Fracture-Dislocations of the Carpus: Perilunate Injury
Orthopedic Surgery Department, Allegheny General Hospital, 1307 Federal Street, 2nd Floor, Pittsburgh, PA 15212, USA.Orthopedic Clinics of North America (Impact Factor: 1.25). 01/2013; 44(1):93-106. DOI: 10.1016/j.ocl.2012.08.009
The progressive perilunar instability model described by Mayfield is still used to predict the pattern of injury. Diagnosis of injury and clinical and radiographic findings depend on the pattern of injury. Open procedures are preferred for anatomic reduction after initial closed reduction is performed for acute injuries. A dorsal, volar, or combined dorsal/volar approach may be necessary and is often decided by surgeon preference. Loss of motion and diminished grip strength are common consequences despite appropriate treatment. Successful outcomes depend on time to treatment, open or closed nature of injury, extent of chondral damage, residual instability, and fracture union.
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ABSTRACT: This retrospective study evaluates the functional and radiological results of a series of acute trans-scaphoid dorsal perilunate fracture-dislocations treated operatively by minimally invasive technique. Twenty-one patients had surgery performed by one of three surgeons between 1994 and 2006, and all cases involved: (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; and (3) closed reduction and multiple Kirschner wire stabilisation of the carpal dissociation. Seventeen males and four females with an average age of 29 years were evaluated. Ninety five per cent of internally fixed scaphoid healed at a mean time of 16 weeks. Radiographic alignment of the carpus was satisfactory in 17 cases. The average Mayo wrist score was 80 with three excellent and two poor results. There was one patient with asymptomatic DISI deformity. Two patients had radiographic evidence of mid-carpal arthritis. One patient with a scaphoid nonunion required surgical repair with bone grafting. The results of this study suggest that a minimally invasive technique for treating acute trans-scaphoid perilunate fracture-dislocations can be considered as an alternative to open approaches.
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ABSTRACT: Correct diagnosis, anatomical reduction, stable fracture fixation, adequate ligament reconstruction and a secure transfixation of unstable joints are the key to successful treatment of acute perilunate dislocations and luxation fractures. Realization of these principles necessitates an early open surgical procedure and a protracted follow-up treatment. These infrequent injuries should be addressed at a specialized center for hand surgery due to the variable and complex injury patterns which require a precise biomechanical knowledge of the carpus and specific surgical experience. By following these prerequisites a good restoration of wrist function is expected to be achieved in most cases. In a number of patients, chondral lesions, avascular osteonecrosis and carpal ligament instability lead to posttraumatic osteoarthritis requiring a secondary salvage procedure. Perilunate injuries are a domain of younger working and active men and are often related to social and occupational problems with returning to work sometimes requiring occupational reorientation, which can result in substantial costs for health insurance companies.
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