Traumatic Wrist Injury - Football

Abstract

HISTORY A 17 year-old right-handed male football player suffered a left wrist injury four days prior to presentation. After a tackle an opponent fell on his hand, forcing the wrist into hyperflexion with axial loading. He had immediate pain and swelling and was unable to continue play. The pain was sharp and located over the volar and dorsal aspects of the wrist. There was no immediate numbness or tingling and sideline exam revealed no neurovascular or tendinous deficiencies of the hand or wrist. He was placed in a volar splint by his trainer and was referred for treatment. He had some improvement in pain and swelling during the interval since injury. He has had no prior injury to the affected wrist and has no significant current or prior medical problems. PHYSICAL EXAMINATION There is ecchymosis, swelling, erythema, and warmth over the dorsal and volar aspects of the left wrist without angulation deformity of the forearm, wrist, or hand. Range of motion is diminished due to pain and swelling. There is no palpable click with passive motion. Tenderness is most intense over the dorsal wrist and vaguely localized to the distal radius and proximal mid-carpal bones. Sensation and pulses are intact. There is no snuffbox tenderness. Tinel's sign at the carpal tunnel is negative. The distal radius and ulna are minimally tender. The skin of the hand, wrist, and arm is grossly intact without obvious trauma. DIFFERENTIAL DIAGNOSIS Carpal Fracture Ligamentous Wrist Injury Carpal Dislocation (Scapholunate Dissociation, Lunate or Perilunate Dislocation) Triangular Fibrocartilage Complex Injury Distal Radius Fracture Cellulitis TEST AND RESULTS A three-view radiograph of the left wrist reveals a volar perilunate dislocation. FINAL WORKING DIAGNOSIS Perilunate Dislocation TREATMENT AND OUTCOMES Open reduction and percutaneous pinning with short arm cast Pain control as needed Post-operative follow-up radiographs at 2,4, and 8 weeks Removal of percutaneous pins at 8 weeks and removal of cast at 12 weeks Progressive, multimodal wrist rehabilitation followed by return to play as tolerated