Translunate fracture with associated perilunate injury: 3 case reports with introduction of the translunate arc concept

Assessment of Ulnar Carpal Translocation and Carpal Alignment After Volar Plate Fixation With Vascularized Bone Graft for Scaphoid Waist Fracture Nonunions

PURPOSE

Multiple fixation methods with or without vascularized graft have been described to treat scaphoid nonunions. This study aimed to assess the incidence of carpal malalignment and the degree of ulnar carpal translocation after scaphoid volar plate fixation with pedicled vascularized bone graft in scaphoid waist nonunions with humpback deformity.

METHODS

A retrospective cohort study of individuals with recalcitrant scaphoid fracture nonunion treated with volar scaphoid plating and vascularized bone graft was analyzed. All patients had radiographs with the wrist at neutral with clinical follow-up of at least 3 months after surgery. Ulnar subluxation of the carpus was assessed by the change in lunate uncovering and carpal-radial distance before and after surgery.

RESULTS

Seventeen patients were included for analysis. Average age was 26 years with an average follow-up interval of 11.0 months. After surgery, 16 patients (94.1%) had fracture union. Between preoperative and initial postoperative imaging, there was an increase in lunate uncovering (mean difference: 8.8%; 95% confidence interval, 4.6% to 13.1%) and carpal-radial distance (mean difference: 3.3% ulnar shift; 95% confidence interval, 1.1% to 5.4%). After surgery, there was minimal change in lunate uncovering and carpal-radial distance from immediately after surgery to final follow-up.

CONCLUSIONS

Preoperative lunate uncovering was lower than normal values, suggesting an abnormal radial shift of the carpus with a collapsed scaphoid. Postoperative lunate uncovering was similar to normal values, reflecting an ulnar shift of the carpus after operative intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Transradial Transcapitate Perilunotriquetral Coalition Fracture Dislocation

Perilunate fracture dislocations (PLFDs) are uncommon, usually resulting from high-energy trauma. Several classification systems describe the patterns of injury seen, but there is still significant variation and patterns of injury that do not fit within these classifications continue to be described. Carpal coalitions are rare, mostly asymptomatic, and are, as a result, usually identified incidentally. We describe the case of a transradial transcapitate PLFD in a patient with a Minnaar Type 3 lunotriquetral coalition. Radiographic, clinical, and patient-reported outcomes are reported. When presented with a rare anatomical variation in the context of a complex injury, the importance of managing these complex injuries according to principles is highlighted.

Treatment and Outcomes of Missed Perilunate Dislocations: A Case Series

Background  Perilunate dislocations are devastating injuries that occur relatively rarely, accounting for only 7% of injuries to the carpus. Unfortunately, approximately 25% of these injuries are missed on initial evaluation. Acutely diagnosed perilunate dislocations may be successfully treated with ligament and osseous repair, depending on the injury pattern. Chronic dislocations, however, are primarily treated with salvage procedures. This case series was performed to investigate the outcomes of patients who sustained a perilunate dislocation that was diagnosed in a delayed fashion and look for any treatment patterns that could be more widely applied to future patients. Methods  Patients presenting to a single institution between 2016 and 2018 with a perilunate injury that either presented in a delayed fashion or was missed on initial assessment were identified and their characteristics were evaluated. The surgical management of these patients was assessed as was their postoperative course at their 2-week, 6-week, 3-month, and 6-month clinic follow-up visits. Results  Eight patients were identified with perilunate dislocations that were diagnosed in a delayed fashion. On average, these dislocations were diagnosed 133 days following the date of injury. All patients were males and 7/8 of them were between 17 and 20 years of age at the time of their injury (mean age: 25.5). They were treated with either primary repair, wrist fusion, proximal row carpectomy, or scaphoid excision and four-corner fusion (SEFCF). Both pain and range of motion improved following surgical management of these injuries. Conclusion  Perilunate dislocations are rare injuries that are notorious for being diagnosed late, at which point primary repair is oftentimes no longer feasible. Salvage procedures are able to improve the range of motion and pain of patients who are found to have chronic dislocations. Our case series highlights the importance of treating each missed perilunate injury individually and avoiding a "one-size-fits-all" approach.

Trans-scaphoid trans-lunate trans-triquetral volar perilunate dislocation: A case report

Introduction

Translunate volar perilunate dislocations are extremely rare, with few documented cases. Only eight instances of volar translunate perilunate dislocation have been described in the literature. This report presents a successfully treated case using early reduction and internal fixation that led to a very satisfying outcome at 9 months follow-up.

Case report

A 20-year-old man presented with left wrist pain and swelling after a fall from a vehicle at 50 km/h, landing on an outstretched right hand. Radiographs and a CT scan identified scaphoid, lunate, and triquetral fractures, along with a volar perilunate dislocation. Surgical treatment was performed with a dorsal approach, including scaphoid and lunate fracture fixation, triquetral avulsion repair, and lunate stabilization with K-wires. The wrist was immobilized for 6 weeks, intense physical therapy started after K-wires removal. At 9 months follow-up, positive results were seen clinically and radiologically.

Discussion

A perilunate fracture-dislocation includes dislocation of the carpus from the lunate. Johnson divided these injuries into lesser arc (pure ligamentous) and greater arc (fracture-related). Bain introduced the translunate arc concept in a case series of three patients, depicting a path through the lunate causing lunate fracture alongside perilunate injury. Treatment focuses on lunate reduction and fixation, combined with addressing greater and lesser arc injuries. Achieving successful lunate realignment and fixation is challenging. However, early diagnosis, prompt reduction, rigid fixation, and repair of both arc injuries can lead to optimal functional recovery.

Suture Anchor Fixation for Lunate Osteochondral Shear Fracture: A Case Report

CASE

A 26-year-old right-hand-dominant man sustained a left transradial, translunate perilunate injury after motor vehicle collision. The proximal lunate fractured a primarily cartilaginous 15 × 15 mm osteochondral shear fragment with 40% articular surface involvement. A novel lunate fracture suture anchor fixation technique is described, which led to fracture healing. The radial styloid was treated with a single screw.

CONCLUSION

Translunate perilunate injuries involving the lunate proximal articular surface are rare. Treatment recommendations are limited to case reports. Suture anchor fixation led to stable fixation and fracture healing at the final 6-month postoperative follow-up.

Outcomes of arthroscopic versus open reduction and internal fixation for the treatment of acute traumatic lunate fractures: a systematic review

The purpose of the study was to compare outcomes of fully-arthroscopic reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) to treat acute traumatic lunate fractures. A literature search was conducted using Medline and Embase. Demographic data and outcomes were extracted for included studies. The search identified 2,146 references: 17 articles were included, reporting on 20 cases (4 ARIF and 16 ORIF). No differences between ARIF and ORIF were found in rate of union (100% vs 93%, P = 1.000), grip strength (mean difference, 8%; 95%CI, -16-31; P = 0.592), rate of return to work (100% vs 100%, P = 1.000), or range of motion (mean difference, 28°; 95%CI, -25-80; P = 0.426). Lunate fractures were not identified in 6 of the 19 radiographs, but were identified in all CT scans. There were no differences in outcome between ARIF and ORIF for the treatment of fresh lunate fracture. The authors recommend surgeons to perform CT scans when diagnosing high-energy wrist trauma so as not to overlook lunate fractures. LEVEL OF EVIDENCE: Level IV.

Perilunate Dislocations: Current Treatment Options

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Approximately 25% of all patients who sustain perilunate dislocations present in a delayed fashion.

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While management of acute injuries is relatively well-described, treatment of chronic injuries can be complex and there is a paucity of scientific evidence to guide management.

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Treatment options include open reduction internal fixation, proximal row carpectomy, scaphoid or lunate excision with or without arthrodesis, and total wrist arthrodesis, although indications vary based on chronicity of injury and patient factors.

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The purpose of this article was to determine the quality of evidence supporting surgical options for the treatment of these injuries.

Dorsal Trans-Scaphoid Perilunate Fracture-Dislocation in Association with Dorsal Dislocation of the Thumb Carpometacarpal Joint: A Rare Injury Pattern

We report a dorsal trans-scaphoid perilunate fracture-dislocation associated with dorsal dislocation of the thumb carpometacarpal joint in a 25-year-old man. This is a rare injury and we discuss a possible mechanism for the injury. Level of Evidence: Level V (Therapeutic).

Perilunate Injuries: Current Aspects of Management

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are high-energy injuries which can result in long-term complications and significant disability. Early identification of these injuries, followed by prompt, appropriate management is key to optimising patient outcomes. Knowledge of the carpal anatomy is essential in order to understand the varied patterns of injury and plan appropriate definitive management. Emergent reduction and close monitoring of the median nerve, followed by prompt stabilisation or repair of the injured structures remain the mainstay of treatment. In this review, we present a summary of the current evidence regarding the identification and management of these complex injuries.

Perilunate instability: A rare variant

Perilunate dislocations and perilunate fracture dislocations are rare injuries that occur as a result of high energy trauma. We describe a case of a volar fracture dislocation of the proximal pole of the scaphoid with an associated scapholunate and lunotriquetral ligament disruption as well as a lunate fossa fracture of the distal radius. These injuries are serious injuries that require a high degree of clinical acumen and radiographic scrutiny to allow for prompt treatment in order to avoid the sequelae of long-term complications that can arise. This case serves as a reminder of the complexity of these injuries and their associated mechanics.

Three Cases of Translunate Perilunate Injury Treated with Wrist Arthroscopy

Background  An acute fracture of the lunate is an uncommon injury with the reported incidence ranging from 0.5 to 1% of all carpal bone fractures. The combination of lunate fracture and perilunate injury is even rarer and Bain et al first introduced the "translunate arc concept" in 2008. We reported three cases of translunate perilunate injury treated with wrist arthroscopy. Materials and Methods  All the three cases had been treated successfully with the use of wrist arthroscopy. A novel technique of arthroscopic reduction and fixation of a volar pole of lunate fracture was illustrated. The lunate fracture healed in all cases with normal carpal alignment. Results  All patients achieved a painless and functional joint with good range of motion at an average follow-up of 15 months. There was no radiological evidence of avascular necrosis of the lunate in all three cases. Conclusion  Translunate perilunate injury is rare and a high index of suspicion is necessary for diagnosis. There was no consensus on the surgical approach to this kind of injury. Wrist arthroscopy had proven to be successful in treating the greater and lesser arc perilunate injury. For translunate perilunate injury, wrist arthroscopy is also a feasible option with the advantages of lower risk of arthrofibrosis and avascular necrosis.

Volar Translunate Perilunate Dislocation: Case Report and Analysis of Review of Literature

Volar translunate perilunate dislocations are the rarest form of perilunate dislocations with only a handful of cases reported till now. The injury mechanism is not uniform, and the pattern of injury does not follow traditional classifications. We report a case of volar translunate perilunate dislocation with a review of literature of very few previous reported cases of these rare injuries.

Retro-lunar dislocation of carpal bones with trans-capitate, trans-lunate fractures and intact scaphoid. What if Bain was right?

We report the case of retro-lunar dislocation of carpal bones detaching the proximal pole of the capitate with intact scaphoid, associated with lunate fracture. A rare case where the pathomechanics of the lesion has not yet been precisely identified. We present our conservative approach in the treatment of the capitate fracture and propose a theory-based explanatory pattern that combines the ligaments injuries sequences described by Mayfield from lateral to medial (corresponding to Johnson's lesser arc injuries), and the displacement of the transmitted force along Wagner's dislocation line from medial to lateral, causing bones injuries, following Johnson's greater arc injuries and Bain's translunate arc. Our management after closed reduction of the dislocation was surgical through dorsal approach and fixation of the proximal pole of the capitate. 25 months after surgery, despite the installation of early osteoarthritis, the functional outcome is satisfactory.

Arthroscopic Treatment of Translunate Perilunate Injuries, Not Dislocated (PLIND)

Background  Translunate perilunate dislocations were recently described as well as perilunate injuries, not dislocated (PLIND). The authors present a case of transradial styloid, translunate PLIND which sustained a full arthroscopic reduction and internal fixation. Case Description  A 33-year-old man sustained a transradial styloid, translunate PLIND due to a fall from a truck with his wrist in hyperextension. The diagnosis was made at the acute stage. Full arthroscopic reduction and internal fixation with Kirschner wires was performed, followed by a 6 weeks' immobilization period. Uneventful healing of both the lunate and radial styloid were observed at 6 weeks and confirmed with a computed tomography scan. At 4 years of follow-up, the Lyon wrist score was 78% (good). Literature Review  Very few lunate fractures are described in the literature. Translunate perilunate dislocations were recently described as well as PLIND. To the best of the authors' knowledge, a case of transradial styloid, translunate PLIND which sustained a full arthroscopic reduction and internal fixation has never been reported so far. Clinical Relevance  This case reports a unique pattern of transradial styloid, translunate PLIND and outlines the usefulness of a full arthroscopic treatment. An open reduction for this pattern of injury would have been extensive, difficult, and probably unreliable.

Evaluation, Management, and Outcomes of Lunate and Perilunate Dislocations

Lunate and perilunate dislocations are potentially devastating injuries that are often unrecognized at initial evaluation. Prompt recognition and treatment is necessary to prevent adverse sequelae, including median nerve dysfunction, carpal instability, posttraumatic arthritis, reduced functionality, and avascular necrosis. In patients who are surgical candidates, operative intervention is warranted to restore carpal kinematics and provide optimal outcomes. [Orthopedics. 2019; 42(1):e1-e6.].

Non-dislocation lunate fracture combined with distal radius fracture: A case report

RATIONALE

Lunate fractures are very rare, accounting for only 0.5% to 6.5% of all carpal fractures. They are mostly caused by high-energy trauma and commonly occur with fractures and dislocations of other carpal bones. It is rarely combined with Colles' fracture and the underlying pathogenesis and prognostic significance still remain controversial.

PATIENT CONCERNS

Here we report a case of a fresh lunate fracture combined with Colles' fracture, without dislocations of other carpal bones caused by a low-energy fall injury.

DIAGNOSES

Lunate fracture, Colles' fracture.

INTERVENTIONS

This patient received closed reduction and internal fixation (CRIF) with K-wire.

OUTCOMES

The patient took follow up 1 year and the patient showed good function of the wrist joint LESSONS:: Lunate fractures have no high misdiagnosis rate. Patients suffering persistent wrist swelling after a trauma should be carefully examined and followed up to prevent severe secondary diseases and wrist joint dysfunction.

Trans-scaphoid perilunate fracture dislocation beyond Mayfield stage IV: a case report on a new classification proposal

This report and review of the literature aims to recognize the complete enucleation beyond stage IV of the classification proposed by Mayfield. The addition of a fifth category is proposed, added for complete ligament injuries that lead to nonexistent circulation for the radiolunate ligament, preventing surgical reconstruction, thus influencing surgical treatment.

Lunate fractures and associated radiocarpal and midcarpal instabilities: a systematic review

The aim of this study was to analyse lunate fractures and any associated osseo-ligamentous injuries. A systematic review identified 34 cases. We identified carpal instabilities at the radiocarpal and midcarpal joints in volar and dorsal directions. Radiocarpal instabilities (10/34) were usually dorsoradial (8/10), with a transverse lunate fracture, best seen on a coronal image. Midcarpal instabilities (24/34) were usually volar (14/18), with a volar lunate shear fracture, best seen on a sagittal image. Instabilities were sub-classified into non-displaced, subluxated and dislocated. Associated fractures of the scaphoid and the radial and ulnar styloid processes were common. Lunate fractures without subluxation or dislocation had good outcomes with cast immobilization or fixation of associated fractures. Lunate fracture-subluxations are unstable injuries that are best managed with fixation of the carpal fractures. Lunate fracture-dislocations are complex injuries, requiring stabilization of the lunate, associated fractures and ligament injuries; complications are common and acute or delayed salvage procedures may be required.

The treatment of perilunate ligament injuries in multiply injured patients

PURPOSE

Perilunate injuries are rare, severe injuries of the carpus. They can present as isolated injuries or in the poly-traumatised patient. This is the first documented series of these injuries treated in a Major Trauma Centre. The aims were to assess the management, treatment algorithm and outcomes, of perilunate injuries in our department, review whether concomitant polytrauma affected those outcomes and identify if delay to definitive treatment had a significant effect on overall outcome.

METHODS

Perilunate injuries admitted to the Royal London Hospital between Oct 2011 and March 2016 were identified. All definitive surgical procedures were performed by the senior author; hand therapists supervised patient rehabilitation. Outcomes were assessed by Mayo Wrist and QuickDASH scores.

RESULTS

We identified 23 perilunate injuries (22 patients). There was an associated nerve injury in 10 cases with other system injuries present in 12 cases. At final review, the mean carpal height ratio was 0.56, Mayo Wrist score was 81 and QuickDASH score was 16.4. There were no differences when comparing the outcomes of patients who had early against those with more delayed definite treatment or when comparing patients with isolated wrist injuries against polytrauma patients.

CONCLUSION

Satisfactory outcomes can be achieved, even in the presence of other injuries, if initial treatment is prompt and follows a clear management protocol. Prompt early reduction and neurological decompression followed by subsequent accurate definitive fixation leads to good outcomes. A delay of definitive fixation of up to 18 days does not appear to have a deleterious effect on outcome.

Transverse translunate fracture-dislocation: A rare injury

Perilunate fracture-dislocation is rare. We report the case of a 24-year-old male who fell from his motorcycle and presented with a transverse lunate fracture with perilunate ligament damage. The initial diagnosis based on X-rays was confirmed by CT scan. A dorsal approach was used to obtain good reduction, double screw fixation and ligament reinsertion protected by temporary K-wires. To the best of our knowledge, this is the first case of transverse lunate fracture within perilunate fracture-dislocation. The patient returned to normal activities after 6 months.

Transtriquetral perihamate fracture-dislocation: case report

The wrist is a region that is very vulnerable to injuries of the extremities. Among these injuries, fractures of the pyramidal bone (or triquetrum) in association with dislocation of the hamate and carpal instability are uncommon. They are generally correlated with high-energy trauma and may be associated with neurovascular deficits, muscle-tendon disorders, skin lesions or injuries to other carpal bones. Thus, in this report, one of these rare cases of transtriquetral perihamate fracture-dislocation with carpal instability is presented, diagnosed by means of radiography on the right wrist of the patient who presented pain, edema and limitation of flexion-extension of the carpus after trauma to the region. The stages of attending to the case are described, from the initial consultation to the surgical treatment and physiotherapy, which culminated in restoration of the strength and range of motion of the wrist.

Understanding carpal instability: a radiographic perspective

The wrist is disposed to a variety of instability patterns owing to its complex anatomical and biomechanical properties. Various classification schemes have been proposed to describe the different patterns of carpal instability, of which the Mayo classification is the most commonly used. Understanding the concepts and pertinent terminology of this classification scheme is important for the correct interpretation of images and optimal communication with referring physicians. Standard wrist radiographs are the first line of imaging in carpal instability. Additional information may be obtained with the use of stress radiographs and other imaging modalities.

Scaphoid and Lunate Dislocation with Complete Soft-Tissue Avulsion: A Case Report

CASE

We describe an intercarpal dislocation with proximal and rotatory displacement of the lunate and with volar and radial dislocation of the scaphoid; both bones were stripped of soft tissue. Treatment involved ORIF (open reduction and internal fixation). Three years postoperatively, the patient had a DASH (Disabilities of the Arm, Shoulder and Hand) score of 10, equivalent grip strength and 50% wrist palmar flexion and 98% wrist dorsiflexion compared with the uninjured side, and radiographic evidence of posttraumatic arthritis.

CONCLUSION

Treatment of simultaneous divergent lunate and scaphoid dislocation with loss of nearly all soft-tissue attachments and vascular supply by means of ORIF and repair of soft-tissue structures can result in a favorable intermediate-term functional outcome and may be superior to other salvage procedures such as proximal row carpectomy.

Uncommon carpal fractures

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.

Misses and errors in upper extremity trauma radiographs

OBJECTIVE

The article reviews a select group of traumatic upper extremity injuries that can be easily misinterpreted on radiographs.

CONCLUSION

The awareness of these specific injuries and an understanding of their underlying pathophysiology and the role that radiographs can play in their evaluation will give the reader the best opportunity to make the important imaging findings and guide appropriate treatment.

Volarly displaced transscaphoid, translunate, transtriquetrum fracture of the carpus: case report

A 16-year-old girl sustained a transscaphoid, translunate, transtriquetrum volarly displaced fracture due to shear stress in the coronal plane. Treatment involved open reduction and internal fixation of the fractures followed by immobilization. At 15 months' follow-up, grip strength and motion were diminished compared with the uninjured wrist. Radiographs demonstrated fully healed fractures with narrowing of the cartilage space between the capitate and the lunate.

Carpal fractures

Carpal fractures are exceedingly rare clinical entities and are often associated with concomitant injuries. In this review, we focus on fractures of the carpus, excluding the scaphoid, and provide an update on the current consensus as to mechanism, diagnosis, management, outcomes, and complications after such injuries.

Perilunate Injuries, Not Dislocated (PLIND)

Purpose We reviewed a series of equivalents of perilunate dislocations and fracture-dislocations (PLDs-PLFDs) in which there was no dislocation of the capitate from the lunate on the initial radiographs. We propose to include these injuries as a variant of perilunate dislocations that we have termed a perilunate injury, not dislocated (PLIND) lesion in a modified classification of perilunate injuries. Methods A review of the records of all acute perilunate injuries and displaced carpal fractures was done in a single-center university hospital wrist surgery unit over a 5-year period. All cases presenting at the acute stage with displaced fractures of scaphoid, lunate, triquetrum, or capitate along with scapholunate and/or lunotriquetral dissociation but no dislocation of the capitate from the lunate in the sagittal or coronal plane were reviewed and considered as PLIND lesions. Results We identified 11 patients with PLIND lesions. Three cases with clinical and radiological follow-up are presented. Discussion Equivalents of PLDs-PLFDs presenting without dislocation of the capitate from the lunate do exist. These injuries may be overlooked despite their severity. They require both osseous and ligamentous repair. Including them into an existing perilunate injuries classification highlights their recognition and enables a better understanding and treatment of both acute and chronic nondislocated perilunate injuries. Level of Evidence Level IV, retrospective case series.

Translunate perilunate injuries-a spectrum of this uncommon injury

Purpose To review a series of translunate perilunate dislocations to analyze the, mechanism of injury, diagnosis, management, and outcome. Methods A literature review and a survey of the International Wrist Investigators Workshop were performed to locate cases. Results Translunate perilunate injuries are rare. There is a spectrum of severity. The mechanism of injury is usually high-energy, and multiple fractures are the norm. High-energy mechanism, perilunate dislocation, comminuted lunate fracture and delayed presentation greater than 7 days are associated with a higher likelihood of a salvage procedure being required. Discussion Translunate injuries are a complex variant of perilunate dislocations. Early diagnosis is critical in understanding the complexity of the injury. Lunate fixation should be performed prior to bony and ligamentous stabilization of the proximal row. In delayed or highly comminuted cases, salvage procedures are the preferred option. Including a translunate arc in addition to the greater and lesser carpal arc would lead to a more inclusive classification. Level of Evidence Level IV.

Fracture-dislocations of the carpus: perilunate injury

The progressive perilunar instability model described by Mayfield is still used to predict the pattern of injury. Diagnosis of injury and clinical and radiographic findings depend on the pattern of injury. Open procedures are preferred for anatomic reduction after initial closed reduction is performed for acute injuries. A dorsal, volar, or combined dorsal/volar approach may be necessary and is often decided by surgeon preference. Loss of motion and diminished grip strength are common consequences despite appropriate treatment. Successful outcomes depend on time to treatment, open or closed nature of injury, extent of chondral damage, residual instability, and fracture union.

Decision making for partial carpal fusions

Limited wrist fusions are effective surgical procedures for providing pain relief while preserving motion of the wrist in patients with localized arthritis of the carpus. In deciding which motion-preserving procedure to perform, the etiology of the arthritis, which joints are involved, and which are spared should be determined. The main principle is to fuse the involved joints and to allow motion through the uninvolved joints. In this article, we discuss the various traumatic and nontraumatic conditions causing arthritis of the wrist and the treatment options for those conditions. Common indications for limited wrist fusions include scapholunate advanced collapse and scaphoid nonunion advanced collapse. Options for treating these conditions include three- and four-corner fusions as well as a proximal row carpectomy. This paper discusses which procedures are the most appropriate as well as the outcomes of these procedures. If the basic principles of limited wrist fusions are adhered to, a good outcome can be obtained. The authors' surgical technique and decision-making processes are discussed.

Perilunate dislocations and fracture dislocations

Perilunate dislocations and fracture dislocations are high-energy injuries that can result in pain, stiffness, weakness, or disability if inappropriately treated. Prompt recognition and surgical treatment with anatomic reduction of carpal malalignment improve the likelihood of optimal, long-term clinical success and patient satisfaction. The progressive development of radiographic evidence of arthrosis is common but has not been shown to consistently correlate with worse patient function and outcomes.

Lunate fractures in the face of a perilunate injury: an uncommon and easily missed injury pattern

Lunate fractures are rare and are usually associated with high-energy trauma. Typically, they are described in isolation or with associated carpal injuries such as scaphoid, capitate, or radial styloid fractures. We report a case of a complex lunate fracture in combination with a perilunate dissociation injury.

Perilunate dislocation and perilunate fracture-dislocation

Perilunate dislocations and perilunate fracture-dislocations usually result from high-energy traumatic injuries to the wrist and are associated with a characteristic spectrum of bony and ligamentous damage. Radiographic evaluation of the wrist reveals loss of normal radiocarpal and intercarpal colinearity and bony insult, which may be overlooked at the initial presentation. Prompt recognition is important to optimize outcomes. Closed reduction is performed acutely, followed by open reduction and ligamentous and bony repair with internal fixation. Complications include posttraumatic arthrosis, median nerve dysfunction, complex regional pain syndrome, tendon problems, and carpal instability. Despite appropriate treatment, loss of wrist motion and grip strength, as well as persistent pain, is common. Medium- and long-term studies demonstrate radiographic evidence of midcarpal and radiocarpal arthrosis, although this does not correlate with functional outcomes.

Complex and rare fracture patterns in perilunate dislocations

INTRODUCTION

The wrist represents a complex anatomic region in the upper extremity and a highly functional and intricate structural joint. Perilunate injuries have classically been described as involving a greater or lesser arc as described by Mayfield and imply a specific pattern of force transmission. The greater and lesser arc classifications do not include descriptions of when non-scaphoid carpal fractures occur as part of a perilunate injury.

METHODS/RESULTS

We present three cases of complex and rare perilunate fracture dislocation patterns and discuss the surgical management as a treatment model for these complex wrist injuries: the trans-scaphoid, trans-capitate perilunate dislocation, the trans-scapholunate ligament, trans-capitate dislocation, and the trans-scaphoid, trans-triquetral perilunate dislocation.

DISCUSSION

Although there is a low incidence of injury to non-scaphoid carpal bones, it is beneficial to understand the approach to the perilunate reduction and scaphoid fixation through a combined volar and dorsal approach, which will also allow for the reduction and fixation of more rare and complex carpal fractures.

Nondisplaced fractures of the proximal carpal row: case report

We present a 24-year-old woman who sustained isolated nondisplaced fractures of the proximal carpal row after a low-energy injury. The radiographic features are most consistent with the recently described translunate arc injury and appear to be a transitional injury between an inferior arc injury as well as the greater and lesser arc injuries. The injury was successfully treated with below-elbow thumb-spica cast immobilization for 10 weeks.