Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture

Jorge Jimenez Lopez; Anastasia Boptsi; Konstantinos Kalousis

Journal of Plastic, Breast & Reconstructive Surgery·Peer-reviewed, open-access surgical case reportsPeer-reviewed · Open access

Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture · JPBRS

Case report

Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture

Jorge Jimenez Lopez¹, Anastasia Boptsi¹, Konstantinos Kalousis¹

¹Universitätsklinikum Schleswig-Holstein Lübeck

Published April 2, 20251060 views4 min read

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Abstract

Carpal dislocation fractures are uncommon injuries, most frequently associated with high-energy trauma. Combined carpal dislocations without associated bone fractures are even rarer. Delayed treatment can have serious consequences. The case presented here involves an 86-year-old man with dislocation of the scaphoid and lunate bones, as well as acute carpal tunnel syndrome resulting from the injury. PRC is mostly a salvage operation but given the severity of ligamentous disruption, the need to restore the patient's mobility and also the fact, that scaphoid was irreducible, a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). Patient medical history The 86-year-old patient crashed the car into the wall of his garage at a speed of 30 km/h. As a result, the patient presented a dislocation of the lunate bone and the scaphoid. The patient lived alone and was completely independent. Regarding other conditions, he suffered from arterial hypertension and prostate cancer. Before and After Patient examination There was a visible deformity at the right wrist with bruising, and swelling. Additionally, a positive Hoffman-Tinel sign was observed with paresthesia in the median nerve area. A radiological examination of the hand was then performed, which revealed a dislocation of the scaphoid and lunate bones. No bone fractures were detected. Pre-operative considerations Given the severity of ligamentous disruption and the need to restore the patient’s mobility a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). 1 Surgical Dorsal Exposure The surgical procedure involved exposing and splitting the 4th and 3rd extensor tendon compartments to facilitate access. The extensor pollicis longus (EPL) tend

Key learning points

Pearls

Pay attention to impingement with the radius

Pitfalls

To avoid complications, we recommend carefully selecting the patient and assessing all aspects before making a surgical decision. Additionally, the procedure should be performed by an experienced hand surgeon. We also recommend intensive physiotherapy to prevent stiffness.

Patient history

The 86-year-old patient crashed the car into the wall of his garage at a speed of 30 km/h. As a result, the patient presented a dislocation of the lunate bone and the scaphoid. The patient lived alone and was completely independent. Regarding other conditions, he suffered from arterial hypertension and prostate cancer.

Examination

There was a visible deformity at the right wrist with bruising, and swelling. Additionally, a positive Hoffman-Tinel sign was observed with paresthesia in the median nerve area. A radiological examination of the hand was then performed, which revealed a dislocation of the scaphoid and lunate bones. No bone fractures were detected.

Pre-operative considerations

Given the severity of ligamentous disruption and the need to restore the patient's mobility a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM).

Step 1 — Surgical Dorsal Exposure

The surgical procedure involved exposing and splitting the 4th and 3rd extensor tendon compartments to facilitate access. The extensor pollicis longus (EPL) tendon was transposed subcutaneously, and the extensor tendons were luxated out of the 4th extensor tendon compartment. The posterior interosseous nerve was identified and divided. Additionally, the dorsal joint capsule was found to be torn, and the scaphoid and lunate bones were luxated ventrally, with the lunate bone rotated 90°

Step 2 — Palmar Approach, Carpal Tunnel Release and Neurolysis of the Median Nerve

A skin incision was made along the Linea vitalis, extending proximally to the distal forearm. The palmar aponeurosis, flexor brevis muscle (which was coagulated), and the flexor retinaculum were divided. The median nerve was exposed and underwent neurolysis, and the palmar branch of the median nerve was also identified and neurolyzed. Both the median nerve and the flexor tendons were retracted to the side. The palmar joint capsule was found to be torn. The scaphoid and lunate bones were displaced into the carpal tunnel. A carpal tunnel release was performed. The lunate and scaphoid bones were only secured by the ventral ligaments. The remaining ligaments, including the SL and LT ligaments, were torn. The lunate and scaphoid bones were then resected from the palmar side.

References

Campano, D. et al. (2024) ‘Dorsal lunate dislocation and en bloc proximal row carpectomy: A case report’, Journal of Surgical Case Reports, 2024(2). doi:10.1093/jscr/rjae043.
Kennedy, S.A. and Allan, C.H. (2012) ‘In brief: Mayfield et al.. classification: Carpal dislocations and progressive perilunar instability’, Clinical Orthopaedics & Related Research, 470(4), pp. 1243–1245. doi:10.1007/s11999-012-2275-x.
Muller, T. et al. (2017) ‘Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy’, Orthopaedics & Traumatology: Surgery & Research, 103(1), pp. 95–99. doi:10.1016/j.otsr.2016.10.014.
Jerome, T.J. and Prabu, G.R. (2021) ‘Proximal row carpectomy for complex perilunate fracture dislocations with migration of proximal scaphoid bone into the forearm’, Hand Surgery and Rehabilitation, 40(3), pp. 299–304. doi:10.1016/j.hansur.2020.12.002.
Della Santa, D.R. et al. (2010) ‘Proximal row carpectomy in emergency’, Chirurgie de la Main, 29(4), pp. 224–230. doi:10.1016/j.main.2010.06.001.

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Related cases

Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture

Abstract

Key learning points

Patient history

Examination

Pre-operative considerations

Step 1 — Surgical Dorsal Exposure

Step 2 — Palmar Approach, Carpal Tunnel Release and Neurolysis of the Median Nerve

References

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Step 3 — Proximal Row Carpectomy

Step 4 — Good immediate result

Post-operative plan

Pearls

Pitfalls