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Perilunate Dislocations

2/23/2015

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HPI: Young male presents after a fall while skiing with right shoulder and wrist pain.

PE: Obvious deformity of the right wrist. No abrasions or ecchymosis. Full thumb abduction, able to flex at DIP and PIP joint of all 5 fingers, full abduction of all 4 palmar fingers, 5/5 strength to finger grip. Unable to range wrist, elbow or glenohumeral joint secondary to pain. Normal sensation to pinprick and two point discrimination of all five fingers. 2+ radial pulse with normal cap refill.  

Imaging:
Picture
Anatomy:
-    Normal wrist anatomy consists of two rows of bones:
      o   Proximal row: Scaphoid, lunate, triquetrum, pisiform
      o   Distal row: trapezium, trapezoid, capitate, hamate
-    Ligaments of the wrist:
      o   Interosseous ligaments run between the carpal bones and stabilizes proximal carpal bones.
      o   Intrinsic ligaments insert and originate among the carpal bones to internally stabilize them.
      o   Extrinsic ligaments connect radius and ulna to the carpus. 
Picture
Picture
How to make diagnosis:
  • Traumatic high energy mechanism when wrist is extended and ulnarly deviated. 
  • Can lead to either Perilunate dislocation where lunate stays in position and carpus dislocates or Lunate dislocates by being forced volar or dorsal while carpus remains aligned
  • Can see median nerve symptoms in ~25% of patients – most common with lunate dislocation into carpal tunnel.

Treatment:
o   Require emergent closed reduction and splinting into sugar tong splint. 
  • Place hand in finger traps at 90 degrees of elbow flexion with 5-10lbs of traction. 
  • Wrist traction with one hand and recreate deformity (volar or dorsal dislocation) and pressing with thumb of the non-extending hand onto dislocated carpal bone attempting to press it back into place. 
  • Reduces median nerve injury and minimizes cartilage damage. 
o   Require open reduction, ligament repair, fixation and possible carpal tunnel release. 
  • Even with reduction and operative treatment may still not return to full function with reduced grip strength and stiffness. 

Pearls:
  • Must obtain a lateral to evaluate for fracture as AP may not reveal obvious carpal misalignment. 
  • Diagnosis missed 25% of the time. 
  • Either lunate stays in position and carpus dislocates or carpus stays in position and lunate dislocates. 
  • Emergent reduction/splinting to reduce incidence of median nerve injury and cartilage damage. 
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Global EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • MATCH 2022
    • Alumni
  • STUDENTS/APPLICANTS
    • Prospective Visiting Students
    • UNC/Wake Forest Students
    • Healthcare Disparities Externship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction