WORKUP	Section 5 of 11
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Imaging Studies:

• Plain x-rays of the wrist, both anteroposterior (AP) and lateral views, are essential to diagnose wrist dislocations (as well as other carpal instabilities).

• On an AP view, 2 arcs should be identified. The first arc consists of the radiocarpal row, which should be smooth and continuous. Disruption is suggestive of a lunate dislocation.

• The second arc consists of the midcarpal row, which also should be smooth and continuous. Disruption of this arc is suggestive of a perilunate dislocation.

• The appearance of the lunate is important on the AP view. Normally, the lunate is quadrangular. With lunate dislocations, it becomes triangular. This may be an additional clue to dislocation.

• On the lateral view, visualize the column, which consists of the radius, lunate, and capitate. The lunate should lie within the radius cup and the capitate should rest within the lunate cup. Loss of this normal column implies lunate or perilunate dislocation.

• Stress x-rays of the wrist may be necessary to demonstrate intercarpal ligamentous instability when no evidence of wrist dislocation is apparent on plain films.

• Stress x-rays obtained with radial and ulnar deviation of the hand may demonstrate scapholunate dissociation.

	TREATMENT	Section 6 of 11
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Prehospital Care:

• Prehospital care includes assessment for other injuries that may accompany the wrist injury.

• If no other injuries are identified, splint the wrist.

• Patients may be transported in their private vehicles, but the prehospital provider must emphasize the potential seriousness of the injury.

• Under no circumstances should a prehospital provider attempt a reduction of a suspected wrist dislocation. It may be a distal radius fracture, which requires significant care to reduce.

Emergency Department Care:

• Patients with wrist injuries have an entire spectrum of possible injuries that represent potential disability.

• Although no specific fracture or dislocation may be seen on x-ray, carpal instability still may be present.

• Therefore, splint with plaster even if no injury is found on x-ray.

• Carefully splint with AP splints to the fingers until a hand specialist can evaluate the injury.

Consultations:

• Patients in whom a wrist dislocation has been identified require referral to a hand specialist who is either an orthopedic or plastic surgeon, depending on local custom.

• Wrist dislocations may be reduced by emergency physicians, but only after consulting with the hand specialist.

• The patient's own primary care physician may follow up, but it is important to stress to the primary care physician the need for hand specialist referral.

	MEDICATION	Section 7 of 11
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The goals of pharmacotherapy are to reduce morbidity and prevent complications.

	MISCELLANEOUS	Section 9 of 11
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Medical/Legal Pitfalls:

• Failure to diagnose wrist injury

• Failure to evaluate for the possibility of wrist dislocation in every patient who has a wrist injury. Systematically evaluating the AP and lateral wrist x-rays should eliminate this mistake.

• Failure to properly follow up. Patients with a wrist dislocation suffer a significant, potentially disabling injury. Follow-up should include referral to a hand specialist.

• Failure to adequately immobilize. Patients who have sustained a wrist dislocation should have AP splints applied, boxed to the fingertips. The hand specialist decides whether a long arm cast extension should be applied to avoid pronation/supination.

Special Concerns:

• A concomitant scaphoid fracture may occur as part of the injury pattern.