Wrist pain after a fall: a simple fracture?
A woman presents with wrist pain after falling on her outstretched hand.
A 58-year-old, right-hand dominant woman fell in the shower and injured her left wrist. She was seen 3 days later at an outside emergency department (ED) where radiographs were obtained. Her wrist was splinted, and then she was sent to an urban ED to “have her arm set.” No reduction was required. She was evaluated, placed in a volar splint, and referred to a specialty hand clinic where she was seen 4 days later. Her splint was then removed, and she was noted to have moderate edema of the distal forearm and hand with no open wounds or skin injury.
There was minimal bruising. Her compartments were soft and compressible. Range of motion of her wrist and fingers was limited, secondary to pain and swelling. Her radial pulse was easily palpated, and motor/sensory function was intact in a median, radial, and ulnar distribution. She complained of severe pain with palpation of the distal radius and dorsolateral carpus with minimal snuff box tenderness. Repeat radiographs (Figures 1 and 2) of the left wrist revealed a comminuted distal radius fracture with possible intra-articular extension but no significant displacement or angulation. Osteopenia was noted with soft tissue swelling over the dorsum of the wrist. No other fractures seen; however, there was evidence of widening between the scaphoid and lunate carpal bones.
Figure 1. Left wrist PA view: Distal radius fracture with widening between the scaphoid and lunate carpal bones, highly suspicious for a scapholunate ligamentous tear.
Figure 2. Left wrist lateral view: Distal radius fracture with no appreciable angulation/displacement. Scapholunate angle 90 degrees (normal 30 to 60 degrees)
The patient was placed in a removable thumb spica splint, and an MRI of the left wrist was obtained. The MRI (Figure 3) showed a subacute transverse distal radius fracture without malalignment, a small joint effusion, and a widened scapholunate (S-L) space associated with a tear of the SL ligament. The patient ultimately underwent surgical repair of this ligament with an uneventful healing of the fracture. She had no residual wrist pain. Had this patient been casted for the fracture with the ligament injury left untreated, she would have been at risk for lingering pain and potential for future morbidity.
Figure 3. MRI of the left wrist (image turned): Distal radius fracture with scapholunate ligamentous widening consistent with an acute tear. Complete disruption seen in additional views with a repairable ligament as noted by the hand surgeon.