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

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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 me- dian 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 SEPTEMBER 2012 | Volume 35 • Number 9 e1427 n Case Report 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 e1428 ORTHOPEDICS | Healio.com/Orthopedics EXTRUSION OF THE LUNATE AND SCAPHOID PROXIMAL POLE | KOH ET AL 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
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