Dorsal Dislocation Research Articles

The surgical outcomes of trans-scaphoid perilunate fracture-dislocations

Background/aim Trans-scaphoid perilunate fracture-dislocation (TSPFD) is a rare injury. TSPFD is a fracture-dislocation that severely disrupts the anatomical structure of the carpal bones and may occur as a result of a high energy trauma of the wrist or a fall on an open hand. In this study, the aim is to provide midterm clinical and radiological evaluations of cases diagnosed and treated as TSPFD.Materials and methods Eleven patients diagnosed with TSPFD as a result of wrist trauma were treated surgically and were analysed retrospectively. Clinical and radiological follow-up of the cases was evaluated. The mean age of the patients was 34 years. All patients were males with a dorsal dislocation according to Herzberg’s perilunate fracture-dislocation classification. The mean follow-up time was 33 months. All of the cases were evaluated with preoperative and postoperative standard wrist anteroposterior and lateral radiographs. A dorsal approach was used in all cases. However, in 1 case a volar approach was also required. The Green and O’Brien evaluation scale modified by Cooney was used for the clinical assessment of pain, wrist range of motion, grip strength, and functional status as excellent, good, moderate, or poor. The wrist range of motion was evaluated goniometrically at the final check-up, and a mid-grade disability was observed compared with the uninjured side. A visual analogue scale was used to evaluate the pain.Results Sufficient union was obtained in all cases with open reduction and internal fixation of the fractures. Grip strength was up to 77.5% of the other side. According to the modified Green and O’Brien clinical evaluation scale, 6 cases were evaluated as good, 3 cases were fair, and 2 cases were poor. No median nerve damage was determined preoperatively or postoperatively and there was no postoperative pin tract infection in any of the patients.Conclusion This kind of injury represents complex biomechanical damage of the wrist anatomy. If it is diagnosed early and treated with open reduction and stable fixation, a functionally adequate and anatomically integrated wrist can be achieved.

Dislocation of the first carpometacarpal joint

First carpometacarpal (CMC1) joint dislocations are uncommon injuries. However, they can limit hand functions and lead to serious complications. Herein, we report the case of a multiple trauma man with dorsal dislocation of thumb CMC joint that was successfully treated with closed reduction and casting. The patient was a 47-year-old male with multiple traumas complaining of right wrist pain. Tenderness, deformity, and reduced range of motion of the right thumb CMC joint were observed. X-ray showed dorsal dislocation of the CMC1 joint. Closed reduction of the dislocated joint was performed under general anesthesia, and the joint was immobilized by a thumb-spica cast for 14 days. The patient was eventually discharged in good condition and had no complications or manual dysfunction after a 1-month follow-up. The optimal management of the CMC1 joint dislocations is controversial. The closed reduction seems adequate for these injuries. However, patients whose joints remain unstable after closed reduction, especially those with manual activities, should be considered for open reduction and surgical ligament repair.

An Unusual Midfoot Fracture-Dislocation: Total Dorsal Dislocation of Midfoot at the Cunei-Navicular Joint Associated with Cuboid Fracture: A Case Report

An Unusual Midfoot Fracture-Dislocation: Total Dorsal Dislocation of Midfoot at the Cunei-Navicular Joint Associated with Cuboid Fracture: A Case Report

Instability of the proximal radioulnar joint in Monteggia fractures\u2014an experimental study

BackgroundA Monteggia fracture is defined as a fracture of the proximal ulna combined with a luxation of the radial head. The aim of the present work is to evaluate the extent of instability of the radius head in the proximal radioulnar joint (PRUJ) as a function of the severity of elbow fracture and ligamentous injury in an experimental biomechanical approach.MethodsEight fresh-frozen cadaver arms were used. All soft tissues were removed except for the ligamentous structures of the PRUJ and forearm. A tensile force of 40 N was exerted laterally, anteriorly or posteriorly onto the proximal radius. The dislocation in the PRUJ was photometrically recorded and measured by two independent examiners. After manual dissection of the ligamentous structures up to the interosseous membrane, the instability was documented and subsequently measured. The following dissection levels were differentiated: intact ligamentous structures, dissection of annular ligament, oblique cord and proximal third of interosseous membrane.ResultsAn anterior instability remains relatively constant until the proximal third of the interosseous membrane is dissected. The radial head already dislocates relevantly in the posterior direction after dissection of the annular ligament with an additional considerable stability anteriorly and laterally. Subsequently, the posterior instability increases less pronouncedly in regard of distal resected structures. The lateral instability increases constantly during the progressing resection of the ligamentous structures.ConclusionOn the one hand, a complete healing of the ligament injury after functional treatment is hardly conceivable with ligamentary damage up to the level of the proximal interosseous membrane. A remaining instability of the proximal radius could therefore be a possible cause for the unsatisfactory clinical results after certain Monteggia fractures. On the other hand, the present study may give a possible explanation (i.e. early dorsal radius head dislocation after dissection of annular ligament) why the Bado II injury is the most frequent type of Monteggia fractures.

Postoperative Dorsal Proximal Interphalangeal Joint Subluxation in Volar Base Middle Phalanx Fractures

Introduction This study was designed to assess factors associated with postoperative dorsal proximal interphalangeal (PIP) joint subluxation after operative treatment of volar base middle phalanx fractures. Our second purpose was to study the association between postoperative dorsal subluxation with postoperative arthritis.Materials and Methods We identified 44 surgically treated volar base PIP joint fractures with available pre- and postoperative radiographs between 2002 and 2015 at two academic medical systems with a median follow-up of 3.5 months. Demographic, injury, radiographic, and treatment data that might be associated with postoperative dorsal subluxation were collected. Three hand surgeons independently assessed subluxation and arthritis on radiographs. Bivariate analysis was performed to analyze our two study purposes.Results Six of 44 (14%) had postoperative dorsal subluxation after initial surgery. Bivariate analysis showed no factors with statistically significant association with postoperative subluxation, assessed independently by three hand surgeons on radiographs. Fifty per cent of the joints with postoperative arthritis had postoperative subluxation compared with 21% of joints without postoperative subluxation. No significant association was found between postoperative dorsal subluxation with postoperative arthritis.Conclusion The association of persistent subluxation and early arthrosis in dorsal PIP joint fracture dislocations needs further study. At this time, it is unclear in what ways persistent subluxation or arthrosis affects the rate of reoperation.Level of Evidence This is a therapeutic level IV study.

Dorsal Barton fracture is a variation of dorsal radiocarpal dislocation: a clinical study.

Dorsal Barton fractures may be better described as variants of dorsal radiocarpal dislocations. We aimed to better characterize these fractures by reviewing 111 patients in the ICUC® dataset who had a dorsally displaced, intra-articular distal radius fracture. We identified 13 patients with a dorsal Barton fracture on radiographs (dorsal articular margin fracture with radiocarpal subluxation and intact volar cortex). All patients with a dorsal Barton fracture had radial styloid involvement and volar cortical disruption that was subsequently identified on three-dimensional CT. Based on three-dimensional CT and intra-operative findings, none of the patients had classically described dorsal Barton fractures. All patients were treated using a volar exposure. A volar capsular tear was identified intra-operatively in three patients and the volar capsule repaired. This series supports the contention that dorsal Barton fractures are better characterized and treated as a variation of a dorsal radiocarpal dislocation. Level of evidence: IV.

Reconstruction of volar plate avulsion injury of proximal interphalangeal joint with mini-anchor

Objective To investigate the clinical efficacy of mini-bone anchor in the treatment of volar plate avulsion injury of proximal interphalangeal joint. Methods From June 2015 to May 2018, 5 patients with dorsal dislocation of proximal interphalangeal joint caused by finger hyperextension injury were treated. The volar plate avulsion accompanied by articular surface avulsion fracture at the base of middle phalanx occurred. The volar approach was used to remove fragments and reconstruct the insertion of volar plate avulsion with mini-anchor. Results All the wounds achieved primary healing. The follow-up period ranged from 4 to 26 months with an average of 12 months. The flexion and extension of the proximal interphalangeal joint ranged from 50° to 85°. The joint was stable and had no lateral abnormal movement. There was no obvious pain and discomfort during the joint movement. According to the upper extremity functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association, the results were excellent in 2 cases and good in 3 cases. Conclusion The reconstruction of volar plate insertion with mini-bone anchor can provide the initial stability of the proximal interphalangeal joint, help early functional exercise, and help to reconstruct the basal articular surface of the middle phalanx. It is one of the ideal choices for the treatment of volar plate avulsion injury of proximal interphalangeal joint. Key words: Volar plate; Treatment outcome; Proximal interphalangeal joint; Mini-anchor

Functional and radiological outcomes of multiple dorsal carpometacarpal fracture dislocations treated with open reduction and internal fixation.

This study aims to evaluate the clinical and radiological results of patients with multiple dorsal carpometacarpal (CMC) joint fracture dislocations treated with open reduction and internal fixation (ORIF). We evaluated 14 patients (12 males, 2 females; mean age 35.1 years; range, 22 to 64 years) between January 2013 and December 2017. Our main outcome measurements were the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, loss of grip strength, limitation of range of motion (ROM), and Kellgren-Lawrence osteoarthritis classification identified with radiographs and computed tomography images. The mean QuickDASH scores at seventh week and third month were 73.57 (range, 65-90) and 29.11 (range, 25-42.5), respectively. The mean QuickDASH score at seventh, ninth, and 12th month, and final follow-up was 4.64 (range, 0-30) and the QuickDASH score at these follow-up points was not 0 for only three patients. The mean loss of grip strength was 32.14% and two patients (14.29%) had limitation of ROM in third proximal interphalangeal joint at final follow-up. Four patients had grade I, nine patients had grade II, and one patient had grade III osteoarthritis according to Kellgren-Lawrence classification at final follow-up. Although functional results demonstrated that multiple CMC joint fracture dislocations can be treated with ORIF, the high rate of osteoarthritis is a disadvantage.

Dorsal Block Splinting of Volar Plate Injuries at Neutral Position.

Volar plate injuries of the proximal interphalangeal joint (PIPJ) of a finger are common, often occurring in sporting or workplace incidents. Treatment of a stable dorsal dislocation entails a conservative approach, directed at preventing hyperextension and allowing the ligament to heal in position that does not negatively impact on healing. Current treatment regimens include dorsal block splinting (DBS) in 30° of flexion, which maintains the PIPJ in flexion in order to prevent any strain on the healing tissue while attempting to restore anatomical position. Recognized complications of DBS are flexion deformities of the joint and hyperextensibility. We propose that DBS in neutral position, rather than 30° flexion, reduces hyperextensibility as well as preventing flexion deformities of the PIPJ, allowing sooner return of function and participation in daily activities. A retrospective review of patients sustaining volar plate injuries was undertaken. Inclusion criteria involved patients splinted at either 30° or neutral position, both those having undergone surgical or conservative regimens and the joint assessed as stable. Data were collected focusing on the number of hand therapy sessions, the time from injury to discharge, active angles of flexion and extension of the PIPJ, and pain. Over 2 years, 125 patients were treated for volar plate injuries: 20 with DBS at neutral position and 105 DBS at 30°. There were no significant differences in patient demographics. There were fewer hand therapy appointments required for those splinted in neutral position and weeks of hand therapy predischarge. There were no flexion deformities for patients undergoing DBS at neutral position, but no difference in PIPJ extension. There were no differences in hyperextensibility or pain. Dorsal block splinting at neutral position results in fewer flexion deformities following volar plate injuries of the PIPJ, without resultant hyperextensibility. There are fewer demands on hand therapy. Dorsal block splinting at neutral position may result in better function for patients suffering this injury, with decreased complications and quicker return to daily activities.

Unstable Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Volar Plate Fixation with or without Bone Graft.

To evaluate the treatment of severe dorsal fracture dislocation (DFD) injuries of the proximal interphalangeal joint (PIPJ) by open reduction, bone grafting and fixation with mini-hook plates. Fourteen patients with extensive dorsal fracture dislocation of the PIPJ were operatively treated to reconstruct the fractured middle phalanx volar lip using a fabricated hook plate in conjunction with elevation and bone grafting of depressed articular fragments where present. Restoration of PIPJ articular anatomy and congruence by hook plate fixation permitted full-range mobilization of the joint during fracture healing, with an average arc of motion of 81° and an average loss of extension of 12.9° at a minimum of 6 months follow up. Hook plate treatment of PIPJ fracture dislocation restores articular anatomy and joint congruence at a single sitting and permits post-operative mobilization without the need for extension block splinting. Our results demonstrate a good range of motion following treatment, however hardware removal and tenolysis was necessary in 36% of cases.

“Locked” Scapholunate Instability Diagnosed with 4D Computed Tomography Scan

Background Scapholunate instability (SLI) has a wide range of clinical and radiological presentations. The management depends on the stage of the disorder. Subluxation of scaphoid is pathognomonic feature of the SLI. We describe a patient with SLI with a dislocated proximal pole of scaphoid, out of the distal radius scaphoid fossa. The 4D (three-dimensions + time) computed tomography (CT) scan demonstrated that the scaphoid did not reduce throughout wrist motion. Case Description A 20-year-old male presented with SLI following a fall skateboarding. The 4D CT scan revealed the dislocated scaphoid that did not reduce with wrist motion. He underwent open reduction of the proximal pole of scaphoid and SL reconstruction using flexor carpi radialis (FCR) tendon graft with the Quad tenodesis technique. At 1 year, he had improved pain, wrist functions, and maintained satisfactory radiological alignment. Literature Review We are not aware of any previous description of the dorsal scaphoid dislocation in association with scapolunate instability. Clinical Relevance We recommend that the SLI staging classification needs to be expanded to include dislocation (locked) stage. The 4D CT has a significant role in identifying the instability and its reducibility. Level of Evidence This is a level V study.

Treatment of distal radius fractures with dorsal dislocation of Fernandez type IV by open reduction and internal fixation

Objective To report the treatment of distal radius fractures with dorsal dislocation of Fernandez type Ⅳ by open reduction and internal fixation via a combined dorsal and volar approach. Methods A retrospective analysis was conducted of the 14 cases of fresh distal radius fracture with dorsal dislocation of Fernandez type Ⅳ which had been treated by open reduction and internal fixation via a combined dorsal and volar approach at Department of Orthopaedic Trauma, Beijing Jishuitan Hospital from July 2010 to June 2016. All the patients were male, with an average age of 38.4 years (from 27 to 52 years). The time from injury to surgery averaged 6.9 days (from 4 to 10 days). Their injury involved 5 left and 9 right wrists. Follow-up was performed at 1, 2, 3, 6 and 12 months after operation when anteroposterior and lateral X-ray films were taken and functional exercise guidance was provided. At 6 and 12 months after operation, all the patients were evaluated using modified Garland-Werley scoring and Patient Rated Wrist Evaluation (PRWE). Results The patients were followed up for an average of 19.4 months (from 15 to 26 months). Their fractures healed well. Their fracture healing time averaged 3.1 months (from 2 to 4 months). Their modified Garland-Werley scores at 6 and 12 months after surgery were 8.9 points (from 6 to 13 points) and 7.3 points (from 4 to 11 points), respectively; their PRWE scores were 17.9 points (from 12 to 25 points) and 16.5 points (from 11 to 23 points), respectively. None of the patients was inflicted by infection, vascular injury or internal fixation failure. Conclusion The open reduction and internal fixation via a combined dorsal and volar approach can restore the stability of both the dorsal osseous structure of the distal radius and the volar ligament structure of the wrist, facilitating postoperative maintenance of the radiocarpal joint stability, improving the wrist function and leading to satisfactory outcomes. Key words: Radius fractures; Fracture fixation, internal; Ligaments; Surgical approach

Dorsal radiocarpal dislocation with fracture of the radial styloid: A case report

Introduction: Radiocarpal dislocation with radial styloid fracture is an infrequent injury with even less number of cases reported. Clinical case: A 19 year old male patient sustained dorsal radiocarpal dislocation with radial styloid fracture following high velocity trauma. The fracture was managed with open reduction and fixation. Postoperative evaluation after 12 weeks showed favourable outcomes. Discussion: This case report contributes to the present scarce literature on such injuries which have uncommon fracture geometry and pathology.

Hook Plate for Volar Rim Fractures of the Distal Radius: Review of the First 23 Cases and Focus on Dorsal Radiocarpal Dislocation.

Background Fragment-specific fixation of the distal radius is born to fix each articular fragment with limited surgical approach and low-profile devices. Over time, many devices with different designs and characteristics have been developed. However, many of them have showed the inability to securely fix marginal, small, and comminuted fragments as bony ligament avulsions and bony compression injuries. Purpose The purpose of this study was to evaluate the clinical and radiological outcome of a new device born to treat marginal articular fractures of the distal radius. Patients and Methods A retrospective review was conducted on 23 patients with a mean follow-up of 21 months including postoperative clinical evaluation, grip strength, computed tomography scan, and X-ray control. Results All fragments healed and maintained reduced until the final follow-up. The carpus was aligned with the distal radius in all patients presenting with a radiocarpal dislocation. Conclusion The volar rim fragment is an attachment site for the short radiolunate and the volar distal radioulnar ligament. Its unstable fixation can lead to articular incongruity, volar or dorsal subluxation of the carpus, and distal radioulnar instability. The involvement of this fragment on distal radius fractures is relatively common and many studies of the literature have been focused on its treatment. The Hook Plate stabilizes distal fragments at their bone-ligament interface. In addition to bony reduction, the device permits to stabilize the capsule and ligaments, as volar bony ligament avulsions, in a picture of dorsal radiocarpal dislocation. Level of Evidence This is a Level IV, case series.

Injuries of the Sportsman’s Hand

Injuries of the Sportsman’s Hand

Hemi-Hamate Autograft Arthroplasty for the Proximal Interphalangeal Joint Revisited: A New Surgical Approach.

The hemi-hamate arthroplasty for proximal interphalangeal joint (PIPJ) dorsal fracture dislocations relies on complete dislocation of the joint using the 'shotgun' approach which provides excellent exposure but damages the delicate intrinsic joint stabilisers. We present a new approach to the PIPJ when performing the hemi-hamate arthroplasty. The volar surgical approach involves freeing up the whole tendon sheath-periosteal unit as a single layer, and retracting this to one side. The articular surface of the joint can then be accessed with a little distraction and hyperextension. The method does not breach the tendon sheath, nor does it damage the collateral ligaments or volar plate. It is akin to the radical total anterior teno-arthrolysis (TATA) technique used for contracted joints, with some crucial differences. We postulate that the new approach causes far less iatrogenic damage and reduces the risk of contractures developing, and in chronic cases, allows concurrent joint release.

Simultaneous dorsal dislocation of the proximal interphalangeal joints in two digits: A case report

Majority of proximal interphalangeal (PIP) joint dislocations are dorsal dislocations but multıple PIP dislocations of the adjacent digits is very rare. This study presents a very rare case of a 82-year-old man who had two PIP dislocations in the same hand. He was successfully treated by closed reduction and he had no loss of function at final follow-up. Multiple PIP dislocations in the same hand are seen rarely, when treated properly, outcome is excellent even in elderly.

Intra-articular Fracture of the Distal part of the Triquetrum within the Pisotriquetral Joint: Case Report and Review of Literature.

Background:Intra-articular fractures of the distal part of the triquetrum within the pisotriquetral joint are uncommon, and can be associated with tears of the dorsal carpal ligaments, pisiform subluxation and/or FCU dislocation. Their diagnosis is difficult and requires a high clinical suspicion and a proper radiological examination including oblique wrist x-rays, computed tomography and MRI scan. These fractures can be delayed diagnosed due to late presentation thus leading to painful nonunion, persistent instability and late pisotriquetral arthritis.Case Report:We present a case of a 40-year-old male who complained about ulnarsided wrist pain after a fall on his extended wrist during bicycling. The diagnosis of triquetrum fracture was suspected on clinical examination and confirmed using standard and oblique radiographs and CT scan evaluation. He was immobilized in a short-arm cast for 6 weeks followed by a progressive return to wrist motion and subsequent strengthening for another 5 weeks. He reported complete resolution of pain and excellent wrist motion and function one year after the injury, demonstrating a Mayo score of 100.Conclusion:Isolated intra-articular fractures of the triquetrum within the pisotriquetral joint are rare injuries and may constitute a subcategory of body fractures other than the dorsal cortical (chip), main body and volar lip avulsion fractures. Early clinical suspicion and proper imagine can lead to a successful outcome.

Pilon Fractures of Middle Phalanx Managed with Lag Screw and Early Mobilisation

Background: Injury following proximal interphalangeal joint fracture dislocation is determined by the direction of force transmission and the position of the joint at the time of impact. Dorsal dislocations with palmar lip fractures are the most frequently encountered. The degree of stability is directly determined by the amount of middle phalangeal volar lip involvement and the degree of commination of the base of the middle phalanx.Methods: Case series of five patients who presented between Jan to June 2015 with pilon fracture of the middle phalanx. Mechanism of injury was axial loading onto to the proximal interphalangeal joint, while playing Australian football. All of them presented within 3 days of their initial injury with fracture of the volar lip of base of middle phalanx with dorsal subluxation along with commination of the base of middle phalanx appreciated on CT scan. All of them underwent open reduction via the shot gun approach and fixation with 1.3 mm lag screw. Also bone graft from the Lister`s tubercle of distal radius was used to realign the joint congruity in cases with severe comminution.Results: Post operatively they underwent early mobilisation within the volar plate protocol and good outcome in terms of proximal interphalangeal joint function and stability.Conclusion: Early intervention in the form of open reduction and internal fixation with or without bone graft in cases of pilon fractures restores the joint congruity and helps in achieving good functional outcome.

Dorsally-Displaced Metacarpal Dislocation-Fracture

History of present illness: A 19-year-old male presents to the emergency department with an injury to his right hand that he sustained after punching a tree while intoxicated. The patient had his fingers flexed and wrist extended while he punched the tree. He was able to move his fingers after the event but was complaining of severe pain over the ulnar aspect of the wrist. The patient denies punching someone in the mouth, obviating concern for a “fight bite.” On exam, the ulnar aspect of the dorsum of the right hand appeared grossly deformed and edematous. There were two abrasions over the dorsum of the hand, without exposed bone, lacerations, ecchymosis, or active bleeding. Capillary refill, strength, and sensation were present in all parts of the hand, including radial, ulnar, and median nerve distribution.Significant findings: A two-view radiograph of the right hand was obtained which revealed a dorsal dislocation of the distal fourth and fifth metacarpals (see red and blue outline, respectively) with a concomitant fracture of the distal fifth metacarpal (see yellow line) and avulsion fracture of the lateral aspect of the hamate (see green line). After reduction the fourth and fifth metacarpal dislocations are resolved; however, the distal fifth metacarpal fracture (yellow line) and avulsion fracture of the lateral aspect of the hamate (green line) are still visible. Discussion: In a case series including 21 patients, dorsal dislocation of carpometacarpal joints was initially missed in 15 of these cases.1 This is often due to the overall swelling that may mask the ulnar deformity as well as failure to obtain a true lateral X-ray. This is a rare injury because there are many strong supporting ligaments.2 The dislocation requires closed reduction, with application of ventral longitudinal pressure and traction of fourth and fifth digit. 3 There is debate amongst hand surgeons if closed reduction followed by casting or open reduction is superior, but there have been no large-scale studies comparing treatment options.4 Post-reduction films were obtained and an ulnar gutter splint was placed. The patient was instructed to follow up with hand surgery in the next week. Topics: Dorsal dislocation of carpometacarpal joints, orthopedics, hand fracture, metacarpal fracture.