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Compound Dorsal Dislocation of Lunate with Trapezoid Fracture

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Compound Dorsal Dislocation of Lunate with Trapezoid Fracture Clinics and Practice 2016; volume 6:879 Compound dorsal dislocation the radio-lunate and radio-scapho-lunate add to the particularly strong fixation of the lunate. Correspondence: Bong-Sung Kim, Department of of lunate with trapezoid Around 18 % of hand fractures involve carpal Plastic Surgery and Hand Surgery - Burn Center, fracture bones with the scaphoid fracture being most University Hospital of the RWTH Aachen, common.2 Overall, perilunate fracture disloca- Pauwelsstrasse 30, 52074 Aachen, Germany. Bong-Sung Kim,1 Gerrit Grieb,1 tions are more common than perilunate dislo- Tel.: +49.241.8036309 - Fax: +49.241.8082634. E-mail: [email protected] Patrick Rhodius,1 Arne H. Böcker,1 cations with the dorsal dislocation being the 3 Jan-Philipp Stromps,1 most frequent pattern. Carpal fractures and Key words: Lunate dislocation, trapezoid fracture, Nils Andreas Krämer,2 Norbert Pallua1 dislocations represent devastating injuries wrist trauma, closed reduction, scapholunate dis- often overlooked, misdiagnosed and inappro- sociation. 1Department of Plastic and priately managed. Reconstructive Surgery, Hand Surgery - Trapezoid fractures and dorsal dislocations Conflict of interest: the authors declare no con- 2 Burn Center; and Department of of the lunate are extremely rare injuries and to flict of interest. Diagnostic and Interventional Radiology, our knowledge we report about the first case of Received for publication: 17 August 2016. RWTH Aachen University, Aachen, both injuries occurring in one patient. This Revision received: 2 November 2016. Germany case provides meaningful insight into carpal Accepted for publication: 17 November 2016. injury patterns helping surgeons to more effi- ciently treat a patient collective with com- This work is licensed under a Creative Commons pound dorsal dislocations of the lunate. Attribution NonCommercial 4.0 License (CC BY- Abstract NC 4.0). ©Copyright B-S. Kim et al., 2016 We report about a dorsal dislocation of the Licensee PAGEPress, Italy lunate accompanied by a trapezoid fracture in Case Report Clinics and Practice 2016; 6:879 a 41-year old male patient after a motorcycle doi:10.4081/cp.2016.879 accident. The lunate dislocation with no dorsal A 41-year old, right-handed male patient or volar intercalated segment instability (DISI, presented in the emergency room after a only VISI) was diagnosed by x-ray whereas the motorcycle accident. The patient collided with with a skin laceration and superficial abra- trapezoid fracture was only diagnosable by a car while grasping the handlebars with both sions on the dorsum of the hand. Additionally, computed tomography. A closed reduction and of his hands but could not remember the exact a skin laceration with a diameter of approxi- internal fixation of the lunate by two Kirschner mechanism of injury. After excluding anyuse life mately two centimeters was located at the area wires was performed, the trapezoid fracture threatening organ injuries the patient was above the lunate on the dorsum of the wrist. was conservatively treated. Surgery was fol- referred to the Department of Plastic Surgery The perfusion and sensibility were without any lowed by immobilization, intense physiothera- for further evaluation of the left hand. The pathological finding. py and close follow-up. Even though complaints clinical examination revealed severe swelling X-ray showed a dorsal dislocation of the such as swelling and pain subsided during the and tenderness of the left hand. Tenderness lunate with no clear signs of fracture or dislo- course of rehabilitation, partial loss of strength was reported especially over the snuffbox, cation of other bony structures (Figure 1). and range of motion remained even after 16 proximal to the base of the second metacarpal Since lunate dislocations often come along months. In conclusion, a conservative treat- bone and distally to the distal radio-ulnar joint ment of trapezoid fractures seems to be suffi- cient in most cases. Closed reduction with K- wire fixation led to an overall satisfactory result in our case. For dorsal lunate disloca- commercial tions in general, open reduction should be per- formed when close reduction is unsuccessful or DISI/VISI are observed in radiographs after attempted close reduction. Non Introduction We herein report a case of a trapezoid frac- ture and dorsal dislocation of the lunate. The carpus is held together by firm ligaments which envelope the carpal bones and protect it from damage. Dorsal and volar extrinsic liga- ments connect the carpal bones with the radius and ulna whereas the intrinsic liga- ments interconnect carpal bones. Most crucial for the stability of the lunate are the scapho- lunate, luno-capitate, and radio-triquetral liga- ments which may rupture in a sequential pat- Figure 1. Plain x-ray of the left wrist immediately after the trauma. The arrow shows the tern during perilunate and lunate dislocations dislocated lunate. The trapezoid fracture is not depictable: A) anterior-posterior view; B) as proposed by Mayfield et al.1 Furthermore, lateral view. [page 108] [Clinics and Practice 2016; 6:879] Case Report with additional carpal bone injuries and pain closing of the fist was not possible especially over trapezoid persisted, a computed tomogra- due to incomplete reduction of swelling of the Discussion and Conclusions phy (CT) of the left hand and wrist was carried dorsum of the hand. No pain was observed over out immediately. It confirmed a dorsal disloca- the trapezoid. In further clinical examinations Constituting only 0.4% of carpal fractures, tion of the lunate and interestingly also a com- after 14 weeks and five months (Table 1), the the trapezoid bone represents the least com- pound sagittal fracture of the trapezoid pain over snuffbox and wrist abated complete- mon carpal fracture with only a handful of (Figures 2 and 3). Furthermore, air pockets in ly. Follow-up examinations 12 and 16 months them reported in the literature.4 The trapezoid the dorsal wrist indicated an open trauma. after initial trauma (Table 1, Figures 6 and 7) is surrounded by the second metacarpal bone, Under general anesthesia, a closed reduc- show a slow improvement of the range of trapezium, scaphoid, capitate and is thus well tion of the lunate was performed by pushing motion and strength. Although the pain com- protected. Further enveloped by strong liga- the lunate to proximopalmar direction while pletely subsided, a diminished radial deviation ments, trapezoid injuries require severe trau- applying longitudinal traction to the fingers with loss of grip strength remained. ma and are often accompanied by fractures of with the wrist fixed in a neutral position. The intraoperative x-ray confirmed anatomical reduction of the lunate. Since no tendency of lunate re-dislocation, neither in neutral nor in hyper-flexed or extended wrist position was seen on x-ray image intensifier dynamic screening, no open ligament reconstruction was carried out. Due to slight carpal instability without confirmed by manual testing under high force we decided to perform an inter- carpal fixation with two 1.6 mm Kirschner wires (K-wires). The first K-wire connected the lunate with the triquetrum, the second lunate with the scaphoid (Figure 4). After K- only wire fixation we did not observe dorsal or volar intercalated segment instability (DISI, VISI) in the intraoperative radiography. The soft tissue damage on the dorsum of the wrist was use explored, irrigated and sutured. The trapezoid was not treated surgically. Afterwards, the left wrist was immobilized in a scaphoid cast for 4 weeks. Post-surgical x-rays three days after surgery revealed a widened scapholunate gap of five millimeters while other carpal bones did not show any abnormalities. An open repair of the scapholunate ligament was suggested but declined by the patient. During the early post- surgical period, the patient complained swelling over the lateral epicondyle of the commercial humerus, pain and loss of strength when extending fingers and wrist. Follow-up x-rays did not show any further changes and K-wires wires were removedNon after six weeks (Figure 5). The patient attended physiotherapy one week after the removal of the K-wires. Eight weeks after the initial trau- ma, the patient underwent a thorough exami- nation (Table 1). Compared to the uninjured Figure 2. Computed tomographic scan of the left wrist showing the trapezoid fracture right wrist, the range of motion (ROM) of the (single arrow) and air inclusion in the soft tissue (double arrow). A) Coronal; B) sagittal; left wrist was significantly restricted. Active C) coronal; and D) axial reformation. Table 1. Clinical examination of the left hand at different time points. Hand Left Right Time 8 weeks 14 weeks 5 months 12 months 16 months Wrist flexion / extension 30° /10° 30° /45° 45° /50° 45° /50° 50° /55° 70° / 60° Wrist ulnar- / radial deviation 25° / 0° 30° / 5° 30° / 10° 30° / 10° 30° / 12° 35° / 20° Active closing of the hand - - + + + + Grip strength (pound force) n/n n/n 36 n/n 83 163 [Clinics and Practice 2016; 6:879] [page 109] Case Report the second metacarpal bone through force with Jeong et al. who successfully treated a mended for most cases and ultimately lead to transmission by the ligaments.5,6 trapezoid fracture with displacement of two good results.7,8,10,11 Blomquist et al. reviewed 305 radiological millimeters conservatively.10 Subsequent clini- Lunate dislocations and fracture disloca- cases of trapezoid fractures found only 4,7% to cal and x-ray examinations showed an incon- tions are more frequent injuries than trape- be solitary.7 Kain et al. reviewed 11 patients spicuous progress of the trapezoid fracture. As zoid fractures but still rare. The scapho-lunate, with trapezoid fractures and observed con- no follow-up CT scan was performed, the bony radio-lunate, radio-scapho-lunate and luno-tri- comitant injuries of the hamate, metacarpals, consolidation of this fracture could not be con- quetral ligaments strongly fixate the lunate capitates, trapezium, phalanx, car- firmed precisely.
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