- Email: [email protected]
Wrist Pain after a Fall
IMAGES IN EMERGENCY MEDICINE Cindy C. Bitter, MD, MPH; Wesley P. Eilbert, MD 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.08.001
Figure 1. Posterior-anterior view of the left wrist showing disruption of the normally smooth arc of the radiocarpal row, as well as an abnormal triangular appearance of the lunate (arrow).
Figure 2. Lateral view of the left wrist showing volar dislocation of the lunate (arrow), the “spilled teacup” sign.
[Ann Emerg Med. 2017;69:e5-e6.] A 26-year-old man presented to the emergency department (ED), complaining of left wrist pain. He reported falling onto his outstretched left hand while ascending stairs the night before while intoxicated. On examination, he had decreased range of motion of the wrist because of pain. Standard posterior-anterior (Figure 1) and lateral (Figure 2) radiographs of the wrist were obtained.
For the diagnosis and teaching points, see page e6. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 69, no. 1 : January 2017
Annals of Emergency Medicine e5
Bitter & Eilbert
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e5)
DIAGNOSIS: Lunate dislocation. Lunate dislocation represents the end stage of injuries causing carpal instability, including scapholunate dissociation and perilunate dislocation. These injuries usually occur in young men and are the result of wrist hyperextension, often caused by a fall from a height, a motor vehicle crash, or contact sports.1 These injuries are frequently missed on examination in the ED, resulting in chronic dislocations with significantly poorer outcomes.1 Lunate dislocation is diagnosed with 2-view radiographs of the wrist. On the posterior-anterior view, the normally smooth arc consisting of the radiocarpal row is disrupted by the volar rotation of the lunate. The lunate loses its typically quadrangular appearance on the posterior-anterior view and assumes a more triangular appearance, also known as the “piece of pie” sign.2 The rotation of the lunate is also visible on the lateral view, where it looks like a teacup tipped in the volar direction that has spilled its contents into the palm, the “spilled teacup” sign.3 Closed reduction may be attempted for lunate dislocations, although open reduction with internal fixation is considered the standard of care.1,4 Author affiliations: From the Department of Emergency Medicine, University of Illinois College of Medicine, Chicago, IL. REFERENCES 1. Grabow RJ, Catalano L. Carpal dislocations. Hand Clin. 2006;22:485-500. 2. Scalcione LR, Gimber LH, Ho AM, et al. Spectrum of carpal dislocations and fracture-dislocations: imaging and management. AJR Am J Roentgenol. 2014;203:541-550. 3. Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls in the ED: lunate and perilunate injuries. Am J Emerg Med. 2001;19:157-162. 4. Kremer T, Wendt M, Riedel K, et al. Open reduction for perilunate injuries—clinical outcome and patient satisfaction. J Hand Surg Am. 2010;35:1599-1606.
e6 Annals of Emergency Medicine
Volume 69, no. 1 : January 2017
Figure 1. Posterior-anterior view of the left wrist showing disruption of the normally smooth arc of the radiocarpal row, as well as an abnormal triangular appearance of the lunate (arrow).
Figure 2. Lateral view of the left wrist showing volar dislocation of the lunate (arrow), the “spilled teacup” sign.
[Ann Emerg Med. 2017;69:e5-e6.] A 26-year-old man presented to the emergency department (ED), complaining of left wrist pain. He reported falling onto his outstretched left hand while ascending stairs the night before while intoxicated. On examination, he had decreased range of motion of the wrist because of pain. Standard posterior-anterior (Figure 1) and lateral (Figure 2) radiographs of the wrist were obtained.
For the diagnosis and teaching points, see page e6. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 69, no. 1 : January 2017
Annals of Emergency Medicine e5
Bitter & Eilbert
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e5)
DIAGNOSIS: Lunate dislocation. Lunate dislocation represents the end stage of injuries causing carpal instability, including scapholunate dissociation and perilunate dislocation. These injuries usually occur in young men and are the result of wrist hyperextension, often caused by a fall from a height, a motor vehicle crash, or contact sports.1 These injuries are frequently missed on examination in the ED, resulting in chronic dislocations with significantly poorer outcomes.1 Lunate dislocation is diagnosed with 2-view radiographs of the wrist. On the posterior-anterior view, the normally smooth arc consisting of the radiocarpal row is disrupted by the volar rotation of the lunate. The lunate loses its typically quadrangular appearance on the posterior-anterior view and assumes a more triangular appearance, also known as the “piece of pie” sign.2 The rotation of the lunate is also visible on the lateral view, where it looks like a teacup tipped in the volar direction that has spilled its contents into the palm, the “spilled teacup” sign.3 Closed reduction may be attempted for lunate dislocations, although open reduction with internal fixation is considered the standard of care.1,4 Author affiliations: From the Department of Emergency Medicine, University of Illinois College of Medicine, Chicago, IL. REFERENCES 1. Grabow RJ, Catalano L. Carpal dislocations. Hand Clin. 2006;22:485-500. 2. Scalcione LR, Gimber LH, Ho AM, et al. Spectrum of carpal dislocations and fracture-dislocations: imaging and management. AJR Am J Roentgenol. 2014;203:541-550. 3. Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls in the ED: lunate and perilunate injuries. Am J Emerg Med. 2001;19:157-162. 4. Kremer T, Wendt M, Riedel K, et al. Open reduction for perilunate injuries—clinical outcome and patient satisfaction. J Hand Surg Am. 2010;35:1599-1606.
e6 Annals of Emergency Medicine
Volume 69, no. 1 : January 2017