A 68-year-old woman comes in after slipping on wet tile, her left wrist held close to her chest like it might shatter if she breathes wrong. The joint is swollen fast, the skin already shiny, and every pulse of movement sends a sharp wince up her face. Her fingers are pink, but she says two of them feel “weirdly asleep,” and she won’t let anyone get near the hand. The x-ray is not yet in view, and the wrist is sitting there in a shape that does not look negotiated.
— What’s your move? Read on.
Before you read
- What deformity or x-ray finding should make you worry about perilunate injury?
- Which wrist injuries need urgent reduction in the ED before anything else?
When to Think of It
Any painful swollen wrist after FOOSH, especially with deformity, limited motion, median nerve symptoms, or abnormal carpal alignment on x-ray. Enter the diagnosis immediately when pain seems out of proportion to a “sprain,” the hand is numb, or the wrist looks angulated or “extended and stuck.”
Sick or Not Sick
The one call that matters most: Is the hand neurovascularly intact and is there a true dislocation/perilunate injury requiring urgent reduction? If pulses, cap refill, motor/sensation, and alignment are all okay, you have time for imaging and splinting; if not, reduce now and escalate.
The First Fifteen Minutes
- Severe pain before imaging or reduction → fentanyl 1–2 mcg/kg IV or hydromorphone 0.5–1 mg IV for analgesia, because pain control improves exam and allows reduction.
- Marked deformity, neurovascular symptoms, or suspected dislocation/perilunate injury → urgent closed reduction under procedural sedation or hematoma block; for hematoma block, lidocaine 1% 5–10 mL without epinephrine into the fracture hematoma, because local anesthesia can facilitate reduction while avoiding full sedation in some patients.
- Procedural sedation if needed for reduction → propofol 0.5–1 mg/kg IV bolus, titrated, or ketamine 1–2 mg/kg IV; dose choice depends on hemodynamics and local practice.
- After reduction with persistent swelling or concern for instability → repeat analgesia as needed and immobilize in a sugar-tong splint or well-padded volar splint, because it prevents redisplacement and limits forearm rotation.
- Open fracture, skin tenting with threatened skin, or gross contamination → cefazolin 2 g IV now (add gentamicin 5–7 mg/kg IV for severe contamination/high-energy open injuries per protocol), because early antibiotics reduce infection risk.
Definitive Care & Disposition
Get post-reduction x-rays. Suspected perilunate dislocation, lunate dislocation, irreducible fracture-dislocation, persistent median nerve deficit, or open fracture needs urgent hand/orthopedic consultation; many require operative fixation. Most reduced, neurovascularly intact, closed distal radius/ulna injuries can go home in a splint with elevation, return precautions, and expedited ortho follow-up in 3–7 days.
How This One Kills
The classic failure is calling a perilunate dislocation a “sprain” or “distal radius fracture,” discharging it splinted but unreduced, and letting median nerve compression or carpal ischemia worsen overnight.
The Differential — What Else Looks Like This
- Simple wrist sprain — normal alignment and benign function; confusing it with a fracture-dislocation delays reduction and pain relief.
- Scaphoid fracture — snuffbox tenderness with often normal initial x-ray; confusing it with a wrist sprain misses the need for thumb spica and follow-up imaging.
- Colles distal radius fracture — dorsal angulation after FOOSH; confusing it with perilunate injury misses the carpal malalignment and urgent reduction requirement.
- Carpal tunnel syndrome — isolated median nerve symptoms without traumatic deformity; confusing it with acute wrist dislocation can distract from the structural injury.
The Second-Day Story
Older adults, intoxicated patients, and people with neuropathy may underreport pain and present with only swelling, refusal to use the hand, or subtle numbness rather than an obvious deformity. High-energy trauma can also produce “normal-looking” skin over a severe carpal injury, so the exam must include median nerve testing, cap refill, and a deliberate look at the lateral x-ray for carpal alignment.
Back to Our Patient
Back to our patient: the 68-year-old woman with the shiny, swollen wrist and “sleepy” fingers has a traumatic wrist fracture-dislocation until proven otherwise. On the bedside exam, the priority is to document pulses, cap refill, and median nerve function, then move fast to x-ray and reduction if alignment is off or neurovascular symptoms persist. Her pain is severe enough to justify IV analgesia, and if the wrist is dislocated or perilunate, she needs urgent closed reduction with sedation or a hematoma block, followed by a sugar-tong splint and repeat films. If post-reduction neuro exam is normal and the injury is closed, she can go home with close hand/ortho follow-up; if median nerve deficit or instability remains, she stays for urgent hand surgery.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“68-year-old woman with a ground-level fall and severe left wrist pain and deformity. She’s got rapid swelling, limited range of motion, and tingling in two fingers, but her hand is still pink with brisk cap refill and palpable radial pulse. No open wound, no other major injuries, and I’m most concerned about a wrist fracture-dislocation or perilunate injury rather than a simple sprain. I’ve given IV pain control, checked median nerve function, and I’m getting x-rays now with plan for urgent reduction if alignment is abnormal. If post-reduction neurovascular exam is stable, I’ll splint in a sugar-tong and arrange hand/ortho follow-up; if not, I’m calling hand surgery.”
Study Directive
- Draw the lateral wrist alignment landmarks from memory: radius, lunate, capitate, third metacarpal.
- Practice reading 5 wrist x-rays and labeling distal radius fracture, perilunate dislocation, and lunate dislocation.
- Rehearse the post-reduction checklist: pain, median nerve, pulses, cap refill, repeat films, splint, consult.
- Review the ED reduction approach and sedation options in your institution’s protocol.
Recent Literature
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Review or guideline Carpal dislocations
Carpal dislocations are easily missed on wrist radiographs, and this review reinforces the ED priorities: scrutinize carpal alignment, assess median nerve function, immobilize/reduce when appropriate, and obtain urgent hand surgery consulta