicine topics:
Cyclooxygenase Deficiency
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs are most commonly used for the relief of mild to moderate pain. The effects of these agents in the treatment of pain tend to be patient specific, yet ibuprofen is usually the drug of choice (DOC) for initial therapy. Other NSAIDs may also be used.
Cyclooxygenase-2 (COX-2) inhibitors may be considered in patients with adverse effects to the NSAIDs discussed here.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
20-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate; not to exceed 2.4 g/d
Coadministration with aspirin increases the risk of serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or 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 patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Flurbiprofen (Ansaid)
May inhibit the cyclooxygenase enzyme, which, in turn, inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Coadministration with aspirin increases the risk of serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
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 are at risk of acute renal failure; leukopenia occurs rarely, is transient, and usually resolves during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Ketoprofen (Oruvail, Orudis, Actron)
For the relief of mild to moderate pain and inflammation. Small initial doses are indicated in small or elderly patients and in those with renal or liver disease.
Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
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 patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprelan, Aleve, Anaprox, Naprosyn)
For the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
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 resolves during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease plasma celecoxib concentrations.
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
May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, conditions predisposing patient to fluid retention; caution in the presence of severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Analgesics
Pain control is essential to providing the quality of care for patients with wrist dislocations. Pain control ensures the patient's comfort and aids in physical therapy regimens. Many analgesics have sedating properties that benefit patients with fractures. Hydrocodone and oxycodone preparations are generally more effective and better tolerated than other narcotic-acetaminophen combinations, such as those containing codeine.
Acetaminophen with codeine (Tylenol-3)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose PO q4-6h based on the codeine content or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose PO q4-6h based on the codeine content; 10-15 mg/kg/dose based on the acetaminophen content; not to exceed 2.6 g/d of acetaminophen
The toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics; rifampin can reduce the analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
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 who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is possible with various dose levels in those with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative acetaminophen doses that exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab, Lorcet-HD)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg acetaminophen/dose 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
Coadministration with phenothiazines may decrease the analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high-altitude cerebral edema or 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
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
More on Wrist Dislocation |
| Overview: Wrist Dislocation |
| Differential Diagnoses & Workup: Wrist Dislocation |
 Treatment & Medication: Wrist Dislocation |
| Follow-up: Wrist Dislocation |
| Multimedia: Wrist Dislocation |
| References |
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References
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Further Reading
Keywords
wrist dislocation, wrist pain, dislocated wrist, dislocation of wrist, lunate dislocation, perilunate dislocation, scapholunate dislocation, hyperextension injury of the wrist, carpal bone injuries, carpal injury, ballottement test, volar tilt test, dorsal tilt test
