Concurrent scaphoid fracture with scapholunate ligament rupture

Various patterns of traumatic carpal injury have been described in the literature. Although the combination of scaphoid fracture and scapholunate ligament rupture in the same injury has been reported and these lesions can no longer be considered mutually exclusive, little information is available on management methods and the long-term results of such seemingly paradoxical complex injuries. This study reviews 11 previously described cases and reports an additional two cases of concurrent scaphoid fracture with scapholunate ligament rupture. This concurrent injury has two presentations; namely perilunate fracture-dislocation, which is the most common presentation, and complex scaphoid fracture. No single mechanism of injury exists that accounts for these complex injuries. High-energy trauma was the only characteristic common to all these cases. Most cases had unsatisfactory radiographic results including scaphoid nonunion, avascular necrosis of the lunate or the proximal pole of the scaphoid and arthrotic wrist changes at an average follow-up of 11 months. Managing these difficult problems needs critical recognition and repair of both bony and ligamentous damage. Early proximal row carpectomy or four-corner midcarpal fusion is another option when these injuries preclude stable reduction and fixation.     

Neglected trans-scaphoid trans-styloid volar dislocation of the lunate. Late result following open reduction and K-wire fixation

A rare case of radiocarpal dislocation is presented. The lunate and proximal pole of the scaphoid were displaced in a volar and proximal direction. The injury was missed initially and the patient was subsequently operated on six weeks later. Open reduction and internal fixation of the scaphoid was performed and this was followed by an uneventful postoperative period, with a satisfactory functional outcome at the eight-year follow-up, despite carpal instability non-dissociative-dorsal intercalated segmental instability configuration of the carpus. We believe that although open reduction in neglected cases carries the potential risks of avascular necrosis and nonunion of the affected carpal bones, an attempt should be made to restore the anatomy of the carpus.     

Scapho-capitate fracture syndrome. A case report

A rare injury of the wrist, scapho-capitate fracture syndrome, in a young patient is reported. Despite early recognition of the injury and surgical intervention, the scaphoid fracture did not unite and another attempt to achieve union with bone grafting and internal fixation also failed. The wrist continued to be painful and stiff. Radiographs of the wrist, 18 months after the injury, showed nonunion of the scaphoid, avascular necrosis of the scaphoid and the lunate and carpal collapse with midcarpal joint arthritis. Due to persistent and disabling symptoms arthrodesis of the wrist had to be carried out. Possible causes for the bad outcome after this injury are discussed. We recommend open reduction for the fracture of the capitate and open reduction and internal fixation with primary bone grafting for a displaced comminuted scaphoid fracture.     

Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. Rationale for the technique, postoperative changes in biomechanics, and results

In cases of static or symptomatic dynamic scapholunate instability, reduction of the scaphoid proximal pole into the scaphoid fossa of the radius and stabilization of the relationship of the scaphoid and lunate by distal arthrodesis to the trapezium and trapezoid will significantly alter carpal mechanics; however, elimination of pain, preservation of a functional arc of motion, and restoration of the ability to pursue routine activities (including heavy labor) all suggest that the planes of radiocarpal and intercarpal motion following distal scaphoid arthrodesis are compatible with long-term physiologic function without late loss of reduction.     

Scapholunate ligament repair with capsulodesis reinforcement

The typical presentation of an acute scapholunate dislocation is swelling, pain, and deformity following acute trauma to the wrist. Radiographs corroborate a gross disturbance of carpal relationships. In a dorsal perilunate dislocation, the lateral radiograph shows the longitudinal axis of the capitate dorsal to the longitudinal axis of the radius and the proximal pole of the scaphoid rotated dorsally. A scapholunate angle of greater than 70 degrees on the lateral view is 1 accepted radiographic criterion for identifying an acute scapholunate dissociation. In the posterior-anterior (PA) projection, the carpus is foreshortened. A scapholunate interval of >2 mm is seen on the PA x-ray (Terry Thomas sign). The lunate is triangular instead of quadrangular in shape. Although closed reduction is possible, maintaining an anatomical reduction is extremely difficult. Therefore, all of these injuries require open reduction and internal fixation and repair of the scapholunate interosseous ligament. Although originally advocated for the treatment of some forms of chronic scapholunate dislocations (>3 months old), dorsal capsulodesis can be useful to reinforce the scapholunate interosseous ligament repair in the subacute setting (>3 weeks old).     

Palmar-divergent dislocation of the scaphoid and the lunate

We describe a patient with palmar-divergent dislocation of the scaphoid and lunate. After successful closed reduction, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach, and the anterior capsule was sutured through the palmar approach. The scapholunate and lunotriquetral joints were fixed with Kirschner wires for 7 weeks. At the 1-year follow-up, magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate, and radiographs showed no evidence of the dorsal and volar intercalated segment instability patterns associated with carpal instability. However, flexion of the scaphoid and a break in Gilula’s line remained. To our knowledge, this is the first report showing treatment of palmar-divergent dislocation of the scaphoid and lunate by suturing the carpal interosseous ligaments.     

Scapholunate stabilization with dynamic extensor carpi radialis longus tendon transfer

Dynamic extensor carpi radialis longus tendon transfer to the distal pole of the scaphoid acts synchronously and synergistically with wrist motion to restore the slider crank mechanism of the scaphoid after scapholunate interosseous ligament (SLIL) injury. The procedure is designed to simulate a hypothetical dorsal radioscaphoid ligament that more closely approximates the normal viscoelastic forces acting on the scaphoid throughout all phases of wrist motion than does the static checkrein effect and motion limitations of capsulodesis or tenodesis. Extensor carpi radialis longus transfer may be independently sufficient to support normal or near-normal scapholunate and midcarpal kinematics and prevent further injury propagation in patients with partial SLIL tears and dynamic scapholunate instability. Extensor carpi radialis longus transfer alone may improve carpal congruity in patients with static scapholunate instability, but SLIL and dorsal lunate ligament repair or reconstruction is essential for favorable durable outcomes. Extensor carpi radialis longus transfer offers a simple and reasonable alternative to capsulodesis or tenodesis to support these ligament repairs or reconstructions, does not require intercarpal fixation, and allows rehabilitation to proceed expeditiously at approximately 1 month after surgery.     

Transscaphoid–transtriquetral–transhamate perilunate fracture–dislocation: case report

A transscaphoid–transtriquetral–transhamate perilunate fracture–dislocation is a very rare pattern of injury among the known spectrum of perilunate dislocations and perilunate fracture–dislocations, and the details of the initial treatment and outcome of this injury have never been reported. We present the case of a 24-year-old, right-handed man, who presented in the emergency department with acute fracture at the waist of the scaphoid, fracture avulsion at the proximal pole of the triquetrum, and fracture of the hamate body with an associated dorsal perilunate dislocation after a fall from 3 m onto his outstretched left hand. Under general anesthesia, closed reduction was attempted with axial traction. After anatomical reduction was achieved, osteosynthesis of the scaphoid was performed using a cannulated screw, and after this was done, percutaneous pinning of the hamate with a K-wire and reconstruction of the scapholunate ligament was performed using an anchor for reinforcement of the scapholunate ligament through a minimally invasive volar approach. A short arm thumb cast splint was applied for 4 weeks, and part-time splinting was continued for another additional 4 weeks. The patient subsequently underwent 3 months of intensive range-of-motion and muscle-strengthening exercises. At the final follow-up examination, 60 months after the initial operation, the range of motion of the left wrist was 145° (extension plus flexion arc), and grip strength, 47 kg, were 91 and 98 % of the values for the unaffected wrist, respectively. Radiographs showed a bony union of the scaphoid, triquetrum, and hamate, and no sign of avascular necrosis in the proximal scaphoid fragment, as well as other carpal bones. No midcarpal or radiocarpal degenerative arthritis was observed, and the normal carpal bone relationships were still maintained, with a scapholunate angle of 49° and a scapholunate distance of 1.5 mm. We recommend closed reduction and minimally invasive volar approach for screw fixation of the scaphoid, as well as percutaneous pinning of the hamate in this case and reconstruction of the disrupted carpal ligaments to minimize the interruption of the blood supply to the carpus and also to obtain rigid fixation during the procedure.     

The diagnosis and treatment of scapholunate instability

Scapholunate instability is the most common form of carpal instability. Pain produced by this condition is caused by the wrist's inability to sustain physiologic loads because of an injury to the linkage between the scaphoid and lunate. The term scapholunate instability may describe a wide spectrum of clinical conditions ranging from mild wrist dysfunction and partial ligamentous tear to debilitating pain with associated rupture of the scapholunate interosseus ligament complex. This article reviews the pathophysiology of scapholunate instability and its identification and treatment.     

Arthroscopic Reduction-Association of the Scapholunate

The reduction-association scapholunate (RASL) procedure for stabilization of the scapholunate joint is an alternative to soft-tissue procedures that do not maintain normal carpal alignment, despite reports of good symptomatic relief. The RASL procedure—indicated for patients with scapholunate instability or scapholunate dissociation without arthritis and, in selected cases, with stage 1 scapholunate advanced collapse of the wrist—can be performed arthroscopically. Radial midcarpal and 3-4 radiocarpal portals are used to excoriate and prepare the scapholunate joint surfaces. By use of 0.62″ K-wire joysticks in the lunate and distal pole of the scaphoid, the scaphoid undergoes dorsiflexion and supination while the lunate undergoes palmarflexion to achieve reduction. A .35″ guidewire is advanced through the scaphoid waist, across the scapholunate joint to the proximomedial corner of the lunate. Supplemental K-wire fixation, from the scaphoid to the capitatum and lunate to the radius, stabilizes the reduction for placement of a cannulated HBS screw (Orthosurgical Implants, Miami, FL) through a 1-2 portal, while reduction and positioning are confirmed arthroscopically. Arthroscopy facilitates anatomic reduction of the joint, as well as the critically important, precise placement of the cannulated HBS screw, by use of 3 portals rather than the traditional 2-incision approach.     

What is the implication of scaphoid ring sign in advanced Kienb?ck's disease? Is it a sign of advanced carpal collapse or rotary scaphoid subluxation?

OBJECTIVE: To discuss the clinical implication of scaphoid ring sign in Lichtman's X-ray IIIB stage of the lunate avascular necrosis. METHODS: In a series of 17 cases of advanced Kienb?ck's diseases, carpal height (CH) and carpal height ratio (CHO) were measured in posteroanterior X-ray view (PA) preoperatively, which included seven cases in stage IIIA and 10 cases in stage IIIB. Radioscaphoid angles were also measured in the lateral X-ray view. All these measurements above were to study what were the differences between stages IIIA and IIIB. In addition, five fresh normal wrist specimens were dissected to observe the ligaments stabilizing the proximal pole of scaphoid. RESULTS: The results of CH and CHR between stages IIIA and IIIB were similar, which illustrated no significant difference in carpal collapse between two substages, however, the results of RSA were significantly different between two substages, which implied the position of the proximal pole of scaphoid changed in two substages. Based on the results of anatomical observation, three ligaments were important to stabilize the proximal pole of scaphoid, namely the radioscaphocapitate (RSC) ligament, long radiolunate (LRL) ligament and scapholunate interosseous ligament (SLIL). The function of RSC ligament was to restrict palmar subluxation of the proximal pole of scaphoid; LRL and SLIL were to restrict dorsal transposition of the proximal pole of scaphoid. CONCLUSION: Based on the results, we suppose the scaphoid ring sign is the implication of rotary scaphoid subluxation in stage IIIB, which was caused by destructions of LRL and SLIL ligaments. All procedures aimed at stage IIIB must account for this important factor.     

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.     

Transscaphoid-lunate dislocation: a report of two cases

Transscaphoid -lunate dislocation is a rare carpal injury resulting in proximal and palmar dislocation of the proximal pole of the scaphoid and lunate as a unit. Treatment in two patients consisted of immediate open reduction and internal fixation. Both patients (at 2 and 4 years' follow-up) are asymptomatic.     

Difficult wrist fractures. Perilunate fracture-dislocations of the wrist

Perilunate dislocations of the wrist have a common pathway of disruption that occurs from extensive dorsiflexion injuries. Open reduction and internal fixation of these injuries is required to provide accurate alignment and the option for ligament repair. Both dorsal and palmar surgical incisions may be indicated. Associated injuries to the median nerve must be recognized. Treatment includes scaphoid and radial styloid stabilization with multiple K-wires or internal compression screw (Herbert or Association for the Study of Internal Fixation [ASIF] screws). In these injuries, the lunate must be reduced first and stabilized. The scaphoid proximal segment follows the lunate unless the scapholunate (SL) ligament is torn. The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires. Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment. These fractures are a real challenge to the treating surgeon who must use patience, precise surgical techniques, and careful roentgenographic study (including tomograms and traction views) to assure the best result.     

Complete dorsal dislocation of the carpal scaphoid with perilunate dorsal dislocation

Complete dorsal dislocation of the carpal scaphoid combined with dorsal perilunate dislocation is an extremely rare carpal injury. We describe the case of a 23-year-old man who presented with a complete dorsal dislocation of the carpal scaphoid, combined with a perilunate dislocation. Surgical treatment was performed with open reduction and interosseus ligament repair. At 4 years follow up, the patient''s wrist pain had completely resolved without limitations of wrist joint motion and without evidence of avascular necrosis of the carpal scaphoid.     

Treatment of scaphoid fractures and nonunions

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.     

Difference in Carpal Alignment between Scapholunate Dissociation and Kienbock Disease: A Retrospective Study

Introduction  Scapholunate dissociation is the most frequent type of wrist instability and, if untreated, can lead to wrist osteoarthritis, known as scapholunate advanced collapse. Kienbock disease can also lead to wrist osteoarthritis. Both involve carpal instability; however, the possibility of completely different mechanisms underlying each ligamentous state and carpal malalignment must be considered. Materials and Methods  We retrospectively reviewed 17 patients with scapholunate dissociation and 14 patients with Kienbock disease. All arthroscopic findings for scapholunate dissociation were classified as Geissler grade 4. All cases of Kienbock disease were treated by lunate resection and vascularized pisiform transfer without interosseous ligament reconstruction. Carpal alignments were evaluated from pre- and postoperative radiographs. Results  Scapholunate dissociation showed greater lunate dorsiflexion and more dorsal locations of the scaphoid and capitate compared with Kienbock disease, but preoperative scaphoid flexion was similar in both groups. Eleven of 17 cases of scapholunate dissociation and no cases of Kienbock disease showed dorsal subluxation of the scaphoid preoperatively. Postoperative radiographs revealed no progression of carpal collapse in either groups. Conclusion  This study revealed the sacrifice of the scapholunate/lunotriquetral interosseous ligament do not incur static scapholunate dissociation, and that the secondary stabilizers may preserve carpal alignment.     

A vascularized bone graft for repair of scaphoid nonunion.

The majority of scaphoid fractures respond to casting, splinting, or open reduction and internal fixation. In patients who fail to heal a scaphoid fracture, several factors may contribute, including delay in treatment, fracture displacement, proximal third location, avascular necrosis, and associated carpal instability.     

A cause of painful clicking wrist: a case report

In a patient with symptomatic unilateral clicking of the wrist, a partial tear of the scapholunate ligament with subsequent scarring of the proximal third of the dorsal portion of the ligament had occurred. At operation the dorsomedial edge of the proximal pole of the scaphoid had snapped over the dorsal edge of the lunate as the palmar-flexed wrist was being returned to a neutral position. Release of the scarred portion of the scapholunate ligament was associated with widening of the scapholunate joint space to normal dimensions and cessation of the clicking phenomenon. Fourteen months after operation there was complete relief of symptoms, a full range of wrist motion and no radiographic evidence of widening of the scapholunate space, ligamentous instability, or rotatory subluxation of the scaphoid.