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Dorsal dislocation of the trapezoid
Dorsal dislocation of the trapezoid A case of dorsal dislocation of the trapezoid associated with dorsal subluxation of the carpometacarpal joints of the index and long fingers is described. The initial trapezoid subluxation was overlooked and it progressed quickly to a complete dislocation. Open reduction and capsular repair without internal fixation was followed by early recurrent trapezoid subluxation. Repeat open reduction combined with a limited intercarpal arthrodesis was used as a salvage procedure and produced a good result. (J HANDSURG1990;15A:874-8.)
David
M. Ostrowski,
John S. Gould,
MD, Birmingham,
MD, Milwaukee,
Ala., Michael
E. Miller,
MD, Atlanta,
Ga., and
Wis.
D
islocation of the trapezoid is a rare injury. Gay’ is acknowledged to have reported the first case in the literature in 1869. He made his diagnosis on physical examination of the anesthetized patient. In 1901, Sheldon* documented a case of dorsal dislocation of the trapezoid with use of fluoroscopy. We have been able to document only 23 other cases in the Englishlanguage and foreign-language literature.3”0 Although the review by Russell” in 1949 did contain two cases with dorsal dislocatibn of the trapezoid, one was a very complex injury with other carpal and metacarpal dislocations and probably should not be numbered with these cases. Eight dislocations have been palmar and the remainder have been dorsal. Treatment has included observation,‘. 3. ‘. lo closed reduction,*, 6. 9, ‘L I6 open reduction,4, 8. lo. 12.14,” and excision of the trapezoid.‘, 9 Goodman and Shankman” reported a case treated by open reduction and limited intercarpal arthrodesis. We also have treated a case of dorsal dislocation of the trapezoid with a limited intercarpal arthrodesis because of recurrent subluxation after open reduction and capsular repair. Case report A 24-year-old white man was seen in the emergency room shortly after his left, nondominant hand had been caught
From the Division of Orthopedic Surgery, Section of Hand Surgery, University
of Alabama
Received for publication 21. 1989.
Hospitals,
Birmingham,
Ala.
June 1, 1984; accepted in revised form Oct.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: David M. Ostrowski, MD, 2022 Brookwood Medical Center Dr., Suite 206, Birmingham, AL 35209.6869. 311117999
874
THE JOURNAL OF HAND SURGERY
Fig. 1. PA x-ray film at the time patient was seen initially demonstrating subluxation of the trapezoid. Note the absence of the usual clear space at the distal end of the scaphoid. The shadow of the trapezoid overlaps the distal scaphoid. between the rollers of a printing press. Initial examination showed a clean, oblique laceration over the volar wrist and distal forearm. The hand was diffusely swollen but not tense. There was no vascular insufficiency or tendon disruption. Sensibility was decreased in the distribution of the palmar cutaneous branch of the median nerve. No other neural deficits were noted. Initial x-ray films were interpreted as normal. The displacement of the trapezoid was not appreciated (Fig. 1). The wound was thoroughly cleansed and a bulky conforming dressing was applied. Clinical signs of a compartment syndrome of the hand or forearm did not develop. The patient was taken to surgery 5 days later for wound closure. On exploration, the palmar cutaneous branch of the median nerve could not be found and was presumably avulsed. No damage to other nerves, tendons, or vessels was apparent. The patient was discharged 48 hours after operation.
Vol. 15A. No. 6 November 1990
Dorsal dislocation of the trapezoid
875
Fig. 2. PA and lateral views of the wrist at the time of the first follow-up visit. The dislocation of the trapezoid is now clearly evident. The associated dorsal subluxation of the base of the second and third metacarpals can also be seen.
Fig. 3. At open reduction, the trapezoid (tip of the forceps) was completely extruded from its normal position and all major soft tissue connections were torn. (Radial side of the wrist is at the top of the figure; hand is to the left.) One week later, the swelling had decreased and a bony prominence was now palpable on the dorsoradial aspect of the carpus. Radiographs revealed an obvious dorsal dislocation of the trapezoid and associated dorsal subluxation of the bases of the second and third metacarpals (Fig. 2, A and B). Two weeks after the injury, an open reduction was accomplished through a dorsal longitudinal incision. The completely extruded trapezoid was attached to its bed by only a thin shred of connective tissue (Fig. 3). The dorsal capsule was folded into the space normally occupied by the trapezoid. After clear-
ing this space of disrupted ligamentous tissue and granulations, the trapezoid could be easily reduced. A seemingly snug repair of the dorsal capsule was obtained. Since the reduction seemed stable through the full passive range of wrist motion, internal fixation was not used. A bulky conforming dressing and splint maintained the wrist in slight extension. Three weeks later, the patient complained of dysesthesias and parestbesias in the distributions of the median and ulnar nerves. The hand was swollen and tender dorsally. There was decreased mobility of the metacarpophalangeal and proximal
876
Ostrowski, Miller, and Gould
Fig. 4. PA x-ray film of the wrist 2 weeks after open reduction. A subluxation of the trapezoid is suggested by the absence of the clear space at the distal end of the scaphoid.
Fig. 5. PA x-ray film shortly after limited intercarpal arthrodesis and Kirschner wire fixation.
interphalangeal joints. Two-point discrimination was greater than 15 mm on the ulnar side of the index finger, on the radial side of the long finger, and on both sides of the small finger. It was 9 mm on the ulnar side of the ring finger and normal on the other fingers. Electrical testing showed slowing of
The Journal of HAND SURGERY
Fig. 6. PA view of the wrist 4 months after fusion. The pins have been removed. The fusion sites between the bases of the second and third metacarpals and between the second metacarpal, trapezoid, capitate, and scaphoid appear well healed. The trapezoid does not appear avascular.
sensory conduction across the wrist segments of the median and ulnar nerves. Radiographs revealed a dorsal subluxation of the trapezoid (Fig. 4). At this time, the senior author (J. S. G.) was consulted. An intensive course of therapy to reduce edema and to gain finger mobility was initiated. Six weeks after injury the patient had release of the carpal tunnel and canal of Guyon. There was extensive scarring in the carpal tunnel and a tenosynovectomy was required to mobilize the flexor tendons. There was perineural fibrosis of both the median and ulnar nerves requiring epineurotomy for decompression. The wrist was explored through a separate dorsal incision. The trapezoid was subluxed dorsally and had no ligamentous attachments. The articulations between the capitate and the second metacarpal, and between the scaphoid and capitate were damaged. The interossei appeared normal, but a biopsy specimen taken from the third dorsal interosseous muscle subsequently revealed areas of focal necrosis and chronic inflammation. We did a limited carpal fusion, including the scaphoid, trapezoid, capitate, and second and third metacarpals. The fusion sites were packed with iliac bone graft and stabilized with Kirschner (K-) wires (Fig. 5). The patient wore a cast for 3 months and a supportive splint for 1 month. Four months after operation, films suggested that the fusion was healed, so the K-wires were removed (Fig. 6). By this time, the patient had recovered full sensibility in the hand and was gaining strength and mobility. He returned to work as a printing press operator 6 months after operation. Seventeen months after operation his wrist motions were: extension 35 degrees, flexion 40 degrees, pronation 85 de-
Vol. 15A, No. 6 Dorsal dislocation of the trapezoid
November 1990
70%
877
of its blood supply dorsally and 30%
grees, supination 90 degrees, ulnar deviation 5 degrees, and
receives
radial deviation 10 degrees. His grip strengths were: Left, 29.5 kg (injured, nondominant); right, 50 kg. His pinch strengths were: pulp, left 5.9 kg, right 6.8 kg; lateral, left 8.6 kg, right 12.3 kg; three jaw chuck, left, 8.6 kg, right 12.3 kg. He had full mobility of the fingers and thumb. He had normal sensibility. His only complaint was occasional aching in the area of the carpometacarpal joint of the thumb, which was related to heavy activities.
palmarly without auastomoses between these systems. It can be readily understood why a complete dislocation may interfere with this blood supply. Surgical dissection may cause further vascular insufficiency. Our treatment goals were to provide stability to the carpal arch, treat posttraumatic arthrosis, and promote revascularization of the presumably avascular trapezoid. Watson et al.**, 23 have shown that a variety of limited intercarpal arthrodeses are consistent with preservation of some wrist motion. The particular combination employed in this case was not described in their 1981 review, although they did mention that the carpometacarpal joints of the index and long fingers might be added to an intercarpal fusion if degenerative changes exist at those sites. Several diagnostic and therapeutic conclusions can be made from the collected experience of the authors reporting on this injury. Careful interpretation of the radiographs is essential after a careful clinical history and examination. Sampson9 has stated that the most useful view is the straight PA. It shows the normal clear space between the distal aspect of the scaphoid and the trapezium and trapezoid with which it articulates. Oblique views are helpful when lesser degrees of subluxation are present. Comparisons with the normal wrist may be useful in the questionable case. Patients with proximal metacarpal fractures or carpometacarpal dislocations should be evaluated carefully to rule out a dislocation of the trapezoid. Closed reduction is the preferable treatment in the early postinjury period. Open procedures are reserved for irreducible dislocations. In either case. K-wire stabilization should be added since osseous geometry makes this a potentionally unstable injury, even if ligaments are repaired. Open reduction and limited intercarpal fusion is a salvage procedure, but can produce a satisfactory functional result.
Discussion Several authors have commented on the anatomic features favoring dorsal dislocation of the trapezoid.?. “*9, “3 15-” It is the keystone of the carpal arch. It is wedge-shaped with its dorsal surface being approximately twice that of the palmar surface. Meyn” demonstrated that with the wrist in slight extension, a ridge of scaphoid covers the articular surface of the trapezoid locking it into position; however, with the wrist in 20 degrees of flexion, the trapezoid becomes exposed dorsally. The primary restraining structures are the strong palmar ligaments. The dorsal ligaments are much weaker. The interosseous ligaments are thought to play a minor role in stabilization of the trapezoid. Thus anatomic features favor dorsal extrusion. The mechanism of dorsal dislocation seems to be a blow to the distal dorsal end of the second metacarpal with the wrist in slight flexion.‘, 3, ‘3 “, ‘5-‘7The mechanism of injury in palmar dislocation is less clear. Rhoades and Reckling” postulate that forced extension of the wrist is the mechanism. They state that hyperextension of the distal pole of the scaphoid with the base of the second metacarpal buttressing the trapezoid dorsally represents the only mechanical situation where palmar dislocation could occur. It would seem to be a very high energy injury since anatomic features favor palmar stability. The treatment of this injury has varied and most authors report reasonably good results. However, follow-up periods are often too short to permit conclusions regarding efficacy of treatment. Treatments used include no reduction,‘, 3. ‘, ‘Oincomplete closed reduction,‘. 6. 9 complete closed reduction,‘, ‘*.I6 open reduction,4. *. lo open reduction and fixation with K-wires or staples, I’, “. 14,” trapezoid excision,‘, 9 and limited fusion.j8 Closed reduction is generally advocated as the initial therapy with open reduction reserved for irreducible cases. In five of eight cases treated by open reduction, avascular necrosis developed but this may not preclude a good result4. 8. ‘L “. *’ Patients are reported to have returned to work and have adequate wrist mobility despite avascular changes in the trapezoid. The elegant studies of Gelberman et al.*’ show that the trapezoid
REFERENCES 1. Gay W. Dislocation of the trapezoid. Boston Med Surg J 1869;81:188. 2. Sheldon JG. Dorsal dislocation of the trapezoid. Am J Med Sci 1901;121:85-9. 3. Frank J. Ontwrichting van het multangulum minus. Ned. Tijdschr Geneeskd 1925;69:200-2. 4. Wablers H. Luxation des multangulum minus. Zentralbl F Chir 1931;58:2626-9. 5. Fantoni A. Un case di Lussazione isolata de1 trapezoid. Rassagna Privid Sociale 1938;25:51-5. 6. Slany A. Uber einen Fall von luxation des OS mutangulum minus carpi. Zentralbl F Chir 1939;66:2581-4. 7. Peterson TH. Dislocation of the lesser multangular. J Bone Joint Surg 1940;22:220-2.
878
Ostrowski,Miller, and Gould
8. Milch H. Isolated luxation of the lesser multangular. Bull Hosp Joint Dis 1943;4:36-40. 9. Sampson AD. Isolated dislocation of the lesser multangular bone. Am J Roentgen01 1948;59:712-16. 10. Russell TB. Intercarpal dislocations and fracturedislocations. A review of fifty-nine case. J Bone Joint Surg 1949;31B:524-31. 11. Lewis HH: Dislocation of the lesser multangular. J Bone Joint Surg 1962;44A: 1421-24. 12. Stein AH. Dorsal dislocation of the lesser multangular bone. J Bone Joint Surg 1971;53A:377-9. 13. Peretti L, Massazza C. Su di un ravo case di lussazione de1 trapezoide. Chir Organi Mov 1979;65:89-92. 14. Rizzo L, de Negri P. Lussazione dorsale trapezoide II metacarpale. Chir Organi Mov 1979;65:89-92. 15. Meyn MA, Roth AM. Isolated dislocation of the trapezoid bone. J HANDSURG 1980;5:602-4. 16. Bendre DV, Baxi VK. Dislocation of the trapezoid. J Trauma 1981:21:899-900.
The Journal of HAND SURGERY
17. Rboades CE, Reckling PW. Palmar dislocation of the trapezoid. J HANDSURG 1983;8:85-8. 18. Goodman ML, Shankman GB . Palmar dislocation of the trapezoid. J HANDSURG 1983;8:606-9. 19. Kopp JR. Isolated palmar dislocation of the trapezoid. J HANDSURG 1985;10A:91-3. 20. Dunkerton M, Singer M. Dislocation of the index metacarpal and trapezoid bones. J HAND SURG 1985;lOB: 377-8. 21. Gelberman RH, Panagis JS, Taleisnik J, Baumgaertner M. The arterial anatomy of the human carpus. Part II: the intraosseous vascular@. J HANDSURG 1983;8:37582. 22. Watson HK, Hempton RF. Limited wrist artbrodesis: Part I: the triscaphoid joint. J HANDSURG 1980;5:320-7. 23. Watson HK, Goodman ML, Johnson TR. Limited wrist artbrodesis. Part II: intercarpal and radio carpal combinations. J HANDSURG 1981;6:223-33.
David
M. Ostrowski,
John S. Gould,
MD, Birmingham,
MD, Milwaukee,
Ala., Michael
E. Miller,
MD, Atlanta,
Ga., and
Wis.
D
islocation of the trapezoid is a rare injury. Gay’ is acknowledged to have reported the first case in the literature in 1869. He made his diagnosis on physical examination of the anesthetized patient. In 1901, Sheldon* documented a case of dorsal dislocation of the trapezoid with use of fluoroscopy. We have been able to document only 23 other cases in the Englishlanguage and foreign-language literature.3”0 Although the review by Russell” in 1949 did contain two cases with dorsal dislocatibn of the trapezoid, one was a very complex injury with other carpal and metacarpal dislocations and probably should not be numbered with these cases. Eight dislocations have been palmar and the remainder have been dorsal. Treatment has included observation,‘. 3. ‘. lo closed reduction,*, 6. 9, ‘L I6 open reduction,4, 8. lo. 12.14,” and excision of the trapezoid.‘, 9 Goodman and Shankman” reported a case treated by open reduction and limited intercarpal arthrodesis. We also have treated a case of dorsal dislocation of the trapezoid with a limited intercarpal arthrodesis because of recurrent subluxation after open reduction and capsular repair. Case report A 24-year-old white man was seen in the emergency room shortly after his left, nondominant hand had been caught
From the Division of Orthopedic Surgery, Section of Hand Surgery, University
of Alabama
Received for publication 21. 1989.
Hospitals,
Birmingham,
Ala.
June 1, 1984; accepted in revised form Oct.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: David M. Ostrowski, MD, 2022 Brookwood Medical Center Dr., Suite 206, Birmingham, AL 35209.6869. 311117999
874
THE JOURNAL OF HAND SURGERY
Fig. 1. PA x-ray film at the time patient was seen initially demonstrating subluxation of the trapezoid. Note the absence of the usual clear space at the distal end of the scaphoid. The shadow of the trapezoid overlaps the distal scaphoid. between the rollers of a printing press. Initial examination showed a clean, oblique laceration over the volar wrist and distal forearm. The hand was diffusely swollen but not tense. There was no vascular insufficiency or tendon disruption. Sensibility was decreased in the distribution of the palmar cutaneous branch of the median nerve. No other neural deficits were noted. Initial x-ray films were interpreted as normal. The displacement of the trapezoid was not appreciated (Fig. 1). The wound was thoroughly cleansed and a bulky conforming dressing was applied. Clinical signs of a compartment syndrome of the hand or forearm did not develop. The patient was taken to surgery 5 days later for wound closure. On exploration, the palmar cutaneous branch of the median nerve could not be found and was presumably avulsed. No damage to other nerves, tendons, or vessels was apparent. The patient was discharged 48 hours after operation.
Vol. 15A. No. 6 November 1990
Dorsal dislocation of the trapezoid
875
Fig. 2. PA and lateral views of the wrist at the time of the first follow-up visit. The dislocation of the trapezoid is now clearly evident. The associated dorsal subluxation of the base of the second and third metacarpals can also be seen.
Fig. 3. At open reduction, the trapezoid (tip of the forceps) was completely extruded from its normal position and all major soft tissue connections were torn. (Radial side of the wrist is at the top of the figure; hand is to the left.) One week later, the swelling had decreased and a bony prominence was now palpable on the dorsoradial aspect of the carpus. Radiographs revealed an obvious dorsal dislocation of the trapezoid and associated dorsal subluxation of the bases of the second and third metacarpals (Fig. 2, A and B). Two weeks after the injury, an open reduction was accomplished through a dorsal longitudinal incision. The completely extruded trapezoid was attached to its bed by only a thin shred of connective tissue (Fig. 3). The dorsal capsule was folded into the space normally occupied by the trapezoid. After clear-
ing this space of disrupted ligamentous tissue and granulations, the trapezoid could be easily reduced. A seemingly snug repair of the dorsal capsule was obtained. Since the reduction seemed stable through the full passive range of wrist motion, internal fixation was not used. A bulky conforming dressing and splint maintained the wrist in slight extension. Three weeks later, the patient complained of dysesthesias and parestbesias in the distributions of the median and ulnar nerves. The hand was swollen and tender dorsally. There was decreased mobility of the metacarpophalangeal and proximal
876
Ostrowski, Miller, and Gould
Fig. 4. PA x-ray film of the wrist 2 weeks after open reduction. A subluxation of the trapezoid is suggested by the absence of the clear space at the distal end of the scaphoid.
Fig. 5. PA x-ray film shortly after limited intercarpal arthrodesis and Kirschner wire fixation.
interphalangeal joints. Two-point discrimination was greater than 15 mm on the ulnar side of the index finger, on the radial side of the long finger, and on both sides of the small finger. It was 9 mm on the ulnar side of the ring finger and normal on the other fingers. Electrical testing showed slowing of
The Journal of HAND SURGERY
Fig. 6. PA view of the wrist 4 months after fusion. The pins have been removed. The fusion sites between the bases of the second and third metacarpals and between the second metacarpal, trapezoid, capitate, and scaphoid appear well healed. The trapezoid does not appear avascular.
sensory conduction across the wrist segments of the median and ulnar nerves. Radiographs revealed a dorsal subluxation of the trapezoid (Fig. 4). At this time, the senior author (J. S. G.) was consulted. An intensive course of therapy to reduce edema and to gain finger mobility was initiated. Six weeks after injury the patient had release of the carpal tunnel and canal of Guyon. There was extensive scarring in the carpal tunnel and a tenosynovectomy was required to mobilize the flexor tendons. There was perineural fibrosis of both the median and ulnar nerves requiring epineurotomy for decompression. The wrist was explored through a separate dorsal incision. The trapezoid was subluxed dorsally and had no ligamentous attachments. The articulations between the capitate and the second metacarpal, and between the scaphoid and capitate were damaged. The interossei appeared normal, but a biopsy specimen taken from the third dorsal interosseous muscle subsequently revealed areas of focal necrosis and chronic inflammation. We did a limited carpal fusion, including the scaphoid, trapezoid, capitate, and second and third metacarpals. The fusion sites were packed with iliac bone graft and stabilized with Kirschner (K-) wires (Fig. 5). The patient wore a cast for 3 months and a supportive splint for 1 month. Four months after operation, films suggested that the fusion was healed, so the K-wires were removed (Fig. 6). By this time, the patient had recovered full sensibility in the hand and was gaining strength and mobility. He returned to work as a printing press operator 6 months after operation. Seventeen months after operation his wrist motions were: extension 35 degrees, flexion 40 degrees, pronation 85 de-
Vol. 15A, No. 6 Dorsal dislocation of the trapezoid
November 1990
70%
877
of its blood supply dorsally and 30%
grees, supination 90 degrees, ulnar deviation 5 degrees, and
receives
radial deviation 10 degrees. His grip strengths were: Left, 29.5 kg (injured, nondominant); right, 50 kg. His pinch strengths were: pulp, left 5.9 kg, right 6.8 kg; lateral, left 8.6 kg, right 12.3 kg; three jaw chuck, left, 8.6 kg, right 12.3 kg. He had full mobility of the fingers and thumb. He had normal sensibility. His only complaint was occasional aching in the area of the carpometacarpal joint of the thumb, which was related to heavy activities.
palmarly without auastomoses between these systems. It can be readily understood why a complete dislocation may interfere with this blood supply. Surgical dissection may cause further vascular insufficiency. Our treatment goals were to provide stability to the carpal arch, treat posttraumatic arthrosis, and promote revascularization of the presumably avascular trapezoid. Watson et al.**, 23 have shown that a variety of limited intercarpal arthrodeses are consistent with preservation of some wrist motion. The particular combination employed in this case was not described in their 1981 review, although they did mention that the carpometacarpal joints of the index and long fingers might be added to an intercarpal fusion if degenerative changes exist at those sites. Several diagnostic and therapeutic conclusions can be made from the collected experience of the authors reporting on this injury. Careful interpretation of the radiographs is essential after a careful clinical history and examination. Sampson9 has stated that the most useful view is the straight PA. It shows the normal clear space between the distal aspect of the scaphoid and the trapezium and trapezoid with which it articulates. Oblique views are helpful when lesser degrees of subluxation are present. Comparisons with the normal wrist may be useful in the questionable case. Patients with proximal metacarpal fractures or carpometacarpal dislocations should be evaluated carefully to rule out a dislocation of the trapezoid. Closed reduction is the preferable treatment in the early postinjury period. Open procedures are reserved for irreducible dislocations. In either case. K-wire stabilization should be added since osseous geometry makes this a potentionally unstable injury, even if ligaments are repaired. Open reduction and limited intercarpal fusion is a salvage procedure, but can produce a satisfactory functional result.
Discussion Several authors have commented on the anatomic features favoring dorsal dislocation of the trapezoid.?. “*9, “3 15-” It is the keystone of the carpal arch. It is wedge-shaped with its dorsal surface being approximately twice that of the palmar surface. Meyn” demonstrated that with the wrist in slight extension, a ridge of scaphoid covers the articular surface of the trapezoid locking it into position; however, with the wrist in 20 degrees of flexion, the trapezoid becomes exposed dorsally. The primary restraining structures are the strong palmar ligaments. The dorsal ligaments are much weaker. The interosseous ligaments are thought to play a minor role in stabilization of the trapezoid. Thus anatomic features favor dorsal extrusion. The mechanism of dorsal dislocation seems to be a blow to the distal dorsal end of the second metacarpal with the wrist in slight flexion.‘, 3, ‘3 “, ‘5-‘7The mechanism of injury in palmar dislocation is less clear. Rhoades and Reckling” postulate that forced extension of the wrist is the mechanism. They state that hyperextension of the distal pole of the scaphoid with the base of the second metacarpal buttressing the trapezoid dorsally represents the only mechanical situation where palmar dislocation could occur. It would seem to be a very high energy injury since anatomic features favor palmar stability. The treatment of this injury has varied and most authors report reasonably good results. However, follow-up periods are often too short to permit conclusions regarding efficacy of treatment. Treatments used include no reduction,‘, 3. ‘, ‘Oincomplete closed reduction,‘. 6. 9 complete closed reduction,‘, ‘*.I6 open reduction,4. *. lo open reduction and fixation with K-wires or staples, I’, “. 14,” trapezoid excision,‘, 9 and limited fusion.j8 Closed reduction is generally advocated as the initial therapy with open reduction reserved for irreducible cases. In five of eight cases treated by open reduction, avascular necrosis developed but this may not preclude a good result4. 8. ‘L “. *’ Patients are reported to have returned to work and have adequate wrist mobility despite avascular changes in the trapezoid. The elegant studies of Gelberman et al.*’ show that the trapezoid
REFERENCES 1. Gay W. Dislocation of the trapezoid. Boston Med Surg J 1869;81:188. 2. Sheldon JG. Dorsal dislocation of the trapezoid. Am J Med Sci 1901;121:85-9. 3. Frank J. Ontwrichting van het multangulum minus. Ned. Tijdschr Geneeskd 1925;69:200-2. 4. Wablers H. Luxation des multangulum minus. Zentralbl F Chir 1931;58:2626-9. 5. Fantoni A. Un case di Lussazione isolata de1 trapezoid. Rassagna Privid Sociale 1938;25:51-5. 6. Slany A. Uber einen Fall von luxation des OS mutangulum minus carpi. Zentralbl F Chir 1939;66:2581-4. 7. Peterson TH. Dislocation of the lesser multangular. J Bone Joint Surg 1940;22:220-2.
878
Ostrowski,Miller, and Gould
8. Milch H. Isolated luxation of the lesser multangular. Bull Hosp Joint Dis 1943;4:36-40. 9. Sampson AD. Isolated dislocation of the lesser multangular bone. Am J Roentgen01 1948;59:712-16. 10. Russell TB. Intercarpal dislocations and fracturedislocations. A review of fifty-nine case. J Bone Joint Surg 1949;31B:524-31. 11. Lewis HH: Dislocation of the lesser multangular. J Bone Joint Surg 1962;44A: 1421-24. 12. Stein AH. Dorsal dislocation of the lesser multangular bone. J Bone Joint Surg 1971;53A:377-9. 13. Peretti L, Massazza C. Su di un ravo case di lussazione de1 trapezoide. Chir Organi Mov 1979;65:89-92. 14. Rizzo L, de Negri P. Lussazione dorsale trapezoide II metacarpale. Chir Organi Mov 1979;65:89-92. 15. Meyn MA, Roth AM. Isolated dislocation of the trapezoid bone. J HANDSURG 1980;5:602-4. 16. Bendre DV, Baxi VK. Dislocation of the trapezoid. J Trauma 1981:21:899-900.
The Journal of HAND SURGERY
17. Rboades CE, Reckling PW. Palmar dislocation of the trapezoid. J HANDSURG 1983;8:85-8. 18. Goodman ML, Shankman GB . Palmar dislocation of the trapezoid. J HANDSURG 1983;8:606-9. 19. Kopp JR. Isolated palmar dislocation of the trapezoid. J HANDSURG 1985;10A:91-3. 20. Dunkerton M, Singer M. Dislocation of the index metacarpal and trapezoid bones. J HAND SURG 1985;lOB: 377-8. 21. Gelberman RH, Panagis JS, Taleisnik J, Baumgaertner M. The arterial anatomy of the human carpus. Part II: the intraosseous vascular@. J HANDSURG 1983;8:37582. 22. Watson HK, Hempton RF. Limited wrist artbrodesis: Part I: the triscaphoid joint. J HANDSURG 1980;5:320-7. 23. Watson HK, Goodman ML, Johnson TR. Limited wrist artbrodesis. Part II: intercarpal and radio carpal combinations. J HANDSURG 1981;6:223-33.