Case Study: Trans-styloid, Trans-scaphoid, Trans-triquetral, and Perilunate Dislocation

Introduction: Perilunate dislocations are rare high-energy injuries, and the diagnosis is not infrequently missed at initial presentation. The combination of fractures resulting in a trans-styloid, trans-scaphoid, and trans-triquetral perilunate fracture dislocation is extremely rare. Early recognition and diagnosis of these injuries is prudent to restore patient function and prevent morbidity. This injury pattern may progress through several distinct phases often involving the greater or lesser arc. The injury begins with traumatic disruption of the scapholunate joint, followed by an ordered progression of injury to the capitolunate, lunotriquetral, and radiolunate joints. When the radiolunate joint is disrupted, the lunate often dislocates volar transposing into the carpal tunnel, associated with median nerve compression. These injuries have the potential to cause lifelong disability of the wrist. Early treatment may prevent or lessen the chance of median neuropathy, post-traumatic wrist arthrosis, chronic instability, and fracture nonunion. Non-operative treatment is not indicated and is associated with poor functional outcomes and recurrent dislocation. Open reduction and internal fixation (ORIF) with ligamentous repair after emergent closed reduction and splinting is indicated for acute injuries (<8 weeks after injury). Case Report: We report a case of a 48-year-old right hand dominant male with a trans-styloid, trans-scaphoid, trans-triquetral, and perilunate dislocation after mechanical fall from height. He was evaluated in the ER and provisionally treated with closed reduction and splinting. ORIF of scaphoid, radial styloid, and triquetrum was performed, with ligamentous repair of the scapholunate joint and carpal tunnel decompression. Conclusion: The combination of fractures/injuries in this case has been very rarely been published in case reports to date. It is necessary to recognize these wrist injuries. Great detail should be given to physical and radiog

Dorsal Spanning Plate for Perilunate Dislocations

Purpose The purpose of this study was to compare radiographic outcomes in patients treated with the traditional method of open reduction, internal fixation (ORIF) and casting as compared with those treated with ORIF and dorsal spanning plate (DSP) fixation. We hypothesized that the application of a DSP to augment the repair of perilunate dislocations would maintain carpal stability while also allowing early loadbearing through the carpus. Materials and Methods This is a retrospective radiographic review of patients with a perilunate dislocation, who were treated with ORIF and casting or ORIF with a dorsal spanning plate between 2012–2018. Scapholunate (SL) and lunotriquetral (LT) intervals were measured immediately after the index surgery and after scheduled hardware removal. A total of 28 patients met inclusion criteria, including 13 cases with traditional treatment and 15 cases with dorsal spanning plate fixation. Results Comparison of the change in SL interval and LT interval between the 13 patients in the traditional treatment group and the 15 patients in the DSP group did not yield any clinically relevant variation after statistical analysis. Both groups demonstrated minimal change in the radiographic markers of carpal stability from postoperative radiographs obtained immediately after the index repair and after the removal of hardware. Conclusion DSP fixation placed at the index surgery with early loadbearing for the treatment of perilunate dislocation is not inferior to the current mainstay of treatment consisting of cast immobilization without loadbearing and does not confer any increased carpal instability in comparison to ORIF and casting.

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

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.

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.