Journal Logo

VIEWPOINTS

Acute Dorsal Radiocarpal Dislocation Associated with Scapholunate Ligament Avulsion: A Proposal for Surgical Treatment

Garcia-Paredero, Ester M.D.; Cecilia, David M.D.; Sandoval, Enrique M.D.

Author Information
Plastic and Reconstructive Surgery: January 2010 - Volume 125 - Issue 1 - p 24e-25e
doi: 10.1097/PRS.0b013e3181c2a27e
  • Free

Sir:

Dislocations of the radiocarpal joint are rare. According to Dunn,1 they represent 0.2 percent of all dislocations. This injury usually combines a volar radiocarpal ligamentous tear and a bony avulsion of the radial and ulnar styloid.2,3 In some cases, it is associated with carpal bone fractures or intracarpal ligament tears.4,5

Many treatments for radiocarpal dislocations have been described, but there is no clear evidence of the optimal management. Two classifications have been proposed that can help with the therapeutic decision: those of Moneim et al.4 and Dumontier et al.3

A 25-year-old man was involved in a motocross accident. He had pain, tenderness, and deformity in his left wrist, with no tendon or neurovascular deficit. Radiographs showed a dorsal radiocarpal dislocation with a radial styloid avulsion (Fig. 1). There were no associated fractures or carpal malalignment. Closed reduction was accomplished in the emergency room. Postreduction radiographs showed the radial styloid avulsion involving less than one-third of the width of the scaphoid fossa (Dumontier type I) and a scapholunate gap. Computed tomographic scanning revealed an avulsion of the radial volar rim and the proximal pole of the scaphoid.

Fig. 1.
Fig. 1.:
Dorsal radiocarpal dislocation with a radial styloid avulsion (lateral view).

Six days after admission, open reduction and internal fixation was performed. The volar approach was performed first. Volar radiocarpal ligaments were torn off the radius and the articular capsule was avulsed from the volar lip of the radius. They were reattached by three bone anchor sutures. The dorsal approach showed an osteochondral fracture involving the proximal pole of the scaphoid, with no scapholunate ligament disruption. The scapholunate ligament was reattached by one anchor suture (Fig. 2) and stabilized with two percutaneous Kirschner wires (lunate-scaphoid and scaphoid capitate). The radial styloid avulsion was reattached with two screws.

Fig. 2.
Fig. 2.:
A dorsal approach showed an osteochondral fracture involving the proximal pole of the scaphoid that was reattached with one suture.

The distal radioulnar joint was stabilized with two Kirschner wires. A splint was applied. Both were removed after 6 weeks.

At 2-year follow-up, the patient reported no pain and had returned to all previous activities without restriction. Range of movement was as follows: extension, 40 degrees; flexion, 45 degrees; pronation, 70 degrees; and supination, 60 degrees. Radiographs demonstrated no radiocarpal or scapholunate collapse. The Spanish version of the Disabilities of the Arm, Shoulder and Hand questionnaire score was 47 (30 = best and 150 = worst).

Radiocarpal dislocations are rare injuries. They must be differentiated from severely displaced distal radius fractures or carpal fracture-dislocations.3 It is important to determine the extent of the ligamentous injury.4

We report on a dorsal radiocarpal dislocation combined with scapholunate dissociation. Open reduction and careful ligament repair was achieved. To our knowledge, there are no other reports in the literature regarding acute surgical repair of volar radiocarpal ligaments and scapholunate ligament in cases of radiocarpal dislocation.

In our opinion, assessing the presence of intracarpal ligamentous tears is essential for determining treatment and prognosis.4 The aim of surgical treatment should be to restore bone and ligamentous anatomy. We believe that the good outcome observed in our report (wrist motion was moderately impaired and the Spanish version of the Disabilities of the Arm, Shoulder and Hand questionnaire score was 47) is related not only to primarily restoring the volar radiocarpal ligament but also to revising the scapholunate and dorsal soft-tissue structures.

We report on a dorsal radiocarpal dislocation associated with a scapholunate ligament avulsion. In our opinion, assessing the presence of intracarpal ligamentous tears is essential for determining the treatment and prognosis of the lesion. Even when successful reduction and fixation of these lesions is carried out, degenerative changes of the wrist are expected to occur.

DISCLOSURE

The authors have no financial interests to declare in relation to the content of this article.

Ester Garcia-Paredero, M.D.

David Cecilia, M.D.

Enrique Sandoval, M.D.

Department of Orthopaedic Surgery and Traumatology II; Hospital 12 de Octubre; Madrid, Spain

REFERENCES

1. Dunn A. Fractures and dislocations of the carpus. Surg Clin North Am. 1972;52:1513–1538.
2. Jebson PJL, Adams BD, Meletiou SD. Ulnar translocation instability of the carpus after a dorsal radiocarpal dislocation: A case report. Am J Orthop. 2000;29:462–464.
3. Dumontier C, Meyer zu Reckendorf G, Sautet A, Lenoble E, Saffar P, Allieu Y. Radiocarpal dislocations: Classification and proposal for treatment. A review of twenty-seven cases. J Bone Joint Surg (Am.) 2001;83:212–218.
4. Moneim MS, Bolger JT, Omer GE. Radiocarpal dislocation classification and rationale for management. Clin Orthop Relat Res. 1985;192:199–209.
5. Howard RF, Slawski DP, Gilula LA. Isolated palmar radiocarpal dislocation and ulnar translocation: A case report and review of the literature. J Hand Surg (Am.) 1997;22:78–82.

Section Description

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2010American Society of Plastic Surgeons