[Stabilization of perilunate and transscaphoid perilunate fracture-dislocations via a combined palmar and dorsal approach]

Abstract

Objective: Restoration of the intercarpal alignment and the radio- and ulnocarpal joint in order to avoid the development of a carpal collapse with concomitant arthritis of the radiocarpal and midcarpal joint.

Indications: All perilunate and transscaphoid perilunate fracture-dislocations. An exception is a pure ligamentous injury with anatomic carpal alignment following closed reduction (computed tomography scan).

Contraindications: General contraindications to an operative procedure.

Surgical technique: It is crucial that all involved bony and ligamentous structures are addressed, using a bilateral approach. Depending on their location, scaphoid fractures are stabilized from proximal or distal, and bony avulsions are fixed at their origin. The typical rent across the palmar ligaments is closed, and the avulsed scapholunate ligament and the dorsal intercarpal ligament are reattached to the adjacent bones. Temporary Kirschner wire fixation is essential for healing.

Postoperative management: Forearm plaster cast with short thumb for 12 weeks. Kirschner wire removal after 8 weeks.

Results: 25 patients (15 perilunate dislocations and ten perilunate fracture-dislocations) could be included for follow-up 5 years after the trauma. Perilunate fracture-dislocations achieved slightly better results than perilunate dislocations. The DASH Score (Disability of the Arm, Shoulder and Hand) averaged 11.3 and 14.2 points, the PRWE Score (Patient- Related Wrist Evaluation) 20.7 and 27.7 points, respectively. The Mayo Wrist Score amounted to 81.5 and 82.7 points. Active range of wrist motion was reduced by one third compared with the opposite side. Grip strength was reduced by 15-20%. The pain level ranged between 2 and 4 on a scale from 0 to 10. In pure ligamentous injuries, degenerative arthritis was more common in the midcarpal joint, whereas radiocarpal arthritis predominated in the fracture-dislocation group.