Palmar-divergent dislocation of the scaphoid and the lunate
© The Author(s) 2011
Received: 13 June 2010
Accepted: 1 February 2011
Published: 22 February 2011
We describe a patient with palmar-divergent dislocation of the scaphoid and lunate. After successful closed reduction, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach, and the anterior capsule was sutured through the palmar approach. The scapholunate and lunotriquetral joints were fixed with Kirschner wires for 7 weeks. At the 1-year follow-up, magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate, and radiographs showed no evidence of the dorsal and volar intercalated segment instability patterns associated with carpal instability. However, flexion of the scaphoid and a break in Gilula’s line remained. To our knowledge, this is the first report showing treatment of palmar-divergent dislocation of the scaphoid and lunate by suturing the carpal interosseous ligaments.
Simultaneous palmar dislocation of the scaphoid and lunate is rare [1–7] and has been classified into two types depending on whether or not the scapholunate ligament is intact. Ten patients with dislocation of the scaphoid and lunate as a unit have been described to date, as well as six patients with divergent dislocation [1–6]. The patient described here is therefore the seventh with palmar-divergent dislocation of the scaphoid and lunate. In this patient, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach, the anterior capsule was sutured through the palmar approach, and the scapholunate and lunotriquetral joints were fixed with Kirschner wires. To our knowledge, this is the first report in which interosseous ligaments were sutured by open surgery for divergent dislocation of the scaphoid and lunate.
The patient provided written informed consent prior to inclusion in this study, which was authorized by the local ethics committee and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki as revised in 2000.
Review of previous patients with divergent dislocation of the scaphoid and lunate
Range of motion
Only open reduction
Flex 1/3 of healthy side
Only open reduction
Open reduction K-wire pinning (S-L)
Palmar & dorsal
CRPS DISI AN (scaphoid, lunate)
Open reduction Anterior capsule suture
Open reduction K-wire pinning (S-L/S-C)
Proximal row carpectomy
Palmar & dorsal
Among the methods recommended to repair, the anterior and posterior ligaments on both sides of the lunate are combined palmar and dorsal approaches , and open reduction and percutaneous pinning of the scapholunate and scaphocapitate joints without suture of the interosseous ligaments . Although we found that suturing of the dorsal scapholunate and lunotriquetral ligaments provided a satisfactory outcome in our patient, wrist stiffness, carpal malalignment due to a break in arc II of Gilula’s line between the lunate and triquetrum, and flexion of the scaphoid still remained. Several problems arose during surgery and postoperative management. First, we should have sutured the palmar, not the dorsal, lunotriquetral ligament because the palmar ligament is stronger. This may have prevented the break in Gilula’s line. Moreover, in addition to fixing the scapholunate and lunotriquetral joints with Kirschner wires, we should have fixed the scaphocapitate joint to maximize anatomical carpal alignment. Fixation of the scaphocapitate joint may have prevented flexion deformity of the scaphoid. Thus, for reliable carpal stability, we recommend ligament repair and temporary joint fixation of the carpal bones. Subsequent wrist stiffness may be prevented by early removal of Kirschner wires after surgery and starting wrist exercises. Indeed, it may be possible to remove Kirschner wires earlier than 6 weeks when interosseous ligaments are sutured .
The injury to our patient may have been accompanied by avascular necrosis of the scaphoid and lunate . PRC on a patient with a scapholunate dislocation and complete scaphoid extrusion resulted in a good clinical outcome , suggesting that PRC may eliminate avascular necrosis and avoid additional surgery in patients with this type of injury. However, although PRC has shown satisfactory clinical outcomes, postoperative ROM and grip strength averaged 50–70% and 60–90%, respectively, compared with the healthy side , outcomes similar to those observed in our patient. Therefore, except when unavoidable, we recommend surgical repair, especially for active young people and manual workers, with PRC considered a salvage procedure.
Conflict of interest
The authors declare that they have no conflict of interest.
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