Trans-triquetral dorsal perilunate fracture dislocation

A rare case of trans-triquetral dorsal perilunate dislocation is described. It differs from the Mayfield and Johnson theory of progressive perilunar instability in greater arc injuries which states that the injury passes from the radial to the ulnar carpal bones and soft tissues in stages. This injury supports the concept of a reverse greater arc injury from ulnar to radial being possible with the radial carpal bones being spared in some cases.     

Greater arc injury of the wrist with fractured lunate bone: a case report

Carpal dislocation and fracture dislocation are uncommon and difficult to treat. Early diagnosis and treatment of such injuries are necessary to prevent progressive carpal instability and traumatic arthritis. Perilunate fracture dislocation is a combination of ligamentous and osseous injuries that involve the 'greater arc' of the perilunate. Despite being severe, these injuries often go unrecognised in the emergency department, leading to delayed diagnosis and treatment. We present a case of greater arc injury of the right wrist with fractures of the lunate and ulnar styloid without perilunate dislocation. This pattern of injury cannot be classified in the available literature on greater arc injury.     

Load transfer characteristics of the wrist. Part II. Perilunate instability

An experimental model with a static positioning frame, pressure-sensitive film (Fuji), and a microcomputer-based video digitizing system, previously developed by the two senior authors, was used in this study to examine the effects of increasing perilunate instability on the load transfer characteristics of the wrist. These effects included a significant dorsal ulnar shift of the scaphoid centroid with increasing perilunate instability together with a less dramatic palmar ulnar shift of the lunate centroid. Overall, the scaphoid contact area was found to decrease as the stage of perilunate instability increased, even in ulnar deviation and/or extension, which in the normal wrist was found to be the positions that had the greatest scaphoid contact area. Average pressures in the high pressure zones were found to significantly increase in wrists with a stage III instability compared with normal wrists. An increase in the intercentroid (scaphoid/lunate) distance was most evident with the wrist in 20 degrees extension, neutral radioulnar deviation, and 90 degrees supination.     

伴月骨周围不稳定的舟骨骨折

目的：探讨日本名古屋地区伴月骨周围不稳定舟骨骨折的发生率、相关因素、诊断和治疗。方法：对11例经腕关节镜检查确认系伴月骨周围韧带损伤的病例进行了回顾性研究，分析其临床特点、治疗方法和疗效。结果：舟骨骨折中，合并舟月或月三角韧带损伤的发生率为20．4％，其韧带损伤与左腕受伤显著相关，63．6％合并近排腕骨背伸不稳定（dorsal intercalated segment instability,DISI), 仅有1例可见明显的舟月分离。通过对应治疗，其疗效与单纯舟骨骨折相比无明显差别。结论：伴月骨周围不稳定的舟骨骨折并不罕见，腕关节镜检查可提高其检出率，积极治疗可取得较好的疗效。     

Chronic lateral elbow instability

Posterolateral rotatory instability of the elbow is the most common pattern of chronic lateral elbow instability. The primary lesion in posterolateral rotatory instability is injury or attenuation of the lateral ulnar collateral ligament. Posterolateral rotatory instability is diagnosed on the basis of careful history taking and specific physical examination techniques. Reconstruction of the lateral ulnar collateral ligament with repair of the surrounding soft tissue structures is recommended in patients who have symptoms of recurrent lateral instability. Open and arthroscopic reconstruction techniques have resulted in improvement of elbow function and satisfactory results in most patients, although mild limitation in terminal extension of the elbow is a common finding.     

月骨周围进行性不稳定的腕运动学研究

目的 探索腕月骨周围进行性不稳定的运动力学变化。方法 对１４具新鲜冷冻尸体腕关节，用计算机辅助测量了正常腕和各阶段月骨周围不稳定时腕动力肌腱在腕屈伸，尺桡偏时滑动幅度，根据肌腱滑动幅度和关节运动范围计算动力肌腱力臂。结果 月骨周围进行性不稳定时屈腕肌腱力臂明显增大，屈指肌腱力臂减小；桡侧腕动力肌腱力臂以增大为主，尺侧肌腱力臂以减小为主。桡侧腕屈肌在腕肌屈伸或尺桡偏时均显著增大，结论 腕运动力学变化     

The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability

This study evaluates the relative roles of the radial collateral ligament, the lateral ulnar collateral ligament, and the overlying musculature in posterolateral rotatory instability of the elbow. Fourteen cadaveric upper limbs underwent sequential arthroscopic sectioning of the lateral collateral ligament complex. After sectioning, arthroscopic and fluoroscopic evaluation of a lateral pivot shift test was done. Minimal instability was noted after the first section, but no difference between radial collateral or lateral ulnar collateral ligament sectioning was found. A greater degree of instability was seen between the first and second cut ( P = .0001), but no significant difference was seen between sectioning the 2 groups ( P = .61). Complete instability occurred only after sectioning the overlying musculature. On the basis of this study, injury to both the radial collateral and lateral ulnar collateral ligaments is necessary to cause significant posterolateral rotatory instability of the elbow. Furthermore, the overlying musculature plays an important role in overall stability.     

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury.     

Posterolateral rotatory instability of elbow: An uncommon entity

Posterolateral rotatory instability of elbow is an exceedingly uncommon entity, which results from injury to the lateral ligamentous complex. Failure of adequate healing of lateral collateral ligaments may necessitate its surgical repair or reconstruction. We describe here a boy 12 years of age who was initially treated as soft tissue injury and later presented with instability of the same elbow. He later required repair of lateral ulnar collateral ligament.     

Perilunate injuries

Perilunate dislocations and fracture dislocations are most often a result of high-energy trauma, exerting an axial load with hyperextension and ulnar deviation of the wrist, along with intercarpal supination. Early treatment of perilunate injuries is necessary to optimize the clinical outcome. Although closed management has been the more commonly reported treatment for perilunate injuries, the current consensus is that anatomic restoration of carpal alignment has better results. The combined dorsal-volar approach offers the advantages of both approaches and is the preferred choice for the authors since it allows assessment of all the injured structures. The surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament are discussed. Current literature regarding treatment and prognosis is also included.     

Dorsal transscaphoid-transtriquetral perilunate dislocation in pseudarthrosis of the scaphoid

A patient reported that he sustained a minor fall on the outstretched hand in hyperextension, pronation, and in ulnar deviation. Initial radiographs suggested dorsal transscaphoid-transtriquetral perilunate dislocation. Traditionally, however, this injury is the result of a high-energy impact. A CT scan obtained after closed reduction of the dislocation revealed not only a fresh fracture of the triquetrum but also two corticalized fragments of the scaphoid. A former major fall on this hand and a normal scaphoid of the other hand made pseudarthrosis more likely than scaphoid bipartition. Arthrography revealed intact lunotriquetral and scapholunate ligaments, precluding the possibility of preexisting ligamentous instability. Pseudarthrosis of the scaphoid with a loss of scaphoid function as a mechanical tie-rod of the carpus is most likely responsible for this complex injury. This is the first clinical study that shows that single scaphoid discontinuity without preexisting ligamentous carpal instability may lead to complex perilunar dislocation in minor trauma.     

Ulnar-sided perilunate instability: an anatomic and biomechanic study

A staging system for ulnar-sided perilunate instability is presented based on a series of cadaver dissections and load studies. Stage I: partial or complete disruption of the lunotriquetral interosseous ligament, without clinical and/or radiographic evidence of dynamic or static volar intercalated segment instability deformity; stage II: complete disruption of the lunotriquetral interosseous ligament and disruption of the palmar lunotriquetral ligament, with clinical and/or radiographic evidence of dynamic volar intercalated segment instability deformity; and stage III: complete disruption of the lunotriquetral interosseous and the palmar lunotriquetral ligaments, attenuation or disruption of the dorsal radiocarpal ligament, with clinical and/or radiographic evidence of static volar intercalated segment instability deformity.     

Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation

Acute proximal row carpectomy is an uncommon definitive treatment for perilunate fracture dislocations. In this report, we present five patients who had acute proximal row carpectomy (PRC) to treat perilunate fracture-dislocations. All patients were men between ages 31 and 87. The indication for PRC was lunate fracture in two patients, concomitant displaced scaphoid fracture and scapholunate ligament injury in two patients, and perilunate fracture-dislocation with preexisting articular damage from long-standing gout in one patient. At the final follow-up ranged from 4.5 month to 7.5 years, four patients had no pain and one patient was lost to follow-up. One patient had a concomitant PRC and a bridging plate that was never removed. The remaining three patients gained satisfactory range of motion. Our observation reveals that acute proximal row carpectomy is an option for some patients with complex carpal fracture dislocations, particularly those with fracture of the lunate, concomitant scaphoid fracture and scapholunate ligament injury, or preexisting wrist arthritis.     

Triple jeopardy: transscaphoid, transcapitate, transtriquetral, perilunate fracture dislocation

Carpal injuries are frequently underdiagnosed and underreported injuries of the hand. Scapholunate perilunate dissociation is the most common perilunate instability pattern seen in clinical practice. Transscaphoid, transtriquetral, transcapitate dislocation with a volar intercalated segment instability pattern is a very rare pattern of carpal injury. We describe a case with this unique pattern of injury, explaining its mechanism and treatment. Good outcome can be achieved in these injuries following open reduction and internal fixation with ligamentous repair.     

Coincident rupture of the scapholunate and lunotriquetral ligaments without perilunate dislocation: pathomechanics and management

Wrist injuries causing coincident disruptions of the scapholunate and lunotriquetral ligaments commonly result in perilunate dislocations. This article (1) describes our management of eight patients with wrist pain after coincident scapholunate and lunotriquetral ligament disruptions in the absence of perilunate dislocation; and (2) reports the results of biomechanical testing of some of the extrinsic and intrinsic wrist ligament and interprets these data to explain the injury seen clinically. The diagnosis of ligament failure was made on the basis of history, physical examination, arthrography and surgical exploration. Surgical treatment of seven patients consisted of concomitant scapho-trapezio-trapezoid fusion and lunotriquetral fusion. Three of seven patients were free of pain, two had pain only at the extremes of motion, and two required additional surgery. Biomechanical analysis of the scapholunate and lunotriquetral ligaments and two extrinsic wrist ligaments, the radiolunotriquetral and the radioscaphocapitate, confirmed the clinical suspicion that the intrinsic ligaments could be completely disrupted while the extrinsics are only partially injured. Such a scenario could account for the residual stability that prevents the development of perilunate dislocations. Coincident disruption of the scapholunate and lunotriquetral ligaments in the absence of perilunate dislocation is an unusual injury. Treatment with lunotriquetral fusion and scapho-trapezio-trapezoid fusion restored functional use in five of seven wrists while maintaining wrist motion.     

Treatment of dorsal perilunate dislocations and fracture–dislocations using a standardized protocol

Background

The aims of this study were to evaluate the associated injuries occurring with acute perilunate instability and to assess the clinical and radiographic outcomes of perilunate dislocations and fracture–dislocations treated with a combined dorsal and volar approach.

Methods

A total of 45 patients (46 wrist injuries) with perilunate dislocations and fracture–dislocations were prospectively evaluated. The size of the mid-carpal ligament tear, the location of the scapholunate ligament tear, and the presence of osteochondral fragments and of the dorsal radiocarpal ligament avulsions were recorded at injury. Final clinical and radiographic outcomes were evaluated in 25 cases (25 wrists) with a minimum of 6 months of follow-up.

Results

Intraoperative examination of the 46 cases with operative treatment showed the volar carpal ligament tear to be present 100 % of the time and to be an average length of 3.4 cm. Complete avulsion of the dorsal extrinsic radiocarpal ligaments was found in 65.2 % of cases. The scapholunate ligament was torn in 35 cases. Osteochondral fragments were found either volarly or dorsally in 74 % of the cases. The average flexion–extension arc was 82°, forearm rotation was 155°, and grip strength averaged 59 % of the uninjured hand. The average final scapholunate angle was 55° and the scapholunate gap was 2.2 mm.

Conclusion

Treatment of perilunate fracture–dislocations with a combined volar and dorsal approach results in reasonable and functional clinical results. The incidence of associated injuries with these carpal dislocations is high. Although the perilunate fracture–dislocations have a slightly better radiologic alignment than the dislocation group, the clinical outcome is similar.     

Magnetic resonance imaging in diagnosis of chronic posterolateral rotatory instability of the elbow

Posterolateral rotatory instability of the elbow can be difficult to diagnose and requires a high degree of clinical suspicion. Cases of chronic posterolateral rotatory instability (symptoms present more than 1 year) may be an even more perplexing subgroup. This is a case report of a patient with a 30-year history of intermittent elbow instability. Clinical examination was equivocal, and magnetic resonance imaging was unable to define any ligamentous injury around the elbow. Examination under anesthesia and surgical findings were consistent with complete disruption of the lateral ulnar collateral ligament. The 12-month follow-up after surgical reconstruction showed complete resolution of symptoms. Posterolateral rotatory instability is a diagnosis largely made by examination under anesthesia. A thorough history and a high clinical suspicion are necessary to support the physician's decision to place the patient under anesthesia. Confirmation of a chronic tear of the lateral ulnar collateral ligament of the elbow with magnetic resonance imaging can be difficult and sometimes misleading.     

Longitudinal split tears of the ulnotriquetral ligament

Unlike tears of the peripheral triangular fibrocartilage or avulsions of the distal radioulnar ligaments, longitudinal split tears of the ulnotriquetral (UT) ligament do not cause any instability to the distal radioulnar joint or the ulnocarpal articulation. It is mainly a pain syndrome that can be incapacitating. However, because the UT ligament arises from the palmar radioulnar ligament of the triangular fibrocartilage complex (TFCC), it is by definition, an injury of the TFCC. The purpose of this article is to describe the cause of chronic ulnar wrist pain arising from a longitudinal split tear of the UT ligament.     

Evaluation of the biomechanical efficacy of limited intercarpal fusions for the treatment of scapho-lunate dissociation

An experimental model that uses a static positioning frame, pressure-sensitive film, and a microcomputer-based videodigitizing system was used to measure the contact areas and pressures in a group of wrists in their "normal" state, after ligament sectioning, which resulted in stage III perilunate instability and then following different types of simulated carpal fusions. Compared with a normal wrist, there is an overall decrease in load in the lunate fossa and a significant increase in load in the scaphoid fossa in the wrist with stage III perilunate instability. Scaphoid-trapezium-trapezoid and scaphoid-capitate fusions transmitted almost all load through the scaphoid fossa. Scaphoid-lunate, scaphoid-lunate-capitate, and capitate-lunate fusions all distributed load more proportionately through both scaphoid and lunate fossae. The positioning of the carpal bones within a limited carpal fusion was also found to affect the load distribution in the wrist. The scaphoid-lunate, scaphoid-lunate-capitate, or capitate-lunate fusions, with attention to the relative carpal alignment within the limited fusion seem to offer more promise for treatment of perilunate instability biomechanically than the scaphoid-trapezium-trapezoid or scaphoid-capitate fusions.     

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.