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7. Hand and Wrist MCQs

Practice Set 68 of 266

This practice set contains high-yield board review questions covering key concepts in 7. Hand and Wrist. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1341

Topic: 7. Hand and Wrist

A still active 86-year-old pastry chef falls in her kitchen and notes pain and deformity of her little finger. There are no open wounds. Radiographs are shown in Figures 49a and 49b. What is the most appropriate management?

. Closed reduction and splinting in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint extension
. Closed reduction and splinting in MCP joint flexion and PIP joint extension
. Reduction and percutaneous fixation
. Open reduction and internal fixation
. Buddy taping and early range of motion

Correct Answer & Explanation

. Closed reduction and splinting in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint extension

Explanation

DISCUSSION: The fracture of the proximal phalanx is clearly displaced.  There is slight comminution at the area of the fracture.  Closed reduction is likely to fail due to the forces of the extensor, flexor, and intrinsic mechanisms.  Percutaneous fixation, unlike open fixation techniques, avoids likely problems with stiffness.REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5.  Philadelphia, PA, Elsevier, 2005, p 281.Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures.  J Am Acad Orthop Surg 2000;8:111-121.

Question 1342

Topic: 7. Hand and Wrist

A 45-year-old man who smokes reports the rapid onset of color changes and coolness in the fingers. Examination shows an abnormal Allen test. Plain radiographs of the hand and wrist are normal. Which of the following studies will best aid in diagnosis?

. Contrast CT of the hand and wrist
. MRI of the hand and wrist
. Contrast angiography of the involved upper extremity
. Digital subtraction angiography
. Single-shot fluoroscopic angiography

Correct Answer & Explanation

. Contrast CT of the hand and wrist

Explanation

DISCUSSION: The patient has symptoms typical of Raynaud’s phenomenon secondary to underlying vascular disease.  The next most appropriate step in the management of this patient should be to perform contrast angiography on the involved upper extremity to look for proximal or distal arterial lesions or insufficiencies.  MRI and contrast CT are not as specific as angiography for the identification of vascular lesions of the upper extremity.  Although patients with primary Raynaud’s vasospastic disease can have normal angiographic findings, they typically are younger than age 40 years, are female, and have normal results on an Allen test.REFERENCES: Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4.  New York, NY, Churchill Livingstone, 1999, pp 2288-2290.Manske PR (ed): Hand Surgery Update.  Rosemont, IL, American Society for Surgery of the Hand, 1994, pp 197-205.

Question 1343

Topic: 7. Hand and Wrist

From which artery does the princeps pollicis artery branch?

. Dorsal radial carpal artery
. Dorsal ulnar carpal artery
. Ulnar artery
. Radial artery

Correct Answer & Explanation

. Dorsal radial carpal artery

Explanation

DISCUSSIONThe princeps pollicis artery can be located on the palmar aspect of the adductor pollicis and emerges into the subcutaneous tissue at the thumb metacarpophalangeal flexion crease. It branches from the radial artery just distal to the location of the deep palmar arch.RECOMMENDED READINGSColeman SS, Anson B: Arterial patterns in the hand based on a study of 650 specimens. Surg Gynec Obstet 1961;4:409-424.Ames EL, Bissonnette M, Acland R, Lister G, Firrell J. Arterial anatomy of the thumb.78J Hand Surg Br. 1993 Aug;18(4):427-36. PubMed PMID: 8409651.View Abstract atPubMed

Question 1344

Topic: 7. Hand and Wrist

Video 1 shows a 20-year-old right-hand dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

. Lunotriquetral fusion
. Distal radioulnar joint (DRUJ) tenodesis
. Triangular fibrocartilage complex (TFCC) repair
. Extensor carpi ulnaris (ECU) tendon sheath reconstructionUpon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Correct Answer & Explanation

. Lunotriquetral fusion

Explanation

A 53-year-old woman is experiencing thumb weakness. She has a remote history of a wrist fracture treated with a cast. She cannot lift her thumb off of a table when her hand is lying flat, palm-down. What is the most appropriate course of treatment?A. Abductor pollicis longus reconstruction with palmaris autograftB. Extensor pollicis brevis repairC. Extensor pollicis longus (EPL) repairD. Extensor indicis proprius (EIP) to extensor pollicis longus tendon transferThe EPL is the only tendon that will lift a thumb off of a table as described. It is the most frequently ruptured tendon associated with distal radius fractures. Rupture is more common with nondisplaced fractures. Rupture after a nondisplaced or minimally displaced fracture suggests an ischemic etiology. The patient will not be able to lift her thumb off of a table with her hand lying flat, palm-down. Direct repair is often difficult because of retraction of tendon ends, atrophy, and fraying. The EIP has a similar amplitude and direction of pull. Prerequisites for the use of the EIP to EPL tendon transfer include independent extension of the index finger.15- Figure 1 is the clinical photograph of a very functional 17-year-old boy with cerebral palsy and quadriplegia. He has no active supination but has full passive supination. His ability to determine position and sensibility without visual input are good. Radiographs show no osseous malalignment. Which treatment can best improve this patient's function?A. Physical therapy for supination strengthening1- Figures 1 through 3 are the radiographs of a 40-year-old woman who sustained a minor injury to her left ring finger. Prior to this injury she was asymptomatic, but she now notes pain and swelling. What is the best course of treatment?A. Observation onlyB. Fluoroscopic-guided intralesional steroid injection followed by serial radiographsC. Immediate curettage without bone graftingD. Splint immobilization with curettage and possible grafting after the fracture has healedThis patient has a fracture of the middle phalanx attributable to the presence of an enchondroma. Enchondromas are the most common benign bone tumor affecting the hand. This particular enchondroma has thinned the cortices extensively so that even minor trauma can cause a pathologic fracture. Observation is not the best treatment because a fracture is present, and, at a minimum, the digit should be immobilized.

Question 1345

Topic: 7. Hand and Wrist

Figures 1 through 3 are the radiographs of a 27-year-old man who has had wrist pain since falling 1 day ago. Which treatment offers the best prognosis for prevention of carpal collapse and progressive arthritis?

. Long-arm cast
. Percutaneous screw fixation
. Open reduction and internal fixation (ORIF) with bone graft
. Proximal row carpectomy

Correct Answer & Explanation

. Long-arm cast

Explanation

EXPLANATION:Although this patient’s history includes a recent fall, the radiographs show evidence of a scaphoid nonunion with carpal collapse but no arthritis. Obtaining union of the scaphoid is important to prevent progressive carpal collapse and arthritic changes. ORIF with bone graft is most appropriate to obtain union and correct the collapse deformity. Screw fixation with volar wedge graft often is performed to realign a scaphoid humpback deformity, although cancellous bone graft also is a reasonable option. Vascularized bone graft is considered for a nonunion of long duration, avascular necrosis of the proximal pole, and failed prior surgery. Cast immobilization will not lead to union of the scaphoid. Percutaneous screw fixation is not indicated for the treatment of a displaced nonunion. A proximalrow carpectomy is a salvage procedure and is not indicated for this patient because there are no arthritic changes.

Question 1346

Topic: 7. Hand and Wrist

A 52-year-old woman slips in her bathroom and strikes her right hand on a cabinet. She notes swelling, ecchymosis, and pain with attempted motion. There are no open wounds. Radiographs are shown in Figures 5a through 5c. What is the most appropriate treatment?

. Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension
. Immobilization of the hand with the MCP joints in extension and the IP joints in extension
. Percutaneous pinning of the proximal phalanx
. Open reduction and internal fixation of the proximal phalanx
. Early motion and pain management

Correct Answer & Explanation

. Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension

Explanation

DISCUSSION: Nondisplaced transverse fractures of the phalanges are stable.  Immobilization in the intrinsic plus position will prevent MCP joint stiffness.  Displaced oblique fractures are more at risk for instability.REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5.  Philadelphia, PA, Elsevier, 2005, p 281.Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures.  J Am Acad Orthop Surg 2000;8:111-121.

Question 1347

Topic: Wrist & Carpus

Video 1 depicts a 20-year-old right-hand-dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

. Triangular fibrocartilage complex (TFCC) repair
. Lunotriquetral fusion
. Distal radioulnar joint (DRUJ) tenodesis
. Extensor carpi ulnaris (ECU) tendon sheath reconstruction

Correct Answer & Explanation

. Triangular fibrocartilage complex (TFCC) repair

Explanation

EXPLANATION:Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Question 1348

Topic: 7. Hand and Wrist

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?

. Central space
. Hypothenar space
. Carpal tunnel
. Posterior adductor space
. Thenar space

Correct Answer & Explanation

. Thenar space

Explanation

DISCUSSION: Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm.  The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm.  The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space.  The three palmar spaces include the hypothenar space, the thenar space, and the central space.  The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3.  Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.Lee D, Ferlic R, Neviaser R: Hand infections, in Berger R, Weiss AP (eds): Hand Surgery.  Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 1784-1785.

Question 1349

Topic: 7. Hand and Wrist

Figure 1 is the right hand of a 65-year-old man with a history of hypertension and rheumatoid arthritis. He is taking immunosuppressive disease-modifying antirheumatic drugs (DMARDs) and is seen in the emergency department with rapid progression of erythema from his right thumb to his right arm during the last 12 hours. He is confused, lethargic, and has these vital signs: blood pressure 92/40, respiratory rate 45, temperature 39.7°C, pulse 135, and oxygen saturation 90% on 4 liters of oxygen by face mask. An examination of his right upper extremity reveals black bulla extending from the metacarpophalangeal down to the tip and no capillary refill at the pulp. Immediate treatment should consist of

. intravenous (IV) antibiotics and admission to a medical intensive care unit.
. emergent radical debridement including thumb amputation.
. emergent revascularization of the thumb with a vein graft.
. urgent irrigation of the thumb flexor tendon sheath.

Correct Answer & Explanation

. intravenous (IV) antibiotics and admission to a medical intensive care unit.

Explanation

EXPLANATION:This patient has multiple criteria for necrotizing soft-tissue infection (NSTI, also known as necrotizing fasciitis) including rapidly progressive infection, black bulla, hypotension and hypoxia, and a history of immune compromise. Aggressive emergent debridement including the removal of all necrotic tissue and IV antibiotics can decrease morbidity and mortality. Not all patients will have such obvious NSTI findings. In less clear cases, a scoring system using laboratory values (the Laboratory Risk Indicator for Necrotizing Fasciitis) can help clarify the diagnosis. IV antibiotics are key to treatment as well, but any delay in surgical treatment can increase morbidity and mortality. The black bulla and necrotic-appearing thumb indicate that this infection is not confined to the flexor sheath, therefore irrigation of the tendon sheath alone would be insufficient treatment. Although the thumb is dysvascular, this is because of aninfection, and revascularization is not indicated.

Question 1350

Topic: 7. Hand and Wrist

The attachments of the transverse carpal ligament include which of the following structures?

. Scaphoid and the ulna
. Trapezium and the hook of the hamate
. Trapezium and the triquetrum
. Trapezoid and the hook of the hamate
. Trapezoid and the pisiform

Correct Answer & Explanation

. Scaphoid and the ulna

Explanation

DISCUSSION: The transverse carpal ligament is the volar boundary of the carpal tunnel.  It attaches to the scaphoid and trapezium radially and the pisiform and the hook of the hamate ulnarly.  The ulna and trapezoid do not receive attachments of the transverse carpal ligament.REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3.  Philadelphia, PA, Harper and Row, 1982, vol 3, pp 471-472.Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2.  Philadelphia, PA, Lippincott-Raven, 1994, pp 168-170.

Question 1351

Topic: 7. Hand and Wrist

A patient undergoes the procedure shown in Figure 19. An important part of this procedure is preservation of what wrist ligament?

. Radioscaphocapitate
. Scapholunate interosseous
. Ulnotriquetral
. Volar radioulnar
. Deep proximal capitohamate

Correct Answer & Explanation

. Radioscaphocapitate

Explanation

DISCUSSION: Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct.  This has been attributed to two factors: 1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and 2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.REFERENCE: Jebson PJ, Engber WD: Proximal row carpectomy.  Tech Hand Up Extrem Surg 1999;3:32-36.

Question 1352

Topic: 7. Hand and Wrist

You are counseling a 55-year-old woman for a right carpal tunnel release. What can you tell her about the treatment benefit (grip strength and paresthesia relief) 1 year after surgery compared with continued splinting, NSAID use, physical therapy, and a single steroid injection?

. No change in paresthesias and grip strength
. Increase in grip strength and decrease in paresthesias
. Decrease in grip strength and increase in paresthesias
. Increase in grip strength and paresthesias

Correct Answer & Explanation

. Increase in grip strength and decrease in paresthesias

Explanation

EXPLANATION:Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength andparesthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength andparesthesias, are not supported by the evidence.

Question 1353

Topic: 7. Hand and Wrist

A 2-year-old child is being evaluated for limb-length and girth discrepancy. As a newborn, the patient was large for gestational age and had hypoglycemia. Current examination shows enlargement of the entire right side of the body, including the right lower extremity and foot. The skin shows no abnormal markings, and the neurologic examination is normal. The spine appears normal. Radiographs confirm a 2-cm discrepancy in the lengths of the lower extremities. Additional imaging studies should include

. bone age of the left wrist.
. MRI of the spine.
. MRI of the brain.
. renal and abdominal ultrasonography.
. hip ultrasonography.

Correct Answer & Explanation

. renal and abdominal ultrasonography.

Explanation

DISCUSSION: The patient may have Beckwith-Wiedemann syndrome (BWS), which consists of exophthalmos, macroglossia, gigantism, visceromegaly, abdominal wall defects, and neonatal hypoglycemia.  Hemihypertrophy develops in approximately 15% of patients with BWS.  Patients with hemihypertrophy that is the result of BWS have a 40% chance of developing malignancies such as Wilms’ tumor or hepatoblastoma; therefore, frequent ultrasound screening is recommended until about age 7 years.  The absence of nevi and vascular markings helps to rule out other causes of hemihypertrophy, such as neurofibromatosis, Proteus syndrome, and Klippel-Trenaunay syndrome.  Bone age estimations are not accurate at this young age but may become more useful later to help predict the timing of epiphysiodesis procedures.REFERENCES: DeBaun MR, Tucker MA: Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry.  J Pediatr 1998;132:398-400.Ballock RT, Wiesner GL, Myers MT, et al: Hemihypertrophy concepts and controversies.J Bone Joint Surg Am 1997;79:1731-1738.Carpenter CT, Lester EL: Skeletal age determination in young children: Analysis of three regions of the hand/wrist film.  J Pediatr Orthop 1993;13:76-79.

Question 1354

Topic: Nerve & Tendon

The posterior cord of the brachial plexus terminates into what two main branches?

. Lateral and medial pectorals
. Lateral pectoral and suprascapular
. Radial and axillary nerves
. Musculocutaneous and the lateral root of the median nerve
. Ulnar and medial roots of the median nerve

Correct Answer & Explanation

. Lateral and medial pectorals

Explanation

DISCUSSION: The posterior cord of the brachial plexus terminates into the radial and axillary nerves.  The lateral cord terminates in branches to the musculocutaneous and the lateral root of the median nerve.  The medial cord terminates in branches to the ulnar and medial roots of the median nerve.REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3.  Philadelphia, PA, Harper and Row, 1982, pp 228-236.

Question 1355

Topic: 7. Hand and Wrist

Based on the MRI scan shown in Figure 6, the abnormal signal is seen in what carpal bone?

. Triquetrum
. Lunate
. Hamate
. Trapezium
. Trapezoid

Correct Answer & Explanation

. Triquetrum

Explanation

DISCUSSION: The MRI scan reveals an abnormal signal in the trapezoid, which lies adjacent to the capitate in the distal carpal row.  The tumor is a giant cell tumor of bone.REFERENCES: Cooney WP, Linscheid RL, Dobyns JH: The Wrist: Diagnosis and Operative Treatment.  St Louis, MO, Mosby-Year Book, 1998, vol 1, pp 278-282.Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4.  New York, NY, Churchill Livingstone, 1999, pp 2238-2240.

Question 1356

Topic: Hand Trauma & Infection

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

. observation.
. marsupialization of the nail fold.
. application of copper sulfate.
. application of calcium gluconate.
. incision and drainage of the pulp.

Correct Answer & Explanation

. observation.

Explanation

DISCUSSION: Small vesicles on the fingers of a health care worker suggest a herpetic infection, and the management of choice is observation.  Incision and drainage may result in a bacterial infection.  Marsupialization is used in the treatment of a chronic paronychia.  Calcium gluconate is used for hydrofluoric acid burns, and copper sulfate is used for white phosphorus burns.REFERENCES: Fowler JR: Viral Infections.  Hand Clin 1989;5:613-627.Jebsen PL: Infections of the fingertip: Paronychias and felons.  Hand Clin 1998;14:547-555.

Question 1357

Topic: 7. Hand and Wrist

-A 42-year-old woman has had right wrist pain for 2 years. She tried splint wear and naproxen and has had 3 steroid injections, each time experiencing less relief.

. Examination revealed tenderness at and just proximal to the radial styloid, with pain exacerbated with thumb flexion and wrist ulnar deviation. What
. is the best next step in treatment?
. Physical therapy
. Continued splint wear
. Repeat injection into the first dorsal wrist compartment
. Incision of the first dorsal wrist compartment at the volar edge
. Incision of the first dorsal wrist compartment at the dorsal edge

Correct Answer & Explanation

. Examination revealed tenderness at and just proximal to the radial styloid, with pain exacerbated with thumb flexion and wrist ulnar deviation. What

Explanation

Question 1358

Topic: 7. Hand and Wrist

Figure 53 shows the arteriogram of a 45-year-old man who has severe vasculitis. What do the findings show?

. A patent ulnar artery and deep palmar arch
. A patent ulnar artery and superficial palmar arch
. A patent radial artery and deep palmar arch
. A patent radial artery and superficial palmar arch
. A patent radial artery and an ulnar artery aneurysm

Correct Answer & Explanation

. A patent ulnar artery and deep palmar arch

Explanation

DISCUSSION: The arterial supply to the hand is abundant and normally duplicated.  The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space.  The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.REFERENCE: Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment.  Philadephia, PA, Mosby-Year Book, 1998, p 110.

Question 1359

Topic: 7. Hand and Wrist

-A 37-year-old woman has a 2-month history of weakness in thumb and finger extension, but has normal radial deviation during extension of the wrist. An MRI scan of her forearm shows no abnormality. She does not recall any traumatic event. Needle electromyography findings show fibrillations and reduced

. recruitment in the extensor pollicis longus, abductor pollicis longus, extensor digitorum communis, and extensor carpi ulnaris muscles. Which nerve is most likely compressed?
. Median
. Radial
. Anterior interosseous
. Posterior interosseous
. Lateral antebrachial cutaneous

Correct Answer & Explanation

. recruitment in the extensor pollicis longus, abductor pollicis longus, extensor digitorum communis, and extensor carpi ulnaris muscles. Which nerve is most likely compressed?

Explanation

Question 1360

Topic: 7. Hand and Wrist

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

. volar open reduction and pinning.
. open reduction, ligament repair, and pinning.
. closed reduction and splinting.
. closed reduction and pinning.
. dorsal open reduction and pinning.

Correct Answer & Explanation

. volar open reduction and pinning.

Explanation

DISCUSSION: The radiograph shows a volarly dislocated lunate.  Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression.  Open reduction and pinning or ligament repair are necessary but are not emergent.  A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation.  Unfallchirurg 2002;105:1133-1138.Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2.  Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

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