A Stepwise Approach to Management of Open Radiocarpal Fracture-Dislocations: A Case Report

Transcription

1 Case Report The Journal of Hand Surgery (Asian-Pacific Volume) 2017;22(3): DOI: /S X A Stepwise Approach to Management of Open Radiocarpal Fracture-Dislocations: A Case Report Colin Yi-Loong Woon*,, Taizoon Baxamusa* *University of Illinois at Chicago, Chicago, Illinois, Department of Orthopaedic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL Radiocarpal dislocations are uncommon and occur after significant trauma. We describe a unique case of open radiocarpal fracture-dislocation presenting with progressive neurovascular compromise. Staged management was necessary. As a first stage, emergent provisional bedside reduction in the emergency room with manual pressure through the open wounds was performed. The second stage then involved formal open reduction and internal fixation as soon as operating room staff and resources became available. Keywords: Perilunate dislocation, Lunate dislocation, Radiocarpal dislocation, Scaphoid fracture, Carpal tunnel INTRODUCTION Radiocarpal fracture dislocations are uncommon injuries. The mechanism of injury usually involves radiocarpal hyperextension, ulnar deviation and intercarpal supination. 1) Open, inside-out injuries usually indicate a significant high-energy deforming force. In cases with severe deformity and neurovascular compromise, initial emergent provisional reduction at the bedside is advocated as a first stage to mitigate further neurovascular damage. The second stage comprises formal surgical stabilization and this is performed as soon as the operating room and staff become available. In this report, we present a case of high-energy open radiocarpal dislocation with contusion of both ulnar and median nerves, and avulsion/transection of the ulnar artery. We further describe the staged management comprising reduction and surgical stabilization of this injury. CASE REPORT A 36-year-old right hand dominant factory worker was struck by a car while riding his motorcycle and landed on his outstretched right hand. He was splinted in situ and transferred to our institution. Examination revealed that both radius and ulna were protruding through the open wound at the volar ulnar aspect of the wrist (Fig. 1). There was burning pain and diminished sensation to pinprick over the ulnar 2 digits that progressively evolved to Received: Dec. 1, 2015; Revised: Feb. 4, 2016; Accepted: Feb. 10, 2016 Correspondence to: Colin Yi-Loong Woon Department of Orthopaedic Surgery, Advocate Lutheran General Hospital, 1775 Dempster Street, Park Ridge, IL Tel: , Fax: wolv23@gmail.com Fig. 1. Injury radiographs of the wrist (left, AP; right, lateral) showing apparent dorsal perilunate fracture dislocation.

2 367 The Journal of Hand Surgery (Asian-Pacific Volume) Vol. 22, No. 3, include the radial 3 digits. The radial pulse was palpable, but the ulnar pulse and Doppler signal were absent distally. Radiographs revealed an open dorsal trans-styloid, trans-scaphoid perilunate fracture dislocation (Fig. 2) with an associated closed thumb interphalangeal joint (IPJ) dorsal dislocation. In the emergency room, we performed emergency irrigation and reduction because of the severity of deformity causing tenting of the vascular bundle and severe kinking of neural structures, as evidenced by advancing dysesthesia. We applied axial traction and a volardirected force over the perilunate carpus, and dorsaldirected counter-pressure on the lunate (from the volar side), followed by palmar flexion to engage the lunate concavity. 2) This was meant to be a provisional reduction while operating room personnel and facilities were mobilized and prepared. Post-reduction examination showed improved patient comfort and capillary refill, reduced deformity, and decreased pain and dysesthesia. This maneuver restored the radiocarpal relationship, but the lunate remained volarly dislocated (Fig. 3). Under general anesthesia in the operating room, we closely reduced the thumb IPJ. We then performed pulsed irrigation, made a dorsal incision, and identified and neurectomized the posterior interosseous nerve. Extensive capsular stripping off the distal radius was noted. We created a longitudinal capsulotomy for intracapsular inspection, taking care to preserve the capsular attachment to the distal pole of the scaphoid, to function as a checkrein for dorsal capsulodesis during closure later. The ulno-volar wound was used for decompression of the ulnar neurovascular bundle through Guyon s canal and treatment of the DRUJ. Intraoperative findings included comminuted fracture of the proximal scaphoid pole, which was rotated 180, linear nondisplaced incomplete fracture of the proximal pole of the capitate, fracture of the lunate with volar fragment extrusion, and triquetral fracture. There was significant associated chondral damage with foci of full thickness and partial thickness cartilage shearing from the carpal bones. There was also disruption of the lunotriquetral (LT) and scapholunate interosseous ligaments (SLIL) and fractures of the radial styloid and ulnar styloid. The median and ulnar nerves were contused but in continuity. The ulnar artery was completely avulsed with thrombosis. Using longitudinal in-line traction, we manually reduced the lunate through the volar wound. We made an open incision in the snuffbox and performed blunt dissection down to the distal pole of the scaphoid, protecting soft tissues with a tissue protector. We then derotated the scaphoid, fixed it provisionally with a K-wire, and reduced the triquetrum. The scaphoid fracture was fixed with a 16 mm cannulated Acutrak screw (Acumed, Hillsboro, OR). Fixation was tenuous across the proximal pole because of comminution. Care was taken to maintain the scaphoid in an extended position with respect to the capitate to prevent mid-carpal row motion. We then pinned the distal scaphoid pole to the capitate, and pinned the triquetral fracture across the LT joint. To address the SLIL, we placed 2 pins across the proximal scaphoid pole into the lunate. The radial styloid was re- Fig. 2. Clinical photograph showing gross limb deformity and volar wound. Fig. 3. Intraoperative fluoroscopy showing the spilled teacup sign with a volar-rotated lunate.

3 368 Colin Yi-Loong Woon and Taizoon Baxamusa. Radiocarpal Fracture-Dislocation duced open and pinned to the distal radius (Fig. 4). The radioscaphocapitate ligaments remained attached to the radial styloid fragment. The ulnar styloid fracture was reduced and held with a 3 0 vicryl suture (polyglactin 910, Ethicon, Somerville, NJ). The distal radioulnar joint (DRUJ) was noted to be reduced and stable. Next, we released the carpal tunnel by dividing the transverse carpal ligament. The median nerve was contused but in continuity and careful external neurolysis was performed. We extended the ulnar wound proximally over Guyon's canal, exposing the ulnar artery and nerve. The intact, contused ulnar nerve was also neurolysed. The ulnar artery was found transected with thrombosed ends and prominent intimal damage, but the radial artery and palmar arch were intact with brisk backflow, and there was brisk digital capillary refill upon tourniquet release. We ligated the ulnar artery with 3 0 vicryl stick ligatures (Ethicon). We then closed the skin loosely without fascial closure, and placed the limb in a sugartong splint in 90 of elbow flexion and neutral forearm rotation. Postoperatively, he was kept non-weightbearing for 6weeks in a long-arm thumb spica cast, followed by six more weeks in a short arm thumb spica cast. He was educated on digital range of motion exercises as well as edema control and cast care. We removed the K-wires at 12 weeks prior to starting formal therapy. He returned to work at 4 months post-op. At 1 year, he had mild stiffness in his wrist and no pain at rest (visual analog scale, 0/10), but had pain Fig. 4. Immediate postoperative radiographs showing pin immobilization across the proximal row and midcarpal joints, with restoration of the normal radiocarpal relationship. There is persistent SL and LT widening. when using vibratory tools (3/10). Examination revealed a warm, well-perfused right hand. Range of active motion was 11 wrist extension, 21 wrist flexion, 10 ulnar deviation, 2 radial deviation, 76 supination and 80 pronation, and full range of digital motion. Grip strength was 32 lbs, lateral pinch was 13.5 lbs, and 3-jaw pinch was 9 lbs (compared with 115 lbs, 16 lbs and 15 lbs, respectively, on the left). There was no DRUJ instability and no clawing. He had normal sensation with sensibility to Semmes-Weinstein monofilaments over all digit tips and thenar and hypothenar eminences. Radiographs revealed lunate sclerosis, capitolunate arthrosis consistent with Watson Grade III scapholunate advanced collapse (SLAC) changes, and dorsal intercalated segmental instability (DISI) deformity. DISCUSSION With radiocarpal dislocation, the wrist undergoes progressive radial-to-ulnar destabilization around the lunate, characterized by Mayfield et al. 3) In our patient, injury radiographs suggested perilunate (Stage III) dislocation (Fig. 1). However, intraoperative exploration and fluoroscopy revealed extensive dorsal capsular stripping, and the spilled teacup sign (Fig. 2) after reduction, signifying lunate rotation on its palmar ligaments, 4) making the injury more accurately a Stage IV injury. With a greater degree of forced wrist hyperextension, carpal bone fractures occur. These involve scaphoid, radial styloid, triquetrum, and capitate, 5) constituting what Mayfield et al. described as a greater-arc injury pattern, 3) and what Cooney et al. categorized as transcarpal perilunate fracture dislocations. 5) Given the emergent presentation, the severity of deformity and neurovascular compromise, immediate provisional reduction in the emergency room was indicated. In a busy level-one trauma center, this emergency treatment is required while awaiting more definitive treatment in the operating room. Emergent reduction in the emergency room prevents further soft tissue compromise arising from the severe deformity, such as neurovascular tenting and tethering on telescoped skeletal structures. However, uncontrolled bedside reduction without direct visualization through an open incision may lead to inadvertent crushing of neurovascular structures. The postreduction examination is thus important to ensure that this has not occurred. Neurological deficits commonly arise from lunate extrusion into the carpal tunnel (median nerve). In our patient, nerve contusions arose from severe deformity and

4 369 The Journal of Hand Surgery (Asian-Pacific Volume) Vol. 22, No. 3, tenting over the prominent volar lip of the distal radius (Fig. 2). As both nerves remain in continuity, the nerve contusion and traction neuropraxia is expected to resolve rapidly after reduction and stabilization. In our patient, reduction was facilitated by extensive radioscaphocapitate ligament disruption, which is important in preventing ulnar translation of the carpus and progressive carpal instability. This is evidenced by the degree of carpal displacement (Fig. 1). In open injuries, direct digital pressure through the open wounds is possible and this allows direct manual counter-pressure on the lunate during the reduction maneuver. With multiple carpal fractures, closed attempts are seldom perfect. On reduction radiographs, signs of persistent carpal instability, such as the Terry Thomas sign of scapholunate widening, loss of parallelism between scaphoid and lunate articular surfaces and irregularity of Gilula s arcs, the flexed scaphoid ring sign, and scapholunate angle >70, were evident. 4) Further, scaphoid fracture (transscaphoid injury) and extreme carpal translation (implying global ligamentous disruption) made the reduction incredibly tenuous and percutaneous pinning was imperative to maintaining a stable reduction (Fig. 4). 4) Surgical approaches for open reduction include isolated volar, dorsal and combined dorsal-volar approaches. 1,2,4,5) The dual approach was facilitated by the preexisting volar wound in this case. Proper carpal bone position can be aided with joysticks. Carpal K-wire fixation mirrors the injured ligaments (scapholunate, lunotriquetral) with a scaphocapitate pin to maintain the appropriate scaphoid position (Fig. 4). 2) Suture anchors are an adjunct to facilitate ligament repair, but was not possible in this case. Fig. 5. Radiographs at 1 year (AP, left; lateral, center; gripped ulnar deviation view, right) with pins removed, showing maintenance of reduction of capitate, lunate and distal radius. There was radiocarpal joint space collapse, lunate sclerosis, SLAC changes and DISI deformity. The sequelae of these injuries are significant. Transient lunate ischemia is not uncommon and may be observed for resolution with soft tissue healing. 1,2) In contrast, extensive degloving may lead to an avascular lunate (Fig. 5). 1,6) Extensive chondral damage contributes to chondrolysis (especially at the proximal capitate pole), joint space collapse and arthritis. 2) Surgical management should be considered if and when symptoms arise. 1,5,7) The restoration of normal carpal alignment is crucial to improve outcomes. 1) However, the prognosis is poor and loss of up to 50% of wrist motion and 60% of grip strength is expected. 2) In conclusion, radiocarpal dislocations represent of spectrum of injury that may involve ligament and/or bone. For open (and even closed) injuries with severe deformity and neurovascular compromise, emergent provisional bedside reduction is indicated as a first stage prior to open reduction and internal fixation in the operating room. REFERENCES 1. Melone CP, Jr., Murphy MS, Raskin KB. Perilunate injuries. Repair by dual dorsal and volar approaches. Hand Clin. 2000;16(3): Kozin SH. Perilunate injuries: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6(2): Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3): Green DP, O'Brien ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg Am. 1978;3(3):

5 370 Colin Yi-Loong Woon and Taizoon Baxamusa. Radiocarpal Fracture-Dislocation 5. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res. 1987;(214): Garcia-Elias M, Irisarri C, Henriquez A, et al. Perilunar dislocation of the carpus. A diagnosis still often missed. Ann Chir Main. 1986;5(4): Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):