Combined Perilunate and Axial Ulnar Dislocation of the Wrist

Abstract

Disruption of the carpal ligaments or fracture of the carpal bones can occur in almost any combination. Axial injuries are rare, devastating, and almost always open and result from disruption of the transverse carpal arches and the longitudinal columns. We investigated a clinical case of palmar dislocation and coronal fracture of the lunate, associated with axial carpal injury of the strong capitohamate and lunotriquetral ligaments with related injuries is the subject of this paper. To our knowledge, there is no previous literature on this injury combination (peri-/translunate, perihamate, peritriquetral carpal dislocation). Our aim is to present novel information on the subject. Case ReportA 54-year-old, right-dominant man presented after a road accident in which high-energy forces caused injury to his right wrist (►Figs. 1 and 2). The patient fell asleep while driving his 4-wheel-drive vehicle and collided head-on with a truck at a high speed. He sustained a mild concussion of the brain, a chest contusion, and an open injury of the wrist. Wound revision, closed reduction, and emergency-pinning of the lunate was done the day after the injury at a local hospital. The initial hospitalization was 4 days where the patient underwent antibiotic therapy 3 Â 1.2 g Phenoxymethylpenicillin intravenously, elevation of the extremity and pain treatment. On admission to our hospital, there was substantial swelling of the injured hand and wrist, but there were no signs of infection or any neurologic symptoms. We found three small wounds, all less than 1 cm in length, palmar, between the thenar and hypothenar. Plain x-rays revealed a poor position of the k-wires. There was no congruency in any of the carpal arches and further surgery was required. Accordingly, 7 days after the primary injury, we performed surgery using both a volar and dorsal approach. Starting on the volar side, with incision from the proximal palmar crease to the proximal wrist flexion crease, we found the transverse ligament of the carpal tunnel ruptured (this injury was indicative of high-energy trauma), but the median nerve was macroscopically intact. The lunate was only attached by the short radiolunate ligament and was nonviable to gross inspection. The lunate was excised using the volar approach. On the dorsal longitudinal approach (underneath the fourth extensor tendon compartment), we found that the radial styloid was fractured with some comminution of the dorsal cortex and subluxations of the 2nd and 3rd CMC joints. Proximal row carpectomy was then performed using a dorsal approach. Keywords► axial carpal injury ► capitohamate injury ► perilunar injury ► lunate fracture ► axial dissociation AbstractCarpal axial injuries are rare and devastating and can be difficult to classify because of various possible injury combinations. A 54-year-old man was involved in a road accident, resulting in serious injury to his dominant right wrist. An axial injury between the capitate and the hamate was combined with open perilunate dislocation and fracture, metacarp...

Traumatic Carpal Axial Instability in a Professional Football Player

“…There have been only 5 published cases describing capitohamate dissociation (axial carpal arch injury) in combination with some type of perilunar injury (transverse carpal arch injury). 3 , 8 - 11 Most of these reports describe high-energy injuries associated with automobile accidents. The treatment of these injuries has varied from closed reduction and casting, percutaneous pinning, and dorsal or combined volar and dorsal ligament repair with open reduction internal fixation.…”