Presentation
Fall from a motorcycle onto an outstretched hand (right). Delayed presentation.
Patient Data
Images obtained through a cast, obscuring fine bony details. Fracture fragment projected adjacent to the ulnar aspect of the proximal carpal row, representing a triquetral fracture. There is disruption of the proximal carpal row and the radiocarpal joint alignment with dorsal dislocation of the capitate consistent with perilunate dislocation. Displaced mid-waist scaphoid fracture.
Patient scanned in cast. There is complete perilunate dislocation with dorsal displacement of the capitate. There is a mid-waist displaced fracture of the scaphoid with dorsal displacement of the distal pole. Mild sclerosis of the proximal pole is present which may indicate early avascular necrosis. Displaced, mildly comminuted fracture of the proximal aspect of the triquetrum. Intra-articular non-displaced fracture of the distal radius at the dorsal aspect. There is preserved alignment of the distal carpal row and carpometacarpal joints. Alignment of the proximal carpal row and the radiocarpal joint is disrupted.
Cannulated screw fixation through the mid-waist scaphoid fracture. K-wire fixation between the lunate and triquetrum. Displaced fracture through the proximal aspect of the triquetrum. Non-displaced intra-articular distal radius fracture at the dorsal aspect. No subluxation or dislocation evident. No metalware complications. Normal radiocarpal alignment.
Case Discussion
A perilunate dislocation is an orthopedic emergency that is commonly missed in the acute setting owing to the rarity of this presentation. The mechanism is usually wrist hyperextension with a degree of ulnar deviation in the setting of high energy trauma.1 Scaphoid fractures can be associated with these injuries in up to 61% of cases.1 Furthermore, acute median nerve compression is common.2
This patient presented with increased pain, swelling and altered sensation of the right wrist/hand in a median nerve distribution three days post right-sided fall onto outstretched hand (FOOSH) following a motorcycle accident. Unfortunately, images in the acute setting are not available. Initially diagnosed and treated as a triquetral fracture with a short-arm backslab. Subsequent imaging revealed a trans-scaphoid perilunate dislocation. Median nerve decompression was performed urgently along with open reduction and internal fixation of the scaphoid with K-wire stabilization between the lunate and triquetrum.
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