71: Open Reduction and Acute Repair of Perilunate Fracture-Dislocations

Procedure 71 Open Reduction and Acute Repair of Perilunate Fracture-Dislocations



Louis W. Catalano, III , Christopher M. Jones



Indications




image Acute and subacute (<6 weeks old) perilunate dislocations are seen.


image Chronic perilunate dislocations (>7 weeks old) may be best treated with salvage procedures such as proximal row carpectomy or wrist fusion.



Examination/Imaging



Clinical Examination




image Severe wrist edema, tenderness, and ecchymosis may accompany the extreme pain that the patient is experiencing.


image Passive wrist motion is usually limited, painful, and disjointed (not smooth).


image It is essential that a thorough neurovascular examination be performed to rule out acute carpal tunnel syndrome.


image If numbness, tingling, and two-point discrimination worsen after closed reduction, immediate carpal tunnel release should be performed (along with open reduction and fixation).


image If the neurovascular examination is improving or normal and a good reduction is achieved, the surgery can be performed electively.



Imaging




image Lunate and perilunate dislocations are occasionally missed in the emergency room and dismissed as a severe wrist sprain despite having adequate imaging. Therefore, it is essential to obtain a thorough radiographic examination and scrutinize the images to prevent missing an acute injury.


image A standard radiographic series of the wrist must be obtained to evaluate for dislocation. Assess for disruption of Gilula arc lines on the posteroanterior image. On a lateral radiograph, the radial shaft, lunate, capitate, and metacarpal shafts should be collinear (Fig. 71-1).


image Radiographs should also be inspected to rule out associated radial styloid, scaphoid, capitate, or triquetral fractures (Fig. 71-2).


image Computed tomography can help better define any questionable fractures of the carpal bones.


image Magnetic resonance imaging is rarely used.


image

FIGURE 71-1


image

FIGURE 71-2



Surgical Anatomy




image The dorsal radiocarpal and intercarpal ligaments are frequently ruptured in these severe injuries (Fig 71-3A).


image The strong volar ligaments have a characteristic transverse rent that is repaired through the volar approach (Fig. 71-3B).


image The lunate dislocates through the space of Poirier, a relatively weak region of the volar capsule just below the arc of the radioscaphocapitate and ulnocapitate ligaments (see Fig. 71-3B).


image The dorsal portion of the scapholunate ligament is the thickest and strongest portion of the C-shaped ligament and should be repaired if adequate ligament tissue is present (Fig. 71-3C).


image The short radiolunate ligament serves as the pivot for the lunate when it dislocates into the carpal tunnel. It also provides blood supply to the dislocated lunate to prevent avascular necrosis.


image

FIGURE 71-3



Positioning




image The patient is positioned supine on the operating room table with the arm abducted on a radiolucent hand table.


image A minifluoroscope is positioned vertically at the end of the hand table with the image intensifier under the table.


image Five to 10 pounds of longitudinal traction using finger traps may be helpful to obtain and maintain lunate reduction and proper position of the carpal bones.



Exposures




image A 7- to 8-cm longitudinal dorsal incision centered over the wrist is made, with exposure of the carpus through the third dorsal compartment (extensor pollicis longus [EPL] sheath).

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 89: Total Wrist Fusion

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 71: Open Reduction and Acute Repair of Perilunate Fracture-Dislocations

Full access? Get Clinical Tree
Get Clinical Tree app for offline access