71: Open Reduction and Acute Repair of Perilunate Fracture-Dislocations

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Procedure 71 Open Reduction and Acute Repair of Perilunate Fracture-Dislocations

Louis W. Catalano, III , Christopher M. Jones

Indications

Acute and subacute (<6 weeks old) perilunate dislocations are seen.

Chronic perilunate dislocations (>7 weeks old) may be best treated with salvage procedures such as proximal row carpectomy or wrist fusion.

Examination/Imaging

Clinical Examination

Severe wrist edema, tenderness, and ecchymosis may accompany the extreme pain that the patient is experiencing.

Passive wrist motion is usually limited, painful, and disjointed (not smooth).

It is essential that a thorough neurovascular examination be performed to rule out acute carpal tunnel syndrome.

If numbness, tingling, and two-point discrimination worsen after closed reduction, immediate carpal tunnel release should be performed (along with open reduction and fixation).

If the neurovascular examination is improving or normal and a good reduction is achieved, the surgery can be performed electively.

Imaging

Lunate and perilunate dislocations are occasionally missed in the emergency room and dismissed as a severe wrist sprain despite having adequate imaging. Therefore, it is essential to obtain a thorough radiographic examination and scrutinize the images to prevent missing an acute injury.

A standard radiographic series of the wrist must be obtained to evaluate for dislocation. Assess for disruption of Gilula arc lines on the posteroanterior image. On a lateral radiograph, the radial shaft, lunate, capitate, and metacarpal shafts should be collinear (Fig. 71-1).

Radiographs should also be inspected to rule out associated radial styloid, scaphoid, capitate, or triquetral fractures (Fig. 71-2).

Computed tomography can help better define any questionable fractures of the carpal bones.

Magnetic resonance imaging is rarely used.

FIGURE 71-1

FIGURE 71-2

Surgical Anatomy

The dorsal radiocarpal and intercarpal ligaments are frequently ruptured in these severe injuries (Fig 71-3A).

The strong volar ligaments have a characteristic transverse rent that is repaired through the volar approach (Fig. 71-3B).

The lunate dislocates through the space of Poirier, a relatively weak region of the volar capsule just below the arc of the radioscaphocapitate and ulnocapitate ligaments (see Fig. 71-3B).

The dorsal portion of the scapholunate ligament is the thickest and strongest portion of the C-shaped ligament and should be repaired if adequate ligament tissue is present (Fig. 71-3C).

The short radiolunate ligament serves as the pivot for the lunate when it dislocates into the carpal tunnel. It also provides blood supply to the dislocated lunate to prevent avascular necrosis.

FIGURE 71-3

Positioning

The patient is positioned supine on the operating room table with the arm abducted on a radiolucent hand table.

A minifluoroscope is positioned vertically at the end of the hand table with the image intensifier under the table.

Five to 10 pounds of longitudinal traction using finger traps may be helpful to obtain and maintain lunate reduction and proper position of the carpal bones.

Exposures

A 7- to 8-cm longitudinal dorsal incision centered over the wrist is made, with exposure of the carpus through the third dorsal compartment (extensor pollicis longus [EPL] sheath).

An extended carpal tunnel release incision is also made at the wrist. This extends from the Kaplan cardinal line distally to 3 to 4 cm proximal to the distal wrist flexion crease (Fig. 71-4).

FIGURE 71-4

Pitfalls

A 90-degree angle should be made at the wrist flexion crease to prevent the longitudinal scar from creating a flexion contracture postoperatively.

Procedure

Step 1: Volar Approach

After the extended carpal tunnel incision, dissection is carried down through the transverse carpal ligament and distal antebrachial fascia to completely decompress the median nerve (Fig. 71-5).

The nerve and all flexor tendons are retracted to expose the floor of the carpal tunnel, the transverse ligamentous rent, and lunate within the carpal tunnel if it had not been previously reduced (Fig. 71-6).

The lunate can be manually reduced with dorsal pressure and some longitudinal traction.

The transverse ligamentous rent is repaired using multiple 3-0 braided nonabsorbable sutures (Fig. 71-7).

FIGURE 71-5

FIGURE 71-6

FIGURE 71-7

Step 1 Pearls

Frequently, osteochondral fractures of the lunate, scaphoid, capitate, and triquetrum are found and must be removed.

Exposure must extend ulnarly to the triquetrum to visualize the lunotriquetral (LT) joint.

Step 2: Dorsal Approach

After elevation and retraction of the EPL, deeper capsular exposure reveals the severe dorsal radiocarpal and intercarpal ligamentous damage (Fig. 71-8).

The ligament disruption often provides adequate exposure of the carpal bones; if not, a longitudinal capsulotomy is performed.

A 0.062-inch K-wire is inserted into the lunate to use as a joystick for reduction.

By means of the joystick, the lunate is made to be collinear with the longitudinal axis of the radius (as verified on the radiographs) and then held reduced with a temporary 0.062-inch dorsal radioulnate K-wire.

Alternatively, a K-wire can be placed retrograde from the capitate through the lunate to hold the lunate reduction. Unlike the radiolunate wire, this wire does not need to be removed at the completion of the surgery.

FIGURE 71-8

Step 2 Pearls

Perfect reduction of the lunate in the fossa and collinear with the radius shaft is the foundation on which the remainder of the carpus will be attached.

Step 3

A 0.062-inch K-wire is inserted into the scaphoid and used as a joystick to extend the scaphoid out of the flexed position.

Once a scapholunate angle of about 45 degrees is achieved, the scaphoid is pinned to the lunate and capitate using two to three 0.045-inch K-wires (Figs. 71-9 and 71-10).

FIGURE 71-9

FIGURE 71-10

Step 4

The LT joint is reduced with a fracture reduction clamp, and the reduction is verified on radiographs.

The LT joint is held with two 0.045-inch K-wires, and the triquetrum can be pinned to the hamate/capitate using another 0.045-inch K-wire (see Figs. 71-9 and 71-10).

Step 4 Pearls

Adequate reduction and fixation of the LT joint is often overlooked. Recall that this joint is completely disrupted (as is the scapholunate [SL] joint) and should be treated similarly.

Additional Steps

A tight dorsal capsular/ligament repair is performed using 3-0 nonabsorbable sutures to help fortify the intrinsic ligament repairs (Fig. 71-12).

Closure: Volar skin closure is achieved with 5-0 nylon sutures, and dorsal skin closure is achieved with 5-0 plain catgut sutures.

FIGURE 71-12

Hildebrand KA, Ross DC, Patterson SD, et al. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg [Am]. 2000;25:1069-1079.

These authors reviewed 22 consecutive patients (23 wrists) who underwent open reduction and internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches using intercarpal fixation only within the proximal carpal row. The follow-up period averaged 37 months. Motion was instituted an average of 10 weeks after injury. Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively. The authors found that the scapholunate angle increased and the revised carpal height ratio decreased over time. Three patients (3 wrists) required wrist arthrodesis, and a fourth patient had an immediate scaphoid excision and four-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched United States population values. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Despite this, 73% of all patients had returned to full duties in their usual occupations, and 82% were employed. (Level V evidence)

Trumble T, Verheyden J. Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire. J Hand Surg [Am]. 2004;29:412-417.

In this study, 22 patients were treated with a combined dorsal and volar approach with intraosseous wiring and pinning for isolated perilunate and lunate dislocations. Outcomes were assessed after an average of 49 months. The authors found that patient satisfaction was high in 15 of 22 patients, and 7 patients stated that they had problems with activities of daily living. Sixteen of the patients said that they were able to return to their previous level of activity. The wrist flexion-extension arc and grip strength averaged 80% and 77%, respectively, and follow-up radiographs showed no significant change in scapholunate angle or gap. The cerclage wire had to be removed in 16 patients. This study demonstrates a reasonable return to function and pain relief, given the magnitude of the injury, using a combined dorsal and volar approach with intraosseous cerclage wire. (Level V evidence)

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Operative Techniques Hand and Wrist Surgery