Management of Radiocarpal
Fracture Dislocations
Ali Ghiassi
USC Department of Orthopedic
Surgery
• No Financial Disclosures
• IMDS, Zimmer
Introduction
• Talk about a
spectrum of
pathology of distal
radius fracture
dislocations
• Not all dislocations
are pure
ligamentous injuries
• Some volar shearing
fracture dislocations
can behave like RC
dislocations
• Rare injury 0.2% of all wrist injuries
• Associated with high energy injuries
• Volar > Dorsal > Ulnar
Extrinsic Ligaments
• Palmar
• Radial column
– RSC
• Intermediate column
– SRL, LRL
• Ulnar
– UL,UT, UC
Carpal Instability
• Dissociative
instability (CID)
– SL = DISI
– LT =VISI
• Non-dissociative
instability (CIND)
– Mid-carpal,
– Radio-carpal
– Ulnar translation
• Adaptive instability-
extrinsic causes:
Treatment Principles
• Concentric reduction
• Stable repair of
osseous-
ligamentous
avulsions
• Additional fixation
– Bridge plate
– External fixation
– RC pinning
Treatment Principles
• Vorsal approach
– FDS and Ulnar nerve
artery
– Standard approach
• Dorsal approach
• Dorsal-Radial approach
– SRN
• DRUJ may also be
unstable
– Open repair of
TFCC/US
– Supplemental k-wire
fixation
RadialIntermediate Ulnar
ORIF vs Suture anchor repair
Stable; Cast in
extension 6 wks
Unstable; BP, CRPP,
Ex. Fix
Unable to
repair, RL
Fusion
Radio-carpal Dislocation
• Disruption of strong
volar RC ligaments
• Rupture of extrinsic
ligaments and
capsule
• High energy injury
Radiocarpal Dislocation
Radiographic Evaluation
• Alignment of carpus
• Ulnar translation
• Disruption of Gilula’s Lines
• Small Styloid Fractures
Radiographic Evaluation
• Loss of ‘co-
linearity’ of
the lunate
• Marginal rim
fractures
Reduction Radiographs
Comparison View
Stress Testing
Radiographic Evaluation
– CT Scan
• Evaluation of
fracture size
• Alignment
• Surgical
planning
• 7 Loss of Articular Reduction
• 4 Radio-carpal subluxation
• 1 required external fixation for
maintenance of reduction
• 1/5 radioscapholunate arthrodesis
• Lunate facet projects out 3 mm
• This projection is 5 mm thick
QuickTime™ and a decompressor
are needed to see this picture.
• Less than 15 mm lunate facet
• Greater than 5 mm subsidence
• Recommend additional fixation
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture. QuickTime™ and a decompressor
are needed to see this picture.
Outcomes
• Satisfactory outcomes
• Few large prospective studies
• 30-40% decrease in total arc of wrist flexion-extension
• Post-traumatic arthritis
• Persistent instability
LITERATURE
• Howard et al. Isolated Palmar Radiocarpal Dislocation and Ulnar translocation: A Case Reprt and Review of the LIterature. JHS. Volume 22, Issue 1, January 1997, Pages 78-82
• Dumontier C, Lenoble E, Saffar P: Radiocarpal dislocations and fracturedislocations, in Saffar P, Cooney WP III (eds): Fractures of the Distal Radius. London, UK: Martin Dunitz, 1995, pp 267-279.
• Mudgal CS, Psenica J, Jupiter JB: Radiocarpal fracture-dislocation. J Hand Surg [Br] 1999;24:92-98.
• Asif Ilyas and Chaitanya Mudgal. Radiocarpal Fracture-dislocations. J Am Acad Orthop Surg 2008;16:647-655.
• Harness et al. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. JBJS Am. 2004 Sep; 86-A(9): 1900-8.
• Dumontier et al. Radiocarpal Dislocations: Classification and Proposal for Treatment. JBJS 83(2). Feb 2001.
• Kamal et al. Arthroscopic Reduction and percutanous pinning of a radiocarpal dislocation. J Bone Joint Surg Am, 2011 Aug 03; 93(15): e84 1-5