Perilunate Injuries: Current Aspects of Management

Surgical management and functional outcomes of perilunate dislocations and fracture dislocations through the dorsal approach

BACKGROUND

Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist, with surgical management leading to acceptable functional results.

PURPOSE

The purpose of this study was to assess the functional outcomes of the patients of our department who were treated with surgical management of PLDs/PLFDs through dorsal approach, as well as to report any complications on their follow-up.

PATIENTS AND METHODS

In this retrospective study, 52 patients with PLD/PLFD, fulfilling the inclusion and exclusion criteria of the study, underwent surgical management of their injury. All patients were followed up at 6 weeks, 12 weeks, 6 months, 1 year postoperatively with radiographic imaging as well as functional scores measured with the modified mayo wrist score and the QuickDASH questionnaire.

RESULTS

The mean postoperative modified Mayo score was 76.8 ± 8.8 and the mean QuickDASH score was 1.52 ± 2.18. Of the 52 cases, 20% had excellent results, 42% had good results, 29% had fair results and 9% had poor results as per the modified Mayo wrist score. No patient signed any symptoms of median nerve neuropathy.

CONCLUSION

In conclusion, open reduction and internal fixation through dorsal approach is a reliable technique to manage perilunate injuries in spite of radiological evidence of wrist arthritis, as it also provides consistently good results in terms of functional outcomes.

LEVEL OF EVIDENCE IV

Retrospective case series study.

Dorsal spanning plate fixation in perilunate injuries: a case report

A 63-year-old male presented with a trans-scaphoid lunate dislocation after a ten-foot fall. Internal fixation included placement of a dorsal spanning plate (DSP). One-year follow-up yielded a satisfactory outcome. A rigid DSP is a useful tool in acute perilunate injuries to protect internal fixation constructs and help with injury rehabilitation.

Perilunate Dislocations: Reduction and Stabilization

Background

The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no arthrosis present. The goal of this procedure is to reconstruct the torn dorsal portion of the scapholunate ligament in order to stabilize the scaphoid and lunate.

Description

A standard dorsal approach to the wrist, extending from the third metacarpal distally to the distal radioulnar joint, is utilized. The extensor pollicis longus is transposed and retracted radially, and the second and fourth extensor compartments are retracted ulnarly. A Berger ligament-sparing capsulotomy is utilized to visualize the carpus. Volarly, an extended open carpal tunnel release is also utilized to relieve any median nerve compression and to aid in reduction. The contents of the carpal tunnel can be retracted radially, allowing for visualization of the carpal bones. Joystick pins are placed in order to reduce the scaphoid and lunate. Reduction is held provisionally by clamping the pins until 4 pins can be placed across the carpal bones. For scapholunate reconstruction, 3 holes are made: in the lunate, proximal scaphoid, and distal scaphoid. Suture tape is then utilized to hold the scaphoid and lunate in their proper position. The dorsal wrist capsule and extensor retinaculum are repaired during closure. The pins are cut near the skin and are removed in 8 to 12 weeks.

Alternatives

Several other methods of scapholunate reconstruction have been described, including capsulodesis, tenodesis, and bone-tissue-bone repairs. Additionally, in patients who are poor candidates for scapholunate reconstruction, wrist-salvage procedures can be utilized as the primary treatment.

Rationale

Scapholunate reconstruction has the advantage of preserving the native physiologic motion of the wrist, in contrast to the many different wrist-salvage procedures that include arthrodesis or arthroplasty. Avoiding arthrodesis is specifically advantageous in patients who have not yet developed arthrosis of the wrist bones.

Expected Outcomes

Outcomes of scapholunate reconstruction vary widely; however, there is a nearly universal decrease in range of motion and strength of the wrist. Wrist range of motion is typically 55% to 75% of the contralateral side, and grip strength is typically approximately 65% of the contralateral side. In a prior study, 50% to 60% of patients whose work involved physical labor were able to return to their same level of full-time work. Disabilities of the Arm, Shoulder and Hand scores average between 24 and 30. Specific patients at risk for inferior outcomes are those with delayed surgical treatment, poor carpal alignment following reduction, or open injuries.

Important Tips

Patients are counseled preoperatively regarding the likelihood of permanent wrist stiffness and the possibility of scapholunate diastasis even in the setting of technically successful repair.Traction and dorsally directed pressure on the lunate through an extended carpal tunnel incision can aid in reduction of the lunate.The joystick pin position in the dorsal scaphoid is angulated from distal to proximal and that in the lunate is angulated from proximal to distal in order to help correct flexion of the scaphoid and extension of the lunate by clamping together the Kirschner wires. Modifying the distance of the clamp from the carpus can allow precision in the degree of scapholunate angle fixation.Intercarpal Kirschner wire fixation of the scapholunate, lunotriquetral, and midcarpal joints (scaphocapitate and triquetrohamate) is best performed with 0.062-in (1.6-mm) Kirschner wires. The insertion angle is best visualized when the Kirschner wire is introduced from inside the incision through the skin, "inside out," in order to best envision the trajectory on the dorsal carpus and define the starting point on the bone. The Kirschner wire is then advanced through the carpus from outside-in at a slightly more volarly translated (but not angulated) position. The Kirschner wires are then cut beneath the skin at a depth that will allow them to be retrieved but will not cause them to become exposed once swelling decreases.The wrist is generally immobilized until the pins are removed at 3 months postoperatively.

Acronyms and Abbreviations

ROM = range of motionK-wire = Kirschner wireDASH = Disabilities of the Arm, Shoulder and HandDISI = dorsal intercarpal ligament instability.

Simultaneous quadruple dislocations of the hand in a motorcyclist: A case report

Herein we present a case of four simultaneous dislocations of the hand resulting from a motorcycle accident in a young man. In this case, the 1st CMC, MCP, and IP joints of the right hand were dislocated along with right perilunate dislocation. Perilunate dislocation was treated with open reduction and internal fixation. Close reduction of IP and CMC was done and CMC was fixed by pins. MCP dislocation was treated by open reduction and pinning in addition to collateral ligament and capsular repair. In follow-up excellent functional activity and range of motion were observed.

Trans-scaphoid Lunate Dislocation Rare Injury: A Case Report

Lunate dislocations are complex and uncommon wrist injuries, often resulting from high-energy trauma like road traffic accidents, falls, and industrial mishaps. Timely diagnosis and appropriate surgical management are critical to achieving favorable outcomes and minimizing long-term disability. Here, we present a case of a 22-year-old male who sustained a trans-scaphoid lunate fracture dislocation due to a motorcycle accident. Prompt wrist x-ray evaluation and subsequent surgical interventions led to the successful restoration of wrist function and stability. This case report highlights the importance of early recognition and discusses the accurate diagnosis and timely management of lunate fracture dislocations to avoid long-term complications and disability.

Ligament Ruptures in Ankle Fractures-Was Lauge-Hansen Right?

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.