Trans-scaphoid Perilunate Dislocation Research Articles

Clinical Features and Classification of Proximal Carpal Fracture Dislocation Through the Radiocarpal Joint.

Background: The most common types of wrist dislocation are trans-scaphoid lunate dislocation (TLD) and trans-scaphoid perilunate dislocation, in which the lunate and proximal scaphoid are dislocated through the midcarpal joint. There is another rare type of dislocation in which the proximal carpi are dislocated through the radiocarpal joint. The purpose of this study is to examine the clinical features of this type of dislocation. Methods: Six cases of the proximal carpal fracture dislocation via the radiocarpal joint were retrospectively reviewed. All patients underwent open reduction and internal fixation with the ligament reconstruction. A Mayo wrist score was assigned to each patient based on the assessment of pain, functional status, range of motion and grip strength at the last follow-up. Clinical subjective evaluation of function and pain was assessed using the patient-rated wrist evaluation (PRWE) method. Results: All patients were male and injured with a median age of 33.5 years. The median follow-up period was 10 months. There were three types of dislocations: Scaphoid fracture dislocation, TLD and scaphoid-lunate dislocation. All patients had satisfactory results with an average PRWE of 7.2 ± 4.7. The preoperative VAS was 6.7 ± 1.0 and the postoperative VAS was 0.7 ± 0.7 (p < 0.01). Postoperative grip strength accounted for 89.2% ± 9.8% of the contralateral side; the Mayo wrist score averaged 90.0 ± 6.5, with four patients obtaining excellent and two good results. Conclusions: Fracture dislocation of the proximal carpal bones through the radiocarpal joint is an independent type of wrist dislocation that tends to occur in young men with high-energy impact. The wrist is most often injured in a pronation hyperextension position. If treatment is timely and appropriate, the prognosis is quite good. Level of Evidence: Level IV (Therapeutic).

112 Trans-Scaphoid Perilunate Dislocation. Two Atypical Presentations with Enucleation of The Proximal Pole

Abstract This article describes two cases of tran-scaphoid perilunate dislocation, both of which have an atypical presentation. In both cases, the proximal pole of the scaphoid was enucleated, one into the carpal tunnel, the other into the distal forearm. In addition, the capitolunate alignment was preserved, with dorsal dislocation of the entire carpus. These cases are presented for educational purposes, as these injuries are highly unstable, and require a different operative approach to a typical perilunate dislocation. In a typical Mayfield II perilunate dislocation, the lunate remains within the lunate fossa, and acts as a 'keystone' for fixation of the dislocated carpus. These cases do not fit the classic Mayfield classification. Given the lunate was also unstable, K-wires were placed through the distal radius into lunate, then from the scaphoid into the lunate. Another learning point for all training levels is that the referring orthopaedic hospital referred one of these injuries incorrectly as a 'lunate dislocation'. This article provides an opportunity to re-cap the Mayfield classification, and clarify the distinction between lunate and perilunate dislocation. In all cases, stringent monitoring for any carpal tunnel syndrome is required, and urgent decompression should be performed if there is any concern.

An Isolated Transscaphoid Perilunate Dislocation Resulting from Airbag Deployment.

A 25-year-old man presented to the Emergency Department (ED) after a transfer from an outside hospital for further orthopedic evaluation of a transscaphoid perilunate dislocation of the right hand. The patient was a restrained front seat passenger who was rear-ended at approximately 40 mph. The deployment of the vehicle's passenger airbag struck the patient in his right hand as his arm was partially extended reading his cell phone. Upon evaluation, the patient stated that his right wrist was his primary source of pain.

Acute Scaphoidectomy and Lunocapitate Fusion for the Surgical Treatment of Compound Trans Styloid, Trans-Scaphoid, Peri-Lunate Fracture-Dislocation with Extensor Tendon Injury

Compound fracture-dislocations of proximal carpal bones are very rare. We report a 54-year-old male, laborer, who sustained a compound Gustilo Anderson type III-A dorsal wound with trans styloid, trans-scaphoid, peri-lunate dislocation with an extensor tendon injury. The patient underwent primary scaphoidectomy with Lunocapitate fusion with extensor tendon repair. On follow-up after 3 months, the patient had partial recovery of range of motion around the wrist without any significant discomfort. Keywords: Compound fracture-dislocation, Primary proximal row carpectomy, Trans-styloid trans scaphoidperilunate 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.

Neglected Trans-Scaphoid Volar Perilunate Dislocation with Post-Operative Complex Regional Pain Syndrome: A Case Report

We present the case report of a 30-year-old male who fell from a height of 15 feet on his palmar-flexed right wrist and came to us 1 month after the injury. He had a swollen, stiff wrist with painful movements and no neurovascular deficit. X-rays showed a trans-scaphoid volar perilunate dislocation. We used the volar approach for open reduction and internal fixation with a headless screw for scaphoid fracture and scapho- lunate and capito-lunate K-wires for intercarpal instability. The wrist was immobilised in a below-elbow POP slab for 6 weeks after which the K-wires were removed. The patient unfortunately developed complex regional pain syndrome (CRPS), which can be attributed to his late presentation after the injury. Active and passive range of motion exercises and contrast bath were initiated and he was kept on low dose amitriptyline. Gradually CRPS resolved and at 6-month follow-up, the patient had a wrist dorsiflexion of 30° and palmar-flexion of 45°.

Outcome assessment of two stage reduction and fixation in neglected trans scaphoid peri lunate fracture dislocation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Perilunate instability is a type of carpal instability complex. Perilunate injuries occur after high-energy traumas to the wrist or falls on the outstretched hand.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The hospital based prospective study was held in the department of Orthopaedics, SMS medical college and Hospital, Jaipur from April 2016 to November 2017. It included 25 cases of neglected trans scaphoid peri lunate fracture dislocation treated in 2 stages surgical procedures.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Median nerve was involved in 6 (24%) patients. Pain was also graded as subjective pain. Most of patients had pain free wrist at 1 year follow up post surgery while 2 patients had pain on routine activity, 5 patients had pain on sternous activity and pain was permanent in 1 patient. Mean scapholunate and radiolunate angles were 54 degrees (range 40 to 60 degrees) and 9.8 degrees (range 5 to 15 degrees) on the immediate postoperative radiographs and 54.8 degrees (range 40 to 65 degrees) and 10.6 degrees (5 to 20 degrees) at 1 years follow up. Mild degenerative changes were seen in the radiocarpal joint in 3 patients and in midcarpal joint in 4 patients one patient had both radiocarpal joint arthritis and midcarpal joint arthritis two patients developed superficial pin tract infection.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; On the basis of our study we finally conclude staged reduction should be considered for neglected trans scaphoid peri lunate dislocations.&lt;/p&gt;

Effectiveness of an Arthroscopic Technique toCorrect Supination Losses of 90° or More.

To present a new arthroscopic method for treating supination losses. Six patients (15-71 y) were eligible for this study. All had a history of trauma to the wrist more than 6 months previously. Five of them had sustained a distal radius fracture: 3 had been treated with a volar plate (1 of them for an extra-articular malunion), 1 with an external fixator and K-wires, and 1 had been treated in a cast. One of these patients underwent a further operation for correcting an intra-articular malunion. The last patient underwent an open reduction of a transscaphoid perilunate dislocation. During a standard radiocarpal arthroscopy, a curved periosteal elevator was inserted through the 6R portal into the volar-radial corner of the triangular fibrocartilage complex and advanced proximally gliding on the anterior ulnar head surface. The volar capsule was then distended with the periosteal elevator and by means of gentle sweeping motion adherences between them, the volar capsule and the ulnar head were freed. Finally, the arthroscopic release was combined with a gentle passive supination force applied by the surgeon. Full supination was maintained in an orthosis for 2 to 3 days. Afterward, regular physical therapy was instituted. Concomitant surgery, arthroscopic or open, was performed in all to treat associated conditions. Full supination (90°) was achieved in all intraoperatively. At a mean follow-up of 3.3years, mean supination was 76° in the latest follow-up (range, 50° to 90°). Mean improvement in supination was 80° (range, 50° to 100°). No distal radioulnar instability or other complications were noted. The method presented proved effective in severe forms of supination deficits. Therapeutic V.

Clinical outcomes of proximal row carpectomy by preoperative midcarpal joint morphological classification: Viegas type I versus type II

The midcarpal joint can be classified into two anatomical types – Viegas type I and Viegas type II – based on the absence or presence of a medial facet for the hamate on the lunate (lunohamate facet). Type I is associated with a round capitate shape, which theoretically allows better congruence with the lunate fossa of the distal radius following proximal row carpectomy (PRC). This morphological feature has never been considered as a predictive factor of clinical outcome for this surgical procedure. This study aimed to compare the clinical and radiological outcomes of the two Viegas types following PRC. A retrospective single-center study was carried out on patients who underwent PRC for wrist osteoarthritis. Minimum follow-up was 2 years. Lunate type was determined based on preoperative CT arthrography. The clinical evaluation included range of motion (ROM) and strength as well as the functional DASH, Mayo Wrist scores and a VAS for pain. The outcome of radiocapitate osteoarthritis was assessed on plain radiographs. Forty patients were reviewed with a mean follow-up of 57 months. Twenty-one Viegas type I and 19 Viegas type II were identified on preoperative CT arthrography. The etiologies included 23 SLAC wrists (12 Viegas type I, 11 type II), 8 SNAC wrists (4 Viegas type I, 4 type II), 6 cases of Kienböck's disease (3 type IIIa, 3 type IIIb with 3 Viegas type I and 3 type II), 1 Preiser's disease and 2 cases of transscaphoid perilunate dislocation of the carpus. Patients with a Viegas type I lunate had significantly greater flexion-extension ROM: 83.5° vs. 71° (P=0.04) and radial deviation: 12° vs. 7° (P=0.013) than those with Viegas type II. However, three cases of complex regional pain syndrome (CRPS) were reported in the Viegas type II group vs. zero in the Viegas type I group. There were no differences between the two groups in terms of strength, functional scores or VAS pain. The outcome of radiocapitate osteoarthritis was similar in both groups. Considering the number of CRPS cases in the Viegas type II group and similar functional results in both groups, the worse outcomes of the Viegas type II patients in terms of ROM cannot be considered as clinically relevant. This comparative study does not provide a reasonable basis for concluding that Viegas type I patients are better candidates for PRC than Viegas type II patients.

Minimally Invasive Surgery of Perilunate Dislocations and Fracture Dislocations

Background: The gold standard for the treatment of perilunate dislocations (PLD) and fracture dislocations is currently an open reduction and internal fixation. However, as many authors have suggested, minimally invasive surgery (MIS) is being positioned as an alternative management of the condition. Purpose: The purpose of this retrospective, nonrandomized study was to evaluate the clinical and radiographic outcomes of a series of acute PLD and trans-scaphoid perilunate dislocation (TSPD) treated operatively by a minimally invasive technique. Patients and Methods: In all, 11 patients (2 PLD and 9 TSPD) had surgery performed between 2005 and 2010. All patients were males with an average age of 34.6 years (range, 17-55) at their final evaluation. The procedure involves (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; (3) closed reduction, k wires, and screws for stabilization of the carpal dissociation. Clinical outcomes were evaluated on the basis of range of motion, pain, functional status, and Mayo scores. We performed a radiographic assessment of the radiolunate angle, scapholunate angle, and gap between these 2 bones. The right wrist was involved in 7 patients, and the left in 4 patients; the dominant hand was affected in 6 occasions. Seven patients sustained a fall from a height with the wrist in hyperextension, 2 cases occurred during sport practice (1 rugby, 1 skiing), and the other 2 were involved in traffic accidents (1 motor vehicle, 1 motorcycle). The average time from injury to operation was 6 days (range, 4-22). Five patients had associated fractures: 3 in upper limb (1 elbow dislocation, 1 clavicle fracture, 1 radial head fracture), 2 in lower limb (1 patellar fracture, 1 calcaneal fracture). Results: The average follow-up period was 28 months (range, 14-52) and no patient was lost to follow-up. All patients achieved satisfactory reduction of the midcarpal joint and intercarpal bone alignment by closed reduction. Clinically, patients had functional mobility with an average loss of about 23% compared with the contralateral wrist. The mean Disabilities of the Arm, Shoulder and Hand (DASH) outcome score was 23, demonstrating a moderate average disability in activities of daily living (ADL). The average Mayo wrist score was 84 with 4 excellent, 6 good and 1 fair result. On the basis of radiographic parameters, reduction obtained during the operation was maintained within normal ranges in all patients. Scaphoid fracture union occurred at an average time of 16 weeks (12-27 weeks) and there was no case of nonunion. Radiographic results showed an average scapholunate angle of 52°, a radiolunate angle of 10°, and a scapholunate distance of 1.6 mm. No case of lunotriquetral instability was noted. In pure injuries, there was almost no loss of scapholunate reduction after removal of trans-articular screw at 7 month. At the last follow-up, arthritis had not developed in any patient. Conclusions: This study suggests that a percutaneous procedure (MIS), with reduction of carpal dislocations and fixation of scaphoid fracture, seems an acceptable method for the treatment of acute and reducible PLD and TSPD in selected cases.

External fixator combined with cannulated screw and Kirschner wire fixation for the treatment of scaphoid fractures and transscaphoid perilunate dislocation

Objective To summarize the clinical outcomes of treating scaphoid fracture and transscaphoid perilunate dislocation using external fixator combined with cannulated screw and Kirschner wire fixation. Methods From December 2009 to December 2014, 18 cases of scaphoid fracture and transscaphoid perilunate dislocation were treated. The external fixator was applied to immobilize the wrist in 9 cases, while the scaphoid fracture was reduced and fixed with a cannulated screw. The capitate lunate joint was fixed temporarily with a Kirschner wire and the intercarpal ligaments were repaired. The other 9 cases were treated with the same internal fixation technique and intercarpal ligament repair, while the wrist joint was immobilized with a plaster cast postoperatively. Results All the patients were follow-up for 12 to 24 months and achieved wrist function recovery. There was no re-dislocation or avascular necrosis of the scaphoid or lunate. The Cooney scoring revealed excellent results in 4 cases, good results in 4 cases and fair results in 1 case in the external fixator group. In the plaster cast group, the results were excellent in 2 cases, good in 2 cases and fair in 5 cases. The difference was statistically significant (P 0.05). Conclusion The external fixator plays an important role in the treatment of scaphoid fracture and transscaphoid perilunate dislocation, as it facilitates early ligament repair and wrist joint function recovery. Key words: Scaphoid bone; External fixators; Scaphoid perilunate dislocation; Plaster external fixation

Imaging quiz cases: imaging of the wrist

There is a fracture through the waist of the scaphoid associated with a perilunate dislocation consistent with a trans-scaphoid perilunate dislocation. This has been treated by open reduction and fixation with Kirschner wires across the lunotriquetral interval and a Herbert compression screw across the trans-scaphoid fracture. These are extremely important injuries, 25% are missed at initial presentation and may lead to serious complications. They can occur following high-energy trauma, such as road traffic accidents or sporting injuries, causing hyperextension of the wrist. 26% of injuries are associated with polytrauma. Perilunate dislocations occur in a sequence of events involving either ligament and/or bony disruption. This injury pattern typically starts on the radial side and destabilizes either through the body of the scaphoid or through the scapholunate interval. Mayfield et al described the ligamentous sequence of events:

Late diagnosis of trans-scaphoid perilunate dislocation: A case report

Perilunate fracture dislocations are rarely seen severe injuries among wrist traumas.Trans-scaphoid perilunate fracture dislocation and dorsal perilunate dislocation are the most commonly encountered types of these injuries. In addition, other pathologies may also accompany in the same extremity. As they are rarely seen, they may be diagnosed late. When these cases are overlooked and not treated in the early stages, there is a high possibility of the development of limited wrist movements and chronic pain. In this respect, the importance of early diagnosis and treatment is evident. With accompanying literature, we present a case of 41-years old male operated for a diagnosis of perilunate dislocation due to falling down. J. Exp. Clin. Med., 2014; 31:59-61

Bipolar dislocation of the forearm (floating forearm)

Bipolar dislocation of the forearm (floating forearm) is an unusual injury and is therefore often overlooked. We report a 28-year-old male patient who presented at another center with a history of a fall while climbing a tree. The patient's left elbow was treated with closed reduction and immobilization with a long-arm cast brace due to elbow dislocation. However, the patient was admitted with pain and swelling of the wrist to our emergency department the following day. Physical and radiological examination revealed dorsal trans-scaphoid perilunate dislocation. A dorsal incision was performed for open reduction and internal fixation to provide wide surgical exposure. Concomitant occurrence of elbow dislocation and fracture-dislocation of the perilunate is infrequent. Therefore, physicians should be aware of possible additional injuries and current recommended treatment methods.

Trans-scaphoid perilunate fracture-dislocation and isolated perilunate dislocations; surgical versus non surgical treatment.

Trans-scaphoid perilunate fracture-dislocation and perilunate dislocations are among uncommon injuries, most commonly seen in young patients due to high energy trauma. The treatment can be achieved either surgically by open reduction and internal fixation or closed reduction and casting. To compare surgical versus non-operative results of treatment after trans-scaphoid perilunate fracture-dislocation and isolated perilunate dislocation, we collected the data of 34 patients who were treated at least 5 years before our study, twenty of whom were treated surgically and fourteen were treated non-surgically. We compared clinical and radiological findings in two groups. Functional outcome was assessed by Mayo wrist score for each patient. The surgically treated patients had much higher Mayo wrist scores, 85 and 87.78 for perilunate dislocation and trans-scaphoid perilunate fracture-dislocation respectively, while 71 and 71.11 in non-surgically treated group respectively. Wrist range of motion was also more favorable in operative group (55 degrees flexion - 54 degrees extension for trans-scaphoid perilunate fracture-dislocation and 50 degrees flexion, 51 degrees extension for perilunate dislocations)than non-operative group(49 degrees flexion, 48 extension for trans-scaphoid fracture-dislocations and 48 degrees flexion, 50 degrees extension for perilunate dislocation). The radiographic changes showed arthritic changes but those changes did not significantly interfered with functional outcome and wrist scores. Regarding our better clinical results after early open reduction and internal fixation for these injuries, we can suggest the operative treatment of these complicated hand injuries.

A case of attritional index flexor tendon ruptures by an old trans-scaphoid perilunate dislocation

A case of attritional index flexor tendon ruptures by an old trans-scaphoid perilunate dislocation

Traumatic Divergent Elbow Dislocation in an Adult with an Associated Fracture of the Distal Part of the Humeral Shaft and an Open Perilunate Dislocation: A Case Report.

Divergent dislocation of the elbow represents an extremely rare injury. The proximal radioulnar joint is disrupted as the distal part of the humerus is driven between the radius and ulna, and the forearm dislocates posteriorly. We believe that DeLee, in 1981, reported the first modern case of divergent elbow dislocation that was confirmed by radiographs in a child1. Subsequently, to the best of our knowledge, there have been twenty-one additional reported cases of divergent elbow dislocation in children2-19. We identified only one previously published case report of traumatic divergent elbow dislocation in an adult20. We present an adult patient with a traumatic divergent dislocation of the elbow with an associated humeral fracture and an open perilunate dislocation. The patient was informed that data concerning the case would be submitted for publication, and he provided consent; the institutional review board approved the submission. ### Initial Patient Presentation A twenty-nine-year-old right-hand-dominant man presented to our emergency department after landing on the outstretched left upper extremity following a 15-foot fall from a ladder. Initial physical examination of the extremity revealed gross deformity of the midhumerus and swelling of the left elbow. A 2-cm wound over the lateral part of the elbow communicated with the radiocapitellar joint. Carpal bones were extruded through a second wound over the volar aspect of the wrist on the same extremity. The patient’s hand was well-perfused with palpable pulses. He reported paresthesias in the median nerve distribution. Radiographs demonstrated a displaced mid-diaphyseal humeral fracture and an open divergent elbow dislocation (Figs. 1-A and 1-B). Distally, the patient had an open trans-scaphoid perilunate dislocation, fracture of the trapezium, and left fourth and fifth metacarpal fractures (Figs. 2-A and 2-B). Additional injuries included fractures of the lumbar transverse processes, ribs, superior and inferior pubic rami, iliac wing, …

Two stage procedure for neglected transscaphoid perilunate dislocation

We report a two-staged surgical procedure for neglected 3 month old volar transscaphoid, transcapitate perilunate fracture dislocation wrist in an 18 year old right handed male student. The lunate with proximal scaphoid and proximal capitate maintained its articulation with distal end radius while the rest of carpal bones had dislocated volarly. In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue. In the next stage open reduction and internal fixation was done by a combined volar and dorsal approach augmented by pronator quadratus flap. At 3 years followup the patient was pain free and had a full range of supination pronation of the forearms and radial and ulnar deviation of wrist with 10° dorsiflexion deficit.

Staged reduction of neglected transscaphoid perilunate fracture dislocation: A report of 16 cases

BackgroundTransscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome.Material & Methods16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1 mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation.ResultsThe mean duration between two surgeries was 2.4 weeks (range 2–4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results.ConclusionStaged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.

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.