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Two stage procedure for neglected transscaphoid perilunate dislocation.

Lal H, Jangira V, Kakran R, Mittal D - Indian J Orthop (2012)

Bottom Line: In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue.In the next stage open reduction and internal fixation was done by a combined volar and dorsal approach augmented by pronator quadratus flap.At 3 years followup the patient was pain free and had a full range of supination pronation of the forearms and radial and ulnar deviation of wrist with 10° dorsiflexion deficit.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Chandigarh, India.

ABSTRACT
We report a two-staged surgical procedure for neglected 3 month old volar transscaphoid, transcapitate perilunate fracture dislocation wrist in an 18 year old right handed male student. The lunate with proximal scaphoid and proximal capitate maintained its articulation with distal end radius while the rest of carpal bones had dislocated volarly. In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue. In the next stage open reduction and internal fixation was done by a combined volar and dorsal approach augmented by pronator quadratus flap. At 3 years followup the patient was pain free and had a full range of supination pronation of the forearms and radial and ulnar deviation of wrist with 10° dorsiflexion deficit.

No MeSH data available.


Related in: MedlinePlus

(a) Immediate postoperative radiograph; red arrow showing K-wires fixing fracture scaphoid and blue arrow showing wire fixing lunate to capitate. (b-f). Postoperative CT scans: yellow arrow – wires in scaphoid; red arrow: wires fixing lunate to capitate
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Figure 3: (a) Immediate postoperative radiograph; red arrow showing K-wires fixing fracture scaphoid and blue arrow showing wire fixing lunate to capitate. (b-f). Postoperative CT scans: yellow arrow – wires in scaphoid; red arrow: wires fixing lunate to capitate

Mentions: We planned two stage treatment. In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue symmetrically, decreasing the risk of neurovascular traction injury and making subsequent open reduction and internal fixation surgery easier [Figure 2a]. The wrist was distracted daily by half a turn/half mm; the distractor was removed after 3 weeks when adequate space, approximately equal to the height of capitate bone, was created between the lunate and third metacarpal on lateral view of the wrist [Figure 2b]. In the next stage, open reduction and internal fixation was done by a combined volar and dorsal approach to the wrist joint. Initially, through a volar approach, the carpal tunnel was released, pronator quadratus osteoperisosteal muscular flap raised, and the scaphoid proximal fracture fragment with lunate was exposed. Then, realignment of the bones was assisted by a second longitudinal dorsal incision. No damage to the articular surface of the proximal fragment of capitate was noted. The scaphoid fracture was reduced and fixed by two 1.5-mm Kirschner wires augmented by the pronator quadratus osteoperisosteal muscular flap [Figure 3a]. The lunate, which was denuded of soft tissue attachments on ulnar side, was stabilized with one Kirschner wire to the capitate (fixing the capitate fracture also) and third metacarpal and the other to the scaphoid [Figure 3b–f]. The width of the pronator quadratus flap was marked up to 1.5 cm at its insertion on the volar aspect of radius. The osteoperisosteal muscular flap was then attached across the scaphoid fracture site and the proximal muscle sleeve's distal part was sutured to the partially ruptured volar radioscaphocapitate ligament as an augment [Figure 4]. Use of musculoperiosteal flaps in fracture neck femur has given good results;10 the same principle prompted us to use such a procedure for fracture scaphoid in our case. Lunotriquetral ligament repair was not possible due to old nature of injury, but augmentation was done by dorsal capsulodesis and adjacent extensor indicis tendon flap. After the reduction and fixation of the bones to their normal position, an above elbow thumb spica slab was applied in functional position of hand and forearm.


Two stage procedure for neglected transscaphoid perilunate dislocation.

Lal H, Jangira V, Kakran R, Mittal D - Indian J Orthop (2012)

(a) Immediate postoperative radiograph; red arrow showing K-wires fixing fracture scaphoid and blue arrow showing wire fixing lunate to capitate. (b-f). Postoperative CT scans: yellow arrow – wires in scaphoid; red arrow: wires fixing lunate to capitate
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3377149&req=5

Figure 3: (a) Immediate postoperative radiograph; red arrow showing K-wires fixing fracture scaphoid and blue arrow showing wire fixing lunate to capitate. (b-f). Postoperative CT scans: yellow arrow – wires in scaphoid; red arrow: wires fixing lunate to capitate
Mentions: We planned two stage treatment. In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue symmetrically, decreasing the risk of neurovascular traction injury and making subsequent open reduction and internal fixation surgery easier [Figure 2a]. The wrist was distracted daily by half a turn/half mm; the distractor was removed after 3 weeks when adequate space, approximately equal to the height of capitate bone, was created between the lunate and third metacarpal on lateral view of the wrist [Figure 2b]. In the next stage, open reduction and internal fixation was done by a combined volar and dorsal approach to the wrist joint. Initially, through a volar approach, the carpal tunnel was released, pronator quadratus osteoperisosteal muscular flap raised, and the scaphoid proximal fracture fragment with lunate was exposed. Then, realignment of the bones was assisted by a second longitudinal dorsal incision. No damage to the articular surface of the proximal fragment of capitate was noted. The scaphoid fracture was reduced and fixed by two 1.5-mm Kirschner wires augmented by the pronator quadratus osteoperisosteal muscular flap [Figure 3a]. The lunate, which was denuded of soft tissue attachments on ulnar side, was stabilized with one Kirschner wire to the capitate (fixing the capitate fracture also) and third metacarpal and the other to the scaphoid [Figure 3b–f]. The width of the pronator quadratus flap was marked up to 1.5 cm at its insertion on the volar aspect of radius. The osteoperisosteal muscular flap was then attached across the scaphoid fracture site and the proximal muscle sleeve's distal part was sutured to the partially ruptured volar radioscaphocapitate ligament as an augment [Figure 4]. Use of musculoperiosteal flaps in fracture neck femur has given good results;10 the same principle prompted us to use such a procedure for fracture scaphoid in our case. Lunotriquetral ligament repair was not possible due to old nature of injury, but augmentation was done by dorsal capsulodesis and adjacent extensor indicis tendon flap. After the reduction and fixation of the bones to their normal position, an above elbow thumb spica slab was applied in functional position of hand and forearm.

Bottom Line: In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue.In the next stage open reduction and internal fixation was done by a combined volar and dorsal approach augmented by pronator quadratus flap.At 3 years followup the patient was pain free and had a full range of supination pronation of the forearms and radial and ulnar deviation of wrist with 10° dorsiflexion deficit.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Chandigarh, India.

ABSTRACT
We report a two-staged surgical procedure for neglected 3 month old volar transscaphoid, transcapitate perilunate fracture dislocation wrist in an 18 year old right handed male student. The lunate with proximal scaphoid and proximal capitate maintained its articulation with distal end radius while the rest of carpal bones had dislocated volarly. In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue. In the next stage open reduction and internal fixation was done by a combined volar and dorsal approach augmented by pronator quadratus flap. At 3 years followup the patient was pain free and had a full range of supination pronation of the forearms and radial and ulnar deviation of wrist with 10° dorsiflexion deficit.

No MeSH data available.


Related in: MedlinePlus