Carpal Dislocations


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Carpal Dislocations


Carl Nunziato MD1, Geert A. Buijze MD PhD2, and David Ring MD PhD3


1Dell Seton Medical Center at the University of Texas at Austin, Austin, TX, USA


2Département de chirugie orthopédique et traumatologie, Montpellier, France


3Department of Surgery and Perioperative Care, Dell Medical School – The University of Texas at Austin, Austin, TX, USA


Clinical scenario



  • A 30‐year‐old man presents to the Emergency Department after a high‐energy motorcycle collision.
  • His only injury is to his right‐dominant wrist, which is painful, swollen, and deformed.
  • Radiographs reveal a dorsal perilunate dislocation of the wrist.
  • The neurovascular examination is unremarkable.

Top three questions



  1. In patients with perilunate dislocations, does advanced imaging (such as CT scan, US, MRI, or arthroscopy) lead to changes in diagnosis or operative planning compared to radiographs alone?
  2. In patients with reducible perilunate dislocations, does delay in operative fixation lead to worse functional outcomes compared with early fixation?
  3. In patients with perilunate dislocations, does temporary fixation of the carpus with screws achieve better functional and radiographic outcomes than Kirschner wire (K‐wire) fixation?

Question 1: In patients with perilunate dislocations, does advanced imaging (such as CT scan, US, MRI, or arthroscopy) lead to changes in diagnosis or operative planning compared to radiographs alone?


Rationale


Perilunate dislocations are usually treated with open reduction and it is not clear that computed tomography (CT) scanning or magnetic resonance imaging (MRI) helps with preparation or understanding of the injury beyond that gained with open visualization of the injury.


Clinical comment


Lateral and posteroanterior radiographs suggest a lesser arc perilunate injury without major fracture, but the anatomy is distorted and there are some bone fragments of unclear source.


Available literature and quality of the evidence



Findings


Despite the fact that posteroanterior and lateral radiographs are almost always sufficient to diagnose carpal dislocations, up to 25% of these injuries are missed at presentation, as shown by Herzberg et al. (level IV).1 One case report describes a delayed diagnosis of perilunate dislocation via ultrasonographic workup of median neuropathy (level V).3 Advanced imaging is not routine, but according to Kaewlai et al. (level V) CT with multiplanar and volumetric reformation can be a useful technique to demonstrate the complexity and extent of fractures and dislocations.2 There are no methodological studies comparing plain radiographs to ultrasound (US), CT imaging, MRI, or diagnostic arthroscopy for carpal dislocations.


Resolution of clinical scenario



  • Advanced imaging would not be helpful in the management of this patient’s perilunate wrist dislocation. Two‐ (2D) and three‐dimensional (3D) CT might be helpful to nonspecialists and can occasionally assist in evaluating of complexity (overall quality: very low).

Question 2: In patients with reducible perilunate dislocations, does delay in operative fixation lead to worse functional outcomes compared with early fixation?


Rationale

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Carpal Dislocations
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