Management of trans-scaphoid perilunate dislocations

A retrospective review of 28 patients with 29 trans-scaphoid perilunate dislocations who underwent open reduction and Herbert screw fixation is presented. The majority of the patients had satisfactory results at 24 months of follow-up. A significantly better range of wrist motion was obtained in postoperative patients treated with cast immobilization for 4 weeks compared with those treated for longer than 5 weeks. The scaphoid fractures united well, with proper alignment of the carpal bones, regardless of the length of cast immobilization. We recommend open reduction, internal scaphoid fixation using a Herbert screw, carpal ligament repair and early cast removal in the management of trans-scaphoid perilunate dislocations.     

早期切开复位Herbert螺钉内固定治疗经舟骨月骨周围脱位

目的 评价早期切开复位、Herbert螺钉内固定治疗经舟骨月骨周围脱位的临床效果.方法 早期采用切开复位、Herbert螺钉内固定治疗新鲜经舟骨月骨周围脱位8例,术后随访X线片了解骨折愈合情况及腕关节轴线恢复情况.Cooney腕关节评分法评价术后腕关节功能恢复程度,DASH问卷调查表行术后腕关节功能自我评价.结果 术后随访时间为7～35个月,平均14个月.根据Cooney腕关节评分:优3例,良2例,中2例,差1例;平均评分值为76.DASH评分值为27.X线片检查舟骨完全愈合,腕关节轴线恢复好.结论 早期切开复位Herbert螺钉内固定能达到舟骨解剖复位、恢复腕关节轴线,术后功能恢复较好,是治疗新鲜经舟骨月骨周围脱位较好的方法.     

Use of external fixation for perilunate dislocations and fracture dislocations

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18–59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2–12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18–68 months). Range of motion and grip strength were measured. Cooney’s scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney’s clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.     

Transscaphoid fracture/dislocations treated with open reduction and Herbert screw internal fixation

Six cases of dorsal transscaphoid perilunate fracture/dislocations and two cases of palmar transscaphoid lunate fracture/dislocations were treated by open reduction and internal fixation of the scaphoid with a Herbert screw. Supplemental Kirschner wire stabilization of the carpus was also used in the two cases of palmar transscaphoid lunate fracture/dislocation. All patients were male, with an average age of 23.6 years. The follow-up averaged 18.9 months. A clinical evaluation scoring system assessing pain, ability to function in an occupation, range of motion, grip strength, and radiographic appearance of the wrist was used. Based on this system the scoring of the six cases of dorsal transscaphoid perilunate fracture/dislocations that were treated was three excellent, one good, and one fair result, while the scoring of both palmar transscaphoid lunate fracture/dislocations showed poor results.     

The Herbert screw for fractures of the scaphoid. A review of results and technical difficulties

We have reviewed 22 patients with scaphoid fractures treated by internal fixation with the Herbert screw. Three patients had trans-scaphoid perilunar dislocations, one had an oblique displaced fracture of the waist of the scaphoid and 18 had fractures with delayed or non-union. Corticocancellous bone grafts were added in nine of the cases of non-union. Results were excellent or good in 80% of cases after a mean duration of postoperative immobilisation of four weeks. The technical difficulties are analysed and the problems of applying the jig and of operative exposure are discussed.     

Unusual combined scaphoid and lunate fracture of the wrist: a case report

All perilunate fracture-dislocations combine ligament ruptures, bone avulsions, and fractures in a variety of clinical forms. The most frequent is the dorsal trans-scaphoid perilunate dislocation. In rare cases, however, these dislocations also have been associated with capitate fractures, triquetral fractures, or lunate fracture. We report a combined scaphoid and lunate fracture of the wrist that was not associated with perilunate dislocation.     

Chronic trans-scaphoid perilunate dislocation: Current management protocol

Trans-scaphoid perilunate dislocations are complex injuries; usually occur as a result of high-energy trauma and are frequently missed. Chronic trans-scaphoid perilunate dislocation is often difficult to manage and delayed presentation leads to poor functional outcomes. Various treatment modalities have been described which range from open reduction and internal fixation, staged reduction, proximal row carpectomy and wrist arthrodesis.     

Surgical treatment of trans-scaphoid, transcapitate, transtriquetral, perilunate fracture-dislocation with open reduction, internal fixation and lunotriquetral ligament repair

This paper presents a rare case of trans-scaphoid, transcapitate, transtriquetral, perilunate fracture-dislocation of the right wrist as a result of a motorcycle accident. Open reduction and internal fixation of the scaphoid and capitate with one screw was performed and the lunotriquetral ligament was repaired using a suture anchor.     

The unreduced carpal dislocation. A method of treatment

Unreduced lunate, perilunate, and transscaphoid perilunate dislocations present a difficult and challenging surgical problem. The authors feel that all efforts should be made to obtain a reduction of the old dislocation. They support a combined dorsal and palmar approach, open reduction, and internal fixation of scaphoid with a Herbert screw to obtain midcarpal stability. A carpal tunnel decompression should be performed if symptoms suggest median nerve entrapment. When the dislocation is unable to be reduced, the authors favor limited wrist arthrodesis or a proximal row carpectomy in the absence of significant arthritis.     

Bilateral dorsal trans-scaphoid perilunate fracture–dislocation: A case report

INTRODUCTION

Perilunate dislocations represent one of the most devastating injuries to the carpus. Fortunately, these injuries are relatively rare, constituting approximately 10% of all carpal injuries. One of the problems associated with this injury is the difficulty of its accurate and early recognition.

PRESENTATION OF CASE

In this study, an uncommon case of bilateral dorsal trans-scaphoid perilunate fracture–dislocation following trauma has been reported. The injury was missed initially and the patient was subsequently operated after two weeks. Anatomic reduction was achieved by closed reduction. After closed reduction, percutaneous pin fixation of the carpus was performed using Kirschner wires. Finally, the scaphoid was stabilized with a headless screw percutaneously. The same procedure was repeated for the other wrist. This was followed by an uneventful post-operative period, with a satisfactory functional outcome at the two-year follow-up, despite non-union of the scaphoid in one side.

DISCUSSION

The case was examined in detail, and compared to the findings in the literature; observations regarding fracture prognosis were also made. Most authors agree that closed reduction is the initial treatment of choice for trans-scaphoid perilunate fracture–dislocations. In addition, treatment often requires intercarpal fixation within the proximal carpal row.

CONCLUSION

We believe that closed reduction in these cases should be attempted regarding the potential risks of avascular necrosis and non-union of the affected carpal bones due to open reduction.     

Open reduction of chronic lunate and perilunate dislocations

Four patients with chronic lunate and perilunate dislocations were treated by open reduction and internal fixation. The interval between injury and operation was 7, 8, 14 and 18 weeks, respectively. Both palmar and dorsal surgical approaches were needed to reduce the old dislocation in all cases. A case of dorsal trans-scaphoid perilunate dislocation showed concurrent partial disruption of the scapholunate ligament. Transient vascular compromise of either the lunate or the proximal scaphoid fragment was noted in three patients. Despite the delay in treatment, all patients had satisfactory outcomes.     

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.     

Greater Arch Injuries

Dislocations and fracture dislocations of carpal bones are uncommon injuries which invariably poses challenges in the management. Perilunate fracture dislocations are the combination of ligamentous and osseous injury that involve the “greater arc” of the perilunate associated instability. Despite their severity, these injuries often go unrecognized in the emergency department leading to delayed diagnosis and treatment. A Prospective study was done from June 2008 to December 2013 in 15 cases of complex wrist injuries which included of greater arch injuries, perilunate fracture dislocation and one dorsal dislocation of Scaphoid. 10 cases of perilunate fracture dislocation underwent open reduction and internal fixation with Herbert screw and k-wire, 4 cases of greater arch injury underwent closed reduction and kwire fixation and one case of neglected dorsal dislocation underwent proximal row carpectomy. One patient had Sudecks osteodystrophy 1 had Scaphoid nonunion and 6 had median nerve compression. Overall outcome according to Mayo wrist score was 53 % excellent, 33 % good and 14 % fair. Greater arch injuries are difficult to treat because injuries to many ligaments are involved and failure to recognize early leads to persistent pain, disability and early onset of arthritis. Prompt recognition requires CT scan and MRI. Management requires reduction and multiple K-Wiring according to merits of the case.     

近排腕骨切除术治疗陈旧性经舟骨月骨周围骨折-脱位

目的报道近排腕骨切除术治疗陈旧性经舟骨、月骨周围脱位的临床效果。方法对 34例应用此手术的患者进行功能评价,平均随访5年3个月。结果29例腕部疼痛症状消失,5例仍有轻微腕部疼痛不适;腕关节屈伸活动度较术前增加了30°～50°;尺、桡偏活动较差,范围20°～30°;握力较健侧稍减弱;29例恢复了原来的工作,5例改为轻工作。结论近排腕骨切除术是治疗陈旧性经舟骨、月骨周围脱位的一种可靠有效的方法。     

Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation

Introduction:

Management of neglected perilunate dislocations is controversial. The various procedures such as open reduction and internal fixation (ORIF), proximal row carpectomy, lunate excision, and wrist arthrodesis have been advocated. The aim of our study was to evaluate the functional outcome of neglected perilunate dislocations managed by ORIF.

Materials and Methods:

Over a period of 10 years (1996 to 2006), 14 patients with neglected perilunate dislocations (undiagnosed or untreated for 6 weeks or more) were managed by ORIF. Six patients had dorsal trans-scaphoid perilunate dislocation, 6 patients had volar lunate dislocation while the remaining two had a dorsal perilunate dislocation The results were evaluated by clinical scoring system of Cooney et al.

Results:

The average followup was 4.1 years (range 2-12 years). All except one of the patients operated earlier than 5 months had good results. Of the four patients operated after 5 months, two had a fair result while two had a poor outcome. Chondral damage to the capitate was noted intraoperatively in both the cases with poor outcomes. The two patients were found to have avascular necrosis (AVN) of the lunate; however, functional outcome was fair in both, and both were able to return to their profession.

Conclusion:

We observed favorable functional results of ORIF in neglected perilunate dislocations up to 5 months after injury. The development of AVN or midcarpal arthritis was not a major disabling factor as long as stability of wrist has been restored. Beyond 5 months, an alternative surgical procedure such as proximal row carpectomy should be contemplated as results of ORIF have not been good uniformly.     

Management of greater arc carpal fractures

Greater arc injuries are fracture dislocations that involve the perilunar carpal bones. The commonest of these injuries is the dorsal transscaphoid perilunate fracture dislocation. The recommended treatment for acute injuries is open reduction and Kirschner wire fixation of the scaphoid fracture through a dorsal midline approach. Stability to the midcarpal joint is thus provided and no further pins are needed. Established scaphoid nonunions are treated by bone grafting and Herbert screw fixation through a volar approach. Scaphocapitate fracture syndrome is treated by open reduction and pin fixation of the displaced capitate fragment through the dorsal approach. If the scaphoid is displaced it is also openly reduced and pinned.     

Trans-scaphoid perilunate dislocation with fractured carpal bones in a child

Transcarpal fractures and dislocations in children are rarely reported in the orthopedics literature. This is a report of a 10-year-old boy who sustained a trans-scaphoid perilunate dislocation with fractures across the carpal structure: these included injuries to the scaphoid, capitate and triquetrum bones. Treatment consisted in a closed reduction for the dislocation and using the dorsal approach of an open reduction with internal fixation of the fractures. The injury healed well with a full return of good wrist function. This unusual pattern of injury is described so that it may be more readily appreciated in the future.     

手法复位外固定治疗经舟骨月骨周围腕关节脱位

目的：探讨手法复位外固定治疗经舟骨月骨周围脱位的方法及对临床评价。方法：对从1996年6月到1999年6月收治的13例经舟骨月骨周围腕关节脱位患采用手法复位外固定方法治疗并总结分析。结果：本组病例一年后随访,优5例,良5例,中1例,差1例,失随1例。其中2例舟状骨骨折不愈合,1例得分为57分,生活有一定困难。另1例得分为87分,主观满意。结论：早期经舟骨月骨周围腕关节脱位病例在周围软组织损伤不十分严重的情况下可经合理的手法复位和固定达到较好的临床效果。临床疗效满意。     

经舟骨月骨周围脱位早期诊断和手术的重要性

目的：评价切开复位内固定同时修复损伤韧带治疗经舟骨月骨周围脱位重要性。方法：1995年6月至2001年6月,采用切开复位内固定同时修复损伤韧带治疗14例经舟骨月骨周围脱位患者,其中男13例,女1例;年龄21～38岁,平均25.4岁。手术均在受伤后2周内进行,所有患者均为后脱位。结果：14例患者均获得随访,时间24～60个月,平均28.3个月。13例舟骨骨折一期愈合,腕关节功能恢复良好;1例出现骨不连,腕关节功能部分受限。未发现舟骨和月骨坏死者。采用Cooney评分法：优9例,良3例,可1例和差1例。结论：对于经舟骨月骨周围脱位患者,如能得到早期诊断,采取早期复位及切开内固定治疗,同时修复损伤的腕掌侧关节囊、桡舟头韧带和桡舟月韧带,可早期提供腕舟骨稳固的固定,有利于舟骨近段和月骨血供的恢复。     

Recurrent dorsal trans-scaphoid perilunate dislocation

A case is presented in which trans-scaphoid perilunate dislocation occurred through a scaphoid non-union. The place of open reduction and immediate bone grafting is discussed.