Bilateral trans-scaphoid perilunate fracture-dislocation: A case report

Abstract

Background

Bilateral trans-scaphoid perilunate fracture dislocation is an infrequent injury that usually occurs following either high-energy trauma or a fall on an outstretched hand. It can be easily overlooked in patients with polytrauma and may lead to an unfavorable prognosis with pain and arthritis.

Case presentation

We present the case of a 26-year-old man with a history of a fall from a two-story building, diagnosed with bilateral trans-scaphoid perilunate fracture-dislocation, bilateral calcaneal fractures, and a burst fracture of the third lumbar vertebra (L3). In the emergency department, the patient underwent closed reduction for a right perilunate dislocation using the Tavernier technique. However, closed reduction could not be achieved on the left side, and was reduced intraoperatively. Bilateral scaphoid fractures were managed through open reduction and fixation using Herbert screws via the volar approach. Bilateral calcaneal and L3 burst fractures were managed in the same setting. Postoperatively, the patient was stable with intact neurological function. Eighteen months after surgery, the patient had no residual pain in his wrist and returned to work.

Conclusion

Diagnosing rare injuries, such as perilunate fracture-dislocations, necessitates a high index of suspicion and scrutiny of the findings, especially in patients with polytrauma. Careful preoperative planning involving a multidisciplinary team, followed by operative management with open reduction and ligamentous repair, can yield optimal functional outcomes. Moreover, immediate closed reduction of perilunate fracture dislocation should be attempted in the emergency department, and if closed reduction fails, an emergency open surgical procedure should be planned.

Background

Trans-Scaphoid perilunate fracture-dislocation (PLFD) is a rare injury that accounts for approximately 10 % of wrist injuries and typically occurs following high-energy trauma [1]. The bilateral occurrence of this uncommon injury pattern is even more infrequent, with only a few reported cases documented [2]. Fractures and dislocations of the carpal bones can be easily overlooked, with an estimated 25 % of cases being missed [3]. Therefore, maintaining a high index of suspicion and carefully examining these findings is of utmost importance.

trans-Scaphoid PLFDs are typically accompanied by scaphoid fractures and ligament disruptions. Misdiagnosis and delayed or inadequate treatment of these injuries can lead to arthritis-related sequelae, including chronic pain, reduced grip strength, and various wrist dysfunctions [2]. Hence, immediate closed reduction of fracture dislocation should be attempted in an emergency setting.

We present a case of bilateral trans-scaphoid PLFD accompanied by bilateral calcaneal fractures and burst fracture of the 3rd lumbar vertebra (L3). The management approach involved closed reduction of the bilateral perilunate dislocation by Tavernier's maneuver and open surgery and internal fixation using a Herbert screw for bilateral scaphoid fractures, performed through a volar approach. This case has been reported in accordance with the SCARE guidelines [4].

Case presentation

A 26-year-old man presented to our emergency department with a history of falling from a two-story building, resulting in injuries to both hands, feet, and the lower back. Upon clinical examination, the patient's vital signs were stable. Both hands showed swelling, diffuse tenderness, and restricted range of motion (ROM), although his distal neurovascular status remained intact. Mild swelling and tenderness were observed over both calcaneums, accompanied by restricted ROM in the feet. Tenderness was also present in the upper lumbar region and no neurological deficits were detected.

Radiological evaluation revealed trans-scaphoid fracture dislocation of both wrists with bilateral calcaneal fractures and a burst fracture of 3rd lumbar vertebra (Fig. 1, Fig. 2).

Fig. 1.

Radiography of the right wrist shows trans-scaphoid perilunate fracture dislocation of the right wrist with a break in the Gilula arcs. It also shows a loss of collinearity between radius, lunate, and capitate.

Fig. 2.

A radiograph of the left wrist shows trans-scaphoid perilunate fracture dislocation of the left wrist with loss of collinearity between the radius, lunate, and capitate. AP view also shows a triangular appearance of the lunate (the piece of pie sign).

The patient was initially managed in the emergency department with immediate closed reduction, which was successful on the right side but not on the left. Reduction was performed using the Tavernier maneuver. A single surgery set-up was planned, during which the patient was positioned supine on the operating table. Under general anesthesia, closed reduction of the left perilunate dislocation was performed and confirmed using fluoroscopy. Bilateral scaphoid fractures were addressed with open reduction and fixation using Herbert screws via a volar approach (Fig. 3, Fig. 4). Bilateral calcaneal and L3 vertebral burst fractures were also addressed in the same set up.

Fig. 3.

Postoperative radiograph of the right wrist AP and lateral views showing normal alignment of carpal bones with restoration of Gilula's arcs and fixation of scaphoid fracture with Herbert screw. The calculated scapholunate angle was 50°.

Fig. 4.

Postoperative radiograph of the left wrist AP and lateral view showing reduced perilunate fracture dislocation with fixation of the scaphoid fracture performed with the Herbert screw. The carpal bones were normally aligned with the restoration of Gilula's arcs, and the scapholunate angle was calculated to be 37°.

At 2 weeks' follow-up, sutures were removed with no post-operative complications. After 18 months of surgery, the patient had no residual pain in his wrist and returned to work.

Discussion

PLFD is an uncommon injury following high-energy trauma, usually resulting from a fall onto an extended wrist, some other wrist hyperextension injury or a direct blow. [5] While trans-scaphoid PLFD is the most common type of perilunate fracture-dislocation, it still represents a relatively rare occurrence, mainly when it presents bilaterally with dorsal dislocation of the distal carpal row and scaphoid fractures. [2,6] Prompt recognition and appropriate management are necessary to achieve optimal outcome. Notably, a significant number of perilunate dislocations are initially missed on conventional radiographs, leading to delays in management and potentially unfavorable outcomes. [3,5]

The first case of perilunate dislocation was described by Malgaigne. [7] In 1980, Mayfield et al. proposed that this injury occurs due to hyperextension and ulnar deviation with intercarpal supination and described its four stages. [8] In cases where a scaphoid fracture is present, the proximal pole of the scaphoid is held in place with the lunate due to ligamentous attachments, which results in trans-scaphoid perilunate fracture-dislocation. [8,9]

Diagnosis is usually made based on a thorough history, physical examination, and appropriate imaging. Patients typically present with a history of high-energy injury, and examination reveals a swollen, painful wrist. [1,2] The carpus is most commonly dislocated dorsally, and physical examination often reveals a prominent, palpable capitate. [10] If the lunate is dislocated, it may encroach on the carpal tunnel, potentially leading to symptoms consistent with median nerve neuropathy. [2]

PLFDs can typically be identified on plain radiographs using Gilula's lines and the arcs of vulnerability. [3] However, robust evidence regarding the utility of cross-sectional imaging in PLFDs is limited. Cross-sectional imaging may be employed for the accurate early diagnosis and staging of PLFD injuries or cases in which clinically relevant findings persist despite a normal radiograph. Additionally, cross-sectional imaging can be valuable for the management of long-term complications, including secondary osteoarthritis. [5]

Treatment options currently used for PLFDs include closed reduction and cast immobilization, closed reduction and percutaneous pinning, and open reduction. [11] Authors have increasingly favored open techniques in response to the evolving awareness of the anatomy and biomechanics of these injury patterns. These techniques provide an opportunity to repair the injured intrinsic and extrinsic carpal ligaments, resulting in better functional outcomes. [2,[7], [8], [9]]

Most authors agree that closed reduction is the initial treatment of choice for trans-scaphoid PLFDs. [2] The techniques for closed reduction of PLFDs have been described by Tavernier. It consists of locking the capitate into the distal concavity of the lunate by combined axial traction and flexion of the distal row, followed by reduction of the capitate-lunate unit on to the radius by an external movement, while externally applying a localized dorsally directed force to the lunate to help reposition it. Patients with PLFDs should be treated initially by closed reduction in the emergency department and cast immobilization in order to prevent an increase of edema and to decrease neurovascular compromise. In cases where reduction is successful definitive treatment by open surgery and fixation can be delayed. Otherwise, emergency open reduction and internal fixation should be done in cases where closed reduction has failed [11].

Open reduction and internal fixation(ORIF) offers advantages such as achieving better anatomic reduction, restoration of proper alignment of the carpal bones, preserving normal wrist biomechanics, better opportunity for ligamentous repair, and reducing the risk of complications in the future. [7,12,13] The choice of approach for ORIF, whether dorsal, volar, or a combined dorsal and volar approach, is often determined based on the surgeon's preference and specific requirements of the case. [9,12] Dorsal approach has the advantage of convenience in the reduction of the scapholunate interval and repair of the dorsal carpal ligaments, viz. the scapholunate ligament and dorsal luno-triquetral ligament, whereas the volar approach allows for repair of the volar carpal ligaments such as the deep volar luno-triquetral ligament, the scapholunate ligament, and the radiolunate ligament. The volar approach also allows for decompression of the carpal tunnel [11]. A combined approach has the advantages of good intra-operative visualization, better anatomic reduction and allows transverse carpal ligament and median nerve to be released. However, the combined approach has the disadvantages of postoperative adhesions, avascular necrosis, and wrist tightness due to extensive dissection [14].

Post-traumatic osteoarthritis of the wrist, typically affecting the radioscaphoid and lunocapitate joints, is a common long-term complication following perilunate injuries, with an average incidence of approximately 38 %. [8] Despite operative management, some patients experience significant reductions in wrist mobility and function, variable decreases in grip strength, and increased pain due to their injuries. [13,14]

Conclusion

Rare injuries, like fracture dislocation of carpal bones, should be considered as one of the differential diagnoses, in any case, presenting with polytrauma. High clinical suspicion and typical imaging features can help diagnose such injuries, which are confirmed intraoperatively. A multidisciplinary approach with a detailed discussion of the surgical procedure should be planned. Moreover, an immediate closed reduction of the fracture dislocation should be attempted to prevent dire complications. If closed reduction fails open reduction and internal fixation should be done in an emergency basis. Open reduction and internal fixation with or without ligamentous repair should be considered the treatment of choice as it is associated with better functional outcomes.

Consent1

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethics approval and consent to participate2

Ethical Approval for a case report is exempt at the authors institution. It is only necessary to obtain the patient's consent.

Provenance and peer review3

Not commissioned, externally peer reviewed.

Funding4

None.

Guarantor5

Krishna Timilsina.

Research registration number6

Not applicable.

CRediT authorship contribution statement

Krishna Timilsina: Writing – original draft, Conceptualization, Data curation. Sandesh Shrestha: Data curation, Conceptualization, Writing – original draft. Om Prakash Bhatta: Data curation, Conceptualization, Writing – original draft. Shirish Adhikari: Supervision, Writing – review & editing. Nitish Bikram Deo: Writing – review & editing, Supervision. Sushil Paudel: Supervision, Writing – review & editing. Suresh Uprety: Supervision, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

All the required information is in manuscript itself.