Cas Clinique

Woman With Pain and Deformity in Left Wrist

Jeffrey T. Sakamoto, MD, Grant S. Lipman, MD

 

A 19-year-old woman presented with left wrist deformity. She had a history of shoulder “hypermobility” and a childhood left ulnar fracture treated nonoperatively. She was stretching her arms with fingers intertwined when she felt a “pop” and left wrist pain. On examination, she had a minimally tender volar deformity at the ulnar styloid, with inability to pronate, limited supination, and preserved wrist flexion and extension. Posteroanterior, lateral, and oblique radiographs were obtained.

Diagnosis

Volar dislocation of the ulna at the distal radioulnar joint. Isolated volar dislocation of the ulna at the distal radioulnar joint without fracture is a rare diagnosis that is usually associated with trauma and may be missed in up to 50% of cases.1, 2, 3, 4, 5Physical examination typically reveals a volar deformity with inability to pronate, with preserved flexion and extension. Subtle radiographic findings include overlap of the distal radius and ulna on oblique view (Figure 1) and volar displacement of the distal ulna beyond the radial cortices laterally (Figure 2). Comparative wrist radiographs can aid in the diagnosis.6

Figure 1Sans titre

Left wrist radiograph (oblique view) showing overlap of the distal radius and ulna (arrow).

 

Figure 2Sans titre2

Left wrist radiograph (lateral view) showing volar displacement of the distal ulna beyond the radial cortices (arrow).

 

Closed reduction was successful (Figures 3and 4), with 1% lidocaine injected into the joint space and then volar pressure on the ulnar head, with hyperpronation.

Figure 3Sans titre3

Left wrist radiograph (oblique view) postreduction showing realignment of the distal ulna and radius (arrow).

Figure 4Sans titre4

Left wrist radiograph (lateral view) showing reduction of the displaced distal ulna (arrow).

 

Reduction may require general anesthesia or surgery.1, 2, 3, 4After reduction, the wrist should be immobilized because the triangular fibrocartilage complex, dorsal radioulnar ligament, or joint capsule may be injured. Orthopedic follow-up is encouraged for possible magnetic resonance imaging.

 

References

  • Kohyama, S., Hara, Y., Fukai, R. et al. Subacute volar dislocation of the distal radioulnar joint without fracture: a case report and literature review. Trauma. 2014; 17: 229–234
  • Mulford, J.S., Jansen, S., and Axelrod, T.S. Isolated volar distal radioulnar joint dislocation. J Trauma. 2010; 68: E23–E25
  • Mittal, R., Kulkarni, R., Subsposh, S.Y. et al. Isolated volar dislocation of distal radioulnar joint: how easy to miss!. Eur J Emerg Med. 2004; 11: 113–116
  • Kumar, A. and Iqbal, M.J. Missed isolated volar dislocation of distal radio-ulnar joint: a case report. J Emerg Med. 1999; 17: 873–875
  • Singletary, E.M. Volar dislocation of the distal radioulnar joint. Ann Emerg Med. 1994; 23: 881–883
  • Russo, M.T. and Maffuli, N. Dorsal dislocation of the distal end of the ulna in a judo player. Acta Orthop Belg. 1991; 57: 442–446

 

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