Total Volar Extrusion of the Lunate and Scaphoid Proximal Pole with Concurrent Scapholunate Dissociation

n Case Report

Total Volar Extrusion of the Lunate and Scaphoid Proximal Pole With Concurrent Scapholunate Dissociation

Kyoung Hwan Koh, MD; Tae Kang Lim, MD; Min Jong Park, MD

abstract Full article available online at Healio.com/Orthopedics. Search: 20120822-33

This article describes a case of a 24-year-old man with a total volar extrusion of the lunate and scaphoid proximal pole with concurrent scapholunate dissociation. The viability of the lunate and the proximal pole of the scaphoid are at high risk in this type of injury. Scaphoid nonunion, avascular necrosis of the lunate and proximal pole of the scaphoid, and carpal instability are inevitable unless the blood supply is re- stored. Thus, proximal row carpectomy at injury may be an acceptable option to avoid these complications and late sequelae, including chronic wrist pain and dysfunction. However, the authors attempted accurate reduction of the extruded bones and internal fixation.Final radiographs and magnetic resonance imaging 12 years postoperatively showed healing without avascular necrosis. Carpal indices involving the scapholunate angle, radiolunate angle, and carpal height ratio were similar in both wrists without evidence of carpal instability or collapse. Range of motion and grip power were 75% and 76%, respectively, compared with those of the uninjured wrist. Clinical scores showed good results, and the patient reported no pain during activities of daily living and was satisfied with his surgical results. Open reduction and internal fixation can be a viable option in this rare pattern of injury. Figure: Intraoperative photograph showing the median nerve (arrow), which was compressed by the displaced lunate (asterisk) and scaphoid fracture.

Dr Koh is from the Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, Dr Lim is from the Department of Orthopaedic Surgery, Wonkwang University Sanbon Hospital, Gunpo, and Dr Park is from the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Drs Koh, Lim, and Park have no relevant financial relationships to disclose. Correspondence should be addressed to: Min Jong Park, MD, Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Korea ([email protected]). doi: 10.3928/01477447-20120822-33

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olar lunate dislocation is rare nerve were noted with nor- compared with dorsal perilunate mal range of 2-point dis- Vdislocation and fracture disloca- crimination. Hand circula- tion, which are caused by a similar injury tion was not compromised. mechanism.1,2 Few cases of volar lunate He had concomitant frac- dislocation accompanied by a displaced tures in the second lumbar scaphoid fracture have been reported.3-8 vertebra and both calcaneus To the authors’ knowledge, transscaphoid bones. volar lunate dislocation combined with Open reduction and in- complete scapholunate dissociation and ternal fixation under gen- total extrusion (ie, complete detachment eral anesthesia and tourni- of the soft tissue) has not been reported. quet control was performed The viability of the lunate and the prox- on the wrist 3 days after the 1A 1B imal pole of the scaphoid are at high risk injury. After initial longitu- Figure 1: Preoperative posteroanterior (A) and lateral (B) radiographs showing the proximally migrated lunate and scaphoid fragment. in this type of injury. Accurate reduction dinal skin incision on the of the extruded bones can be attempted; volar side, the transverse however, scaphoid nonunion, avascular carpal ligament and fore- necrosis of the lunate and proximal pole arm fascia were released. of the scaphoid, and carpal instability are The lunate and proximal inevitable unless the blood supply is re- fragment of the scaphoid, stored.9 Consequently, dysfunction of the which were lying under wrist with pain and limited range of mo- the median nerve and flex- tion (ROM) due to degenerative arthrosis or carpi radialis and com- are the most likely late sequelae.2,3,10-12 pressing the median nerve, Proximal row carpectomy at injury may were identified (Figure 2). be an acceptable option to avoid these The soft tissues, including complications.13,14 the scapholunate interosse- Despite the risk of failure, the authors ous ligament, lunotrique- 2A 2B performed open reduction and internal tral interosseous ligament, Figure 2: Intraoperative photographs showing the median nerve fixation. The patient was followed for and volar radiocarpal liga- (black arrow), which was compressed by the displaced lunate (as- more than 10 years; therefore, the authors ments connecting to the lu- terisk) and scaphoid fracture (A) and the proximal scaphoid fragment present the long-term results. The patient nate, were disrupted. The (white arrow) (B). was informed that the data concerning the volar capsule of the wrist case would be submitted for publication. was transversely ruptured. The extruded lunate and proximal the scapholunate interosseous and lunotri- Case Report scaphoid was manually replaced into the quetral interosseous ligaments because of A 24-year-old, right-hand-dominant joint through the volar capsular rent. A insufficient substance to be purchased. man was transferred after a fall from a subsequent dorsal approach was used to Accurate reduction, restoration of nor- height of approximately 10 m. The patient precisely reduce and securely fix the dam- mal carpal alignment, and proper K-wire had severe pain and swelling around the aged structures. Using the triquetrum as a position were confirmed under an image right wrist with no external wound. He did reference, the reimplanted lunate was ana- intensifier. The volar capsule, dorsal cap- not remember exactly how he fell on his tomically reduced and transfixed with two sule, and extensor retinaculum were re- right hand. Radiographs revealed a scaph- 1.4-mm K-wires. The proximal fragment paired (Figure 3). oid waist fracture and a volar lunate dislo- of the scaphoid was aligned with the re- Postoperatively, the median nerve symp- cation. The lunate and proximal fragment duced lunate and transfixed with K-wires. toms resolved within 2 weeks. The wrist of the scaphoid were completely extrud- Finally, the reduced scaphoid fracture was was immobilized in a long-arm thumb spica ed from the radiocarpal joint, separated fixed with K-wires. More stabilization cast for 4 weeks and then in a short-arm from each other, and migrated proximally was obtained by transfixing the scaphoid thumb spica cast for an additional 11 weeks (Figure 1). Paresthesia and a mild sensory and capitate. No bone grafting was per- until radiographs showed union of scaphoid decrease in the territory of the median formed. No attempt was made to repair fracture. After the K-wires were removed

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at 15 weeks, active-assisted and gentle pas- ratio (.51) were similar in sive range of motion exercise were started. both wrists, with no evi- No formal physiotherapy was administered. dence of carpal instability Six months postoperatively, he regained or collapse. Range of mo- functional range of motion and adequate tion (volar flexion, 70° vs strength and returned to his previous job as 80°, respectively; dorsi- an electrical engineer with some limitations. flexion, 50° vs 80°, respec- Radiographs 6 months postoperatively tively; radial deviation, revealed no evidence of carpal malalign- 20° vs 20°, respectively; ment or avascular necrosis. Three years and ulnar deviation, 25° postoperatively, bone absorption was vs 40°, respectively) and noted in the articulation between the grip power (75 vs 85 lb) 3A 3B scaphoid and lunate (Figures 4A, B). The were measured to be 75% Figure 3: Postoperative posteroanterior (A) and lateral (B) radio- evidence of avascular necrosis and carpal and 76%, respectively, graphs showing the carpal bones reduced and fixed with K-wires. instability was unclear, although slightly compared with those of increased radiodensity in the lunate and the uninjured wrist. The mild arthritic change between the scaph- patient demonstrated a negative scaph- of transscaphoid volar lunate dislocation oid and capitate was suspicious. oid shift test. The Disabilities of the Arm, with or without disruption of the scaph- Final radiographs 12 years postop- Shoulder, and Hand score was 7 (best olunate interosseous ligament4,6,12,15,16 and eratively showed widened scapholunate score, 0; worst score, 100), the patient-rat- transscaphoid transtriquetral volar lunate interval without further bone absorption. ed wrist score was 4 for pain (best score, fracture dislocation.7 The current case is The density in the lunate and scaphoid 0; worst score, 50) and 6 for function (best unique because it involved a totally ex- proximal pole appeared to become nor- score, 0; worst score, 100), and the modi- truded pattern because the lunate and mal. Mild arthritic change was evident, fied Mayo Wrist Score was 85 (best score, proximal fragment of the scaphoid had no with an irregular surface in the scaphocap- 100; worst score, 0). The patient reported soft tissue attachments. itate joint. The viability of lunate could be no pain during activities of daily living Given the potential risks of avascular verified on MRI, although it was impos- and mild pain after strenuous exercise. He necrosis, scapholunate instability, and sible to show the scaphoid proximal pole was satisfied with his surgical results. the development of secondary arthritis and scapholunate joint articulation due to after open reduction, the results should a metal artifact from the remnant K-wire Discussion be evaluated based on long-term follow- (Figures 4C-F). The radiographic mea- The current patient presented with a up. The authors examined the patient and surements of scapholunate angle (59°), rare pattern of perilunate fracture dislo- obtained radiographs until 12 years after radiolunate angle (4°), and carpal height cation. Case reports have been published injury.

4A 4B 4C 4D 4E 4F Figure 4: Posteroanterior (A) and lateral (B) radiographs 3 years postoperatively showing bone resorption in the scapholunate interval. Carpal height and alignment were maintained without definite evidence of avascular necrosis (A). Posteroanterior (C) and lateral (D) radiographs showing no interval progression of bone resorption and maintained carpal indices. T1-weighted coronal (E) and T2-weighted sagittal (F) magnetic resonance images 12 years postoperatively showing a viable lunate.

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The treatment principle for a volar lu- ments, excellent functional recovery was 4. Ekerot L. Palmar dislocation of the transscaphoid-lunate unit. J Hand Surg Br. 1995; nate fracture dislocation is to perform open achieved with the restoration of normal 20:557-560. reduction and internal fixation to achieve carpal alignment. 5. Papadonikolakis A, Mavrodontidis AN, Zala- normal carpal alignment and proper heal- The scaphoid fracture healed unevent- vras C, Hantes M, Soucacos PN. Transscaph- ing.4,7,12,15 Many reports demonstrated that fully 15 weeks postoperatively, and no evi- oid volar lunate dislocation. A case report. J Bone Joint Surg Am. 2003; 85:1805-1808. avascular necrosis of the lunate rarely de- dence existed of necrosis of the scaphoid 6. Stern PJ. Transscaphoid-lunate dislocation: a velops because the blood supply is main- proximal pole. The authors assumed that report of two cases. J Hand Surg Am. 1984; tained through intact volar radiocarpal lig- the avascular proximal pole had been re- 9:370-373. aments.2,3,11 Ekerot4 reported that revascu- vascularized through the creeping substi- 7. Stevanovic M, Schnall SB, Filler BC. larization of the lunate may be achieved tution as the fracture healed. Despite the Trans-scaphoid, transtriquetral, volar lunate fracture-dislocation of the wrist. J Bone Joint through a united scaphoid fracture and concern about avascular necrosis in the Surg Am. 1996; 78:1907-1910. an intact scapholunate interosseous liga- current patient, recent radiographs showed 8. Givissis P, Christodoulou A, Chalidis B, ment. However, complete extrusion of the the recovery of normal radiodensity, indi- Pournaras J. Neglected trans-scaphoid trans- styloid volar dislocation of the lunate. Late lunate and proximal scaphoid fragment cating revascularization. It was confirmed result following open reduction and K-wire with no soft tissue connections should based on magnetic resonance imaging 12 fixation. J Bone Joint Surg Br. 2006; 88:676- result in total disruption of the blood sup- years after injury. However, it is difficult to 680. ply with a high risk of avascular necrosis. explain how an avascular large bone can be 9. Green DP, O’Brien ET. Open reduction of carpal dislocations: indications and operative Significant numbers of avascular necrosis successfully revascularized simply by re- techniques. J Hand Surg Am. 1978; 3:250- of the lunate or scaphoid proximal pole in placing it. Another remarkable radiograph- 265. transscaphoid perilunate dislocation was ic finding was bone resorption between the 10. Habernek H, Weinstabl R, Kdolsky R, Fialka C, noted,17 and the reported outcomes were scaphoid and the lunate, which was noted 2 Barisani G. Volar lunate fracture-dislocations of the wrist: case report for two patients treated less satisfactory because of secondary ar- years postoperatively. It suggests the pos- with external frame and internal open reduc- thritic changes.2,3,10-12 sibility of scapholunate instability; how- tion. J Trauma. 1998; 45:975-978. Some authors have reported satisfac- ever, no further resorption occurred, and 11. Morawa LG, Ross PM, Schock CC. Fractures tory results by proximal row carpectomy carpal alignment was maintained with no and dislocations involving the navicular-lunate axis. Clin Orthop Relat Res. 1976; (118):48- in cases with marked displacement of the evidence of dorsal intercarpal segmental 53. carpal bones and complete ligamentous instability. 12. Schakel M, Dell PC. Trans-scaphoid palmar disruption.13,14 The current case may rep- lunate dislocation with concurrent scapholunate ligament disruption. J Hand Surg Am. resent an indication for primary proximal Conclusion 1986; 11:653-655. row carpectomy. However, the current Transscaphoid volar lunate dislocation 13. Draaijers LJ, Kreulen M, Maas M. Palmar authors were determined to attempt re- with complete ligament disruption can be dislocation of the lunate bone with complete duction of displaced fragments to restore treated successfully with early open re- disruption of all ligaments. A report on two cases. Acta Orthop Belg. 2003; 69:452-454. the normal carpal joint. They thought that duction and internal fixation despite the 14. van Kooten EO, Coster E, Segers MJ, Ritt proximal row carpectomy could be per- risks of avascular necrosis and carpal in- MJ. Early proximal row carpectomy after formed subsequently if open reduction stability. severe carpal trauma. Injury. 2005; 36:1226- and internal fixation failed. The extruded 1232. lunate and proximal scaphoid fragment References 15. Kamano M, Honda Y, Kazuki K. Palmar lunate transscaphoid fracture-dislocation could be easily replaced into the joint 1. Cooney WP, Bussey R, Dobyns JH, Lin- caused by palmar flexion injury. J Orthop through the volar approach. However, scheid RL. Difficult wrist fractures. Perilu- Trauma. 2001; 15:225-227. nate fracture-dislocations of the wrist. Clin the dorsal approach is required to achieve Orthop Relat Res. 1987; (214):136-147. 16. Viegas SF, Hoffmann FJ. Palmar lunate dislo- anatomic reduction and secure fixation, cation with a dorsal scaphoid fracture variant. 2. Green DP, O’Brien ET. Classification and J Hand Surg Am. 1988; 13:440-443. which is essential to avoiding complica- management of carpal dislocations. Clin Or- thop Relat Res. 1980; (149):55-72. 17. Panting AL, Lamb DW, Noble J, Haw CS. tions, including scaphoid nonunion, car- Dislocations of the lunate with and without pal collapse, and late arthrosis. Although 3. Adkison JW, Chapman MW. Treatment of fracture of the scaphoid. J Bone Joint Surg acute lunate and perilunate dislocations. Clin Br. 1984; 66:391-395. the authors repaired no interosseous liga- Orthop Relat Res. 1982; (164):199-207.

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