Continuing Education Activity

Carpal instability represents about 7 to 10 percent of all reported carpal bone injuries. The majority of carpal instability is centered around the lunate, which is located in the middle of the wrist. Injuries progress sequentially depending on the severity, from scapholunate instability to lunate dislocation. Perilunate dislocations and lunate dislocations are high-energy wrist injuries involving falls from high elevations, motor vehicle collisions, or athletic injuries. These injuries are not uncommon and can result in a multitude of complications. Despite the great force typically required for these injuries, up to 25 percent of these injuries are missed clinically and radiographically. Perilunate and lunate dislocations associated with fractures are twice as prevalent as those without fracture. This activity reviews the causes, diagnosis, and presentation of wrist dislocations and highlights the role of the interprofessional team in the management of affected patients.

Objectives:

• Identify the causes of wrist dislocation.
• Describe the presentation of a wrist dislocation.
• Outline the treatment options for wrist dislocation.
• Explain the importance of enhancing care coordination among interprofessional team members to improve outcomes for patients with wrist dislocations.

Introduction

Wrist dislocations can occur at the radiocarpal joint, the midcarpal joint, the distal radioulnar joint or may represent a combination of these injuries in severe trauma. Carpal instability in the form of lunate and perilunate dislocations are uncommon injuries but can be frequently missed. Distal radioulnar joint dislocations are most commonly associated with distal third radius fractures. This injury complex is called a Galeazzi fracture-dislocation. Radiocarpal dislocations are rare injuries accounting for 0.2% to 2.7% of wrist injuries[1][2][1].

Carpal instability represents about 7% to 10% of all reported injuries to the carpal bones. The carpal bones are held together by intrinsic ligaments and extrinsic ligaments connect the carpus to the radio- and ulnocarpal joints. Disruption of these ligaments results in wrist instability. Carpal instability can be classified as carpal instability dissociative, carpal instability non-dissociative (CIND), maladaptive carpal instability, and carpal instability complex. Carpal instability dissociative occurs within a carpal row. A common example is a scapholunate injury resulting in a dorsal intercalated segment instability (DISI) complex. In contrast, CIND is less common and occurs due to instability between carpal rows.

The majority of carpal instability is centered around the lunate, given its location in the middle of the wrist. Injuries progress sequentially depending on the severity, from scapholunate instability to lunate dislocation. Perilunate dislocations and lunate dislocations are high-energy wrist injuries involving falls from height, motor vehicle collisions, or athletic injuries. While not common, these injuries can result in a multitude of complications. Despite the great force typically required, up to 25% of these injuries are missed clinically and radiographically. Perilunate and lunate dislocations with an associated fracture are twice as prevalent as those without fracture.[3] 

Etiology

Anatomy

Extrinsic ligaments stabilize the carpus to the radius and ulna proximally and to the metacarpals distally. The intrinsic ligaments connect the carpal bones to each other. The volar extrinsic ligaments are stronger compared the dorsal extrinsics. The short radiolunate ligament is a volar ligament connecting the lunate to the distal radius. 

The Distal Radioulnar Joint

The distal radioulnar joint is primarily stabilized by the deep dorsal and volar radioulnar ligaments within the fovea of the triangular fibrocartilage complex (TFCC). Disruption of these ligaments in the context of a TFCC tear and/or a Galeazzi fracture-dislocation can result in chronic DRUJ instability.

The lunate is a crescent-shaped carpal bone that articulates with the distal radius proximally, and the capitate distally. It is located between the scaphoid radially and the triquetrum ulnarly in the proximal row of carpal bones. The scapholunate, capitolunate, and lunotriquetral intrinsic ligaments all stabilize the lunates position in the wrist. There are no muscular of tendinous insertions onto the lunate. The proximal carpal row is relatively unstable when compared to the distal forearm and distal carpal row, resulting in a higher propensity for injury.

Carpal instability is frequently the result of trauma. These injuries frequently result in a fall on an outstretched hand, during which an axial force is directed on the carpals with the wrist in hyperextension. Injury progresses around the lunate in a clockwise semicircular pattern depending on the severity of the injury. The Mayfield classification involves 4 stages describing the sequence of ligamentous and carpal disruptions caused by wrist hyperextension, ulnar deviation, and intercarpal supination reliably reproduced on cadavers. The scapholunate ligament is disrupted in the first stage, resulting in instability between the scaphoid and lunate. In the second stage, there is a disruption of the capitolunate articulation resulting in possible dislocation of the capitate. In the third stage, there is disruption of the lunotriquetral articulation resulting in the lunate dislocating dorsally. In the fourth and final stage, there is a failure of the dorsal radiocarpal ligament, and this results in volar dislocation of the lunate into the carpal tunnel.[4]

Epidemiology

Wrist fracture-dislocations are common. Isolated dislocations are uncommon.

History and Physical

History

The patient typically presents with a history of trauma to the wrist. The mechanism of injury is often a fall on a hyperextended wrist in ulnar deviation. These injuries can also occur in polytrauma patients and there may be other distracting injuries. Pain may be reported localized in the middle of the wrist, although pain can be reported to be more widely depending on the severity of the injury.

These injuries may be associated with neurovascular compromise. It is important to elicit a history of paraesthesia (tingling, pins, and needles) in the hand to help determine the presence of an acute carpal tunnel syndrome.

Patients presenting with upper limb injuries should always be asked about their hand dominance, occupation, hobbies, medical co-morbidities, and smoking status.

Physical Examination

Patients should be assessed according to Advanced Trauma Life Support principles as these injuries are often due to high energy trauma. On a normal physical examination, the lunate can be palpated distal to the radius and in line with the middle finger. With flexion of the wrist, the lunate becomes more prominent.

Because of the wide range of ligamentous injuries, clinical findings vary significantly. Physical findings associated with scapholunate ligament injury can be subtle. The scapholunate ligament is the most commonly injured ligament of the wrist. Patients may report localized pain and swelling to the radial side of the wrist. They may also report a snapping or clicking sensation with wrist deviation. Joint instability should be assessed using the scaphoid shift test. Patients may also report pain with hyperextension.

In perilunate and lunate dislocations, patients present with generalized pain and swelling to the wrist. Pain is typically worsened with wrist range of motion. Unlike many other joint dislocations, gross deformity is not typically present in carpal dislocations. There may be a possible fullness of the carpal tunnel appreciated. Median nerve injury is common if the lunate dislocates volarly into the carpal tunnel.

Acute carpal tunnel syndrome in the setting of trauma is a surgical emergency and it should be diagnosed as soon as possible. This is a clinical diagnosis. A thorough neurological assessment of the hand can help confirm its presence. The median and anterior interosseous nerve functions must be assessed and documented clearly in the patient's medical notes.

Median nerve sensory function: Compromise of the nerve in the carpal tunnel can result in reduced sensation in the thumb, index, and middle fingers, and radial half of the ring finger.

Median nerve motor function: Decreased strength of thumb flexion, opposition, and abduction may also be seen with median nerve injuries. Thumb abduction should be assessed with palpation of the thenar eminence and the abductor pollicis brevis muscle as it contracts. This identifies its action and differentiates it from abductor pollicis longus.

Anterior interosseous nerve (AIN): No deficit should be expected in the AIN because it arises from the median nerve in the forearm. The patient may still be able to make an 'OK' sign.

Palmar cutaneous branch of the median nerve: Patients would be expected to have sensation in the palm over the thenar eminence. The palmar cutaneous branch of the median nerve arises approximately 5cm proximal to the carpal tunnel.

If the wrist dislocation has occurred in association with other proximal injuries in the same limb,  the AIN and palmar cutaneous nerves may also be deficient.

Acute carpal tunnel syndrome has been reported in up to 46% of dislocations.[5]

Evaluation

Plain Radiographs

An x-ray series of the wrist including anteroposterior (AP), lateral, and oblique views are necessary to identify a wrist dislocation. Although carpal instability injuries are frequently missed, the diagnosis should be able to be made using these plain films.

Gilula's lines

Gilula described three lines on a AP of the wrist outlining:

1. The proximal aspect of the proximal carpal row (scaphoid, lunate and triquetrum),

2. The distal aspect of the proximal carpal row

3. The proximal aspect of the capitate and hamate

A disruption in Gilula's lines on the AP view should prompt the clinician to have a high index of suspicion for a perilunate injury.

Intervals between Carpal Bones

In normal wrist radiographs, the distance between the ulnar border of the scaphoid and the radial border of the lunate is less than 3 millimeters. In scapholunate dissociation, posteroanterior radiographs may demonstrate a widened scapholunate space, commonly referred to as the "Terry Thomas" sign. If the injury is not seen on routine wrist films, the abnormal gap seen may be reproduced by obtaining a grip compression view. When scapholunate ligament instability occurs, the scaphoid rotates to a more transverse position. This results in an increased scapholunate angle to greater than 60 degrees. The scaphoid becomes shortened and develops a dense ring-like image around its distal edge, referred to as the "signet-ring sign." 

For perilunate dislocations, the lateral view will reveal the lunate in its correct position aligned with the distal radius, but the capitate will be dorsally dislocated. A perilunate dislocation may obscure associated carpal bone fractures of the scaphoid and lunate.

In the case of lunate dislocations, the lateral x-ray shows the lunate displaced volarly but, the distal radius, carpus, and metacarpals are otherwise in normal alignment. This is frequently referred to as the “spilled teacup” sign. On the posteroanterior view, a lunate dislocation will have a characteristic triangular appearance due to the rotation of the lunate in a volar direction. This is referred to as the “piece of pie sign."

Treatment / Management

Patients with suspected scapholunate dissociation should be placed in a thumb spica, radial gutter, or short arm volar splint. Referral to an orthopedist or hand surgeon is necessary, as closed reduction with percutaneous pinning or open reduction is required for treatment. The patient is placed in a short-arm cast postoperatively, and k-wires are removed in 8 to 10 weeks. Patients are unable to perform heavy lifting using the wrist for 4 to 6 months post-injury.[6]

Immediate reduction is essential when a lunate or perilunate dislocation is present, to relieve pressure on the median nerve and prevent further cartilage damage. These injuries require immediate orthopedic or hand surgery consultation for reduction and stabilization and frequently require arthroscopically guided reduction. Closed reduction is achieved using finger traps, with elbow at ninety-degrees of flexion. The hand is held in traction, while dorsal dislocations are reduced by wrist extension, traction, and finally wrist flexion. A sugar tong splint is then applied and followed up with surgical repair. There is frequently injury to all perilunate ligaments, requiring surgical stabilization. Without intervention, progressive instability may occur. A short arm cast is placed post-operatively for at least 6 weeks duration.[7][8][9]

Differential Diagnosis

The evaluation of patients with acute wrist pain is broad. Patients with acute carpal instability frequently have associated carpal bone fracture. Scaphoid fractures are the most commonly fractured carpal bone. Other fractures, including the most common fracture of the wrist, the distal radius fracture, should be the clinician's differential diagnosis. Wrist sprains, frequently involving only the extrinsic ligaments, can be diagnosed after more serious injuries have been carefully excluded.

Staging

Mayfield Classification of Perilunate Injuries

Prognosis

Prognosis depends on a range of factors. Provided that a patient's wrist dislocation is identified and treated in a timely manner, then one can expect a reasonable outcome. In the setting of recurrent instability and abnormal carpal biomechanics, there is a higher risk of developing post-traumatic arthritis. For patients with chronic scapholunate dissociation, they may go on to develop scapholunate advanced collapse. 

Complications

Scapholunate dissociation is the most common cause of degenerative arthritis of the wrist. Without early recognition and treatment, there may be a proximal migration of the capitate between the scaphoid and lunate. This results in a degenerative disease known as SLAC wrist (scapholunate advanced collapse). 

Wrist osteoarthritis is a common long-term complication after perilunate and lunate injuries. Other complications include chronic carpal instability, rupture of tendons, delayed union, nonunion, malunion, median nerve compression, complex regional pain syndrome, and avascular necrosis of the lunate.

Deterrence and Patient Education

Wrist dislocation encompasses a range of injuries. Wrist dislocations associated with fractures may be treated in the acute setting with surgery. Ligament injuries do not always heal and can result in long-term instability. This may increase of developing arthritis in future. If there is ongoing pain, giving way, clunking or locking of the wrist, medical review is recommended.

Enhancing Healthcare Team Outcomes

The diagnosis of a wrist dislocation and management is incredibly complex. The majority of these patients first present to the emergency department or to the primary care provider/nurse practitioner. Lunate and perilunate dislocations are often missed due to the lack of experience of the practitioners who may be reviewing them.[10] Because there are many critical structures within the wrist that may be damaged, it is important to refer these patients to a hand surgeon or orthopedic surgeon without delay. Most wrist dislocations require immediate reduction to relieve pressure on the median nerve and prevent damage to the cartilage. While some dislocations may be managed by closed reduction, others may require ORIF. [11][12]

The outlook for patients with wrist dislocations is guarded. Chronic pain, restricted range of motion and osteoarthritis are common chronic complaints. In some cases, the injury can be disabling.[13]