Fracture-Dislocations of the Wrist

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The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires.

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Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment.

If the capitate is centered over the radius and the lunate is tilted out, it is a lunate dislocation. If however the lunate centers over the distal radius and the capitate is dorsal, we are dealing with a perilunate dislocation figure. The scaphoid shape changes with movement of the wrist. In ulnar deviation or extension the scaphoid elongates to fill the space between the radial styloid and the base of the thumb the trapezium. Both with radial deviation aswell as flexion of the wrist the space between the radial styloid and trapezium is reduced.

As scaphoid fills this space it will foreshorten and tilt towards the palm. This will give scaphoid a signet ring appearance figure.

Drawing the longitudinal axes of some of the carpal bones on a lateral radiograph and measuring the angles between them is a good method of determining the wrist bones? The three most important axes are those through the scaphoid, the lunate and the capitate, drawn on the lateral radiograph. The true axis of the scaphoid is the line through the midpoints of its proximal and distal poles. Since the midpoint of the proximal pole is often difficult to appreciate, an almost parallel line can be used that is traced along the most ventral points of the proximal and distal poles of the bone figure.

The axis of the lunate runs through the midpoints of the convex proximal and concave distal joint surfaces and can best be drawn by finding the perpendicular to a line joining the distal palmar and dorsal borders of the bone as demonstrated on the left. Scapholunate angle Normal: 30 - 60? Questionably abnormal: 60 - 80? This indicates instability of the wrist.

The capitate axis joins the midportion of the proximal convexity of the third metacarpal and that of the proximal surface of the capitate. DISI is short for dorsal intercalated segmental instability. The intercalated segment is the proximal carpal row identified by the lunate. The term 'intercalated segment' refers to it being the part in between the proximal segment of the wrist consisting of the radius and the ulna and the distal segment, represented by the distal carpal row and the metacarpals.

So all this means is that in DISI or dorsiflexion instability the lunate is angulated dorsally. If you think lunate is tilted, measure the scapholunate angle ?

Peri-lunate dislocation and fracture-dislocation of the wrist: Retrospective evaluation of 65 cases

As mentioned before this angle is considered abnormal if greater then 80 degrees. Volar intercalated segmental instability or palmar flexion instability is when the lunate is tilted palmarly too much. In the next cases we advise you to first look at the images on the left and give a full description of the radiographs. Look for symmetry, parallelism, and the shape and axis of the carpal bones.

Find out if there are any fractures and then try to make the diagnosis Then read the text on the right to see if you're right. Case 1 Systematic interpretation of the case on the left shows us the following: 1. On the PA-view all the carpal bones parallel each other except for the lunate. Triangular shaped lunate So by just looking at the PA view we can make the diagnosis of lunate dislocation. Case 2 Analysis: 1. No parallelism at the TL joint since there is overlapping of the triquetrum and the lunate.

Also overlapping of the hamate and the lunate. There is parallelism between radius, lunate, proximal pole of scaphoid and proximal pole of capitate. So these bones form a unit. Also parallelism between triquetrum, hamate, distal pole of capitate, trapezium and distal pole of scaphoid. Fracture of capitate and scaphoid So these findings indicate that this is a transscaphoid, transcapitate perilunate fracture-dislocation. Case 3 Analysis: 1. Fracture of scaphoid and ulnar styloid process.

Some parallelism between lunate and proximal pole of scaphoid with the radius. Scaphoid is foreshortened so it is tilted and has moved towards the palm. All the other carpals show parallelism exept for lunate, the proximal pole of scaphoid and the radius. Although this probably is a perilunate dislocation, based on the PA-view alone it is very difficult to say if this is a lunate or perilunate dislocation. The triangular shape of the lunate could be the result of just tilting or dislocation with tilting.

Perilunate Dislocation and Fractures of the Lunate

Same case with the lateral view also shown. Now we see that there definitely is a perilunate dislocation. So the triangular shape of the lunate is the result of just tilting. On the lateral view a fracture of the volar tip of lunate is seen. So this patient is at risk for recurrent dislocation.

Carpal arcs are normal and there is normal paralelism. The scaphoid is elongated which means it is dorsally tilted. On the lateral view we can see that the lunate is also tilted dorsally. The proximal carpal row has moved as a unit, so there is no dissociation. Principles of hand surgery and treatment. Philadelphia: Saunders; Radiology of trauma to the wrist: dislocations, fracture dislocations, and instability patterns. Skelet Radiol.

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Mayfield JK. Mechanism of carpal injuries. Clin Orthop Relat Res. Carpal dislocations: pathomechanics and progressive perilunar instability. Trans-triquetral dorsal perilunate fracture dislocation. J Hand Surg Eur. Instabilidade do carpo. Rev Bras Reumatol. Traumatic axial dislocations of the carpus. Translunate fracture with associated perilunate injury: 3 case reports with introduction of the translunate arc concept.

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