Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation

Perilunate Dislocations: Current Treatment Options

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Approximately 25% of all patients who sustain perilunate dislocations present in a delayed fashion.

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While management of acute injuries is relatively well-described, treatment of chronic injuries can be complex and there is a paucity of scientific evidence to guide management.

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Treatment options include open reduction internal fixation, proximal row carpectomy, scaphoid or lunate excision with or without arthrodesis, and total wrist arthrodesis, although indications vary based on chronicity of injury and patient factors.

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The purpose of this article was to determine the quality of evidence supporting surgical options for the treatment of these injuries.

Perilunate dislocation and fracture dislocation of the wrist: Outcomes and long-term prognostic factors

INTRODUCTION

Perilunate dislocations and fracture-dislocations are severe injuries that often have serious functional sequelae. Our goal was to evaluate the long-term clinical and radiological results of these perilunate injuries, and to look for prognostic factors of a poor clinical outcome.

HYPOTHESIS

All patients who suffered perilunate injuries in their wrist have functional sequelae and long-term radiographic changes despite optimal treatment with anatomical surgical reduction.

MATERIALS AND METHODS

We did a single-center, retrospective study of 32 patients who had either an isolated perilunate dislocation (n=7) or fracture-dislocation (n=25) in their wrist. Pain, range of motion, strength and functional scores (MWS, PRWE, QuickDASH) were evaluated. Radiographs were analyzed to look for signs of osteoarthritis or carpal instability.

RESULTS

The mean follow-up time was 9.9years (3.5-24). The wrist joint had a mean flexion-extension of 86° (0-140), radioulnar deviation of 38° (0-65) and pronosupination of 153° (120-180). The mean grip strength was 35kg (5-56). The mean MWS, PRWE and QuickDASH scores were 65/100, 32/100 and 29/100, respectively. At the final assessment, 23 patients (79%) had radiographic signs of osteoarthritis while 5 patients (16%) had residual carpal instability. Three patients subsequently underwent palliative treatment. Opening the carpal tunnel and the magnitude of the lunate's displacement are significant predictors of a poor long-term functional outcome (p<0.05). Older age at the time of injury was a predictor for the development of osteoarthritis.

DISCUSSION

Despite optimal treatment, perilunate dislocations and fracture-dislocations at the wrist cause functional sequelae such as pain, stiffness, strength deficit and posttraumatic arthritis in nearly 80% of patients. The functional outcomes are determined by the amount of lunate displacement (stage) and the patient's age. We do not recommend opening the carpal tunnel, even when signs of median nerve compression are present; reducing the dislocation helps to relieve the neurological symptoms.

LEVEL OF EVIDENCE

IV; retrospective observational study.

Perilunate Injury Timing and Treatment Options: A Systematic Review

Introduction  Perilunate injuries are uncommon yet challenging and often missed injuries, representing 7% of all carpal traumas. Two types of injuries can be identified as follows: perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD). The purpose of this study was to conduct a systematic review and meta-analysis to establish which surgical treatment is superior for patients with perilunate injuries and the significance of delayed treatment. Methods  A total of 2056 articles were screened, and 16 articles were included. Risk of bias for case-control series and case series were assessed through the National Institute of Health study quality assessment tool. Qualitative outcomes of clinical scores for hand function were compared between different time points (acute, < 7 days; delayed 7-45 days; chronic > 45 days), open and closed reduction, and PLD and PLFD. Results  Overall, the clinical outcome scores of patients treated within 7 days are good. The results suggest that closed reduction and internal fixation (CRIF) offers slightly better outcomes than open reduction and internal fixation (ORIF) for PLFD. Patients treated 6 weeks or more after the initial injury seem to have the worst overall outcomes than patients in the acute or delayed setting. The results suggest that patients with chronic PLD have even worse outcomes than patients with chronic PLFD. Conclusions  Timing of surgery is essential for an optimal outcome. When there is a delay of treatment, the outcomes are inferior to those treated acutely. Early referral to centralized treatment units for perilunate injuries would allow for targeted treatment and facilitate research on this difficult wrist injury.

Perilunate Injuries: Current Aspects of Management

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are high-energy injuries which can result in long-term complications and significant disability. Early identification of these injuries, followed by prompt, appropriate management is key to optimising patient outcomes. Knowledge of the carpal anatomy is essential in order to understand the varied patterns of injury and plan appropriate definitive management. Emergent reduction and close monitoring of the median nerve, followed by prompt stabilisation or repair of the injured structures remain the mainstay of treatment. In this review, we present a summary of the current evidence regarding the identification and management of these complex injuries.

Primary Vascularized Bone Graft for the Extruded Scaphoid Proximal Pole: A Case Report

CASE

A 52-year-old man sustained a radiocarpal dislocation with extrusion of the scaphoid proximal pole, which was completely detached from the soft tissue. To reduce the risk of avascular necrosis (AVN), treatment involved simultaneous anatomic reduction and internal fixation of the fracture and vascularized bone graft (VBG) for the scaphoid proximal pole. At 4 months, magnetic resonance imaging and 36 months of follow-up radiography showed a healed scaphoid and revealed no evidence of AVN in the scaphoid proximal pole.

CONCLUSION

If the risk of AVN is high, we recommend considering the combination of internal fixation and VBG for the fresh scaphoid fracture.

Proximal row carpectomy for complex perilunate fracture dislocations with migration of proximal scaphoid bone into the forearm

Complex perilunate dislocations include scaphoid, triquetrum, radial styloid fractures, and associated ligamentous injuries. The purpose of the study is to assess the role of proximal row carpectomy (PRC) in such complex injuries involving the proximal scaphoid migration and analyze the outcome. We operated on eighteen patients with complex perilunate dislocations and extreme proximal migration of proximal scaphoid by PRC between 2012 and 2018. We analyzed the postoperative radiographs, VAS pain score, range of motion, return to work, Quick DASH and Mayo wrist scores and assessed the overall functional outcome. The average follow-up was 46 months. The mean range of wrist flexion was 65%, extension 70 %, pronation 88%, supination 90%, and grip strength 70% of the opposite side. The median VAS pain score was 0.1 (range, 0-3). Median Quick DASH score was 4.4 (range, 3.3-6.7), and Mayo wrist score 70 (range, 65-75). The age, gender, side of injury, dominant hand, fracture displacement or type, osteochondral fracture of the capitate head, and treatment delay had no significant impact on the functional outcome. The presence of degenerative changes had no significant association with age, grip strength, range of movements, pain, and outcome scores. All patients had good subjective satisfaction with the surgery and functional outcome. PRC is a reliable option for complex perilunate fracture-dislocations with extended proximal migration of the scaphoid proximal pole. The degenerative changes after PRC may progress with time, mostly when done for young patients. Outcomes of salvage procedure in the long-term follow-up need to be taken into account when counselling patients on the treatment of these injuries.

Nuanced Trans-scaphoid, Perilunate Fracture Dislocations With Complete Scapholunate Dissociation: Two Cases With Proximal Row Preservation

We offer two reports of trans-scaphoid perilunate fracture dislocations, both involving complete dissociations and loss of vascular supply to the proximal scaphoid poles. Case 1 involves a 25-year-old man who fell on an outstretched hand and suffered a trans-styloid, trans-scaphoid, perilunate fracture dislocation. The patient underwent open reduction and screw fixation of the scaphoid using a dorsal approach. Kirchner wire fixation and suture anchor ligamentous repairs were used to reduce the scapholunate, lunar-triquetral, and radioscaphocapitate intervals. At 6 months, the patient was released to work without restrictions. Case 2 is a 66-year-old man who suffered a trans-scaphoid, perilunate fracture dislocation after a fall from a horse. A portion of the completely torn scapholunate ligament remained intact to the proximal pole, but no soft-tissue attachment to the rest of the carpus remained. The patient underwent open reduction of the scaphoid with compression screw and Kirschner wire fixation to repair the scapholunate and lunar-triquetral ligaments. At 1-year, the patient was released to full activity. Intraoperatively, the proximal scaphoid poles were completely devoid of any uninterrupted soft-tissue attachments, elevating concern for osteonecrosis. Although both patients showed radiographic signs of transient ischemia, neither patient displayed osteonecrosis or proximal pole collapse at their terminal visits.

Total Scapholunate Extrusion Into the Forearm in a Transscaphoid, Transcapitate Perilunate Fracture Dislocation: A Case Report

CASE

A 50-year-old woman involved in a motorcycle accident sustained a transscaphoid transcapitate perilunate fracture dislocation with complete extrusion of the proximal scaphoid pole and lunate as a unit into the forearm. The patient underwent urgent open reduction and internal fixation (ORIF) with screw fixation of the capitate and Kirschner wire fixation of the scaphoid, midcarpal joint, and lunotriquetral intervals. At 1-year postoperatively, radiographs confirm healing of capitate and scaphoid fractures, with no signs of avascular necrosis of the lunate.

CONCLUSION

Despite a complex fracture-dislocation pattern, treatment with ORIF can successfully lead to scaphoid and capitate union and lunate revascularization.

Functional Outcomes After Salvage Procedures for Wrist Trauma and Arthritis (Four-Corner Fusion, Proximal Row Carpectomy, Total Wrist Arthroplasty, Total Wrist Fusion, Wrist Denervation): A Review of Literature

Background:

Several salvage procedures for the arthritically destroyed wrist exist. Each of these has advantages as well as disadvantages.

Aims:

The aim of this article is to give practical insights for the clinician on: (1) biomechanical and clinical fundamentals of normal and impaired wrist motion; (2) difficulties in assessment of postoperative outcome between measured motion by the surgeon and self-reported outcome by the patient; (3) indications for each procedure; and (4) differences in functional outcome between partial and complete motion-preserving as well as complete motion-restricting salvage procedures.

Methods:

In trend, Proximal Row Carpectomy (PRC) is slightly superior over four-corner fusion (4CF) in terms of functional outcome, but the methodology-related postoperative motion is decreased for both procedures. Furthermore, PRC is easier to perform, needs lower costs, and has fewer complications than 4CF. Total Wrist Arthroplasty (TWA) has the advantage compared to PRC and 4CF that the preoperative motion values are preserved, but it is limited by decreased load-bearing capacity for the wrist. Total Wrist Fusion (TWF) is associated with a higher load-bearing capacity for the wrist than TWA, but it is limited for carrying out essential activities of daily living. Both PRC and 4CF can be combined primarily by wrist denervation. Wrist denervation alone does not impair the movement of the wrist.

Results and Conclusion:

Salvage procedures for the arthritically destroyed wrist should be detected regarding patients age- and gender-related claims in work and leisure. Not all of them can be successfully re-employed in their original occupations associated with high load-bearing conditions.

Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy

PURPOSE

Some authors have proposed performing proximal row carpectomy (PRC) as the initial treatment for perilunate dislocations.

HYPOTHESIS

The goal of this retrospective study was to compare the results of a cohort of perilunate dislocation cases that were operated by open reduction and internal fixation (ORIF) or by PRC between 2006 and 2011.

METHODS

The cohort consisted of 21 men with a mean age of 33years, who either had an isolated perilunate dislocation (7 cases) or a fracture-dislocation (14 cases). All dislocations were dorsal, with 10 stage I and 12 stage II. Thirteen patients had been treated by ORIF (group 1) a mean of 1.2days after the injury. Eight patients had been treated by PRC (group 2) a mean of 18.7days after the injury. Immobilization time was 6-12weeks in group 1 and 2weeks in group 2.

RESULTS

The mean operative time was 95minutes in group 1 and 65minutes in group 2. After a mean follow-up of 35months, the following outcomes were found for groups 1 and 2, respectively: pain 3/10 and 1/10, strength 77% and 73%, strength in supination 79% and 93%, strength in pronation 67% and 95%, QuickDASH 27/100 and 16/100, PRWE 43/150 and 15.5/150, flexion 69% and 57%, extension 84% and 58%, pronation 97% and 103%, supination 98% and 97%. There were four cases of osteoarthritis in both groups.

CONCLUSION

Treatment of acute perilunate dislocations by PRC leads to medium-term results that are at least as good as those with ORIF treatment. The surgery duration is shorter with PRC, as is the immobilization period.

TYPE OF STUDY

Retrospective comparative.

LEVEL OF EVIDENCE

III.