Case 29: Wrist Injury

A 32-year-old male presents to the ED with a wrist injury after falling from his skateboard. He has no other injuries or complaints. His x-ray is shown below. How may injuries can you find?

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Answer: 4 injuries

Ulnar styloid fracture, intra-articular distal radius fracture, mid scaphoid fracture, and finally, a lunate dislocation.

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Selected Wrist Injuries from

“QUICK ESSENTIALS: EMERGENCY MEDICINE“

Lunate: Be suspicious with any intra-articular wrist fracture, ESPECIALLY if midline.
Dislocation common & missed in 25%. Normal alignment: Capitate sits in cup of the lunate.
Rx: Ortho consult and reduction of dislocation, usually in the OR. Check median nerve.

Radius: Carpals OK? Median nerve injury? EPL tendon rupture? Age < 11 look for Torus fx
Comps: Median or ulnar nerve, extensor pollicus longus tendon, compartment , stiff, RSD.
Scapholunate dislocation or scaphoid fx is common in association with a radial styloid fx.
Splint: Sugar tong with wrist in 15d flexion and 15d ulnar deviation. Then cast x 6wks.  Reduce: Needs reduction if: 5mm loss of height, dorsal tilt >10d (nl is negative15d).

Scaphoid: Mechanism: FOOSH, Missed punch.
Exam: Can’t extend/supinate vs resistance, snuffbox tenderness, axial thumb pressure > pain
Rx: Displaced: OR. Nondisplaced/occult: long arm thumb spica x 6wk. Or same day MRI

Scapholunate Disassociation: OFTEN MISSED & very serious: x-ray space > 3mm=”Terry Thomas sign”

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