Marc Gracia-Elias, MD
Institut Kaplan, Hand and Upper Extremity.
Passeig de la Bonanova, 9, 2nd floor, 2nd door
08022 Barcelona, Spain.

Question 1: What associated problem had been missed, making an adequate recovery impossible ?

Fig 1a and 1b

Scapholunate dissociation. (Note by Dr. Nelson: notice on the PA view how the profile of the lunate is abnormal, with its volar (pointed) pole extending quite a bit more distally than normal. The lateral view shows the lunate in an extended position, while the scaphoid is in a normal alignment.)

Question 2: What three examination tools would have been useful to recognize this problem?

(1) traction views probably would have shown an unusual distal shift of the scaphoid relative to the lunate
(2) arthroscopy, if available
(3) open arthrotomy, during the reduction procedure

Question 3: In case, if you had recognized this this complication initially, would your treatment had been different?

Once the radius reduced and stabilized with the EF, the dorsal scapholunate ligament should be repaired and the SL joint fixed with K-wires.

Question 4: Assuming integrity of the cartilage at the head of the capitate, and a badly damaged radioscaphoid and radiolunate joint cartilages, what options do you consider?

(1) Total wrist fusion
(2) The so-called "dye-punch" operation described by Foucher
(3) A radio-scapho-lunate fusion
(4) the later option plus distal scaphoidectomy

Fig 2a and 2b

On March 3, 1998, under an axillary block, we approached the dorsum of the wrist using the traditional longitudinal incision, sectioning of the extensor retinaculum along the III compartment and elevating the two retinacular flaps radially and ulnarly, and opening both the II and IV compartments. The extendor tendons were retracted, and the PIN ressected.

The proximal pole of the scaphoid was protruding through the dorsolateral capsule. In fact, there was no total dislocation owing to the presence of the K-wire (see fig. 2B). Once the capsule was opened as described by Berger and Bishop (ligament splitting technique), the wrist joints were inspected. Badly damaged cartilages were only located at the radioscaphoid and radiolunate joints. Because of the presence of a normal midcarpal joint, and the wish of the patient to retain some motion, we decided to perform a radioscapholunate fusion. In previous cases, however, we had found that RSL fusions do not allow more than 30 dgs of wrist flexion and no radial deviation owing to the presence a fixed scaphoid acting as a barrier to prevent such motion. To improve our results, we started a series of patients (not yet published material) in whom we ressected the distal third of the scaphoid. This allows much more freedom to the midcarpal joint, which is allow to behave more as a "ball & socket" joint. In a way this technique is in between the techniques suggested by Foucher (1) and the radioscapholunate fusion (2).

Figure 3

This is what we did in this case. See how we used 3 K-wires to fix the reduced bones (fig 3). Nine months after surgery there was minimal discomfort at the extremes of motion, but the patient had resumed his work effectively. Wrist motion was: flexion 40º; ext 38º, rad. dev 15º, ulnar dev. 18º. Normal pronosupination. Grip strength was 14 kgrs vas 40 kgrs the contralateral side.

Figures 4a & 4b

These followup xrays reflect the concept of a stable "ball&socket" midcarpal joint. The patient is definitively satisfied.

References

1) Foucher G (1995). L'operation dite "die punch" dans les sequelles de fractures articulaires du radius. Ann Chir Main 14:100-102.

2) Nagy L, Buchler U (1997) Long-term results of radioscapholunate fusion following fractures of the distal radius. J Hand Surg 22B: 705-710.