Perilunate dislocations represent a spectrum of severe injuries with expected decreases in range of motion (ROM) and grip strength (2,3). We describe a division 1 college football player who sustained a volar lunate dislocation that, like 25% of others, was initially missed on radiographic evaluation (3,8). Decreasing return to play time and on-field optimization were of high priority. The patient underwent closed reduction with percutaneous screw fixation.
A 20-yr-old male major college football linebacker sustained a ligamentous volar lunate dislocation on the football field. The injury pattern was not immediately identified on fluoroscopy by a team physician. Next, radiographic imaging and MRI were obtained by the covering sports team physician. Once the dislocation was diagnosed, the athlete was scheduled for urgent outpatient surgery approximately 36 h after injury.
Successful closed reduction was performed using longitudinal traction and direct volar pressure over the lunate. Remaining lunate extension deformity was corrected with a percutaneous k wire, which was removed before the patient left the operating room. After reduction was confirmed, two cannulated 3.0-mm screws (Synthes, Paoli, PA) were inserted. Using real-time fluoroscopy, there was good motion at the radiocarpal and midcarpal joints, as well as appropriate hardware placement (Figs. 1 and 2). The lunate appeared stable and overall carpal alignment was excellent. At this point, single stitches were placed over the percutaneous entry sites. Patient was initially placed in a short arm splint.
Short arm casting was performed at the first postoperative visit and sutures were removed (2 wk postoperative), and the patient was optimized for play with a cast foam cover greater than half-inch thick as designated by article 5 of the National Collegiate Athletic Association (NCAA) football rules and regulations (9). The patient returned to the football field and resumed a high level of play less than 3 wk after injury and donned a cast for the remainder of the season. He subsequently returned to play in nine games since this high-energy wrist injury and finished the season with 27 tackles and 12 assisted tackles since his return to play. He was second leading tackler at the linebacker position for the year. At 6 months, he had the screws removed. Grip strength testing at this time was 95% of the uninjured side.
Perilunate dislocations are difficult to manage, but operative treatment produces better Mayo Wrist Performance scores and range of motion compared to nonoperative management (1,6). However, common problems, such as loss of motion and decreased grip strength can persist, despite appropriate operative fixation (5). Perilunate dislocations represent a spectrum of injury and can be purely ligamentous dislocations or include fracture of carpal bones or the distal radius and ulna. These injuries can be difficult to recognize because several are missed on initial radiographic assessment. These can be difficult to ascertain to the untrained eye. Please note the break in Gilula’s arc and the superimposition of the other carpal bones with the lunate on the PA wrist radiograph (Fig. 3). Additionally, one should recognize the loss of collinearity between the radius, lunate, and capitate as well as the volar tilt of the lunate on the lateral view (Fig. 4).
Our patient missed only 2 games, achieving an immediate return to a high level of play. His injury was made more challenging given that he was a D1 college football linebacker. Typical surgical treatment of ligamentous injuries around the lunate involve percutaneous pinning that is frequently left out of the skin, necessitating future removal. Raab et al. (4) showed good results in professional athletes with purely ligamentous perilunate injuries at 5 yr follow-up. All were treated with either open or closed reduction followed by percutaneous k-wire fixation. These athletes were all held out of play for 4 weeks minimum unlike our patient who returned in less than 3 wk. Recently, Souer et al. (7) compared the use of temporary screws versus k-wires for such injuries. In their series, there was no statistical difference between the two groups. However, the wrist motion was 24 degrees better, and the strength was better in the screw cohort. It should be noted that their patient population included polytrauma patients which may have skewed their data set. While not statistically significant in the comparison of these groups, we feel that this motion and strength would be very clinically significant and relevant to a division 1 college football player. We were satisfied with our reduction and buried implant technique using screws; this allowed the training staff to modify a cast according to NCAA rules permitting this linebacker to return to immediate play. Our technique used percutaneous screw fixation to provide ease of casting and early return to sport.
The authors declare no conflict of interest and do not have any financial disclosures.
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