Wrist Dislocation in Sports Medicine 

Updated: Sep 27, 2018
Author: Kadeer M Halimi, DO; Chief Editor: Sherwin SW Ho, MD 

Overview

Background

Wrist injuries are common among athletes. Emergency physicians and/or family practitioners frequently perform the initial evaluation of wrist injuries and determine the initial treatment. Recognizing wrist dislocations early and properly referring patients with wrist dislocations can prevent complications, including prolonged pain and discomfort, surgery, and lost time from sports participation.

See the image below.

Perilunate dislocation. The lunate is in a normal Perilunate dislocation. The lunate is in a normal anatomic position with respect to the radius. The rest of the carpal bones are displaced dorsally.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Wrist Injury.

Epidemiology

Frequency

United States

In a study by Larsen and Lauritsen, as many as 2.5% of all emergency department visits were made by patients with wrist injuries.[1] A small number of those patients present with wrist dislocations. Subluxations and dislocations account for 10% of carpal injuries, with perilunate dislocation being the most common type of dislocation.[2]

Kerr and colleagues concluded that dislocation/separation injuries represent a relatively small proportion of all injuries sustained by high school athletes in the United States; however, the severity of these injuries indicates a need for enhanced injury prevention efforts.[3]

Functional Anatomy

The wrist joint is composed of distal radial and ulnar surfaces, 8 carpal bones, and the proximal metacarpal bones. The distal carpal row consists of the following bones: hamate, capitate, trapezoid, and trapezium. The proximal row consists of the following bones: scaphoid, lunate, triquetrum, and pisiform.

The carpal bones are held together by a complex set of ligaments, including the interosseous, volar, and dorsal ligaments and a triangular fibrocartilage complex (TFC). The dorsal ligaments are weaker than the volar ligaments, making dorsal dislocation more common.[2]

Sport-Specific Biomechanics

The mechanism of injury for a wrist dislocation is usually a fall on an outstretched hand (ie, FOOSH injury) that results in a hyperextension type of injury to the wrist. High energy is a common characteristic feature in these injuries.[4] The distal row of carpal bones is commonly displaced dorsal to the proximal row. This displacement occurs as a result of a scaphoid fracture or a scapholunate dislocation, and if the force is severe, a perilunate dislocation occurs.[5] Trans-scaphoid perilunate fracture-dislocation is slightly more common than perilunate dislocation.

Different posttraumatic deformity patterns can cause the lunate to lose its linear relationship with the capitate and to tilt dorsally or volarly, resulting in a collapse deformity. The most common collapse deformity is caused by the lunate dorsiflexing on the radius. This is compensated by the capitate flexing volarly. This deformity is also known as the dorsiflexed intercalated segment instability (DISI) pattern. DISI normally occurs in unrecognized scaphoid subluxations or scaphoid fractures. The opposite type of deformity is known as the volar intercalated segment instability (VISI) pattern. Although VISI can be seen in healthy patients with lax ligaments, posttraumatically, it is a result of the lunate flexing volarly on the radius as the capitate tilts dorsally.[6, 7] VISI also is a sign of midcarpal instability or lunotriquetral injury.

Mayfield and coworkers have classified wrist dislocation as follows (see the image below)[8] :

Progressive perilunar instability pattern as repor Progressive perilunar instability pattern as reported by Mayfield et al. Stage I involves scaphoid instability; stage II, scaphoid and capitate instability; stage III, scaphoid, capitate, and triquetrum instability; and stage IV, lunate dislocation.

See the list below:

  • Stage I – Scapholunate dislocation resulting from a tear in the scapholunate interosseous ligament and radiolunate ligament

  • Stage II – Lunate-capitate subluxation resulting from injury to the capitolunate joint

  • Stage III – Lunate-triquetral dislocation resulting from injury to the triquetrolunate interosseous ligament

  • Stage IV – Lunate dislocation resulting from dorsal radiolunate ligament injury

 

Presentation

History

The typical history for a wrist dislocation is one of an athlete who has fallen on an outstretched hand to break a fall or who has mistimed a landing, as in gymnastics.[9] The patient usually presents with vague wrist pain and the sensation of clicks or clunks. Patients may also complain of decreased grip strength with minimal pain. Localized pain is sometimes reported.

Physical

See the list below:

  • Localized tenderness, especially over the dorsoradial aspect of the wrist, may be revealed. The tenderness is worse with dorsiflexion.

  • Crepitus or a click with movement and apprehension with radial or ulnar deviation are signals of instability.

  • A positive ballottement test result is suggestive of wrist dislocation. To perform the ballottement test, the physician grasps the lunate between the index finger and the thumb of one hand and the triquetrum with the other hand. Volar and dorsal (forward and backward) laxity, crepitus, and pain yield a positive test finding.[9]

  • To perform a volar and dorsal shift test, the physician stabilizes the patient's forearm with one hand and volarly and dorsally translates the patient's wrist with the other. Volar subluxation at the midcarpal joint is normal, whereas dorsal subluxation indicates scapholunate instability.[5]

  • Tenderness in the anatomic snuffbox can indicate a carpal etiology of pain, although it more reliably suggests a scaphoid fracture.

  • A decrease in grip strength may also be seen in patients with wrist injury.

  • Median nerve symptoms may be present as a result of volar displacement of carpal bones into the carpal tunnel.[10]

  • Lunate dislocation can cause volar swelling on the median nerve. This swelling causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. Patients with lunate dislocations often prefer to hold their fingers in partial flexion because they have pain on active and passive extension.[6]

  • Perilunate dislocation can appear with considerable swelling. A miniature "dinner-fork" deformity is often present, which is produced by dorsal displacement of the distal fracture fragments. The edge of the capitate may be palpable if the swelling is not profound.

  • Scapholunate dislocation usually presents with a minimal amount of swelling, and pain is localized over the dorsal scapholunate region. Pain is increased by dorsiflexion. Tenderness over the scaphoid tuberosity may also be present.[6]

Causes

See the list below:

  • Repeated stress on carpal ligaments renders them more prone to injury, especially in athletes.

  • The carpal bones serve as a link between the hands and the upper body; a great deal of force is transmitted through them.

  • Sports with increased force vectors (height and speed), such as adult in-line skaters and football players,[11] commonly experience such injuries. Other examples of risks are falls from a height; these occur in athletes such as gymnasts, among others.

  • Although high energy is the most common cause of injury, some reports describe low-energy trauma as the cause of carpal dislocation.[12]

 

DDx

 

Workup

Laboratory Studies

Laboratory studies typically are not necessary in the evaluation of wrist dislocations if the history includes acute injury.

Imaging Studies

Plain radiographs are helpful.

  • Obtain posteroanterior (PA) and lateral radiographs in all patients who present with a history of acute wrist trauma.

  • PA and lateral radiographs should also be obtained with 10- to 15-lb traction on the upper arm.

  • The normal PA view should show 2 rows of carpal bones in a normal anatomic position with uniform joint spaces of no more than 1-2 mm. No overlap should be seen between the carpal bones or between the distal ulna and the radius.

  • On a normal lateral radiograph, the 4 C s should be easily visualized. The 4 C s are the convexity of the distal radius, the convexity and the concavity of the lunate, and the convexity of the capitate (see the image below).

    On a normal lateral radiograph, the 4 Cs should be On a normal lateral radiograph, the 4 Cs should be easily visualized. The 4 Cs are the convexity of the distal radius, the convexity and the concavity of the lunate, and the convexity of the capitate. A longitudinal axis aligns the radius, the lunate, the capitate, and the third metacarpal bone. The scapholunate angle is normally 30-60 degrees.
  • A longitudinal axis aligns the radius, the lunate, the capitate, and the third metacarpal bone. The scapholunate angle is normally 30-60° as depicted below.[5]

    On a normal lateral radiograph, the 4 Cs should be On a normal lateral radiograph, the 4 Cs should be easily visualized. The 4 Cs are the convexity of the distal radius, the convexity and the concavity of the lunate, and the convexity of the capitate. A longitudinal axis aligns the radius, the lunate, the capitate, and the third metacarpal bone. The scapholunate angle is normally 30-60 degrees.
  • One order of obtaining radiographs is as follows:

    1. Anteroposterior (AP) and/or PA views, with the lateral view as a screening test

    2. Navicular series

    3. Possibly, a clenched-fist view with radial and ulnar deviation. (This forces the capitate head into the scapholunate joint and widens it if laxity is present.)

    4. Possibly, traction views

    5. Possibly, comparison views, especially in patients with nonfused growth plates

  • Radiographic findings for the various types of dislocation are as follows:

    1. Lunate dislocation: On the usual PA image, the lunate has a trapezoidal shape that changes with flexion and extension. In this type of dislocation, the lunate is displaced volarly and rotated with the capitate. The rest of the carpal bones are in a normal anatomic position in relation to the radius. On the lateral radiograph, the lunate has the classic "spilled-teacup" sign from the disruption of the 4 C s. On the PA image, the lunate has a triangular or pie shape as shown below.

      Lunate dislocation. Posteroanterior projection of Lunate dislocation. Posteroanterior projection of the wrist showing the pie shape of the lunate.
    2. Perilunate dislocation: The lunate is in a normal anatomic position with respect to the radius, and the rest of the carpal bones are displaced dorsally. On the PA radiograph, crowding is evident between the proximal and distal carpal bones as depicted in the images below.

      Perilunate dislocation. On the posteroanterior rad Perilunate dislocation. On the posteroanterior radiograph, crowding is evident between the proximal and distal carpal bones.
      Perilunate dislocation. The lunate is in a normal Perilunate dislocation. The lunate is in a normal anatomic position with respect to the radius. The rest of the carpal bones are displaced dorsally.
    3. Scapholunate dislocation (rotary subluxation of the scaphoid)

      • On a PA radiograph, the scapholunate space is usually greater than 4 mm, a scenario also known as the Terry-Thomas sign, named after the British comic with frontal dental diastema.[13]

      • On the clenched-fist and PA views with the wrist in ulnar deviation, the scapholunate gap is increased. The scaphoid rotates to a more transverse position when the ligaments between the lunate and scaphoid are interrupted, increasing the scapholunate angle to greater than 60°.[2] This rotation causes the scaphoid to be viewed end-on, producing the classic signet-ring sign (see the image below).

        Scapholunate dislocation. The scapholunate space i Scapholunate dislocation. The scapholunate space is usually greater than 4 mm, a scenario also known as the Terry-Thomas sign. Rotation of the scaphoid causes the scaphoid to be viewed end-on, producing the classic signet-ring sign.

Magnetic resonance imaging (MRI) can be considered for patients with wrist pain or instability but who have normal radiographic findings. MRI may be less important in patients with a ligament injury; in these patients, arthrography may be considered.

 

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The rehabilitation of wrist injuries can be divided into 5 phases, as follows[6] :

  • 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.

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.[6]

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 al[14] ; 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.[14]

A study to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation concluded that the use of this treatment is associated with satisfactory midterm functional and radiographic outcomes.[15]

Consultations

Promptly consult an orthopedic specialist.

Other Treatment

Most complications can be avoided with prompt diagnosis and treatment.[16, 17]

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

Medication Summary

Pain control is essential in providing quality patient care to those with wrist dislocations. Pain control ensures patient comfort and aids physical therapy regimens.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

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.

Flurbiprofen (Ansaid)

May inhibit the cyclooxygenase enzyme, which, in turn, inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

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.

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.

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.

Analgesics

Class Summary

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.

Codeine/acetaminophen (Tylenol-3)

Indicated for the treatment of mild to moderate pain.

Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab, Lorcet-HD)

Drug combination indicated for moderate to severe pain.

 

Follow-up

Return to Play

Athletes with wrist injuries, including wrist dislocations, are advised not to return to play until full recovery has been achieved.

Complications

See the list below:

  • A missed or late diagnosis may lead to complications.

  • Carpal tunnel syndrome may result.

  • Malunion or nonunion may occur. This is a misnomer because no fracture occurs; therefore, malunion or nonunion is not technically possible. Stiffness may be present. On rare occasions, late instability or apposition of the carpal bones may occur.

  • Degenerative joint disease is possible.

Prevention

Wrist injuries can be prevented by implementing proper technique; maintaining good strength; maintaining good flexibility; and, if the sport permits, using wrist guards.

Prognosis

If the diagnosis is established early (< 3 mo) and if the proper treatment is administered, the prognosis of wrist dislocations is excellent.

Education

Athletes should be educated about how to recognize wrist injuries. Seeking early medical attention for wrist injuries is important and should be emphasized to athletes. Proper technique, flexibility, and strengthening should also be emphasized.