A 35 year old male attended casualty after falling onto his dominant outstretched hand. He was tender all over the wrist joint but more so medial to the scaphoid area with an obvious deformity. There was no neurovascular deficit. The above xray was done and patient was sent home with a diagnoses of soft tissue injury and follow up appt in clinic.
4 days later in clinic his pain is no better so he was given more analgesia and a high arm sling. There was no neurovascular deficit noted.
2 weeks later patient requested to be seen again after complaining of un-abating pain on his wrist and swelling which has not subsided since his initial injury. He also complains of numbness over the medial 3 and half fingers.
What is the diagnoses based on the x-ray?
What is the cause of the neurological findings?
What is the preferred option for treatment?
Answer: (posted on the 20/12/2008)
It is a Perilunate dislocation, with scapho-lunate dissociation.
The Neurology is a median nerve compression
The treatment is immediate MUA (closed reduction), however with a 2 week old injury it can be difficult (almost impossible)
Well done to those who got it right!
In this case we attempted initially closed reduction but was unsuccessful. So we went for open reduction. After open reduction, under image intensifier the scapho-lunate dissociation was very obvious so k-wire fixation was necessary to maintain reduction. These are the post-operative xrays.
4 comments:
could it be a scaphoid fracture as there is a gap in between the wrist joint. btw is it a medial 31/2 or lateral 3/1/2 of the finger which may indicate impingement of the median nerve
lunate dislocation with median nerve compression due to pressure of the dislocated bone. needs reduction under anaesthesia +/- open as it is 2 weeks old
oic
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