Overview
A wrist dislocation is a serious orthopedic injury that occurs when one or more bones in the wrist joint are displaced from their normal anatomical positions. The wrist is a complex joint consisting of eight small carpal bones arranged in two rows, connected to the radius and ulna bones of the forearm. When these bones are forced out of alignment, it results in a dislocation that can cause severe pain, loss of function, and potential long-term complications if not treated promptly.
Wrist dislocations are relatively uncommon compared to other joint dislocations, accounting for less than 10% of all wrist injuries. However, they are considered orthopedic emergencies that require immediate medical attention. The most common types include perilunate dislocations, lunate dislocations, and radiocarpal dislocations, each involving different patterns of bone displacement.
These injuries typically result from high-energy trauma, such as falls on an outstretched hand, motor vehicle accidents, or sports-related injuries. The mechanism of injury usually involves hyperextension of the wrist combined with axial loading, causing the carpal bones to lose their normal relationships with each other and the forearm bones.
Early recognition and appropriate treatment are crucial for preventing long-term complications such as chronic pain, arthritis, carpal instability, and functional impairment. Without proper treatment, wrist dislocations can lead to permanent disability and significant impact on quality of life, particularly in individuals who rely on fine motor skills for their occupation or daily activities.
Symptoms
The symptoms of wrist dislocation can vary depending on the severity of the injury, the specific bones involved, and the presence of associated injuries. Recognition of these symptoms is crucial for seeking appropriate medical care.
Immediate Symptoms
- Severe hand and finger pain: Intense, sharp pain that is typically constant and worsens with movement
- Visible deformity: Obvious change in the shape or appearance of the wrist
- Swelling: Rapid onset of significant swelling around the wrist joint
- Loss of function: Inability to move the wrist or use the hand normally
- Tenderness: Extreme sensitivity to touch around the wrist area
Associated Symptoms
- Arm pain: Pain that may radiate up the forearm or down into the fingers
- Elbow weakness: Weakness or instability in the elbow and upper arm
- Numbness and tingling: Sensory changes in the hand and fingers due to nerve compression
- Color changes: Pale, blue, or mottled appearance of the hand indicating circulation problems
- Temperature changes: Cool or cold sensation in the affected hand
Neurological Symptoms
- Depression: Psychological impact from chronic pain and functional limitations
- Anxiety: Worry about long-term consequences and recovery
- Sleep disturbances: Difficulty sleeping due to pain and discomfort
- Cognitive effects: Difficulty concentrating due to chronic pain
Vascular and Nerve Complications
- Weak or absent pulse: Reduced blood flow to the hand
- Delayed capillary refill: Sluggish return of color when pressing on fingernails
- Motor weakness: Difficulty moving fingers or gripping objects
- Sensory loss: Decreased feeling in specific areas of the hand
Long-term Symptoms
- Chronic pain: Persistent discomfort that may worsen with weather changes
- Stiffness: Reduced range of motion in the wrist and fingers
- Grip weakness: Decreased strength in gripping and pinching activities
- Functional limitations: Difficulty with fine motor tasks and daily activities
- Arthritis symptoms: Joint pain and stiffness that develops over time
Causes
Wrist dislocations result from various mechanisms of injury, most commonly involving high-energy trauma that forces the wrist beyond its normal range of motion.
Traumatic Causes
- Falls on outstretched hand (FOOSH): The most common mechanism, occurring when someone falls and instinctively extends their arm to break the fall
- Motor vehicle accidents: High-impact collisions that cause forceful wrist hyperextension
- Sports injuries: Contact sports, gymnastics, skateboarding, and cycling accidents
- Industrial accidents: Workplace injuries involving heavy machinery or falls
- Assault: Physical violence resulting in direct trauma to the wrist
Sports-Related Mechanisms
- Gymnastics injuries: Falls during dismounts or complex maneuvers
- Contact sports: Football, rugby, or hockey collisions
- Martial arts: Impact from punching or defensive movements
- Extreme sports: Skateboarding, snowboarding, or mountain biking crashes
- Ball sports: Impact from balls or collision with other players
Mechanism of Injury
- Hyperextension: Forced backward bending of the wrist beyond normal limits
- Axial loading: Compressive forces transmitted through the extended wrist
- Rotational forces: Twisting motions that disrupt normal joint alignment
- Direct impact: Blunt trauma directly to the wrist area
- Combined mechanisms: Multiple forces acting simultaneously
Age-Related Factors
- Young adults: Higher activity levels and risk-taking behaviors
- Elderly individuals: Falls due to balance problems or frailty
- Children: Playground accidents and sports participation
- Athletes: Sport-specific injury patterns and mechanisms
Associated Injury Patterns
- Fracture-dislocations: Combined bone breaks and joint displacement
- Ligament tears: Disruption of stabilizing structures
- Nerve injuries: Compression or stretching of peripheral nerves
- Vascular injuries: Damage to blood vessels supplying the hand
Risk Factors
Several factors can increase the likelihood of sustaining a wrist dislocation or experiencing complications from such an injury.
Demographic Risk Factors
- Age groups: Bimodal distribution with peaks in young adults (20-30 years) and elderly (>65 years)
- Gender: Males have higher rates due to increased participation in high-risk activities
- Occupation: Manual laborers, construction workers, and athletes
- Activity level: Individuals engaged in high-risk sports or activities
Medical Risk Factors
- Previous wrist injuries: History of fractures, sprains, or dislocations
- Ligament laxity: Conditions causing joint hypermobility
- Osteoporosis: Weakened bones more susceptible to injury
- Arthritis: Joint degeneration affecting stability
- Connective tissue disorders: Conditions affecting ligament strength
Lifestyle Risk Factors
- Sports participation: Contact sports, gymnastics, cycling, and extreme sports
- Alcohol use: Impaired coordination and judgment increasing fall risk
- Poor conditioning: Inadequate strength and flexibility
- Risk-taking behavior: Participation in dangerous activities without proper safety measures
Environmental Risk Factors
- Workplace hazards: Unsafe working conditions or inadequate safety equipment
- Home environment: Stairs, slippery surfaces, and poor lighting
- Weather conditions: Icy or wet surfaces increasing fall risk
- Equipment failure: Faulty safety gear or protective equipment
Biomechanical Risk Factors
- Muscle weakness: Inadequate strength to protect the joint
- Poor proprioception: Decreased awareness of joint position
- Flexibility deficits: Limited range of motion increasing injury risk
- Coordination problems: Difficulty with balance and movement control
Diagnosis
Accurate diagnosis of wrist dislocation requires a systematic approach combining clinical examination, imaging studies, and assessment of associated injuries.
Clinical History
- Mechanism of injury: Detailed description of how the injury occurred
- Symptom onset: Timeline of symptoms and their progression
- Previous injuries: History of wrist problems or treatments
- Functional impact: Effect on daily activities and work
- Associated symptoms: Numbness, tingling, or color changes
Physical Examination
- Visual inspection: Assessment of deformity, swelling, and skin condition
- Palpation: Evaluation of tenderness, bony landmarks, and joint alignment
- Range of motion testing: Assessment of active and passive movement
- Strength testing: Evaluation of grip strength and muscle function
- Stability testing: Assessment of joint stability and ligament integrity
Neurological Assessment
- Sensory testing: Evaluation of feeling in different areas of the hand
- Motor testing: Assessment of muscle function and movement
- Reflex testing: Evaluation of nerve function
- Nerve compression tests: Specific tests for carpal tunnel or other nerve injuries
Vascular Assessment
- Pulse examination: Evaluation of radial and ulnar artery pulses
- Capillary refill testing: Assessment of circulation to fingertips
- Color and temperature: Evaluation of hand appearance and warmth
- Allen's test: Assessment of arterial circulation patterns
Imaging Studies
- X-rays: Standard anteroposterior, lateral, and oblique views
- Stress views: X-rays taken with specific positioning to assess stability
- CT scan: Detailed evaluation of bone structure and alignment
- MRI: Assessment of soft tissues, ligaments, and cartilage
- Arthrography: Injection of contrast to evaluate joint structures
Specialized Tests
- Arthroscopy: Direct visualization of joint structures
- Nerve conduction studies: Assessment of nerve function
- Vascular studies: Evaluation of blood flow if circulation is compromised
Treatment Options
Treatment of wrist dislocation aims to restore normal anatomy, maintain joint function, and prevent long-term complications. The approach depends on the type of dislocation, associated injuries, and patient factors.
Emergency Treatment
- Pain management: Immediate pain relief with appropriate analgesics
- Immobilization: Splinting to prevent further injury
- Neurovascular assessment: Evaluation and monitoring of circulation and nerve function
- Reduction attempts: Emergency reduction if circulation is compromised
- Imaging: Urgent X-rays to assess the injury pattern
Closed Reduction
- Anesthesia: Local anesthesia or conscious sedation for comfort
- Reduction technique: Gentle manipulation to restore normal bone alignment
- Post-reduction imaging: X-rays to confirm adequate reduction
- Immobilization: Cast or splint application to maintain reduction
- Neurovascular reassessment: Verification of restored circulation and nerve function
Surgical Treatment
- Open reduction: Surgical exposure and direct manipulation of bones
- Internal fixation: Use of pins, screws, or plates to maintain alignment
- Ligament repair: Surgical repair of torn stabilizing structures
- Carpal tunnel release: If nerve compression is present
- Bone grafting: For complex injuries with bone defects
Post-Treatment Management
- Immobilization period: 6-12 weeks depending on injury severity
- Progressive mobilization: Gradual increase in activity as healing progresses
- Physical therapy: Structured rehabilitation program
- Occupational therapy: Training for daily activities and work tasks
- Regular monitoring: Follow-up visits to assess healing and complications
Rehabilitation Phase
- Range of motion exercises: Gradual restoration of wrist and finger movement
- Strengthening exercises: Progressive strengthening of hand and forearm muscles
- Functional training: Practice of specific activities and skills
- Pain management: Ongoing strategies for managing chronic pain
- Return to activity: Gradual progression back to full function
Complications Management
- Infection treatment: Antibiotics for surgical site infections
- Nonunion management: Additional surgery for bones that don't heal
- Hardware complications: Removal or revision of implants
- Arthritis treatment: Management of post-traumatic arthritis
Prevention
While not all wrist dislocations can be prevented, many can be avoided through appropriate safety measures and risk reduction strategies.
Sports Safety
- Protective equipment: Appropriate wrist guards and protective gear
- Proper technique: Learning correct techniques for sports activities
- Conditioning: Adequate strength and flexibility training
- Equipment maintenance: Regular inspection and maintenance of sports equipment
- Rule compliance: Following safety rules and regulations
Workplace Safety
- Safety training: Proper education on workplace hazards and prevention
- Personal protective equipment: Use of appropriate safety gear
- Ergonomic practices: Proper body mechanics and workplace setup
- Regular breaks: Avoiding repetitive stress and fatigue
- Hazard identification: Recognition and elimination of workplace risks
Home Safety
- Fall prevention: Removing tripping hazards and improving lighting
- Stair safety: Handrails and adequate lighting on stairs
- Bathroom safety: Non-slip surfaces and grab bars
- Ladder safety: Proper ladder use and positioning
- Home maintenance: Keeping walkways clear and in good repair
Vehicle Safety
- Seatbelt use: Always wearing appropriate restraints
- Defensive driving: Safe driving practices and hazard awareness
- Vehicle maintenance: Regular maintenance of brakes and safety systems
- Weather awareness: Adjusting driving for weather conditions
Physical Conditioning
- Strength training: Building upper extremity and core strength
- Flexibility exercises: Maintaining joint range of motion
- Balance training: Improving coordination and stability
- Bone health: Adequate calcium and vitamin D intake
When to See a Doctor
Wrist dislocations are orthopedic emergencies that require prompt medical attention. Recognizing when to seek immediate care is crucial for optimal outcomes.
Seek Emergency Care Immediately
- Obvious deformity or abnormal appearance of the wrist
- Severe pain that doesn't respond to pain medication
- Inability to move the wrist or hand
- Numbness or tingling in the fingers
- Color changes in the hand (pale, blue, or mottled)
- Absent or weak pulse in the wrist
- Cold sensation in the hand or fingers
- Inability to feel touch in the hand
- Weakness in gripping or finger movement
- Signs of infection (fever, redness, discharge)
Schedule Urgent Medical Attention
- Persistent pain: Ongoing pain after a wrist injury
- Swelling: Significant swelling that doesn't improve
- Functional limitations: Difficulty performing daily activities
- Recurrent symptoms: Return of symptoms after initial treatment
- Delayed healing: Slower than expected recovery
Follow-up Care Indications
- Post-treatment monitoring: Regular assessment of healing progress
- Cast or splint problems: Issues with immobilization devices
- Therapy needs: Assessment for rehabilitation services
- Return to activity: Medical clearance for sports or work
- Long-term complications: Development of chronic problems
Warning Signs of Complications
- Worsening pain or swelling
- New numbness or tingling
- Changes in skin color or temperature
- Loss of previously regained function
- Signs of infection or wound problems
- Persistent stiffness or weakness
References
- Mayfield, J. K., Johnson, R. P., & Kilcoyne, R. K. (1980). Carpal dislocations: pathomechanics and progressive perilunar instability. Journal of Hand Surgery, 5(3), 226-241.
- Green, D. P., & O'Brien, E. T. (1978). Classification and management of carpal dislocations. Clinical Orthopaedics and Related Research, 134, 259-267.
- Herzberg, G., Comtet, J. J., Linscheid, R. L., et al. (1993). Perilunate dislocations and fracture-dislocations: a multicenter study. Journal of Hand Surgery, 18(5), 768-779.
- Knoll, V. D., Allan, C., & Trumble, T. E. (2005). Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with 16-year follow-up. Journal of Hand Surgery, 30(6), 1145-1152.
- Stanbury, S. J., & Elfar, J. C. (2011). Perilunate dislocation and perilunate fracture-dislocation. Journal of the American Academy of Orthopaedic Surgeons, 19(9), 554-562.