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Translunate, transmetacarpal, scapho-radial fracture with perilunate dislocation a case report
Translunate, Transmetacarpal, Scapho-Radial Fracture with Perilunate Dislocation A Case Report P. TOFT, K. BERTHEUSSEN and S. OTKJAER From Vejle Hospital, Denmark. A case translunate, transmetacarpai, scapho-radial fracture with perilunate dislocation occurred as a young man drove his motorcycle into the side of a car. Closed reduction was performed initially. Open reduction was performed with a screw in the lunate. Eighteen months later the screw was removed and after two and a half years x-rays revealed no signs of avascular necrosis or arthrosis. The patient fully recovered. This case stresses the necessity of open reduction in cases of complicated carpal fracture dislocations.
Carpal injury comprises 0.2 to 2~ (Morawa, 1976) of all fractures. Generally, perilunate dorsal dislocation is considered the most frequent fracture-dislocation, but some sources quote more incidences of trans-scaphoid dorsal perilunate dislocation (Russell, 1949; Dunn, 1972). If the scaphoid is not fractured but the hyperextension injury continues, causing perilunate dislocation, an additional avulsion fracture of the radial and ulnar styloid processes often occurs (Wagner, 1956). Russell found that a trans-scaphoid perilunate dislocation was accompanied by fractured styloid processes in more than one third of his reviewed cases. A few case reports have described trans-scaphoid, perilunate dislocation with accompanying capitate and triquetral fracture (Weseley, 1972; Pfeiffer, 1978), but, to our knowledge, never with an associated lunate fracture. The case reported combines translunate, scapho-radial fracture with perilunate dislocation and fracture of the fifth metacarpal.
Fig. l b
D r a w i n g o f l a illustrates f r a c t u r e p o s i t i o n .
Case Report
An eighteen-year-old man was admitted after driving his motorcycle into the side of a car. The patient had amnesia for the accident but was conscious on arrival at hospital. On examination both wrists were tender and swollen, but the pulse was normal and sensation intact. Further, the accident had caused a penetrating lesion of the left eye which led to blindness, and a fracture of the left femur which recovered following osteosynthesis. Fig. l a
Initial x - r a y .
Received for publication March, 1985. Palle Toft, M.D., Sjaellandsgade 112, 8000 Aarhus C, Denmark.
382
Initial x-rays of the right wrist revealed fractures of the lunate, the scaphoid and fifth metacarpal and fracture of the radial and ulnar styloid processes. Further, a perilunar dislocation was revealed. X-rays of the left THE JOURNAL OF HAND SURGERY
DISLOCATION OF WRIST
and dorsal lunate fragments; the volar lunate fragment was tilted forwards and the volar radio-carpal ligaments had burst open. At operation the scaphoid fracture was seen in anatomical position. The interposed joint capsule was removed, the fractured lunate was reduced and fixed with a lag screw and the radio-carpal ligament was sutured. Per-operative roentgenograms revealed a position not quite ideal as the luxation had been slightly over-corrected and the scaphoid too vertically positioned. Postoperatively, the fracture was treated with an encircling plaster cast for ten weeks and a plaster cast below the elbow for six weeks. Eighteen months after the operation the fixation elements were removed and two and a half years later control x-rays revealed no indication of avascular necrosis or arthrosis. The patient was completely asymptomatic. Fig. 2
Lateral x-ray after reduction of the perilunate luxation draws attention to the lunate fracture.
wrist showed fracture of the distal radius without dislocation and fracture of the capitate. Closed reduction was performed on the right carpus. The left wrist was fixed by a dorsal plaster cast. Twenty days later an open reduction was performed and the carpus was exposed through a volar incision. The volar joint capsule was revealed interposed between the volar
Fig. 3a and
3b.
Anteroposterior
VOL. 10-B No. 3 OCTOBER 1985
and
lateral
x-rays
Discussion A fracture dislocation of the present type has not previously been reported, and we have not been able to find a case which has had a lunate fracture treated with osteosynthesis as described here. The joint capsule which was interposed between the lunate fragments made it impossible to obtain an acceptable position by closed reduction. Accordingly,
after osteosynthesis with a lag screw.
383
P. TOFT, K. BERTHEUSSEN AND S. OTKJAER
Fig. 4a and 4b.
Anteroposterior and lateral x-rays two and a half years later.
this case suggests the wisdom of open reduction in cases of complicated carpal fracture dislocations. Peroperatively, osteosynthesis of the scaphoid was considered, but the increased exposure which would have been necessary would also have caused an increased risk of reducing the blood supply to the carpus. The patient stated that he was in the habit of steering his cycle with a slightly dorsiflexed, ulnar deviated wrist. This indicates that he suffered a hyperextension injury. Most likely, the various dorsal perilunate fracture dislocation types are caused by variations in intensity of the hyperextending force and different radial/ulnar deviation at the moment of injury. Editor's Note
The authors are to be congratulated on the accuracy of the diagnosis and reduction in this very complicated
384
injury. However, the follow-up x-rays show persistent extreme carpal instability (visi) with the lunate rotated forwards and the scaphoid in marked flexion. References DUNN, A. W. (1972). Fractures and Dislocations of the Carpus, Surgical Clinics of North America 52: 1513-1538. MORAWA, L. G., ROSS, P. M. and SCHOCK, C. C. (1976). Fractures and dislocations Involving the Navicular-Lunate Axis. Clinical Orthopaedics and Related Research 118: 48-53. PFEIFFER, K. M. (1978). Perilunare transskaphoidale, transkapitale, transstyloidale Handgelenks-Luxationsfraktur. Operative Rekonstruktion. Handchirurgie 10: (1) 39-40. RUSSELL, T. B. (1949). Inter-Carpal Dislocations and Fracture-Dislocations. A Review of Fifty-nine Cases. The Journal of Bone and Joint Surgery 31B (4):524-531. WAGNER, C. J. (1956). Perilunar Dislocations. The Journal of Bone and Joint Surgery 38A (6): 1198-1230. WESELEY, M. S. and BARENFELD, P. A. (1972). Trans-Scaphoid, Transcapitate, Transtriquetral, Perilunate Fracture-Dislocation of the Wrist. A Case Report. The Journal of Bone and Joint Surgery 54A (5):1073-1078.
THE JOURNAL OF HAND SURGERY
Carpal injury comprises 0.2 to 2~ (Morawa, 1976) of all fractures. Generally, perilunate dorsal dislocation is considered the most frequent fracture-dislocation, but some sources quote more incidences of trans-scaphoid dorsal perilunate dislocation (Russell, 1949; Dunn, 1972). If the scaphoid is not fractured but the hyperextension injury continues, causing perilunate dislocation, an additional avulsion fracture of the radial and ulnar styloid processes often occurs (Wagner, 1956). Russell found that a trans-scaphoid perilunate dislocation was accompanied by fractured styloid processes in more than one third of his reviewed cases. A few case reports have described trans-scaphoid, perilunate dislocation with accompanying capitate and triquetral fracture (Weseley, 1972; Pfeiffer, 1978), but, to our knowledge, never with an associated lunate fracture. The case reported combines translunate, scapho-radial fracture with perilunate dislocation and fracture of the fifth metacarpal.
Fig. l b
D r a w i n g o f l a illustrates f r a c t u r e p o s i t i o n .
Case Report
An eighteen-year-old man was admitted after driving his motorcycle into the side of a car. The patient had amnesia for the accident but was conscious on arrival at hospital. On examination both wrists were tender and swollen, but the pulse was normal and sensation intact. Further, the accident had caused a penetrating lesion of the left eye which led to blindness, and a fracture of the left femur which recovered following osteosynthesis. Fig. l a
Initial x - r a y .
Received for publication March, 1985. Palle Toft, M.D., Sjaellandsgade 112, 8000 Aarhus C, Denmark.
382
Initial x-rays of the right wrist revealed fractures of the lunate, the scaphoid and fifth metacarpal and fracture of the radial and ulnar styloid processes. Further, a perilunar dislocation was revealed. X-rays of the left THE JOURNAL OF HAND SURGERY
DISLOCATION OF WRIST
and dorsal lunate fragments; the volar lunate fragment was tilted forwards and the volar radio-carpal ligaments had burst open. At operation the scaphoid fracture was seen in anatomical position. The interposed joint capsule was removed, the fractured lunate was reduced and fixed with a lag screw and the radio-carpal ligament was sutured. Per-operative roentgenograms revealed a position not quite ideal as the luxation had been slightly over-corrected and the scaphoid too vertically positioned. Postoperatively, the fracture was treated with an encircling plaster cast for ten weeks and a plaster cast below the elbow for six weeks. Eighteen months after the operation the fixation elements were removed and two and a half years later control x-rays revealed no indication of avascular necrosis or arthrosis. The patient was completely asymptomatic. Fig. 2
Lateral x-ray after reduction of the perilunate luxation draws attention to the lunate fracture.
wrist showed fracture of the distal radius without dislocation and fracture of the capitate. Closed reduction was performed on the right carpus. The left wrist was fixed by a dorsal plaster cast. Twenty days later an open reduction was performed and the carpus was exposed through a volar incision. The volar joint capsule was revealed interposed between the volar
Fig. 3a and
3b.
Anteroposterior
VOL. 10-B No. 3 OCTOBER 1985
and
lateral
x-rays
Discussion A fracture dislocation of the present type has not previously been reported, and we have not been able to find a case which has had a lunate fracture treated with osteosynthesis as described here. The joint capsule which was interposed between the lunate fragments made it impossible to obtain an acceptable position by closed reduction. Accordingly,
after osteosynthesis with a lag screw.
383
P. TOFT, K. BERTHEUSSEN AND S. OTKJAER
Fig. 4a and 4b.
Anteroposterior and lateral x-rays two and a half years later.
this case suggests the wisdom of open reduction in cases of complicated carpal fracture dislocations. Peroperatively, osteosynthesis of the scaphoid was considered, but the increased exposure which would have been necessary would also have caused an increased risk of reducing the blood supply to the carpus. The patient stated that he was in the habit of steering his cycle with a slightly dorsiflexed, ulnar deviated wrist. This indicates that he suffered a hyperextension injury. Most likely, the various dorsal perilunate fracture dislocation types are caused by variations in intensity of the hyperextending force and different radial/ulnar deviation at the moment of injury. Editor's Note
The authors are to be congratulated on the accuracy of the diagnosis and reduction in this very complicated
384
injury. However, the follow-up x-rays show persistent extreme carpal instability (visi) with the lunate rotated forwards and the scaphoid in marked flexion. References DUNN, A. W. (1972). Fractures and Dislocations of the Carpus, Surgical Clinics of North America 52: 1513-1538. MORAWA, L. G., ROSS, P. M. and SCHOCK, C. C. (1976). Fractures and dislocations Involving the Navicular-Lunate Axis. Clinical Orthopaedics and Related Research 118: 48-53. PFEIFFER, K. M. (1978). Perilunare transskaphoidale, transkapitale, transstyloidale Handgelenks-Luxationsfraktur. Operative Rekonstruktion. Handchirurgie 10: (1) 39-40. RUSSELL, T. B. (1949). Inter-Carpal Dislocations and Fracture-Dislocations. A Review of Fifty-nine Cases. The Journal of Bone and Joint Surgery 31B (4):524-531. WAGNER, C. J. (1956). Perilunar Dislocations. The Journal of Bone and Joint Surgery 38A (6): 1198-1230. WESELEY, M. S. and BARENFELD, P. A. (1972). Trans-Scaphoid, Transcapitate, Transtriquetral, Perilunate Fracture-Dislocation of the Wrist. A Case Report. The Journal of Bone and Joint Surgery 54A (5):1073-1078.
THE JOURNAL OF HAND SURGERY