Arthroscopic Treatment of Radiocarpal Dislocation (SS-48)

Abstract

Introduction Radiocarpal dislocations are complex injuries characterized by having a high-energy shear and rotational force to the wrist. While these injuries were previously managed using closed reduction and immobilization, recent reports have recognized the instability of these complex injuries, and have described treatment algorithms using open reduction and internal fixation. Current management of radiocarpal dislocations has been based on the following previously described principals: concentric reduction of the radiocarpal joint, identification and appropriate treatment of intercarpal ligament injuries, and stable repair of the osseous-ligamentous avulsions. Treatment with wrist arthroscopy has never been described. We report a case of ulnar radiocarpal wrist dislocation successfully treated with wrist arthroscopy and percutaneous pinning Methods A 23-year-old right-hand–dominant man presented after a motor vehicle accident with a right ulnar radiocarpal wrist dislocation, ulnar styloid fracture, and triquetrum avulsion fracture. The patient was taken to the operating room where a closed reduction was attempted. During stress exam under fluoroscopic imaging, it was apparent that a closed reduction was unobtainable, and we converted to wrist arthroscopy. From the 3-4 portal, a portion of the radioscaphocapitate ligament was seen interposed within the radiocarpal joint preventing concentric reduction of the carpus. The ligament was reflected back into position and the carpus subsequently concentrically reduced. From the 4-5 portal the dorsal radiocarpal ligament was found to be ruptured and was debrided. Two K-wires were placed across the wrist; one was placed proximal to the radial styloid through the scaphoid and capitate, and the second placed from proximal to the radial styloid through the radius, and across the lunate and triquetrum. The wrist was immobilized for 3 months, and the pins were then removed. Results At the 4-month follow-up appointment, the patient had grip strength of 86 lbs, compared to 145 lbs in his contralateral hand (59%), with 40 degrees of flexion and 60 degrees of extension. At 10 months, the patient had full pronation and supination, grip strength of 130 lbs compared to 155 lbs in the contralateral hand (84%), and lacked only 20 degrees of wrist flexion compared to the contralateral side. He returned to his pre-injury job as a manual laborer. Conclusion This is the first description of an ulnar radiocarpal dislocation successfully treated with wrist arthroscopy and percutaneous pinning. While the current applications for wrist arthroscopy are extensive, its use in fracture and dislocations of the carpus are limited. Advantages of wrist arthroscopy are that it allows for direct visualization and treatment of intercarpal and midcarpal injuries. More importantly, treatment of these injuries can be completed with minimal disruption of the soft tissues. While our treatment algorithm followed the majority of the previously described treatment principles for the treatment of radiocarpal dislocations, we did not address neurovascular structures and the extrinsic wrist ligaments, which would require open decompression. Our results show that a successful clinical outcome and stable radiocarpal wrist joint are obtainable by addressing intercarpal injuries arthroscopically, and stabilizing the radiocarpal joint.