Surgical Management

Most acute perilunate dislocations require surgery. Closed reduction is possible, but it is unlikely that the reduction will be maintained by immobilization. A ligamentous injury alone can be treated with a dorsal approach only; however, the status of the median nerve may require a combined dorsal and palmar approach.

For the dorsal approach, an incision is made in line with Lister's tubercle. An interval between the third and fourth dorsal compartments is made by dividing the distal portion of the extensor retinaculum and the septum between the two compartments. The tendons are retracted and the capsulotomy is performed unless it is torn from the injury. The dorsal attachments to the carpal bones are released and the scaphoid, lunate capitate, and the triquetral articulations are visualized (Fig. 62-7). Care should be taken to preserve blood supply to the proximal pole of the scaphoid.

The scaphoid and lunate are manipulated into anatomic position. A .062-inch Kirschner wire (K wire) is placed in a dorsal-palmar direction into the lunate and another parallel K wire is placed in the proximal pole of the scaphoid. The K wires are placed close to the palmar cortex so they can be used as levers to restore the scaphol-unate angle. The scaphoid is manipulated to reduce palmar flexion, and the lunate is

Carpal Bone Anatomy Dorsal And Palmar
Figure 62—7. Palmar and dorsal perspective of the ligamentous anatomy of the wrist.

manipulated to reduce dorsiflexion. Two .045-inch K wires are then percutaneously drilled from the radial side of the carpus through the proximal pole and midpole of the scaphoid into the lunate. A third wire is placed the proximal from pole of the scaphoid and into the capitate. If the scapholunate interosseous ligament is torn off the bone, additional K wires may be placed. A suture is also placed to repair the torn ligament to the bone surface. The K wires restore the anatomic relationships (Fig. 62—8). The wrist capsule is closed and the extensor retinaculum is sutured. At this point some surgeons perform a reverse Blatt capsulodesia prior to closure. The skin is closed.

Torn Ligament The Finger

Figure 62—8. Radiograph demonstrates K wires in place with internal fixation for a perilunate dislocation.

A long-arm bulky splint with the forearm in neutral and the wrist in neutral alignment is applied for 2 weeks. A spica cast is applied at 14 days and at 8 weeks is changed to a Muenster type cast. Pins may be removed at 8 to 12 weeks. Finger motion should be encouraged throughout the immobilization period. At 8 weeks we place a short arm cast for 6 weeks. We begin active motion of the wrist at 3/2 to 4 months.

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  • Sinead
    Why does the radius articulate with the lunate and scaphoid?
    6 years ago

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