Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation

Perilunate Dislocations: Cadaveric Model K-Wire Versus Compression Staple Fixation

Purpose

Repair of perilunate dislocations requires stabilization of the carpal bones, although there is limited research on the preferred method(s) of stabilization. We compared the biomechanical characteristics of K-wire versus staple fixation of scapholunate (SL) and lunotriquetral (LT) intervals in the wrist.

Methods

After creating a grade IV instability model, 20 cadaver wrists were randomized into 2 stabilization model groups using K-wires or surgical staples across the SL and LT intervals. For each ligament, two K-wires or one surgical staple was used to stabilize the proximal carpal row. Each wrist was loaded with 15 N of force and cycled 5,000 times at an angular velocity of 10 rpm. Displacement between bones was measured at different cycles (10, 100, 500, 1,000, 2,000, 3,000, 4,000, and 5,000). A t test was used for comparisons.

Results

For the LT K-wire group, the average displacement at 10 cycles was 0.08 mm, and at 5,000 cycles, 0.163 mm. For the SL K-wire group, the average displacement at 10 cycles was 0.025 mm, and at 5,000 cycles, 0.129 mm. For the LT and SL staple fixation models, the average shifts at 10 cycles were 0.029 and 0.063 mm, and at 5,000 cycles, 0.098 and 0.176 mm, respectively. No significant difference between the fixation models was found at any interval. Notably, in each group, a similar number of small outliers with higher amounts of displacement was observed.

Conclusions

Either K-wire or surgical staple stabilization is suitable for perilunate dislocations. The surgical method should be selected based on patient-specific circumstances and the provider's judgment.

Type of study/level of evidence

Therapeutic III.

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches

BACKGROUND

Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes.

METHODS

A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD.

RESULTS

Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%.

CONCLUSION

Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability.

LEVEL OF EVIDENCE

I, Systematic Review.

Trans-scaphoid trans-lunate trans-triquetral volar perilunate dislocation: A case report

Introduction

Translunate volar perilunate dislocations are extremely rare, with few documented cases. Only eight instances of volar translunate perilunate dislocation have been described in the literature. This report presents a successfully treated case using early reduction and internal fixation that led to a very satisfying outcome at 9 months follow-up.

Case report

A 20-year-old man presented with left wrist pain and swelling after a fall from a vehicle at 50 km/h, landing on an outstretched right hand. Radiographs and a CT scan identified scaphoid, lunate, and triquetral fractures, along with a volar perilunate dislocation. Surgical treatment was performed with a dorsal approach, including scaphoid and lunate fracture fixation, triquetral avulsion repair, and lunate stabilization with K-wires. The wrist was immobilized for 6 weeks, intense physical therapy started after K-wires removal. At 9 months follow-up, positive results were seen clinically and radiologically.

Discussion

A perilunate fracture-dislocation includes dislocation of the carpus from the lunate. Johnson divided these injuries into lesser arc (pure ligamentous) and greater arc (fracture-related). Bain introduced the translunate arc concept in a case series of three patients, depicting a path through the lunate causing lunate fracture alongside perilunate injury. Treatment focuses on lunate reduction and fixation, combined with addressing greater and lesser arc injuries. Achieving successful lunate realignment and fixation is challenging. However, early diagnosis, prompt reduction, rigid fixation, and repair of both arc injuries can lead to optimal functional recovery.

Outcomes of acute perilunate injuries-a systematic review

PURPOSE

The objective of this systematic review was to perform epidemiological as well as clinical, radiological and patient-reported outcome analysis of surgically treated perilunate dislocations and fracture dislocations (PLDs and PLFDs) based on the so far largest pooled patient population to date.

MATERIAL AND METHODS

This systematic review was written according to the updated guideline for reporting systematic reviews by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. A comprehensive literature search of Pubmed, Embase, CENTRAL, and CINAHL databases was performed. All studies reporting on complications, radiological, functional and/or patient-reported outcomes of surgically treated acute PLDs and PLFDs with a minimum follow-up of 12 months were included.

RESULTS

Twenty-six studies encompassing 550 patients with 553 operatively treated acute perilunate injuries (106 PLDs and 447 PLFDs) were included. The overall postoperative complication rate was 15.0% with secondary reduction loss representing the main contributing factor (10.1%). The overall reoperation rate was 10.4% and the incidence of salvage procedures was 2.8%. The risk for secondary reduction loss was higher for PLD than for PLFD injuries (24.2% vs. 7.0%, relative risk [RR] 3.5, 95% confidence interval [CI] 1.6-7.5). There was a higher overall complication rate for the combined dorsopalmar approach when compared to the isolated dorsal approach (17.4% vs. 8.4%, RR 0.5, 95% CI 0.2-1.0, number needed to treat [NNT] 11.2) and for open surgery versus arthroscopic surgery (17.4% vs. 4.8%, RR 0.3, 95% CI 0.1-0.9, NNT 8.0). A significant correlation was found between radiological osteoarthritis (rOA) and follow-up duration of the individual studies, while functional and patient-rated outcomes were comparable.

CONCLUSIONS

Regardless of surgical technique, PLFDs appear to be less susceptible to secondary reduction loss than PLDs. Whenever possible, less invasive (e.g. arthroscopic) surgery should be performed to minimize postoperative complications. The rate of rOA is high and increases significantly with follow-up duration. Interestingly, rOA does not seem to correlate with reduced wrist function nor patient dissatisfaction and the need for salvage surgery is surprisingly rare.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Carpal dislocations

Carpal dislocations result from sequential disruption of the complex relationship between the bones and ligaments of the wrist. Injuries to the carpus occur via predictable mechanisms, an understanding of which is critical to identify and treat these frequently missed patterns of injury and to avoid the sequela of chronic instability. Lunate dislocations are by far the most common, but isolated dislocation of other carpal bones can also occur. Open reduction and internal fixation still remains the gold standard for treatment regardless of the debate around the specific approaches. These high-energy injuries are associated with significant long-term morbidity even when identified promptly and appropriately treated. This review will focus on the evaluation and management of common forms of carpal dislocations.

Outcomes of arthroscopic versus open reduction and internal fixation for the treatment of acute traumatic lunate fractures: a systematic review

The purpose of the study was to compare outcomes of fully-arthroscopic reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) to treat acute traumatic lunate fractures. A literature search was conducted using Medline and Embase. Demographic data and outcomes were extracted for included studies. The search identified 2,146 references: 17 articles were included, reporting on 20 cases (4 ARIF and 16 ORIF). No differences between ARIF and ORIF were found in rate of union (100% vs 93%, P = 1.000), grip strength (mean difference, 8%; 95%CI, -16-31; P = 0.592), rate of return to work (100% vs 100%, P = 1.000), or range of motion (mean difference, 28°; 95%CI, -25-80; P = 0.426). Lunate fractures were not identified in 6 of the 19 radiographs, but were identified in all CT scans. There were no differences in outcome between ARIF and ORIF for the treatment of fresh lunate fracture. The authors recommend surgeons to perform CT scans when diagnosing high-energy wrist trauma so as not to overlook lunate fractures. LEVEL OF EVIDENCE: Level IV.

Immediate Proximal Row Carpectomy for Severe Perilunate Dislocation Injuries: A Minimum 5-Year Follow-Up

Background: In patients with perilunate injuries (PLI) with multiple ligamentous and bony injuries involving the proximal carpal row, open reduction and internal fixation (ORIF) can be difficult and lead to poor functional outcomes. Proximal row carpectomy (PRC) is an alternative procedure that has been used for severely comminuted fractures. The aim of our study is to evaluate the long-term functional outcome (minimum 5 years) of patients that underwent an emergency PRC for PLI. Methods: We conducted a retrospective study of patients who underwent PRC at our centre between 2001 and 2016. Only patients with follow-up data of more than 5 years were included in the study. We evaluated range of motion, grip strength, Mayo Modified Wrist Score (MMWS) and Quick Disabilities of Arm, Shoulder and Hand (Quick-DASH). Radiographic analyses were performed to assess the presence of radiocarpal osteoarthritis and the space between the radius and capitate. Results: Thirteen patients were included, with an average follow-up of 78.07 months (6.5 years). The MMWS was 65 points (four excellent and good, four fair and five poor results) and the Quick-DASH score was 30 points. X-ray analysis reported only 15.3% of patients with radiocarpal arthrosis and an average radio-capitate joint space of 1.92 mm. Conclusions: The outcomes of PRC in the management of PLI are comparable to the results reported in literature for conventional ORIF. PRC is a simpler procedure that minimises the need for re-intervention. Level of Evidence: Level IV (Therapeutic).

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.

Scapholunate and lunotriquetral interosseous ligament augmentation with internal bracing in perilunate dislocation: Case reports

RATIONALE

The goals of surgical treatment of the perilunate dislocation (PLD) are confirmation of reduction, ligament repair, and supplemental fixation of the bony architecture. Open reduction and direct repair of the torn ligament are recommended for acute PLD. However, repair of the scapholunate interosseous ligament (SLIL) and lunotriquetral interosseous ligament (LTIL) is often unreliable, and secure repair is challenging. Internal bracing (IB) is an augmentation method that uses high-strength non-absorbable tape and enhances strength and support during the critical period of ligamentous healing. However, there is a paucity of data on the application of IB for PLD in the wrist. We report 3 cases of PLD that were augmented with IB after SLIL and LTIL repair.

PATIENT CONCERNS

All 3 cases were men who visited our emergency department with wrist after falling off a ladder.

DIAGNOSES

Initial radiographs revealed a dorsal PLD.

INTERVENTIONS

Surgically, complete rupture of the SLIL and LTIL were confirmed. K-wires were placed into the scaphoid and lunate and used as joysticks to correct the intercalated segment instability pattern. This usually requires correcting scaphoid flexion and lunate extension and closing the scapholunate interval. Prior to SLIL and LTIL repair, temporary intercarpal fixation was performed with K-wires to maintain the carpal relationship. The dorsal SLIL and LTIL were carefully repaired using suture anchors. However, ligament repair was unreliable, and insecure. In view of the likelihood of insufficient repair, we performed IB augmentation using synthetic tape.

OUTCOMES

At the last follow-up, all cases were pain-free and had returned to all activities. The last follow-up radiographs showed good alignment of the carpal bones and no arthritic changes.

LESSONS

IB augmentation can reduce the period of K-wire fixation and cast immobilization and can enable early joint motion. We believe that interosseous ligament augmentation using IB is a reasonable treatment option for PLD.

Avascular necrosis of the lunate secondary to perilunate fracture dislocation: Case report and review of the literature

This is a 39-year-old male, fell from a bike, left wrist with trans-styloid perilunate fracture dislocation that underwent open reduction internal fixation, 20 months after surgery the patient developed avascular necrosis of the lunate, final wrist fusion was performed secondary to the arthritic changes on the wrist. Anatomic dissection was performed and vascularity of the lunate was identified, its origin is from the volar palmar arch, when dislocated palmarly and more than 90 degrees the vessel is still intact. More than 512 patients with perilunate dislocation and perilunate fracture dislocation are included we identified in the literature transient avascular necrosis of the lunate in nine and seventeen of pure avascular necrosis of the lunate. Concluding that avascular necrosis of the lunate after perilunate dislocation or perilunate fracture dislocation is an infrequent finding especially when the volar ligaments are intact.

Diagnostic Failure Rate in Detecting Perilunate Carpal Fractures and Dislocations Using Plain Wrist X-Rays

Objectives  The present study aimed to evaluate the diagnostic failure rate in detecting perilunate fractures and dislocations using plain wrist radiographs by orthopedists and orthopedic residents. A secondary objective was to identify possible groups with a greater or lesser chance of establishing a correct diagnosis.

Methods  An online questionnaire was sent to several orthopedists through e-mail, social networks, and smartphone-based communication applications to assess the rate of diagnostic failure in detecting perilunate fractures and dislocations using plain radiographs.

Results  A total of 511 responses was obtained, with a diagnostic error rate of 8.81% for simple dislocations and 1.76% for trans-scaphoid perilunate fractures. Group stratification showed that residents presented the highest error rates in simple perilunate dislocations (23.91%), whereas hand surgeons presented the lowest error rates (1.74%).

Conclusion  Compared with the literature, the failure rates found were lower, suggesting that plain radiography is effective and that the error rate may not be as high as reported.

Three Cases of Translunate Perilunate Injury Treated with Wrist Arthroscopy

Background  An acute fracture of the lunate is an uncommon injury with the reported incidence ranging from 0.5 to 1% of all carpal bone fractures. The combination of lunate fracture and perilunate injury is even rarer and Bain et al first introduced the "translunate arc concept" in 2008. We reported three cases of translunate perilunate injury treated with wrist arthroscopy. Materials and Methods  All the three cases had been treated successfully with the use of wrist arthroscopy. A novel technique of arthroscopic reduction and fixation of a volar pole of lunate fracture was illustrated. The lunate fracture healed in all cases with normal carpal alignment. Results  All patients achieved a painless and functional joint with good range of motion at an average follow-up of 15 months. There was no radiological evidence of avascular necrosis of the lunate in all three cases. Conclusion  Translunate perilunate injury is rare and a high index of suspicion is necessary for diagnosis. There was no consensus on the surgical approach to this kind of injury. Wrist arthroscopy had proven to be successful in treating the greater and lesser arc perilunate injury. For translunate perilunate injury, wrist arthroscopy is also a feasible option with the advantages of lower risk of arthrofibrosis and avascular necrosis.

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.

Treatment of acute perilunate dislocation or fracture dislocation using dorsal approach and diamond-shaped Kirschner-wire fixation

Objectives

This study aims to evaluate the clinical and radiological outcomes of diamond-shaped Kirschner (K)-wire fixation for the treatment of acute perilunate dislocation (PLD) or trans-scaphoid perilunate fracture dislocation (PLFD).

Patients and methods

We performed a retrospective review of 18 patients (18 wrists; 17 males, 1 female; mean age 31.5±2.6 years; range, 18 to 47 years) treated for PLD/PLFD using a dorsal approach with the diamond-shaped K-wire fixation between November 2001 and September 2017. The mean follow-up of cohort was 27 (range, 13 to 74) months. Using a dorsal approach, open ligament repair and bone fixations were performed. Perilunate dislocation was reduced and the carpal bones and midcarpal joint were held in anatomical position using four K-wires transfixing the scapholunate (SL), lunotriquetral, scaphocapitate, and triquetrohamate joints in such a shape that each bone received two K-wires.

Results

The mean range of motion and grip strength measured using a Jamar® dynamometer of the injured wrist compared to the uninjured extremity were 84.3% and 78.8%, respectively. The mean Mayo wrist score was 78.3 (range, 70 to 90). The mean Visual Analog Scale score was 1.2 (range, 0 to 4). The average SL gap at the final follow-up evaluation was 1.62 (range, 1 to 2.3) mm. The mean SL and capitolunate angles were 49.3° (range, 40 to 75°) and 4.2° (range, 2 to 12°), respectively.

Conclusion

Because every bone is fixed with two K-wires using this configuration, a closed ring is created; hence no motion is possible between the scaphoid, capitate, hamate, triquetrum, lunate and the midcarpal joint. We believe that diamond-shaped fixation may provide reliable fixation and satisfactory clinical outcomes in patients with PLD and PLFD.

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 Outcome of Surgically Managed Perilunate Injuries

BACKGROUND

Perilunate injuries are rare and quite often missed. We present our experience and outcomes, surgically managing these difficult injuries.

METHODS

We analysed data from 14 patients who underwent open reduction and internal fixation of perilunate injuries. All patients underwent open reduction and fixation through the dorsal approach. Fractures were fixed with either K-wires or Headless compression screws. At regular intervals radiographs, range of motion, grip strength, modified Mayo score, Quick DASH score and Lyon wrist scores were collected.

RESULTS

The average age of our patients was 29.2. Average time to surgical intervention was 11.3 days. The mean follow-up period was 42.3 months. modified Mayo wrist score, QuickDASH score and Lyon wrist scores were 77.86, 1.62 and 80.86, respectively. Wrist flexion/extension arc was 101.43. Wrist radial/ulnar deviation was 50.0. Mean grip strength was 69.93% of the opposite side. Radiological evidence of wrist arthritis and lunate avascular necrosis was seen in 8 (57.14%) and 4 (28.6%) cases, respectively.

CONCLUSION

Early open reduction of perilunate injuries gives reliable results, in spite of radiological evidence of wrist arthritis in a majority of the cases.

Perilunate Injury with Concomitant Short Radiolunate Ligament Disruption: Prevalence and Surgical Outcomes-"An Unusual Perilunate Injury Variant"

Background  In the classic description of perilunate injuries, the short radiolunate ligament (SRL) remains intact. Objective  This study was aimed to determine the occurrence of SRL disruptions with perilunate injuries and review the clinical and radiographic outcomes after surgical management. Patients and Methods  A retrospective review was conducted for patients who sustained a perilunate injury and a concomitant disruption of the SRL at a single-level-1 trauma center between January 2013 and January 2017. Patients with the combined injury pattern were compared with those with perilunate injury alone without SRL injury during the study period. Outcome measures included pain scores (visual analogue score), wrist and forearm range of motion, patient's return to their former occupation, and multiple radiographic parameters. Results  Twenty-seven patients were treated operatively for a perilunate injury. Eight of these patients (30%) were found to have associated disruption of the SRL. When compared with patients with perilunate injury alone, these patients had a lower rate of return to work (57% [4 of 7] vs. 92% [12 of 13]), a significantly longer mean length of time to return to work (5.9 vs. 3.8 months), and a higher rate of associated upper extremity injury (75% [3 of 8] vs. 16% [3 of 19]. Conclusion  Combined SRL disruption and perilunate dislocation or fracture dislocation represent a high-energy variant from the classic description of a perilunate injury. A heightened awareness for this combined injury pattern should be maintained when treating patients with perilunate injuries. Level of Evidence  This is a Level III, prognostic study.

Perilunate injuries: biomechanics, imaging, and classification

Perilunate injuries are uncommon injuries that are often misdiagnosed. Although conventional radiographs can underestimate the severity of the perilunate injuries, assessment with cross-sectional imaging can be complex, and terminology is inconsistent in the scientific literature. The aim of this paper is to describe the biomechanics, anatomy, and classification of perilunate trauma in order to provide a systematic approach to the description and diagnosis of these injuries.

Perilunate Dislocations and Perilunate Fracture Dislocations in the U.S. Military

Background  Perilunate dislocations and perilunate fracture dislocations (PLDs/PLFDs) are rare and often associated with poor outcomes. Heretofore, these outcomes have not been evaluated in a high-demand military population. Questions/Purpose  The purpose of this study was to evaluate the outcomes in a young, active population after sustaining PLD/PLFD injuries. Patients and Methods  We retrospectively reviewed the U.S. military service members who underwent surgical treatment for a PLD/PLFD (Current Procedural Terminology codes 25695 and 25685) between June 1, 2010, and June 1, 2014 through the Military Health System Management Analysis and Reporting Tool (M2) database, capturing patients with a minimum 2-year follow-up. Patient characteristics and outcomes were gathered; however, radiographic analysis was not possible. Results  In this study, 40 patients (40 wrists) were included with an average follow-up of 47.8 months. The average age was 28.8 years. Twenty-two injuries (55%) were PLFD and 22 (55%) cases involved the nondominant extremity. On initial presentation, 11 (27.5%) were missed and 50% of patients were presented with acute carpal tunnel syndrome. Range of motion (ROM) was 74% and grip strength was 65% compared with the contralateral wrist; 78% reported pain with activity and only 55% remained on active duty status at final follow-up. Injuries to the nondominant extremity were significantly more likely to experience a good to excellent outcome and regained a more ROM. Patients with ligamentous PLD had less pain at rest and were more likely to return to sport. Conclusion  Worse outcomes can be expected for PLD/PLFD of the dominant extremity, transscaphoid PLFD, greater arc injuries, and those undergoing pinning alone. A high-demand patient may expect worse functional results with a higher degree of limitation postoperatively. Level of Evidence  The level of evidence is therapeutic IV.

Perilunate fracture-dislocations: clinical and radiological results of 21 cases

BACKGROUND

Perilunate dislocations and fracture-dislocations are a subcategory of the carpal instability complex. Herein, we report our university hospital experience with this complex injury. The goal of our study was to find predictive factors and quantify the development of arthritis and lunate necrosis. We tried to measure the impact of arthritis on hand function.

METHODS

Between January 2000 and December 2014, 21 patients underwent surgery for perilunate dislocations and perilunate fracture-dislocations of the wrist in our tertiary university center. Mean patient age was 29.3 ± 10.0 years (range 18-49 years). All displacements were posterior. They were reviewed both clinically and radiologically.

RESULTS

Complications included misdiagnosed Essex-Lopresti-like lesion in one case, insufficient reposition of the carpus in two cases (LT in one case, SL in one case), and iatrogenic injury to the radial artery immediately sutured in one case. All 3 cases underwent a second procedure with satisfactory outcome. After a mean follow-up of 112 ± 60 months (range 12-210 months), the average Cooney score was 80 ± 19 (range 50-125). The mean PRWE score was 10 ± 8 (range 0-25). The mean DASH score was 40 ± 13 (range 30-75 months). Mean pain on load, measured with VAS was 1.1 ± 1.6; Clinical examination assessed a mean wrist extension/flexion of 42.4° ± 17.2°/48.4° ± 15.2°. Mean wrist ulnar/radial deviation was, respectively, 22.9° ± 11.3°/15.3° ± 7.0°. Mean pro/supination was, respectively, 75.2° ± 11.5°/76.3° ± 8.1°. Mean pinch strength was 9.4 ± 2.2 kg (87.4 ± 17.7% of the contralateral side). Mean power strength was 41.9 ± 9.9 kg (76.2 ± 19.2% of the contralateral side). Two patients had a scaphoid non-union identified on their most recent imaging. The mean carpal height ratio was 0.53 ± 0.05 (range 0.44-0.65). All except one patient developed arthritis: Grade 1 in 11 patients, Grade 2 in 3 patients, and Grade 3 in the remaining 6 patients. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis (p < 0.001). Lunate avascular necrosis assessed by magnetic resonance imaging was present in 6 patients: Stage 2 in 4 patients, Stage 3a in 1 patient, and Stage 3b in the remaining patient. All these patients' intraoperative findings showed lesion of the cartilage of the radial side of the lunate. However, the small number of patients who developed lunate necrosis did not allow satisfactory statistical analysis.

CONCLUSIONS

This retrospective study demonstrates good functional results despite the high rate of radiological wrist arthritis. Age, length of follow-up, and loss of reduction were significantly associated with wrist arthritis in our series.

Case Report of an Acute Complex Perilunate Fracture Dislocation Treated with a Three-Corner Fusion

Perilunate fracture dislocations are a rare but devastating injury, which is often missed on initial presentation leading to significant delays in treatment. With the delay in treatment and a high energy mechanism of injury, patients are at increased risk of developing complex regional pain syndrome following trauma. In this report, we review the case of a 57-year-old left-hand dominant female who presented to a clinic with a five-and-a-half-week-old transtriquetral, perilunate fracture dislocation with comminution of the scaphoid facet. Due to the increased likelihood of a secondary procedure and low probability of a satisfactory outcome with open reduction internal fixation secondary to the loss of the scaphoid articulation, a salvage procedure was deemed her best option. To our knowledge, this is the first case reported in the literature in which a scaphoidectomy, triquetromy, and midcarpal fusion (three-corner fusion) was performed in the acute setting for a perilunate fracture dislocation.

The treatment of perilunate ligament injuries in multiply injured patients

PURPOSE

Perilunate injuries are rare, severe injuries of the carpus. They can present as isolated injuries or in the poly-traumatised patient. This is the first documented series of these injuries treated in a Major Trauma Centre. The aims were to assess the management, treatment algorithm and outcomes, of perilunate injuries in our department, review whether concomitant polytrauma affected those outcomes and identify if delay to definitive treatment had a significant effect on overall outcome.

METHODS

Perilunate injuries admitted to the Royal London Hospital between Oct 2011 and March 2016 were identified. All definitive surgical procedures were performed by the senior author; hand therapists supervised patient rehabilitation. Outcomes were assessed by Mayo Wrist and QuickDASH scores.

RESULTS

We identified 23 perilunate injuries (22 patients). There was an associated nerve injury in 10 cases with other system injuries present in 12 cases. At final review, the mean carpal height ratio was 0.56, Mayo Wrist score was 81 and QuickDASH score was 16.4. There were no differences when comparing the outcomes of patients who had early against those with more delayed definite treatment or when comparing patients with isolated wrist injuries against polytrauma patients.

CONCLUSION

Satisfactory outcomes can be achieved, even in the presence of other injuries, if initial treatment is prompt and follows a clear management protocol. Prompt early reduction and neurological decompression followed by subsequent accurate definitive fixation leads to good outcomes. A delay of definitive fixation of up to 18 days does not appear to have a deleterious effect on outcome.

Perilunate carpal dislocation. Clinical evaluation of patients operated with reduction and percutaneous fixation without capsular-ligament repair

Objective

To qualitatively assess surgeries performed in patients with perilunate dislocations without associated fractures, who were operated using the closed reduction and percutaneous fixation method. The follow-up time ranged from one to seven years.

Methods

628 patient records with traumatic wrist injuries, operated by the same group of Hand Surgeons between 2008 and 2014 due to acute trauma were collected, with a mean follow-up of 3.2 years. Of these, 51 were cases of perilunate fracture-dislocations, and 38 were pure perilunate dislocations without associated fractures; of these, only 32 underwent percutaneous fixation without ligamentous repair, thus meeting the inclusion criteria. Of the nine patients with perilunate dislocations who were treated using the closed reduction and percutaneous fixation method, whose mean age was 38 years (range 26–49 years), the dominant side was the left in two-thirds of the cases, and the predominant trauma mechanism was direct trauma.

Results

This study is in agreement with the literature, showing that cases treated early present good results.

Conclusion

88% of patients who were treated by closed reduction and percutaneous fixation method maintained their daily activities and were assessed as excellent or good by the Clinical Scoring Chart.

[Fenton's naviculo-capitate fracture syndrome (about a case)]

La fracture scapho-capitale ou syndrome naviculo-capital de Fenton, est une lésion très rare, souvent méconnue. Elle résulte d'un traumatisme du poignet de haute énergie. Son mécanisme est controversé. Les auteurs rapportent l'observation d'un patient,qui a présenté dans les suites d’un accident de la voie publique une fracture du scaphoïde associée à une fracture du capitatum, du triquetrum et de la styloïde cubitale. La voie d'abord dorsale, a permis une réduction et une contention par embrochage de la première rangée, indépendamment de la deuxième rangée. Les ligaments interosseux scapho-lunaire et lunaro-triquétral étaient intacts. Une immobilisation plâtrée antébrachio-palmaire a été mise en place pour 12 semaines. La rééducation a durée six mois. A deux ans de recul, le score fonctionnel de Cooney était bon et l'ensemble des fractures a consolidé sans aucune désaxation intracarpienne. La reprise du travail était au huitième mois après l’accident.

Scapho-capitate fracture or Fenton’s naviculo-capitate fracture syndrome is a very rare and often ignored lesion. It is caused by a high-energy traumatic injury to the wrist. Its mechanism is controversial. This study reports the case of a patient with scaphoid fracture associated with fracture of the capitatum, triquetrum and ulnar styloid due to public road accident. Dorsal approach allowed reduction and containment by internal fixation in the first row, regardless the second row. Scapholunate interosseous ligaments and luno-triquetral were intact. The patient underwent antebrachial-palmar plaster immobilization for 12 weeks. Rehabilitation program lasted for six months. Cooney’s wrist function score was good and all fractures consolidated without intracarpal malalignment at 2 years follow up. The patient resumed work in the eighth month after the road accident.

Arthroscopic management of articular and peri-articular fractures of the upper limb

The management of articular fractures is always a matter of concern. Each articular fracture is different from the other, whatever the classification system used and the surgical or non-surgical indications employed by the surgeon. The main goals remain anatomical reduction, stable fixation, loose body removal and minimal invasiveness.

Open procedures are a compromise. Unfortunately, it is not always possible to meet every treatment goal perfectly, since associated lesions can pass unnoticed or delay treatment, and even in a ‘best-case’ scenario there can be complications in the long term.

In the last few decades, arthroscopic joint surgery has undergone an exponential evolution, expanding its application in the trauma field with the development of arthroscopic and arthroscopically-assisted reduction and internal fixation (ARIF) techniques. The main advantages are an accurate diagnosis of the fracture and associated soft-tissue involvement, the potential for concomitant treatments, anatomical reduction and minimal invasiveness. ARIF techniques have been applied to treat fractures affecting several joints: shoulder, elbow, wrist, hip, knee and ankle.

The purpose of this paper is to provide a review of the most recent literature concerning arthroscopic and arthroscopically-assisted reduction and internal fixation for articular and peri-articular fractures of the upper limb, to analyse the results and suggest the best clinical applications.

ARIF is an approach with excellent results in treating upper-limb articular and peri-articular fractures; it can be used in every joint and allows treatment of both the bony structure and soft-tissues.

Post-operative outcomes are generally good or excellent. While under some circumstances ARIF is better than a conventional approach, the results are still beneficial due to the consistent range of movement recovery and shorter rehabilitation time.

The main limitation of this technique is the steep learning curve, but investing in ARIF reduces intra-operative morbidity, surgical errors, operative times and costs.

Cite this article: Dei Giudici L, Faini A, Garro L, Tucciarone A, Gigante A. Arthroscopic management of articular and peri-articular fractures of the upper limb. EFORT Open Rev 2016;1:325-331. DOI: 10.1302/2058-5241.1.160016.

Fractures and dislocations of the hand in polytrauma patients: Incidence, injury pattern and functional outcome

INTRODUCTION

Injuries of the hand can cause significant functional impairment, diminished quality of life and delayed return to work. However, the incidence and functional outcome of hand injuries in polytrauma patients is currently unknown. The aim of this study was to determine the incidence, distribution and functional outcome of fractures and dislocation of the hand in polytrauma patients.

METHODS

A single centre retrospective cohort study was performed at a level 1 trauma centre. Polytrauma was defined as patients with an Injury Severity Score of 16 or higher. Fractures and dislocations to the hand were determined. All eligible polytrauma patients with hand injuries were included and a Quick Disability of Arm, Shoulder and Hand questionnaire (QDASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) were administered. Patients were contacted 1-6 years after trauma.

RESULTS

In a cohort of 2046 polytrauma patients 72 patients (3.5%) suffered a hand injury. The functional outcome scores of 52 patients (72%) were obtained. The Metacarpal (48%) and carpal (33%) bones were the most frequently affected. The median QDASH score for all patients with hand injury was 17 (IQR 0-31) and the PRWHE 14 (IQR 0-41). Patients with a concomitant upper extremity injury (p=0.002 for PRWHE, p0.006 for QDASH) and those with higher ISS scores (p=0.034 for PRWHE, QDASH not significant) had worse functional outcome scores. As an example, of the 5 patients with the worst outcome scores 3 suffered an isolated phalangeal injury, all had concomitant upper extremity injury or neurological injuries (3 plexus injuries, 1 severe brain injury).

CONCLUSION

The incidence of hand injuries in polytrauma patients is 3.5%, which is relatively low compared to a general trauma population. Metacarpal and carpal bones were most frequently affected. The functional extremity specific outcome scores are highly influenced by concomitant injuries (upper extremity injuries, neurological injuries and higher ISS).

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.

Comparative Outcome Analysis of Arthroscopic-Assisted Versus Open Reduction and Fixation of Trans-scaphoid Perilunate Fracture Dislocations

PURPOSE

To compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with trans-scaphoid perilunate fracture dislocations.

METHODS

This retrospective study included consecutive patients with trans-scaphoid PLFDs who underwent arthroscopic-assisted reduction and fixation (group A) or open reduction and fixation (group O), and who were followed up for a minimum of 2 years between May 2005 and March 2013. We excluded initially missed patients. Each different surgeon who was on call had performed each experienced operation. These clinical outcomes were assessed: range of motion, grip strength, Mayo wrist score, and Disabilities of Arm, Shoulder, and Hand (DASH) score. For radiologic outcomes, the scapholunate angle, radiolunate angle, and lunotriquetral distance were measured.

RESULTS

The total number of included patient was 20 (11 in group A and 9 in group O). Scaphoid union occurred in all patients except 1 individual (11 of 11 in group A, and 8 of 9 in group O). At the last follow-up, the mean flexion-extension arc was significantly greater in group A (125.0°) than in group O (105.6°) (P = .028). The mean grip strength was 81.1% that of the contralateral side in group A and 80.9% in group O (P = .594). The mean Mayo wrist score was 85.5 in group A and 79.4 in group O (P = .026), and the mean DASH score was 10.6 in group A and 20.8 in group O (P = .001); however, only the DASH score showed a minimum clinically important difference. The mean scapholunate angle, radiolunate angle, and lunotriquetral distance were similar between the 2 groups: 47.2°, 1.7°, and 2.0 mm in group A and 48.8°, 5.6°, and 2.1 mm in group O, respectively.

CONCLUSIONS

Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with trans-scaphoid PLFDs, it is shown that the arthroscopic-assisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Scaphoid and Lunate Dislocation with Complete Soft-Tissue Avulsion: A Case Report

CASE

We describe an intercarpal dislocation with proximal and rotatory displacement of the lunate and with volar and radial dislocation of the scaphoid; both bones were stripped of soft tissue. Treatment involved ORIF (open reduction and internal fixation). Three years postoperatively, the patient had a DASH (Disabilities of the Arm, Shoulder and Hand) score of 10, equivalent grip strength and 50% wrist palmar flexion and 98% wrist dorsiflexion compared with the uninjured side, and radiographic evidence of posttraumatic arthritis.

CONCLUSION

Treatment of simultaneous divergent lunate and scaphoid dislocation with loss of nearly all soft-tissue attachments and vascular supply by means of ORIF and repair of soft-tissue structures can result in a favorable intermediate-term functional outcome and may be superior to other salvage procedures such as proximal row carpectomy.

Peri-lunate dislocation and fracture-dislocation of the wrist: Retrospective evaluation of 65 cases

INTRODUCTION

Peri-lunate wrist dislocations and fracture-dislocations are related to high-energy trauma. Prognosis is often compromised because of the complexity of the lesions. The purpose of this study was to assess outcomes of acute peri-lunate injuries and correlate them with the type of lesion and management.

MATERIEL AND METHODS

A monocenter retrospective study has been conducted. Sixty-five patients (65 wrists) were reviewed. According to Herzberg's classification, there were 18 isolated peri-lunate dislocations and 47 peri-lunate fracture-dislocations - 27 with a scaphoid fracture and 20 with an intact scaphoid. The displacement was dorsal in 62 cases. All patients were treated surgically.

RESULTS

At an average follow-up of 8 years (2-16) the average Cooney score was 66 points, quick-DASH score 21 points, and PRWE score 28 points. Pain score was 1.3 out of 10 points at rest and 4.3 out of 10 with effort. The flexion-extension arc was 96° with an average strength of 38kg (70±23% of opposite side). Radiographic analysis has shown decrease in carpal height, increase in ulnar translation, and DISI. Sign of wrist arthritis was found in 58.5% of the cases. The rate of osteonecrosis was 7.7%. Regional sympathetic painful syndrome was observed in 12%. In 26% of the cases a secondary surgery was needed. No influence has been found with the final results between fracture-dislocation and isolated dislocation, and delay of treatment. Osteochondral lesions observed at surgery (P=0.035), osteonecrosis at follow-up (P=0.017), and modification of the scapho-lunate angle (P=0.029) were correlated with the occurrence of osteoarthritis.

DISCUSSION

Peri-lunate dislocation and fracture-dislocation represent severe wrist trauma with often numerous sequelae with follow-up: pain, stiffness, loss of strength, carpal instability and arthritis. Early diagnosis and anatomic reduction are prerequisite to a satisfactory functional result. Capsulo-ligamentous lesions must be repaired and fractures must be fixed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Patient-Reported Outcomes Following Surgically Managed Perilunate Dislocation: Outcomes After Perilunate Dislocation

BACKGROUND

Perilunate dislocations (PLDs) are uncommon high-energy injuries that may result in significant morbidity if inadequately treated. We report the midterm outcomes following surgical intervention and the validity of the Patient-Rated Wrist Evaluation (PRWE) score as an assessment tool post injury.

METHODS

We prospectively present outcomes in 16 patients with perilunate injuries. Definitive surgical management comprised fixation of all fractures and anatomical reconstruction of ruptured ligaments where possible. All patients completed the Disabilities of the Arm, Shoulder and Hand (DASH), 12-Item Short-Form Health Survey, and PRWE, for which internal consistency and construct validity were assessed.

RESULTS

At 24 months, the mean grip strength was 59% of the uninjured side (range 33%-85%) and the mean range of flexion was 71% and extension was 58%. Eighty-eight percent of patients returned to work within 6 months and 63% to sport within 1 year. The PRWE score was 36.2 (range 14.5-77.3) and DASH 25.2 (range 7.5-91.7). The mean visual analog scale (VAS) satisfaction score was 7.9 (range 0-10), VAS pain at rest 1.9 (range 0-6) and on activity 3.3 (range 1-6). DASH and PRWE demonstrated similar internal consistencies with Cronbach alphas of .98 and .91, respectively, and a strongly positive correlation coefficient of r = +.7 (P < .05).

CONCLUSIONS

Surgical treatment of PLDs can provide good clinical outcomes allowing patients to return to normal activities in a reasonable timescale when delays to surgery are kept to a minimum. The PRWE demonstrated high internal consistency and was found to be a valid questionnaire with advantages over the DASH for use following severe carpal injures.

Surgical treatment of dorsal perilunate fracture-dislocations and prognostic factors

INTRODUCTION

Perilunate injuries are rare entities which can be difficult to diagnose. Most common type is dorsal perilunate fracture dislocation (97%). The purpose of treatment is anatomic reduction and stable fixation. We aimed to present the radiologic and functional results of surgically treated dorsal perilunate fracture-dislocations and discuss the factors influencing the prognosis.

METHODS

Between 2007 and 2013, 17 patients were operated for perilunate fracture-dislocations. The mechanism of injuries, soft tissue traumas, etiologic factors and stages according to Herzberg classification were determined. The MAYO wrist score was used for functional evaluation. Scapholunate distance and scapholunate angle were measured and, degenerative changes were investigated by comparing with contralateral side on plain x-ray images in terms of radiologic evaluation.

RESULTS

Mean follow-up was 37,8 (range, 16-84) months. The average age at surgery was 35.1 (range, 18-51) years. Fifteen patients were male and two were female. Functional results were excellent in four (23.5%), good in two (11.8%), satisfactory in five (29.4%) and poor in six (35.3%) patients. Degenerative changes were determined in radiocarpal and mid-carpal joints of 14 wrists (82.4%). Scapholunate dissociation more than 2 mm was detected in three wrists. In four wrists osteochondral fragments were determined on the head of the capitate. Stage 2 lesions, delayed presentations, open fractures, scapholunate dissociations more than 2 mm had worse functional results.

CONCLUSION

Despite anatomic reduction, ligamentous and chondral injuries that occured at the time of trauma may cause persistant wrist pain in patients who suffer perilunate fracture dislocation. Mechanism of injury, presence of soft tissue defects and the time between injury and treatment can affect clinical and radiologic results.

Results of Perilunate Dislocations and Perilunate Fracture Dislocations With a Minimum 15-Year Follow-Up

PURPOSE

To evaluate the long-term clinical, functional, and radiological outcomes in 30 patients with at least 15 years of follow-up.

METHODS

We performed a retrospective study that identified 73 patients. Thirty patients agreed to participate and were included. The mean follow-up was 18 years (range, 15-24 years). There were 14 cases of perilunate dislocation and 16 cases of perilunate fracture-dislocation (including 13 transscaphoid perilunate fracture-dislocations). At the last follow-up, the clinical and functional evaluation was based on the range of motion, grip strength, the Mayo wrist score, the Quick Disabilities of the Arm Shoulder and Hand score, and the Patient-Rated Wrist Evaluation score. Radiological abnormalities, according to the Herzberg classification, were 5 type A1 cases, 7 type B, 16 type B1, and 2 type C.

RESULTS

The mean flexion-extension arc, radial-ulnar abduction arc, and pronation-supination arc were, respectively, 68%, 67%, and 80%, relative to the contralateral side. The mean grip strength was 70%, relative to the contralateral side. The mean Mayo wrist score was 70, and the mean Quick Disabilities of the Arm Shoulder and Hand and Patient-Rated Wrist Evaluation scores were, respectively, 20 and 21. Five patients had secondary procedure. Six patients had a complex regional pain syndrome type 1.

CONCLUSIONS

Although arthritis occurred in 70% of cases, its clinical and functional impact appeared to be low. However, the 2 lowest Mayo wrist scores corresponded to the patients with the most advanced arthritis. Complex regional pain syndrome appeared to have an impact on long-term outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Perilunate Dislocations and Fracture Dislocations

Perilunate dislocations and fracture dislocations are the result of an axial load with hyperextension and ulnar deviation of the wrist, combined with intercarpal supination. Prompt treatment injuries is essential. There is a high rate of missed or incorrect diagnosis. In the past, closed management was recommended. These methods proved to be ineffective. Current research and data show better results with anatomic restoration of carpal alignment and direct ligament repair. A combined dorsal and volar approach is preferred. This article reviews the current literature and discusses the surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament.

Acute Median Neuropathy and Carpal Tunnel Release in Perilunate Injuries Can We Predict Who Gets a Median Neuropathy?

This study addressed the following null hypotheses: 1) There are no demographic differences between patients with perilunate dislocation (PLD) or fracture-dislocation (PLFD); 2) There are no factors associated with the development of median nerve symptoms in the setting of a PLD or PLFD; and 3) There are no factors associated with carpal tunnel release. Using a retrospective search of a prospective trauma database, we identified all patients who had sustained a radiologically confirmed PLD or PLFD over a 10-year period at two trauma centers. From the medical records we identified median nerve symptoms and carpal tunnel release in addition to demographic and injury characteristics. Among the 71 patients treated for PLD or PLFD, acute median neuropathy was diagnosed in 33 patients (47 %). The only significant difference between PLD and PLFD was a younger age with PLFD. No demographic or injury factors were associated with symptoms of median neuropathy. Carpal tunnel release surgery during the initial operative management was related to the presence of median nerve symptoms and the trauma center. We report a high incidence of acute median neuropathy accompanying perilunate injuries. As there are no demographic or injury factors associated with symptoms of median neuropathy; all patients with PLD/PLFD merit equally high vigilance for acute median neuropathy.

LEVEL OF EVIDENCE

Level III, prognostic study.

Factors associated with unplanned reoperation in perilunate dislocations and fracture dislocations

Background Perilunate injuries are complex and uncommon injuries that are typically the result of a high-energy injury and are nearly always treated operatively. Little is known about factors associated with unplanned reoperations after surgery for perilunate injuries. Purpose To assess the rate and types of unplanned reoperation after operative treatment of a perilunate dislocation. Patients and Methods We reviewed 115 patients of all ages with unplanned reoperations after operative treatment of perilunate injuries at five hospitals. Planned removal of implants were not considered as unplanned reoperations. Results Sixteen patients had an unplanned reoperation, including four for compartment syndrome (three hand, one forearm); three for deep infection; three for malalignment or an errant screw; two for early salvage procedures; and four for other reasons. We considered seven unplanned reoperations necessary (forearm compartment syndrome, infection, loss of alignment, errant screw) and nine debatable or unnecessary (hand compartment syndrome, early salvage procedures, suspected malunion, etc.). Patients who had an unplanned reoperation were younger (median age 24 versus 34 years; p = 0.0034); had earlier surgery (median days to surgery 0 versus 3; p = 0.0068); and were more likely injured in a motor vehicle collision (50% versus 17%; p = 0.0070). Accounting for interaction among the variables using multivariable analysis, the factors independently associated with unplanned reoperation were young age (odds ratio 0.92) and motor vehicle collision accidents (odds ratio 4.1). Conclusion We conclude that higher-energy injuries may be at greater risk for unplanned reoperation, but more than half of the unplanned reoperations were for debatable indications. Level III Retrospective Cohort Review.

Arthroscopic treatment of perilunate dislocations and fracture dislocations

Background The key to a successful result in the treatment of perilunate dislocations (PLDs) and fracture-dislocations (PLFDs) is the restoration of normal alignment of the carpal bones, followed by stable maintenance until healing. This article aimed to assess whether arthroscopic techniques are a reliable surgical option for the treatment of this challenging injury. Materials and Methods Twenty patients with an acute PLD or PLFD were treated by an arthroscopic technique. They were retrospectively reviewed at an average follow-up of 31.2 months (range 18-61 months). Functional outcomes were assessed with the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and Patient-Rated Wrist Evaluation (PRWE) score as well as radiographic evaluations. Description of Technique Arthroscopic reduction and percutaneous fixation was performed to the scapholunate and lunotriquetral intervals using Kirschner wires (K-wires) as joysticks as well as to the scaphoid using a cannulated headless screw for transscaphoid-type injuries. The K-wires were removed at 10 weeks postoperation. Results Overall functional outcomes according to the MMWS were rated as excellent in three patients, good in eight, fair in seven, and poor in two. The mean DASH score was 18, and the mean PRWE score was 30. On the basis of radiographic parameters, reduction obtained at the operation was maintained within normal ranges in 15 patients. No patient had developed arthritis by the last follow-up. Conclusions The medium-term results show that arthroscopic treatment can provide proper restoration and stable fixation of carpal alignment and results in satisfactory functional and radiologic outcomes for acute perilunate injuries. Level of Evidence Level IV.

Perilunate dislocations treated with external fixation and percutaneous pinning

Background The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations (PLDs) and fracture-dislocations (PLFDs) treated with external fixation and Kirschner wires (K-wires). Materials and Methods Twenty patients (18 males and 2 females) with a mean age of 38 years (range 18-59) with an acute PLD or PLFD were treated with external fixator and K-wires. There were 12 PLDs and seven transscaphoid and one transstyloid PLFDs. The median time from trauma to operation was 8 hours (range 2-12 hours). Indirect reduction via ligamentotaxis was achieved in 17 patients with a mean age of 38years (range 18-59). There were 12 PLDs and 5 trans-scaphoid PLFDs; however, in three cases (two transscaphoid and one transstyloid PLFDs), indirect reduction failed and an open reduction was required. The intercarpal ligaments were not repaired even after open reduction. Results The mean follow-up was 39 months (range 18-68 months). The flexion-extension range of motion (ROM) and grip strength of the injured wrist averaged 80% and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney's scoring system, overall functional outcomes of the 17 patients were rated as excellent in 4 patients, good in 8, fair in 4, and poor in 1. Fifteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid, and two developed posttraumatic arthritis. Conclusion External fixation plus percutaneous K-wires for the treatment of acute PLDs has satisfactory midterm functional and radiographic outcomes. When successful, this minimally invasive technique is simple and provides restoration of the carpal alignment. It may especially be useful in the polytrauma patient, thanks to its decreased operative time and diminished blood loss, when other emergent surgical procedures may be necessary. An open reduction with possible fixation may be necessary for PLDs and PLFDs, especially in the presence of polytrauma and scaphoid comminution.

LEVEL OF EVIDENCE

IV.

Perilunate dislocation in an asymptomatic SNAC wrist: an uncommon presentation requiring a scaphoidectomy and four corner fusion

This report describes a 53-year-old man who presented, following a motocross injury, with a Mayfield stage 1 perilunate dislocation through a pre-existing asymptomatic scaphoid non-union with a degenerative midcarpal joint. A salvage reconstruction with scaphoid excision and four corner midcarpal arthrodesis resulted in a satisfactory outcome. Follow-up at 6 years demonstrated no instability and no further progression of the osteoarthritis.

Misses and errors in upper extremity trauma radiographs

OBJECTIVE

The article reviews a select group of traumatic upper extremity injuries that can be easily misinterpreted on radiographs.

CONCLUSION

The awareness of these specific injuries and an understanding of their underlying pathophysiology and the role that radiographs can play in their evaluation will give the reader the best opportunity to make the important imaging findings and guide appropriate treatment.

Use of external fixation for perilunate dislocations and fracture dislocations

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18–59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2–12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18–68 months). Range of motion and grip strength were measured. Cooney’s scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney’s clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.

Fracture-dislocations of the carpus: perilunate injury

The progressive perilunar instability model described by Mayfield is still used to predict the pattern of injury. Diagnosis of injury and clinical and radiographic findings depend on the pattern of injury. Open procedures are preferred for anatomic reduction after initial closed reduction is performed for acute injuries. A dorsal, volar, or combined dorsal/volar approach may be necessary and is often decided by surgeon preference. Loss of motion and diminished grip strength are common consequences despite appropriate treatment. Successful outcomes depend on time to treatment, open or closed nature of injury, extent of chondral damage, residual instability, and fracture union.

Treatment of dorsal perilunate dislocations and fracture-dislocations using a standardized protocol

BACKGROUND

The aims of this study were to evaluate the associated injuries occurring with acute perilunate instability and to assess the clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with a combined dorsal and volar approach.

METHODS

A total of 45 patients (46 wrist injuries) with perilunate dislocations and fracture-dislocations were prospectively evaluated. The size of the mid-carpal ligament tear, the location of the scapholunate ligament tear, and the presence of osteochondral fragments and of the dorsal radiocarpal ligament avulsions were recorded at injury. Final clinical and radiographic outcomes were evaluated in 25 cases (25 wrists) with a minimum of 6 months of follow-up.

RESULTS

Intraoperative examination of the 46 cases with operative treatment showed the volar carpal ligament tear to be present 100 % of the time and to be an average length of 3.4 cm. Complete avulsion of the dorsal extrinsic radiocarpal ligaments was found in 65.2 % of cases. The scapholunate ligament was torn in 35 cases. Osteochondral fragments were found either volarly or dorsally in 74 % of the cases. The average flexion-extension arc was 82°, forearm rotation was 155°, and grip strength averaged 59 % of the uninjured hand. The average final scapholunate angle was 55° and the scapholunate gap was 2.2 mm.

CONCLUSION

Treatment of perilunate fracture-dislocations with a combined volar and dorsal approach results in reasonable and functional clinical results. The incidence of associated injuries with these carpal dislocations is high. Although the perilunate fracture-dislocations have a slightly better radiologic alignment than the dislocation group, the clinical outcome is similar.