Triple jeopardy: transscaphoid, transcapitate, transtriquetral, perilunate fracture dislocation
© The Author(s) 2012
Received: 16 September 2011
Accepted: 19 March 2012
Published: 4 April 2012
Carpal injuries are frequently underdiagnosed and underreported injuries of the hand. Scapholunate perilunate dissociation is the most common perilunate instability pattern seen in clinical practice. Transscaphoid, transtriquetral, transcapitate dislocation with a volar intercalated segment instability pattern is a very rare pattern of carpal injury. We describe a case with this unique pattern of injury, explaining its mechanism and treatment. Good outcome can be achieved in these injuries following open reduction and internal fixation with ligamentous repair.
Carpal injuries are frequently underdiagnosed and underreported injuries of the hand. Scapholunate perilunate dissociation is the most common perilunate instability pattern seen in clinical practice [1, 2]. Perilunate dislocations may be due to ligamentous injuries (following the lesser arc) or osseoligamentous disruption combining fracture of one or more carpal bones with ligament injuries (the greater arc route). Various greater arc injury patterns have been identified, among which transscaphoid is the commonest, followed by transscaphoid, transcapitate, perilunate fracture dislocation [3, 4]. Other uncommon patterns include transscaphoid, transcapitate, transhamate fracture dislocation, transscaphoid, transcapitate, transtriquetral, perilunate fracture dislocation, and transscaphoid, transtriquetral, perilunate fracture dislocation [5–8].
Transscaphoid, transcapitate, transtriquetral dislocation is a very rare pattern of carpal injury, with only two cases reported in the literature [5, 9]. A unique feature of this injury is its volar intercalated segment instability (VISI) pattern. Below, we describe a case with this unique pattern of injury, explaining its mechanism and treatment.
Perilunate fracture dislocations can have a complex pattern of ligament and bony injuries. Transscaphoid perilunate fracture dislocation is the most common pattern of perilunate injury. Fenton  reported a case of simultaneous fracture of the capitate and the scaphoid (naviculocapitate syndrome). Several cases of transscaphoid, transcapitate, perilunate dislocation have been reported in the literature, but transscaphoid, transcapitate, transtriquetral, perilunate dislocations are extremely rare.
The direction of the forces that acted across the carpal bones at the time of injury can be postulated based on the radiological findings. The injury resulted from the hyperextension forces, with the ligaments on the ulnar side giving way first, resulting in the VISI pattern. This contrasts with the more common mechanism of perilunate injury (Mayfield’s classification), where the forces cause disruption of the ligaments from the radial side, resulting in a dorsal intercalated segment instability (DISI) pattern . This reverse Mayfield pattern then resulted in the transcapitate and transscaphoid disruptions. This would happen with an axial load on a dorsiflexed hand, with the hypothenar part bearing the deceleration forces. After the ulnar aspect of the hand impacts the ground, there is forced dorsiflexion and intercarpal pronation, followed by the radial deviation. This causes lunotriquetral dissociation in the form of a lunotriquetral ligament tear or avulsion or triquetrum fracture. Next, the scaphoid comes into contact with the dorsal lip of the distal radial articular surface, resulting in a scaphoid fracture. Thus, ulnar stablizers of the lunate are lost, causing it to tilt volarly. This is a rare mechanism of injury. Not only are ulnar injuries to the carpal bones rare, but they are also poorly understood and diagnosed.
Another point of interest in this patient was the unusual shape of the distal radial articular surface. A certain degree of hypoplasia of the ulnar part of the distal radial physis is evident on the radiographs. Though negative ulnar variance was maintained, there was increased slope of the distal radial articular surface. This is consistant with a milder form of Madelung’s deformity . There would be some associated stretching and weakening of the distal radioulnar joint. Also, the lunate will be proximally and ulnarly migrated because of the deformity, leading to abnormal stresses across the lunatotriquetral joint. This would have led to the intrinsic weakening of the ligaments around these joints, prompting these ligaments to give way at the first instance.
The dorsal approach is the most commonly used approach for the reduction and fixation of perilunate injuries. It provides good exposure of the intercarpal relations, facilitating an assessment of adequate reduction. The scapholunate ligament is generally preserved in a transscaphoid injury. The scaphocapitate ligament and lunotriquetral ligaments were found to be torn at the time of surgery and were repaired. Repairing the ligaments is important, as it can prevent a loss of reduction. This patient received adequate reduction intraoperatively, which was maintained during the follow-up.
Thus, transscaphoid, transcapitate, transtriquetral, perilunate dislocations are extremely rare injuries, and are best treated using open reduction and internal fixation with ligamentous repair. A good outcome can be achieved for these injuries following fixation.
Conflict of interest
The authors declare that they have no conflict of interest.
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