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 was involved location of a radiocarpal , 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 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 , and frac- pain and numbnessin the left 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 . 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. The following day, the wrist joint was ex- t his dorsal surface of the radius. two

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VOL. 59-A, NO. 2, MARCH1977 2OO Z. JOHN BILOS, A. M. PANKOVICH, AND SHARUKINYELDA

FIG. 3-A FIG. 3-B " FIo. 3-C Figs. 3-A through 3-E: Case 3, a twenty-two-year-old manwho fell downa flight of stairs injuring the left wrist and sustaining a compression fracture of the second lumbar vertebra. Figs. 3-A and 3-B: Original roentgenograms,showing marked radial displacement of the carpus with a large fragment of the radial styloid process, volar dislocation of the lunate, and fractures of the ulnar styloid process and of the volar rim of the radial articular surface. Fig. 3-C: Postoperative roentgenogramat six weeks, showingthe internal fixation.

showed irregularity and widening of the lunate-triquetral joint, a moderate extension displacement of the lunate, and a healed radial frac- ture in satisfactory position (Figs. 3-D and 3-E).

CASE4. A twenty-one-year-old right-handed man was thrown from his motorcycle whenit was hit by an automobile. After he was brought to the hospital he complainedof severe pain in the abdomenand left flank, pain in the left wrist, and numbnessof the left hand. There was marked dorsoradial displacement of the hand, the fingers were cold, and the ra- dial pulse was very weak. Anesthesia in the distribution of the was also noted. Roentgenograms(Figs. 4-A and 4-B) of the left wrist showeda dorsoradial fracture-dislocation of the carpus with a comminutedcompression fracture of the radial styloid process, a fracture of the dorsal rim of the radial articular surface, an avulsion fracture of FIG. 3-D FIG. 3-E the ulnar styloid process, and a coronal fracture of the lunate. Onefrag- Twenty-twomonths after injury, the fracture of the radial styloid pro- ment of the lunate remainedin place in the wrist joint. cess has healed in satisfactory position but there is wideningand irregu- Immediate closed manipulation was performed to reduce the larity of the lunate-triquetral joint and moderateextension of the lunate with respect to the adjacent structures. fracture-dislocation and restore the circulation. Roentgenograms(Fig. 4-C) then showedsatisfactory, reduction of the radial styloid and carpus. and lift heavy objects, a consequence of the spine injury. At his last However.. the fragments of the lunate remained separated, and seven clinic visit, twenty-two months after injury, the wrist remained days after injury the wrist was exposed through a volar approach. The asymptomfitic and wrist motions were: extension to 45 degrees, flexion yolar capsule was found to be widely lacerated, with part of it displaced to 55 degrees, radial deviation to 20 degrees, ulnar deviation to 30 de- into the joint between the fragments of the lunate. The proximal frag- grees, and supination and pronation to 90 degrees each. The left and ment of the lunate was attached on its ulnar surface to an unusually thick right grip strengths were nearly equal. The: roentgenogramsat that time ulnar pahnar carpal ligament. This fragment was secured to the rest of

FIG. 4-A F!~. 4-B FIG. 4-C F~G.~--D injury to c~,e lef~ wrist,

Fig. 4-C: After closed reduction, fragments of the iunate ccm:ain separated, Fig. 4-D: At o~n reduction, the t?actures of the luna{e and radial styloid pr~>cc~swere stabilized with Kirschner wires. FRACTURE-DISLOCATIONOF THE RADIOCARPALJOINT 201 pearance of the spastic quadriparesis. Six weeks after injury, fusion of the radius to the prordmal carpal row was performedusing iliac cancel- lous bone grafts along with partial excision of the distal end of the ulna. Only the proximal fragment of the navicular was included in the fusion. The wrist was immobilizedin a long cast for six weeks and in a short cast for four more weeks. The patient then had persistent pain in the region of the: ulnar styloid process, and five and one-half monthsafter injury the head and styloid process of the ulna wereresected. Eight monthsafter injury, at the: last follow-up examination, he had mild pain in the wrist. At that time there was a 5-degree flexion contracture of the wrist and flexion to45 degrees, supination to 70 degrees, pronation to 70 degrees, and fixed radial deviation of 10 degrees, with further radial deviation to 20 degrees. The grip strength of the left handwas 80 per cent of that on the right. Roentgeno- grams (Figs. 5-E and 5-F) showeda solid fusion between the proximal carpal row and the distal end of the radius. FiG. 4-E FtG. 4-F Twenty-six months after the injury, the fractures of the lunate and Treatment radial styloid process have healed in satisfactory position, but mere is some narrowing of the radiocarpal and naviculolunate cartilage spaces. Radiocarpal dislocations and fracture-dislocations are the lunate by two Kirschner wires, and the radialstyloid was reduced and severe, complicated lesions, usually associated with in- fixed with another Kirschner wire (Fig. 4-D). The volar capsule was then juries of other parts of the body. Before any treatment of repaired, and a long cast was applied and worn for eight weeks, the wrist is attempted, it is imperative that the entire pa- The patient returned te full-time construction work in four months, tient be carefully examinedto identify other injuries which despite some discomfort in the wrist. At his last follow-up visit, twenty- may be more serious and have priority in treatment. six months after injury, he had no wrist discomfort and the motions of from the left wrist were: flexion to 60 degrees, extension to 75 degrees, supi- Immediate manipulation of the wrist is necessary in ~htto nation to 90 degrees, pronation to 75 degrees, no radial deviation, and all cases because of the marked deformity and the iank, ulnar deviation to 22 degrees. Roentgenograms (Figs. 4-E and 4-F) circulatory embarrassment that is often present. After ~rked showedthat the fractures of the lunate and radial styloid were healed in manipulation, improvementof vascular status of the hand satisfactory position, but there was some narrowing of the radiocarpal e ra- was prompt in all of our patients, and further vascular era- alnar and naviculolunate cartilage spaces, ." left ith a cture re of frag-

’, the (Fig. rpus. ;even , The laced frag- thick ~st of Fro. 5-A FiG. 5-B FiG. 5-C FIG. 5-D Figs. ;-A through 5-F: Case 5, a twemy-two-year-oldmale roofer whofell from a three-story building, sustaining a cerebral contusion which was treated by craniotomy, multiple other contusions, and a fracture-dislocation of the left wrist. Figs. 5-A and 5-B: Initial roemgenograms,showing marked comminution of the distal end of the radius, dorsal dislocation of the carpus, fracture of the navicular, and radio-ulnar dislocation. Figs. 5-C and 5-D: Manipulation did not ~mprovethe position.

CASE5. A twenty-two-year-old right-handed male roofer who fell from the roof of a three-story building sustained a cerebral contusion with spastic quadriparesis, for which he underwent cramotomy,as well as contusions of the right kidney, right side of the chest, and right eye. The left wrist was swollen and deformed, and there was a two by three- centimeter loss of skin over the thenar eminence.The skin over the wrist was intact and the circulation in the hand was normal. Roentgenograms (Figs. 5-Aand 5-B) of the left wrist s boweda dorsal radiocarpal disloca- tion, a severely comminutedfracture of the radial styloid process and of the dorsal two-thirds of the radial articnlar surface, .a displaced fracture the led an of the navicv,~~r. ~mda diskv:a,’.lo~o( v’c r:.’.d:,>u~:’:~ :,;in~. Since tytoid was madeand t~e wrist was imnlt;odiLed ill a ~ODg C 2

craniotomy and then gradually regained cerebrai funczion, with disap- 202 Z. JOHN BILOS, A. M. PANKOVICH, AND SHARUKIN YELDA

barrassment, ischemic phenomena, and subsequent nerve surgery, a larger than usual ulnar palmar carpal ligament s damagewere not observed. However, satisfactory reduc- was attached to the fragment of the lunate retained in the tion was not achieved by manipulation in four of our five joint. It is possible that necrosis of this fragmentdid not patients. Openreduction was not done at the time of the develop because there was an adequate blood supply initial manipulationbecause other injuries had priority in through the attached ligament. Careful dissection and treatment. preservation of soft-tissue attachments to such fragments Open procedures were required in four patients. The is essential. goal of these operations was firm internal fixation of the Either a volar or a dorsal approachto the wrist maybe fractures of the carpal bones and radius as well as stable used, depending on the type of injury and the location of reduction of the dislocation. In three patients this goal was fracture fragments. Whennecessary, both approaches achieved and the results so far have been excellent. In the should be used to facilitate reduction and fixation of the fourth patient, failure of the original manipulation and a injured structures. delay of six weeks from the time of injury madeopen re- duction impossible, and wrist arthrodesis was required. Discussion : Analysis of these five cases indicates considerable Radiocarpaldislocations and fracture-dislocations are variability of the lesions. A large or small displaced frag- infrequent and are not even mentioned in some standard ment of the radial styloid process was always present and textbooks ~,7,~o. Fromthe analysis of the cases in the contributed considerably to the instability of the wrist. present series and of those described in the literature, it is Anatomical reduction and fixation of this fragment ap- ,evident that these injuries of the radiocarpal joint can be peared to be essential, not only for the stability of the classified into four general types -- dorsal, volar, radial, radiocarpal joint but also for the restoration of the articular .and ulnar -- dependingon the direction in whichthe car- surface of the radius. Oncethe fracture was reduced, fixa- pus is displaced. tion was easily accomplishedin these cases using a sepa- The mechanismsof these injuries are not established. rate small incision over the tip of the styloid process to in- ’Weiss and associates produceddorsal fracture-dislocations sert either a Kirschner wire or a navicular screw (Cases 2, in cadavera by applying a compressive and torsional force 3, and 4). Small fragments of the dorsal rim of the radial ~;o the hyperextendedand pronated wrist. In B/Shler’s case, articular surface were excised or removedfrom the joint or an open dorso-ulnar dislocation was produced when the adjacent soft tissue. Radio-ulnar separation was seen in patient’s hyperextended wrist was hit by a car while the only one wrist (Case 5). Partial resection of the distal end was fixed against a wall. Our patients were not able of the ulna done at the time of the wrist arthrodesis was to describe the mechanismof their injuries. Large forces followed by persistent pain. Completeresection had to be must be applied to the wrist to produce these injuries, and done subsequently to relieve pain and improverotation of the lesions usually are the result of falls from a height or the forearm. motor-vehicle accidents. Major injuries of other systems Fracture of the navicular was present in three . are often present and should be identified and treated if In one (Case 1), the fracture was undisplaced and healed need be before treatment of the wrist is undertaken. after closed reduction of the radiocarpal dislocation. In the The wrist injury should be carefully assessed,--since it second (Case 2), the proximal fragment was widely sepa- often involves manycomponents of the wrist joint: the dis- rated and. displaced dorsally. It was reduced and fixed with tal ends of the radius and ulna, the distal radio-ulnar joint, a navicular screw four days after the injury, but two years and the individual carpal bones, particularly the proximal after surgery there was partial resorption of the proximal carpal row. Not infrequently .there are dislocations or fragment although the fracture had united. The functional t~racture-dislocations of multiple carpal bonesand ;. result at that time, however, was excellent. In this wrist, In our five cases there werenine carpal lesions: three frac- an initial openreduction was indicated with fixation of the tures of the navicular, one fracture of the lunate, one dis- navicular to the lunate because the naviculolunate liga- location of the lunate, three naviculolunate dissociations, ment was ruptured. In the third instance (Case 5), open re- and one lunate-triquetral dissociation. duction had to be delayed because of the patient’s general condition, and the wrist was subsequently fused. Conclusions Dislocation of the lunate was present in Case 3. Early Fromthis small series, it appears that open anatomi- open reduction was done, placing the naviculolunate com- cal reduction with stabilization of all injured structures, plex in the reduced position. However, the latest followed by six to eight weeks of immobilization in a long roentgenograms showed changes suggesting disruption of cast, is probably optimumtreatment. The operative proce- the lunate-triquetral joint, even, thoughthe clinical result dure should be doneas early after injury as possible, espe.- was excellent. It would have been better to stabilize the cially if fragmentsOf the car~-.:’.~?~:~:.:::..; ara. dis~{:.:::~.dfar c",~o,,~.~.~. w’i~h~7.i:~.c!~..::,. ~:~:~,: :inserted in the lunate f:-~ t.’.’~.,:/r ar.~at,.~micaipos~dc.~~, ~:i~,~ 3eepardizi:~z their capitate and to repair d~e iuaate-triquetral ligament if feas- vascuiar supply. Anypatient wi~()se generaf co~d/~ic.~pre-. ibie. c :i :s a [~)ngoperation on tl~e w,ist shouldha,,,:: - .ioseci Coronali"racmr~: ./,~: i~.mate was seen in Case 4. reductioa and probably percutaneous fixation ot majo~ .... 203 FRACTURE-DISLOCATION OF THE RADIOCARPAL JOINT must be guarded. Presumably it depends on the type and gament 8 fragments with Kirschner wires, particularly when extent of the injury, the accuracy of reduction of all le- ed in the emergencyprocedures on other vital structures are being sions, maintenance of the reduction during the period of did not done. Late reconstructive procedures on the wrist will thus postoperative immobilization, and the vigor and motiva- supply be facilitated. tion of the patient during the rehabilitation phase. Since there was only one nerve injury in our five pa- tion and Although the results in our four patients whose wrists ragments tients, a neurapraxiaof the ulnar nerve, it seemsthat trac- could be treated early were good, it seemspossible that with tion or compressionof the nerves at the wrist does not occur longer follow-up wrist pain due to post-traumatic arthritis ;t maybe readily despite the severity of the injury. may develop. cation of Prognosis after a radiocarpal fracture-dislocation proaches References ~n of the ANDERSON,L. D.: Fractures. In Campbell’s Operative Orthopaedics, edited by A. H. Crenshaw. Ed. 5, vol. 1, pp. 477-691. St. Louis, C. V. Mosby, 1971. B6HLER,LO~Er~Z: Verrenkungen tier Handgelenke. Acta Chit. Scandinavica, 67: 154-177, 1930. DEs’to’r, E’r~EN~E:Injuries of the Wrist. A Radiological Study. NewYork, P. B. Hoeber, 1926. Do~s, J. D., and L~scr~E~D,R. L.: Fractures and Dislocations of the Wrist. In Fractures, edited by C. A. Rockwood,Jr., and D. P. Green. ~tiol~Sare Vol. 1, pp. 345-440. Philadelphia, J. B. Lippincott, 1975. standard Dt~, A. W.: Fractures and Dislocations of the Carpus. Surg. C~,An. North America, 52: 1513-1538, 1972. F~r~z’~, J. H.: Fractures and Dislocations about the Wrist. Surg. Clin. North America, 37: 19-40. 1957. Is in the 6. 7. FL~’~, J. E.: Hand Surgery. Ed. 2. Baltimore, Williams and Wflkins, 1975. .ture, it is Lzw~s, O. J.; H~,~s~E~, R. J.; and Bt~cK~, T. M.: The Anatomyof the Wrist Joint. J. Anat., 106: 539-552, 1970. 8. WaGNEr,C. J.: Fracture-Dislocations of the Wrist. Clin. Orthop., 15: 181-196, 1959. nt can be 9. W/~’rsor~-Jo~Es, REG|~O:Fractures and Joint Injuries. Ed. 4, vol. 2. London, E. and S. Livin.~stone, 1956. I0. WE|ss, CHa~ES;L/~s~<~, R. S.; and S~,~E~, Mo~-ror~: Irreduciiole Radiocarpal Dislocation. A ~ase Report. J. Bone and Joint Surg., 52-A: tr, radial, 11. h the car- 562-564, April 1970.

:ablished. ;locations ~nal force er’s case, ~’hen the ~hile the not able ge forces ~ries, and height or r systems treated if ken. d, since it ~t: the dis- lnar joint, ~ proximal ;ations or .rid joints. :hree frac- ;, one dis- ~ociations,

~ anatomi- ~tructures, a in a long :ive proce- ible, espe- placed far zing their dition pre- ’e a closed of major