Chronic Isolated Dorsal Dislocation of the Lunate. A Rare Presentation of Carpal Instability

Abstract

A bstract Isolated dorsal lunate dislocation is a rare injury. Only one case has been reported previously in which the treatment was performed in the chronic stage. In this report, we present the case of a 49-year-old handworker male who presented a dorsal dislocation of the lunate after a traffic accident. He was referred to our clinic 2.5 months later due to an initial misdiagnosis. Surgical treatment was performed and consisted of an open reduction using a nerve-sparing dorsal approach. A complete rupture of the perilunate ligaments and a marked instability of the lunate were detected. Stabilisation of the scapholunate, lunotriquetral and scaphocapitate spaces with a compression screw and Kirschner wires, respectively, was performed. The persistence of pain and functional limitation after the surgery along with an insufficient reduction of the scapholunate space on the X-ray and the development of a fistula on the ulnar edge of the carpus prompted reintervention. A hardware-free total wrist arthrodesis was preferred over other procedures, such as proximal row carpectomy, owing to the important articular damage. At the 3-month follow-up, he was clinically stable, consolidation of arthrodesis was documented and he had returned to his previous activities. Isolated dorsal dislocation of the lunate is a rare lesion. There is no consensus on the management of isolated chronic dislocations of the lunate. The frequent delay in the diagnosis compromises the final outcome of reconstructive techniques and introduces the risk of residual instability, increasing the incidence of chronic pain associated with post-traumatic osteoarthritis. In the case of chronic lesions, treatment with palliative techniques, such as proximal carpectomy or joint arthrodesis, should be considered. How to cite this article Alonso-Tejero D, Luengo-Alonso G, Jiménez-Díaz V, et al . Chronic Isolated Dorsal Dislocation of the Lunate. A Rare Presentation of Carpal Instability. Strategies Trauma Limb Reconstr 2022;17(1):59–62.

Dorsal spanning plate fixation in perilunate injuries: a case report

“…There is no consensus on the management of perilunate injuries. Described interventions encompass utilizing closed reduction and percutaneous pinning, ORIF and ligamentous repair, arthroscopy, external fixation, proximal row carpectomy, or wrist arthrodesis depending on the acuity and severity of the injury [ 1 , 2 , 4 , 5 , 7 , 8 , 11 , 14–16 ]. Yet even with these treatments, perilunate injuries lead to long term sequelae such as pain, stiffness or posttraumatic arthritis in up to 80% of patients [ 7 ].…”

“…However, the population studied largely consisted of polytrauma patients in which DSP fixation occurred in a delayed fashion at 19 ± 36 days after the inciting event in comparison to ORIF with casting occurring within 3 ± 5 days [ 5 ]. Persistent unreduced dislocations generally warrant salvage procedures to achieve satisfactory outcomes, although recent studies have debated this [ 3 , 8 , 16 ]. DSP use in PLDs in the more acute setting has yet to be reported.…”

“…DSP use in PLDs in the more acute setting has yet to be reported. Acute management of perilunate injuries is paramount as tissue distortion, scarring, ligament contraction, and vascular supply disruption can affect fixation success and the ability to perform ligamentous repair [ 1 , 8 , 15 , 16 , 18 ]. In our report, the patient presented with an isolated upper extremity injury and underwent definitive fixation within 24 h.…”

“…Mayfield staging was initially presented in 1980 and detailed the predictable pathomechanical process of sequential ligamentous rupture and joint disruption that occurs in perilunate injury progression ( Table 1 ) [ 1 , 3 , 4 , 10 , 11 ]. The most severe stage IV perilunate injuries, or lunate dislocations (LD), commonly occur volarly into the space of Poirier [ 3 , 6 , 8 , 10 ].…”