Neurobionplus
Home About Journal AHEAD OF PRINT Current Issue Back Issues Instructions Submission Search Subscribe Blog    
Login 

Users Online: 237 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
 


 
 Table of Contents    
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 45  |  Issue : 5  |  Page : 427-431
Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation


Department of Orthopedics, PGIMER, Chandigarh, India

Click here for correspondence address and email

Date of Web Publication18-Aug-2011
 

   Abstract 

Introduction: Management of neglected perilunate dislocations is controversial. The various procedures such as open reduction and internal fixation (ORIF), proximal row carpectomy, lunate excision, and wrist arthrodesis have been advocated. The aim of our study was to evaluate the functional outcome of neglected perilunate dislocations managed by ORIF.
Materials and Methods: Over a period of 10 years (1996 to 2006), 14 patients with neglected perilunate dislocations (undiagnosed or untreated for 6 weeks or more) were managed by ORIF. Six patients had dorsal trans-scaphoid perilunate dislocation, 6 patients had volar lunate dislocation while the remaining two had a dorsal perilunate dislocation The results were evaluated by clinical scoring system of Cooney et al.
Results: The average followup was 4.1 years (range 2-12 years). All except one of the patients operated earlier than 5 months had good results. Of the four patients operated after 5 months, two had a fair result while two had a poor outcome. Chondral damage to the capitate was noted intraoperatively in both the cases with poor outcomes. The two patients were found to have avascular necrosis (AVN) of the lunate; however, functional outcome was fair in both, and both were able to return to their profession.
Conclusion: We observed favorable functional results of ORIF in neglected perilunate dislocations up to 5 months after injury. The development of AVN or midcarpal arthritis was not a major disabling factor as long as stability of wrist has been restored. Beyond 5 months, an alternative surgical procedure such as proximal row carpectomy should be contemplated as results of ORIF have not been good uniformly.

Keywords: Carpal, neglected, open reduction internal fixation, perilunate dislocation

How to cite this article:
Dhillon MS, Prabhakar S, Bali K, Chouhan D, Kumar V. Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation. Indian J Orthop 2011;45:427-31

How to cite this URL:
Dhillon MS, Prabhakar S, Bali K, Chouhan D, Kumar V. Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation. Indian J Orthop [serial online] 2011 [cited 2019 Jun 24];45:427-31. Available from: http://www.ijoonline.com/text.asp?2011/45/5/427/83138

   Introduction Top


Perilunate injuries are high energy injuries and encountered in young adults. [1] Up to 25% are diagnosed late, either due to delay in presentation, poor interpretation of radiographs or due to associated injuries that require more urgent attention. [1],[2],[3] Patients who present within 6 weeks of injury are managed in a manner similar to acute injuries. [3],[4] The treatment in such cases is accurate reduction, ligament reconstruction, and stable fixation till the construct is healed. [5],[6] However, in neglected cases there is no consensus on the most appropriate treatment method. [5] The alternative procedures such as proximal row carpectomy, [7],[8] lunate excision, [9],[10] and wrist arthrodesis are described. [11] Some have even reported long-term good results with an unreduced dislocation. [12]

We present a retrospective analysis of functional outcome of perilunate dislocation managed with ORIF.


   Materials and Methods Top


Fourteen patients between 1996 and 2006 with neglected perilunate dislocations were treated. One patient had bilateral volar lunate dislocation. The cases were classified as neglected if these were undiagnosed or untreated for 6 weeks or more.

Out of 14 patients, 10 cases were initially managed in peripheral centers where the diagnosis was missed. Three patients got treatment from osteopaths. The patient with bilateral volar lunate dislocation remained undiagnosed due to polytrauma and associated head injury. The diagnosis was made subsequently when an attempt was made to mobilize the patient with crutches and he complained of pain in both wrists. The average age of these patients was 34.6 years (range 21 - 48 years).The age with a predominance of males (12 males, 2 females). The dominant hand was involved in 11 patients, non-dominant side in 2 patients, and 1 patient had bilateral involvement. The treatment delay is ranged from 6 weeks to 1.5 years [Figure 1].
Figure 1 (a and b): Anteroposterior and lateral views of wrist showing dorsal transscaphoid perilunate dislocation

Click here to view


Out of 14 cases, 6 patients had a dorsal trans-scaphoid perilunate dislocation, 2 patients had a dorsal perilunate dislocation, and 6 patients had a seven volar lunate dislocation with one patient having bilateral volar lunate dislocation. All the patients had painful restriction of wrist movements or weak grip strength. Four patients with volar lunate dislocation had symptoms of chronic median nerve compression; one patient with bilateral volar lunate dislocation had symptoms of median nerve dysfunction in one hand and ulnar nerve dysfunction in the other.

Open reduction was performed through the dorsal approach in eight patients (six with dorsal trans-scaphoid perilunate dislocation and two with dorsal perilunate dislocation). The dense fibrous tissue from the carpal joint spaces using a fine bone nibbler was removed. The scaphoid fracture surfaces were freshened using a fine curette. Manual longitudinal distraction was then applied intraoperatively. A blunt small curved periosteum elevator was used to carefully shoe-horn or lever the capitate into the lunate fossa and reduce the luno-capitate joint. In two patients with dorsal perilunate dislocations, two 1.5 mm K-wires were used as joysticks in the scaphoid and lunate. The lunate was flexed and the scaphoid extended, while an assistant drove K-wires across scapho-lunate, luno-triquetrum, and capito-lunate articulations. The scaphoid fractures in the six patients with dorsal trans-scaphoid perilunate dislocations were fixed using Herbert screws. Bone grafting was done in all six cases with graft taken from the distal radius. Combined volar and dorsal approach was used in the six patients with seven volar lunate dislocations. The volar approach enabled decompression of the median nerve and facilitated clearing of the lunate fossa and subsequent lunate reduction. K-wires were used to stabilize the scapho-lunate, luno-triquetrum, and capito-lunate articulations. The capsular rents were repaired using reabsorbable sutures.

Postoperatively, the wrist was immobilized in the neutral position, using a below elbow Plaster of Paris (POP) cast. The POP was changed at 4 weeks, and discontinued after 8 weeks post-surgery, when K-wires were removed. A wrist brace was continued for another 4 weeks along with wrist mobilization exercises. In patients (n=6) with scaphoid fracture, the cast was continued for 12 weeks post-surgery.

Serial wrist radiographs were done routinely at 6 weeks, 12 weeks, 6 months and at last followup. Clinical and radiological assessment of results was done at last followup. The patients were evaluated according to the clinical scoring system described by Cooney et al.[13] [Table 1].
Table 1: Clinical scoring chart (Cooney, 1987)13


Click here to view


The patients were followed-up for an average period of 4.1 years (2-12 years). Among the six patients with dorsal trans-scaphoid perilunate dislocation, four patients had a good outcome score [Table 2]. There was one fair and one poor outcome. Among the six patients with volar lunate dislocation, there were four good results and two fair outcomes. Among the two cases with dorsal perilunate dislocation, one patient had a good result and the second patient presenting 68 weeks after the injury had a poor result. One patient with dorsal trans-scaphoid perilunate dislocation had delayed fracture healing. The scaphoid eventually united by 4.5 months. The patient with dorsal perilunate dislocation presenting at 68 weeks developed mid-carpal arthritis clearly seen at 2 year followup visit [Figure 2]. Two patients (including the patient with bilateral involvement) with volar lunate dislocation presenting more than 5 months after injury eventually developed avascular necrosis (AVN) of the lunate and mid-carpal arthritis of all the involved wrist joints [Figure 3] and [Figure 4]. Over all 5 wrist (3 volar dislocation, 1 trans-scaphoid and one dorsal dislocation were operated after 5 monhs had poor (n=2), fair (n=3) result.
Table 2: Summary of the patients


Click here to view
Figure 2: (a) Preoperative X-ray picture, lateral view, of a 1.5-year-old showing unreduced perilunate dislocation. (b and c) anteroposterior and lateral view of same case after open reduction and internal fixation with K-wires. (d) Follow-up X-ray at 2 years

Click here to view
Figure 3 (a-d): X-ray photographs. AP and lateral views of both wrists showing bilateral volar lunate dislocation

Click here to view
Figure 4 (a and b): Clinical outcome of same case (as in Figure 3) at one year post surgery showing fair result
Figure 4 (c-f): X-ray results of both sides, showing evidence of AVN, collapse, and mid-carpal arthritis


Click here to view



   Results Top


No patient had an excellent result. All patients except two returned to pre-injury work at an average time period of 25 weeks (20-36 weeks). No patient had post-operative wound healing problems. No post-operative neurological deterioration was encountered. The four patients (3 median N + one ulnar N) with pre-operative neurological deficit improved gradually over a period of 10 to 18 weeks postoperatively (average 13.5 weeks).


   Discussion Top


Perilunate dislocations represent approximately 10% of all wrist injuries and are diagnosed late in 25% of cases. [5] This percentage may be even higher in developing countries where lack of awareness and inadequate penetration of medical facilities in rural areas compounds the problem.

Late diagnosed perilunate dislocation (PLD) presents with many issues; principal among these are the anticipated complications at surgery due to extensive fibrosis and scarring, uncertainty of return of full function after reduction, and possibility of developing AVN of reduced lunate postoperatively. There is always potential for mid-carpal arthritis to develop in late cases. Furthermore, numerous treatment options have been advocated. These range from ORIF, [14],[15] proximal row carpectomy, [7],[8] lunate excision, [9],[10] and wrist arthrodesis. [11]

There is no consensus about the upper time limit till when open reduction of perilunate dislocations could be attempted without significant complications. Komurcu et al.[16] performed ORIF in six cases with trans-scaphoid perilunate dislocation up to 40 days post-injury (average 26 days) and reported favorable results. Takami et al.[17] recommended ORIF up to 2 months post-injury. Seigert et al.[18] reported good results of chronic perilunate dislocations reduced as late as 35 weeks after injury; nevertheless, the incidence of good results reduces significantly with delays more than 8-12 weeks post-injury. In our series, cases operated earlier than 5 months have good results. Of the four patients (5 wrist) operated after 5 months, two had a fair result while three wrist had a poor outcome. Our findings are similar to those of Kailu et al.[5] who have reported a favorable outcome in cases delayed up to 25 weeks.

Kailu et al.[5] have also noted that poor results correlate with not only duration of injury but with also the presence of chondral damage. This is also borne out by our study as significant chondral damage to the capitate was noted intra-operatively in both the cases with poor results.

Dimitriou et al.[19] have noted that avascular collapse of lunate does not always leads to significant functional disability. This observation is supported by our study. Both our patients with AVN of the lunate had a fair outcome and were able to return to their professions. Kailu et al.[5] have emphasized repair of scapho-lunate and lunotriquetral ligaments in neglected perilunate dislocations. Seigert [18] performed ligament repair in one out of six patients with chronic perilunate dislocation. In our experience with 14 cases, stabilization of the reduced carpus with K-wires across the scapho-lunate, luno-capitate, and luno-triquetral joints provides a satisfactory functional outcome. We believe that with extensive fibrosis and scarring in chronic cases and the extensive dissection required to reduce the dislocation; attempting to repair the retracted ligament ends is not worthwhile. Both Kailu et al.[5] and Siegert et al.[18] have not commented on the technique used to perform repair in neglected cases. Furthermore, it may be suggested to use a wrist distracter intra-operatively or if possible, a few days preoperatively to help overcome the extensive fibrosis and scarring and to facilitate the clearing of the lunate fossa.

Other options for management in this unique neglected injury pattern have been reported. Arthrodesis of wrist is reported to give painless and stable joint, it may not be acceptable to most patients. MacAusland [9] and Russell [10] reported satisfactory results after excision of the lunate in cases with lunate dislocations. Later on, Seiegert et al.[18] and Inoue et al.[20] reported that excision of lunate alone may lead to irreversible changes due to the development of radioscaphoid arthritis. Seigert et al.[18] and Rettig [8] have reported favorable results with proximal row carpectomy in 2 and 12 cases, respectively. This study indicates that the functional results of ORIF in neglected perilunate dislocations up to 5 months after injury are favorable and even the development of AVN or midcarpal arthritis may not be a major disabling factor, as the benefits of a stable wrist could outweigh the disadvantages. However, beyond 5 months, an alternative surgical procedure such as proximal row carpectomy may be kept in mind.

 
   References Top

1.Sauder DJ, Athwal GS, Faber KJ, Roth JH. Perilunate injuries. Orthop Clin North Am 2007;38:279-88.  Back to cited text no. 1
    
2.Givissis P, Christodoulou A, Chalidis B, Pournaras J. Neglected trans-scaphoid trans-styloid volar dislocation of the lunate. Late result following open reduction and K-wire fixation. J Bone Joint Surg Br 2006;88:676-80.  Back to cited text no. 2
    
3.Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture dislocations:a multicenter study. J Hand Surg Am1993;18:768-79.  Back to cited text no. 3
    
4.Jebson PJ, Engber WD. Chronic perilunate fracture dislocations and primary proximal row carpectomy. Iowa Orthop J 1994;14:42-8.  Back to cited text no. 4
    
5.Kailu L, Zhou X, Fuguo H. Chronic perilunate dislocations treated with open reduction and internal fixation: Results of medium term follow-up. Int Orthop 2010;34:1315-20.  Back to cited text no. 5
    
6.Inoue G, Imaeda T. Management of trans-scaphoid perilunate dislocations, Herbert screw fixation, ligamentous repair and early wrist mobilization. Arch Orthop Trauma Surg 1997;116:338-40.  Back to cited text no. 6
    
7.Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br 1964;46:708-11.  Back to cited text no. 7
    
8.Rettig ME, Raskin KB. Long-term assessment of proximal row carpectomy for chronic perilunate dislocations. J Hand Surg Am 1999;24:1231-6.  Back to cited text no. 8
    
9.MacAusland WR. Perilunar dislocation of carpal bones and dislocation of lunate bone. Surg Gynaecol Obstet 1944;79:256-66.  Back to cited text no. 9
    
10.Russell TB. Inter-carpal dislocations and fracture-dislocations; a review of 59 cases. J Bone Joint Surg Br 1949;31:524-31.  Back to cited text no. 10
    
11.Wagner CJ. Perilunar dislocations. J Bone Joint Surg Am 1956;38:1198-207.  Back to cited text no. 11
    
12.Bathala EA, Murray PM. Long-term follow-up of an undiagnosed trans-scaphoid perilunate dislocation demonstrating articular remodeling and functional adaptation. J Hand Surg Am 2007;32:1020-3.  Back to cited text no. 12
    
13.Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture dislocations of the wrist. Clin Orthop Relat Res 1987;214:136-47.  Back to cited text no. 13
    
14.Green DP, O'Brien ET. Open reduction of carpal dislocations: Indications and operative techniques. J Hand Surg Am 1978;3:250-65.  Back to cited text no. 14
    
15.Fisk GR. The wrist. J Bone Joint Surg Br 1984;66:396-407.   Back to cited text no. 15
    
16.Komurcu M, Kurklu M, Ozturan KE, Mahirogullari M, Basbozkurt M. Early and delayed treatment of dorsal transscaphoid perilunate fracture-dislocations. J Orthop Trauma 2008;22:535-40.   Back to cited text no. 16
    
17.Takami H, Takahashi S, Ando M, Masuda A. Open reduction of chronic lunate and perilunate dislocations. Arch Orthop Trauma Surg 1996;115:104-7.  Back to cited text no. 17
    
18.Siegert JJ, Frassica FJ, Amadio PC. Treatment of chronic perilunate dislocations. J Hand Surg Am 1988;13:206-12.  Back to cited text no. 18
    
19.Dimitriou CG, Chalidis B, Pournaras J. Bilateral volar lunate dislocation. J Hand Surg Eur Vol 2007;32:447-9.  Back to cited text no. 19
    
20.Inoue G, Shionoya K. Late treatment of unreduced perilunate dislocations. J Hand Surg Br 1999;24:221-5.  Back to cited text no. 20
    

Top
Correspondence Address:
Kamal Bali
Department of Orthopedic Surgery, PGIMER, Chandigarh - 160 012
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.83138

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]

This article has been cited by
1 Multiple Flexor Tendon Ruptures with Compression Neuropathy at Neglected Volar Lunate Dislocation
Jung Hyun Park,Hong Je Kang,Jong Seok Baik
Journal of the Korean Orthopaedic Association. 2015; 50(4): 348
[Pubmed] | [DOI]
2 Perilunate dislocation
Navaratnam, A.V. and Ball, S. and Emerson, C. and Eckersley, R.
BMJ (Online). 2012; 345(7885)
[Pubmed]



 

Top
 
 
 
  Search
 
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
    References
    Article Figures
    Article Tables
 

 Article Access Statistics
    Viewed3560    
    Printed156    
    Emailed5    
    PDF Downloaded185    
    Comments [Add]    
    Cited by others 2    

Recommend this journal