Fracture luxation trans-scapho rétrolunaire dorsale bilatérale – à propos de deux cas

Abstract

Trans-scaphoid perilunate fracture–dislocations represent a rare injury. These are responsible of one of the most devastating damages of the carpus. These injuries may be easily overlooked or misdiagnosed which deteriorate its prognosis. The aim of this study is to present two unique cases of this injury, comparision to the reported cases and discuss the prognosis factors and treatment options. The first case is a 21-year-old male labourer injured secondary to a motor-cycle accident. Urgent open reduction and stabilization of both wrists was done. Currently, the wrist is stable with functional range of motion and bony union at 18 months. The second case is a 30-year-old male farmer, who presented a polytrauma of after a fall. The patient was referred to our department twelve days after the trauma. Open reduction was first done with a fixation of the carpus and stabilization of the scaphoid were performed using Kirschner wires with ligamentous repair for both wrists. Functional outcomes were satisfactory despite non-union of the scaphoid on one side at two year follow-up. Perilunate dislocations are devastating high-energy wrist injuries. These injuries combine bony avulsions, ligament disruption and fractures in different forms. The present concept of the mechanism of dorsal perilunate dislocation in literature is a fall on outstretched hand with ulnar deviation and supination of the wrist. Dislocation in this region requires rapid realignment, as untreated, it will lead to serious secondary damage. Diagnosis can be difficult as it was missed in our patient, it is frequently the case due to other associated injuries or inadequate interpretation of radiographs of the wrist. Treatment options include closed reduction and cast immobilization, closed reduction and percutaneous pinning, and open reduction. We have performed an open reduction through a dorsal approach with repair of the damaged ligaments and stabilization with K-wires of the carpus and the scaphoid fracture with good functional results for both patients. Early open reduction and restoration of carpal anatomy and repair of damaged ligaments are emphasized in order to restore the complex anatomic inter-carpal anatomy. Non-union rate of the scaphoid was relatively higher in the series treated by closed reduction. These are high velocity injuries and are often missed. Early diagnosis of this entity is essential to prevent complication, through clinical examination and careful evaluation of the radiographs. When detected and treated early patient can have a satisfactory functional outcome.