Radiocarpal Dislocation Classification Rationale for Management and

More documents

Recommendations

Info

$fracture dislocations of the proximal ... - Northwestern University$

208 Moneim et al. No uniformity of opinion exists in the literature with regard to the indications for either closed or open reduction. Factors that affect the prognosis are not well outlined in the literature. Bohler in t9302 reported on a group of patients with radiocarpal dislocation and recommended skeletal traction to regain length with a nail through the metacarpals and another through the olecranon with the arm stretched in a screw-extension apparatus. He also used this method in conjunction with open reduction for lunate and scaphoid dislocations. One of his cases was a volar radiocarpal dislocation, similar to Case 1, that had a recurrence of the volar dislocation soon after a successful closed reduction. Dunn 4 reported on five cases with radiocarpal dislocation that were treated by closed reduction and additional skeletal fixation for unstable cases. On follow-up evaluation only one patient had recovered painless motion; however, the other four had some limitation and some pain at follow-up study. Fahey5 reported a single case of volar radiocarpal dislocation with a fracture of the radial styloid that was treated by closed reduction with a good result at two years of follow-up study. The carpus was dislocated as one 6 unit in this case. Freund and Ovesen reported on a case of dislocation of the radiocarpal joint. This dislocation was dorsal without an associated fracture of the radius and was treated by closed reduction with good result at 12 months. In this case also, the carpus was dislocated as one unit without any intercarpal instability. Recently, Bilos et. al., ~ reported on five cases ofradiocarpal dislocation. Four were treated by open reduction and closed reduction was performed in one. They recommended early open reduction with internal fixation of the fracture and repair of all torn ligaments. The classification given here is based on the extent of the injury and can be used to predict the outcome in a given case. One can also formulate a plan of management depending on that classification. Clinical and Related In Type I dislocation there is less and the ligamentous disruption is between 1 distal radius and the carpus, as one unit. the one case of dorsal dislocation treated open reduction, the tear affected the volar ra.: diolunate ligament and extended to affect the radioulnar lunate capsular There was also a fracture of the volar the radius. Type I dislocation should be 1 by closed reduction and plaster immoi tion for six weeks. During the first four a long-arm cast is applied and is then changN to a short-arm cast for two weeks. Open duction is reserved for cases where closed duction fails because of interposition in joint of bony fragments or for ’ " anatomical reduction of the radial styloid. can expect a good result in these cases. If the reduction is unstable, one can consider pinning of the radiocarpal joint to prevent future subluxation, as in Case 1. In Type II dislocation, the trauma is severe and the ligamentous disruption involves several areas. The authors found a dorsal tear affecting the dorsal capsular ligaments between the radius and the scaphoid and lunate, and an extensive volar midcarpal tear between the lunate and the capitate that extended radially into the radiocapitate and radiolunate ligaments and ulnarly into the triquetrocapitate ligament. The scapholunate intercarpal ligament was also torn. In contrast to other published reports,1 all cases of Type II dislocation :in the authors’ series were volar dislocations. The lunate was severely displaced volarly in all cases. The authors agree with others I that the proper management of these severe dislocations is open reduction through both volar and dorsal approaches. The radial styloid should be pinned in anatomic position to achieve radiocarpal stability. Then the scaph-i old should be pinned to the lunate to achieve : midcarpal stability. Any other large fragments of bone are also pinned and all torn ligamentous structures repaired. Even then the nosis is guarded in these patients. If secondary procedures are deemed necessary because .... 192 19~ results, tl ~ion rather ttlatter pr( lction of t! ~as a result oft ses had assc joi of fractu: carpal and di terposition ir i fra,,g, ment fro iclosed reduc: ,’ur. I pai: The authors Thomas Flemim in this report. t. Bilos, Z, J.. dislocation of five case
Clinical and Related ,cation there is less traui ~ us disruption is between ~ the carpus, as one unit orsal dislocation treated ~e tear affected the volar It and extended alnar lunate capsular fracture of the volar or results, the author~ recommend wrist fu- ~on rather than proximal row carpectomy. :The latter procedure will fail because of degruction of the distal radial articular surface a result of the injury) ~ None of the authors’ had associated dislocation of the inferior nt. Weiss et al. ~3 reported on a lp lff~ of fracture-dislocation of both the radio- :tislocation should be |~:camal and distal radioulnar joints. Bony in- )n and plaster imnaobil~ L~ terposition ~n the joint of an osteochondra During the first four ~fragment from the distal radius prevented applied and is then N~’:elosed reduction. Open reduction resulted in st for two weeks. Open good result at 14 months of follow-up study. d for cases where closed Residual pain at the distal ulna can, however, ruse of interposition in the ~qents or for those ion of the radial ACKNOWLEDGMENTS ! result in these cases. If the The authors wish to thank Drs. Robert Turner and ble, one can consider cross- Thomas Fleming for contributing two of the cases included tdiocarpal joint to in this report. a, as in Case 1. REFERENCES ,cation, the trauma is severe )us disruption involves sev- 1. Bilos, Z. J.. Pankovich, A. M.. and Yelda. S.: Fracturedislocation of the radiocarpal joint. A clinical study uthors found a dorsal tear of five cases. J. Bone Joint Surg. 59A:198, 1977. [ capsular ligaments between e scaphoid and lunate, and ’ midcarpal tear between the ~itate that extended radially ,kate and radiolunate ligay into the triquetrocapitate lpholunate intercarpal liga-, n. In contrast to other pubcases of Type II dislocation des were volar dislocations. ,~verely displaced volarly in : hors ~ agree with others that ;ement of these severe diseduction through both volar )aches. The radial 1 in anatomic position to al stability. Then the scaphned to the lunate to ¢. Any other large fragments i inned and all torn ligamen- ~aired. Even then the prog- . these patients. If secondary :emed necessary because of 1985 Radiocarpal Dislocation 209 2. Bohler, L.: Verrenkungen der Handgelenke. Acta Chit. Scand. 67:154, 1930. 3. Dobyns, J. D., and Linscheid, R. L.: Fractures and dislocations of the wrist. In Rockwood, C. A. Jr., and Green, D. P.(eds.): Fractures, vol. 1. Philadelphia, J. B. Lippincott, 1975, pp. 345-440. 4. Dunn, A. W.: Fractures and dislocations of the carpus. Surg. Clin. North Am. 52:1513, 1972. 5. Fahey, J. H.: Fractures and dislocations about the wrist. Surg. Clin. North Am. 37:19, 1957. 6. Freund, L. G., and Ovesen, J.: Isolated dorsal dislocation of the radiocarpat joint: A case report. J. Bone Joint Surg. 59A:277, 1977. 7. Green, D. P., and O’Brien, E. T.: Open reduction of carpal dislocations--lndications and operative techniques. J. Hand Surg. 3:250, 1978. 8. Gui, L.: Fratture e lussazioni. Firenze. Edizioni scientifiche Instituto ortopedico toscano, 1957, p. 510. 9. Lourie, J. A.: An unusual dislocation of the lunate of the wrist. J. Trauma 22(I 1): 966, 1982. 10. Mullan, G. B., and Lloyd, G. J.: Complete carpal disruption of the hand. Hand 12:39, 1980. 11. Neviaser, R. J.: Proximal row carpectomy for posttraumatic disorders of the carpus. J. Hand Surg. 8:30 l, 1983. 12. Rosado, A. P.: A possible relationship of radiocarpal dislocation and dislocation of the lunate bone. J. Bone Joint Surg. 48B:504. 1966. 13. Weiss. C., Laskin. R. S., and Spinner, M.: Irreducible radiocarpal dislocation: A case report. J. Bone Joint Surg. 52:562, 1970.
Page 1 and 2: , with absorption and ~~:~ en lorgn
Page 3 and 4: TABLE 1. Radiocarpal Dislocation: M
Page 5 and 6: FIG. 1. and lateral rad showin of t
Page 7 and 8: Clinical, 1985 and Related 7. Anter
Page 9: FIG. 9. Patient in 7 at follow-~ No

Radiocarpal Dislocation Classification Rationale for Management and

Create successful ePaper yourself

Delete template?

Save as template?