Wrist Joint Dislocation: Causes, Symptoms, Treatment- PT, Close Reduction, Surgery

Wrist joint is the link between hand and forearm. Wrist joint is formed by 15 bones spread in three sections.

• Proximal Wrist Joint- Close to Forearm.
• Intermediate Wrist Joint.
• Distal Wrist Joint- Close to Hand.

• First segment is formed by pivot joint between radius and ulna. Head of distal end of ulna is covered with smooth cartilage, which lies against ulnar notch of radius bone. Joint is covered by synovial capsule. Lax synovial capsule surrounds the wrist joint. Flaccid capsule allows semi-rotation of joint during pronation and supination. Volar dislocation is often difficult to diagnose.
• Second segment is link or joint between distal end of radius and part of ulna with proximal row of three carpal bones. Proximal row of carpal bone is formed by Scaphoid, Lunate and Triquetrum.

Intermediate Wrist Joint is link or joint between proximal rows of carpal bones (Scaphoid, Lunate and Triquetrum) and distal rows of carpal bones (Trapezium, Trapezoid, Capitate, Hamate and Pisiform). The joint is also known as inter-carpal wrist joint.

Distal row of carpal bones Trapezium, Trapezoid, Capitate, Hamate and Pisiform are linked with five metacarpal bones.

• The wrist joint links hand to forearm.
• Wrist joint supports hand movements like flexion, extension, abduction, adduction, lateral tilt, supination and pronation.
• Wrist joint protects tendon, nerves and blood vessels underneath flexor and extensor retinaculum.

Dislocation is a separation of two bones, which are linked to each other. Wrist joint is formed by 15 bones and each bone is linked to one to four bones. Isolated dislocation of carpal bone is rare, since wrist joint dislocation is often associated with fracture of one of the wrist joint bone.

Most of the wrist joint dislocation is associated with fracture of one of the wrist joint bone. Wrist joint dislocation and fracture is one of the common injury observed in emergency room.

• Several tough ligaments support wrist joint – Forceful pull of the ligament generates severe force between carpal bones resulting in fracture of one of the wrist bone.
• Ligamental tear– Severe accelerating force causes tear of the ligament and hairline or complete fracture of one of the wrist bone.
• Dislocation– Direct impact results in fracture as well as dislocation of less resistant carpal bone.
• Twist and turn of the wrist joint– Twist and turn of the joint in abnormal position results in severe opposing force between ligaments and causes tear or fracture of the wrist bone.

• Ligamental Laceration or Tear.
• Tendon Rupture or Tear.
• Nerve Injuries.
• Vascular (blood vessels) Tear Causing Hematoma (blood clots).

• Automobile Accident Injury.
• Work Accident.
• Sport Injuries.
• Domestic Fall.
• Slip and Fall On Slippery Surface.

• Anterior Dislocation.
• Posterior Dislocation.

• Dislocation between Radius and Ulna.
• Dislocation between Radius and Proximal Rows of Carpal Bones.
• Dislocation between Carpal Bones.
• Dislocation between Carpal Bone and Metacarpal Bone.

Causes of Anterior or Posterior Dislocation Are As Follows-

• Wrist joint in extension position.
• Arm in flexed position.
• Arm in stretched position during fall.

• Direct impact on dorsal or back of the hand.
• Impact results in an extreme hyperextension of the wrist joint at the time of impact.

• Fall or impact when wrist joint is in flexed position.
• Arm is stretched at the time of fall or impact.

Isolated carpal dislocation is dislocation of single carpal bone of proximal or distal row. Isolated carpal dislocation is extremely painful and often associated with hairline fracture.

• Extremely Rare
• Difficult to Treat
• Most Common Carpal Dislocation Is Dislocation Of Lunate.
• Dislocation Is Often In A Palmar (Anterior) Direction.
• The Rare Dorsal Dislocation Occurs During Wrist Flexion Injury.

Isolated acute distal radio-ulnar joint (DRUJ) dislocation is a rare injury. Very few cases of bilateral radio-ulnar dislocation has been documented.

• Fracture of ulna.
• Fracture of radius.
• Fracture of radius associated with rupture of interosseous membrane, also known as Essex–Lopresti injury.

• Lunate Dislocation As Described By Mayfield et al.
• Dislocation of Scaphoid Bone Following Scapho-Lunate Ligament Tear.
• Capitate Dorsal Dislocation.
• Dislocation of Lunate Following Luno-Triquetral Ligament Disruption. Lunate Often Remains Aligned With The Radius.
• Lunate Dislocation And Displacement Following Ligamental Tear. The Capitate Remains Aligned With The Radius, While The Lunate Is Squeezed Out In A Volar Direction.

• Wrist Joint Pain.
• Restricted wrist joint movements.
• Abnormal sensory symptoms like tingling and numbness.

Wrist joint pain is observed over front and back of the wrist.

• Pain is referred to forearm and hand.
• Pain intensity is increased with movement of wrist joint.
• Pain is less severe when arm is held above the shoulder.
• Pain is throbbing and continuous.

• Injured patient is unable to move wrist joint.
• Passive movement is painful and restricted.
• Wrist joint is often observed in locked position of extension or flexion.

Symptoms such of tingling and numbness are observed following irritation or pinch of the sensory nerve fibers of radial, ulnar or median nerve.

Ulnar nerve injury causes tingling and numbness along the front and back of inner side of hand (includes small finger and ring finger).

Median nerve injury causes symptoms of tingling and numbness on palmar surface along outer side of hand (includes thumb, index and middle finger).

Radial nerve injury causes tingling and numbness of the skin over back of the hand between wrist and thumb as well as lower 2/3rd of index and middle finger.

• Muscle Weakness.
• Ulnar Nerve Palsy.
• Radial Nerve Palsy.
• Median Nerve Palsy.

• Patient is unable to perform fine activities using fingers like writing and holding paint brush.
• Patient is unable to flex or extend hand and fingers.

• Seen following ulnar nerve injury.
• A hand is in claw position resulting in flexion or curls up position of small and ring finger.

Clinical Sign Is Evaluated As Follows-

• Arm is flexed or extended at elbow.
• Palm is facing ground.
• Hand is flexed or in drop position.
• Patient is unable to extend hand at wrist joint in this position.

• Patient is unable to count using thumb.
• Patient is unable to touch other fingers with thumb.
• Patient is also unable to bring and hold index and middle fingers together.
• Atrophy of the thumb muscles (thinner muscles.)

Tenderness–

Palpation of wrist joint indicates joint is extremely painful. Active (performed by patient) or passive (assisted by examiner) movements of the wrist joint are very painful and restricted.

Deformity–

Joint deformity is observed because of one of the dislocated bone is in out of place from the joint. Joint distortion also interferes and prevents joint movements.

Bruising–

Skin bruising are observed as a result of laceration and subcutaneous hematoma (blood clots)

Lump–

Soft to firm lump is felt underneath the skin over fractured wrist joint. Lump is secondary to subcutaneous hematoma (blood clot).

• Radius and Ulna Dislocation.
• Carpal Bone Dislocation.
• Dislocation between Carpal Bone and Metacarpal Bone.
• X-ray will show fracture.
• X-ray may not show hairline fracture or ligament tear.

• Radius and Ulna Dislocation.
• Carpal Bone Dislocation.
• Dislocation Between Carpal Bone And Metacarpal Bone.
• Fracture Associated With Wrist Joint Dislocation.
• Hairline Fracture
• Hematoma (blood clot)
• Osteoporosis
• Necrotic Fracture Bone

• Radius and Ulna Dislocation.
• Carpal Bone Dislocation.
• Dislocation Between Carpal Bone And Metacarpal Bone.
• Fracture Associated With Wrist Joint Dislocation.
• Hematoma (blood clot).

• Wrist Joint Dislocation.
• Wrist Joint Fracture.
• Hematoma Within Wrist Joint.
• Subcutaneous hematoma.

Blood examination is done to rule out joint infections. Following abnormal blood examinations are observed if joint is infected-

• Increased white blood cell count.
• Increased Erythrocyte Sedimentation Rate.

• Conservative Treatment
• Medications
• Physical Therapy
• Interventional Pain Therapy
• Close Reduction
• Surgical Treatment

• Restrict Activities of The Wrist Joint.
• Heat or Cold Therapy for Joint Edema and Swelling.
• Apply Wrist Joint Braces.
• Weight Loss- Loss of Weight and Obesity Helps To Reduce Pain.
• Daily Exercise of Fingers and Forearm Muscles.

• NSAIDs.
• Opioids.
• Muscle Relaxants.

NSAIDS are Non-Steroidal anti-inflammatory Medications.

• Chronic Pain.
• Wrist Joint Inflammation Caused By Dislocation.

• Motrin
• Naproxen
• Daypro
• Celebrex

• NSAIDs Resistance– Opioids Are Prescribed When Pain Is Not Responding To NSAIDS Treatment
• Pain During Activities Only– If pain is severe during walking and less severe at rest then pain is treated with short acting opioids.
• Pain at Rest– Severe pain at rest is treated with long acting opioids and breakthrough pain is treated with short acting opioids.

Muscle pain or spasm is treated with muscle relaxants (medications) or physical therapy.

• Baclofen
• Flexeril
• Skelaxin
• Robaxin

• Chronic Pain Not Responding To NSAIDS and Opioids.
• Following Surgery to Optimize Joint Mobility and Movements.
• Aggressive Physical Therapy Is Combined With Interventional Pain Therapy.
• Physical Therapy Is Prescribed For Muscle Spasm If Pain Is Tolerable.
• Physical Therapy Is Advised For Joint Stiffness Following Surgery.
• Joint Instability.

• Chronic Pain Not Responding To Pain Medications.
• Prior to Physical Therapy or After Failed Physical Therapy.
• Failed Surgery.
• Interventional Pain Therapy Is Indicated For Chronic Pain and Inflammation.

• Cortisone Injection
• Local Anesthetic Injection
• Nerve Ablation
• Spinal Cord Stimulator
• Intrathecal Catheter and Pump Placement

• Inflammation-Cortisone injection is performed to reduce inflammation.
• Chronic Pain-Pain if not responding to NSAIDs and opioids then chronic pain is treated with frequent cortisone injection scheduled between 3 to 4 months. Treatments last until pain is tolerable and joint movement are improved.
• Contraindications– Cortisone injection is not recommended for chronic pain associated with Gout and Septic Wrist Joint Arthritis.

Therapeutic value of just local anesthetic injection is very limited and the procedure is performed only as a diagnostic procedure. Procedure is also performed prior to physical therapy in few cases.

Cortisone or local anesthetic Injection is performed either at doctor’s office or outpatient surgery. Wrist joint cortisone injection in majority of the patient is performed under local anesthesia. In most of the cases image intensifier (portable X-Ray) is used for placement of needle.

Not really, pain specialist is trained for needle placement. Physician will spray skin with numbing medicine so first prick or insertion of needle is painless and then he will inject local anesthetics to numb all the tissue to be treated including skin. Few patients suffer with “needle phobia” (fear of needle) in such cases physician will provide oral or intravenous antianxiety medications or sedation.

Treatment is very rarely needed. Wrist joint dislocation after completion of treatment may result in severe continuous chronic pain because of peripheral pinch nerve. Nerve ablation is a lesioning of nerve using cryo probe or radiofrequency heat.

Pain specialist will conduct detailed examination, which will be followed by nerve study. The examinations and various tests will conclude the diagnosis of nerve causing pain.

Treatment is performed under local anesthesia. The skin and subcutaneous tissue is anesthetized using local anesthetics. Cryo probe is carefully passed through tiny skin incision and kept over the nerve. Probe is cooled down to -90 degree C.

Radiofrequency needle is much smaller in diameter than cryo probe. Radiofrequency needle is placed just like cryo probe over pinched or irritated nerve. Radiofrequency waves are generated at the tip of the needle, which results in increased temperature. Temperature is maintained between 75 to 90 degree C for 75 to 90 seconds to accomplish nerve ablation.

Yes, procedure is directed to tiny nerves. Area to be treated is limited to less than a millimeter. Surrounding tissue is not exposed to same temperature.

Spinal Cord Stimulator is rarely indicated for wrist joint pain. Chronic wrist joint pain is considered for spinal cord stimulator therapy if all the treatment including surgical correction of dislocation failed to relieved severe intractable pain.

Spinal cord stimulator may not relieve all chronic pain. Procedure is performed in 2 stages. First stage is diagnostic procedure and second is permanent placement of stimulator and generator. During diagnostic procedure, stimulator is placed either over pinched nerve in wrist or epidural space in neck. Stimulator is stimulated using external generator. Pain relief over 50% is considered satisfactory by majority of the patient and permanent placement is considered.

Stimulator is placed over irritated or pinched nerve over the wrist joint or in the epidural space in neck.

Intrathecal opioid is prescribed when all other treatment including surgery and spinal cord stimulator fails to relieve chronic intractable pain.

Intrathecal opioid therapy means delivering opioid into CSF. Three layers of membrane called pia, arachnoid and dura covers Spinal Cord. The space between pia and arachnoid contains fluid known as Cerebro Spinal Fluid or CSF. A tiny catheter is placed into the CSF and opposite end is connected to an electronic small pump known as intrathecal opioid delivery pump or morphine pump. Opioid medication is stored in one of the chamber of morphine pump. The electronic motor controlled by computer device delivers opioid from opioid chamber into CSF.

Pain receptors are located over posterior (back) surface of spinal cord. Intrathecal catheter lies and floats over the posterior surface of spinal cord. Opioids when delivered into spinal cord blocks the pain impulses passing to brain at the pain receptors. Blocking of pain impulses going to brain decreases pain intensity by 50% or more.

Orthopedic Surgeon performs close reduction in out-patient surgery. Isolated wrist joint dislocation is often treated with close reduction of dislocation. Close reduction is done under sedation or general anesthesia. Patient is given deep sedation so muscles of the hand and forearm arm are relaxed. Wrist joint is stretched to optimum level by pulling forearm and hand in opposite direction. Procedure does not involve any surgery. Distal radio-ulnar joint dislocation is often irreducible with close reduction.

• Reduction of Dislocation– Open Reduction- Dislocated wrist joint is reduced using special equipment after joint is exposed by surgery.
• Stabilization of Wrist Joint– After open reduction of the dislocation, the joint is stabilized to prevent recurrence of dislocation.

• Placement of plate between adjacent bones.
• Insertion of rod or wire between dislocated bone and adjacent bone.
• Double breasted slip to stabilize extensor retinaculum.

• Insertion of wires between dislocated bones and adjacent bone.
• Placement of nail between dislocated and adjacent carpal bone.

Also Read:

• Wrist Ganglion: Types, Causes, Symptoms, Treatment, Exercises
• Tendonitis Wrist or Wrist Tendinitis: Causes, Signs, Symptoms, Treatment, Exercises, Tests
• Wrist Pain: 9 Major Medical Conditions that Cause Wrist Pain or Wrist Joint Pain
• Wrist Pain, Wrist Joint Pain: Symptoms, Treatment- Conservative, PT, Surgery, Prevention
• Wrist Joint Tendonitis: Causes, Symptoms, Treatment-Medications, PT, Surgery
• Wrist Joint Arthritis: Symptoms, Causes, Treatment- Medications, NSAIDs, PT, Surgery
• Treatment for Wrist Joint Pain: Conservative, Medications, PT, Surgery
• Wrist Joint Anatomy: Bones, Movements, Ligaments, Tendons- Abduction, Flexion
• Wrist Joint Fracture: Types, Causes, Symptoms, Treatment- Medications, PT, Surgery

References

• Traumatic volar dislocation of the distal radioulnar joint.

  Orthopedics. Rainey RK, Pfautsch ML. 1985;8:896–900.

• Traumatic dislocation of the distal radio-ulnar joint.

  Dameron TB.,

  Jr Clin Orthop Relat Res. 1972;83:55–63.

• Complex dislocations of the distal radio-ulnar joint: Recognition and Management.

  Bruckner JD, Lichtman DM, Alexander AH.

  Clin Orthop Relat Res. 1992 Feb;(275):90-103.

  Department of Orthopaedic Surgery, Naval Hospital, Oakland, California 94627-5000.

• Acute injuries of the distal radioulnar joint.

  Nicolaidis SC, Hildreth DH, Lichtman DM.

  Hand Clin. 2000;16:449–459.

• Bilateral dorsal dislocation of the distal radio-ulnar joint.

  Pezeshki C, Weiland AJ. J Trauma. 1978;18:673–676.

• In Brief: Mayfield et al. Classification: Carpal Dislocations and Progressive Perilunar Instability

  Stephen A. Kennedy, MD, FRCSC and Christopher H. Allan, MD

  Clinical Orthopedic and related research

• Distal radioulnar joint subluxation and dislocation diagnosed by standard roentgenography.

  Nakamura R, Horii E, Imaeda T, Tsunoda K, Nakao E.

  Skeletal Radiol. 1995;24:91–94.

• Acute irreducible distal radioulnar joint dislocation.

  Garrigues GE, Aldridge JM., III A case report. J Bone Joint Surg Am. 2007;89:1594–1597. doi: 10.2106/JBJS.F.01566.

• Stabilisation of the distal radioulnar joint with a double-breasted slip of the extensor retinaculum.

  Gupta RK, Singh H, Sandhu VP. J Bone Joint Surg Br. 2008;90:200–202.