A Painful Wrist After A Fall On Outstretched Hand
Asım KALKAN,1 Ozkan KOSE2
Department of Emergency Medicine, Recep Tayyip Erdogan University Faculty of Medicine, Rize;
Department of Orthopedics And Traumatology, Antalya Training and Research Hospital, Antalya
A 24-year-old otherwise healthy man was admitted to our emergency department after a fall from height
(~2m) on his left outstretched hand. The patient presented with complaints of left wrist pain and weakness
of grip. On physical examination, there was swelling and tenderness over the dorsal aspect of the wrist (Figure 1a). The range of wrist movements was painful and restricted. Neurovascular examination was normal.
Standard antero-posterior and lateral wrist radiographs were taken (Figure 1b, 1c).
Figure 1. (a) Clinical appearance of the patient’s wrist. (b) Lateral wrist radiograph. (c) Anteroposterior wrist radiograph.
Submitted (Geliş tarihi): 13.09.2012 Accepted (Kabul tarihi): 15.10.2012
Published online (Online baskı): 18.07.2013
Correspondence (İletişim): Dr. Asım Kalkan. Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı,
53100 Rize, Turkey.
e-mail (e-posta): [email protected]
Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2013;13
doi: 10.5505/1304.7361.2013.15045
DIAGNOSIS: Trans-Scaphoid Perilunate
Trans-scaphoid perilunate fracture-dislocations (a)
(TSPLFD) are relatively uncommon but potentially
serious wrist injuries. Due to subtle clinical and radiographic findings, approximately 25% cases are
missed at initial admission in emergency departments.[1] In case delayed diagnosis, complex surgical procedures are needed for reconstruction and
considerable long term morbidity including radiocarpal arthritis, carpal instability, or median nerve
damage may occur.[2] Therefore, it is important to
recognize these rare injuries at initial admission to
prevent possible loss of wrist function.
Figure 2. (a) The first arc is a smooth curve outlining the
Timely identification of these injuries necessitates
detailed physical examination, proper radiographic
interpretation and high index of suspicion. Clinically,
there is usually dinner fork deformity, however, gross
swelling may masquerade this typical finding. The
range of normal wrist motion is restricted and there
may be median nerve compression findings such as
hypoesthesia and tingling in the first finger through
third. Physical examination findings are often not
very specific, and radiographic examination should
be performed.
Although standard antero-posterior and lateral wrist
radiographs are usually adequate for a correct diagnosis, a systematic evaluation of radiographs is essential. On a normal AP wrist radiograph, there are
three imaginary carpal arcs joining the surfaces of
the carpal bones, so called the ‘Arcs of Gilula’ (Figure
2a). Arcs of Gilula show the anatomic alignment of
the carpal bones, and extend parallel to each other.
Intersection of these lines with each other, and
loss of symmetry and parallelism in the joint spaces
should alert us for a possible trans-scaphoid perilunate fracture-dislocation (Figure 2b). A lateral wrist
radiograph provides more valuable information
about the extent of injury. On a normal lateral wrist
radiograph, the radius, lunate, capitate and the third
metacarpal bone should be on the same line (Figure 3a). In case of transscaphoid perilunate fracture
dislocation, this normal alignment is disrupted, and
Türkiye Acil Tıp Dergisi - Tr J Emerg Med
proximal convexities of the scaphoid, lunate and triquetrum.
The second arc traces the distal concave surfaces of the same
bones, and the third arc follows the main proximal curvatures
of the capitate and hamate (red lines) (b) The intersection of
arcs of Gilula and scaphoid fracture (black asterix) is seen.
Figure 3. (a) Normal lateral wrist radiograph showing the
proper alignment of radius, lunate, capitates and metacarpal
shaft. (b) Disruption of the alignment in transscaphoid perilunate fracture-dislocation. (c) The sagittal reconstruction
of wrist CT of the patient showing the dorsal dislocation of
the lunate loses its relation with capitate (Figure 3b).
Computerized Tomography (CT), particularly the
sagittal reconstruction, clearly delineates this abnormal alignment (Figure 3c).[4]
doi: 10.5505/1304.7361.2013.15045
Emergency physicians should be familiar with the 2. Komurcu M, Kürklü M, Ozturan KE, Mahirogullari M,
Basbozkurt M. Early and delayed treatment of dorsal
normal and abnormal radiographic anatomy of the
transscaphoid perilunate fracture-dislocations. J Orwrist in order to reduce the risk of misdiagnosis of
thop Trauma 2008;22:535-40.
this decapacitating injury.
3. Najarian R, Nourbakhsh A, Capo J, Tan V. Perilunate injuries. Hand (N Y) 2011;6:1-7.
1. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC,
Cooney WP, Stalder J. Perilunate dislocations and frac- 4. Stanbury SJ, Elfar JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg
ture-dislocations: a multicenter study. J Hand Surg
Am 1993;18:768-79.
Türkiye Acil Tıp Dergisi - Tr J Emerg Med
doi: 10.5505/1304.7361.2013.15045

A Painful Wrist After A Fall On Outstretched Hand