- Email: [email protected]
Volar intercalary carpal instability following a seemingly innocent wrist fracture
VOLAR INTERCALARY CARPAL INSTABILITY FOLLOWING A SEEMINGLY INNOCENT WRIST FRACTURE 1. W. BROWN. From St George’s Hospital, London A case of volar of intercalary carpal instability following a radial fracture is described and the mechanics of injury examined. Such an injury is rare and the type of radial fracture which produced it unusual. Continued instability of the carpus produces late degenerative changes. In contrast to the many reports of early and persistent pain and functional limitation this patient’s wrist settled rapidly.
Falls on the outstretched hand produce injuries to the wrist and carpus which vary with the severity of the applied force, its direction and the age of the patient. This paper describes such an injury in which the radius suffered an unusual fracture which nevertheless healed with conventional treatment, but later another and rarer injury was revealed. Case Report
In June 1983, a sixty-eight-year-old right-handed man presented to the Accident department of St George’s Hospital after falling ten feet from a ladder onto his outstretched left hand. In view of the force involved, a perilunar dislocation was initially suspected. Radiographs, however, showed a vertical, undisplaced fracture of the ulnar aspect of the distal radius with associated avulsion fractures of the posterior lip (Figure 1). The scapho-lunate distance was normal. A plaster of Paris back-slab was applied and later completed. This was removed four weeks later and radiographs taken. There was extreme carpal instability, with wide scapho-lunate diastasis and dorsal displacement and volar flexion of the lunate (Figure 2). The wrist was swollen, painful and tender and the patient was referred to the Fracture Clinic. On examination there was marked weakness of grip, palmar wrist flexion was 30” and dorsiflexion 10”; both were accompanied by pain. In view of the patient’s age, and the fact that the injury was now four weeks old and affected his non-dominant hand, he was given a removable wrist splint and advised to mobilise the wrist as much as possible. Six weeks later he attended for review. He had only infrequent pain and the total range of dorsal and palmar flexion had increased to 60”. He was advised to discard the splint. Radiographs showed no significant change, from the last ones. Eighteen weeks after the injury there was only minimal discomfort on forced ulnar deviation. Total flexion was 100” and pain-free. He was discharged. Received for publication 26 March; 1986. lvan W. Brown F.R.C.S., Orthopaedic Registrar, Western Road, Gloucester GLI 3NN.
54
Gloucestershire
Royal Hospital,
Great
Discussion
Lewis et al. (1970), in a paper mainly concerned with the descriptive and comparative anatomy of the radiocarpal ligaments and the triangular fibro-cartilage, also describe the dorsal rotation of the lunate which occurs by tightening of the palmar radio-capitate ligament during wrist dorsiflexion. Mayfield et al. (1976) decribed the vital importance of the carpal ligaments in preserving carpal integrity and stability. They induced experimental fractures and dislocations following division of the dorsal radio-carpal ligament. Study of the descriptions of ligamentous anatomy suggests that in this patient’s wrist there was disruption of the volar radio-lunate-scaphoid ligament and dorsal radio-scapho-lunate ligament as the result of the vertical and marginal fractures of the radius. There was almost certainly disruption of the scapho-lunate interosseous and radio-scaphoid ligaments allowing the scaphoid to rotate in a volar direction as did the lunate. Together with scapho-lunate diastasis, the volar rotation permitted intrusion of the capitate into the proximal carpal row (Figure 2). There are many reviews of the treatment of lunate subluxations and dislocations alone, and in association with other injuries. Campbell et al. (1965) were the first to suggest open reduction when conservative methods failed. This view was supported by Morawa et al. (1976), Spar (1978), Green and O’Brien (1978, 1980), Adkinson and Chapman (1982) and Panting et al. (1984) maintained this emphasis and in a large series with prolonged follow-up showed the undesirable sequelae of perilunar instability and subsequent degenerative changes if primary treatment was inadequate. However, Mayfield et al. (1980) obtained equivalent results with closed treatment only. Authorities have divided over the ideal treatment for those related late problems since they were catalogued by Brolin (1964), Mayfield et al. (1980) and Taleisnik et al. (1982), between advocates of silastic replacement, such THE JOURNAL
OF HAND
SURGERY
VOLAR
Fig.
1
P.A.
and lateral
radiographs
of the wrist
INTERCALARY
CARPAL
INSTABILITY
on the day of injury.
as Barber and Goodfellow (1974) and Eiken and Holmqvist (1977), and excision of the proximal row of the carpus (Inglis and Jones, 1977). Limited arthrodeses have found favour (Watson et al. 1986).
presumption of a Colles’ fracture. Mangler and Strauch (1980) decribed an analogous case in German in which a similar sequence of events occurred, but which they interpreted as dorsal subluxation of the lunate alone.
It was not felt that such procedures were justified in this patient, nor, in view of the time that had elapsed since injury that open reduction and internal fixation was likely to succeed. Indeed, almost all authorities suggest that late open reduction produces marked stiffness and poor carpal function. Tendon grafting as described by Linscheid et al. (1972) was not considered appropriate for this patient.
Conclusion
Rawlings (1981) studied thirty cases of volar dislocation of the lunate and drew attention to the scapho-lunate gap as a predictor of lunate instability and potential displacement. King (1983) and King et al. (1981, 1982) also stressed this important measure of carpal injury whose increase is clearly due to rupture of the scapholunate interosseous ligament. Tanz (1968), Berger et al. (1982) and Taleisnik et al. (1982) have illustrated the rotating movements of individual carpal bones. Drawing on the work of Kauer (1980), Taleisnik et al. (1982) have suggested that the lunate displaces dorsally when the wrist is pronated in ulnar deviation. It is suggested that this mechanism, together with rupture of the individual ligaments whose bony attachments were injured by the distal radial fractures was responsible in this case for the volar intercalary carpal instability produced since the wrist was immobilised in just this position, on the VOL.
12-B No. 1 FEBRUARY
1987
A patient is presented who sustained a moderately severe injury to the wrist resulting in an unusual wrist fracture disturbing the origins of important carpal ligaments. The fracture was erroneously interpreted as a Colles’ fracture and plaster applied. On removing the plaster, a complex injury with volar intercalary carpal instability was revealed. This was managed conservatively with an acceptable early result. It is suggested that the mechanism of production of this injury was rupture of the radial attachments of the volar radio-lunate-scaphoid and dorsal scapho-lunate ligaments, together with disruption of the scapho-lunate interosseous ligaments. This produced rotatory instability of the lunate and scaphoid which was increased by the volar flexion and ulnar deviation produced by the plaster of Paris. The absence of scapholunate diastasis on the initial radiograph does not preclude it and seems to reinforce the view of Fisk (1970) that stress views may yield vital clues as to carpal stability or otherwise. Acknowledgment 1 am most grateful report this case.
to Mr Bendall, whose patient
this was, for encouraging
me to
55
I. W. BROWN
Fig. 2
P.A.
and lateral
radiographs
of the wrist
after
removal
of the plaster
References ADKINSON, J. W. and CHAPMAN, M. W. (1982). Treatment of Acute Lunate and Perilunate Dislocations. Clinical Orthopaedics and Related Research, 164: 199.207. BARBER, H. M. and GOODFELLOW, J. W. (1974). Acrylic Lunate Prosthesis. A Long-term Follow-up. The Journal of Bone and Joint Surgery, 568: 4: 706-7 Il. BERGER, R. A., CROWNINSHIELD, R. D. and FLATT, A. E. (1982). The Three dimensional Rotational Behaviours of the Carpal Bones. Clinical Orthopaedics and Related Research, 167: 303-310. BROLIN, I. (1964). Post-Traumatic Lesions of the Lunate Bone. Acta Orthopaedica Scandinavica, 34: 167-182. CAMPBELL, R. D., THOMPSON, T. C., LANCE, E. M. and ALDER, J. B. (1965). Indications for Open Reduction of Lunate and Perilunate Dislocations of the Carpal Bones. The Journal of Bone and Joint Surgery, 47A: 5: 915.937. EIKEN, 0. and HOLMQVIST, K-G. (1977). Replacement of Carpal Bones with Exact-Fitting Silicone Rubber Implants. An Experimental Study. Scandinavian Journal of Plastic and Reconstuctive Surgery, 11: 189.193. FISK, G. R. (1970). Carpal Instability and the Fractured Scaphoid. Annals of the Royal College of Surgeons of England, 46: 2: 63-76. GREEN, D. P. and O’BRIEN, E. T. (1978). Open reduction of carpal dislo cations. Indications and operative techniques. The Journal of Hand Surgery, 3: 3: 250-265. GREEN, D. P. and O’BRIEN, E. T. (1980). Classification and Management of Carpal Dislocations. Clinical Orthopaedics and Related Research, 149: 33-44. 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: 4: 460.463. KAUER, J. M. G. (1980). Functional Anatomy of the Wrist. Clinical Orthopaedics and Related Research, 149: 9-20. KING, R. J. and MacKENNEY, R. P. (1981). A method for the closed treatment of fractures of the carpal scaphoid. The Journal of Bone and Joint Surgery, 63B: 4: 633-634. KING, R. J. MacKENNEY, R. P. and SALAH-ELNUR. (1982). Suggested method for closed treatment of the carpal scaphoid: hypothesis supported by dissection and clinical practice. Journal of the Royal Society of Medicine, 75: 860-867.
56
cast four
weeks
later.
KING, R. J. (1983). Scapholunate diastasis associated with a Barton fracture treated by manipulation, or Terry-Thomas and the wine waiter. Journal of the Royal Society of Medicine, 76: 421.423. LEWIS, 0. .I., HAMSHERE, R. J. andBUCKNILL, T. M. (1970). Theanatomy of the wrist joint. Journal of Anatomy, 106: 3: 539-552. LINSCHEID, R. L., DOBYNS, J. H., BEABOUT, J. W. and BRYAN, R. S. (1972). Traumatic instability of the wrist: Diagnosis, classification and pathomechanics. Journal of Bone and Joint Surgery, 54A: 1612.1632. MANGLER, K. H. and STRAUCH, W. (1970). Eine dorsale subluxation des OS lunatum. Beitrage zur Orthopaedic, 17: 316-321 MAYFIELD, J. K., JOHNSON, R. P. and KILCOYNE, R. F. (1976). The Ligaments of the Human Wrist and Their Functional Significance. Anatomical Record, 186: 417-428. MAYFIELD, J. K., JOHNSON, R. P. and KILCOYNE, R. K. (1980). Carpal dislocation: Pathomechanics and progressive per&mar instability. The Journal of Hand Surgery, 5: 3: 226-241. 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. PANTING, A. L., LAMB, D. W. NOBLE, J. and HAW, C. S. (1984). Dislocations of the Lunate With and Without Fracture of the Scaphoid. The Journal of Bone and Joint Surgery, 66B: 3: 391.395. RAWLINGS. I. D. (1981). The management of dislocations of the caroal lunate. Injury, i2: 4: 3i9-33b. SPAR, I. (1978). Bilateral Per&mate Dislocations: Case Report and with Review of Literature and Anatomic Study. The Journal of Trauma, 18: 1: 64-65. TALEISNIK, J., MALEVICH, M. and PRIETTO, M. (1982). Palmar carpal instability secondary to dislocation of scaphoid and lunate: Report of a case review of the literature. Journal of Hand Surgery, 7: 6: 606-612. TANZ, S. S. (1968). Rotation Effect in Lunar and Perilunar Dislocations. Clinical Orthopaedics and Related Research, 57: 147-52. WATSON, H. K., GOODMAN, M. L. and JOHNSON, T. R. (1981). Limited Wrist Arthrodesis. Part II: Intercarpal and radiocarpal combinations. Journal of Hand Surgery, 6A: 223-233.
THE
JOURNAL
OF HAND
SURGERY
Falls on the outstretched hand produce injuries to the wrist and carpus which vary with the severity of the applied force, its direction and the age of the patient. This paper describes such an injury in which the radius suffered an unusual fracture which nevertheless healed with conventional treatment, but later another and rarer injury was revealed. Case Report
In June 1983, a sixty-eight-year-old right-handed man presented to the Accident department of St George’s Hospital after falling ten feet from a ladder onto his outstretched left hand. In view of the force involved, a perilunar dislocation was initially suspected. Radiographs, however, showed a vertical, undisplaced fracture of the ulnar aspect of the distal radius with associated avulsion fractures of the posterior lip (Figure 1). The scapho-lunate distance was normal. A plaster of Paris back-slab was applied and later completed. This was removed four weeks later and radiographs taken. There was extreme carpal instability, with wide scapho-lunate diastasis and dorsal displacement and volar flexion of the lunate (Figure 2). The wrist was swollen, painful and tender and the patient was referred to the Fracture Clinic. On examination there was marked weakness of grip, palmar wrist flexion was 30” and dorsiflexion 10”; both were accompanied by pain. In view of the patient’s age, and the fact that the injury was now four weeks old and affected his non-dominant hand, he was given a removable wrist splint and advised to mobilise the wrist as much as possible. Six weeks later he attended for review. He had only infrequent pain and the total range of dorsal and palmar flexion had increased to 60”. He was advised to discard the splint. Radiographs showed no significant change, from the last ones. Eighteen weeks after the injury there was only minimal discomfort on forced ulnar deviation. Total flexion was 100” and pain-free. He was discharged. Received for publication 26 March; 1986. lvan W. Brown F.R.C.S., Orthopaedic Registrar, Western Road, Gloucester GLI 3NN.
54
Gloucestershire
Royal Hospital,
Great
Discussion
Lewis et al. (1970), in a paper mainly concerned with the descriptive and comparative anatomy of the radiocarpal ligaments and the triangular fibro-cartilage, also describe the dorsal rotation of the lunate which occurs by tightening of the palmar radio-capitate ligament during wrist dorsiflexion. Mayfield et al. (1976) decribed the vital importance of the carpal ligaments in preserving carpal integrity and stability. They induced experimental fractures and dislocations following division of the dorsal radio-carpal ligament. Study of the descriptions of ligamentous anatomy suggests that in this patient’s wrist there was disruption of the volar radio-lunate-scaphoid ligament and dorsal radio-scapho-lunate ligament as the result of the vertical and marginal fractures of the radius. There was almost certainly disruption of the scapho-lunate interosseous and radio-scaphoid ligaments allowing the scaphoid to rotate in a volar direction as did the lunate. Together with scapho-lunate diastasis, the volar rotation permitted intrusion of the capitate into the proximal carpal row (Figure 2). There are many reviews of the treatment of lunate subluxations and dislocations alone, and in association with other injuries. Campbell et al. (1965) were the first to suggest open reduction when conservative methods failed. This view was supported by Morawa et al. (1976), Spar (1978), Green and O’Brien (1978, 1980), Adkinson and Chapman (1982) and Panting et al. (1984) maintained this emphasis and in a large series with prolonged follow-up showed the undesirable sequelae of perilunar instability and subsequent degenerative changes if primary treatment was inadequate. However, Mayfield et al. (1980) obtained equivalent results with closed treatment only. Authorities have divided over the ideal treatment for those related late problems since they were catalogued by Brolin (1964), Mayfield et al. (1980) and Taleisnik et al. (1982), between advocates of silastic replacement, such THE JOURNAL
OF HAND
SURGERY
VOLAR
Fig.
1
P.A.
and lateral
radiographs
of the wrist
INTERCALARY
CARPAL
INSTABILITY
on the day of injury.
as Barber and Goodfellow (1974) and Eiken and Holmqvist (1977), and excision of the proximal row of the carpus (Inglis and Jones, 1977). Limited arthrodeses have found favour (Watson et al. 1986).
presumption of a Colles’ fracture. Mangler and Strauch (1980) decribed an analogous case in German in which a similar sequence of events occurred, but which they interpreted as dorsal subluxation of the lunate alone.
It was not felt that such procedures were justified in this patient, nor, in view of the time that had elapsed since injury that open reduction and internal fixation was likely to succeed. Indeed, almost all authorities suggest that late open reduction produces marked stiffness and poor carpal function. Tendon grafting as described by Linscheid et al. (1972) was not considered appropriate for this patient.
Conclusion
Rawlings (1981) studied thirty cases of volar dislocation of the lunate and drew attention to the scapho-lunate gap as a predictor of lunate instability and potential displacement. King (1983) and King et al. (1981, 1982) also stressed this important measure of carpal injury whose increase is clearly due to rupture of the scapholunate interosseous ligament. Tanz (1968), Berger et al. (1982) and Taleisnik et al. (1982) have illustrated the rotating movements of individual carpal bones. Drawing on the work of Kauer (1980), Taleisnik et al. (1982) have suggested that the lunate displaces dorsally when the wrist is pronated in ulnar deviation. It is suggested that this mechanism, together with rupture of the individual ligaments whose bony attachments were injured by the distal radial fractures was responsible in this case for the volar intercalary carpal instability produced since the wrist was immobilised in just this position, on the VOL.
12-B No. 1 FEBRUARY
1987
A patient is presented who sustained a moderately severe injury to the wrist resulting in an unusual wrist fracture disturbing the origins of important carpal ligaments. The fracture was erroneously interpreted as a Colles’ fracture and plaster applied. On removing the plaster, a complex injury with volar intercalary carpal instability was revealed. This was managed conservatively with an acceptable early result. It is suggested that the mechanism of production of this injury was rupture of the radial attachments of the volar radio-lunate-scaphoid and dorsal scapho-lunate ligaments, together with disruption of the scapho-lunate interosseous ligaments. This produced rotatory instability of the lunate and scaphoid which was increased by the volar flexion and ulnar deviation produced by the plaster of Paris. The absence of scapholunate diastasis on the initial radiograph does not preclude it and seems to reinforce the view of Fisk (1970) that stress views may yield vital clues as to carpal stability or otherwise. Acknowledgment 1 am most grateful report this case.
to Mr Bendall, whose patient
this was, for encouraging
me to
55
I. W. BROWN
Fig. 2
P.A.
and lateral
radiographs
of the wrist
after
removal
of the plaster
References ADKINSON, J. W. and CHAPMAN, M. W. (1982). Treatment of Acute Lunate and Perilunate Dislocations. Clinical Orthopaedics and Related Research, 164: 199.207. BARBER, H. M. and GOODFELLOW, J. W. (1974). Acrylic Lunate Prosthesis. A Long-term Follow-up. The Journal of Bone and Joint Surgery, 568: 4: 706-7 Il. BERGER, R. A., CROWNINSHIELD, R. D. and FLATT, A. E. (1982). The Three dimensional Rotational Behaviours of the Carpal Bones. Clinical Orthopaedics and Related Research, 167: 303-310. BROLIN, I. (1964). Post-Traumatic Lesions of the Lunate Bone. Acta Orthopaedica Scandinavica, 34: 167-182. CAMPBELL, R. D., THOMPSON, T. C., LANCE, E. M. and ALDER, J. B. (1965). Indications for Open Reduction of Lunate and Perilunate Dislocations of the Carpal Bones. The Journal of Bone and Joint Surgery, 47A: 5: 915.937. EIKEN, 0. and HOLMQVIST, K-G. (1977). Replacement of Carpal Bones with Exact-Fitting Silicone Rubber Implants. An Experimental Study. Scandinavian Journal of Plastic and Reconstuctive Surgery, 11: 189.193. FISK, G. R. (1970). Carpal Instability and the Fractured Scaphoid. Annals of the Royal College of Surgeons of England, 46: 2: 63-76. GREEN, D. P. and O’BRIEN, E. T. (1978). Open reduction of carpal dislo cations. Indications and operative techniques. The Journal of Hand Surgery, 3: 3: 250-265. GREEN, D. P. and O’BRIEN, E. T. (1980). Classification and Management of Carpal Dislocations. Clinical Orthopaedics and Related Research, 149: 33-44. 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: 4: 460.463. KAUER, J. M. G. (1980). Functional Anatomy of the Wrist. Clinical Orthopaedics and Related Research, 149: 9-20. KING, R. J. and MacKENNEY, R. P. (1981). A method for the closed treatment of fractures of the carpal scaphoid. The Journal of Bone and Joint Surgery, 63B: 4: 633-634. KING, R. J. MacKENNEY, R. P. and SALAH-ELNUR. (1982). Suggested method for closed treatment of the carpal scaphoid: hypothesis supported by dissection and clinical practice. Journal of the Royal Society of Medicine, 75: 860-867.
56
cast four
weeks
later.
KING, R. J. (1983). Scapholunate diastasis associated with a Barton fracture treated by manipulation, or Terry-Thomas and the wine waiter. Journal of the Royal Society of Medicine, 76: 421.423. LEWIS, 0. .I., HAMSHERE, R. J. andBUCKNILL, T. M. (1970). Theanatomy of the wrist joint. Journal of Anatomy, 106: 3: 539-552. LINSCHEID, R. L., DOBYNS, J. H., BEABOUT, J. W. and BRYAN, R. S. (1972). Traumatic instability of the wrist: Diagnosis, classification and pathomechanics. Journal of Bone and Joint Surgery, 54A: 1612.1632. MANGLER, K. H. and STRAUCH, W. (1970). Eine dorsale subluxation des OS lunatum. Beitrage zur Orthopaedic, 17: 316-321 MAYFIELD, J. K., JOHNSON, R. P. and KILCOYNE, R. F. (1976). The Ligaments of the Human Wrist and Their Functional Significance. Anatomical Record, 186: 417-428. MAYFIELD, J. K., JOHNSON, R. P. and KILCOYNE, R. K. (1980). Carpal dislocation: Pathomechanics and progressive per&mar instability. The Journal of Hand Surgery, 5: 3: 226-241. 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. PANTING, A. L., LAMB, D. W. NOBLE, J. and HAW, C. S. (1984). Dislocations of the Lunate With and Without Fracture of the Scaphoid. The Journal of Bone and Joint Surgery, 66B: 3: 391.395. RAWLINGS. I. D. (1981). The management of dislocations of the caroal lunate. Injury, i2: 4: 3i9-33b. SPAR, I. (1978). Bilateral Per&mate Dislocations: Case Report and with Review of Literature and Anatomic Study. The Journal of Trauma, 18: 1: 64-65. TALEISNIK, J., MALEVICH, M. and PRIETTO, M. (1982). Palmar carpal instability secondary to dislocation of scaphoid and lunate: Report of a case review of the literature. Journal of Hand Surgery, 7: 6: 606-612. TANZ, S. S. (1968). Rotation Effect in Lunar and Perilunar Dislocations. Clinical Orthopaedics and Related Research, 57: 147-52. WATSON, H. K., GOODMAN, M. L. and JOHNSON, T. R. (1981). Limited Wrist Arthrodesis. Part II: Intercarpal and radiocarpal combinations. Journal of Hand Surgery, 6A: 223-233.
THE
JOURNAL
OF HAND
SURGERY