Carpal Fractures and Dislocations

1
Carpal Fractures and Dislocations

• John T. Capo, MD
• Original Authors Thomas F. Varecka, MD
• and Andrew H. Schmidt, MD March 2004
• New Author John T. Capo, MD Revised January
  2006

2
Anatomy of the Wrist

• Carpal bones tightly linked by capsular and
  interosseous ligaments.
• Capsular (extrinsic) ligaments originate from the
  radius and insert onto the carpus.
• Interosseous (intrinsic) ligaments traverse the
  carpal bones.
• The lunate is the key to carpal stability.

3
Lunate

• Connected to both scaphoid and triquetrum by
  strong interosseous ligaments.
• Injury to the scapholunate or lunotriquetral
  ligaments leads to asynchronous motion of the
  lunate and leads to dissociative carpal
  instability patterns.

4
Intercarpal Ligaments

• The proximal and distal carpal rows are attached
  by capsular ligaments on each side of the
  lunocapitate joint.
• Injury to these ligaments leads to abnormal
  motion between the two rows, and nondissociative
  wrist instability patterns.

5
Dorsal Extrinsic Ligaments
DIC
DRC
6
Volar Ligaments
7
SL
LT
TFCC
Interosseous Ligaments looking dorsal to volar
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Scapholunate Ligament

• 3 Portions
• Dorsal
• Strongest
• Membranous
• Capsule
• Palmar

10
Imaging

• Plain radiographs multiple views necessary
• Anteroposterior
• Lateral
• Oblique
• Clenched-fist AP
• Radial and ulnar deviation

11
General Principles of Treatment

• Carefully evaluate x-rays for subtle fractures
  and/or evidence of carpal instability.
• Immobilize suspected scaphoid fractures or
  perilunate injuries pending definitive diagnosis.
• Diagnose and appropriately treat ligament
  injuries.

12
Scaphoid Fractures
Therapy of this fracture has been characterized
by confusion, impatience, invention,
intervention, reaction, re-evaluation and
frustration.
Mazet Hohl, JBJS, 45A, 1963
13
Introduction

• Scaphoid most commonly fractured carpal bone
• Incidence of scaphoid fractures estimated to be
  15 of all wrist injuries.
• Munk, Acta Orthop Scand, 1995 160 scaphoid fxs
  among 1,052 pts. Seen in E.D. for wrist injuries.

14
Mechanism of Injury

• Fall on outstretched hand
• 75 to 80
• Kick-back injury, e.g., jammed drill, etc
• 12 to 15
• Direct Blow
• 2 to 3

15
Evaluation

• History - suspect scaphoid injury in anyone with
  radial wrist pain after an injury
• Physical Exam
• Imaging

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Physical Findings

• Snuff box tenderness
• scaphoid waist exposed with ulnar deviation
• Pain with palpation of scaphoid tuberosity
• Limited painful wrist ROM, especially forced
  dorsiflexion

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Differential Diagnosis radial sided wrist pain

• Scapholunate instability
• Pain and clicking in wrist
• Tender just distal to Listers tubercle
• Positive Watson test
• Lunate dislocation
• FCR tendon rupture or tendinitis
• Radial styloid fracture
• Trapezium fracture
• deQuervains disease
• CMC (basal) joint arthrosis
• Radio-scaphoid arthrosis

18
Imaging

• X-rays
• Initial films nondiagnostic in up to 25 of cases
  
• Bone Scan
• CT Scan
• MRI- most accurate

19
Radiographic Imaging of Scaphoid Fractures

• PA of wrist
• Lateral of wrist
• Scaphoid view (oblique film AP x-ray with wrist
  supinated 30 degrees and in ulnar deviation)
• Pronated oblique view

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PA Wrist View
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CT scan
-In plane of scaphoid -demonstrates mal-alignment
well
22
Classification

• Typically by location
• Tuberosity
• Proximal third
• Middle third (Waist)
• Distal Third

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Scaphoid Fxs Location Of Fracture

• Tuberosity 17 to 20
• Distal Pole 10 to 12
• Waist 66 to 70
• Horizontal oblique 13 to 14
• Vertical Oblique 8 to 9
• Transverse 45 to 48
• Proximal Pole 5 to 7

Leslie, JBJS 63-B, 1981
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Example Middle Third Fracture
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Why is Fracture Location so Important in the
Scaphoid?

• Answer Because of the blood supply
• Primary vascular supply enters distal pole and
  runs retrograde to the proximal scaphoid
• The more proximal the fracture, the more likely
  are healing complications.

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Scaphoid blood supply
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Management of Suspected Scaphoid Fracture

• In patients with an injury and positive exam
  findings but normal x-rays, immobilize for 7-10
  days (thumb spica best)
• Repeat x-rays if patient still symptomatic
• If pain still present but x-ray continues to be
  normal consider MRI (or bone scan)
• If acute diagnosis necessary, consider MRI or CT
  immediately.

28
Treatment Options - Acute Injuries

• Nonoperative
• Short vs. long-arm cast
• Thumb spica vs. standard cast
• Operative
• Percutaneous pin or screw fixation
• ORIF

29
Indications for Nonoperative Treatment

• Ideal indication nondisplaced distal third
  fracture
• Tuberosity fractures also heal well with casting
• 80-90 of middle third fractures heal
• Only 60-70 of proximal third fractures heal - of
  those that do, many have deformity

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Nonoperative Treatment

• Immobilize in slight flexion and slight radial
  deviation.
• Initial cast long-arm thumb spica cast for 6
  weeks (shown to lead to more rapid union and less
  nonunion).
• Replace with short-arm thumb spica cast until
  united.
• Expected time to union
• Distal third 6-8 weeks
• Middle third 8-12 weeks
• Proximal third 12-24 weeks

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Cast Management Alternatives

• Bond, AAOS (2000),
• Acute screw fixation vs. cast immobilization a
  prospective study
• 25 pts 11 screw, 14 cast
• ALL healed, clinically by x-ray
• faster healing time in screw group
• one re-operation in screw group

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Cast Management Alternatives

• Mayr, AAOS (2000)
• Retrospective study of cast alone vs cast
  ultrasound
• 30 pts all healed clinically and by x-ray
• Time to union 6.2 weeks in US group, 8.8 weeks
  in cast group

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Choice of Management

• Does it work?
• Is it reproducible?
• Is it reliable?
• Is it economical?
• Alternatives?
• Complications?

34
Cast Management Does It Work?
35
Cast Management Is It Reliable?

• Cooney, CORR (1980)
• Overall, 37 / 45 (82) acute fxs healed
• Nondisplaced fx 27 / 27 healed
• time to union 9.4 weeks
• Displaced fx 10 / 13 healed (77)
• 4 with asymptomatic malunions

36
Cast Management Is It Reliable?

• Gellman, JBJS-Am, (1989)
• 51 acute fxs followed prospectively
• Short- vs long-arm cast
• LAC n28, 100 union
• Time to union 9.5 weeks
• SAC n23, 65 union 2 nonunions, 6 delayed
  unions
• Time to union 12.7 weeks
• Improved results with long arm cast

37
Cast Management Is It Economical?

• Cost of cast treatment to union for acute
  scaphoid fracture 1550 (HCMC, 1999)
• 4 sets x-rays, 4 casts, 6 clinic visits, 2
  therapy sessions
• Cost of ORIF for subacute scaphoid fracture
• 6290
• Cost of loss of work and productivity must be
  factored in
• -earlier RTW with percutaneous fixation

38
Cast Management Alternatives

• Open reduction, internal fixation (ORIF)
• Herbert screw
• Accutrak screw
• K-wires
• Percutaneous fixation with cannulated screw
• Healing acceleration
• ultrasound

39
Cast Management Complications

• Non-union lt 10 for acute, non-displaced
  fractures.
• Non-union 20 for acute, displaced fractures.
• Non-union 30 to 35 for fractures which
  displace in cast
• Mal-union symptoms???

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Cast Management Summary

• Cast treatment of scaphoid fractures is safe,
  effective, reliable, reproducible
• Some fractures clearly benefit from ORIF
• Trans-scaphoid perilunate dislocation
• For experienced surgeon, ORIF may return patients
  to work faster and lower rehab costs.
• with advent of percutaneous techniques, early
  fixation is becoming more appealing

41
Indications for Surgery

• Unstable Scaphoid Fractures
• Displacement of gt 1 mm
• Radiolunate angle gt 15 degrees
• Scapholunate angle of gt 60 degrees
• Humpback deformity
• intra-scaphoid angle gt10 degrees
• Nonunion

42
Surgical Techniques

• Most involve the insertion of cannulated headless
  screws.
• Open techniques needed for nonunions and
  fractures with unacceptable and unreducable
  displacement
• Percutaneous techniques appropriate for acute
  fractures with minimal displacement

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Herbert Screw
Differential pitch and jig provides compression
44
Results of Surgical Treatment

• Union rate 93 - 97
• Return to work 3.7 weeks average

45
Fracture of the Carpal Scaphoid.A Prospective,
Randomised 12 Year Follow-up Comparing Operative
and Conservative Treatment

• 30 cases treated nonoperatively
• 32 cases treated with a Herbert screw
• No differences in function, radiological healing,
  or wrist arthritis at 12 years
• Earlier return to work in blue-collar workers
  after surgery.

Saedén et al, JBJS 83B 230, 2001
46
ORIF volar approach
47
Herbert screw with compression jig
48
Final screw placement
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Dorsal Approach
Proximal pole fractures
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Headless, Compression Screw Results

• Herbert, Fischer, JBJS(B)Management of the
  fractured Scaphoid using a new Bone Screw
• 158 patients
• 100 union for acute fractures
• 80 for non-unions

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Percutaneous Fixation
Dorsal
Volar
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Guidewire centered in scaphoid in all views
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Derotation pin- cannulated drill
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Cannulated Screw
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Percutaneous Scaphoid Fixation

• Bond, Shin et al, JBJS, 2001 Percutaneous screw
  fixation or cast immobilization for non-displaced
  scaphoid fractures
• Prospective randomized-25 pts
• 11 perc screw
• union _at_ 7 weeks
• Work _at_ 8 weeks
• 14 casted
• Union_at_ 12 weeks
• Work _at_ 15 weeks

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Outcomes and Complications

• AVN of proximal pole
• Nonunion
• Malunion
• Arthritis (SNAC) wrist

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Scaphoid Non-Union

• Introduction
• How does it occur?
• Should it be treated?
• Can it be treated?
• How and when should it be treated?

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Scaphoid Fractures Non-Union

• Leslie IJ, Dickson RA JBJS, 63-B 1981
• 222 consecutive patients
• Fxs most common in ages 15y to 29y. (65)
• MaleFemale 6.51
• 11 Non-unions
• all in men, all in 15-29y/o group
• 9/11 in R sided fracture (81)
• overall, 46 R sided fractures (plt0.05)

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Treatment Options - Scaphoid Nonunion Scaphoid
preserving

• ORIF with cancellous bone graft
• ORIF with structural tricortical graft
• ORIF with vascularized graft
• Percutaneous fixation alone

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Treatment Options - Scaphoid Nonunion Salvage

• Proximal row carpectomy
• Scaphoid excision and limited inter-carpal
  fusion four corner
• Distal pole excision
• Proximal pole excision or replacement

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INITIAL FILM
AFTER 4 MON IN CAST
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CT SCAN AT 4 MON. POST TREATMENT
65

• Prevalence of asymptomatic non-unions unknown
• Sehat, et al., Injury, 2000 reviewed 2857 wrist
  radiographs
• 51 with anomalies of the scaphoid
• 4 with frank, established non-union
• Conclude that prevalence of unrecognized
  non-union is rare

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51 y/o man presents with acute onset ulnar sided
wrist pain after playing golf
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Scaphoid Nonunion Diagnosis

• Non-union often an incidental finding after
  re-injury to wrist
• Probable disruption of a previous stable, and
  therefore asymptomatic, scaphoid non-union
• Exam tender, loss of motion, weakness

68
Non-union How Does It Occur?

• Fractures at risk
• Waist fracture, especially if fracture line is
  transverse to scaphoid axis (Russe)
• Displacement gt 1mm associated with fracture
  instability (Weber, Gellman)
• Fracture displacement occurring while in cast
  (Leslie, Herbert)
• Inadequate treatment (Dias)

69
Non-union How Does It Occur?

• Fractures at risk
• Disrupted vascular patterns

Gelberman, J Hand Surg, 1980
70
Scaphoid Non-union Should It Be Treated ?

• Natural history of scaphoid nonunion suggests
  high incidence of wrist arthrosis
• Mack, et al., JBJS, 1984
  
• 47 scaphoid nonunions, ranging from 5 to 53 yr.
  duration
• All developed degenerative changes
• Duration of non-union correlated with degree of
  arthrosis
• 3 patterns of degeneration

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Scaphoid Non-union Should It Be Treated ?

• Natural history of scaphoid nonunion suggests
  high incidence of wrist arthrosis
• Belsky,et al., JBJS, 1985
• 55 scaphoid non-unions, followed for longer than
  10 yrs.
• Earliest degenerative changes noted by 5 yrs.
  
• All had significant arthrosis by 10 yrs.

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Scaphoid Non-union predictable pattern of
arthrosis
TYPE I DJD N/U lt 10 YR.
TYPE II DJD N/U 15 YR.
TYPE III/IV DJD N/U gt 25 YR.
MACK, et al., JBJS, 1984
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Chronic Non-union SNAC wrist

• Scaphoid Non-union Advanced Collapse
• Radial styloid -scaphoid arthritis (1)
• Radius- proximal scaphoid joint (2)
• Mid-carpal joint (3)

3
1
2
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Scaphoid Non-union Should It Be Treated ?

• Natural history studies strongly suggest scaphoid
  fractures left untreated lead to carpal collapse
  patterns and almost 100 certainty of developing
  degenerative changes
• Treatment of n/u is recommended

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Scaphoid Non-union Can It Be Treated?

• Results of treatment of non-union vary widely
• Russe, JBJS, 1960
• 63 patients with established non-union
• All treated with (cortico-cancellous) bone grafts
• Reports all did well -- average follow-up only
  3 months
• No follow-up gt 2 yr.

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Scaphoid Non-union Can It Be Treated?

• Results of treatment of non-union vary widely
• Green, J Hand Surg, 1984
• Reports results of Russe type bone grafts
• Addresses effect of avascular changes in proximal
  pole
• 88 union rate all patients with non-unions lt
  2yrs.
• AVN not absolute contra-indication to treatment

77
Scaphoid Non-union Can It Be Treated?

• Results of treatment of non-union vary widely
• Schuind, et al., J Hand Surg, 1999
• Multivariate analysis of 138 surgically treated
  scaphoid nonunions
• 75 healing rate
• Negative factors duration gt 5 yr. Radial
  styloidectomy dorsal approach

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Scaphoid Non-union Can It Be Treated?

• Results of treatment of non-union vary widely
• Recent literature reports more favorable healing
  rates, up to 95 when
• 1) deformity corrected
• 2) iliac crest bone graft used
• 3) rigid internal fixation employed. ( Daly,1996
  Cooney, 1996 Feldman, 1996)

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Scaphoid Non-unionHow And When

• Volar approach waist and distal third
• Dorsal approach proximal pole fractures
• Fibrous interposition material to be removed
• Liberal use of bone graft
• Iliac crest better in most reports

80
Scaphoid Non-unionHow And When

• Before degenerative changes begin
• Poorer prognosis for healing and functional
  recovery if non-union greater than 5 yr.
• Internal fixation positively correlates with
  improved chances of healing

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Technique Volar ORIF with bone graft
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Exposure

• Gentle zig-zag incision directly over the course
  of the flexor carpi radialis tendon

83
FCR TENDON stay on radial side
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Fibrous non-union removed
86
Iliac crest graft placed into defect
87
Compression largely provided by jig and not screw
Herbert Screw
88
Compression Screw Insertion Jig
89
Edge of trapezium needs to be removed for proper
screw placement
90
26 y/o male, injured skiing film at 10 days
91
4 months post injury, fracture has displaced in
cast -delayed union
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18 months post ORIF, full motion, no pain, has
returned to full activity
94
Non-union Results

• Düppe, JBJS-A (1994)
• 36 year follow-up of 56 fxs
• 52 acute fxs, 91 union
• 9 N/Us 4 primary, 5 ? treatment
• 3 with DISI
• 5 with DJD
• ALL healed patients working

95
Non-union Results

• In non-unions where stage I arthrosis is present,
  ORIF gives consistently satisfactory results.
• In nonunions gt 5 yrs, achieving union is very
  difficult.
• Repeat procedure for persistent non-union has
  high percentage failure.

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Early Non-union
Mild cystic changes, minimal collapse
97
Percutaneous internal fixation of selected
scaphoid non-unions with an arthroscopically
assisted dorsal approachSlade, Geissler et al
JBJS-2003(85)

• 15 patients with early non-unions
• All cases with percutaneous screw fixation and
  arthroscopic assistance
• No bone grafts used
• All scaphoids healed at average of 14 weeks

98
Perc screw placement- dont over compress
99
Non-union healed at 10 weeks
100
Non-union Salvage

• Arthrodesis
• Limited radio-scapho-lunate 4 corner
• Difficult, results vary
• Proximal row carpectomy
• Treatment of choice
• Arthroplasty not recommended

101
Non-union Summary

• Scaphoid non-union is challenging problem with
  significant risk for the wrist.
• Left untreated, scaphoid non-unions have a near
  100 rate of degenerative disease.
• If present for more than 5 yrs, Scaphoid n/u
  unlikely to heal.

102
Non-union Summary

• Degenerative changes apparent as early as 5 yrs.
• Current trend is to fix non-union, as well as
  bone graft
• Seems to give better results
• Challenging surgery best done by experienced
  surgeons

103
Perilunate Injuries
104
Mechanism of Injury

• Perilunate injuries load applied to thenar
  eminence forcing the wrist into extension and
  ulnar deviation
• Severe ligament injury necessary to tear the
  distal row from the lunate to produce perilunate
  dislocation
• Injury progresses through several stages
• usually begins radially destabilizes thru body
  of scaphoid (w/ fx) or thru scapholunate interval
  (w/ dissociation)
• scaphoid bridges the proximal and distal carpal
  rows
• w/ dislocation between these rows, the scaphoid
  must either rotate or fracture
• force is transmitted ulnarly thru the space of
  Poirier (between lunate and capitate)
• next force transmission disrupts the
  luno-triquetral articulation

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Evaluation

• Dorsal displacement of the carpus may be seen
• If lunate is dislocated, median nerve symptoms
  may be present.

107
Imaging

• Note lack of colinearity among the radius,
  lunate, and capitate on the lateral x-ray.

108
Imaging

• Note loss of normal carpal arcs and abnormal
  widening of the scapholunate interval.
• Look for associated fractures trans-scaphoid
  injuries

109
X-ray usually Obvious
110
X-ray may be subtle
111
Initial Treatment

• Closed reduction is performed with adequate
  sedation.
• Early surgical reconstruction if swelling allows.
  Immediate surgery needed if there are signs of
  median nerve compromise.
• Delayed reconstruction if early intervention is
  not feasible.

112
Technique of Closed Reduction

• Longitudinal traction for 5 -10 minutes
• For dorsal perilunate injuries apply dorsal
  directed pressure to the lunate volarly while a
  reduction maneuver is applied to the hand and
  distal carpal row
• Palmar flexion then reduces the capitate into the
  concavity of the lunate.

113
Closed Reduction and Pinning

• Poor results with closed reduction and pinning
  alone
• Very difficult to reduce adequately
• wrist needs to be ulnarly deviated to correct
  scaphoid flexion
• radial deviation needed to close S-L gap
• paradox of reduction

114
ORIF with volar and dorsal approaches Procedure
of choice
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116
Provisional closed reduction
117
Dorsal Approach
Repair S-L ligament
118
Volar Approach
119
Volar mid-carpal ligament tear
Lunate may be dislocated volarly
120
Reduce lunate first- temporary pinning to radius
121
Pin Carpus S-L, L-T and mid-carpal joints
122
Trans-scaphoid Perilunate Injuries

• Require reduction and fixation of the fractured
  scaphoid.
• Most of these injuries best treated by open volar
  and dorsal reduction and repair of injured
  structures.
• Open repair supplemented by pin and screw
  fixation.

123
Trans-scaphoid Perilunate Dislocations
124
Fix scaphoid first dorsal approach
125
Pin L-T and Mid-carpal joints
126
Make sure Radius-Lunate-Capitate are colinear
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128
Outcome of Perilunate Injuries

• 14 cases followed for mean of 8 years
• All treated operatively (avg 6 days post-injury)
• 11 dorsal approach
• 3 combined dorsal/volar approaches
• Mayo wrist scores
• 5 excellent
• 3 good
• 5 fair
• 1 poor
• All cases had radiographic arthrosis that did not
  correlate with Mayo scores.

Herzberg Forissier, J Hand Surg Br 27 498-502,
2002
129
Perilunate Injuries Conclusion

• Perilunate fracture dislocations are high-energy
  injuries
• Must recognize different injury patterns
• transcaphoid
• pure ligamentous
• trans radial-styloid
• Early open and anatomic fixation with volar and
  dorsal approaches is the best chance at a
  reasonable functional result

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