CASE REPORT

Dislocation of the distal carpal row

Richard Pennington *, David Fisher, Guy Selmon

Department of Trauma and Orthopaedics, The Conquest Hospital, The Ridge,St Leonards-on-Sea, East Sussex TN37 7RD, United Kingdom

Accepted 16 April 2007

Injury Extra (2008) 39, 20—22

www.elsevier.com/locate/inext

A 35-year-old right hand dominant man presented toour Accident and Emergency Department havingfallen off his motorbike at an unknown but highspeed.

After the initial primary survey, it was noted thathe had a significant, painful deformity of his leftwrist. It was a closed injury and there was noassociated neurovascular deficit.

Radiographs (Fig. 1a and b) revealed dislocationsof both the lunate (volarly) and the distal carpal row(radially) taking the scaphoid with it. There was noevidence of metacarpal ‘‘diastasis’’. An ulna styloidavulsion fracture was also present.

The patient was taken to the operating theatreafter appropriate stabilisation and under generalanaesthetic closed reduction was performed. Reduc-tion was achieved by longitudinal traction with ulnardeviation and direct pressure on the lunate.

The wrist was approached dorsally between thethird and fourth extensor compartments. The prox-imal row was stabilised with two smooth 1.6 mmKirschner wires, one placed through the scaphoidand lunate, the other through the triquetral and intothe lunate (Fig. 2).

The scapholunate ligament was repaired using aMitek suture anchor placed into the scaphoid. Theremnants of the capsule and the extensor retinacu-lum were repaired with a 1 vicryl suture.

Figure 1 (a) Pre-operative radiograph showing AP viewof left wrist. (b) Pre-operative radiograph showing lateralview of left wrist.

* Corresponding author. Tel.: +44 7973 715 930.E-mail address: richiepenn@yahoo.com (R. Pennington).

1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2007.04.018

Dislocation of the distal carpal row 21

Figure 2 Post-operative radiograph of left wrist showing reduction and position of K-wires.

A below-elbow cast was applied post-operatively.The Kirschner wires were removed after six weeksand the wrist further immobilised for 2 weeks.

After removal of the plaster, the patient under-went intensive physiotherapy and occupationaltherapy (Fig. 3).

At 5 months following the injury, he had a painfree wrist and had returned to work as a telephone

Figure 3 AP and lateral radiographs foll

engineer. He had also returned to his main hobby ofweightlifting. He is currently able to bench-press100 kg. Hewas noted to have 608 of extension, 758 ofsupination and full pronation. Flexion was measuredat 408.

Radiographs (Fig. 4) showed maintained carpalalignment with no evidence of avascular necrosis orearly osteoarthritis.

owing removal of K-wires at 8 weeks.

22 R. Pennington et al.

Figure 4 AP and lateral radiographs of the left wrist at 5 months following surgery.

Discussion

Dislocation of the distal carpal row is a rare injury,with only one series reported in the literature.3 Thereis no report of this specific injury. Themajority of thereported cases were open injuries and 12 out of 13were due to crush injuries. The exact mechanism ofinjury in our case is unknownbut presumably involvedhyperextension and a combination of other forcesaround the wrist. Most other cases were associatedwith significant neurovascular injury.

Garcia-Elias et al. 1 reported 16 patients withcarpal disruption and stated that the carpus sepa-rated longitudinally with the respective metacar-pals.

There was no such separation seen in our case.In our operative procedure, we used a dorsal

approach and this enabled us to visualise the extentof the osseous disruption and repair it appropriately.We found no previous reports of acute scapholunateligament repair using a suture anchor. Closed K-wiring of these injuries obviously does not afforda direct view of this ligament.

Five months following surgery our patient has apain-free wrist with near normal range of move-

ment. Regaining strength has been slower but he isalready able to lift significant weights in the gymalthough only half of what he was lifting before theinjury!

The literature suggests that for any carpal dis-ruption the earlier the treatment the better theeventual result.1—3 We suggest an open surgicalprocedure to assist in obtaining a stable, anatomicalreduction of these injuries.

In summary, we present an unusual case of severecarpal disruption not reported previously. Followingopen surgical stabilisation he has made remarkableprogress and continues with his main hobby ofweight lifting.

References

1. Garcia-Elias M, Dobyns JH, Cooney WP, Linscheid RL. Trau-matic axial dislocation of the carpus. J Hand Surg 1989;14A:446—57.

2. Norbeck DE, Larson B, Blair SJ, Demos TC. Traumatic long-itudinal disruption of the carpus. J Hand Surg 1987;12A:509—14.

3. Pai CH,Wei DC. Traumatic dislocations of the distal carpal row.J Hand Surg 1994;19B(5):576—83.