Dislocation Wrist Joint (PERILUNATE DISLOCATION )
Describe x-ray
Lateral and PA view of left wrist showing Perilunate dislocation
PA shows disruption of Gilula's smooth carpal lines.
it joins proximal row of carpal bones at Radiocarpal joint.
it joins proximal surface of distal row of carpal bones.
Hyperflexion of scaphoid (scaphoid signet ring sign ).
Abnormal triangular appearance of lunate , lunate in its fossa.
overlapping of lunate and triquetrum.
no obvious fracture of radial styloid, scaphoid , triquetrum, hamate, capitate or ulnar styloid.
Lateral View
Dorsal dislocation of capitate head from its articulation with lunate at mid carpal joint and dorsal translation of distal carpal row and metacarpals relative to long axis of radius.
How to classify ?
Mayfield sequencing of ligamentous injuries
Greater Arc - fracture in one of radial styloid, scaphoid, triquetrum, capitate, hamate
Lesser Arc- No fractures
Stage I - Failure of Radiocarpal ligament
Stage II -Failure of SL Ligament
Stage III -Failure of LT ligament and dorsal midcarpal dislocation
Stage IV- Palmar dislocation of lunate at Radiocarpal joint.
Perilunate dislocation - Mayfield stage III Lesser Arc Injury.
How do you assess this condition ?
Detailed history, handedness, occupation, Mechanism of injury, Co-morbidities and time spent since last meal.
Examination- abnormal wrist contour, pain and swelling, signs of median nerve compression, document median nerve function sensory and motor functions
Will be managed as below.
Management
Initial Mx.
1.Exclude other injuries
2.Provide analgesia
3.Regular neurovascular observations.
4. Splintage
5.Elevation (Bradford sling or chinese finger traps )
6. Counselling
7. Prepare and consent patient for urgent theatre.
8. Minimum initial intervention
close / open reduction of dislocation
Carpal tunnel decompression
Definitive
CR assisted with joystick k-wires and buried k wires passed to stabilize SL,LT and midcarpal joints.
Open Reduction
Open dorsal anatomical carpal reduction
Buried K-wires stabilization ,repair of SL, LT, dorsal and palmar Radiocarpal ligaments.
Post operative
High elevation and careful neurovascular observation.
cast for 2 weeks, k wires removal at 8 weeks and mobilization
Risk of post traumatic carpal instability or stiffness
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