A 46 year-old male presents with wrist pain after sustaining a mechanical fall and catching himself on his outstretched hand. An anteroposterior (left) and lateral (right) plain films of the wrist are obtained (photo credit).
What is the diagnosis (hint – there are 2 findings), injury classification system, associated findings, and the recommended management plan?
Mayfield Classification: A mechanism of forced wrist extension with ulnar deviation produces a classic pattern of injuries that progressively worsen in severity:1-4
Stage I: Scapholunate dissociation (Figure 2A)
Stage II: Perilunate dislocation (Figure 2B)
Stage III: Perilunate dislocation with dislocation of triquetrum
Stage IV: Lunate dislocation (Figure 2C)
Figure. A. Scapholunate dissociation evidenced by widening between scaphoid and lunate (Terry Thomas sign). B. Perilunate dislocation (note that lunate articulates appropriately with radius). C. Lunate dislocation (tipped teacup with normal alignment of radius and capitate). Images courtesy of Radiopaedia on scapholunate dislocation (Radswiki), lunate dislocation (Dr. Andrew Dixon), and trans-scaphoid perilunate dislocation (Dr. Andrew Dixon). These injuries are important to identify as misdiagnosis and mistreatment may result in chronic instability, arthritis, or scapholunate advanced collapse (SLAC) with significant functional impairment. 1, 3, 4
Pearls to assess for an occult scapholunate dissociation
Perform a Watson’s scaphoid shift test. Production of a clunk or pop during radial deviation or after releasing scaphoid pressure indicates possible scapholunate instability.4 The movement is the scaphoid subluxing or relocating, respectively.
If you suspect this injury, obtain a clenched fist view or a PA view with the wrist in ulnar deviation to accentuate scapholunate dissociation.3
A lunate dislocation will likely require an orthopaedics or hand surgery consultation in the ED unless appropriately reduced and immobilized.
Overview on Lunate Injuries
Cock-up or volar wrist splint
Outpatient follow-up with an orthopedist or hand specialist within 1 week
Perilunate or lunate dislocation
Consult an orthopedist or hand surgeon. Closed reductions are often unsuccessful.
If a specialist is not available, attempt closed reduction by applying traction, extending and ulnar-deviating the wrist to recreate the injury. Then perform carpal pronation, radial deviation, and wrist flexion.1
Indications for emergent surgery include:
Median nerve involvement
Unsuccessful closed reduction
Kennedy SA, Allan CH. In brief: Mayfield et al. classification: Carpal dislocations and progressive perilunar instability. Clin Orthop Relat Res. 2012;470(4):1243-1245. PMID 22322787
Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5:226–241. PMID 7400560
Williams D, Kim H. Wrist and forearm. In: Marx J, ed. Rosen’s Emergency Medicine Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier, Saunders; 2014: 570-595.e2
Tsyrulnik A. Emergency department evaluation and treatment of wrist injuries. Emerg Med Clin N Am. 2015;33(2): 283-296. PMID 25892722
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