An unusual wrist injury in a parkour-athlete: Transstyloid, transscaphoid, transtriquetral perilunate dislocation

Abstract

Perilunate dislocations are uncommon high energy injuries. The combination of fractures resulting in a trans-styloid, trans-scaphoid, and trans-triquetral perilunate fracture dislocation is extremely rare. We describe a 20 year old male who suffered this injury after a fall from height while parkouring. He underwent open reduction and internal fixation with ligamentous repair and carpal tunnel decompression. After 3 months, he was noted to have a radiographic evidence of scapholunate dissociation and he returned to the operative room for definitive fixation. Despite this complication, the final functional outcome 6 months after the second surgery was satisfying.

Introduction

Dislocations and fracture dislocations of carpal bones are uncommon but devastating injuries which always poses challenges in the management. Perilunate fracture dislocations are the combination of ligamentous and osseous injury that involve the “greater arc” of the perilunate associated instability. Roughly 25 % of cases may be missed in the ED due to poor radiographs and inexperience. The treatment for these injuries consists of reposition, fracture fixation, and ligament repair as well as carpal tunnel release if needed [1]. Transstyloid, transscaphoid, transtriquetral perilunate dislocations are extremely rare carpal dislocations with only 4 cases mentioned in the literature. We report such a case complicated with late scapholunate dissociation 6 weeks after the initial surgical treatment.

Statement of informed consent

The patient was verbally consented for inclusion of case details and imaging for publication. No identifying patient information is included. The patient agreed to these terms.

Case presentation

A 20-year-old right hand dominant man presents in our department with swelling, pain, and deformity of the left wrist. The patient reports that while parkouring, he fell from a height on his outstretched hand. He reports no previous history of injury to his hand or wrist. The clinical examination showed a slightly swollen left wrist with tenderness and pain dorsal and palmar after palpation. No signs of vascular damage or nerve compression were obvious, yet he had a mild decrease in sensation within the distribution of the median nerve. No other obvious injuries or deformities were found. Posteroanterior and lateral views of the left wrist showed a trans-radial styloid, trans-scaphoid and perilunate dislocation (Fig. 1). The trans-triquertal component revealed on computed tomography (CT) which was obtained after the reduction to aid to pre- operative planning (Fig. 2). This combination of injuries was compatible with a Mayfield 3 injury pattern, with force exiting the triquetrium bone rather than the lunotriquetral ligament. The patient underwent open reduction of the fracture dislocation under general anaesthesia. A volar approach was used first for an extended carpal tunnel release. After careful inspection, the palmar radiocarpal, ulnocarpal and intercarpal ligaments were found torn. Moreover, there was a bony avulsion of the volar lunotriquetral (LT) ligament from the triquetrum. Through the volar approach the triquetrum was fixed with a2.25mm headless screw while the avulsed LT ligament was repaired with a suture anchor. The mentioned torn volar ligaments were repaired with suture Vicryl 2-0. To address the remaining injuries, a separate dorsal approach was used. During the surgical approach, the dorsal capsule was found completely detached from the radius so that the scaphoid, lunate capitate, and the triquetral articulations could be visualized. The scaphoid fracture was reduced with a joystick technique and fixed with a 3.0 headless screw and a 0.045 K-wire. The latter osteosynthesis was demanding and time consuming due to proximal pole comminution. The dorsal scapholunate (SL) interosseous ligament found partially avulsed from the scaphoid and it was repaired with a suture anchor. The scapholunate gap was reduced and held in place with a 0.045 K-wire. A K-wire was placed across the SL interval to hold reduction. A suture anchor was placed in the lunate to repair the torn dorsal LT ligament. The radial styloid fracture was fixed with a 1.6 mm K-wire. The wrist capsule was closed using multiple suture anchors. Finally, for further stability an external spanning fixator was applied in a standard fashion and left in place for 8 weeks.

Fig. 1.

Initial radiographs of the left wrist (anterior-posterior, and lateral). Note the “piece of pie sign” on the AP view and the “spilled tea cup sign” on the lateral view.

Fig. 2.

Computed tomography 3D reconstruction of the right wrist. The yellow arrow shows the trans-triquertal component while the red one shows the trans-scaphoid fracture. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

At 12 weeks post-surgery, when the patient returned to the clinic for a scheduled visit, he was noted to have a radiographic evidence of scapholunate dissociation (Fig. 3). Therefore, he was scheduled for SL ligament reconstruction. He underwent scapholunate reconstruction using a split extensor carpi radialis brevis (ECRB) tendon graft via a dorsal approach. The reconstruction is achieved by utilizing a strong anchor construct (3 × 3.5 mm DX SwiveLock SL anchors) that incorporates a combination of a biologic tendon graft reconstruction into bony tunnels with static suture reinforcement with InternalBrace™ ligament augmentation (Arthrex). Moreover, two K-wires were placed through the scaphocapitate and lunotriquetral respectively to support ligamentous repair. The patient was placed into a thumb spica plaster splint. K-wires were removed after 8 weeks whereas the spica remained for another 2 weeks. At 3 months after the second surgery the wrist – after vigorous physiotherapy – regained 80 % of its normal movements. The dash score was 15. At 6 months post-operatively the patient was able to flex up to70° and extend up to 80°. The X-rays during the follow up have shown a stable scapholunate space and no worsening of the SL dissociation. By this time, he had no pain and had returned to work as a military cadet. The dash score was then 7.

Fig. 3.

Postsurgical radiographs immediately and after 4, 12 weeks respectively. The black arrow demonstrates the scapholunate dissociation.

Discussion

Perilunate fractures dislocation represents only 5 % of fractures about the wrist [2]. Using the terminology popularized by the Johnson et al. those injuries are also known as “greater arc” injuries. The majority of them combine ligament ruptures, bone avulsions, and fractures in a variety of clinical forms, the most usual being the dorsal trans-scaphoid perilunar dislocation [3]. Transstyloid, transscaphoid, transtriquetral perilunate dislocations has been infrequently cited in the medical bibliography with only 4 cases so far (Table 1). The mechanism of injury is usually a fall from height on the outstretched hand with the wrist being extended and ulnarly deviated [4].In our case the injury initiated with the fracture of styloid proceeding via scaphoid and continued by creating an avulsion fracture of the triquetrum and finally exited via ulna styloid.

Table 1.

The table summarizes the published studies regarding the reported injury. The treatment preference and the outcome were reported. OR; open reduction.

Study	Treatment	Outcome
Schranz & Fagg [14]	OR & Herbert screw & kwire & carpal tunnel release	Good
Majeed & Kumar [15]	OR & Herbert screw & Kwire & Ex-fix	Excellent
Morin & Becker [16]	OR & Herbert screw & plate & kwire & carpal tunnel release	Excellent
Frane et al. [17]	OR & Herbert screw &suture anchors &kwire &carpal tunnel release	Excellent

High index of suspicion is necessary as the diagnosis is often missed on clinical and radiographic evaluation, up to 25 % of cases. Early identification and treatment is of the utmost importance for favorable outcomes. A multicenter review of these injuries showed that even though the injury pattern had little influence on outcome, delay in care did have a harmful effect on the results [5]. When correctly obtained and interpreted, plain radiographs are enough to make evident the nature of the injury. Thus, physician should pay attention for any disruption in Gilula's lines or abnormal widening of scapholunate interval (>3 mm) on the PA views while alignment on the lateral view should also be verified. CT and 3D reconstruction consist of valuable tool for more detailed evaluation of bony injury as well as for preoperative planning [6,7].

Non-operative treatment with closed reduction and cast immobilization is not considered acceptable and is associated with poor results and recurrent dislocation [1,8]. Open reduction and internal fixation is the best option to obtain anatomic reduction of the bony fragments, to repair the different ligaments, and to stabilize adequately the different structures that are involved in the injury. The sooner after injury reduction and repairs can be provided, the easier will be treatment and the better the ultimate prognosis [5,[9], [10], [11]]. Most of the authors treat these lesions with a combination of carpal tunnel release, k-wires, headless screws and sutures anchors with or without applying external fixator. For chronic and neglected injuries as well as recurrent surgical failures with degenerative changes, proximal row carpectomy or total wrist arthrodesis can be considered.

Complications are often due to inadequate treatment of ligament injuries leading to carpal instability and arthrosis [10]. This is also true for our case in which there was scapholunate dissociation 3 months after the initial fixation. In such cases, on condition that malalignment is reducible and cartilage is intact, successful functional outcomes could be achieved with scapholunate reconstruction revision as in our patient. Finally, transient ischemia of the lunate is a frequent finding in those injuries, yet seldom evolves into progressive collapse of the bone with revascularization being often occurred after several months [12,13].

Conclusion

Greater arch injuries are difficult to be diagnosed and treated, posing a challenge to surgeon due to the complex anatomy. The combination of fractures resulting in a trans-styloid, trans-scaphoid, and trans-triquetral perilunate fracture dislocation is extremely rare. From previous case reports it seems that open reduction and internal fixation joined with ligamentous repair are most likely to maximize return of function especially in acute setting. Post-operative follow up is crucial to evaluate patient's outcome and identify any inadequate ligament treatment avoiding late arthritis.

Sources of funding

None.

Ethical approval

This case report got ethical approval from our institution.

Declaration of generative AI and AI-assisted technologies in the writing process

All authors disclose no use of generative AI and AI-assisted technologies in the writing process.

Declaration of competing interest

The authors declare that they have no competing interest.