classification and management of carpal...

~ical OrthopaedicsRelated Research

tability of the2. 1972.t bone, J. Bone

and Kilcoyne,wrist and their186:417, 1976.and Kilcoyne,nechanics andI. Hand Surg.

irdman, A. C.,inhenz,, W. A.,1 properties ofFrans. 3:2:143.

,s of the carpal:82, 1963.of the carpal’8:83, 1944.:ions and frac-;urg. 31B:524,

:afima. J. Bone

wrist, J. Hand

ion and injury,,~dic Surgeons~l. XXVII, St.61.and perilunate968.recurrent sub-J. Bone Joint

Fractures andrg. Clin. North

~s of the wrist,

:ions, J. Bone

n experimental;caphoid waist’~,

: Fractures and,ondon, J. B.

of movement1935.tt, A. E., and

the wrist I:dnar deviationint Surg. 60A:

Classification and Management of

Carpal Dislocations

DAVID P. GREEN, M.D., AND EUGENE T. O’BRIEN, M.D.

Although carpal dislocations have been atopic of interest for many years, some con-fusion still exists regarding their classifica-tion and management. The literature on thissubject is replete with inconsistencies andcontroversies, because many of the con-clusions reached have been based on insuf-ficient clinical data and single case reports.Recognizing that these complex injuries arestill not fully understood, we have at-tempted in this article to put the historicalaspects of ,carpal dislocations into somesort of reasonable perspective, and haveoffered a classification and plan of manage-ment based upon the current state of ourknowledge.

RELATIONSHIP BETWEENPERILUNATE AND LUNATE

DISLOCATION

Detailed descriptions of wrist anatomyand mechanisms of injury are presentedelsewhere in this volume. Suffice it to sayhere that most carpal dislocations are causedb.y acute hyperextension (dorsiflexion) in-juries, often the ~ult of violent traumasuch as that sustained in falls from heightsor in motorcycle accidents. The primary

From The Hand Surgery Services, University ofTexas Health Science Center at San Antonio, andWilford Hall, USAF Medical Center, San Antonio,Texas.

Reprint requests to: Dr. David P. Green, 8042Wurzbach, Suite 530, San Antonio,q’X 78229.

Received: October 22, 1979.

di.@slocation ~c.~r.s_at the m~idcaq~ol joinLwhdre" the capitate i~ 7asually displaced

na e. uc attention h~sbd~ unique anatomic posi-tion of the scaphoid, which bridges the 2carpal rows and is in fact a part of both ....the proximal and distal rows.a°’ag’az’za’74 Be-cause of this relationship, wh, b_en__g_~the capit~e

disl.__ocates dorsal to the _l_una~e_~hthe sca_ phoid_.must either_fracture or rotate, a conceptprobably first recognized by Destot in 1925’-’~

and later emphasized by Cave~a andWagner.8~,~° If no fracture occurs, the liga-ments supporting the proxim~escap-qS~Fd--are ruptured, ~11o~ t-ffi2 proKi’~Y13~_.~ t.o___.Ero~_~_dors~ally. T-h~-’~’-’in ai3erpendicular orientation of the scap_hoid

the lateral view, and the injury is called a

h-~-~g~-~-~ggoid is fractured th_ro~u~hit~~i ~le d{sl6cates_ do}-~flywith the capit.a_t_e, and the proximal poler~-rnains attached to-the lunate~_x_re_s_u_l_tin, g

location.--T-I~ Same mechanism that results in a

dorsal perilunate dislocation may also prog-ress to volar dislocation of the lunate. Inthe 1920s, a number of case reports andarticles describing series of patients withlunate dislocations were published in whichthe discussion was focused only on thevolar’ displacement of the lunate as anisolated injury,m~’~r’~sa°’av’48,~’~v’v’a Although

0009-921X/80/0600/0055 $01.40 © J. B. Lippincon Co.

55

56 Green and O’Brien Clinical Orthopaedicsand Related Research

TABLE 1. Classification of CarpalDislocations

I. Dorsal perilunate/volar lunate dislocation*II. Dorsal transscaphoid perilunate dislocation*

III. Volar perilunate/dorsal lunate dislocationIV. Variants

A. Transradial styloid perilunate disloca-tion*

B. Naviculocapitate syndromeC. Transtriquetral fracture-dislocationD. Miscellaneous

V. Isolated rotary scaphoid subluxationA. Acute subluxationB. Recurrent subluxation

has thus been our practice to considerperilunate and lunate dislocations as dif--ferent stages or radiographic manifestationsof the same injury. The key distinctions

to be made in the ~ation are:°~’]~ whether the scaphoid is subluxated orf~~ncl"(2) whether tlae chsplace-

~ of the distal carpal row is dorsal or

v_qlar: These distinctions allow us to classifycarpal dislocations according to clinicalmanagement of the various patterns ofinjury, as outlined in Table 1. A briefdiscussion of each of these entities follows.

VI. Total dislocation of the scaphoid

Themostcommon patterns o! injury./DORSAL PERILUNATE/VOLAR

these authors failed to recognize the dis, ....... -Ree-6~-fi]i]-~-~f dorsal perilunate disloca-placement of other carpal bones in these tion is most easily made on the lateralcomplex injuries, a careful review of theillustrations in some of these and laterarticles,’~°’’~’37,4s’5~’Ss’7~ clearly shows dorsaldislocation of the capitate (or os magnumas it was called then). This relationshipbegan to be appreciated, and as early as1926,27 it was suggested that a lunate dis-location is the end stage of a perilunatedislocation, i.e., the result of spontaneousreduction of a dorsal perilunate dislocation.Many authors since then have agreed withthis concept.3,5,7,8,10,11,24,44,47,54,75,83,89,90

In the past, there has been an attemptto consider perilunate and lunate disloca-tions as separate and distinct entities. How-ever, there may be ~onsiderable diagnosticoverlap between these 2 injuries. When apatient is first seen, the original lateralradiograph may show a "pure" lunate orperilunate dislocation, or it may depict aconfiguration of the carpal bones that liessomewhere in between these 2 extremes,i.e., with the lunate being displaced slightlyvolarly from its normal position. As in allligamentous injuries, there is a spectrum ofdamage in carpal dislocations, ranging frompartial tears to total disruption of the com-plex ligamentous structure of the wrist. It

radiograph, which shows displacement ofthe ca~kale..xto.ua~te the !,_,n~ ~epr_o~ole of scaphoid rotated dorsally(Fig. 1A). In the anteroposterior view, anyoverlap density between the proximal anddistal rows of carpal bones (especiallycapitate and lunate) is suggestive of thediagnosis (Fig. 1B). The carpus may foreshortened, and there may be a gap

’between the scaphoid and lunate. In somecases, the forces of injury may havespontaneously reduced the capitate and

Fro. 1A. Dorsal perilunate dislocation, lateralview. The capitate is displaced dorsal to thelunate, which remains nestled in the concavityof the distal radius. The proximal pole ~scaphoid is rotated dorsally,.

Orthopaedicsated Research

consider.s as dif--~estations~tinctions.tion are:~xated ordisplace-dorsal oro classify

clinicaltterns of

A brief; follows.

;LAR

." disloca-te lateralement ofand the

I dorsallydew, any.imal and’.speciallye of themay be

,e a gapIn some

ay havetate and

on, lateralsal to theconcavityI pole of

Number149June. 1980

Carpal Dislocations 57

the rest of the distal row, displacing thelunate volarly, resulting in a so-called volarlunate dislocation. The lateral radiograph

in. t___his ._..simat.io.~~.wJlL-shaa-wpartially articulating with the distal radius,an--d-tl~l"~-n--~-’_d]s’-~t -- ~ne i oft he’Tg~i’[{~,~,ith ~i~lti_n~f its distal concavity,ca.u~-i-fi~e ~-~lled teacu - sin (Fig. ~).The diagnosis of volar lunate dislocationcan also be made on the anteroposteriorview by noting a triangular or wedge-shaped configuration of the lunate, ratherthan its normal trapezoidal shape (Fig. 2).

As mentioned above, the initial radio-graphs may show an intermediate patternsomewhere between "pure" dorsal peri-lunate and volar lunate dislocation. In suchcases, the lateral view will show only slightdorsal displacement of the capitate, andpartial volar tilting of the lunate. In theanteroposterior view. capitate-tunate over-lap, scapholunate gap, and a triangular-shaped lunate can be seen.

The initial clinical evaluation of all carpaldislocations must include careful assess-ment of the neurovascular status, sincemedian nerve damage is a frequent con-

FlO. lB. Dorsal perilunate dislocation, antero-posterior view. Ngtice the overlap....betweenthe proximal and distal carpal rows. Any dis-t o r tiT~n---o-Dthe-r~m’gt~wattngt~-5.1ign m e nt ofthe carpal bones on the AP view should makeone think of a carpal dislocation.

F~G. 2. Volar lunatedislocation, (Left) lateralvie’w. The capitate hasspontaneously reduced,and now articulates withthe distal radius. Thelunate has been displacedvolarly and is rotated,resulting in the "spilledteacup" sign. (Right) An-teroposterior view..Atriangular or wedg~--~ a p~tho-~gnomomc s~gn o~


comitant injury.7,8,1°,tt,2.3,24,27.:34,.37,.19,41,46‘s4.60,_6a.6r,73.9’, If the patient is seen early, lle-

duction of the midcarpal dislocation canusually be achieved relatively easily byclosed manipulation. Satisfactory anesthesiato provide complete muscle relaxation andsustained traction for 10-15 minutes areessential to an atraumatic closed reduction.Although many different types of reductionmaneuvers have been described,1.7.11.1-~,~--17.’eo,~a.6o,76,~o,~.~ the technique described by

Watson-Jones9’’9:~ seems to have prevailedas the most frequently employed method.After the period of sustained traction,anteroposterior and lateral radiographstaken with the hand suspended in tinge.r-traps will often give better visualization ofthe individual carpal bones than could be seenin the initial films before reduction. Dorsi-flexion is then applied to the wrist, fol-lowed by gradual palmar flexion to reducethe capitate back into the concavity ,ofthe lunate, maintaining longitudinal tractionthroughout the maneuver. Pronation of thehand on the forearm may be helpful as well.8’~

If the lunate is dislocated volarly, theoperator’s thumb stabilizes the lunate asthe capitate is brought over into palmarflexion. Often the initial stages of reductioriof the lunate will reproduce the dorsalperilunate stage.

Anteroposterior and lateral radiographtsare then taken in plaster to assess criticallythe reduction with particular attention givento: (1) rotary subluxation of the scaphoid;(2) lunate (intercalary segment) instability.Although these are essentially 2 corn-ponents of the same instability pattern, wediscuss them separately to emphasize theimportance of recognizing both.

ROTARY SUBLUXATION OF THE SCAPHOID

In a perilunate dislocation in which thescaphoid is not fractured, the ligamentsstabilizing the scaphoid are ruptured, re,-suiting in so-called rotary scaphoid subluxa-tion. Following successful closed reduction

of the midcarpal joint (capitate-lunate re-lationship), residual subluxation of thescaphoid frequently persists, since it isdifficult to hold the scaphoid reduced ana-tomically after its supporting structureshave been torn. This residual scaphoidsubluxation must be recognized and cor-rected.

Although Destot’-’1 clearly illustrated scaph-oid subluxation in 1926, this concept didnot appear in English medical literatureuntil 1949, When Russell r:~ and Vaughan-Jackson,~s in separate articles, pointed outthe typical radiographic appearance. Thomp-son, Campbell and Arnoldss further em-phasized its importance. The key fea-tures, as seen in Fig. 3, are as follows:

i. Widening of the space between thescaphoid and lunate in the anteroposteriorprojection. This is usually seen better withthe hand in full supination (anteroposteriorrather than posteroanterior view),ss or withthe wrist in radial deviation. 4" A scapho-lunate gap greater than 2 mm is said tobe diagnostic of scapholunate dissocia-tion. ~-~ This typical radiographic patternhas also been called the "Terry Thomassign.’

2. A foreshortened appearance of thescaphoid on the anteroposterior view.8~,88

3. A cortical "ring" shadow seen in theanteroposterior view, which represents--anaxial projection of the abnormally orientedscaphoid.

4. In the lateral view, the long axis ofthe scaphoid lies perpendicular to the longaxis of the radius, rather than at its usualangle of 45-60°.~z,88

Although Tanz8. and Morawa et al. 6~ re-port that residual scaphoid subluxation isinconsequential and does not require treat-ment, most authors believe that non-treat-ment will usually lead to a poor result. Somereports have shown that degenerative arthri-tis of the wrist is a likely, if not inevitable,result of untreated residual scaphoid sub-luxation.9,~,8~

Clinical Orthopaedicsmd Related Research

ate-lunate re-ation of the;, since it isreduced ana-

ng structureslual scaphoidized and cor-

astrated scaph-s concept didical fiteratureand Vaughan-s, pointed outvance. Thomp-5 further em-[’he key fea-~s follows:: between thenteroposterioren better withnteroposterioriew),~5 or with~.4., A scapho-

nm is said tonate dissocia-:aphic pattern"ferry Thomas

arance of theriot view.8~’s8

ow seen in therepresents an

¯ mally oriented

e long axis ofdar to the long:an at its usual

awa et al. 63 re-subluxation is

~t require treat-that non-treat-

~or result. Some:nerative arthri-’not inevitable,

scaphoid sub-

Number 149 Carpal Dislocations 59June, 1980

Fro. 3. Rotary subluxation of the scaphoid after closed reduction of a perilunate dislocation. (Left)In the lateral view, the axis of the scaphoid is almost 90° to the long axis of the radius. (Right)In the AP view, the scaphoid is foreshortened, there is a gap between the scaphoid and lunate. Thecortical ring sign appears in the scaphoid.

LUNATE (INTERCALARY SEGMENT)INSTABILITY

In the normal wrist, the lunate is cen-tered precisely in the lateral view, with itslong axis colinear with the axes of thecapitate and the radius, its concavity facingdirectly distalward, with no volar or dorsaltilt. In 1943, Gilford et al?~ presented theconcept of the wrist as a "link" system,with the middle link or intercalary segment(the proximal carpal row) being stabilizedby the intact scaphoid. If this stabilityis lost either by fracture or rotary sub-luxation of the scaphoid, a collapse de-formity takes-place within the carpus,~°

allowing the concavity of the lunate totilt dorsally. Fi~’~~e term~on-

ce~ifiS-’do 1-Ii~se"; Linscheid et al. ~ called it"dorsiflexion instability." More detaileddiscussions of these instability patterns ap-pear elsewhere in this symposium; theimportant point to be made here is thatthey should be specifically looked for inthe immediate postreduction and serialfollow-up radiographs in any patient with acarpal dislocation.

Early recognition of scaphoid subluxationor lunate instability is an important stepin the proper management of these in-juries, since accurate reduction and liga-mentous healing are much more likely tobe successful in the acute injury than inchronic subluxation.

Several techniques for closed reductionof scaphoid subluxation have been de-~cribed~,Ta.8~,~; however, our cineradio-graphic studies have demonstrated that nosingle po siti__oo or.maneuver will consis2-ent--flTl~re u-dfl-~ the scaphoid witho~-~ ~t~y.r’e-d~-Ydl-g-pT~-ing~pitate gfi-dT-6g--llmate. ~anatomic-reducfi on-is-achie~ed-b-y-clo sed

reduction, and if plaster immobilizationalone is used, weekly radiographs areabsolutely essential, since loss of the re-duction is likely to occur.

Percutaneous pin fixation following closedreduction is occasionally possible, but ismuch more difficult than in isolated rotarysubluxation of the scaphoid (discuSsedbelow). The image intensifier is essentialif closed pinning is attempted, and it isimperative to secure anatomical position ofthe scaphoid, lunate, and capitate.

60 Green and O’BrienClinical Orthopaedicsand Related Research

If an accurate reduction cannot be achievedby closed manipulation or if follow-upradiographs show loss of reduction, thenopen reduction is indicated.

OPEN REDUCTION

Most authors4’z6’4~’89’9° have advocated adorsal approach, although Dobyns andSwansonz3 stated that a combination of dorsaland volar approaches should probably bedone to allow the surgeon to assess and re-pair ligamentous as well as bony structuresabout both surfaces of the wrist. One ofus (DPG) now routinely employs bothapproaches in open reduction of dorsalperilunate or volar lunate dislocations. Theother (ETO) prefers the dorsal approac]h,adding the volar exposure only if lunatedislocation or instability ’~6 can be dem-onstrated.

Recent anatomic studies by Taleisnik~’82

and Mayfield et al. 57 have more clearlyidentified the ligamentous anatomy of thewrist, demonstrating several important points:(1) ot_h_e_m__ajo_Lr ligaments of the wrist areintracapsular, making them difficult to v--~-ua~Ze-5i-t-h~-time of operation, since the, y.,are covered by the capsule; (2) the volarligaments are much more subst~i~idthey more important) than thed~sa~aments; (3) the general configura-tion-~f-A-h.e--"colar ligaments is a doubleV-shaped structure, with an area of po-

~ kness between them (the space

y!~c_t~ over the ca~tate-~lu n-a~-~rticulation.

.~T-be-l] xn~ operation have been fairlyconsistent in the perilunate and lunate dis-locations which we have explored acutely.On the volar side, there has been a verytypical transverse rent llT"t~ capsule andligaments ~~ether or not t-h-g-lgn-gt-~ig-dis-placed volarly into the carpal canal. Al-though it is virtually impossible to identifyand repair the individual ligaments de-scribed by Taleisnik and Mayfield, anadequate repair of the yolar ligamentous

complex can easily be accomplished bysuturing the transverse rent. On the dorsalside, the entire ligamentous complex gen-erally has been stripped completely from thecarpal bones, and repair of these rela-tively weak structures is difficult and some-what unsatisfying. The paucity of solidligamentous tissue available for repair andthe tendency for rotary subluxation of thescaphoid to recur after removal of theKirschner wires suggest that" some type ofreinforcement may be des~a-gh-6Wgh~ve-~-h-g~ not u--~-d--~ffy of the ~-~sdescribed by Dobyns et al. ~- or Taleisnik8z

for reinforcement of these ligaments in anyof our acute cases.

Osteochondral fractures of the carpalbones, especially the capitate and lunate,are frequent concomitant injuries in thesepatients?~’~9"~3 Often the damage to articularsurfaces is rather extensive, and attemptsshould be made to remove small fragmentsand reattach larger ones if possible (oc-c~-~fhey are avulsed-g-y ~ntercarpalligaments).

It is essential to stabilize the restoredanatomic relationships of the scaphoid,capitate, and lunate, and we generally dothis with 0.045-inch Kirschner wires. It hasbeen advised that the pins be removedat times varying from 6 to 12 weeks.4’~,4

Recurrence of scaphoid subluxation folio--w2ing pin removal 6 weeks postoperativelyhas been reported,~,~ and we now routinelyleave the pins in 1~ for 8 weeks. Be-ca~e wires traverse the ~-~d- andintercarpal joints, it is necessary to im-mobilize the wrist in plaster until the pinsare removed. We generally use a removablevolar splint for an additional 4 weeks after

Our-isltmned operative sequence is thusas follows: (I) expose the carpus throughboth volar and dorsal approaches; (2) reducethe lunate and repair the volar capsule andligaments; (3) reduce the capitate andscaphoid from the dorsal side and securethe position.of all 3 bones with Kirschner

nical OrthopaedicsRelated Research

aplished byn the dorsal)mplex gen-ely from thethese rela-

It and some-ty of solidr repair andation of the)val ~of the~me type of[e, although

techniques: Taleisnik8~

aents in any

the carpaland lunate,’ies in these~ to articularnd attempts.ll fragmentsossible (oc-’ intercarpal

he restored~ scaphoid,generally do~vires. It has~e removed2 weeks.4,14

ttion follow-toperatively)w routinelyweeks. Be-.~ mid- andsary to im-atil the pinsa removableweeks after

race is thuspus throughs; (2) reducecapsule andapitate andand secure

h Kirschner

Number 149June, 1980 Carpal Dislocations 61

wires; (4) repair the dorsal ligaments; (5)carefully assess the adequacy of reductionand the position of the pins with antero-posterior, lateral and oblique radiographs.

DORSAL TRANSSCAPHOIDPERILUNATE DISLOCATION

In this injury, the midcarpal dislocationis accompanied by a fracture through thewaist of the scaphoid, and the distal poleof the scaphoid displaces dorsally with thecapitate, leaving the proximal pole attachedto the lunate (Figs. 4A and B). As in theperilunate dislocation without fracture ofthe scaphoid previously discussed, theforces of injury may result in volar dis-location of the lunate. In this situation,however, the proximal pole of the scaphoidis usually dispel-

"Th-~i-/i~i~-i clinical assessmen-T-fffi-d-~losedreduction techniques are identical to thosedescribed previously for dorsal perilunatedislocation without fracture. Often the extentof damage can be visualized better afterthe closed reduction while the hand is stillsuspended in finger-trap traction. Again,reduction of the midcarpal dislocation(capitate-lunate relationship) is usually easyto accomplish in acute injuries, but criticalanalysis of the scaphoid must be madeafter the closed reduction.

If the radiographs in traction show goodreduction of the midcarpal joint and ana-tomic reductionof the scaphoid, a thumb

FIG. 4A. Transscaphoid perilunate dislocation,lateral view. Dorsal displacement of the capitatecan be seen, but notice that the scaphoid isnot rotated.

Fro. 4B. Transscaphoid perilunate disloca-lion, anteroposterior view. The fracture throughtli’e waist of the scaphoid is clearly seen, withthe proximal pole still attached to the lunate.

:spica cast is applied with the wrist in-:neutral or slight flexion, and new films are,taken in plaster. It may be difficult tovisualize the scaphoid reduction adequately:in plaster, but we believe it;is imperativeto take enough different views to be ab-solutely certain there is no displacement.of the fracture. If anatomic reduction is.obtained and maintained in plaster, satis-:factory healing of the fracture and a gopdresult can be achieved (Fig. 6). However,serial follow-up radiographs are necessary,since loss of reduction of the scaphoidwill very likely lead to nonunion of thefracture and/or late posttraumatic dorsiflex-ion instability (Figs. 7A and B),

It has long been recognized that failureto reduce the fracture anatomically will


FIG. 5A. A transscaphoid perilunate disloca-tion which has progressed to volar lunate dis-location. Notice that the scaphoid retnainsattached to the lunate and is also dislocatedvolarly. This type of injury has a poor prog-nosis.

yield a poor result, 97 but the problem ofthe unreduced scaphoid fracture has been asubject of considerable controversy. Earlierauthors recommended excision ofi m al -~fiV-gv--p-rmd-mak-r-e~ - e-ao~pe c-

poor results with open reduction that he

FIG. 5B. Another view of the transscaphoidperilunate dislocation (see Fig. 5A).

FI6. 6A. Not all transscaphoid perilunatedislocations demand open reduction. A 25-year-old man had a typical transscaphoid perilunatedislocation which was treated by closed reduc-tion (see Fig. 6B).

advised primary arthro@.~j~...of the.__wris~ inall’~~_O~’~~i~s-~~phoid perilunate dis-location i~-~h-i~-~-~-~~i~fC-fiI~Y~ikaT~-t-i~n_ of

-~-fi-~---~~-~-~~d~~-i-~~ ~ achieved by

closed reduction. Few authors share thatextreme degree of pessimism, and sincepublication of the excellent a~icle byCampbell et al., in 1965,n several au-thors ~,*~,a~,au,sr have recommended open

Fro. 6B. Two years after closed reductiontreatment of dislocation, radiographs show com-plete healing of the scaphoid fracture and es-sentially normal carpal architecture. The pa-tient’s active range of wrist motion was 75% ofnormal (seb Fig. 6A).

ical OrthopaedicsRelated Research

,id perilunate~n. A 25-year-~id perilunateclosed reduc-

’ the wrist inrilunate dis-reduction ofachieved by’s share that1, and since: article byseveral au-

.ended open

osed reduction~phs show com-:acture and es-cture. The pa-ion was 75% of

Number 149June. 1980

reduction and internal fixation if anatomicalreduction of the scaphoid fracture cannotbe achieved and maintained in plaster. Caveactually advocated this principle in 19417’~

Several pertinent points, however, remaindisputed: (1) the timing of operative inter-vention; (2) the surgical approach; (3) type of fixation; (4) whether or not bonegrafting is indicated at the time of openreduction: (5) the incidence of avascularnecrosis of the proximal fragment.

TIMING OF OPERATIVE INTERVENTION

Specific details concerning operative treat-ment of the displaced scaphoid fractureare skimpy in the many articles on carpaldislocations. What little mention is given tothe timing of open reduction of the scaphoidis at wide variance. Cave~:~ said that openreduction must be done "’within a fewdays," believing that later it may be im-possible to realign the fragments satis-factorily. Worland and Dicksr also favoredimmediate operative intervention, but HilP’~

preferred to defer open reduction untilafter 3 to 4 weeks of immobilization, in

Fro. 7A. Radiographs of a transscaphoid ̄perilunate dislocation in 22-year-old man dem-onstrate what is likely to happen if reductionof the scaphoid fracture is lost in plaster.Radiograph in plaster at 6 days reveals whatwas thought to represent acceptable reduction.However, there was gradual loss of reduction(see Fig. 7B).


FIG. 7B. At 5 months, not only was theredelayed union of the fracture, but dorsiflexioninstability as well (see Fig. 7A).

order to allow the intercarpal ligaments toheal. We advise open reduction as soonafter injury as ~s prg~lSlyvnt~nq-fi-2--~e~~ believe that this en-hances potent~l for healing and revas-cularization of the proximal pole. Also,anatomic reduction of the scaphoid, evenunder direct vision, becomes more difficultafter 2 or 3 weeks.

-" TYPE OF FIXATION AND

OPERATIVE APPROACH

The type of internal fixation favoredby most authors has been Kirschnerwires,a°,3~,38,6z,sr although Cave~ reported~he successful use of dowel grafts takenfrom the tibia. Cave’s approach was a.curved radial incision exposing the scaphoidjust anterior to the tendons of the firstdorsal compartment. Worland and Dick~r

advocated a dorsal approach for primaryopen reduction, since this necessitates nofurther dissection of the soft-tissue structuresbecause they are usually completely stripped

off as a result of the perilunate disloca-tion. They reserved the volar (Russe typerz)

approach for later bone grafting if indicated.Keeping in mind that the primary ob-

jective of open reduction in these patientsis to stabilize the scaphoid and prevent

64 Green and O’Brien

subsequent collapse deformity, we fre-quently expose only the scaphoid through alimited Russe approach,72 which allowsdirect visualization of the fracture site dur-ing insertion of the Kirschner wires. How-ever, at the time of open reduction, it isextremely important to assess critically thereduction of the lunate as well. If fixationof the scaphoid adequately stabilizes themidcarpal joint, no further fixation is re-quired. Midcarpal stability must be assessedradiographically after fixation of the scaph-old, since the lunate-capitate relationshipis not well visualized through the relativelysmall Russe-type incision. If the midcarpaljoint is not anatomically reduced, additionalKirschner wires should be inserted tostabilize the lunate and capitate. Failure todo this may result in late dorsiflexioninstability.

We have not used screw fixation of thescaphoid4a in these acute cases, primarilybecause of the technical difficulties involvedin the screw’s precise insertion and place-ment. However, if the surgeon is familiarwith the use of this device, certainly ade-quate fixation can be achieved with it ratherthan with Kirschner wires.

BONE GRAFT

The need for bone graft at the time ofopen reduction has seldom been men-tioned. Cave6,~a used his bone graft as thesole means of internal fixation, and Hilla9

reported that bone graft should be used inconjunction with internal fixation. As notedabove, Worland and Dick9r preferred to de-lay bone grafting for 6 weeks, using it onlyif there were signs of avascular necrosisor early nonunion. Although we have usedsupplemental bone graft in some of ouropen reductions, it is probably not neces-sary, since we have had several successfulunions using only internal fixation withoutbone graft,a6

INCIDENCE OF AVASCULAR NECROSIS

Broad disagreement exists as to theincidence of avascular necrosis of the prox-

Clinical Orthopaedicsand Related Research

imal pole following transscaphoid perilunatedislocation. Campbell et al. 1° said that it isnot common, but they did not report anyfigures regarding its incidence in their largeseries. Morawa and his associates63 had only2 cases among their 21 patients. Wagnerss

said, however, that the incidence was 50%with accurate reduction of the scaphoidand 100% without anatomic reduction, al-though he did not support this statementwith clinical data. Hawkins and Torkelson’~8

reported 100% avascular necrosis in their16 patients, although all of the 8 patientstreated with open reduction had union ofthe fracture. Avascular necrosis of theproximal pole developed in 8 of Worlandand Dick’s:~7 9 cases, and 13 of Russell’s73

27 patients.The mere presence of avascular necrosis

of the proximal pole is, in itself, not anindication for bone grafting. We haveseen several patients with transient radio-graphic changes suggestive of this, whononetheless went on to successful healingof the fracture. If the fracture appears tobe healing, we will continue immobilizationfor 6 to 12 months until radiographic

.,union is seen. If serial radiographs showno progression toward healing, we considerbone grafting as early as 4 months afterinjury. If grafting is necessary, we use ,the volar approach and technique described--by Russe.7z

Our worst results with carpal dislocations

~ e patients with trans-

th~ lunate and proximal poleh~-e b-~-en dislocated volarly into thettrrrrrelT.’~r~-Tl~ese are-fF~-quently open ~n-juafies, with severe concomitant soft-tissueinjury, and despite early open reduction,the prognosis in these cases is poor.

VOLAR PERILUNATE/DORSALLUNATE DISLOCATION

VOLAR PERILUNATE DISLOCATION

O.nly a few. isolated cases of volarperilunate dislocation have appeared in

linical Orthopaedics}d Related Research

rid perilunate~aid that it is,t report anyin their large:es6:~ had onlyts. Wagner89

ace was 50%he scaphoideduction, al-is statementl Torkelson’~8

osis in their~e 8 patientsmd union of"osis of theof Worland

~f Russell’sv3

Jlar necrosisself, not an

We haveasient radio-.f this, who~sful healing.~ appears tomobilizationradiographic;raphs showwe consideraonths afterry, we useJe described

dislocationswith trans-

as in whichof scaphoid:o the carpaly open in-t soft-tissuei reduction,poor.

,ORSAL’ION

)CATION

:s of volar~ppeared in

Number 149June, 1980

the literature?,z°,9~ This rare injury, like itsmore common dorsal counterpart, requireseither a fracture or dorsal subluxation ofthe scaphoid. The lunate is palmar-flexedand the capitate is displaced volarly. Be-cause of the rarity of the injury, the properdiagnosis is liable to be missed. One of ourcases was not diagnosed for 5 months.

Forced hyperflexion from a fall on theback of the hand has been proposed as themechanism of injury by Aitken and Nale-buff? Two of our patients, however, werequite certain that they fell with the wrist indorsiflexion. One of our patients died ofother injuries 2 weeks after his volarperilunate dislocation. Manipulation of thedissected hand showed that the midcarpaldisplacement could be recreated by supina-tion of the proximal segment on the extendeddistal segment, rotation occurring aroundthe triquetrum. A fall on the hyperextendedwrist with supination of the forearm andproximal row on the fixed hand and distalrow appears to be the likely mechanismfor this injury.

In acute injuries, closed reduction utiliz-ing finger-trap traction supplemented withsupination of the hand and distal row onthe fixed forearm and proximal row is some-times successful. Correction of residualscaphoid subluxation should be performedthrough a dorsal approach. Kirschner-wirefixation must be maintained at least 8 weeks.

VOLAR TRANSSCAPHOID

PERILUNATE DISLOCATION

Volar transscaphoid perilunate disloca-tion TM is apt to be widely displaced andmay be more unstable than the more com-mon dorsal variety. Open reduction to cor-rect any residual displacement between thescaphoid fragments is best accomplishedthrough a volar Russe-type incision (Figs.8A-F).

DORSAL LUNATE DISLOCATION

Dorsal lunate dislocation is even moreuncommon than volar perilunate disloca-tion. The mechanism of injury is unknown.


FIGS. 8A and B. Volar transscaphoid peri-lunate dislocation. (A, upper; B, lower) A 25-year-old man fell on his outstretched righthand. There was an abrasion over the distalpalm, suggesting a dorsiflexion injury.

VARIANTS

TRANSRADIAL STYLOIDPERILUNATE DISLOCATION

A significant number of perilunate/lunatedislocations have a~ccompanying radial sty-

66 Green and O’Brien

F~cs. 8C and D. (C, upper; D, lower) Closedreduction with finger-trap traction reduced theperilunate displacement, but residual displace-ment of the scaphoid fracture necessitatedopen reduction and Kirschner-wire fixationthrough a volar Russe approach. The pins wereleft in place for 8 weeks and plaster immo-bilization was continued for a total of 12 weeks.

loid fractures.36,z,~,ar These appear to be lessfrequent with the transscaphoid type ofinjury, but are relatively common withperilunate dislocations or rotary subluxation

Clinical Orthopaedicsand Related Research

of the scaphoid. These injuries occur to-gether sufficiently often that one should beon the alert when evaluating a patient witha radial styloid fracture. Although isolatedradial styloid fractures do occur, con-comitant carpal bone injury must be spe-cifically ruled out when evaluating thesepatients clinically and radiographically. Fig-ure 9A shows a patient who was treatedfor what was thought to be an isolatedradial styloid fracture, but follow-up filmsone month later (Fig. 9B) revealed rotary

FIGS. 8E and F. (E, upper; F, lower) Twoarid one-half years after injury, the patient had90% o.f normal wrist motion and only a 20-1bdiminution of grip strength.

i!

Orthopaedics~tated Research

occur to-

should beLtient withh isolated:ur, con-;t be spe-:ing thesecally. Fig-is treateda iso)atedv-up filmsied rotary

9wer) Two~atient hadaly a 20-1b


subluxation of the scaphoid, which had notbeen recognized at the time of injury.

If the carpal dislocation requires openreduction, the associated radial styloidfracture should be reduced anatomicallyand held with additional Kirschner wiresat the same time. In some patients theradial styloid is severely comminuted, andin these cases, the most expeditious treat-ment may appear to be excision of thefragments. However, since this creates apotentially unstable situation by removingimportant bony and ligamentous support ofthe scaphoid, it is probably preferable tomold the fragments back into place as nearlyanatomically as possible.

NAVICULOCAPITATE SYNDROME

The naviculocapitate syndrome is a rela-tively uncommon variation of midcarpaldislocation in which the capitate is frac-tured, with the proximal pole rotating 90 or180°. The first reported case was by Nichol-son~ in 1940. Fenton-°8"29 coined the term"naviculocapitate syndrome" in 1956, pos-tulating that the fracture resulted from aforce transmitted from the radial styloidthrough the waist of the scaphoid. Steinand SeigelTM presented what appears to be

¯ FIG. 9A. Always look for a carpal dislocationin any patient with a radial styloid fracture.This patient was thought to have an isolatedradial styloid fracture and was treated in ashort arm cast (see Fig. 9B).


]?m. 9B. One

i ~" ’’~:’ "’ ..4 :~!: "

month later, scapholunatedissociation is clearly visible. This case alsodemonstrates that the AP (palm up) view is morehe]ipful than the PA (palm down) in delineatingscaphoid subluxation (see Fig. 9A ).

the most logical mechanism of injury~ i.e.,direct compression of the capitate by thedorsal lip of the radius with the wrist inacute hyperextension, a theory also sup-ported by Monahan and Galasko.~-~

Since radiographic interpretation of thisinjury may be confusing, it is helpful toobtain films with the hand suspendrd infinger-trap traction. The squared-off end ofthe proximal capitate is easily seen on thisview (Fig. 10).

Fentonz8 advocated excision of the proxi-mal pole as primary treatment because hebelieved avascular necrosis and nonunionwere inevitable. Although Jones~9 and Adlerand Shaftanz have described cases in whichthe fragment healed in its malrotated posi-tion, Marsh and Lampros~8 subsequentlydemonstrated that the fragmrnt may un-dergo necrosis if left unreduced. However,Meyers et al. 8~ described a case in whichunion was accomplished by opeh reductionand internal fixation with Kirschner wires.Weseley and Warenfeld9~ achieved success:ful healing in their single case with pri-mary bone grafting after open reductionof the capitate. Adler and Shaftan, z intheir comprehensive article on capitatefractures, made the important point thattreatment of the displaced capitate fractureshould-be determined on the basis of other


FIG. 10. Naviculocapitate syndrome. Thesquared-off end of the proximal capitate is seenbest on, a distraction view.

associated carpal injuries. Agreeing with"this basic concept, we believe that per-sistent displacement of a capitate fractureafter closed reduction is an indication foropen reduction. We try to achieve exactanatomic reduction of both the scaphoid

and capitate through a dorsal approach.Transient avascular changes in the proximalpoles of both bones are common, but heal--ing usually occurs.

TRANSTRIQUETRAL

FRACTURE-DISLOCATION

In some carpal dislocations, the line ofcleavage separating the midcarpaljoint mayextend through the triquetrum (Fig. 11),leaving its proximal pole attached to thelunate and allowing the distal fragment to

displace with the capitate. This can occurwith the standard type of perilunate dis-location, or, as in the case reported byWeseley and Warenfeld,9~ be part of trans-scaphoid, transcapitate perilunate disloca-tion (naviculocapitate syndrome). We haveencountered this variant in several patients,noting that occasionally the triquetral frac-ture may be severely comminuted. Wehave directed no special attention to thisparticular aspect of the injury, except forremoving nonviable free fragments of bonefrom the triquetrum. Generally, the tri-quetral fracture is restored into an acceptableposition with reduction of the midcarpaljoint.

MISCELLANEOUS

Several case reports of unusual variantsof carpal dislocations have appeared overthe years. They are mentioned here onlyfor the sake of completeness. A dorsalperilunate dislocation was reported bvMcGoey’~’~ in a patient with a congenit£1coalition of the triquetrum and lunate. Thedislocation was managed satisfactorily withclosed reduction. Gordon:~5 reported a casein which both the scaphoid and the lunate

Fro. 11. Transtriquetral transscaphoid peri-lunate dislocation. Notice that the fracture linesin both the scaphoid and tdquetrum (arrows)are directly in line with the midca~al joint.

linical Orthopaedicsid Re~ated Research

Js can occur;rilunate dis-reported by

9art of trans-hate disloca-te). We haveeral patients,iquetral frac-ainuted. Wention to this~, ex~cept fortents of bonedly, the tri-an acceptable~e midcarpat

sual variants~peared over.~d here only.s. A dorsalreported bya congenital1 lunate. The’actorily with)orted a casetd the lunate

,caphoid peri-fracture lines

:rum (arrows)rpal joint.

Number 149June, 1980 Carpal Dislocations 69

were dislocated volarly. Weiss et al.’~4

reported a very unusual irreducible trans-scaphoid peritunate dislocation in whichthe proximal pole of the scaphoid wasdislocated volarly and rotated 180°. Openreduction was required. This case report issignificant because it demonstrates thatthere can be simultaneous fracture of thescaphoid and rupture of the scapholunateligaments.

One of the most unusual carpal fracture-dislocations was reported by Noble andLamb,86 in which the fracture line ranacross the radial styloid, scaphoid andlunate. Although not a true dislocation inthe strictest sense, it is of related interest.This patient also required open reduction.

ISOLATED ROTARY SCAPHOIDSUBLUXATION

ACUTE SUBLUXATION

Although rotary scaphoid subluxation isseen most commonly in combination with aperilunate.dislocation, several reports sup-port the concept that primary (isolated)scaphoid subluxation can occur.4,9.18,19,28,-41,42,69,85,86,91 Presumably, this results from

more limited ligamentous damage than thatrequired to produce a perilunate dislocation.Both Taleisniks" and Mayfield et al. 57 havenoted that the key ligament associatedwith rotary subluxation of the scaphoid isthe volar radioscaphoid ligament, a shortbroad structure arising from the volar lipof the radius and inserting into the scaphoid(and probably the lunate also). Althoughrupture of the scapholunate ligaments is alsonecessary to produce rotary subluxation,both authors reported that this will not occurunless the radioscaphoid ligament is tornas well. They suggest that rotary scaphoidsubluxation may be the first stage of aperilunate dislocation.

Early diagnosis is essential for success-ful treatment. Since the radiographic find-ings in these patients may be more subtle,

additional views may be necessary?’~ Theseinclude the 6-view "motion study" sug-gested by Dobyns et al. zz (neutral antero-posterior, neutral lateral, lateral in flexion,lateral in extension, anteroposterior in radialdeviation, and anteroposterior in ulnardeviation), and an anteroposterior viewwith clenched fist, which provides longi-tudinal compression and may widen thescapholunate gap.

If the diagnosis is made early, the propertreatment for isolated rotary subluxationof the scaphoid would appear to be the sameas for residual scaphoid subluxation asso-ciated with a perilunate dislocation, i.e.,either closed reduction and percutaneouspinning or open reduction, internal fixationand ligamentous repair. Closed reductionand pinning, rl which we prefer for thisentity, may be successful as late as 6 to 8weeks following injury. The image intensifieris essential in achieving accurate reductionand pin placement.

Unfortunately, the literature reflects thefact that delay in diagnosis is common.In late cases, our experience has beenthat closed reduction is impossible and~open reduction is difficult. At operation,one finds considerable scar tissue betweenthe scaphoid and lunate, and extensivedissection and soft-tissue stripping is gen-erally required to effect reduction, Even--then, anatomic restoration of the scaphoidmay be impossible. Some type of ligamen-tous reconstruction is gene.rally necessaryas well. Although Howard et al. 41 havereported good results using the recon-structive techniques described by Dobynset al., ~2 our experiences have not beenparticularly rewarding. For operative de-tails of these procedures, the reader i~ re-ferred to articles that deal with the specificprocedures,2’’4°’68’82 as well as to otherchapters in this symposium. ~

Other .authors have resorted to inter-carpal arthrodesis as treatment for thelate rotary subluxation,r7 although failureof fusion is not uncommon.4,r ’*


RECURRENT SUBLUXATION

It is our opinion that so-called recurrentsubluxation probably represents unrecog-nized rotary subluxation of the scaphoid,even though there may be no specifichistory of injury recalled by. the patient.Vance et al. 87 reported a patient withbilateral asymptomatic scapholunate dis-sociation, in whom they suggested gen-eralized ligamentous laxity as a possibleetiologic factor. They emphasized the valueof bilateral radiographic evaluation in pa-tients with this condition.

Some of these patients are relativelyasymptomtic and require no treatment. Ifsymptoms warrant intervention, either liga-mentous reconstruction or intercarpal fusionas noted above are recommended, keepingin mind that the results from these pro-cedures may be unpredictable.

DISLOCATION OF THE SCAPHOID

Isolated total dislocation of the scaphoidwithout associated injuries to other carpalbones is an exceedingly rare injury, butsuch cases have been documented. Toofew cases have been reported to makeany specific comments, but different typeshave been noted. Walker~ reported a dis-location in which the scaphoid had rotated180° in the coronal plane, with the waist ofthe scaphoid lying horizontally between theradial styloid and the trapezium. In Thomas’case,s4 the entire scaphoid was dislocatedvolar to the carpus, and reduction wasachieved by closed manipulation. In thecase reported by Murakami,64 open reduc-tion without Kirschner-wire fixation re-sulted in early loss of reduction and per-sistent rotary subluxation of the scaphoid.We have had no personal experience withthis injury.

SUMMARY

A classification and plan of managementfor carpal dislocations are presented, basedupon the following basic premises: peri-lunate and lunate dislocations are different

stages of the same injury and are there-fore managed identically; displacement maybe either dorsal or volar; anatomic restora-tion of the 3 key elements (scaphoid,lunate, and capitate) is essential. Follow-ing initial closed reduction, rotary sub-luxation of the scaphoid and intercalarysegment instability must be specificallylooked for and corrected in the patientwith perilunate or lunate dislocation with-out fracture of the scaphoid. In trans-scaphoid perilunate dislocation, anatomicreduction of the scaphoid fracture and main-tenance of that reduction is necessary toprevent nonunion of the fracture and/orlate dorsiflexion instability of the carpus. Aswith all ligamentous injuries, early diagnosisand treatment are essential. Failure to ob-tain or maintain anatomic position byclosed methods is an indication for openreduction and internal fixation. Combineddorsal and volar approaches are recom-mended for perilunate and lunate disloca-tions. In some cases of transscaphoidperilunate dislocations, a limited Russe ap-proach to stabilize the scaphoid fracturemay be sufficient. Frequent concomitantinjuries include median nerve damage,osteochondral fractures of the carpal bones,and fracture of the radial styloid. Isolatedrotary subluxation of the scaphoid withoutperilunate dislocation is a more subtleinjury which may require special radio-graphic views, and also demands earlydiagnosis and treatment.

REFERENCES

1. Adams, J. D.: Displacement of the semilunarcarpal bone, J. Bone Joint Surg. 7:665, 1925.

2. Adler, J. B., and Shaftan, G. W.: Fractures-ofthe capitate, J. Bone Joint Surg. 44A:1537, 1962.

3. Aitken, A. P., and Nalebuff, E. A.: Volar trans-navicular perilunar dislocation of the carpus,J. Bone Joint Surg. 42A:1051, 1960.

4. Armstrong, G. W. D.: Rotational subluxation ofthe scaphoid. Can. J. Surg. 11:306, 1968.

5. Aufranc, O. E., Jones, W. N., and Harris, W. H.:Transnavicular retrolunar dislocation of the wrist,JAMA 181:131, 1962.

6. Aufranc, O. E., Jones, W. N., and Turner, R. N.:Transnavicular perilunar carpal dislocation,JAMA 196:130. 1966.

nical Oft hoi~aedicsRelated Research

:l are there-.cement maymic restora-

(scaphoid,:ial. Follow-rotary sub-intercalaryspecificallythe patient

cation with-1. In~ trans-n, anatomicre and main-~ecessary to:ture and/ore carpus. Asfly diagnosis~ilure to ob-position by~n for open¯ Combinedare recom-

~ate disloca-ansscaphoid.’d Russe ap-oid fractureconcomitantce damage,arpal bones,)id. Isolatedmid withoutnote subtle,ecial radio-aands early

the semilunar:665, 1925..: Fractures of4A:1537, 1962.t.: Volar trans-~f the carpus,3.subluxation of,1968:Harris, W. H.:on of the wrist,

Turner, R. N.:~1 dislocation,


20.

21.

22.

7. Bohler, L.: The Treatment of Fractures. 4thEnglish edition, Baltimore, William Wood &Co., 1935, p. 235.

8. Bohler. L.: The Treatment of Fractures. 5th Eng-lish edition, New York and London, Grune andStratton, 1956, p. 826.

9. Boyes, J. G.: Subluxation of the carpal navicularbone, South. Med. J. 69:141, 1976.

10. Campbell, R. D., Jr., Lance, E. M., and Yeoh,C..B.: Lunate and perilunar dislocations, J. BoneJoint Surg. 46B:55, 1964.

11. Campbell, R. D., Jr., Thompson, T. C., Lance,E. M., and Adler, J. B.: Indications for openreduction of lunate and perilunate dislocationsof the carpal bones, J. Bone Joint Surg. 47A:915, 1965.

12. Cave, E. F.: Fractures and dislocations of thecarpal bones. In: Wilson, P. D. (ed.), Manage-ment of Fractures and Dislocations, Philadelphia.J. B. Lippincott Co., 1938, p. 39.

13. Cave, E. F.: Retrolunar dislocation of the capitatewith fracture or subluxation of the navicular bone,J. Bone Joint Surg. 23:830, 1941.

14. Cave, E. F.: Injuries to the wrist joint, A.A.O.S.Instructional Course Lectures 10:1, St. Louis,C. V. Mosby Co., 1953.

15. Cohn, I.: Dislocations of the semilunar carpalbone, Ann. Surg. 73:621, 1921.

16. Connell, M. C., and Dyson, R. P.: Dislocationof the carpal scaphoid, J. Bone Joint Surg.37B:252. 1955.

17. Conwell, H. E.: Closed reduction of acute dis-locations of the semilunar carpal bone, Ann. Surg.82:289, 1925.

18. Cranmer, R. R., and Foss, A. R.: A report ofthree cases of dislocated semilunar bone, Minn.Med. 5:484, 1922.

19. Crittenden, J. J., Jones, D. M., and Santarelli,A. G.: Bilateral rotational dislocation of the carpalnavicular, Radiology 94:629, 1970.Davis, (3. G.: Treatment of dislocated semi-lunar carpal bones, Surg. Gynecol. Obstet. 37:225,1923.Destot, E.: Injuries of the Wrist: A RadiologicalStudy. English edition, Atkinson, F. R. B.(trans.), London, Ernest Benn Ltd., 1925.Dobyns, J. H., Linscheid, R. L., Chao, E. Y. S.,Weber, E. R., and Swanson, G. E.: Traumaticinstability of the wrist, A. A. O. S. InstructionalCourse Lectures 24:182, St. Louis, C. V. MosbyCo., 1975.

23. Dobyns, J. H., /[iad Swanson, G. E.: Fractureconference: A 19-year-old with multiple fractures,Minn. Med. 56:143, 1973.

24. Dunn, A. W.: Fractures and dislocations of thecarpus, Surg. Clin. North Am. 52:1513, 1972.

25. Eggers, G. W. N.: Anterior dislocation of oslunatum, J. Bone Joint Surg. 15:394, 1933.

26. England, J. P. S.: Subluxation of the carpalscaphoid, Proc. R. Soc. Med. (Orthop.) 63:581,1970.

27. Farr, C. E.: Dislocation of the carpal semilunarbone, Ann. Surg. 84:112, 1926.

28. Fenton, R. L.: The naviculo-capitate fracture syn-drome, J. Bone Joint Surg. 38A:681, 1956.


29. Fenton, R. L., and Rosen, H.; Fracture of thecapitate bone: Report of two cases, Bull. Hosp.Joint Dis. 11:134, 1950.

30. Fisk, G. R.: Carpal instability and the fracturedscaphoid, Ann. R. Coll. Surg. Engl. 46:63, 1970.

31. Frankel, V.H.: The Terry-Thomas sign. Clin.Orthop. 129:321, 1977.

32. Gilford. W. W., Bolton, R. H., and Lambrinudi,C.: The mechanism of the wrist joint with specialreference to fractures of the scaphoid, Guy’sHosp. Rep. 92:52, 1943.

133.Gilula, L. A., and Weeks, P. M.: Post-traumaticligamentous instability of the wrist, Radiology129:641, 1978.

134.Golden, W. W.: Dislocation of the semilunarbone: Report of case in which reduction wassuccessful, JAMA 76:446, 1921.

135.Gordon. S. L.: Scaphoid and lunate dislocation:Report of a case in a patient with peripheralneuropathy, J. Bone Joint Surg. 54A: 1769, 1972.

136.Green, D. P., and O’Brien, E. T.: Open reductionof carpal dislocations: Indications and operativetechniques, J. Hand Surg. 3:250, 1978.

137.Hamill, R. C.: Forward dislocation of semilunarbone: undiagnosed, Int. Clin. 3:124, 1920.

38. Hawkins, L., and Torkelson, R.: Transnavicularperilunar fracture-dislocations of the wrist (ab-stract). J. Bone Joint Surg. 56A:1087, 1974.

39. Hill, N. A.: Fractures and dislocations of thecarpus, Orthop. Clin. North Am. 1:275, 1970.

40. Horwitz, T.: An anatomical and roentgenologicstudy of the wrist joint, Surgery 7:773, 1940.

41. Howard, F. M., Fahey, T., and Wojcik, E.:Rotatory subluxation of the navicular, Clin.Orthop. 104:134, 1974.

42. Hudson, T. M., Caragol, W. J., and Kaye, J. J.:Isolated rotatory subluxation of the carpal na-vicular. Am. J. Roentgenol. 126:601, 1976.

4~..Huene, D. R.: Primary internal fixation of carpalnavicular fractures in the athlete, Am. J. Sports.Med. 7:175, 1979.

44. Kaplan, L.: Treatment of fractures and dis-locations of the hand and fingers, Surg. Clin.North Am. 20:1695, 1940.

45. Keenan, C. B., and Wilkie, A. L.: Dislocationof the semilunar bone of the wrist, Can. Med.Assoc. J. 20:639, 1929.

46. Kellam, H. I. J., and McGoey, P. F.: Reviewof fractures and dislocations ofthe carpus, Can.Med. Assoc. J. 53:332, 1945.

¯ 47. Key, J. A., and Conwell, H. E.; The Managementof Fractures, Dislocations and Sprains, 3rd edi-tion, St. Louis, C. V. Mosby Co., 1942, p. 781.

48. Kleinberg, S.: Dislocation of the carpal scaphoidand semilunar bones, JAMA 74:312, 1920.

49. Jones, G. B.: An unusual fracture-dislocationof the carpus, J. Bone Joint Surg. 37B:146, 1955.

50. Landsmeer, J. M. F.: Studies in the anatomy ofarticulation. I. The equilibrium of the "inter-calated" bone, Acta Morphol. Need. Scand.3:287, 1961.

51. Lediard, H. A.: Dislocation of the semilunarbone, Edinburgh Med. J. 30:244, 1923.

52. Linscheid, R. L., Dobyns, J. H., Beabout, J. W.,and Bryan, R. S.: Traumatic instability of the


wrist: Diagnosis, classification and pathomechan-ics. J. Bone Joint Surg. 54A:1612, 1972.

53. MacConaill, M. A.: The mechanical anatomy ofthe carpus and its bearings on some surgicalproblems, J. Anat. 75:166, 1941.

54. MacAusland, W. R.: Perilunar dislocation of thecarpal bones and dislocation of the lunate bone,Surg. Gynecol. Obstet. 79:256, 1944.

55. Mahomet, H. R., and Meade, W. H.: Operationfor dislocated semilunar bone of the wrist, Surgery5:249, 1939.

56. Marsh, A. P., and Lampros, p. J.: The naviculo-capitate fracture syndrome, Am. J. Roentgenol.82:255, 1959.

57. Mayfield, J. K., Johnson, R. P., and Kilcoyne,R. F.: The ligaments of the human wrist and theirfunctional significance, Anat. Rec. 186:417, 1976.

58. McBride, E. D.: An operation for late reductionof the semilunar bone, South. Med. J. 26:672,1933.

59. McGoey, p. F.: Fracture-dislocation of a fiJsedtriangular and lunate (congenital): Report of case. J. Bone Joint Surg. 25:928, 1943.

60. McLaughlin, H. L.: Trauma, Philadelphia, W. B.Saunders Co., 1959.

61. Meyers, M. H., Wells, R., and Harvey, J. p., Jr.:Naviculo-capitate fracture syndrome: Review ofthe literature and a case report, J. Bone JointSurg. 53A:1383, 1971.

62. Monahan, p. R. W., and Galasko, C. S. B.:T.he scapho-capitate fracture syndrome: A mecha-msm of injury. J. Bone Joint Surg. 54B: 122, 19’72.

63. Morawa, L. G., Ross, P. M., and Schock, C. C.:Fractures and dislocations involving the navicular-lunate axis, CIin. Orthop. 118:48, 1976.

64. Murakami, y.: Dislocation of the carpal scaphoid,Hand 9:79, 1977.

65. Nidholson, C. B.: Fracture-dislocation of the osmagnum, J. R. Nay. Med. Serv. 26:289, 1940.

66. Noble, J., and Lamb, D. W.: Translunate scapho:radial fracture: A case report, The Hand 11:47,1979.

67. Noon, C.: Dislocation of the semilunar bone: Wkhnotes of a case, Lancet 208:432, 1925.

68. Palmer, A. K., Dobyns, J. H., and Linscheid,R. L.: Management of posttraumatic instabilityof the wrist secondary to ligament rupture, J’.Hand Surg. 3:507, 1978.

69. Parkes, J. C., and Stovell, P. B.: Dislocation ofthe carpal scaphoid: A report of two cases, J.Trauma 13:384, 1973.

70. Pournaras, J., and Kappas, A.: Volar perilunardislocation:-A case report. J. Bone Joint Surg.61A:625, 1979.

71. Rask, M. R.: Carponavicular subluxation: Re..port of a case treated with percutaneous pins..Orthopedics 2:134, 1979. ¯

72. Russe, O.: Fracture of the carpal navicular, J.Bone Joint Surg. 42A:759, 1960.

73. Russell, T. B.: Inter-carpal dislocations andfracture-dislocations: A review of fifty-nine cases,J. Bone Joint Surg. 31B:524, 1949.

74. Sebald, J. R., Dobyns, J. H., and Linscheid, R. L.:The natural history of collapse deformities of thewrist, Clin. Orthop. 104:140, 1974.

75. Spar, I.: Bilateral perilunate dislocations: Casereport with review of literature and anatomicstudy, J. Trauma 18:64, 1978.

76. Speed, K.: Fractures and dislocations of thecarpus, Calif. Med. 72:93, 1950.

77. Stark, W. A.: Recurrent perilunar subluxation,Clin. Orthop. 73:152, 1970.

78. Stein, F., and Seigel, M. W.: Naviculocapitatefracture syndrome: A case report, J. Bone JointSurgl 51A:391, 1969.

79. Stern, W. C.: Dislocations of the carpal semilunarbone, JAMA 75:1389, 1920.

80. Stevenson, D. L. : Dislocations of the carpal lunate,Br. Med. J. 1:126, 1940.

81. Taleisnik, J.: The ligaments of the wrist. J.Hand Surg. 1:110, 1976.

82. Taleisnik, J.: Wrist: anatomy, function and injury,A. A. O. S. Instructional Course Lectures 27:61,St. Louis, C. V. Mosby Co., 1978.

83. Tanz. S. S.: Rotation effect in lunar and perilunardislocations, Clin. Orthop. 57:147, 1968.

84. Thomas, H. O.: Isolated dislocation of the carpalscaphoid, Acta Orthop. Scand. 48:369, 1977.

85. Thompson, T. C., Campbell, R. D., Jr., andArnold, W. D.: Primary and secondary dis-location of the scaphoid bone, J. Bone JointSurg. 46B:73, 1964.

86. Tullos, H. S., Erwin, W. D., and Fain. R. H.:Isolated subluxation of the carpal scaphoid asso-ciated with secondary displacement of the capitate.South. Med. J. 66:568, 1973.

87. Vance, R. M., Gelberman, R. H., and Braun,R. M.: Chronic bilateral scapholunate dissocia-tion without symptoms, J. Hand Surg. 4:178, 1979.

88. Vaughan-Jackson, O. J.: A case of recurrent sub-luxation of the carpal scaphoid, J. Bone JointSurg. 31B:532, 1949.

89. Wagner, C. J.: Perilunar dislocations, J. BoneJoint Surg. 38A:1198, 1956.

90. Wagner, C. J.: Fracture-dislocations of the wrist,Clin. Orthop. 15:181, 1959.

91. Walker, G. B. W.: Dislocation of the carpal sca_p_ii-old reduced by open operation, Br. J. Surg.30:380, 1943.

92. Watson-Jones, R.: Carpal semilunar dislocationsand other wrist dislocations with associated nervelesions, Proc. R. Soc. Med, (Orthop)22:1071, 1929.

93. Watson-Jones, R.: Fract~ares and Joint Injuries.3rd edition, Edinburgh, E & S Livingstone,1943, p. 568.

94. Weiss, C., Laskin, R. S., and Spinner, M.: Ir-reducible trans-scaphoid perilunate dislocation: Acase report. J. Bone Joint Surg. 52A:565,. 1970.

95. Weseley, M. S., and Warenfeld, p. A.: Trans-scaphoid, transcapitate, transtriquetral, p~rilunatefracture-dislocation of the wrist: A case report,J. Bone Joint Surg. 54A:I073, 1972.

96. Woodward, A. H., Neviaser, R. J., and Nisen-feld, F.: Radial and volar perilunate trans-scaphoidfracture-dislocation: A case report, South. Med.J. 68:926, 1975.

97. Worland, R. L., and Dick, H..M.: Transnavicularperilunate di.slocations, j. Trauma 15:407, 1975.

classification and management of carpal...

Documents