Wrist Dislocation

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Wrist Dislocation
Wrist Factures

Wrist Dislocation

Synonyms and related keywords: lunate dislocation, perilunate dislocation, scapholunate dislocation, hyperextension injury of the wrist, carpal injury

  AUTHOR INFORMATION Section 1 of 11    Click here to go to the next section in this topic
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Author: Kadeer M Halimi, DO, Department of Emergency Medicine, Texas A&M University Health Sciences Center

Coauthor(s): Thomas Russell Jones, MD, FAAEM, Assistant Professor of Emergency Medicine, Texas A&M University Health Sciences Center; Consulting Staff, Department of Emergency Medicine, Scott and White Memorial Hospital; Derek K Lichota, MD, Assistant Professor, Department of Surgery, Texas A&M University College of Medicine; Senior Staff, Department of Orthopedics, Division of Sports Medicine, Scott and White Memorial Hospital

 

Kadeer M Halimi, DO, is a member of the following medical societies: American College of Emergency Physicians, and Emergency Medicine Residents' Association

 

Editor(s): Craig C Young, MD, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Associate Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical College of Wisconsin; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Russell White, MD, Clinical Associate Professor, Department of Family Medicine, University of South Florida College of Medicine; Director, Center for Sports Medicine, Associate Program Director, Bayfront Medical Center; Jon Whitehurst, MD, Fellow, Sports Medicine, Southern California Orthopedic Institute; and Wylie D Lowery, Jr, MD, Associate Professor, Department of Orthopedic Surgery, George Washington University
  INTRODUCTION Section 2 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Background: Wrist injuries are common among athletes. Emergency physicians or family practitioners frequently perform the initial evaluation of wrist injuries and determine the initial treatment. Recognizing wrist dislocations early and properly referring patients with wrist dislocations can prevent complications, including prolonged pain and discomfort, surgery, and lost time from sports participation.

 

Frequency:
bulletIn the US: In a study by Larsen, as many as 2.5% of all ED visits were made by patients with wrist injuries. A small number of those patients present with wrist dislocations. Subluxations and dislocations account for 10% of carpal injuries, with perilunate dislocation being the most common type of dislocation (Schwartz, 2000).

Functional Anatomy: The wrist joint is composed of distal radial and ulnar surfaces, 8 carpal bones, and the proximal metacarpal bones. The distal carpal row consists of the following bones: hamate, capitate, trapezoid, and trapezium. The proximal row consists of the following bones: scaphoid, lunate, triquetrum, and pisiform. The carpal bones are held together by a complex set of ligaments, including the interosseous, volar, and dorsal ligaments and a triangular fibrocartilage complex (TFC). The dorsal ligaments are weaker than the volar ligaments, making dorsal dislocation more common (Schwartz, 2000).

 

Sport Specific Biomechanics: The mechanism of injury usually is a fall on an outstretched hand resulting in a hyperextension type of injury to the wrist. The distal row of carpal bones commonly is displaced dorsal to the proximal row. This displacement occurs as a result of a scaphoid fracture or a scapholunate dislocation, and if the force is severe, a perilunate dislocation occurs (Browner, 1998). Trans-scaphoid perilunate fracture-dislocation is slightly more common than perilunate dislocation.

Different posttraumatic deformity patterns can cause the lunate to lose its linear relationship with the capitate and to tilt dorsally or volarly, resulting in a collapse deformity. The most common collapse deformity is caused by the lunate dorsiflexing on the radius. This is compensated by the capitate flexing volarly. This deformity is also known as the dorsiflexed intercalated segment instability pattern (DISI). DISI normally occurs in unrecognized scaphoid subluxations or scaphoid fractures. The opposite type of deformity is known as volar intercalated segment instability pattern (VISI). Although VISI can be seen in healthy patients with lax ligaments, posttraumatically, it is a result of the lunate flexing volarly on the radius as the capitate tilts dorsally (Lichtman, 1997; Linscheid, 1972). VISI also is a sign of midcarpal instability or lunotriquetral injury.

Mayfield and coworkers have classified wrist dislocation as follows (see Image 5):

 
bulletStage I - Scapholunate dislocation resulting from a tear in the scapholunate interosseous ligament and radiolunate ligament

 

bulletStage II - Lunate-capitate subluxation resulting from injury to the capitolunate joint

 

bulletStage III - Lunate-triquetral dislocation resulting from injury to the triquetrolunate interosseous ligament

 

bulletStage IV - Lunate dislocation resulting from dorsal radiolunate ligament injury

  CLINICAL Section 3 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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History: The typical history is one of an athlete who has fallen on an outstretched hand to break a fall or who has mistimed a landing, as in gymnastics (Ried, 1992). The patient usually presents with vague wrist pain and the sensation of clicks or clunks. Patients may also complain of decreased grip strength with minimal pain. Localized pain is sometimes reported.

Physical:
bulletLocalized tenderness, especially over the dorsoradial aspect of the wrist, may be revealed. The tenderness is worse with dorsiflexion.
bulletCrepitus or a click with movement and apprehension with radial or ulnar deviation are signals of instability.
bulletA positive Ballottement test result is suggestive of wrist dislocation. To perform the Ballottement test, the physician grasps the lunate between the index finger and the thumb of one hand and the triquetrum with the other hand. Volar and dorsal (forward and backward) laxity, crepitus, and pain yield a positive test finding (Ried, 1992).
bulletTo perform a volar and dorsal shift test, the physician stabilizes the patient’s forearm with one hand and volarly and dorsally translates the patient’s wrist with the other. Volar subluxation at the midcarpal joint is normal, whereas dorsal subluxation indicates scapholunate instability (Browner, 1998).
bulletTenderness in the anatomic snuffbox can indicate a carpal etiology of pain, though it more reliably suggests a scaphoid fracture.
bulletA decrease in grip strength may also be seen in patients with wrist injury.
bulletMedian nerve symptoms may be present as a result of volar displacement of carpal bones into the carpal tunnel (Meldon, 1995).
bulletLunate dislocation can cause volar swelling on the median nerve. This swelling causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. Patients with lunate dislocations often prefer to hold their fingers in partial flexion because they have pain on active and passive extension (Lichtman, 1997).
bulletPerilunate dislocation can appear with considerable swelling. A miniature dinner-fork deformity often is present. The edge of the capitate may be palpable if the swelling is not profound.
bulletScapholunate dislocation usually presents with a minimal amount of swelling, and pain is localized over the dorsal scapholunate region. Pain is increased by dorsiflexion. Tenderness over the scaphoid tuberosity may also be present (Lichtman, 1997).

Causes:
bulletRepeated stress on carpal ligaments renders them more prone to injury, especially in athletes.
bulletThe carpal bones serve as a link between the hands and the upper body; a great deal of force is transmitted through them.
bulletSports with increased force vectors (height and speed), such as adult in-line skaters, commonly experience such injuries. Other examples of risks are falls from height; these occur in athletes such as gymnasts, among others.
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Carpal Bone Injuries
Hamate Fracture
Hand Dislocation
Metacarpal Fracture and Dislocation


Other Problems to be Considered:

Distal radius fracture
Distal radial-ulnar joint injury or subluxation
TFC tear
Scaphoid fracture
Scaphoid nonunion
DISI/VISI
de Quervain tenosynovitis
Septic wrist
Gout


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Lab Studies:
bulletLaboratory studies typically are not necessary if the history includes acute injury.

Imaging Studies:
bulletPlain radiographs are helpful.
bulletObtain posteroanterior (PA) and lateral radiographs in all patients who present with a history of acute wrist trauma.

bulletPA and lateral radiographs should also be obtained with 10- to 15-lb traction on the upper arm.
bulletThe normal PA view should show 2 rows of carpal bones in a normal anatomic position with uniform joint spaces of no more that 1-2 mm. No overlap should be seen between the carpal bones or between the distal ulna and the radius.
bulletOn a normal lateral radiograph, the 4 Cs should be easily visualized. The 4 Cs are convexity of the distal radius, the convexity and the concavity of the lunate, and the convexity of the capitate.
bulletA longitudinal axis aligns the radius, the lunate, the capitate, and the third metacarpal bone. The scapholunate angle is normally 30-60° (see Image 6) (Browner, 1998).
bulletOne order of obtaining radiographs is as follows:

 

  1. Anteroposterior (AP) and/or PA views, with the lateral view as a screening test

     

  2. Navicular series

     

  3. Possibly, a clenched-fist view with radial and ulnar deviation. (This forces the capitate head into the scapholunate joint and widens it if laxity is present.)

     

  4. Possibly, traction views

     

  5. Possibly, comparison views, especially in patients with nonfused growth plates
bulletRadiographic findings for the various types of dislocation are as follows:

 
bulletLunate dislocation: On the usual PA image, the lunate has a trapezoidal shape that changes with flexion and extension. In this type of dislocation, the lunate is displaced volarly and rotated with the capitate. The rest of the carpal bones are in a normal anatomic position in relation to the radius. On the lateral radiograph, the lunate has the classic spilled-teacup sign from the disruption of the 4 Cs. On the PA image, the lunate has a triangular or pie shape (see Image 1).

 

bulletPerilunate dislocation: The lunate is in a normal anatomic position with respect to the radius, and the rest of the carpal bones are displaced dorsally. On the PA radiograph, crowding is evident between the proximal and distal carpal bones (see Images 2-3).

 

bulletScapholunate dislocation (rotary subluxation of the scaphoid): On a PA radiograph, the scapholunate space is usually greater than 4 mm, a scenario also known as the Terry-Thomas sign, named after the British comic with frontal dental diastema (Frankel, 1977). On the clinched-fist and PA views with the wrist in ulnar deviation, the scapholunate gap is increased. The scaphoid rotates to a more transverse position when the ligaments between the lunate and scaphoid are interrupted, increasing the scapholunate angle to greater than 60° (Schwartz, 2000). This rotation causes the scaphoid to be viewed end-on, producing the classic signet-ring sign (see Image 4).

bulletMRI can be considered for patients with wrist pain or instability but normal radiographic findings. MRI may be less important in patients with a ligament injury; in these patients, arthrography may be considered.
  TREATMENT Section 6 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Acute Phase:

bullet

Rehabilitation Program:

bulletPhysical Therapy: The rehabilitation of wrist injuries can be divided into 5 phases, as follows (Lichtman, 1997):

 
bulletPhase I: Control inflammation and edema by using rest, ice, compression, and elevation (RICE).

 

bulletPhase II: Restore the normal soft-tissue environment by using modalities such as scar massage, whirlpool therapy, and elastomer application.

 

bulletPhase III: Increase the range of motion (ROM).

 

bulletPhase IV: Increase strength.

 

bulletPhase V: Work on hardening and/or conditioning.

Proper pain control and anti-inflammatory medication are the cornerstone of all phases of rehabilitation.

 

bulletOccupational Therapy: Occupational therapy can be an essential part of rehabilitation, depending on the expertise of the therapist and the motivation of the patient.

 

bullet

Medical Issues/Complications: An expected outcome of the surgery is some loss of motion. The goal of surgery and rehabilitation is to minimize the loss of motion in the athlete.

 

 

bulletSurgical Intervention: Closed reduction of the dislocation can be attempted after a complete neurovascular examination is performed and proper radiographs are obtained. The patient should be adequately anesthetized by means of an axillary block or general anesthesia. Closed reduction may be difficult if not impossible; the patient should be advised that open reduction may be needed.

For a perilunate dislocation, initial dorsiflexion is followed by gradual volar flexion. Pronation is then used to reduce the capitate back into the lunate (Lichtman, 1997).

For a lunate dislocation, the steps of perilunate reduction are followed by the operators stabilizing the lunate with their thumb as the capitate is brought into palmar flexion. The initial stages of reduction reproduce perilunate dislocation before final reduction.

With a scapholunate dislocation, the wrist is dorsiflexed and radially deviated.

Once closed reduction is attempted, PA and lateral images are obtained to confirm adequate reduction. The carpal bones are then pinned by using Kirschner wire because closed reduction is rarely effective by itself. If closed reduction is not successful, the surgeon must attempt open reduction. The wrist is then placed in a cast for 4-6 weeks.

 

bullet

Consultations: Promptly consult an orthopedic specialist.

 

bullet

Other Treatment (injection, manipulation, etc.): Most complications can be avoided with prompt diagnosis and treatment.

 

Recovery phase:

bullet

Rehabilitation Program:

bulletPhysical Therapy: The type of physical therapy depends on the needs of the individual patient. Therapeutic modalities may be continued throughout the recovery phase, in addition to ROM and strengthening activities as needed.

 

bullet

Other Treatment (injection, manipulation, etc.):

 

Maintenance Phase:

bullet

Rehabilitation Program:

bulletPhysical Therapy: The goal of the maintenance phase is to regain full strength and ROM of the wrist to enable the patient to complete his or her functional daily activities and to gradually return to sports participation or work. The patient independently functions in a work hardening or sport-specific training program during this phase to continue strengthening to the affected upper extremity.

 


  MEDICATION Section 7 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Pain control is essential in providing quality patient care to those with wrist dislocations. Pain control ensures patient comfort and aids physical therapy regimens.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs) -- These agents are most commonly used for the relief of mild to moderate pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually the drug of choice (DOC) for initial therapy. Other NSAIDs may also be used.

COX-2 inhibitors may be considered in patients with adverse effects to the NSAIDs discussed here.
Drug Name
Ibuprofen (Ibuprin, Advil, Motrin) -- DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose 400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose 20-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate; not to exceed 2.4 g/d
Contraindications Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Drug Name
Flurbiprofen (Ansaid) -- May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult Dose 200-300 mg/d PO divided bid/qid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion are at risk of acute renal failure; leukopenia occurs rarely, is transient, and usually resolves during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug
Drug Name
Ketoprofen (Oruvail, Orudis, Actron) -- For relief of mild to moderate pain and inflammation. Small initial doses are indicated in small or elderly patients and in those with renal or liver disease.
Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult Dose 25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose 3 months to 12 years: 0.1-1 mg/kg PO q6-8h
12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Drug Name
Naproxen (Naprelan, Aleve, Anaprox, Naprosyn) -- For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult Dose 250-500 mg PO bid; may increase to 1.5 g/d for limited periods
Pediatric Dose <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions Coadministration with aspirin increases risk serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT with concurrent anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually resolves during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug
Drug Name
Celecoxib (Celebrex) -- Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult Dose 200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease plasma celecoxib concentrations
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Pregnancy category D in third trimester; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing patient to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Drug Name
Rofecoxib (Vioxx) -- Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of rofecoxib for each patient.
The suspension dose, 12.5 mg/5 mL or 25 mg/5 mL, may be substituted for 12.5- or 25-mg tablets, respectively.
Adult Dose 50 mg PO qd; subsequent doses are 50 mg qd prn; use for >5 d in management of pain not established; tablets may be taken with or without food
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with fluconazole may increase rofecoxib plasma concentrations because of inhibition of rofecoxib metabolism; coadministration of rofecoxib with rifampin may decrease plasma rofecoxib concentrations
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Pregnancy category D in third trimester; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing patient to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Drug Name
Valdecoxib (Bextra) -- Second generation COX-2 inhibitor that offers a very rapid onset and prolonged efficacy. Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, valdecoxib does not inhibit COX-1 isoenzyme, decreasing GI toxicity.
Adult Dose 20 mg PO bid prn
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with fluconazole may cause increase in valdecoxib plasma concentrations; coadministration of valdecoxib with rifampin may decrease valdecoxib plasma concentrations
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Pregnancy category D in third trimester; abdominal pain, nausea, and diarrhea may occur; caution in compromised cardiac function, hypertension, conditions predisposing patient to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Drug Category: Analgesics -- Pain control is essential to providing the quality of care for patients with wrist dislocations. Pain control ensures the patient’s comfort and aids in physical therapy regimens. Many analgesics have sedating properties that benefit patients with fractures. Hydrocodone and oxycodone preparations are generally more effective and better tolerated than other narcotic-acetaminophen combinations, such as those containing codeine.
Drug Name
Acetaminophen with codeine (Tylenol-3) -- Indicated for the treatment of mild to moderate pain.
Adult Dose 30-60 mg/dose PO q4-6h based on codeine content or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric Dose 0.5-1 mg/kg/dose PO q4-6h based on codeine content; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Contraindications Documented hypersensitivity
Interactions Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIS, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics; rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen possible with various dose levels in those with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative acetaminophen doses exceeding recommended maximum dose
Drug Name
Hydrocodone and acetaminophen (Vicodin, Norcet, Lortab, Lorcet-HD) -- Drug combination indicated for moderate to severe pain.
Adult Dose 1-2 tab or cap PO q4-6h prn pain
Pediatric Dose <12 years: 10-15 mg/kg acetaminophen per dose PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Contraindications Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Interactions Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
  FOLLOW-UP Section 8 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Return to Play: Athletes with wrist injuries are advised not to return to play until full recovery has been achieved.

 

Complications:
bulletA missed or late diagnosis may lead to complications.

 

bulletCarpal tunnel syndrome may result.

 

bulletMalunion or nonunion may occur. This is a misnomer because no fracture occurs; therefore, malunion or nonunion is not technically possible. Stiffness may be present. On rare occasions, late instability or apposition of the carpal bones may occur.

 

bulletDegenerative joint disease is possible.

 

Prevention: Wrist injuries can be prevented by implementing proper technique; maintaining good strength; maintaining good flexibility; and, if the sport permits, using wrist guards.

 

Prognosis: If the diagnosis is established early (<3 mo) and if the proper treatment is administered, the prognosis is excellent.

 

Education: Athletes should be educated about how to recognize wrist injuries. Seeking early medical attention for wrist injuries is important and should be emphasized to athletes. Proper technique, flexibility, and strengthening should also be emphasized.

  MISCELLANEOUS Section 9 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Medical/Legal Pitfalls:
bulletFailure to diagnose wrist dislocations
bulletFailure to perform a complete neurological examination, with resultant median nerve damage
bulletAvascular necrosis of the lunate (Kienböck disease)
  PICTURES Section 10 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Caption: Picture 1. Wrist dislocation. Lunate dislocation. Posteroanterior projection of the wrist showing the pie shape of the lunate.
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Caption: Picture 2. Wrist dislocation. Perilunate dislocation. On the posteroanterior radiograph, crowding is evident between the proximal and distal carpal bones.
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Caption: Picture 3. Wrist dislocation. Perilunate dislocation. The lunate is in a normal anatomic position with respect to the radius. The rest of the carpal bones are displaced dorsally.
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Caption: Picture 4. Wrist dislocation. Scapholunate dislocation. The scapholunate space usually is greater than 4 mm, a scenario also known as the Terry-Thomas sign. Rotation of the scaphoid causes the scaphoid to be viewed end-on, producing the classic signet-ring sign.
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Caption: Picture 5. Wrist dislocation. Progressive perilunar instability pattern reported by Mayfield et al. Stage I involves scaphoid instability; stage II, scaphoid and capitate instability; stage III, scaphoid, capitate, and triquetrum instability; and stage IV, lunate dislocation.
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Caption: Picture 6. Wrist dislocation. On a normal lateral radiograph, the 4 Cs should be easily visualized. The 4 Cs are the convexity of the distal radius, the convexity and the concavity of the lunate, and the convexity of the capitate. A longitudinal axis aligns the radius, the lunate, the capitate, and the third metacarpal bone. The scapholunate angle is normally 30-60°.
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  BIBLIOGRAPHY Section 11 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page
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bulletBrowner BD: Skeletal Trauma. Philadelphia: WB Saunders Co; 1998: 1359-81.
bulletFrankel VH: The Terry-Thomas sign. Clin Orthop 1977 Nov-Dec; (129): 321-2[Medline].
bulletLarsen CF, Lauritsen J: Epidemiology of acute wrist trauma. Int J Epidemiol 1993 Oct; 22(5): 911-6[Medline].
bulletLichtman DM, Alexander AH: The Wrist and Its Disorders. Philadelphia: WB Saunders Co; 1997.
bulletLinscheid RL, Dobyns JH, Beabout JW: Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972 Dec; 54(8): 1612-32[Medline].
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