Arch Hand Microsurg.  2021 Jun;26(2):69-81. 10.12790/ahm.21.0080.

Trans-scaphoid Perilunate Fracture Dislocation

• Kim HS
• Oh WT
• Koh IH
• Choi YR
• Kang HJ

• KMID: 2516151
• DOI: http://doi.org/10.12790/ahm.21.0080

Abstract

Trans-scaphoid perilunate fracture dislocations, which account for more than half of total cases of perilunate injuries, are common in young patients and occur as a result of high-energy injuries, and improper management can impair wrist alignment and function. Understanding the related wrist anatomy and pathomechanics may help surgeons evaluate and diagnose patients. Early operation to reduce and fix the injuries should be considered to achieve optimal clinical and radiological outcomes. In this review article, we present an overview of wrist pathoanatomy, the pathomechanics of trans-scaphoid perilunate fracture dislocations, operative treatment options including an arthroscopic procedure, and reported clinical and radiological outcomes.

Keyword

Trans-scaphoid perilunate fracture dislocation; Pathoanatomy; Pathomechanics; Operative treatment; Arthroscopic treatment

Figure

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  Fig. 1. Diagram of eight carpal bones and the three carpal columns (red, radioscaphoid column; green, lunate column; blue, ulnotriquetral column). (A) Volar view and (B) dorsal view. C, capitate; H, hamate; L, lunate; P, pisiform; R, radius; S, scaphoid; Td, trapezoid; Tm, trapezium; Tr, triquetrum; U, ulna.

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  Fig. 2. The most well-characterized carpal ligaments with consensus. SL, scapholunate; LT, lunotriquetral.

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  Fig. 3. Carpal ligament schematic. (A) The palmar intrinsic carpal ligaments from a palmar perspective. (B) The palmar carpal ligaments from a palmar perspective. (C) The dorsal carpal ligaments from a dorsal perspective. Ligaments: CH, capitohamate; CT, capitotrapezoid; DIC, dorsal intercarpal; DRC, dorsal radiocarpal; LRL, long radiolunate; LT, lunotriquetral; PRUL, proximal palmar radioulnar ligament; RSC, radioscaphocapitate; RSL, radioscapholunate; SC, scaphocapitate; SL, scapholunate; SRL, short radiolunate; ST, scaphotrapezium; TC, triquetrocapitate; TH, triquetrohamate; TT, trapeziotrapezoid; UC, ulnocapitate; UL, ulnolunate; UT, ulnotriquetrum.

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  Fig. 4. Mechanism of dorsal trans-scaphoid perilunate dislocations. (A) Perilunate injury typically results from an axial load applied to outstretched hand. (B) The load applied to fixed pronated forearm leads to hyperextension, intercarpal supination, and ulnar deviation of the wrist.

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  Fig. 5. (A) Stages of trans-scaphoid perilunate dislocations according to Mayfield et al. [2]. Stage I involves trans-scaphoid fracture. Stage II shows interruption of the lunocapitate connection. In stage III, the capitate and triquetrum peel away from the lunate. In stage IV, the lunate dislocates from radius fossa. (B) Stages of trans-scaphoid perilunate dislocations according to Herzberg et al. [11]. In stage I, the capitate dislocates dorsally, but the lunate remains in the lunate fossa. Stage II means dislocation of the lunate and is divided into stages IIA and IIB based on 90° of lunate rotation.

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  Fig. 6. Radiograph of the wrist showing the three “Gilula’s arcs.” The first arc (1) outlines the major convexities of the proximal articular surfaces of the scaphoid, lunate, and triquetrum. The second arc (2) conforms to the distal concave surface of these same carpal bones. The third arc (3) contours the proximal cortical surface of the capitate and hamate.

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  Fig. 7. Open reduction and fixation for trans-scaphoid perilunate fracture dislocation (PLFD). (A) Posteroanterior and lateral views of the preoperative radiographs of a 46-year-old man showing a dorsal trans-scaphoid PLFD of the left wrist. (B) Approaching on the dorsal aspect of the wrist, the extensor pollicis longus tendon (asterisk) is retracted radially, and the scaphoid (Sc) fracture is shown with a displacement (arrow). Sc, scaphoid. (C) The postoperative radiographs show proper fixation and normal carpal alignment. (D–F) The radiological measurements after 2 years postoperatively identify 2.0 mm of lunotriquetral distance (D), 56.0° of scapholunate angle (E), and 4.6° of radiolunate angle (F). Reprinted from Oh et al. [60] with the permission of Elsevier.

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  Fig. 8. Arthroscopic-assisted reduction and fixation for a trans-scaphoid perilunate fracture dislocation (PLFD). (A) Posteroanterior (PA) and lateral views of the preoperative radiographs of a 21-year-old male showing a dorsal trans-scaphoid PLFD of the left wrist. (B, C) An arthroscopic photo viewed from the ulnar midcarpal portal, showing a scaphoid fracture and instability of the lunotriquetral joint. (D) The scaphoid fracture was reduced with manipulation of the distal fragment using an 18-gauge needle. Then a Kirschner wire was inserted from the scaphoid tubercle and passed through the fracture site for temporary fixation. (E) The lunotriquetral joint was reduced using a probe and percutaneously pinned from the ulnar side of the wrist. (F) The lunotriquetral joint was well reduced after pinning. (G, H) The optimal starting point for screw fixation of the scaphoid is targeted using the arthroscope and fluoroscope. (I) The postoperative PA and lateral views showing proper fixation and normal carpal alignment. L, lunate; Sc, scaphoid; Tr, triquetrum.

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