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Introduction
Perilunate injuries or dislocation of the carpus relative to the lunate, which remains in normal alignment with the distal radius, were relatively uncommon. 25% of those were missed at the initial evaluation. The injuries frequently occurred after severe accident. The transscaphoid perilunate fracture-dislocation was accounted for 61% 1of those injuries. Initial treatment began in the emergency operating room. The traction immediately applied on wrist joint to restore bony alignment. The reduction maneuver described by Tavernier 2,3should be administered. This was followed by the operative treatments: open reduction and internal fixation or percutaneous reduction and internal fixation to restore the bones and joint positions around lunate (scaphocapitate, triquetrocapitate and lunotriquetral joints) with Kirschner wire and fixation of scaphoid fracture with headless compression screw. The open reduction could however result in limited range of motion and limited grip strength as the procedure inevitably causes tissue and ligament damage 4,5 .The percutaneous reduction and internal fixation of scaphoid could be indicated if the appropriate closed reduction was achieved. This procedure would result in less damage to surrounding tissue and ligaments 6 .Therefore this study aimed to report a series of 10 cases that underwent the percutaneous fixation of transscaphoid perilunate fracture-dislocation.
Materials and Methods
This is a retrospective study reporting 10 patients who were treated at Khon Kaen Hospital between July 2016 and December 2017. Radiographs from all patients were evaluated and classified into different patterns of injuries according to Herzbergs classification 1 which is based on position of lunate (Figure 1). Then under general anesthesia, the traction was applied to the wrist joint. The arm was suspended with 10 lbs when the elbow was flexed at 90 degree for 10-15 minutes. This was followed by the traction on the extended wrist. The surgeons thumb was placed on the lunate volarly, and then the wrist was flexed, with traction still maintained, to restore position of capitates on lunate. The quick administration of maneuver was recommended as this would ease the reduction. The slow administration may result in failure and may indicate further open reduction. Then the radiographs were examined if the relative positions of the bones were appropriate based on scapholunate gap, scapholunate angle, lunocapitate angle, modified carpal height ratio7 and scaphoid fracture. The percutaneous reduction was followed with a small, less than 5 mm incision for internal fixation of scaphoid with headless compression screw (2.4 mm) and internal fixation of lunate: scaphocapitate, triquetrocapitate and lunotriquetral joints with Kirschner wires. In patients with compressive neuropathy of median nerve, the corrective operation would be carried out simultaneously. After the surgery, the short arm slab was casted for two-week wearing and it would be re-casted for a total of 6 weeks wearing. The casts and wires were removed at the same visit, 6 weeks after surgery. Then the patients started physical therapy program. The follow-up were appointed at 2 weeks, 6 weeks, 3 months and 6 months after surgery. The measuring outcomes included Mayo Wrist Score 8 (Table 1) and radiographic parameters measured from radiographs at the last follow-up ( 6 months after surgery).
Figure 1 illustrate the pattern and progression of perilunate dislocation and transscaphoid fracture-dislocation. It shows the relative movement/dislocations of lunate, capitates and radius. Stage I: lunate is still maintained its position at radius; Stage IIa: lunate is volarly dislocated but rotates less than 90 degree; Stage IIb: lunate is volarly dislocated and rotates more than 90 degree(1).
Surgical procedures
All 10 patients were operated by a principal investigator using percutaneous fixation with headless compression screw (2.4 mm) for scaphoid and Kirschner wires (1.6 mm) for scaphocapitate, triquetrocapitate and lunotriquetral joints. In some patients with compressive neuropathy of median nerve after injury, the procedure would include release of the entrapped nerve using volar standard approach as shown in Figure 2.
Mayo Wrist Score
Table 1 shows Mayo Wrist Score
|
Pain (25 points) |
25 points No pain |
Range of Motion (25 points) Both hands are examined. (Percentage of contra lateral side range) |
25 points 100% |
|
|
20 points Mild, occasional |
|
15 points 75-99% |
|
|
15 points Moderate, tolerable |
|
10 points 50-74% |
|
|
0 points Severe to intolerable |
|
5 points 25-49% |
|
Functional status (25 points) |
25 points Returned to regular employment |
|
0 points 0-24% |
|
|
20 points Restricted employment |
Grip strength (25 points ,percentage of contralateral side range) |
25 points 100% |
|
|
15 points Able to work, unemployed |
15 points 100% |
|
|
0 points Unable to work because of pain |
10 points 50-75% |
|
|
|
|
5 points 25-50% |
|
|
|
|
0 points 0.-25% |
|
Excellent: 90-100 points, Good: 80-89 points, Fair: 65-79 points, Poor : less than 65 points |
Result
10 patients were recruited for this study. They were 8 males. The average age was 29 ± 7.84 years (range: 20 - 43 years). The mechanism of transscaphoid perilunate fracture-dislocation started with falls from a height (5 cases), road traffic injury (4 cases) and falls (1 case). They were dislocated dorsally. There were associated median nerve injuries in 3 cases. The average duration between time of injury, diagnosis and reduction was 2.6 ± 3.06 days (range: 1 11 days). The average duration between time of injury and surgery was 11.8 ± 6.33 days (range: 3 -24 days). The longest duration was when the patient was referred from other province (Bangkok) but the patient had been initially treated with the closed reduction. All patients were classified according to Herzbergs classification based on lunate dislocation. The scaphoid fracture configurations were all waist (two patients had comminution pattern) as shown in Table 2. There were 3 cases presenting with other associated injuries: 1 case with severe head injury (case #9), 1 case with mild head injury and clavicle fracture (case #8), and 1 case with 4th metacarpal fracture (case #5).
After the surgery, the radiographs from all patients were examined using measuring outcomes at shown in Table 3 and were evaluated after 6 months follow-up (short term). It was found that the averaged total range of flexion-extension and the averaged grip strength (kg) of the affected side (kg) were 76.26% ± 4.42% and 77.04% ± 1.01% respectively, of those measured from the contralateral side. The averaged total range of motion was 116 ± 10.22 degrees. According to Mayo Wrist Score, it was found that the averaged point was 74.5 ± 8.64 points and classified as Excellent (n=1), Good (n=3), Fair (n=5) and Poor (n=1).
Table 2 Demographic information of the study population, clinical presentation, range of motion, grip strength and Mayo Wrist Score.
|
Case ID |
Age |
Gender |
The averaged duration between time of incidence and surgery |
Herzberg classification |
Scaphoid fracture configuration |
Range of Motion (degree/% of contra lateral side range) |
Grip strength (Kg/% of contralateral side range) |
Modified Mayo Wrist Score |
|
1 |
32 |
Male |
10 |
I |
Waist, comminution |
130/83.8 |
35.1/78.0 |
80 |
|
2 |
26 |
Male |
5 |
I |
Waist |
135/81.8 |
28.4/75.7 |
80 |
|
3 |
20 |
Female |
15 |
I |
Waist |
110/75.8 |
18.2/75.0 |
70 |
|
4 |
21 |
Male |
9 |
I |
Waist |
110/75.9 |
46.3/99.3 |
90 |
|
5 |
29 |
Male |
3 |
IIa |
Waist, comminution |
110/75.8 |
28.3/77.5 |
80 |
|
6 |
22 |
Male |
14 |
I |
Waist |
120/77.4 |
33.5/78.8 |
70 |
|
7 |
25 |
Male |
24 |
I |
Waist |
105/67.7 |
18.5/56.57 |
60 |
|
8 |
40 |
Male |
13 |
IIa |
Waist |
105/75.0 |
29.5/77.0 |
75 |
|
9 |
32 |
Male |
18 |
I |
Waist |
120/78.7 |
27.5/75.5 |
65 |
|
10 |
43 |
Female |
7 |
IIb |
Waist |
115/76.7 |
28.4/76.9 |
75 |
Table 3 shows treatment outcomes from radiographic examination.
|
|
Scapholunate gap (mm) |
Scapholunate angle (degrees) |
Modified carpal height ratio (degrees) |
Lunocapitate angle (degrees) |
|
Mean |
1.33 |
58.16 |
1.51 |
13.23 |
|
Range |
1.05 - 1.53 |
51.48 68.14 |
1.43 1.61 |
2.38 18.09 |
|
Standard deviation |
0.16 |
5.62 |
0.06 |
5.8 |
Figure 2 illustrates transscaphoid perilunate fracture-dislocation Pattern IIa according to Herzbergs classification; (Figure A, B) show anteroposterior and lateral X-ray images of the wrist before the intervention; (Figure C, D) show anteroposterior and lateral X-ray images of the wrist after the treatment/intervention ( with associated 4th metacarpal fracture).
Discussion
The transscaphoid perilunate fracture-dislocation was commonly found in severe high energy trauma such as falls from a height or road traffic accident. The reported rate of missed initial diagnosis was 25% and in some studies the rate could even reach 63.6% 1,9 . In our study, 9 out of 10 patients were initially diagnosed. The next step of intervention was a closed reduction. 50% of all patients were treated within the first day, 4 patients were treated within 3 days. In one patient, the diagnosis was delayed 7 days after the injury, so the reduction was administered on day 11th, then he underwent surgery. It can be seen that there was considerably delayed surgical preparation (averaged waiting duration 11.8 ± 6.33 days (range: 3 24 days)) due to general management of the operating theater.
According to Herzberg and his colleagues, they found that delayed surgery affected the prognosis. Clinical scoring described by Green and OBrien from a group of patients who had delayed surgery within 7 days after the injury and a group of patients with delayed surgery between 7 and 45 days were 80 and 71 respectively (p value = 0.07). Similarly, the study carried out by Komurcu and colleagues showed Clinical scoring from two groups: a group with early treatment (surgery within 7 days) (n=6) and other group with delayed treatment (delayed surgery within 7-40 days) (n=6) were 89.2 and 72.5 respectively. The study carried out by Gupta and colleagues showed that treatment outcomes from a group of patients who underwent surgery within 6 weeks was better than those from a group who underwent surgery after 6 weeks. This result was statistically significant (p < 0.05). In this study, similarly, a group with early treatment (surgery within 10 days after injury) (n= 5) showed better measuring outcomes than those from a group with a delayed surgery after 10 days (n=5). The averaged ranges of motion were 120 ± 1.17 degrees and 112 ± 7.58 degrees, the averaged grip strength were 81.49 ± 9.99 และ 72.58 ± 9.07 and Mayo Wrist Scores for both groups were 81 ± 5.47 และ 68 ± 5.7 respectively 1,9,10.
Moreover, restoration of bony alignment to their anatomical positions and accurate articulation affects the treatment outcomes. The outcomes were measured from radiographs. In this study, scapholunate gap, lunocapitate angle and modified carpal height ratio were measured and were within normal range. However, the averaged scapholunate angle was 58.16 ± 5.62 degrees. This value is relatively high when compared with other studies e.g. the studies carried out by Chou with his colleagues (49 degrees) and Komurcu with his colleagues (47.5 degrees). The reasons for the differences from previous studies could be the chosen surgical techniques. The surgical techniques described by Chou and colleagues utilized 2 mm Kirschner wire to fix capitates and lunate together. This was to stabilize them for 8 weeks. On the other hand, the study carried out by Komurcu and colleagues chose the open dorsal approach and, if necessary, combined with volar approach as well in order to appropriately restore bony alignment. The open reduction is common in the treatment of transscaphoid perilunate fracture-dislocation because the restoration of bony alignment could be directly visualized but it results in large incision. Therefore, the combined approach is common resulting in 6-8 cm incision with partial retraction of ligaments around the wrist. In this study, the surgical method resulted in less than 5 mm incision. It was expected that the measuring outcomes including the range of wrist motion and the grip strengths as a result of this technique were better than the conventional open reduction. The averaged range of motion and averaged grip strength were 76.86% ± 4.42% and 77.04% ± 1.01% respectively, relative to the contralateral side. These values were similar to those reported in Forli and colleagues study ( 76% and 87%) but the averaged grip strength was higher than those from studies carried out by Hildebrand and colleagues (57% and 73%) and Kara and colleagues (the averaged grip strength was 63.4%)6,1014.
Therefore, the outcomes which consists of range of motion, grip strength and Mayo Wrist Score from the treatment of transscaphoid perilunate fracture-dislocation with percutaneous fixation are similar to those outcomes from the open reduction including dorsal, volar and combined approaches. However, the author believe that small incision would minimize damage on surrounding tissue and minimally disturb blood vessels around scaphoid. So, scaphoid could be quickly healed and joint contracture could be minimized. Another option for the treatment is an arthroscopic-assisted surgery. The outcomes from two groups of patients: the patients underwent the arthroscopic-assisted surgery and the patients underwent conventional open reduction were compared. The arthroscopic assisted surgery resulted in the patients with better range of motion but the grip strength and Mayo Wrist Score were similar to those resulted from the patients underwent the open surgery. Meanwhile, the other study on the arthroscopic assisted surgery reported range of motion and grip strength 79% and 78% respectively. These are similar to the results from our study. Therefore, the arthroscopic assisted surgery is likely to be a recommended treatment for transscaphoid perilunate fracture-dislocation 15,16.
There are a few limitations in this study. This is a retrospective study with small sample size. The follow-up period is short and many patients presented with associated juries which could affect the outcomes of the intervention in this study. Moreover, there is only one type of treatment administered without any comparisons which could be other surgical techniques including an open surgery and an arthroscopic assisted surgery.
Conclusion
The transscaphoid perilunate fracture-dislocation is the severe injury. The early diagnosis and early treatment would be recommended. Recently there has not been any standard surgery recommended as Best Practice. In this study, percutaneous fixation technique had acceptable short-term outcomes. However, an arthroscopic assisted surgery is likely to be a recommended treatment for transscaphoid perilunate fracture-dislocation in the future.
Reference
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