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A painful and deformed wrist

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Q1: What does the radiograph show (see p 183)?

The radiograph is an anterior posterior view of the left wrist, showing fracture of the radial styloid, transverse middle third fracture of the scaphoid, and radiocarpal dislocation with ulna displacement.

Q2: What are the possible complications associated with this injury?

Complications could be early or late. Early complications are neurological injuries, with symptom and signs of median nerve compression, and injury to the ulna nerve. Vascular injury is another early complication. Compartment syndrome of the hand could occur with the hallmark of diagnosis being pain on passive stretching of the involving intrinsic muscles and intrinsic paralysis. Late complications are non-union of the scaphoid fracture, post-traumatic osteoarthritis of the radiocarpal joint, and post-traumatic carpal instability.

Learning points

  • Radiocarpal dislocation is a rare injury of the wrist.

  • The patient should be examined for neurovascular deficit.

  • This injury requires urgent reduction and stabilisation.

  • In post-traumatic carpal instability, a contralateral radiograph is useful in excluding ligaments laxity.

Q3: How will you treat this injury?

Initial assessment of the patient should be carried out, and the hand should be examined for neurovascular deficit, and other associated injuries, followed by splinting before radiography.

Manipulation should be done under general anaesthesia as an emergency to reduce the dislocation and the radial styloid fracture and to fix it with Kirschner wires. Considering that this is a high energy injury the carpal tunnel will be decompressed.

It may be necessary to fix the scaphoid fracture internally if there is instability or displacement after reducing and fixing the radial styloid fracture.

Below elbow plaster should be applied for six weeks, then a futura splint for another two weeks. This should be followed by physiotherapy, weekly radiographs for the first three weeks, and another at six weeks after the injury. Kirschner wire should be removed after three weeks.

Discussion

Radiocarpal dislocation is a rare injury to the wrist and the incidence with or without fracture of the styloid process or intercarpal subluxation is about 0.2% of all dislocations.1

The mechanism of this injury is not really known but Rosado has tried to explain the mechanism as injury resulting from increasing violence.2

1. Contusion and sprain with no bone or ligament damage.

2. Radiocarpal dislocation with torn radiocarpal ligament but intact intercarpal ligaments, the hamate impinges on the anterior radial lip and prevents spontaneous reduction of the carpus.

3. Anterior lunate dislocation with torn radiocarpal and intercarpal ligament.

4. Displaced fracture dislocation with multiple fractures and ligament damage.

Reduction is usually easy but stability has to be maintained either by external or internal skeletal fixation.

If stability without fixation is attempted in dorsal dislocation then it should be immobilised in extension,3 and palmar dislocation should be immobilised with above elbow cast in slight flexed position for four weeks then gentle mobilisation.2 This injury is quite unstable and regular review with radiographs is necessary to detect early loss of reduction.

Dislocation without fracture could be stabilised with Kirschner wire passed from the radial styloid into the carpus and plaster.4 If the radial styloid is fractured it should be fixed with Kirschner wire and plaster applied for six weeks.

If there is an associated scaphoid fracture, internal fixation may be necessary if it is displaced or unstable.

Post-traumatic carpal instability could be a complication of radiocarpal dislocation. While this instability pattern may occasionally be seen with traumatic laxity of the palmar radiocarpal ligament, it is frequently seen bilaterally as a congenital condition, possibly a sequel of ligament laxity.5,6

Radiography of the contralateral wrist will often be helpful in differentiating those patients with post-traumatic instability from ligament laxity.

Final diagnosis

Radiocarpal dislocation of the wrist.

References

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