Management of Radiocarpal

Fracture Dislocations

Ali Ghiassi

USC Department of Orthopedic

Surgery

• No Financial Disclosures

• IMDS, Zimmer

Introduction

• Talk about a

spectrum of

pathology of distal

radius fracture

dislocations

• Not all dislocations

are pure

ligamentous injuries

• Some volar shearing

fracture dislocations

can behave like RC

dislocations

• Rare injury 0.2% of all wrist injuries

• Associated with high energy injuries

• Volar > Dorsal > Ulnar

Extrinsic Ligaments

• Palmar

• Radial column

– RSC

• Intermediate column

– SRL, LRL

• Ulnar

– UL,UT, UC

Carpal Instability

• Dissociative

instability (CID)

– SL = DISI

– LT =VISI

• Non-dissociative

instability (CIND)

– Mid-carpal,

– Radio-carpal

– Ulnar translation

• Adaptive instability-

extrinsic causes:

Treatment Principles

• Concentric reduction

• Stable repair of

osseous-

ligamentous

avulsions

• Additional fixation

– Bridge plate

– External fixation

– RC pinning

Treatment Principles

• Vorsal approach

– FDS and Ulnar nerve

artery

– Standard approach

• Dorsal approach

• Dorsal-Radial approach

– SRN

• DRUJ may also be

unstable

– Open repair of

TFCC/US

– Supplemental k-wire

fixation

RadialIntermediate Ulnar

ORIF vs Suture anchor repair

Stable; Cast in

extension 6 wks

Unstable; BP, CRPP,

Ex. Fix

Unable to

repair, RL

Fusion

Radio-carpal Dislocation

• Disruption of strong

volar RC ligaments

• Rupture of extrinsic

ligaments and

capsule

• High energy injury

Radiocarpal Dislocation

Radiographic Evaluation

• Alignment of carpus

• Ulnar translation

• Disruption of Gilula’s Lines

• Small Styloid Fractures

Radiographic Evaluation

• Loss of ‘co-

linearity’ of

the lunate

• Marginal rim

fractures

Reduction Radiographs

Comparison View

Stress Testing

Radiographic Evaluation

– CT Scan

• Evaluation of

fracture size

• Alignment

• Surgical

planning

• 7 Loss of Articular Reduction

• 4 Radio-carpal subluxation

• 1 required external fixation for

maintenance of reduction

• 1/5 radioscapholunate arthrodesis

• Lunate facet projects out 3 mm

• This projection is 5 mm thick

QuickTime™ and a decompressor

are needed to see this picture.

• Less than 15 mm lunate facet

• Greater than 5 mm subsidence

• Recommend additional fixation

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are needed to see this picture.

QuickTime™ and a decompressor

are needed to see this picture. QuickTime™ and a decompressor

are needed to see this picture.

Outcomes

• Satisfactory outcomes

• Few large prospective studies

• 30-40% decrease in total arc of wrist flexion-extension

• Post-traumatic arthritis

• Persistent instability

LITERATURE

• Howard et al. Isolated Palmar Radiocarpal Dislocation and Ulnar translocation: A Case Reprt and Review of the LIterature. JHS. Volume 22, Issue 1, January 1997, Pages 78-82

• Dumontier C, Lenoble E, Saffar P: Radiocarpal dislocations and fracturedislocations, in Saffar P, Cooney WP III (eds): Fractures of the Distal Radius. London, UK: Martin Dunitz, 1995, pp 267-279.

• Mudgal CS, Psenica J, Jupiter JB: Radiocarpal fracture-dislocation. J Hand Surg [Br] 1999;24:92-98.

• Asif Ilyas and Chaitanya Mudgal. Radiocarpal Fracture-dislocations. J Am Acad Orthop Surg 2008;16:647-655.

• Harness et al. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. JBJS Am. 2004 Sep; 86-A(9): 1900-8.

• Dumontier et al. Radiocarpal Dislocations: Classification and Proposal for Treatment. JBJS 83(2). Feb 2001.

• Kamal et al. Arthroscopic Reduction and percutanous pinning of a radiocarpal dislocation. J Bone Joint Surg Am, 2011 Aug 03; 93(15): e84 1-5