Wrist Pain in a Football Player

Abstract

HISTORY: A 21 year old college wide receiver fell on his outstretched dominant right hand. He had immediate pain and "shifting" in his right wrist. Initially there was no swelling, but tenderness at the wrist without bony instability. He was taped and continued in the next play, but again had the same complaint. A perilunate dislocation was suspected, so traction in extension with direct pressure volarly was applied. A clunk was felt, but reduction remained uncertain, so a splint was placed and sent to the ED. PHYSICAL EXAM: Swelling along the dorsal aspect of the right hand with point tenderness along both sides. Limited active volar and dorsiflexion secondary to pain. A palpable clunk with positioning into dorsiflexion. Prominence volarly just above the wrist crease. Normal capillary refill with palpable pulses. Neurovascularly intact, normal sensation to light touch along the median nerve distribution. Decreased two-point discrimination. DIFFERENTIAL DIAGNOSIS: Lunate/Perilunate dislocation Scapholunate dissociation Scaphoid Fracture Distal Radius Fracture TESTS AND RESULTS: Radiographs, three views: Lunate dislocation volarly and medially indicating underlying ligamentous injury to the scapholunate and lunate-triquetral ligaments. No definite scaphoid fracture identified; rotational subluxation of the scaphoid, possible scapholunate ligament disruption. All other carpal bones maintained their normal relationships. FINAL WORKING DIAGNOSIS: Perilunate Dislocation TREATMENT AND OUTCOMES: An orthopedic resident attempted a closed reduction with traction under conscious sedation, but was unable to maintain a reduction. The patient developed numbness in the median nerve distribution so he was sent for urgent open reduction and internal fixation of the perilunate dislocation. Surgical Treatment: ORIF of right lunate dislocation via volar and dorsal approach Scapholunate, lunotriquetral and lunoscaphoid ligament repair with percutaneous pins along the lunotriquetral articulations and a cancellous screw within the scapholunate articulation ORIF of lunotriquetral interval Right carpal tunnel release Post-Op: Placed in a short arm volar wrist splint ROM exercises Pins left intact for 6 weeks Return in 3 months for removal of the scapholunate cannulated screw