Open Reduction and Internal Fixation Perilunate Dislocation via Dorsal Approach

39 Open Reduction and Internal Fixation Perilunate Dislocation via Dorsal Approach

Indications

Any perilunate dislocation

Technique

Make a longitudinal incision over the third to fourth extensor compartment (Fig. 39-1).
Incise the extensor retinaculum just ulnar to the Lister’s tubercle to enter the third extensor compartment.
Release and retract the extensor pollicis longus (EPL) in a radial direction (Fig. 39-2).
Reflect the extensor digitorum communis (EDC), keeping its tendon sheath intact, and incise the dorsal wrist capsule transversely to protect the dorsal intercarpal ligament, as described by Berger and Weiss.
Reflect the capsule off the distal radius and carpal bones until the lunate, scaphoid, and proximal two thirds of the capitate are exposed.
Reduce dorsal perilunate injuries using longitudinal traction and palmar pressure on the distal carpal row. A Freer elevator can be used to shoehorn the lunate to restore the relationship. This is an important step because the dislocation needs to be reduced before fixation can start. A palmar approach may be needed if the lunate is dislocated into the carpal tunnel.
For palmar lunate dislocations, apply traction and reduce the lunate into place manually or with an elevator.
After the dislocation is reduced place a 0.045 in. Kirschner wire into the most proximal, dorsal surface of the lunate, avoiding the capitate sulcus. Place a second wire into the distal pole of the scaphoid.
Rotate the lunate into flexion to cover the head of the capitate. The scaphoid must be extended to complete the reduction.
Via a radial approach a 0.062 in. Kirschner wire is placed across the scapholunate (SL) joint paralleling the radial inclination of the radius. A second 0.062 in. wire is placed across the scaphocapitate (SC) articulation (Fig. 39-3).
If there is a residual instability of the capitolunate joint it may signify lono-triquetral (L-T) injury (greater arc) as well and may require an L-T pinning from the ulnar side.
Remove joystick wires and cut and bend the percutaneous wires.
Close the dorsal capsule without imbrication.
Place a short-arm thumb spica splint.