Treatment of Trans-Scaphoid Perilunate Dislocations Using a Volar Approach With Scaphoid Osteosynthesis and Temporary Kirschner Wire Fixation

Transcription

1 MILITARY MEDICINE, 176, 9:1077, 2011 Treatment of Trans-Scaphoid Perilunate Dislocations Using a Volar Approach With Scaphoid Osteosynthesis and Temporary Kirschner Wire Fixation Mario Malović, MD * ; Roman Pavić, MD, PhD ; Milan Milošević, MD ABSTRACT Trans-scaphoid perilunate fracture dislocations (TSPLD) are uncommon injuries and constitute about 3% of all carpal injuries. Up to 25% of these high energy trauma cases go undiagnosed. Presented are 43 (3 female, 40 male) consecutive patients treated for dorsal TSPLD, all were closed fractures. Patients were between 17 and 66 years old. Twenty male patients were injured in active duty military service. Surgical treatment was made with a volar approach using titanium cannulated headless compression screws (3.2mm) placed via a guide wire. Repositioning the dislocated carpus is then conducted using 3 temporary fixation Kirschner wires (1.6mm). The patient had a volar short arm splint for 4 weeks, then given an orthosis. Triple fixation Kirschner wires were removed 6-8 weeks postoperatively. Mean followup period was 29 months (range 20 38). The average Mayo wrist score for all 43 patients is 87 (good) (range 65 99). All patients returned to their previous employment. INTRODUCTION Perilunate injuries are uncommon, severe disruptions of carpal anatomy. These injuries affect both soft tissues and bony elements of the wrist and present in two common patterns: The perilunate dislocation (PLD) and the trans-scaphoid perilunate fracture dislocation (TSPLD). 1 The PLD is a soft tissue circumferential disruption around the lunate. Theoretically the injury pattern occurs sequentially, starting at the scapholunate joint, then to the lunocapitate and lunotriquetral joints, and finally complete dislocation of the lunate. TSPLDs are more common than PLDs and are different because they involve a scaphoid fracture rather than a scapholunate lunate ligamentous disruption. 2 (Figs. 1 and 2 ). Carpal dislocations were first described by Etienne Destot in ,3 Both PLD and TSPLD are high-energy trauma, and a significant number of cases go undiagnosed.4 Some authors estimate up to 25% 1,2,5 of cases are undiagnosed. These injuries are mostly the result of a fall from a height, a motor vehicle or motorcycle accident, or a sporting event. Young men are usually affected by this injury, with an average age of 30. 1,2,6 Approximately two-thirds of carpal dislocations involve a fracture through the middle third of the scaphoid, with TSPLD being the most common injury encountered in all published series. 1,7 If left untreated, PLDs and TSPLDs lead to poor functional and radiographic results. 1,4 Herzberg et al 1 have classified TSPLD into 3 phases; the acute phase is less than 7 days postinjury, the delayed phase is the time more than 7 days and less than 45 days postinjury, and the chronic phase is more than 45 days postinjury. 8 Authors agree that fracture treatment delayed for more than 2 weeks * Department of Hand Surgery, University Hospital of Traumatology, Draškovićeva 19, Zagreb, Croatia. Surgery Clinic, Department of Traumatology, University Hospital Osijek, J. Huttlera 4, Osijek, Croatia. PolyClinic Dr. MM, Ribnjak 6, Zagreb, Croatia. are much more difficult to treat. 9 However, Weir9 presents cases in which late open reduction gave satisfactory functional results with follow-up of 8 to 18 months suggesting that even late treatment improves the patient s recovery. The recommended treatment for PLD and TSPLD is surgery. Because of the complex ligament and/or bony injuries, accurate open reduction and restoration of anatomy is required; and to maintain reduction, internal fixation must be used. 2 MATERIAL AND METHODS Between January 2003 and January 2009, 43 consecutive patients were treated for dorsal TSPLDs. The mean age of our patient series was 33 years (range 17 66). Patients with associated fractures of os triquetrum and os capitatum were excluded from the patient group. However, four patients were included who presented with concurrent fracture of the radial styloid. The mean follow-up period was 29 months (range months). Objective assessments included range of motion, grip strength, and radiographs, which were evaluated at the final assessment of each patient. Grip strength was evaluated using a Jamar dynamometer. Wrist range of motion was measured using a goniometer according to the American Medical Association guidelines. Radiographs were evaluated by radiologists specialized in trauma injuries, independent of the surgery team, with regard to incidence and time to scaphoid union and the lunotriquetral gap at the time of surgery and at follow-up examination. The scapholunate angle is created by the long axis of the scaphoid and a line perpendicular to the capitolunate joint. We considered 30 to 60 normal range of the scapholunate angle. The scapholunate gap is measured from the proximal ulnar corner of the scaphoid to the proximal radial corner of the lunate. We considered a schapholunate gap <3.0 mm normal size. Measurements of scapholunate angle and scapholunate gap were also evaluated by radiologists specialized in trauma injuries. MILITARY MEDICINE, Vol. 176, September

2 FIGURE 1. TSPLD anteroposterior projection. FIGURE 2. TSPLD lateral projection. Range of motion measurements were made by a physiatrist preoperatively, postoperatively, and after the completion of physical rehabilitation. The Mayo score described by Cooney et al and modified from Green and O Brien 2,10 12 was used to evaluate overall functional recovery. This rating gives a maximum score of 100 with a higher score reflecting a better outcome. The four parameters assessed are pain, functional status (ability to work), range of motion, and grip strength, each parameter is worth 25 points. A score of 90 to 100 points is excellent, 80 to 90 points is good, 60 to 80 points is satisfactory, and less than 60 points is poor. 10 Statistical analysis was completed using the exact Mann Whitney U test. Tests are shown significant at p < Surgical Technique All operations were conducted under regional anesthesia (interscalene) with a pneumatic tourniquet and preoperative prophylactic antibiotics. Hand placement was supine forearm on a hand table. All surgeries were performed by a single surgeon (MM). A volar approach was used with cannulated titanium headless compression screw fixation of the scaphoid in all cases. To use the volar approach, a skin incision is made over the flexor carpi radialis tendon, which is exposed and retracted ulnarly. The radial artery is protected. The dorsal sheath of the flexor carpi radialis is incised longitudinally, and pericapsular fat is divided. The anterior capsule of the wrist is divided, and the proximal pole scaphoid and lunate are visualized. Fibrin and clot are removed from the fracture surface and dorsally as far as possible by placing traction on the hand. This should expose the distal fragment of the scaphoid and the head of the capitate. The proximal fragment is pushed dorsally, whereas the distal fragment is pulled volarly. Reduction of the scaphoid fragments is made and a cannulated titanium headless compression screw (3.2mm) is placed via a guide wire. Repositioning the carpus is then conducted. To stabilize the reposition, 3 Kirschner wires (1.6 mm) are used to make temporary fixation. The Kirschner wires are placed in the following manner: The first wire is placed from the lunate volarly through the capitate and pulled dorsally percutaneously. The second wire is placed percutaneously through the scaphoid and into the lunate, this provides additional protection of the fracture. The third wire is placed through the capitate to the scaphoid ( Figs. 3 and 4 ). The lunotriquetral ligament is sutured, therefore a k-wire was not placed through the lunotriquetral joint. The wires are placed from inside to out so that there is only one end of each wire percutaneous. Closure is routine. The same technique was used in all cases presented regardless of delay in treatment MILITARY MEDICINE, Vol. 176, September 2011

3 FIGURE 3. TSPLD after osteosynthesis scaphoid fracture and temporary triple Kirschner wire fixation anteroposterior projection. FIGURE 4. TSPLD after osteosynthesis scaphoid fracture and temporary triple Kirschner wire fixation lateral projection. In four cases, we had accompanying radial styloid fracture; these injuries are termed trans-radial-trans-scaphoid styloid fracture-dislocations. If a radial styloid fracture was encountered without displacement, fixation was not made; if there was minimal displacement or there was comminution, 2 Kirschner wires were placed. In patients with a larger fracture fragment, a cannulated, titanium headless compression screw ( mm depending upon styloid fragment size) was used for osteosynthesis. We have found in TSPLD injuries the scapholunate ligament is usually not disrupted, but always, once the scaphoid has been stabilized the scapholunate interosseous ligament and the lunotriquetral ligament are inspected. These ligaments are all accessed volarly. The temporary fixation Kirschner wires are removed 6 to 8 weeks after surgery. The cannulated titanium headless compression screws were not removed from the scaphoid or from the radial styloid in the affected 4 patients. Postoperative Treatment After surgery, a volar short arm splint was applied for 4 weeks. During this time, only finger motion was possible in metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints. After 4 weeks, gentle range of motion was introduced. At this time, the short arm cast was replaced with an orthosis, which the patient removed several times daily to allow gentle radial carpal joint movement. Transfixation wires do not pass through the radius, therefore gentle motion is possible between the radius and carpus. Following 6 to 8 weeks, after the removal of the temporary fixation Kirschner wires, patients were sent to the hospital rehabilitation center for intensive rehabilitation therapy. The patient retained the orthosis to wear overnight, as necessary, to reduce pain. Patient functional recovery was tracked by the Mayo Wrist Score. 10 RESULTS Of the 3 female and 40 male patients, 24 injuries were caused by a fall from height, 5 were injured in automobile accidents, 4 were injured in motorcycle accidents, 3 had bicycling accidents, and 7 were injured in sporting accidents. Twenty of the 40 male patients were injured during active military duty. All injuries were closed fractures. Thirty patients were operated within 7 days (acute phase) of injury, 8 patients were operated between 7 and 45 days (delayed phase) after injury, and 5 were MILITARY MEDICINE, Vol. 176, September

4 operated more than 45 days (chronic phase) after injury. Treatment delays of more than 7 days were because the patient either did not present earlier at our facility or because the diagnosis was not recognized before presenting at our facility. All scaphoid fractures united. The complete union of the scaphoid could be seen on plain X-rays so that follow-up CT was deemed unnecessary. Radiologist made X-rays in standard projection and oblique projection of both the injured wrist and contralateral wrist. The radiologist then made the determination of healing. Following rehabilitation, the combined wrist extension and flexion averaged (range ) for the injured wrist. This was an average of 92% of the contralateral wrist with an average range of 130 (range ). Average combined radial and ulnar deviation averaged 41 (range ) for the injured wrist, which was 91% of the contralateral wrist 45 (range ). Combined supination and pronation averaged 151 (range ) for the injured wrist, whereas that of the contralateral wrist averaged 155 (range ). The average grip was 33.0 kg (range kg) for the injured wrist and 44.0 kg (range kg) for the contralateral wrist. Patients achieved an average of 75% grip strength of the uninjured side at the final evaluation. At the final follow-up examination, the scapholunate gap averaged in our patients 2.5 mm (range mm) and the scapholunate angle averaged 50 (range ), both are within normal range. The average Mayo wrist score result for the 30 acute phase patients is 91 (excellent) (range 75 99, SD 4.8). The average Mayo wrist score result for the 8 delayed phase patients is 81 (good) (range 73 92, SD 5.9), and 75 (fair) (range 65 80, SD 5.9) for the 5 chronic phase patients. The average Mayo wrist score for all 43 patients is 87 (good) (range 65 99, SD 7.9). Statistical analysis of the Mayo wrist score results, using the exact Mann Whitney U test, showed a significant difference between the acute phase group and the delayed phase group ( p = ) as well as between the acute phase group and the chronic phase group ( p = ). The lack of significance ( p = ) between the delayed phase and the chronic phase groups may be because of the smaller amount of patients in these groups. None of the patients developed volar intercalated instability deformity. At the final examination, none of the patients had radiographic evidence of early arthritis. Of course, arthritis is expected as a later change because of the complexity of the injury. All 43 patients returned to their previous employment. Seventeen patients returned to work within 3 months, 19 patients returned to work within 4 months, and the remaining 7 patients returned to work within 5 months. Complications In a 45-year-old patient who was injured in a fall from height, one of the Kirschner wires used for temporary triple fixation moved and the patient was reoperated using the same technique. Carpal tunnel syndrome developed in a 23-year-old patient who was injured in a motorcycle accident. The carpal tunnel symptoms appeared 6 weeks after injury because of adhesion of M. palmaris longus to N. medianus, which was cared for by removing the adhesion on N. medianus and resection of M. palmaris longus. There were no further complications with either patient. Other complications such as infections, nonunion, or avascular necrosis were not seen. DISCUSSION TSPLDs account for more than 50% of all PLDs, but these injuries are uncommon and constitute only about 3% of all carpal injuries. 14,16 Operative treatment of TSPLD is important because untreated dislocations lead to poor results including post-traumatic arthritis, decreased range of motion, chronic carpal tunnel syndrome, and even attritional rupture of flexor tendons secondary to a curically dislocated lunate. 4,17 Further, abnormal carpal mechanism can decrease function and lead to arthritis. 4 There are different methods used to treat TSPLD, the most frequently used is a dorsal approach, 2,4,18 21, then a volar approach, 2,21,22 or a combination of these two. 2,6,23 28 It depends primarily upon the surgeon s preference as to which method is used. Regardless of the method used, the scaphoid must be reduced, the carpus must be repositioned, and the carpal mechanism must be stabilized. In our study, we used a volar approach for several reasons. We found it easier to reduce the fractured scaphoid and reposition the PLD using the volar method. The volar method allows control over the median nerve, which is not possible using the dorsal method, and allows visualization of damage to the PLD. Repair of a ruptured palmar radiocarpal ligament is better accessed with the volar method. Advantages of the volar approach also include decreased adhesion to the flexor tendons as compared to extensor tendons using a dorsal approach. We have experienced increased adhesions form more frequently on extensor tendons as well as forming between the extensor tendons and retinaculum. We found that flexor tendons adhesions likewise form, but rehabilitation proceeds easier and in less time with flexor tendons. We experienced a lower incidence of avascular necrosis while using the volar approach to the scaphoid as well. Temporary k-wire fixation is performed to care for the PLD. We operated under a fluoroscope so that we intraoperatively visualized the position of the scaphoid, lunate, and capitate after triple fixation Kirschner wire placement so secondary movement was controlled. Temporary fixation with 3 Kirschner wires applied as a treatment for TSPLD has not been described in literature to our knowledge. In all of our 43 patients, the same method of temporary triple fixation following cannulated titanium headless compression screw reduction of the fractured scaphoid was applied regardless of the time between injury and treatment. Time until the removal of the Kirschner wires is standard in most works about the treatment of TSPLD. It is important to care for the lunotriquetral ligament that is typically damaged in TSPLD. Biomechanical studies have 1080 MILITARY MEDICINE, Vol. 176, September 2011

5 shown that the lunotriquetral ligament is a key element in volar intercalated instability. 4,29,30 However, Knoll et al 4 states that the repair of the lunotriquetral ligament has been mentioned by others, but it is not clear in what percentage of their patients this was performed or how this was accomplished. 27 The state of the ligament varies greatly between injuries, and it is difficult to standardize treatment. Lunotriquetral ligament repair is best made with bone anchors, 4 though lacking these, we sutured on all presented lunotriquetral ligaments and our results were satisfactory. The reconstruction of the lunotriquetral ligament is considerably easier within the first 10 days after injury; however, lunotriquetral ligament repair is important even in chronic cases. If reconstruction is inadequate, there are a few techniques with which repair between the lunate and the triquetrum can be made such as mini anchors, a transosseal suture, or as a last resort, a mini graft of the palmaris longus tendon (about 1 cm) can be taken and fixed instead of the lunotriquetrial ligament between the lunate and triquetrum. The average time to scaphoid union using headless screw fixation was 16 weeks. 2,4 Most series with operative stabilization of the scaphoid have a 100% union rate. 4,6,17 Some surgeons believe that primary bone grafting is unnecessary, 4,31 and others apply grafts only in cases of comminution of the scaphoid.4 We did not use any grafting in these 43 patients and all scaphoid in our series healed without complication. Five patients, in the time frame of the study, presented with comminuted scaphoid fractures were treated with a bone graft from the iliac crest; however, none of these patients were included in this study. In cases where comminution exists, we agree that bone grafting is necessary. Our patients wrists were immobilized for 4 weeks, with a short arm cast. Most authors use immobilization longer than 4 weeks (6 weeks: Knoll, weeks: Forli, 5 10 weeks: Saunder, 2 10 weeks: Komurcu, 8 10 weeks: Leung, weeks: Weir, 9 and 13 weeks: Herzberg 17 ). In our technique, temporary triple fixation provides stabilization of the ligaments and the screw secures reduction of the fractured scaphoid allowing cast immobilization time to be reduced. Inoue and Imaeda 22 presented better range of motion function if cast immobilization was used for 4 weeks following open reduction and internal fixation with Herbert screws. We confirm these results. Our range of motion using the Mayo wrist score was excellent for acute phase patients, good for delayed patients, and fair for chronic phase patients. Furthermore, all patients returned to their previous occupations. 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