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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