Outcome of treatment of complex, perilunate fracture-dislocation of the wrist: a case report

Complex, perilunate fracture-dislocations of the wrist comprise severe and challenging injuries, characterised by a total loss of contact between the lunate bone and the head of the capitate as well as fracture of one, or more bones surrounding lunate bone. The principle of treatment of such injuries involves stable fixation of fractures, anatomical reduction of the displaced carpal bones with temporary arthrodesis wit K-wires to maintain their position. We present a patient who sustained a complex, perilunate fracture-dislocation of the wrist with fractures of the scaphoid, hamate and base of the IV metacarpal bone, as a result of a blast. Assessment at one year after the surgery showed satisfactory result: mean range of motion in the wrist was 50-60% of the healthy side, grip strength was 55%, DASH score of 36 and Mayo score of 65.

The use of temporary screw augmentation for the treatment of scapholunate injuries

INTRODUCTION

Injuries to the scapholunate (SL) interosseous ligament can have devastating consequences to carpal stability. The purpose of this study is to provide a technique for screw augmentation to SL reconstruction, while comparing radiographic outcomes to a traditional Kirschner wire fixation cohort.

METHODS

A retrospective review of all patients treated by screw fixation for SL ligament injuries was cross-matched to a cohort of patients treated with pin fixation for age and length of time from the time of injury to surgical fixation. Outcomes were the values of SL gap and SL angle on plain radiographs as averaged between 2 independent reviewers, as well as complications.

RESULTS

Seven patients who received screw augmentation had an average follow-up of 8.7 months. When compared with the Kirschner wire cohort, there was improvement of immediate postoperative gap in the screw cohort of 3.1 versus 1.3 mm. There was also better reduction in SL angle in the screw group (22 vs. 10.4 degrees correction). At 4 months follow-up, both the SL gap and SL angle were maintained better in the screw group. There was 1 infection in each cohort, 1 pin migration in a screw/pin combination patient counted in the screw group, and 1 pin migration in the pin cohort.

CONCLUSIONS

Our study suggests that temporary screw augmentation for SL ligament injuries results in more effective SL gap and SL angle correction both immediately and in short-term follow-up than does pin fixation. Longer follow-up is needed to evaluate longevity of reduction, and larger, prospective studies with clinical outcomes are needed to show statistically significant benefits to screw augmentation.

Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.

Proximal row carpectomy for chronic unreduced perilunate dislocations

We evaluated the results of proximal row carpectomy (PRC) for unreduced perilunate dislocation in 6 patients. The average period from the injury to the operation was 24 weeks. The modified Mayo wrist score was used for clinical evaluation. Radiological evaluation was based on the radius-capitate alignment. Pain disappeared in 4 cases; mild pain during activity persisted in 2 cases. The average flexion-extension are was 59% of the values on the unaffected side. The average grip strength was 72% of the unaffected side, and the average modified Mayo wrist score was 71 points. Three patients showed favourable radius-capitate alignment, while the other 3 patients showed poor radius-capitate alignment on the radiographs. The postoperative radius-capitate alignment was related to the preoperative position of the capitate on the lateral view. Those with poor radius-capitate alignment tended to obtain lower scores compared to those with favourable alignment.

Antero-medial approach to the wrist: anatomic basis and new application in cases of fracture of the lunate facet

The Henry approach is the classical anterolateral surgical exposure of the volar aspect of the distal radius. This approach does not allow good access to the medial side of the volar distal radius (lunate facet) and the distal radio-ulnar joint, unless it is extended proximally, retracting the tendons and the median nerve medially, which can cause some trauma. The purpose of our study was to investigate the anatomic basis and to outline the advantages of the unusual anteromedial approach, reporting our experience in the treatment of 4 distal radius fractures, with a 90° or 180° twist of the lunate facet, and 10 wrist dissections on cadavers. The average follow-up was 68.8 months (range 18 to 115 months). In our series, this approach did not cause any nerve injuries or any sensory loss of the distal forearm and the palm. All the fractures of the lunate facet and of the radial styloid process healed. One patient with an ulnar styloid process fracture associated showed pseudarthrosis, but with no instability of the distal radio-ulnar joint or pain on the ulnar side. Using the criteria of Green and O'Brien, modified by Cooney, the results were: excellent in two cases, good in one case, and average in another. The evaluation of arthritis according to Knirk and Jupiter's classification showed grade 0 in three cases and grade 3 in one case with osteochondral sclerosis. We showed that the anteromedial approach is reliable and convenient in the case of fractures situated in the antero-medial portion of the radius, for the double objective of reducing the fracture under direct control and checking the congruence of the distal radio-ulnar joint.

[Scapholunate instability of the wrist--a review]

Injury to the scapholunate ligament is considered the most common and burdened with the most negative squeals cause of the carpal instability. The article provides information on the functional anatomy of the scapholunate complex and the consequences of the tear of the ligament that joints these bones. Rupture of this ligament, associated with tear of extrinsic (secondary) stabilizers of the wrist leads on to dislocation of the carpal bones one against another and, finally, results in carpal instability. Classifications of the severity of the instability based on radiological and arthroscopic grounds were presented. Clinical symptoms and signs of the condition were described as well as imaging techniques helpful in its diagnosing. The usefulness of arthroscopy was emphasised in diagnosing of scapholunate complex disturbances, particularly those which are negative radiologically and present with no typical symptoms.

Transradial radial perilunate: a case report

We report a rare case of transradial styloid radial perilunate dislocation in a patient who presented with ulnar nerve symptoms, and we describe our treatment approach to this unusual injury. In a literature search, we found no other report of such an injury.

[Importance of early diagnosis and operative treatment for trans-scaphoid perilunate dislocation]

OBJECTIVE

To evaluate the effectiveness of open reduction and internal fixation and repair of palmar ligment in treating trans-scaphoid perilunate dislocation.

METHODS

From June 1995 to June 2001,14 patients with trans-scaphoid perilunate dislocation were treated with open reduction and internal fixation and repair of palmar ligment. Among them,there were 13 males and 1 female,the ranging in age from 21 to 38 years,averaged 25.4 years. All patients were posterior dislocation and all operations were performed within 2 weeks after injury.

RESULTS

All patients were followed up from 24 to 60 months with an average of 28.3 months. Thirteen scaphoid fractures were primary healed and functions of wrist joint were good. Bone disunion was found in 1 case and part functions of wrist joint were limited. No found necrosis of lunate and scaphoid. According to clinical scoring system of Cooney, 9 case got excellent results, 3 good, 1 fair and 1 poor.

CONCLUSION

Open reduction and internal fixation and repair of palmar ligament is effective in treating trans-scaphoid perilunate dislocation,which can early provide steady fixation for scaphoid,and profit to recover blood supply of lunatum and subterminal scaphoid.

Traumatic mechanisms and therapeutic results of the perilunate injuries

OBJECTIVE

In this study, eighteen patients who have had perilunate injury with dislocation or fracture, were evaluated and the patho-mechanics and surgical treatment were studied.

SUBJECTS AND METHODS

According to the Green and O'Brien's classification, type 1 injury occurred in one patient, type 2 in nine, type 4A in five, type 4C in one and type 4D in one. The other one case could not be classified using the Green and O'Brien's criteria.

RESULTS

According to the Evans scoring system, good results were achieved in thirteen patients, fair results, in four, poor results in one and very poor results in none. When the patho-mechanics was estimated based on the Mayfield's criteria, seventeen patients were classified as stage 3. However only one case was extremely unusual and should be classified as a subtype of stage 2.

CONCLUSION

The results were good in the majority of patients who had repair of perilunate injury.

[Perilunar dislocation of the corpus in a patient with aplasia of the scaphoid]

Congenital aplasia of the scaphoid is a rare abnormality arising when the distal row of carpal bones is dislocated radially and proximally, the capitate replaces the scaphoid, and the lunate is triangular instead of quadrilateral in shape. The scaphoid bone which makes a functional bridge between the proximal and the distal row is a stabilising element under normal anatomical conditions. If it is absent, the carpus structure is disturbed and its radial part is prone to perilunar dislocation, because stability is provided only by the ligaments. However, a perilunar dislocation associated with aplasia of the scaphoid has not been described in the literature yet. In the case reported here, after arthroscopic examination ascertaining that the capsular ligaments are not interposed between the joints, the dislocation was managed by closed reduction and Kirschner wire transfixation for 8 weeks, and the wrist was immobilised with a below-elbow plaster splint for the same period. A 22-month follow-up did not show any signs of wrist instability or restriction in hand function.

Carpal tunnel syndrome associated with a fracture of a silicone implant for Kienböck's disease: two case reports

In this report, two cases presenting with CTS including a fracture of the silicone implant for Kienböck's disease after replacement over 20 years postoperatively where CTR ceased the symptoms of CTS. The major symptom characteristic was the median nerve impairment with less emphasis on the limited range of motion of the wrist or wrist pain due to a fracture of the silicone implant. There was an unlikely association between the fracture of the implant and CTS, which was confirmed by the operative findings of tenosynovitis and thickness of the degenerated transverse ligament without a significant protrusion of the silicone implant.

[Volar transscaphoid perilunate fracture dislocation. A case report]

Volar perilunar dislocations of the carpus are rare. They occur in young patients following a violent injury. Open reduction is often needed because of instability of the lesion. The authors report a case of volar transscaphoid perilunate fracture-dislocation treated surgically, with a satisfactory functional result after a follow-up of two and a half years.

Apparent visi deformity: periscaphoid perilunate dissociation - a case report

We report a case of carpal instability complex, which presented apparent volar intercalated segmental instability (VISI) caused by acute injury. Proper diagnosis and treatment by ligament repair and Kirschner wire fixation yielded good clinical results.

Dynamic stabilization of chronic scapholunate dissociation with palmaris longus transfer: a new technique

This report presents a new procedure of palmaris longus tendon transfer to the scaphoid and lunate, with reconstruction of the scapholunate ligament in chronic scapholunate dissociation. From 1988 to 2006, 10 cases of dynamic stabilization of chronic scapholunate dissociation were treated by palmaris longus tendon transfer to the scaphoid and lunate. The tendon transfer to the scaphoid and the reconstructed scapholunate ligament appeared to create a resultant force that corrected the scaphoid drift. The transfer to the lunate neutralized its dorsal intercalary segment instability posture. A normal scapholunate interval was restored at about 2 years postoperatively, and the lunate malrotation remained permanently corrected. Recovery of the scapholunate interval paralleled the recovery of the scapholunate angle and grip strength. These remained unchanged with long-term follow-up of between 3 and 18 years. The tendon transfer appeared to function like other tendon transfers in the upper extremity, providing active stabilization of the scaphoid and the lunate despite increasing loads on the wrist. Unfortunately, in the absence of symptoms of peripheral nerve entrapment, insurance approval could not be obtained for electromyography studies to document the activity of the transferred tendon. The forces of tendon transfer on the scaphoid and the reconstructed scapholunate ligament seem to generate a resultant force that acted on the scaphoid to maintain it in its fossa. The tendon transfer to the lunate corrected the dorsal intercalary segment instability orientation of the lunate at long-term follow-up of up to 18 years.

Stress injury of the lunate in tennis players: a case series and related biomechanical considerations

OBJECTIVE

To investigate clinical and imaging differential diagnosis and tennis stroke biomechanics potentially involved in lunate stress injury pathogenesis.

METHODS

The present report describes five competitive tennis players with overuse-related dorsal wrist pain assessed by magnetic resonance imaging.

RESULTS

Magnetic resonance imaging revealed the presence of lunate stress injury. All players were treated conservatively, with symptom resolution and complete functional recovery achieved at 14 weeks.

CONCLUSIONS

Lunate stress injuries should be considered in the differential diagnosis of overuse-related dorsal wrist pain in tennis players.

Delayed post-traumatic midcarpal dislocation

We report a case of delayed post-traumatic volar midcarpal dislocation in a 39 year-old woman. The dislocation was a gradual process starting from the time of injury. Initial X-rays showed a normal midcarpal joint. By 6 weeks, lunocapitate subluxation was apparent radiologically and by the 18 week X-ray, midcarpal dislocation had occurred. This type of wrist injury has not been previously reported. Because of advanced degenerative changes in the lunocapitate joint, a partial wrist fusion was performed with a successful outcome.

Long-term follow-up of an undiagnosed trans-scaphoid perilunate dislocation demonstrating articular remodeling and functional adaptation

The most common perilunate dislocation is the trans-scaphoid dorsal perilunate variant. It is estimated that up to 25% of perilunate injuries are diagnosed late. We report 66-year follow-up of an unreduced, previously undiagnosed trans-scaphoid perilunate dislocation of the wrist. At follow-up, unique post-traumatic articular remodeling was seen on wrist radiographs, and the patient had only a mild functional deficit.

Fracture luxation rétrolunaire du carpe avec fracture du lunatum. Une nouvelle forme clinique. À propos d'une observation

A fracture of the semi-lunar in the frontal plan seems to be a rare and still exceptional hurt when it accompanies a retro-lunar dislocation of carp. Our case allows to see again the lesionnel mechanism of the dislocations of carp particularly in its retro-lunar variety and so to classify our case or rather to individualize it and to put it there "except series".

Bilateral volar lunate dislocation

A 12 years follow-up of a case of bilateral volar lunate dislocation treated by open reduction and K-wire stabilisation of both wrists six days after injury is described. Despite aseptic necrosis of both lunates, the patient is pain free and has useful function, without the development of lunate ischaemia and collapse, carpal instability or posttraumatic osteoarthritis.

Bilateral osteochondroma of the scaphoid causing scapholunate dissociation: a case report

A case with bilateral scaphoid osteochondroma (exostosis) with scapholunate dissociation. In both the cases a proximal row carpectomy was performed with excellent outcome.

[Wrist perilunate dislocation]

Carpal perilunate dislocations are rare and underdiagnosed because of an ignorance of the pathology and an inappropriate incidence of radiography. The carpus is composed of two rows of bones and 33 ligaments. These ligaments are fundamental for wrist stability. Typically, the injury occurs in young male adults exposed to high-energy trauma with a wrist in hyperextension. The diagnosis is easy with a physical examen and standard postero-anterior and lateral radiographs. The Witvoët and Allieu classification of the perilunate dislocations is the most used. This classification is composed of three grades. The treatment is usually surgical and has to be realised in a short delay to minimize the important complications.