- Email: [email protected]
Translunate scapho-radial fracture
Translunate Scapho-Radial Fracture J. Noble and D. W. Lamb
TRANSLUNATE SCAPHO-RADIAL FRACTURE A Case Report J. NOBLE, Manchester and D. W. LAMB, Edinburgh SUMMARY A rare fracture of the carpus is described, which illustrates the importance of treating the patient, rather than the X-ray. INTRODUCTION Although the incidence of lunate fracture amongst carpal fractures is quoted by Boyes (1970) to have been 5.3070 in one series and 6.5070 in another, no details are given. Other m a j o r reviews (Campbell 1964, Stewart 1968, Linscheid 1972, Pellegrino 1973 and Dunn 1973) make no mention of fractured lunate, except that f r o m Campbell, w h o stated that in one of fifty cases the lunate was " b r o k e n and dislocated". Review of our material from the Edinburgh H a n d Clinic over fifteen years revealed no other lunate fracture (Panting 1978). We present a case of transverse fracture of the lunate associated with a similar fracture of the scaphoid and across the radial styloid. We can find no similar case reported in the literatur6 and the mechanical and prognostic implications are discussed. CASE REPORT In December, 1975, an eighteen year old painter fell thirty feet from a scaffold. He landed with outstretched hands behind him and the only significant injury was to the left wrist, the radiograph of which (Figs. 1 and 2) showed fractures across the lunate, scaphoid and radial styloid with the proximal poles of lunate and scaphoid lying anterior to the distal remainder of those bones, having rotated through about 150 ~ Consequently the injury was explored through a long curved volar incision. Nerves and tendons were intact and the volar radio-carpal ligaments had burst open. The lunate fracture was still attached by a distal soft tissue hinge. There was an indentation in the radial articular cartilage, running into the styloid fracture. Normal anatomy was restored and held with a Kirschner wire passed through the capitate into the lunate fragments and the distal radius with the wrist flexed to 20 ~ The wire was removed at three weeks and the plaster in seven weeks, whereupon the wrist was mobilised. By six months the patient had returned to his work, but not to scaffolds. When reviewed two and a half years after injury he had occasional slight pain, a good range of m o v e m e n t and was managing his work well, despite having a non-union of both fractures, the fragments of which also appeared to be avascular (Fig. 3). DISCUSSION The striking feature is the exactly transverse and very proximal nature of the fractures across the lunate and scaphoid into the radial styloid. The two fragments were joined together and lay in front of the bodies of the lunate and scaphoid. To do so the wrist must have been forcibly dorsiflexed and probably adducted. That this unusual combination of fractures occurred in an eighteen year old boy may do no J. Noble, F.R.C.S. (E), University of Manchester, Hope Hospital, Eccles Old Road, Salford, M6 8HD The H a n d - - Vol. 11
No. 1
1979
47
Translunate Scapho-Radial Fracture J. Noble and D. W. Lamb
Fig. 1. and Fig. 2. X-ray after injury, showing fractures of lunate, scaphoid and radial styloid.
Fig. 3. X-ray showing non-union and avascular necrosis of the fragments of scaphoid and lunate, two and a half years after injury. 48
The HancI--VoL 11
No. I
1979
Translunate Scapho-Radial Fracture J. Noble and D. W. Lamb
more than demonstrate that under high impact stress, bone is more likely to break before ligament. The management of this case also illustrates the futility of attempting closed reduction in severe fracture dislocations of the carpus. Moreover, despite splitting the flexor retinaculum down into the palmar aponeurosis and up into the deep forearm fascia, this boy had very severe pain with median and ulnar nerve neurapraxia for several days. The most interesting feature is that in a little less than six months he had returned to his trade and that two and a half years later, despite his radiographic appearances, he remains almost asymptomatic. This questions the more radical approach of removing the fragments, advocated by Campbell (1965). ~qhile internal fixation subsequently failed after removal of the wire, such early mobilisation now seems justified by the good range of movement this patient has achieved. It is encouraging that Inglis (1977), whilst criticising wrist arthrodesis and advocating proximal carpectomy, had stressed that radio-carpal osteoarthritis is now a contra-indication to carpectomy, which will probably prove to be necessary at some stage with this patient. This patient also reveals the potential danger of treating the X-ray, rather than the patient, in cases with non-union or avascular necrosis, following carpal inj uries. REFERENCES BOYES, J. H. Bunnell's Surgery of the Hand. Philadelphia and Toronto. J. B. Lippincott Company (1970) p.591-597. CAMPBELL, R. D. Jr., LANCE, E. M. and YEOH, C. B. (1964) Lunate and Perilunar Dislocations. The Journal of Bone and Joint Surgery. 46B: 55-72. CAMPBELL, R. D. Jr., THOMPSON, T. C., LANCE, E. M. and ADLER, J. B. (1965) Indications for Open Reduction of Lunate and Perilnnate Dislocations of the Carpal Bones. The Journal of Bone and Joint Surgery. 47A: 915-937. DUNN, A. W. (1973) Fractures and Dislocations of the Carpus. The Journal of Bone and Joint Surgery. 55A: 1319. INGLIS, A. E. and JONES, E. C. (1977) Proximal Row Carpectomy for Diseases of the Proximal Row. The Journal of Bone and Joint Surgery. 59A: 460-463. LINSCHEID, R. L., DOBYNS, J. H., BEABOUT, J. W. and BRYAN, R. S. (1972). Traumatic Instability of the Wrist. Diagnosis, Classification and Pathomechanics. The Journal of Bone and Joint Surgery. 54A: 1632. PANTING, A. (1978) Unpublished data. PELLEGRINO, E. A. Jr. and PETERSON, E. D. (1973) Trans-scaphoid - - Perilunate Dislocations of Wrist. The Journal of Bone and Joint Surgery. 55A: 1319. STEWART, M. and CROSS, H. (1968) The Management of Injuries of the Carpal Lunate with a Review of Sixty Cases. The Journal Of Bone and Joint Surgery. 50A: 1489.
The H a n d - - Vol. 11
No. 1
1979
49
TRANSLUNATE SCAPHO-RADIAL FRACTURE A Case Report J. NOBLE, Manchester and D. W. LAMB, Edinburgh SUMMARY A rare fracture of the carpus is described, which illustrates the importance of treating the patient, rather than the X-ray. INTRODUCTION Although the incidence of lunate fracture amongst carpal fractures is quoted by Boyes (1970) to have been 5.3070 in one series and 6.5070 in another, no details are given. Other m a j o r reviews (Campbell 1964, Stewart 1968, Linscheid 1972, Pellegrino 1973 and Dunn 1973) make no mention of fractured lunate, except that f r o m Campbell, w h o stated that in one of fifty cases the lunate was " b r o k e n and dislocated". Review of our material from the Edinburgh H a n d Clinic over fifteen years revealed no other lunate fracture (Panting 1978). We present a case of transverse fracture of the lunate associated with a similar fracture of the scaphoid and across the radial styloid. We can find no similar case reported in the literatur6 and the mechanical and prognostic implications are discussed. CASE REPORT In December, 1975, an eighteen year old painter fell thirty feet from a scaffold. He landed with outstretched hands behind him and the only significant injury was to the left wrist, the radiograph of which (Figs. 1 and 2) showed fractures across the lunate, scaphoid and radial styloid with the proximal poles of lunate and scaphoid lying anterior to the distal remainder of those bones, having rotated through about 150 ~ Consequently the injury was explored through a long curved volar incision. Nerves and tendons were intact and the volar radio-carpal ligaments had burst open. The lunate fracture was still attached by a distal soft tissue hinge. There was an indentation in the radial articular cartilage, running into the styloid fracture. Normal anatomy was restored and held with a Kirschner wire passed through the capitate into the lunate fragments and the distal radius with the wrist flexed to 20 ~ The wire was removed at three weeks and the plaster in seven weeks, whereupon the wrist was mobilised. By six months the patient had returned to his work, but not to scaffolds. When reviewed two and a half years after injury he had occasional slight pain, a good range of m o v e m e n t and was managing his work well, despite having a non-union of both fractures, the fragments of which also appeared to be avascular (Fig. 3). DISCUSSION The striking feature is the exactly transverse and very proximal nature of the fractures across the lunate and scaphoid into the radial styloid. The two fragments were joined together and lay in front of the bodies of the lunate and scaphoid. To do so the wrist must have been forcibly dorsiflexed and probably adducted. That this unusual combination of fractures occurred in an eighteen year old boy may do no J. Noble, F.R.C.S. (E), University of Manchester, Hope Hospital, Eccles Old Road, Salford, M6 8HD The H a n d - - Vol. 11
No. 1
1979
47
Translunate Scapho-Radial Fracture J. Noble and D. W. Lamb
Fig. 1. and Fig. 2. X-ray after injury, showing fractures of lunate, scaphoid and radial styloid.
Fig. 3. X-ray showing non-union and avascular necrosis of the fragments of scaphoid and lunate, two and a half years after injury. 48
The HancI--VoL 11
No. I
1979
Translunate Scapho-Radial Fracture J. Noble and D. W. Lamb
more than demonstrate that under high impact stress, bone is more likely to break before ligament. The management of this case also illustrates the futility of attempting closed reduction in severe fracture dislocations of the carpus. Moreover, despite splitting the flexor retinaculum down into the palmar aponeurosis and up into the deep forearm fascia, this boy had very severe pain with median and ulnar nerve neurapraxia for several days. The most interesting feature is that in a little less than six months he had returned to his trade and that two and a half years later, despite his radiographic appearances, he remains almost asymptomatic. This questions the more radical approach of removing the fragments, advocated by Campbell (1965). ~qhile internal fixation subsequently failed after removal of the wire, such early mobilisation now seems justified by the good range of movement this patient has achieved. It is encouraging that Inglis (1977), whilst criticising wrist arthrodesis and advocating proximal carpectomy, had stressed that radio-carpal osteoarthritis is now a contra-indication to carpectomy, which will probably prove to be necessary at some stage with this patient. This patient also reveals the potential danger of treating the X-ray, rather than the patient, in cases with non-union or avascular necrosis, following carpal inj uries. REFERENCES BOYES, J. H. Bunnell's Surgery of the Hand. Philadelphia and Toronto. J. B. Lippincott Company (1970) p.591-597. CAMPBELL, R. D. Jr., LANCE, E. M. and YEOH, C. B. (1964) Lunate and Perilunar Dislocations. The Journal of Bone and Joint Surgery. 46B: 55-72. CAMPBELL, R. D. Jr., THOMPSON, T. C., LANCE, E. M. and ADLER, J. B. (1965) Indications for Open Reduction of Lunate and Perilnnate Dislocations of the Carpal Bones. The Journal of Bone and Joint Surgery. 47A: 915-937. DUNN, A. W. (1973) Fractures and Dislocations of the Carpus. The Journal of Bone and Joint Surgery. 55A: 1319. INGLIS, A. E. and JONES, E. C. (1977) Proximal Row Carpectomy for Diseases of the Proximal Row. The Journal of Bone and Joint Surgery. 59A: 460-463. LINSCHEID, R. L., DOBYNS, J. H., BEABOUT, J. W. and BRYAN, R. S. (1972). Traumatic Instability of the Wrist. Diagnosis, Classification and Pathomechanics. The Journal of Bone and Joint Surgery. 54A: 1632. PANTING, A. (1978) Unpublished data. PELLEGRINO, E. A. Jr. and PETERSON, E. D. (1973) Trans-scaphoid - - Perilunate Dislocations of Wrist. The Journal of Bone and Joint Surgery. 55A: 1319. STEWART, M. and CROSS, H. (1968) The Management of Injuries of the Carpal Lunate with a Review of Sixty Cases. The Journal Of Bone and Joint Surgery. 50A: 1489.
The H a n d - - Vol. 11
No. 1
1979
49