Bilateral Trans-Scaphoid Perilunate Fracture Dislocation

bilateral Trans-Scaphoid Perilunate Fracture DislocationBILATERAL TRANS-SCAPHOID PERILUNATE FRACTURE DISLOCATION OF THE CARPUS. (CASE REPORT)AbstractTrans- scaphoid perilunate switchs- crack-ups be r ar lesions. They occur in a high-energy suffering. The concomitent lesion of dickens(prenominal) wrists is exceptional. We explanation a case of bilateral trans-scaphoid perilunate dislocated wrist fracture in a 21-year-old earthly concern. The disturbance was treated by passed decrement and fractures by inner infantile arrested development. The functional resolution was satisfying by and by some(prenominal) old age of follow-up.IntroductionTrans-scaphoid perilunate fracture-dislocations argon relatively uncommon.1 These are the most common chassis of the complex carpal bone bone dislocations2,3 causing marked disruption of the carpal anatomy. clock from injury to preaching ( check in treatment), anatomic classication, and open or unkindly nature of the injury are the major work outs that determine the clinical outcome in trans-scaphoid perilunate fracture-dislocations.4,5Late presentation combined with missed diagnosis lots causes critical delay in the treatment of these injuries. If the swell phase is missed, then some authors recommend alternative procedures such as wrist arthrodesis and proximal row carpectomy which are relatively mutilating surgeries that leave a significant functional deficit.4,6,7 The acute phase is defined as the first week aft(prenominal) injury, whereas the retard phase is the period between the seventh and 45th twenty-four hour period and later onward 45 days the injury is said to be in the chronic phase.4We report the case of a long-suffering who referred to our department two weeks after the initial trauma with bilateral abaxial trans-scaphoid perilunate fracture-dislocations of the carpus. anatomic reduction, transcutaneous pin infantile fixing of the carpus and fixation of scaphoid fractures of bo th(prenominal) wrists were performed by opened reduction under fluoroscopic control.Presentation of caseA 21-year-old, right-hand-dominant man sustained an isolated injury to his both wrists after a refund from a height of approximately 4.5 m. The carpal injuries of both wrists were missed initially and both wrists had been bandaged for two weeks after the trauma. He was referred to our department two weeks later with increasing painful sensation.The patient reported that he fell on his outstretched hands with both wrists in extension. Both wrists were deformed in marked dorsiflexion, painful, swollen, and tender to palpation, with limitation of relocation. The patient complained of paresthesia in both of his hands. On sensible examination, meticulous cutaneous sensory mapping was performed of both hands to determine the area of decreased sensation. This was done with the use of the calculating end of a paperclip while applying a constant pressure. This revealed electric s ha ve gotr numbness in the median nerve distribution area of both hands (thumb, index, middle finger, and the stellate side of the ring finger). The two-point discrimination was usual on both sides. The mobility of the fingers was normal but painful, and there was a subtle decrase in grip strength of both hands. Motor power in abductor pollicis brevis and opponens pollicis muscles was full (5/5) on both sides. The Tinels sign was negative all over the carpal tunnel in both sides. The findings of the patient led us to think that there is non any condition like acute carpal tunnel syndrome collectable to fracture-dislocation.We thought that the numbness of the patient was due to temporary traction injury of the median nerve caused by dislocation on both sides. The vascular status was normal on physical examination. Study of the anteroposterior, oblique and lateral plane radiographs showed that the patient had bilateral dorsal trans-scaphoid perilunate fracture-dislocations of the c arpi (Fig. 1). According to the classification described by Herzberg et al., the fracture-dislocations were trans-scaphoid as path of trauma and Stage 1 as displacement of capitate on both sides.4The patient was advised about his pathology and advised to undergo surgery. If possible the patients mouthful was closed treatment. Therefore, we initially recommend closed reduction and transcutaneous fixation. However, if this was non possible or in the situation of a failure we informed him about the open procedure.Under general anesthesia, a closed reduction was attempted with traction manoeuvre described by Tavernier8under fluoroscopic control. The reduction was not satisfactory,we opted for the open reduction by posterior approach.After anatomical reduction was achieved, intercarpal fixation was utilize to carpal bones using three K-wires. The first K-wire was applied to scaphoide- lunate, the second K-wire was applied to- lunate-triquetrum and the third K-wire was applied to capi tatum-lunate. After the procedure, reduction and fixation of carpal bones was confirm under fluoroscopy. The same procedure was tell for the other wrist. We noticed that the scaphoid fracture was reduced spontaneously along with the reduction of the carpal bones. So we performed fixation of the odd scaphoid fracture using a 3.5 mm mini Acutrak headless compression know by means of the fracture line from a dorsal-proximal to a volar-distal direction. Intraoperative fluoroscopic control confirmed anatomic reduction of the scaphoid fracture.. Finally, standard radiograms were obtained and both wrists were immobilized in a short arm cast (Fig. 2).The patient noted complete comforter of symptoms the day after surgery. The pain and the paresthesia that the patient complained preoperatively was relieved dramatically and the function recovered. The post-operative period was uneventful. Four weeks after surgery, the casts and the K-wires were removed. New casts were applied for some ot her 4 weeks when spousal relationship was visible on radiographs. The casts were removed eight weeks after surgery. There was radiographic evidence of union of the scaphoid on the left side, but on the right side radiography revealed delayed union of the scaphoid. The patient subsequently underwent 3 months of intensive range-of-motion and muscle-strengthening exercises. Intermediate clinical and radiographic examinations were performed 6 and 12 months after surgery.At the two-year follow-up, the radiographs showed normal carpal bone relationships on both sides, complete union of the scaphoid on the left side(Fig.3). Wrist motion on the left side was minute with 70 of palmar flexion, 80 of dorsiflexion, full supination and pronation, full radial and ulnar deviation. The right wrist could achieve 60 of palmar flexion and 70 of dorsiflexion, full supination and pronation, but with a flabby decrease in radial and ulnar deviation. The grip strength of the right hand was 30 kg while t hat of the left side was 38 kg, measured with the Jamar dynamometer (J.A. Preston, Jackson, Michigan) .Fig.3 repair wrist and Left wrist anteroposterior and lateral view after two-years.At the two-year follow-up, the patient was symptom-free concerning median nerve functions. The patient was free of pain on the left side. On the right side there was mild pain with wrist motions due to non-union of the scaphoid.The patient was able to perform activities of nonchalant living and he had returned to all of his previous activities. The functional outcome was favourable on the left side, with a mayonnaise wrist score of 80/100. The functional outcome was satisfactory on the right side, with a Mayo wrist score of 65/100. Radiographs of both wrists revealed no evidence of radiocarpal or midcarpal arthritis. No osteonecrosis of the lunate or the scaphoid was evident. The lunate position was correct, without signs of unbalance. Anatomic relationships of the carpal bones were maintained.Dis cussion Carpal fracture-dislocations are rare injuries thence their classification and treatment are rather difficult. Osseous variants of this injury are common the trans-scaphoid perilunate fracture-dislocation constitutes 61% of all perilunate dislocations and 96% of fracture-dislocations.4 The trans-scaphoid perilunate fracture-dislocation is an uncommon injury sustained due to force transmission done a hyperextended wrist.9,10These injuries may be easily overlooked or misdiagnosed.4 After a delay in diagnosis of several weeks or months, the clinical prognosis is poor compared with injuries that are treated acutely.11 According to the classification described by Herzberg et al., we initially diagnosed our patient in the delayed phase.4Regarding the literature, the management of such injuries in case of delayed presentation is rare.12,13Dislocation in this region requires rapid realignment, as untreated perilunate dislocation will lead to serious secondary damage.13,14Perilunat e fracture-dislocations are high-energy injuries, produced by wrist hyperextension.3,15 There is disruption of the palmar capsuloligamentous complex, starting radially and propagating through the carpus in an ulnar direction.3,15 This dislocation takes a transosseous route through the scaphoid resulting in a trans-scaphoid perilunate fracture-dislocation.10 In trans-scaphoid perilunate dislocations the fractured scaphoid is the initial destabilizing factor of the carpus.16 Regarding the literature, we believe that the mechanism of injury in our patient was fall from a height on the outstretched hands.Treatment options currently used for perilunar instability patterns include closed reduction and cast immobilization, closed reduction and percutaneous pinning, and open reduction. As the awareness of the anatomy and biomechanics of these injury patterns has evolved, authors have tended toward treatment approaches that attempt to repair the injured intrinsic and extrinsic carpal ligamen ts, that is, open techniques.4,8,11Most authors agree that closed reduction is the initial treatment of plectron for trans-scaphoid perilunate fracture-dislocations.2,8,17 In addition, treatment often requires intercarpal fixation within the proximal carpal row. Most authors have agreed that the key to a good clinical result in the management of trans-scaphoid perilunate dislocation is the anatomic union of the scaphoid and the riposte of proper alignment of the carpal bones.17In this case, we prefer a opened reduction and intercarpal fixation with K-wires, as well as chouse fixation of the scaphoid, because we didnt achieve a good fracture alignment after closed reduction .Gellman et al. suggested that anatomical reductions of the scaphoid, as well as the mid-carpal joint, and the restoration of the articular surface of the lunate are the most important aspects ascertain the prognosis.11An open reduction further increases the risk of a scaphoid consanguinity supply interruptio n, whereas percutaneous screw fixation of the scaphoid minimizes this risk.3,17,18 In addition, a rigid fixation with a percutaneous screw can besides reduce the immobilization period and allow for an earlier rehabilitation. Acutrak screw fixation allows earlier discontinuance of the cast than K-wire fixation. In our case, the range-of-motion exercises of the wrist were started earlier after the initial operation.The nonunion rate was relatively higher in the series that were treated by closed reduction.19,20 In our case study the radiographs obtained two years after surgery revealed a non-union of the right scaphoid. We believe that the delay in treatment and maybe the malrotation of the scaphoid that we overlooked on the initial radiographs led to the interruption of the blood supply which was possibly responsible for the non-union of the scaphoid. patronage the non-union of the scaphoid, the functional outcome of our patient was satisfactory, with mild pain, good range of movem ent and good grip strength. Similarly, Herzberg et al.4 reported that unsatisfactory radiographs did not equate to a poor clinical outcome. We planned to perform open reduction and internal fixation with grafting for the non-union of the right scaphoid.ConclusionAs the injury have led bilateral dorsal trans-scaphoid perilunate fracture-dislocations,we therefore recommend minimally encroaching(a) techniques if an anatomical closed reduction anda percutaneous rigid fixation of the scaphoid is achieved on the intraoperative evaluations.