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Impaired Functional Outcome Associated with Perilunate Injuries of the Wrist
Sanjeev Kakar, MD; MRCS, MBA1; Brandon Yuan, MD2; Peter Rhee, DO3, David Jones, MD3; Steven L. Moran, MD4
1Orthopaedics, Mayo Clinic, Rochester, MN; 2Orthopedic Surgery, Mayo Clinic, Rochester, MN; 3Orthopaedic Surgery, Mayo Clinic, Rochester, MN; 4Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
Hypothesis: Patients sustaining perilunate dislocations/fracture dislocations experience impaired functional outcome with associated radiographic deterioration over time.
Methods: A retrospective review was conducted analyzing the outcome of all perilunate dislocations and fracture dislocations from 1985 to 2009. Standardized postoperative assessments included wrist range of motion, grip strength and Mayo Wrist Score. Pre and postoperative radiographs were examined to ascertain the incidence of post traumatic arthritis.
Results: Ninety four patients were treated over the last 25 years. There were 30 perilunate dislocations and 64 fracture dislocations (5 open & 89 closed injuries). Complete radiographs were present in 57 patients and included 20 perilunate dislocations and 37 fracture dislocations (4 open & 53 closed injuries). Forty one patients were treated with combined volar and dorsal approaches, 11 dorsal and 5 volar approaches. There were no statistically significant differences between the pure dislocation versus the fracture dislocation groups with respect to contralateral grip strength (64% versus 68% respectively). The fracture dislocation group tended to have improved flexion to extension arc compared to the purely ligamentous injury patients (86 degrees versus 74 degrees). Thirty three percent of patients underwent additional secondary procedures. The pure dislocation patients went onto a higher rate of salvage procedures compared to the fracture dislocation patients (35% versus 5%). According to the Mayo wrist scores, 23% of patients had good to excellent results and at final follow up, only 59% of patients returned to work. Normal scapholunate (SL) angles were achieved intraoperatively in 18 of 20 dislocations and 34 of 37 fracture dislocations. At follow up, 13 of 20 and 31 out of 37 patients within the respective groups maintained normal SL angles. The presence of a type 2 lunate did not guard against DISI development. Radiographic analysis demonstrated signs of degenerative changes in both injury groups (35% dislocation only and 52% fracture dislocation patients). This may have been attributable to difficulties in maintaining the lunate within its fossa. At latest follow up, 16 of 20 and 31 of 37 patients within the dislocation and fracture dislocation groups, respectively, had evidence of greater than one third of ulnar translocation of the lunate. Compared to immediate post operative radiographs, there was a 16% and 8% decrease in carpal height ratio at follow up within the dislocation and fracture dislocation patients, respectively.
Conclusion: Perilunate dislocations and fracture dislocations result in significant morbidity and impaired functional outcome in patients over the long term.
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