Unusual Wrist Injury Presentation in a Football Player

Abstract

HISTORY: 17-year-old high school football player presented for sideline evaluation with right wrist pain. The injury occurred when he was tackled and had his wrist twisted and caught under another player. His coach kept him in the game and after one more play, his teammates called out for medical attention. He had diffuse swelling and pain along the ulnar aspect of the distal forearm and wrist. He was placed in a volar splint and sent to the emergency department where x-ray imaging of the wrist was read by radiologist as normal. The athlete followed up in clinic four days later. He continued to have pain, restricted range of motion, and decreased strength. Review of systems was otherwise normal. Past medical history was unremarkable. PHYSICAL EXAMINATION: Wrist examination showed moderate diffuse swelling but no ecchymosis or deformity. He had tenderness along the ulnar aspect of the distal wrist. There was no tenderness at the anatomic snuff box or scaphoid tubercle. Range of motion was limited in all directions, especially in supination. Strength was 4+/5 in all motions except for supination, which was 3+/5. Special tests including triangular-fibrocartilage complex grind, Watson’s, and Finkelstein’s were equivocal. Sensation to light touch was intact. Radial pulses were equally palpable bilaterally. DIFFERENTIAL DIAGNOSIS: 1) Ulnar styloid or hook of hamate fracture. 2) Distal radioulnar joint injury. 3) TFCC injury. 4) Scapholunate or lunotriquetral dissociation. TESTS AND RESULTS: Initial x-rays at ED were read as normal. Repeat x-rays were concerning for volar ulna dislocation. MRI without contrast showed volar dislocation of the ulna. FINAL/WORKING DIAGNOSIS: Radioulnar joint dislocation with volar displacement of ulna. TREATMENT AND OUTCOMES: 1. Orthopedic hand surgery referral. Given the length of time since initial injury, closed reduction was performed under general anesthesia. 2. Long arm cast with the forearm in supination position for 4 weeks. Repeat x-rays demonstrated maintenance of reduction. After cast removal, the patient returned to football with a removal wrist splint.