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Axial-Ulnar Carpal Dislocation The Pincer Sign and Treatment with Capito-hamate Arthrodesis
Jin Xi Lim, MBBS, MRCS1; Joel CH Ho, MBBS, MRCS, MMed2; Alphonsus KS Chong, MBBS, FRCS, FAMS1; David Meng Kiat Tan, MBBS, MRCS, MMED1
1National University Health System, Singapore; 2Khoo Teck Puat Hospital, Singapore

Introduction: Axial disruptions of the carpus are rare injuries and have been previously classified into axial-ulnar, axial-radial and axial-radial-ulnar types. We present 3 patients with crushing injury to the wrist and sustained an axial-ulnar carpal dislocation. The focus of this discussion is on the physical sign and the treatment of this condition.
Case Series: Patient 1 sustained an open injury with dissociation of the 3rd and 4th metacarpal base, the capito-hamate and the luno-triquetral joint. He was treated with Kirschner wire fixation and a free lateral arm flap. Patient 2 sustained an open injury with dissociations of the 3rd and 4th metacarpal base, the capito-hamate and the piso-triquetral joint. He was initially treated with Kirschner wire fixation and had persistent axial instability with significant pain at 5 months post-fixation. He was later treated with capito-hamate arthrodesis and excision of pisiform. Patient 3 sustained a closed injury with dissociation of the 3rd and 4th metacarpal base, a fracture thru the hamate, and dissociation of the piso-triquetral joint. He was treated with primary fusion of the capito-hamate joint and the 3rd and 4th metacarpal base. All 3 patients displayed divergence of the 3rd and 4th ray of the hand (Figure 1).


Results: At 6 months post-fixation, patient 1 had 88% of wrist motion and 33% of grip strength but with moderate to severe difficulties on daily activities due to pain. Patient 2 had a significant improvement in the pain level with >90% wrist movement and 50% of grip strength at 4 months post- fusion. Patient 3 was pain free at 6 weeks post-fusion of the capito-hamate joint and was keen to return to light duties.
Conclusions: From these 3 cases, the authors noted that the divergence of the 3rd and 4th ray of the hand is a useful sign with regards to axial-ulnar carpal dislocation. This sign has been previously reported but have not been given enough attention to in the literature. Authors frequently reported outcomes from this injury with regards to only wrist motion and grip strength. However, chronic pain is a common problem after treatment of this condition. We suggest that fusion of the capito-hamate joint in axial-ulnar carpal dislocations addresses the axial instability, thereby reducing pain.


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