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

Elbow stability after simple elbow dislocation

Aim We aimed to compare the clinical results after ligamentous elbow dislocation between patients treated nonoperatively (group A) and patients who underwent ligamentous repair (group B). Methods Hospital records were investigated for cases of ligamentous elbow dislocation from January 2015 to December 2018. In total, 30 patients were identified: nine with nonoperative treatment and 21 with surgical ligamentous repair. The range of motion (ROM) including arc of extension/flexion and pronation/supination, valgus instability, and posterolateral rotatory instability were evaluated. The scores of several outcome measures assessing elbow injury were evaluated. Sonographic examination was performed on all patients to evaluate translation under valgus and posterolateral rotatory stress. Results Overall, 14 patients with simple elbow dislocation (group A n = 5, 46.4 ± 19.3 years, follow-up [FU] 27 ± 12.4 months; group B n = 9, 57.3 ± 21.0 years, FU 36 ± 11.1 months; 4 female patients in each group) were evaluated. No significant difference was seen in extension/flexion and ext/flex-arc although there was a tendency to limited extension (p = 0.07) in group A. A significantly reduced supination (84 ± 15° vs. 77 ± 21°, p = 0.02) was observed regarding the contralateral side in group B. There was no significant difference in the evaluated scores between the groups. A significantly increased medial angulation during ultrasound evaluation was found in group B compared with the contralateral side. Conclusion There were no significant differences concerning ROM and functional scores between the nonoperative treatment and ligamentous repair groups. On clinical evaluation, a higher rate of sufficiently healed ligaments was found following surgical repair, although this was not reflected in the ultrasound evaluation.

Operative Management of Unstable Radial Head Fractures in a Young Active Population

Background: Radial head and neck fractures are the most common elbow fracture in the general adult population; however, the optimal treatment for radial head fractures remains a topic of ongoing clinical controversy. The purpose of this study was to determine the rate of return to function, complications, and reoperation following operative management of unstable radial head fractures in a young, active patient population with intense upper extremity demands. Methods: A military health care database was queried for all US military servicemembers undergoing open reduction with internal fixation (ORIF; Current Procedural Terminology [CPT] code: 24665) and radial head arthroplasty (RHA; CPT code: 24666) between 2010 and 2015. All patients with minimum 2-year follow-up were included. Univariate and chi-square analyses were performed to evaluate the association between potential risk factors and the primary outcome measures. Results: A total of 67 ORIF (n = 69 elbows) and 10 RHA patients were included. The average age was 31 ± 8.0 years. At mean follow-up of 3.5 ± 1.1 years, 90% of patients overall were able to return to active military service, 96% of which with unrestricted upper extremity function. Nearly one-third (31.2%) of patients developed at least 1 postoperative complication. RHA has higher overall complication rates (70% vs 48%) when compared with ORIF, but this finding did not reach statistical significance ( P = .073). However, RHA had significantly higher rates of implant failure (20% vs 2.9%, P = .0498). Seventeen (21%) individuals required reoperation, 5 of which (6.3%) were revision procedures. Dislocation, coronoid fracture, and concomitant ligamentous repair portended a significantly increased risk of sustaining 1 or more complications ( P < .05), while dislocation and requirement for ligamentous repair independently predicted revision surgery ( P < .05). Conclusions: Arthroplasty and ORIF are both viable options for treating unstable radial head fractures in a young, athletic population, offering comparable return to function despite increased complications with RHA.

Assessment and decision making in the unstable elbow: management of simple dislocations

Simple elbow dislocations are usually treated conservatively. Radiographs are negative in simple dislocations. Results are generally good, although a small percentage of patients may develop chronic instability. Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. Chronic instability is classified per their direction. Surgery is often indicated in the chronically unstable elbow.