Staged reduction of neglected transscaphoid perilunate fracture dislocation: A report of 16 cases
© Garg et al.; licensee BioMed Central Ltd. 2012
Received: 20 March 2011
Accepted: 2 May 2012
Published: 20 May 2012
Transscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome.
Material & Methods
16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1 mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation.
The mean duration between two surgeries was 2.4 weeks (range 2–4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results.
Staged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.
Transscaphoid perilunate dislocations are rare injuries. It is estimated that upto 25% of these injuries are diagnosed late . This percentage is still higher in developing countries due to lack of awareness and facilities for diagnosis and treatment.
Treatment of neglected injuries carries a poorer prognosis as compared to fresh injuries [2, 3]. Late reduction of perilunate dislocations is difficult and after 3 months salvage procedures such as proximal row carpectomy, excision of the lunate or wrist arthrodesis have been recommended . Most of the patients treated with these methods do not achieve good functional outcomes and have limitations of activities due to reduced range of motion, pain, and loss of grip strength. Treatment of these neglected injuries with open reduction and internal fixation would theoretically give better functional results as compared to salvage procedures [1, 3, 5]. However, this often requires extensive soft tissue releases to achieve reduction, leading to scarring and loss of vascularity of carpal bones, thus compromising the outcomes. We propose that staged reconstruction of these injuries is superior to single stage surgical release. Soft tissues and carpal bones are gradually distracted with a spanning external fixator followed by open reduction and fixation using dorsal approach.
We aim to study functional outcomes in 16 patients treated this novel technique over a mean follow up of 4.2 years. Search of medical literature on this topic did not reveal any series on neglected dislocations using this technique.
This was followed by a second stage open reduction and internal fixation of the carpal bones and intercarpal ligament reconstruction using dorsal approach. A dorsal transverse incision was given about 1 cm distal to the radiocarpal joint extending from the radial styloid to the ulnar styloid.
In the immediate postoperative period limb was rested in a volar below elbow slab for three weeks. Mobilisation of the shoulder, elbow and digital articulations were started in the immediate postoperative period. Active assisted and passive mobilisation of the wrist was started at 2 weeks. Intrinsic muscle strengthening and grip exercises were begun at 2 months. Return to full activities or sports was allowed at 4–6 months.
Results and discussion
Mechanism of injury and presenting signs and symptoms
Mode of injury
No of patients
Fall from height
Presenting symptoms and signs
Median nerve symptoms
Functional outcome of patients at follow up
No of patients
Return to regular employment
Range of motion (% of normal side)
Grip strength (% of normal side)
Mild degenerative changes were seen in the radiocarpal joint in 3 patients and in midcarpal joint in 6 patients. Avascular changes were seen in the scaphoid in 1 patient. According to Herzberg”s radiological classification, 10 patients were type A, 5 were type B1 and 1 was type C1. There were no wound related complications. Two patients developed reflex sympathetic dystrophy and were treated with stellate ganglion block. Functional scores in both these patients was 70.
There are many reports on treatment of acute perilunate dislocations. But treatment of chronic perilunate dislocations is less often discussed. Late presentation of these injuries not only complicates the treatment but also makes results less satisfactory. Proper evaluation of patients with wrist injuries is thus very important to exclude perilunate instability. Failure to get stress views in suspected cases and unfamiliarity of the treating physician with the normal carpal anatomy can lead to perilunate dislocation being missed at the time of injury. These present later with chronic wrist pain, swelling or median nerve symptoms. Interestingly these patients may regain range of motion with subsidence of pain but function of the wrist joint remains poor with poor grip strength and inability to return to previous activities.
Causes of unsatisfactory results following late fixation of neglected radiocarpal dislocations include scarring, avascularity of the carpal bones particularly the scaphoid either due to the injury or secondary to extensive dissection at the time of open reduction, articular cartilage damage and remodelling of the carpal bones. Avascular necrosis of scaphoid may occur in these cases as in other scaphoid fractures but avascular necrosis of lunate is rare. More common is transient ischemia of the lunate, seen as rediodense lunate amidst osteopenic carpal bones in chronic cases. But this has been found to improve after the dislocation has been reduced and fractures fixed .
Contractions of soft tissues, ligaments and neurovascular structures especially the median nerve preclude attempts at reduction of these neglected dislocations. Staged treatment of these injuries has several advantages. The soft tissues are stretched gradually to achieve some alignment of the bones before surgery. This avoids the need of extensive dissection and soft tissue stripping at the time of surgery. Secondly the distractor unloads the carpal bones of excessive and nonanatomic forces. This may help in cartilage regeneration and fibrocartilage formation. Four of our patients had median nerve symptoms at the time of presentation. When distraction was applied using external fixator none of them showed any evidence of worsening of median nerve symptoms. This is probably because the carpal bone are aligned as the distraction is applied and pressure over the median nerve is offloaded.
No clear association is seen between the development of degenerative changes in the radiocarpal and midcarpal articulations and pain. Both our patients who had pain on routine activities had degenerative changes in the midcarpal joints. Out of 5 patients who had pain on sternous activities only 2 patients had degenerative changes in rafiocarpal and midcarpal joints on follow up.
Comparison of functional outcomes of patients treated with internal fixation for acute fracture dislocations, for neglected injuries and salvage procedure for neglected injuries
Grip strength (percentage of normal wrist)
Acute injuries treated with internal fixation
Chronic injuries treated with salvage procedure
Proximal row carpectomy
Proximal row carpectomy
Chronic injuries treated with internal fixation
Siegert et al 
6/16 (37.5%) satisfactory results
Mean interval between injury and surgery- 17 weeks
3 good, 1 fair and 2 poor
Mean interval between injury and surgery- 16 weeks
Kailu L et al 
four good, one fair, and one poor
Mean interval between injury and surgery- 17 weeks
Komurcu M et al 
Mean interval between injury and surgery- 26 days
If properly executed, a good functional pain free range of motion is the usual outcome.
Neglected transscaphoid perilunate dislocation sre rare but challenging injuries. It is difficult to achieve good results in these injuries. Our experience with two staged reduction and fixation of these injuries is encouraging. This limits the need for soft tissue dissection at the time of surgery and achieves better outcomes as compared to salvage procedures or single stage open reduction.
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