|Year : 2013 | Volume
| Issue : 2 | Page : 111-113
Compound transstyloid, transscaphoid, perilunate fracture dislocation
Nadeem Ali1, Suhail Ahmad Bhat1, Avijit Mahajan2, Abedullah Bhat1
1 Department of Orthopedics, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Orthopedics, Sir Ganga Ram Hospital, New Delhi, India
|Date of Web Publication||23-Jul-2013|
Room No. 219B, PG Boys Hostel, Government Medical College, Bakshi Nagar, Jammu - 180 001, Jammu and Kashmir
Source of Support: Support in the form of drugs, equipment was
provided by the hospital itself., Conflict of Interest: None
Compound fracture dislocations of proximal carpal bones are very rare. We report a 26-year-old male, Defense personnel by profession, who sustained a compound Gustilo Anderson type IIIA transstyloid, transscaphoid, perilunate dislocation. The patient underwent primary proximal row carpectomy and stabilization with uni-planar, uni-lateral external fixator, and K-Wires. On follow-up after a year, the patient had almost negligible range of motion around wrist without any significant discomfort.
Keywords: Compound fracture dislocation, primary proximal row carpectomy, transstyloid transscaphoid perilunate dislocation
|How to cite this article:|
Ali N, Bhat SA, Mahajan A, Bhat A. Compound transstyloid, transscaphoid, perilunate fracture dislocation. J Sci Soc 2013;40:111-3
| Introduction|| |
Among all wrist dislocations, the perilunate is the most common. Most patients are usually young males as the bone stock of the distal radius and the scaphoid needs to be strong enough to resist the amount of torque that is involved in these dislocations. Perilunate dislocations are characterized by a disruption of most capsular and ligamentous connections of the lunate to the adjacent carpal bones and radius. Ligament disruption may be associated with different carpal fractures around the lunate. 
Most perilunate fracture-dislocations combine ligament ruptures, bone avulsions, and various types of fractures, the most common being the transscaphoid perilunate fracture dislocation. 
Primary proximal row carpectomy is useful in treating severe open carpal fracture-dislocations characterized by significant disruption of the bony architecture, comminuted fractures of the scaphoid and lunate, and disruption of the blood supply to the lunate and scaphoid.
| Case Report|| |
A 26-year-old male, defense personnel (constable) by profession had a road traffic accident and presented in Emergency Department of our hospital within half an hour after injury. On examination, patient had a grossly swollen, deformed and tender right wrist, along with swelling in forearm on the ipsilateral side. Patient had a lacerated wound of about 5 × 3 cm on the volar aspect of the wrist. Proximal carpal bones were visible with multiple fragments. Neurovascular examination distal to injury was normal. Anteroposterior and lateral radiographs of the wrist [Figure 1] showed fracture of triquetrum and radial styloid process along with dislocation of scaphoid and lunate into the forearm and, hence, a diagnosis of transstyloid, transscaphoid, perilunate dislocation was made. The wound was thoroughly irrigated with normal saline and was debrided. Forearm was immobilized in a splint and a trial was given for closed reduction under axillary block but with unsuccessful results. Primary proximal row carpectomy was planned.
|Figure 1: Preoperative anteroposterior and lateral radiographs showing transstyloid, transscaphoid, perilunate dislocation. Arrow showing dislocated scaphoid and lunate in the volar aspect of distal forearm|
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The patient underwent primary proximal row carpectomy and stabilization of wrist by uniplanar-unilateral external fixator coupled with two K-wires through volar approach to wrist. Curved skin incision was made along the medial side of the thenar crease starting at the junction of distal two-third and proximal one-third of the palm and extended proximally over flexion crease of the wrist to join it with the preexisting wound in the forearm. To avoid problems in skin healing, incision was avoided into the thenar crease itself. Scaphoid and lunate bones were retrieved from forearm about 5 cm proximal to distal end of radius between and deep to tendons of flexor carpi radialis and flexor digitorum profundus.
Multiple small bony fragments were retrieved along the distal aspect of the incision. The remaining comminuted parts of scaphoid, lunate, and triquetral bones were removed and external fixator was applied by putting two 2.5 mm Schanz pins in second metacarpal and two 3.5 mm Schanz pins in distal radius with ligamentotaxis. Two additional 1.8 mm K-wires were inserted, one through radius and trapezoid and another one through ulna engaging capitate [Figure 2]. The volar capsule was repaired meticulously; subcutaneous tissue and skin were approximated. The external fixator was left in place for 2 weeks to allow daily wound inspection and stitches were removed after 2 weeks. A short arm cast was applied and K-wires were removed at 6 weeks. Physiotherapy was started after K-wire removal. There after patient was followed every 4 weeks up to 6 months for clinical and or radiological evaluation [Figure 3]. At 1 year follow-up, patient had almost negligible range of motion but adequate grip to carry out his routine without any wrist pain or any other complication [Figure 4].
|Figure 2: Postoperative anteroposterior and lateral radiographs showing primary proximal row carpectomy and stabilization with external fixator and two K-Wires|
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|Figure 3: At 6 months of follow-up, anteroposterior and lateral radiographs of the wrist|
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|Figure 4: Clinical photographs showing scar on volar aspect and negligible range of motion of right wrist with normal grip strength at 1 year follow-up|
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| Discussion|| |
The diagnosis of fractures and dislocations of the carpal bones can be difficult for several reasons. The outlines of the eight bones are superimposed in most radiographic views. Even in the anteroposterior view, at least one bone overlies another. All views must be interpreted with an understanding of the normal bone contours, the relationships between the bones, and the changing relationships during the various arcs of wrist motion. Because of the difficulty in recognizing fractures in acute injuries, fractures in this region may not be seen at initial examination. Articular damage and ligamental injuries are even more difficult to evaluate. 
Proximal row carpectomy is used as a reconstructive procedure for posttraumatic degenerative conditions in the wrist, especially conditions involving the scaphoid and lunate.  Reports by Stamm, Crabbe, Inglis and Jones, Jorgensen, Neviaser, Green, and Calandruccio support its use as an alternative to arthrodesis. ,,,,, Reports by Cohen and Kozin and Krakauer et al., comparing proximal row carpectomy with limited intercarpal fusion confirmed that satisfactory relief of pain and preservation of motion and strength can be achieved.  It is considered to be a satisfactory procedure in patients who have limited requirements, desire some wrist mobility, and accept the possibility of minimal persistent pain. If, however, proximal row carpectomy fails to meet the patient's needs, arthrodesis remains an option. 
Primary proximal row carpectomy can be useful in treating severe open carpal fracture-dislocations characterized by significant disruption of the bony architecture, comminuted fractures of the scaphoid and lunate, and disruption of the blood supply to the lunate and scaphoid.  Excision of the triquetrum, lunate, and entire scaphoid usually is recommended.  Excision of the pisiform is unnecessary because of its location in the flexor carpi ulnaris tendon as a sesamoid. The bones usually are removed piecemeal; threaded Kirschner wires or screws used as "joysticks" or handles are helpful to lever the bone at the wrist.  Neviaser popularized the technique of proximal row carpectomy through dorsal approach besides other techniques.  In our case, the patient already had lacerated wound on volar side of forearm, thus we performed proximal row carpectomy through volar approach.
| Conclusion|| |
Primary proximal row carpectomy is a satisfactory procedure for severely comminuted compound fracture dislocation and disrupted blood supply of multiple carpal bones in the proximal row in patients who do not require fine movements at the wrist to carry out their routine occupational work.
| References|| |
|1.||Gaebler C, McQueen MM. Carpus fractures and dislocations. In: Bucholz RW, editor. 7 th ed. Rockwood and Green's Fractures in Adults. Alphen aan den Rijn: Wolters Kluwer; 2010. p. 781-825. |
|2.||Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilunate fracture-dislocations: Medium-term results. J Hand Surg Br 2002;27:498-502. |
|3.||Phillip E, Wright II. Wrist disorders. In: Canale ST, editor. 11 th ed. Campbell's Operative Orthopaedics. Maryland Heights: Mosby Elsevier; 2008. p. 3999-4091. |
|4.||Stamm TT. Excision of the proximal row of the carpus. J R Soc Med 1944;38:74. |
|5.||Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br 1964;46:708-11. |
|6.||Inglis AE, Jones EC. Proximal row carpectomy for diseases of the proximal row. J Bone Joint Surg Am 1977;59:460-3. |
|7.||Jorgensen EC. Proximal row carpectomy: An end-result study of twenty-two cases. J Bone Joint Surg Am 1969;51:1104-11. |
|8.||Calandruccio JH. Proximal row carpectomy. J Am Soc Surg Hand 2001;1:112. |
|9.||Neviaser RJ. Proximal row carpectomy for posttraumatic disorders of the carpus. J Hand Surg Am 1983;8:301-5. |
|10.||Cohen MS, Kozin SH. Degenerative arthritis of the wrist: Proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. J Hand Surg Am 2001;26:94-104. |
|11.||Green DP. Proximal row carpectomy. Hand Clin 1987;3:163-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]