Transverse translunate fracture–dislocation: a rare injury

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Sabri MAHJOUB, Bertrand DUNET, Patricia THOREUX, AlainCharles MASQUELET

-Transverse translunate fracture–dislocation: a rare injury - Hand Surgery and Rehabilitation - Vol. 35, n°3, p.220-224 - 2016

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Transverse

translunate

fracture–dislocation:

A

rare

injury

Fracture-luxation

translunaire

transversale

:

une

lésion

exceptionnelle

S.

Mahjoub

,

B.

Dunet

*

,

P.

Thoreux

,

A.C.

Masquelet

a _{Servicedechirurgieorthopédiqueettraumatologique,hôpitalAvicenne,125,ruedeStalingrad,93000Bobigny,France} b

Unitémembresupérieur,servicedechirurgieorthopédiqueettraumatologique,hôpitalPellegrin,placeAmélie-Raba-Léon,33076Bordeauxcedex,France

c

Servicedechirurgieorthopédiqueettraumatologique,hôpitaldeLibourne,112,ruedelaMarne,33505Libourne,France

Abstract

Perilunatefracture–dislocationisrare.Wereportthecaseofa24-year-oldmalewhofellfromhismotorcycleandpresentedwithatransverse lunatefracturewithperilunateligamentdamage.TheinitialdiagnosisbasedonX-rayswasconfirmedbyCTscan.Adorsalapproachwasusedto obtaingoodreduction,doublescrewfixationandligamentreinsertionprotectedbytemporaryK-wires.Tothebestofourknowledge,thisisthefirst caseoftransverselunatefracturewithinperilunatefracture–dislocation.Thepatientreturnedtonormalactivitiesafter6months.

Keywords:Carpus;Lunate;Dislocation;Fracture;Ligament

Résumé

Lesfractures-luxationspérilunairesducarpesontrares.Nousrapportonslecasd’unhommede24ans,droitierqui,danslessuitesd’unechute paraccidentdelavoiepublique enmoto,aprésentéune fracture-luxationtranslunaireavecatteinteligamentairepérilunaire.Lediagnostic, suspectésurlesradiographiesinitiales,aétéconfirméparunscanner.Unabordpostérieuraétéréalisépourpermettreuneréductiondelafracture fixéeparundoublevissageenfoui,associéeàuneréinsertionligamentaireetbrochagetemporaireenprotection.Ils’agit,ànotreconnaissance,du premiercasrapportédefracturetransversaledulunatumdanslecadred’unefracture-luxationpérilunaire.Lepatientapureprendresesactivités dansundélaide6mois.

Motsclés: Carpe;Lunatum;Luxation;Fracture;Ligament

1. Introduction

Perilunatefracture–dislocationsofthecarpalbonesarerare

[1–3]. We will describe the first case involving a transverse

fracture of the lunate with complex perilunate ligament damage.

2. Casereport

Thiswasayoungmanof24yearswhosufferedtraumato bothwristsfollowingamotorcycleaccidentinSeptember2009. The initialexaminationfoundpainfulswellingofbothwrists associated with total functional disability and pain during passive motion of the fingers with no sensory or motor neurologicaldeficit, vasculardamageor skindisorder.

The initial radiological assessment performed in the emergency room revealed a perilunate fracture–dislocation oftheleftwristandalunotriquetralseparationwithstaticvolar axialmisalignmentof theintermediatesegment(VISI)ofthe

* Correspondingauthor.

rightwrist(Figs.1and2).Specializedadvicewassought,and afterrereadingthe initialx-rays,aCTscanwasperformedto confirmthediagnosisof transverselunatefractureinthe left wristassociatedwithacomminutedintra-articularfractureof the radial styloid process and a fractureof the ulnar styloid process(Figs.3and4).TheCTscanalsoconfirmedthedorsal displacement of the distal fragment of the lunate and the integrityof thearticularlunocapitatesurfaces.

Because of the observed displacement, we decided to perform urgent surgical treatment. Treatment consisted of a dorsalapproachwith capsulotomyaccording toBergeretal.

[4],combiningcompressionof the boneblock withflathead screwsfor thelunateandreductionof thearticularsurfaceof the radial styloid process under visual control. Surgical exploration confirmed the scapholunate and lunotriquetral ligament tears. Ligament reattachment with a MitekTM microanchor was performedandthe repair was protected by temporaryK-wirepinningintheleftwrist(Fig.5).Theulnar styloid process fracture was not fixed because the distal radioulnarjointintheleft wristwas notunstable.

The patientused asimplewristsplint for 45days. Active mobilization of themetacarpophalangeal andinterphalangeal

Fig.1. StandardpreoperativeA/Pandlateralradiographsoftheleftwrist.

Fig.3. InitialCTscanwithfrontalandsagittalsectionsshowingthelunateandradiusfractures. Fig.2. StandardpreoperativeA/Pandlateralradiographsoftherightwrist.

jointswasallowedduringtheimmediatepostoperativeperiod. Unionofthebonefractureswasconfirmedat6weeksandthe K-wirewasremovedduringoutpatient surgery.

Atthe1-yearfollow-up,the patienthasregainedallofhis range of motionsymmetricallywith708 inextension,608 in flexion,308inulnardeviationand158inradialdeviation;he hadno specificlimitations inhis activities. He hada PRWE totalscoreof8/100[5]andagripstrengthof45kgonaJamar dynamometerintherighthandand40kginthelefthand[6]. Noasepticnecrosisofthelunatewasobservedduringthefinal assessmentof theleftwrist(Figs. 6and7).

3. Discussion

Malgaigne was the first to describe perilunate fracture– dislocationin1855[7].Lunatefracturesrepresent2%to3.9% of all carpal fractures [2,8] and occur in combination with perilunate fracture–dislocation in5% to7% of wrist injuries

[7,9]. Perilunate fracture–dislocation usually occurs among

menbetween 20and30yearsof agefollowingafall froma significantheightorinamotorvehicleaccidentinvolvinghigh kineticenergy[10].Predominantly,perilunatedislocationsare dorsalwithonly3%beingvolar[10].Conwayetal.reported

Fig.5. StandardintraoperativeA/Pandlateralradiographsoftheleftwrist.

Fig.4. InitialCTwith3Dreconstruction(A).DiagramoftheinjuryarcsdescribedbyBain(B):greenline:translunatearc;redline:smallarc;blueline:largearc.

three cases of volar translunate fracture–dislocation in 1989

[11].In2008,Lavelleetal.reportedonecaseofcoronallunate fractureassociated with ligament damage [12]. It is onlyin 1988thatatruetransversefracture, isolatedfrom the lunate, wasreported[13].Yakoubi etal., in2007,reportedafrontal lunate fracture with dislocation of the perilunate [14]. Bain et al. reported several cases of frontal translunate fracture– dislocation,butnoneweretransverse[3].Duringourliterature search,wefoundnocasewithaninjurycombinationlikethe onedescribedhere(Table1).

Our hypothesis is that our patient was subjected to a movement combining extension, supination and ulnar devia-tion.Webelieve ourpatientinitially placedhis handson the hypothenareminenceinhyperextensionandulnardeviationof thewrist,causingthescaphoidandthelunatetoflexandleaving thetriquetruminabnormalextension.Thisledtobreaking of the lunotriquetral joint and that trauma was followed by hyperextensionandradial translation thatcausedthe scapho-lunateligamenttearandthe radiusfracture[15,16].Thisisa transverseshearmechanismofinjury.Mayfieldetal.described the mechanism of perilunate dislocation, suggesting that injuring forces spread around the lunate but not through it, which is contrary to our case [17]. This is how Johnson describedthedamagetothefirstandsecondGilulacarpalarcs accordingtoBain (Fig.4,red andblueline)[18].LikeBain etal., we believe thatlesionsof the translunate arc must be added(Fig.4,greenline)[3,16].UnlikeBainetal.,wedonot believethatcapitateimpactiononthelunateistheoriginofthe fracture; instead there is hyperextension with the forearm

extending from supination and pronation, leading to a transverse translation from the ulnar side to the radial side

[19].Ourcasecouldbeclassifiedasavariantofthetranslunar fracture–dislocation on an intact scaphoid with dorsal displacement(Fig.8)[10].

Thediagnosisisbasedonclinicalexaminationandstandard radiographs.CTscanmustbeperformedifthereisanydoubt, inordertoavoidadelayindiagnosis[1,2];thisensuresbetter planningoftheprocedurebyavoidingintraoperativediscovery of a fracture [20]. The CT scan can determine the type of fractures,theirdisplacementandrevealanyassociatedligament injuries.

Treatment uses a dorsal approach to reduce the intra-articularfractureofthelunateandreducethescapholunateand lunotriquetral diastasisby ligamentreattachment and tempo-raryK-wirepinning.In2008,FirthandAdenrecommendeda dualdorsal/volarapproachtoreattachthedorsalscapholunate andvolarlunotriquetralligaments[21].Despitetheseverityof theinitialinjury,noosteonecrosisofthelunatewasobserved

[9].Earlylunatefixationislikely toreducethisrisk [9,11]. Unlikesomeauthors[9],wehavenotyetusedarthroscopyin the careof thesecomplexfracture–dislocationsofthecarpus affecting the proximal and distal carpal rows. Some of the potentialadvantagesof arthroscopyare:

comprehensiveassessmentofligamentdamage,namelythe intrinsic,extrinsic andcartilaginousligaments;

reduction in the size of the surgical incision, thereby postoperativestiffness;

Fig.7.Comparativeclinicaloutcomeinflexionandextensionafter1year.

Table1

Summaryofcasesoftranslunatefracture–dislocations.

Authors Numberofcases Lunatefracturetype TeisenandHjarbaek[13] 1 Transverse(typeIV) Conwayetal.[11] 3 Scaphoidfrontaldamage Amavaratietal.[8] 1 Sagittal

Yakoubietal.[14] 1 Frontal Lavelleetal.[12] 1 Frontal BriseñoandYao[20] 1 Frontal Bainetal.[16] 22 Frontal Akaneetal.[9] 1 Frontal

Ourstudy 1 Transversewithperilunate ligamentdamagewithout

scaphoidlesion Fig. 8. Alternative mechanism in the Herzberg classification: translunate fracture–dislocationofintactscaphoidandstageIIIdorsaldisplacement.

 helpdeterminethemechanismofinjuryandtherebypropose aspecifictreatment[22].Theuseofarthroscopycanalsobe consideredforanisolatedfractureofaboneintheproximal

row[22–24].It does notseem appropriateto useproximal

rowcarpectomyas first-linetreatment[14,25–27]. 4. Conclusion

Ourcaseisthefirstreportedcaseofatransversefractureof the lunate as part of a translunar fracture–dislocation with lunotriquetral and scapholunate damage. The injury mecha-nismconfirmsthetranslunatearchypothesis.CTscanshould beperformedwhentheinitialdiagnosticisuncertaininorder not to delay the treatment. The fracture must be perfectly reducedandrequires–inouropinion–asurgicalapproachthat allows for screw insertion and ligament repair to obtain satisfactoryfunctionalresults.

Disclosureofinterest

Theauthorsdeclare thattheyhavenocompeting interest. References

[1]SuhN,EkET,WolfeSW.Carpalfractures.JHandSurgAm2014;39:785–91.

[2] Hey HW, Chong AK, Murphy D. Prevalence of carpal fracture in Singapore.JHandSurgAm2011;36:278–83.

[3] BainGI,PallapatiS,EngK.Translunateperilunateinjuries–aspectrum ofthisuncommoninjury.JWristSurg2013;2:63–8.

[4] BergerRA,BishopAT,BettingerPC.Newdorsalcapsulotomyforthe surgicalexposureofthewrist.AnnPlastSurg1995;35:54–9.

[5] MacDermidJC,TurgeonT, RichardsRS,Beadle M,RothJH.Patient ratingofwristpainanddisability:areliableandvalidmeasurementtool.J OrthopTrauma1998;12:577–86.

[6] MathiowetzV,WeberK,VollandG,KashmanN.Reliabilityandvalidity ofgripandpinchstrengthevaluations.JHandSurgAm1984;9:222–6.

[7] KaewlaiR,AveryLL,AsraniAV,AbujudehHH,SacknoffR,Novelline RA.MultidetectorCTofcarpalinjuries:anatomy,fracturesandfractures– dislocations.Radiographics2008;28:1171–84.

[8] AmavaratiRS,SajiMJ,RajagopalHP.Greaterarcinjuryofthewristwith fractured lunate bone: a case report. J Orthop Surg (Hong Kong) 2005;13:310–3.

[9] AkaneM,TatebeM,IyodaK,OtaK,IwatsukiK,YamamotoM,etal. Partialnecrosisofthelunateafteratranslunatepalmarperilunatefracture– dislocation.NagoyaJMedSci2014;76:211–6.

[10] HerzbergG,ComtetJJ,LinscheidRL,AmadioPC,CooneyWP,StalderJ. Perilunatedislocationsandfracture–dislocations:amulticenterstudy.J HandSurgAm1993;18:768–79.

[11] ConwayWF,GilulaLA,ManskePR,KriegshauserLA,RhollKS,Resnik C. Translunate,palmarperilunatefracture–subluxationofthewrist.J HandSurgAm1989;14:635–9.

[12] LavelleWF,WhippleR,UhlR.Translunatetransradialstyloidfracture– dislocation:acasereport(araretranslunatefracture–dislocation).Injury 2008;39:359–63.

[13] TeisenH,HjarbaekJ.Classificationoffreshfracturesofthelunate.JHand SurgBr1988;13:458–62.

[14] YakoubiM,MezianiN,YahiaCherifM,KasbiA,BenbakoucheR.Carpal dislocationcombinedwithalunatefracture.Reportofacaseofthisnew variety.ChirMain2007;26:247–9.

[15] Garcia-Elias M.Lunotriquetral complex lesions:treatment principles. ChirMain2003;22:57–64.

[16] BainGI,McLeanJM, TurnerPC,SoodA,PourgiezisN.Translunate fracturewithassociatedperilunateinjury:3casereportswithintroduction ofthetranslunatearcconcept.JHandSurgAm2008;33:1770–6.

[17] Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanicsandprogressiveperilunarinstability.JHandSurg1980;5: 226–41.

[18] JohnsonRP.Theacutelyinjuredwristanditsresiduals.ClinOrthopRelat Res1980;149:33–44.

[19] ChristodoulouL,PalouCH,ChamberlainST.Proximalrowtranscarpal fracturefromapunchinginjury.JHandSurgBr1999;24:744–6.

[20] BriseñoMR,YaoJ.Lunatefracturesinthefaceofaperilunateinjury: an uncommon and easily missed injury pattern. J Hand Surg Am 2012;37:63–7.

[21] FirthGB,AdenA.Treatmentoflunateandperilunatedislocationswitha combinedapproachandanchorrepairofthedorsalscapholunate inter-osseousligament.SAOrthopJ2008;32–8.

[22] VanOverstraeten L,Camus EJ.Asystematic methodof arthroscopic testingofextrinsiccarpalligaments:implicationincarpalstability.Tech HandUpExtremSurg2013;17:202–6.

[23] DanaC,DoursounianL,NourrissatG.Arthroscopictreatmentofafresh lunate bone fracture detachingthe scapholunateligament. Chir Main 2010;29:114–7.

[24] SlutskyDJ,TrevareJ.Useofarthroscopyforthetreatmentofscaphoid fractures.HandClin2014;30:91–103.

[25] MarzoukiA,AlmoubakerS,HambiO,LaharchK,BoutayebF. Trans-scaphoidperilunatedislocationwithproximaldisplacementofthelunate andproximalscaphoid.Acasereport.ChirMain2013;32:96–9.

[26] HuishJrEG,VitalMA,ShinAY.Acuteproximalrowcarpectomytotreat a transscaphoid,transtriquetral perilunate fracture–dislocation: a case reportandreviewoftheliterature.Hand2013;8:105–9.

[27] RazafimahandryHJC,Rakoto-RatsimbaHN,GilleO.Opentransscaphoid perilunate dislocation with proximal displacement of the lunate and proximalscaphoid.ChirMain2009;28:113–5.