Perilunate injuries. Repair by dual dorsal and volar approaches

Controversy persists regarding optimal management of perilunate injuries. Traditionally, closed treatment, with or without percutaneous pin fixation, was advocated for these highly unstable carpal disruptions, but the inconsistent and often disappointing outcome of closed reduction, coupled with the recognition that functional recovery closely parallels the accuracy of restoring carpal alignment, have led to increasing enthusiasm for open treatment. The favorable outcome reported in this article supports both the contention that the acute perilunate injury affords the opportune time for operative preservation of carpal stability and the efficacy of the combined dorsal and volar approaches as the optimal means of surgical repair. This clinical experience also corroborates experimental evidence that perilunate injuries are apt to cause a predictable spectrum of osseous and soft tissue lesions--lesions usually suitable for early, precise repair. For the skilled athlete, prompt recognition and precision treatment of all components of injury are the critical factors to attain a functional outcome commensurate with a successful return to competition.

[Anterior trans-scaphoid-lunate luxation of the wrist. Apropos of a case]

About one uncommon case of anterior perilunate fracture-dislocation, the authors show the interest of posterior approach of the wrist to treat all the lesions. The scaphoïd is screwing proximally to distally and a pin is used to stabilise the pyramidolunare articulation. The clinical results are good on motion, on strength; the lunate doesn't present necrosis on radiology at 4 years.

[Surgical treatment possibilities of advanced carpal collapse (SNAC/SLAC wrist)]

Longstanding and untreated scaphoid fractures and scapholunate dissociations lead to painful destruction of the wrist with carpal collapse. The severity of degenerative arthrosis is classified in three stages and can be treated adequate operatively. SNAC wrist (scaphoid nonunion advanced collapse) after failed fusion of the scaphoid and SLAC wrist (scapholunate advanced collapse) after scapholunate dissociation should be differentiated. The reconstruction of the scaphoid or scapholunate ligament in stage II and III is no reasonable option. Motion preserving procedures such as proximal row carpectomy or midcarpal arthrodesis are preferable in this situation. Thirty-one male patients (average 41 years) were treated for SNAC or SLAC wrist with midcarpal arthrodesis. All patients were reexamined, the mean follow-up was 15 months. Grip strength was measured with the Dexter-System, pain was evaluated by a visual analogue scale (VAS 0-100). Patients' daily activities and general quality of life were estimated with the DASH-questionnaire. Pain was reduced to 50% compared to the preoperative situation. Grip strength improved to 60% of the opposite side. Active range of motion reached 50% of the contralateral wrist. Total DASH-score reached 39.0. Nonunion at the fusion site necessitated additional surgery in four patients resulting in total wrist arthrodesis. 80% of the patients returned to their original occupation. Midcarpal fusion is a reliable procedure for treating the difficult condition of advanced carpal collapse if proper realignment of the carpus is performed. The DASH-score reflects the subjective impressions of the patients in daily life and justifies the choice of a salvage procedure preserving wrist mobility. Total wrist fusion represents the last line of defense.

[Interscapholunate carpal axial dislocation: a case report]

We present a case of a patient presenting a right wrist injury due to a motor vehicule accident. X-rays and CT Scan showed transcapholunate axial dislocation with the capitate impacted between the scaphoid and the lunate without perilunate dislocation. This injury was associated to a fracture of radial styloid process, trapezium, triquetrum, hamate, and a pisotriquetral and intermetacarpal dissociation. We did not find any similar case in French or English litterature. Treatment associated closed reduction and percutaneous pinning. At one year follow-up the wrist was painless with a normal range of motion. This lesion contributes to the understanding of carpal injuries mechanism. Capitate ascension within the scapholunar joint due to an important compression force is a pathogenic factor of scapholunate dissociation.

Long-term assessment of proximal row carpectomy for chronic perilunate dislocations

Twelve patients with chronic stage III or stage IV perilunate dislocations were managed over the past 7 years by proximal row carpectomy. All dislocations were untreated or incompletely reduced for a minimum of 8 weeks after injury. The mean time from injury to definitive treatment was 15 weeks (range, 8 weeks to 6 months). Surgical management was inclusive of a dual dorsal and volar approach. Median nerve decompression, lunate excision, and capsuloligament repair was performed volarly and scaphoid and triquetrum carpectomy was accomplished dorsally. Temporary radio capitate K-wire fixation during early soft tissue healing was uniformly performed. All patients were evaluated at an average postoperative duration of 40 months (range, 28 months to 7 years). Marked relief of wrist pain and median nerve dysesthesias was routinely achieved. Effective wrist range of motion and grip strength were restored. Untreated stage III and IV chronic perilunate dislocation treated by proximal row carpectomy eliminates pain and restores function to a severely injured wrist.

[Scapholunate dissociation. Results of ligament suture and ligament-plasty]

The diagnosis of scapholunate ligament rupture is frequently missed. Untreated, it will lead to carpal collapse and arthrosis of the wrist, and ultimately to scapholunate advanced collapse (SLAC-wrist). We report the results of 20 patients treated either by direct suture or reconstruction of the ligament with a follow-up of three to five years after surgery. The operation was performed between 0.5 and 120 months (suture 2.6 months, reconstruction 28 months) after the original trauma. The results of direct repair were superior to ligament reconstruction. In our experience, direct ligament repair was only possible up to four to six months after trauma, this study emphasizes the importance of early diagnosis and treatment by anatomical reposition of scapholunate ligament rupture.

MR imaging of the type II lunate bone: frequency, extent, and associated findings

OBJECTIVE

Type II lunate bones have an "extra" facet that articulates with the hamate bone, which frequently leads to arthritis. Because the only prior studies, to our knowledge, on this common and clinically significant variant involved dissection of cadavers, we performed an MR imaging study of the type II lunate.

MATERIALS AND METHODS

We retrospectively reviewed MR images obtained at 1.5 T of 186 wrists for frequency of type II lunates, size of the extra facet, amount of hamatolunate apposition, and presence of hamate subchondral edema. Of the 186 wrists, 28 also had correlation with findings on wrist arthroscopy.

RESULTS

One hundred seven wrists (57.5%) had type II lunates with an average extra facet size of 4.6 mm (range, 1.2-12.0 mm). Apposition (articulation) of the extra lunate facet with the hamate averaged 77.4% (range, 0-100%). Hamate edema was seen in only nine wrists (4.8%), all of which had type II lunates. Arthroscopic evidence of focal hamate chondromalacia and MR imaging evidence of marrow edema were seen in six of these nine wrists; marrow edema was seen only in wrists with frank cartilage changes on arthroscopy.

CONCLUSION

An extra facet (type II lunate) was seen in approximately half of 186 wrists. On MR imaging, type II lunates usually have an innocuous appearance. A large percentage of patients with type II lunates also have chondromalacia, which often is occult on MR imaging. When visible, such chondromalacia is the cause of marrow edema similar to that seen in patients with carpal fractures.

[Conservative versus surgical therapy of perilunar dislocation and dislocation fractures]

18 perilunate dislocations and fracture-dislocations were treated at the Trauma Center of the Vienna General Hospital during the period from 1992 to 1995. Only five cases were treated without surgery. 15 of these 18 patients returned for follow-up after an average of 16 months. In ten cases good results were achieved. Radiologically, eight patients were classified as good. Overall better results were seen after surgical treatment.

Fracture-dislocation of the lunotriquetral coalition

Bony fusions involving the carpus have a much higher prevalence in blacks relative to whites. This article describes a case of lunotriquetral coalition fracture-dislocation in an African American. This lesion is best treated through open reduction and pin fixation.

MRI of fractures of the distal radius: comparison with conventional radiographs

OBJECTIVE

To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury.

DESIGN AND PATIENTS

Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation.

RESULTS

Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears.

CONCLUSION

MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intraarticular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.

Stabilization of an acute perilunate dislocation using the "TAG" suture anchor

A case of acute perilunate dislocation associated with acute scapholunate dissociation and acute carpal tunnel syndrome is described in which the treatment was facilitated by the use of the TAG suture anchor.

Early results of a modified Brunelli procedure for scapholunate instability

Twenty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure. The overall results of this short follow-up study showed that a majority of patients (17 out of 22) had relief of pain. Grip strength recovered well. Postoperative range of motion was reduced in extension and flexion, remained unchanged for radial deviation and improved for ulnar deviation. The radiological appearance of dynamic or static scapholunate instability did not change after the procedure. Most patients (17 out of 22) felt subjective improvement and would have the operation again. A significantly poorer result was seen in those patients with an unresolved medicolegal claim. Although short-term results are encouraging for some patients, the authors feel that more long-term follow-up is needed before recommending the procedure.

Proximal and palmar dislocation of the lunate and proximal scaphoid as a unit in a case of scaphocapitate syndrome. A 32-month follow-up

Various patterns of transscaphoid, transcapitate fracture-dislocations have been described in the literature. There is little information on the method of management and the long-term results of such severe and rare injuries. The case described here involved a transscaphoid, transcapitate, palmar perilunate fracture-dislocation with ejection of the proximal pole of the scaphoid and lunate into the palmar aspect of the forearm. The functional result 32 months after delayed open reduction and internal fixation is reported.

Median nerve neuropathy from an old lunate dislocation

The case of an old volar dislocation of the lunate, associated with median nerve neuropathy, is described in a 37-year-old patient. The treatment took into account the age of the patient and the relative tolerance to the dislocation. We performed a simple excision of the lunate combined with a release of the transverse carpal ligament in order to free the median nerve, together with a tenosynovectomy of flexor digitorum profoundus. Two years after operation, wrist function was virtually complete and the patient was asymptomatic and had resumed his occupation.

Perilunate injuries: diagnosis and treatment

Perilunate injuries are severe disruptions of the carpus, which present a formidable challenge to the treating physician. Accurate recognition of the pattern of injury is not always straightforward. The injury can propagate through ligaments and/or bone, creating multiple variations of a basic injury pattern. Posteroanterior and lateral radiographs will depict a perilunate injury, but additional views may be necessary to appreciate subtle carpal fractures. Once the diagnosis has been established, early intervention is necessary for optimal results. An initial closed reduction with sedation and traction is performed to restore overall carpal alignment. However, subsequent closed or open reduction is necessary to restore anatomic alignment of all injured structures. The outcome of perilunate injuries correlates with the adequacy of reduction. Complications such as chondrolysis, carpal instability, and traumatic arthritis can occur despite satisfactory treatment.

[Pathological study of Kienboeck's disease]

Besides from diagnosed and undiagnosed fractures of the lunate, one should mainly remember in the pathogenesis of Kienböck disease anatomic propersities and particularly ulnar shortness and relation-ship between the radius and the lunate. These disorders cause an excessive stress on the lunate, producing osteomalacia. Our study of 133 wrists specifies the causative factors.

[Traumatic etiology of Kienboeck's disease. (Perilunate subluxations and semilunate necrosis)]

The authors have studied the incidence of lunate necrosis in 110 perilunate dislocations. Twenty-one cases (19%) developed a necrosis. The classification into three types, according to the amount of damage to the perilunar ligaments, is of prognostic value. There is no risk of necrosis in type 1, 17% in type II, and 50% in type III. An associated fracture of the scaphoid does not modify the risk. In neglected lesions, reduction of the lunate dislocation should be attempted, even at a late date, the risk of necrosis then being 50%. Surgical reduction increases the risk of secondary necrosis to a greater extent than does orthopedic treatment, but it is generally use in the most complex cases too. The authors advocate a closed reduction with percutaneous pin fixation.

Trapeziolunate external fixation for transscaphoid perilunate dislocations of the wrist: report of 2 cases

Two transscaphoid perilunate dislocations of the wrist, treated by trapeziolunate external fixation--1 after closed and the other after open reduction--are reported.

[Luno-triquetral angle and dislocation of the wrist]

The mediocarpal force, determined by the distal articular surface of both, lunate and triquetral bones, abuts against the double bolt, composed of the scaphoid and the radial styloid process. An important wrist trauma can rupture this bolt and cause a proximal and lateral translation of the distal carpal row. This situation may present under 3 forms: fracture of the scaphoid bone and midcarpal dissociation; fracture of the radial styloid process with scapholunate dissociation; scapholunate dissociation, associated with a dorsal radiotriquetral ligament rupture and medial translation of the lunotriquetral block. Experimental and clinical illustration of this process, discussion and treatment.

[Post-traumatic carpal collapse (SLAC- and SNAC-wrist)--stage classification and therapeutic possibilities]

Longstanding scaphoid nonunion or scapholunate ligament injuries can lead to carpal collapse. SLAC-wrist (scapholunate advanced collapse) following scapholunate dissociation and SNAC-wrist (scaphoid nonunion advanced collapse) after missed fusion of scaphoid fracture should be differentiated. Severity of degenerative changes is classified by three stages. In stage I where arthrosis is limited to the radial styloid reconstructive procedures of the scaphoid or scapholunate ligament are the treatment of choice. In stage II including arthrosis of the radioscaphoid joint and stage III with additional arthrosis in the midcarpal joint these procedures are excluded. Salvage procedures preserving wrist mobility like midcarpal fusion or proximal row carpectomy are preferable to total wrist fusion which represents the last line of defence.

[Scapholunar ligament injuries in acute wrist trauma. Arthroscopic diagnosis and minimally invasive surgery]

The final result of the treatment of distal intraarticular radius fractures depends both on the accuracy of the fracture reduction and on the presence or absence of additional carpal injuries. In particular, lesions of the intrinsic ligaments usually cause severe degenerative damage of the wrist joint if they are missed primarily. With the introduction of wrist arthroscopy these tears can be evaluated and treated earlier. Since 1993 arthroscopically assisted treatment has been performed in 23 patients with distal intraarticular fractures of the radius (mainly C fractures according to the AO classification system or group VII and VIII fractures according to Frykman). SL tears have been found in 11 patients (47.8%), 7 of whom showed marked instability and were stabilised at the time of surgery.