Hand: Scaphoid fracture, with perilunate fracture dislocation

Trans-scapho-perilunate fracture dislocations are rare severe wrist injuries.

What is the difference between this and a simple scaphoid fracture?

Compared to simple isolated scaphoid fractures, trans-scapho-perilunate fracture-dislocations are much more severe injuries.

In addition to the scaphoid fracture, the trans-scapho-perilunate injury includes a lunate dislocation. Specifically, the ligaments that attach the lunate to the rest of the carpus are torn.

Do these injuries all need surgery?

Yes, but some patients may choose to not have surgery if they are elderly, etc.

Treatment strategy consists of anatomic reduction, which was performed through a dorsal incision, followed by stabilization.

The stabilization of the scaphoid is done as with any other scaphoid waist fracture, nothing special about it. The lunotriquetral ligaments can be stabilized with temporary pins or screws, with suture anchors, etc.

Case study

This case is from my first couple of months of work as a new orthopedic surgeon.

Notice the proximal scaphoid and the lunate which are still attached to each other and to the radius, but with incorrect relationship to the rest of the carpus and hand. On the other side, the distal scaphoid is still attached to the trapezium, trapezoid, capitate, hamate, triquetrum, and the rest of the hand.

In this case I used a dorsally inserted Accutrak screw. In addition, the lunate-capitate, and lunate-triquetral joints are reduced and stabilized. In the case of my patient I used Mitek Minilok suture anchors to repair the dorsal lunotriquetral ligaments as well as percutaneous K-Wires. For added protection, the whole thing was covered with a cast.

It is important to understand that the lunotriquetral ligaments are never again the same after this injury. Some permanent aches and pains are normal after this type of injury.

Here's a an x-ray of my patient's wrist after surgical treatment:

I kept him in a cast for more than two months. Follow up xrays looked good each time. Out of an abundance of caution, I wanted to get a CT scan to make sure that the scaphoid had indeed healed prior to allowing return to work, but the young man to whom the wrist belongs knew better. He went right back to work - as a mover - without getting that CT.

Some time later I convinced him to come in for some follow up xrays. These last xrays were done at about 7 months after the injury.

PA.

Lateral.

And here are clinical views of his wrist, first the surgery scar at the back of the wrist:

His wrist motion was good as well. Extension, flexion, supination, pronation.

State-of-the-art treatment, no doubt.