Late Treatment of a Dorsal Transscaphoid,

Transtriquetral Perilunate Wrist Dislocation With

Avascular Changes of the Lunate
Downloaded from http://journals.lww.com/clinorthop by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/06/2021

HARRIS M.D.,* STEVEN

GELLMAN, J. BOTTE,M.D.,**
M.D.,* MICHAEL
D. SCHWARTZ,
AND LAWRENCEFEIWELL,
M.D.*

The outcome of delayed treatment of an unreduced time limit considered consistent with an ac-
transscaphoid, transtriquetral, perilunate fracture ceptable result has been reported to be six
dislocation of the carpus is unpredictable. Long- week^.^^^.''-" For the patient who presents af-
term follow-up observations in a 22-year-old man
treated three months postinjury showed changes in ter six weeks, alternative procedures such as
the b a t e consistent with avascular necrosis at the proximal row carpectomy or selective inter-
time of open reduction and internal fixation. Early carpal or radiocarpal arthrodeses have been
resolution of this was evident by nine months, and recommended.2,4,5.I I , 14-1 6 There have been
complete resolution was seen at the follow-up ex- few reports in the literature concerning the
amination (four years and two months). Despite
delay in treatment, this patient had full, pain-free management of the patient who presents af-
wrist motion. Consequently, avascular changes of ter six weeks with an unreduced fracture dis-
the carpus following wrist dislocation do not pre- location of the ~ a r p u s . ~' *-I 7~ *In' addition,
clude a good result. Anatomic reduction of the when roentgenographic changes suggestiveof
scaphoid, as well as the midcarpal joint, and resto- avascular necrosis of carpal bones develop,
ration of the articular surface of the lunate, are
most important in determining prognosis. optimal management becomes more com-
plex and the prognosis less predi~table.~,'
Fracture dislocations of the carpus repre- This report presents the results of treat-
sent complex and challenging injuries. Con- ment of a dorsal transscaphoid, transtrique-
troversy continues to exist regarding treat- tral, perilunate fracture dislocation of the car-
ment protocols. Most authors agree that early pus three months postinjury. Roentgeno-
open reduction and internal fixation are nec- graphic changes consistent with avascularity
essary to obtain optimum result^.^^^-^^' '-I4 of the lunate as well as symptoms of chronic
There are no large series, however, that report median nerve compressive neuropathy were
the results of delayed treatment. The upper present at the time of treatment.

CASE REPORT
* From the Department of Orthopaedic Surgery, Uni- A 22-year-old right-hand-dominant male la-
versity of Southern California. borer was involved in a motorcycle accident on
** From the Division oforthopaedic Surgery, Univer- November 14, 1982. He was hospitalized for one
sity of California, San Diego.
Reprint requests to Hams Gellman, M.D., Depart- month following the accident because of a sub-
ment of Orthopaedic Surgery, University of Southern dural hemorrhage. Shortly after discharge on De-
California, 2300 S. Flower Street, Suite 200, Los Angeles, cember 14th he reported experiencing progressive
CA 90007. left wrist pain and weakness of grip. He was first
Received: June 29, 1987. seen in the orthopedic hand clinic on December

196
Number 237
December. 1988 Late Treatment of Carpal Dislocation 197

FIGS.1 A AND 1B. Wrist of a 22-year-old man

with a transscaphoid perilunate fracture-dislo-
cation. (A) Anteropostenor (AP) roentgeno-
gram taken one month after injury. (B) Lateral
roentgenogram taken at the same time (ar-
row-proximal pole of scaphoid).

20th. The patient could not recall injury to his crease. There was moderate thenar atrophy, im-
wrist during the accident. A physical examination paired sensation in the median nerve distribution,
revealed tenderness ofthe left wrist with a palpable and a positive percussion (Tinel’s) sign over the
palmar mass proximal to the distal wrist-flexion median nerve. Pulses were intact. Range of mo-

FIGS.2A AND 2B. (A) AP and (B) lateral roentgenograms taken three months after injury. Avascular
changes in the lunate are evident. Note increased density of the lunate when compared to the surrounding
carpal bones (arrow).
 Ciinicai Orthopaedi
198 Gellman et al. and Related Research

FIGS.3A AND 3B. (A) AP and (B) lateral roentgenograms taken during surgery after reduction.

tion was 10' of dorsiflexion and 30" of palmar then utilized. After release of the transverse carpal
flexion. Roentgenograms demonstrated an unre- ligament, contusion of the median nerve caused
duced transscaphoid, perilunate fracture disloca- by the palmarly dislocated h a t e was noted at the
tion of the left wrist with an avulsion fracture of proximal edge of the carpal canal. After gently re-
the radial inferior pole of the triquetrum (Figs. 1A tracting the median nerve, the lunate was visible
and 1B). He was scheduled for surgery the follow- with the capitate fossa facing palmarward. The ar-
ing day but failed to return until February 16,1983 ticular surface of the lunate was found to be intact
(three months postinjury). His physical examina- and smooth. Scar tissue which had formed about
tion was unchanged. Roentgenograms again dem- the lunate was excised. The h a t e was then easily
onstrated an unreduced, transscaphoid, perilunate reduced. At reduction, the palmar soft-tissue cap-
fracture dislocation with the additional finding of sular attachments to the volar pole of the lunate
roentgenographic changes of the h a t e consistent were intact, and there was no evidence of an osteo-
with avascular necrosis as well as a marked os- chondral fracture along the articular surface of the
teopenia of the surrounding carpal bones (Figs. 2A lunate. The scaphoid fracture was reduced and in-
and 2B). ternally fixed with two 0.045-inch Kirschner wires.
Surgery was performed February 17 through The scaphoid and h a t e were then reduced and
a combined volar and dorsal approach. When immobilized with 0.045-inch smooth pins placed
viewed through the dorsal incision, abundant scar across the scapholunate and scaphocapitate joints.
tissue was present in the radiocarpal joint with mi- After reduction, the wrist was stable to palmar
gration of the capitate proximally into the articu- flexion and dorsiflexion. Intraoperative radio-
lar surface of the radius. The scar tissue was ex- graphs confirmed anatomic reduction of the
cised from the joint, and the palmar approach was scaphoid fracture (Figs. 3A and 3B).
Number 237
December. 1988 Late Treatment of Carpal Dislocation 199

FIGS.4A AND 4B. (A) AP and (B) lateral roentgenograms taken five months after injury and two months
after reduction showing evidence that avascular necrosis of the h a t e remains.

Postoperatively the patient was immobilized in 5A and 5B). The patient was experiencing no pain
a long-arm thumb spica cast for eight weeks. The at that time and had returned to work as a cook's
cast and pins were removed on April 12, and occu- helper. At nine months postinjury, range of mo-
pational therapy was started. At pin removal, tion was dorsiflexion 30", palmar flexion 3o", ra-
roentgenograms demonstrated a marked relative dial deviation lo", and ulnar deviation 20", with
increased radiodensity of the lunate. The scaphoid full pronation and supination. Sensibility testing
and triquetral fractures had healed by this time remained normal. The roentgenographic changes
(Figs. 4A and 4B). At seven months postinjury, in the lunate appeared to be resolving (Figs. 6A
range of motion of the left wrist was 20" dorsiflex- and 6B).
ion, lo" palmar flexion, lo" radial deviation, and The patient was lost to follow-up evaluation un-
20" ulnar deviation. Full pronation and supination til January 1987 (four years and two months post-
and full active flexion and extension of all digits injury). He continues to work as a cook's helper
(including thumb opposition) were present. Two- and remains pain free. Range of motion was dorsi-
point discrimination was normal (n s 6 mm in flexion, 65'/35" (right and left wrists, respectively);
all digits). Roentgenographic changes ofthe lunate palmar flexion, 70"/65"; ulnar deviation, 40'/35";
persisted. The scaphoid fracture had healed (Figs. and radial deviation, 25"/2o". Grip strength was
 ClinicalOrthopaedics
200 Gellman et al. and Related Research

FIGS.5A AND 5B. (A) AP and (B) lateral roentgenograms taken seven months after injury and four
months after reduction showing that the scaphoid fracture has healed (arrow),but that avascular changes
of the lunate persist.

1 15 pounds on the right and 90 pounds on the left. further complicated management. Although
Follow-up roentgenograms showed resolution of the proximal pole of the scaphoid presum-
the roentgenographic changes of the lunate and ably is rendered more devoid of vascularity
maintenance of the scapholunate articulation
(Figs. 7A and 7B). than the lunate, the scaphoid fracture healed
without the development of avascular necro-
DISCUSSION sis despite the three-month delay in treat-
ment. This case illustrates that avascular
Delayed treatment of an unreduced trans- changes of the lunate developing after wrist
scaphoid, transtriquetral, perilunate fracture dislocation may be transient. Some mention
dislocation of the carpus is difficult. In large has been made in the literature regarding
series, up to 25% of perilunar dislocations are avascular changes in the lunate and their res-
originally missed for up to six weeks. In this olution after wrist dislocation. However, the
case, the additional problem of roentgeno- vast majority of authors have stated that evi-
graphic changes of the lunate consistent with dence of avascularity of the lunate precludes
avascularity and median nerve compression a good result, although there have been al-
Number 237
December. 1988 Late Treatment of Carpal Dislocation 201

FIGS.6A AND 6B. (A) AP and (B) lateral roentgenograms taken nine months after injury and six months
after reduction showing that avascular changes of the lunate have resolved (arrow).

most no documented reported cases of true at the time of initial dislocation and the pal-
fragmentation of the lunate occurring after mar ligament was stretched and impinged
perilunar dislo~ation.',~~~*'~~'~~'~
White and upon by the postinjury configuration of the
Omer" reported that three of 24 wrist dislo- proximal carpus. Therefore, perhaps the vas-
cations developed evidence of transient avas- cularity within the ligament may have been
cular compromise of the lunate in similar in- compromised by torquing of the palmar liga-
juries and suggested that patients with this ment leading to the avascular changes.'0314
finding be treated expectantly rather than ag- Possibly, anatomic reduction of the carpus
gressively. relieved the impingement of the vascular sup-
The complete resolution of the roentgeno- ply to the lunate. Although Figure 7A shows
graphic changes of the lunate in this case sug- a slight increase in the scapholunate distance
gests the prolonged absence of anatomic re- and Figure 7B shows an apparent increase in
duction as a possible mechanism for these the scapholunate angle, the patient had a
changes. The vascular supply to the lunate pain-free functional range of motion of the
courses through the palmar and dorsal carpal involved wrist.
ligaments. The dorsal ligament was disrupted When the median nerve was examined af-
 Clinical Orvlopaedii
202 Gellman et at. and Related Research

FIGS.7A AND 7B. (A) AP and (B) lateral roentgeno-

grams taken at the final follow-up examination 50
months after injury.

ter release of the transverse carpal ligament, months postinjury remain a viable primary
an area of contusion of the nerve was found treatment alternative despite roentgeno-
where the nerve passed over the volarly dis- graphic evidence of avascular changes of the
placed lunate. Although the patient had ab- lunate if a satisfactory reduction of the scaph-
normal sensibility in the median nerve distri- oid and midcarpal joint is obtained. If evi-
bution as a result of the chronic compression, dence of articular damage to the lunate,
sensibility had returned to normal by seven scaphoid, or distal radius is present, consider-
months postinjury. The good result obtained ation should be given to other treatment al-
in this case raises questions about the upper ternatives such as a limited radiocarpal ar-
time limit of delayed treatment of these inju- throdesis or proximal row carpectomy.
ries. In the past it was thought that late treat-
ment precluded the possibility of good re-
sults, probably because of damage to the ar- REFERENCES
ticular surfaces of the carpal bones. The
I . Aitken, A. P., and Nalebuff, E. A.: Volar transnavic-
recovery seen in this patient suggests that ular perilunar dislocation of the carpus. J. Bone
‘‘late’’ reduction and internal fixation at three Joint Surg. 42A: 105 1, 1960.
Number 237
December. 1988 Late Treatment of Carpal Dislocation 203

2. Beckenbaugh, R. D., Shives, T. C., Dobyns, J. H., pal bones and dislocation of the lunate bone. Surg.
and Linscheid, R. L.: Kienbock’s Disease. The natu- Gynecol. Obstet. 79:256, 1944.
ral history of Kienbock‘s disease and consideration 10. Marek, F. M.: Avascular necrosis of the carpal lu-
of h a t e fractures. Clin. Orthop. 149:98, 1980. nate. Clin. Orthop. 10:96, 1957.
3. Campbell, R. D., Jr., Lance, E. M., and Yeom, 1I . Morawa, L. G., Ross, P. M., andSchock, C. C.: Frac-
C. B.: Lunate and perilunar dislocations. J. Bone tures and dislocations involving the navicular-hate
Joint Surg. 46B:55, 1964. axis. Clin. Orthop. 118:48, 1976.
4. Campbell, R. D., Thompson, T. C., Lance, E. M., 12. OBrien, E. T.: Acute fractures and dislocations of
and Adler, J. B.: Indications for open reduction of the carpus. Orthop. Clin. North Am. I5:237, 1984.
h a t e and perilunate dislocations of the carpal 13. Rawlings, I. D.: The management of dislocations of
bone. J. Bone Joint Surg. 47:915, 1965. thecarpallunate. Injury 12:319, 1981.
5. Cave, E. F.: Fractures and Other Injuries. Chicago, 14. Russell, T. B.: Inter-carpal dislocations and fracture
Year Book Medical Publishers, 1958, p. 338. dislocations: A review of fifty-nine cases. J. Bone
6. Coll, G. A.: Palmar dislocation of the scaphoid and Joint Surg. 31B:524, 1949.
lunate. J. Hand Surg. 12A:476, 1987. 15. Taleisnik, J.: The Wrist. New York, Churchill Liv-
7. Green, D. P., and O’Brien, E. T.: Open reduction of ingstone, 1985, pp. 209-210.
carpal dislocations: Indications and operative tech- 16. Wagner, C. J.: Perilunar dislocations. J. Bone Joint
niques. J. Hand Surg. 3:250, 1978. Surg. 38A:1198, 1956.
8. Green, D. P., and OBrien, E. T.: Classification and 17. White, R. E., Jr., and Omer, G . E., Jr.: Transient
management of carpal dislocations. Clin. Orthop. vascular compromise of the lunate after fracture-dis-
149:55, 1980. location or dislocation of the carpus. J. Hand Surg.
9. MacAusland, W. R.: Perilunar dislocation ofthe car- 9A:181, 1984.