Mateusz Gładysz FESSH prep

FESSH prep Wrist trauma Mayfield mechanism and stages, Herzberg's multicentre series, closed versus open treatment, long term post traumatic arthritis

Perilunate dislocations and fracture-dislocations

Last reviewed v1.0

FESSH-052Wrist trauma●●○ intermediate

Regarding perilunate dislocations and fracture-dislocations:

  1. 1.In Mayfield's cadaveric loading model, perilunate dislocation was produced by loading the wrist in extension, ulnar deviation and intercarpal supination, and reduction was achieved by reversing that mechanism.

  2. 2.Stage I of Mayfield's progressive perilunar instability is disruption of the lunotriquetral link.

  3. 3.In Herzberg's multicentre series of 166 perilunate injuries, the diagnosis was missed at the initial presentation in about a quarter of cases.

  4. 4.After a successful closed reduction, cast immobilisation alone reliably maintains carpal alignment, so operative stabilisation is optional.

  5. 5.Radiographic post-traumatic arthritis is the most frequent late finding after operatively treated perilunate injuries — about 30 % of wrists in pooled analysis and more than half in long-term series.

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Question ID
FESSH-052
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. In Mayfield's cadaveric loading model, perilunate dislocation was produced by loading the wrist in extension, ulnar deviation and intercarpal supination, and reduction was achieved by reversing that mechanism.

    True

    Mayfield, Johnson and Kilcoyne loaded 32 cadaver wrists to failure and produced 13 perilunate and two lunate dislocations. The mechanism was extension, ulnar deviation and intercarpal supination; the ligaments failed sequentially around the lunate, and reduction was accomplished by intercarpal pronation, radial deviation and palmar flexion — the basis of the closed reduction manoeuvre used in the emergency department.

    • Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3):226-41. PMID 7400560

  2. 2. Stage I of Mayfield's progressive perilunar instability is disruption of the lunotriquetral link.

    False

    The sequence begins on the radial side: stage I is scapholunate failure (scapholunate diastasis, the least unstable stage), stage II is radiocapitate ligament failure with opening of the space of Poirier and capitolunate dislocation, stage III adds radiotriquetral and lunotriquetral failure — the perilunate dislocation — and stage IV, with dorsal radiocarpal ligament disruption, is dislocation of the lunate itself, the most unstable stage. Lunotriquetral disruption is therefore a stage III, not a stage I, event.

    • Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5(3):226-41. PMID 7400560
    • Mayfield JK. Patterns of injury to carpal ligaments. A spectrum. Clin Orthop Relat Res. 1984;(187):36-42. PMID 6744735

  3. 3. In Herzberg's multicentre series of 166 perilunate injuries, the diagnosis was missed at the initial presentation in about a quarter of cases.

    True

    The 1993 study from seven centres found the diagnosis missed initially in 41 of 166 cases (25 %). Displacement was dorsal in 97 %, fracture-dislocations outnumbered pure dislocations two to one, and dorsal trans-scaphoid perilunate fracture-dislocations made up 61 % of the whole series. Open injury and delay in treatment worsened the clinical result, and even after early treatment post-traumatic arthritis was seen in 56 %; the best radiological results followed open reduction and internal fixation.

    • Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):768-79. PMID 8228045

  4. 4. After a successful closed reduction, cast immobilisation alone reliably maintains carpal alignment, so operative stabilisation is optional.

    False

    Adkison and Chapman achieved an anatomical closed reduction in 67 % of 55 wrists, but 59 % of those lost position within six weeks despite adequate immobilisation, so closed treatment alone succeeded in only 27 %, whereas open treatment was uniformly successful in maintaining reduction; they recommended open reduction and Kirschner-wire fixation. Apergis' comparison found only fair or poor results after closed reduction, against excellent or good results in 13 of 20 cases after early open reduction with ligament repair. Closed reduction remains the emergency step; open reduction, ligament repair and fixation is the definitive treatment.

    • Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res. 1982;(164):199-207. PMID 7067286
    • Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracture-dislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl. 1997;275:55-9. PMID 9385268

  5. 5. Radiographic post-traumatic arthritis is the most frequent late finding after operatively treated perilunate injuries — about 30 % of wrists in pooled analysis and more than half in long-term series.

    True

    Lee's systematic review of 43 studies (880 patients) found arthritis the commonest complication (30 %), ahead of carpal instability (15 %), avascular necrosis of the lunate (12 %), complex regional pain syndrome (11 %) and scaphoid nonunion or necrosis (9 %). Herzberg reported arthritis in 56 % of early-treated cases, and Krief's 30 patients followed for at least 15 years had arthritis in 70 %, yet its functional impact was low: the flexion–extension arc averaged 68 % and grip 70 % of the other side, with a mean Mayo wrist score of 70.

    • Lee CH, Lee BG, Kim JH, Yoon HS, Han KJ, Choi WS. Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review. J Hand Surg Eur Vol. 2023;48(7):625-629. PMID 36708152
    • Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):768-79. PMID 8228045
    • Krief E, Appy-Fedida B, Rotari V, David E, Mertl P, Maes-Clavier C. Results of Perilunate Dislocations and Perilunate Fracture Dislocations With a Minimum 15-Year Follow-Up. J Hand Surg Am. 2015;40(11):2191-7. PMID 26328900