Miller, Nathan F

Song, Ethan

Wallace, Sean J, MD

Weiss, Lawrence

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Surgery Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion and Scaphoid Nonunion Advanced Collapse (SNAC). Sean J. Wallace MD Lehigh Valley Hospital, sean.wallace@lvhn.org Ethan Song Lehigh Valley Health Network Nathan F. Miller Lehigh Valley Health Network, Nathan.Miller@lvhn.org Lawrence Weiss Lehigh Valley Health Network, Lawrence.Weiss@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/surgery  Part of the Surgery Commons Published In/Presented At Wallace, S. J., Song, E., Miller, N. F., & Weiss, L. E. (2020). Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion and Scaphoid Nonunion Advanced Collapse (SNAC). Eplasty, 20, ic9. This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. 2/22/22, 11:11 AM Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion an…https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270226/ 1/3Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting ofPrevious Scaphoid Nonunion and Scaphoid Nonunion Advanced Collapse (SNAC)Sean J. Wallace, MD, Ethan Song, BA, [...], and Lawrence E. Weiss, MDDESCRIPTIONA 59-year-old man fell onto his outstretched hands. He was diagnosed with a left-sided transscaphoid transcapitate perilunate fracture-dislocation inthe setting of previous scaphoid open reduction internal fixation (ORIF), resulting in a nonunion and scaphoid nonunion advanced collapse (SNAC).Wrist salvage in the form of primary partial wrist fusion was performed and resulted in excellent clinical and functional outcomes.QUESTIONS1. What are perilunate dislocations and/or perilunate fracture-dislocations?2. What physical and radiologic examination findings are typically encountered with perilunate dislocations and fracture-dislocations?3. How are perilunate dislocations and fracture-dislocations managed?4. When a perilunate fracture-dislocation presents in the setting of previous scaphoid nonunion and SNAC wrist, what is the best surgicaloption to give the best functional outcome?DISCUSSIONPerilunate dislocations and fracture-dislocations are debilitating wrist injuries resulting from high-energy trauma. Dislocations can be purelyligamentous or involve a combination of bony and ligamentous structures. When involving only ligaments surrounding the lunate, these dislocationsare referred to as lesser arc injuries. When the dislocation is associated with a radial styloid or carpal bone fractures, they are referred to as greater arcinjuries.  A stepwise injury progression has been previously described by Mayfield et al.  Ligamentous injuries commonly progress from radial toulnar, disrupting the scapholunate ligament first. As the force transmits, ulnar, capitolunate, and lunotriquetral articulations are disrupted sequentially,which leads to failure of the dorsal radiocarpal ligament and dislocation of the lunate from the lunate fossa. When greater arc injuries occur, the forcetransmits through the radial styloid and carpus. These injuries commonly result in transscaphoid perilunate fracture-dislocations, but they can alsoinvolve the radial styloid or other carpal bones.  Despite proper reconstruction, outcomes for perilunate dislocations and perilunate fracture-dislocations are notoriously poor. Patients often develop decreased grip strength and range of motion. Patients may go on to develop traumatic arthritisof the wrist requiring wrist salvage procedures such as 4-corner fusion or proximal row carpectomy.Physical examination often reveals a grossly swollen wrist with limited range of motion with or without signs of acute median neuropathy. Thepresence of acute carpal tunnel syndrome is an indication for urgent operative intervention if closed reduction has failed. Posteroanterior radiographicevaluation may demonstrate alteration of Gilula's lines with loss of carpal height (Fig 1). There may also be widening of the scapholunate interval withan associated cortical ring sign of the scaphoid. On a lateral radiograph, the capitate may be displaced posterior relative to the lunate, disrupting thecollinear relationship between the radius, lunate, and capitate (Fig 2).Figure 1Preoperative posteroanterior radiograph of transscaphoid transcapitate perilunate fracture-dislocation demonstrating previous scaphoidopen reduction internal fixation resulting in nonunion and scaphoid nonunion advanced collapse wrist. Also demonstrated ...1 2342/22/22, 11:11 AM Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion an…https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270226/ 2/3Figure 2Preoperative lateral radiograph of transscaphoid transcapitate perilunate fracture-dislocation in the setting of scaphoid nonunion andscaphoid nonunion advanced collapse demonstrating posterior displacement of the capitate relative to the lunate.Surgical correction involves acute carpal tunnel decompression, relocation of the carpus, repair of the capsular rent, and stabilization of the carpuswith percutaneous pin fixation. Controversy exists whether acute scapholunate ligament reconstruction should be performed.  In the setting ofscaphoid fractures associated with the injury, the scaphoid is often stabilized with cannulated screw fixation with or without autologous bone grafting.However, because of the retrograde blood supply of the scaphoid to the proximal pole, scaphoid fractures may lead to nonunion or malunion.Unrepaired scaphoid fractures may develop SNAC and can progress to pan-carpal arthritis. Wrist salvage procedures are indicated when the arthritishas advanced to a degree of which the patient cannot tolerate the pain.We present a case of a patient who suffered a transscaphoid transcapitate perilunate fracture-dislocation in the setting of a prior scaphoid nonunion andSNAC wrist. Radiographs revealed a greater arc injury with transmission of force through the previous scaphoid nonunion site, resulting indisplacement of the cannulated screw from the proximal pole of the scaphoid (Figs 1 and 2). Scaphoid nonunion was suspected on radiographs andcomputed tomographic scan and was confirmed with intraoperative evaluation that revealed sclerotic bone with avascular changes within the proximalpole and a displaced previously placed surgical screw transfixing the nonunion site. Visual intraoperative confirmation of the SNAC was evidenced bydegenerative changes at the radioscaphoid joint and radial styloid, as well as significant midcarpal joint arthrosis (Fig 1). In this setting, we theorizedthat a primary wrist salvage procedure would provide the best outcome. A standard ORIF would leave the midcarpal arthrosis unresolved. Given thepresence of a proximal capitate fracture and concomitant midcarpal arthrosis, a midcarpal arthrodesis was favored over proximal row carpectomy. Toeliminate the amount of fusion that needed to occur, we excised the proximal pole of the capitate. The shortened capitate created certain challenges interms of considering the standard scaphoidectomy and 4-corner fusion. To adjust for the decreased height of the capitate in relation to the triquetral-hamate articulation, the triquetrum was excised. This afforded the opportunity to fuse the shortened capitate to the lunate using a headless screw alongwith distal radius bone graft (Fig 3). Ultimately, that patient developed 40° of flexion and extension of both wrists, full digital flexion, andconsolidation of fusion (Fig 4) and was able to return to work, performing all of his previous activities.Figure 3Intraoperative fluoroscopic view after reduction and primary partial midcarpal wrist arthrodesis.Figure 4Postoperative posteroanterior, lateral, and oblique radiographs at 4 months revealing consolidation of primary partial midcarpal wristarthrodesis.Article informationEplasty. 2020; 20: ic9.Published online 2020 May 11.PMCID: PMC7270226PMID: 32537045Sean J. Wallace, MD, Ethan Song, BA, Nathan F. Miller, MD,  and Lawrence E. Weiss, MDDivision of Plastic & Reconstructive Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PaMorsani College of Medicine, University of South Florida, TampaDivision of Orthopedic Hand Surgery, OAA Orthopedic Specialists, Allentown, PaCorrespondence:Email: seanjwallace@gmail.com.Keywords: perilunate dislocation, May eld's classi cation, scaphoid nonunion, scaphoid nonunion advanced collapse, wrist salvage44,5 a b a cabc2/22/22, 11:11 AM Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion an…https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270226/ 3/3Copyright © 2020 The Author(s)This is an open-access article whereby the authors retain copyright of the work. The article is distributed under the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Articles from Eplasty are provided here courtesy of HMP GlobalREFERENCES1. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand SurgAm. 1993;18(5):768–79. [PubMed] [Google Scholar]2. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3):226–41.[PubMed] [Google Scholar]3. Dunn JC, Koehler LR, Kuznezov NA, et al. Perilunate dislocations and perilunate fracture-dislocations in the U.S. military. J Wrist Surg. 2018;7(1):57–65.[PMC free article] [PubMed] [Google Scholar]4. Subramanian K, Arora B, Bhatnagar A, Jan I. Perilunate dislocation—case report and review of the literature. 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Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion and Scaphoid Nonunion Advanced Collapse (SNAC).

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Wrist Salvage in a Transscaphoid Transcapitate Perilunate Fracture-Dislocation in the Setting of Previous Scaphoid Nonunion and Scaphoid Nonunion Advanced Collapse (SNAC).

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