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Fracture-Dislocation of the .Radiocarpal Joint

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Fracture-Dislocation of the .Radiocarpal Joint Fracture-Dislocationof the .RadiocarpalJoint A CLINICAL STUDY OF FIVE CASES BY Z. JOHN BILOS, M.D.*, ARSEN M. PANKOVICH, M.D.*, AND SHARUKIN YELDA, M.D.*, CHICAGO, ILLINOIS From the Division of Orthopaedic Surgery, Cook County Hospital, and Hektoen Institute for Medical Research, Chicago ABSTRACT:In five patients with fracture-dis- inen in their early twenties, and the left wrist was involved location of a radiocarpal joint, the wrist injury wasse- in each instance. All the injuries were caused by Severe vere and associated with injuries to other systems. Typ- trauma: a motorcycle accident in two cases and a fall from ically there was neurovascular impairmentand closed a height, in three. All five patients had other severe in- reduction was performedas soon as possible to relieve juries. pressure or tension on vessels and nerves. Fracture of Twoother patients were also seen: one, a sixty-fiw~- the radial and ulnar styloid processes, fracture of the year-old womanwith an open volar fracture-dislocation of dorsal rim of the radial articular surface, and a mul- the left wrist caused by an automobile accident, and the titude- of carpal and intercarpal injuries were present other, a thirty-year-old manwith a closed dorsal fracture- in all cases. Early open reduction, internal fixation of dislocation of the right wrist, treated by closed reduction. the fractures, and repair of all torn ligaments appeared Both of these patients were lost to follow-up after thre, e to be the treatment of choice. monthsand are not included in this series. Radiocarpal dislocation is an uncommoninjury. Ac- Case Reports cording to Dobynsand Linscheid, it is often associated CASE1. A twenty-five-year-old right-handed male carpenter fell with fracture of the dorsal rim of the radial articular sur- about 4.6 meters from a scaffold, landing on his left side. Hewas uncon- scious briefly and on admission, one hour later, he complainedof severe face, rupture of the palmar radiocarpal ligament, and frac- pain and numbnessin the left hand and wrist. Examination revealed dor- ture of the radial and ulnar styloid processes. In most soradial displacement of the hand and wrist in relation to the forearm. cases, therefore, it is a fracture-dislocation. BiShler re- The radial pulse was present and the sensation of the hand was normal. ported five cases of radiocarpal dislocation. In two of The patient also had contusions about the left orbit and the left knee. them, the carpus was displaced dorsally; in two, volarly; Roefitgenogramsrevealed dorsoradial dislocation of the carpus, a large, comminuted,displaced fracture 6f the radial styloid process, and multi- and in one there was an open dorso-ulnar dislocation. De- pie smaller fragments from the volar and dorsal rims of the radial articu- stot saw one open dorsoradial dislocation without a frac- lar surface. There was also an undisplaced fracture of the navicular tur6 over an eighteen-year period. Fahey described a case (Figs. 1-A and l-B). Satisfactory reduction of the dislocation arrd radial in whichthe radial styloid process was fractured and dislo- fractures was ’easily accomplished by traction on the hand under local cated volhrly together with the carpus. Weiss and as- anesthesia with 1 per cent Xylocaine (lidocaine). The limb was held for nine weeks in a long cast with the forearm in slight pronation and the sociates recorded an irreducible dorsal dislocation as- ’wrist in slight flexion and ulnar deviation. Numbnessof the fingers re- sociated Withfractures of the radial and ulnar styloid pro- :solved several days after reduction of the dislocation, but recovery was cesses and separation of the distal radio-ulnar joint. Dunn, complicated by dizziness and nausea which were attributed to the head in a review of 112 carpal fracture-dislocations, found six injury. The patient was able to do limited work in six months and re- radiocarpal fracture-dislocations: three dorsal, two volar, turned to regular employmentabout one year after injury. At that tin:re, he still bad pain over the ulnar side of the wrist after heavylabor, but his and one in which all of the carpal bones were crushed and condition continued to improve during the next year and at follow-up two dislocated in various directions. Wagnerreported two dor- years after injury he had only mild, intermittent aching in the wrist, re- sal dislocations of the carpus: one with a fracture of the quiring no medication. Motions of the left wrist were: extension to 55 radial styloid process and the other with no fracture. degrees, flexion to 45 degrees, supination to 65 degrees, pronation to 70 Duringthe last several years we have treated five pa- degrees, radial deviation to 5 degrees, and ulnar deviation to 30 degrees. Grasp of the left hand was 75 per cent of that on the right. Roentgeno- tients with radiocarpal fracture-dislocations, four of them gramsrevealed someresidual irregularity of the distal articular surface followed for from sixteen to twenty-six months. Since few of the radius, but the joint space was still maintained.The fracture of the injuries of this type have been reported in the literature, navicular had healed completely (Figs. I-C and l-D). the findings and results of treatment in these cases were radiecm-~ai1"racture-dislecations were treated in our pri- sti~ioid proce:ssand a displacedfr:.,.:~are ,,.’,t ’~henavicuiar, v,~i :c,.e prox- vate practice and at r.he CookCounty Hospital. Ail were imal fragme~t completely separa~c~ and lying on the dorsai ~’.~rface of the radius. T~:e dislocation was easily reduced in the emer,:ency room FRACTURE-DISLOCATION OF THE RADIOCARPAL JOINT 199 ’olved FIG. I-A FiG.I-B FIG. I-C FIG. I-D ;¢v¢re Figs. 1-A through l-D: Case 1, a twenty-five-year-old male carpenter whofell 4.6 meters from a scaffold, injuring the left wrist. Figs. 1-A and l-B: Roentgenogramsmade on admission, showinga comminutedcompression fracture of the radial styloid process, a fracture of the from dorsal rim of the radial articular surface, an avulsion fracture of the ulnar styloid process, and an undisplaced fracture of the navicular. re in- Figs. 1-C and l-D: Twoyears after injury, there is someirregularity of the distal end of the radius and the fracture of the navicular has healed. roentgenograms revealed that the wrist was still subluxated and the posed through a dorsolateral approach. The carpal and lunate disloca- -five-’- navicular fragments were separated. Four days after admission, the wrist tions were reduced and the radial styloid process was stabilized with a [on of joint was exposed through a dorsolateral incision. The fracture of the cancellous screw and a Kirschner wire. At operation it was apparent that d the navicular was reduced and the two fragments were fixed with a navicular the naviculolunate ligament was ruptured and that the navicular was sub- screw. The radial styloid process was also fixed with a navicular screw .’ture- luxated dorsally. The navicular was reduced and stabilized with two (Figs. 2-C and 2-D). Postoperatively, a long cast was worn for seven ;tion. Kirschner wires: one was inserted into the lunate and the other, into the weeks. The patient regained useful wrist motion and strength quickly capitate (Fig. 3-C). Postoperatively the wrist was immobilizedin a long three and returned to his work as a welder one monthlater. At his last clinic cast for six weeks, and the screw and Kirschner wires were removed visit, fifteen monthsafter injury, he had point tenderness over the screw eight weekslater. heads but no pain in the wrist. The wrist motions were: extension to 45 Thereafter the patient had practically no pain in the wrist, but he degrees, flexion to 55 degrees, supination to 90 degrees, pronation to 65 was unable to find workbecause of his inability to stand for long periods degrees, radial deviation to 12 degrees, and ulnar deviation to 15 de- ~r fell grees. Grip on the left was 10 per cent stronger than on the right, even .ncon- though he was right-handed. The patient, an Olympic boxing-team as- ~evere -i dor- pirant, ascribed this difference to favoring his left hand in boxingand to xveight-lifting prior to the accident. Roentgenogramsat this time showed earm. the fracture of the radial styloid to be healed in good position, and there final. was partial resorption of the proximal fragment of the navicular (Figs. knee. 2-E and 2-F). nultio CASE3. A twenty-two-year-old right-handed man fell down a flight rticu- of stairs and on admission to the emergencyroom was found to have a cular compressign fracture of the second lumbar vertebra and a grossly de- ’adial formed left wrist. The left hand was cool and the radial pulse was not local palpable. Roentgenograms (Figs. 3-A and 3-B) revealed a severely d for comminutedcompression fracture of the radial styloid process and adja- :t the cent metaphysis, which was displaced radially with the carpus; an undis- FIG. 2-A FIG. 2-B -- placed fracture of the volar rim of the radial articular surface; and an Figs. 2-A through 2oF: Case 2, a twenty-year-old man who sustained was avulsion fr.acture of the ulnar styloid process. There was also a volar dis- head an injury to the left wrist in a motorcycleaccident. location of the lunate. The wrist was manipulatedinitially to reduce the Figs. 2-A and 2-B: Roentgenograms made on admission, showing an t re- dislocation and restore the circulation to the hand, and the wrist was im- avulsion fracture of the radial styloid process and a fracture of the ime, navicular, with the proximal fragment, displaced proximally onto the mobilized: with a volar splint.
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