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Updated: May 13 2021

Radiocarpal Fracture Dislocation

  • Summary
    • A radiocarpal dislocation (RCD) is the total loss of contact between the carpus and the radius.
    • Diagnosis is confirmed by orthogonal radiographs of the wrist.
    • Treatment is usually internal fixation of the fractured bones, radiocarpal pinning and repair of the radiocarpal ligaments.
  • Epidemiology
    • Incidence
      • 0.2% of injuries to the wrist annually
    • Demographics
      • male > females
      • dorsal dislocation > volar dislocation
    • Risk factors
      • high-energy trauma
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • high energy shear or rotational force to a hyperextended and pronated wrist
          • often due to falls from height and motor vehicle accidents
    • Associated conditions
      • orthopaedic conditions
        • open fractures
        • distal radius fractures
          • radial styloid avulsion fractures
            • attachment of the radioscaphocapitate (RSC) ligament
          • volar lunate facet fractures
            • attachment of the short radiolunate ligament
        • ulnar styloid fracture
        • carpal bone fractures (scaphoid, lunate and trapezium)
        • medial nerve injury > ulnar nerve injury
        • irreducible DRUJ with soft tissue interposition
        • intercarpal injury (scapholunate or lunotriquetral dissociation)
  • Anatomy
    • Osseous
      • distal radius
        • articular surface is biconcave and triangular with the radial styloid forming apex of triangle
        • sigmoid notch forms the base and articulates with head of the ulna
        • dorsal surface of distal radius is convex and serves as floor of the dorsal extensor compartments
    • Ligamentous
      • radiocarpal ligaments, capsule, and the scaphoid and lunate fossa of the distal radius provide stability to the radiocarpal joint
        • short radiolunate ligament is the primary soft-tissue restraint against volar translation of the carpus
          • short radiolunate ligament attaches to the volar lunate facet of the disal radius
        • radioscaphocapitate ligament (RSC) provides restraint against ulnar translation of the carpus
          • RSC ligament attaches to the radial styloid
        • ulnolunate and ulnotriquitral ligaments originate on the volar side of the TFCC (which inserts into base of ulnar styloid)
  • Classification
      • Moneim Classification
      • Type 1 
      • Radiocarpal fracture-dislocation without associated intercarpal dissociation
      • Type 2
      • Radiocarpal fracture-dislocation with an associated intercarpal dissociation
      • Dumontier Classification
      • Group 1 
      • Radiocarpal fracture-dislocation that is purely ligamentous or involves only a small cortical avulsion fracture off the radius
      • Group 2
      • Radiocarpal fracture-dislocation associated with a large radial styloid fracture fragment (involving at least one-third of the scaphoid fossa)
  • Presentation
    • History
      • high energy trauma to the wrist
    • Symptoms
      • common symptoms
        • pain and swelling of the wrist
        • numbness and tingling
    • Physical exam
      • inspection
        • radiocarpal deformity based on direction of dislocation (volar or dorsal)
        • ecchymosis & swelling
        • pale and cold hand
      • motion
        • document flexion-extension and pronation-supination
          • crepitus should be noted
      • neurovascular
        • median nerve injuries > ulnar nerve injuries
        • radial and ulnar artery injury is common due to the deformity causing arterial occulsion
  • Imaging
    • Radiographs
      • recommended views
        • PA view of the wrist
          • radiolunate alignment
            • normally two-thirds of the lunate articulates with distal radius
              • in complete radiocarpal disruption, carpus translates ulnarly
            • intercarpal widening
            • evaluate for scapholunate or lunotriquetral dissociation
            • break in the Gilula arcs
              • the radiocarpal, proximal midcarpal, distal midcarpal arcs should be colinear
        • lateral view of the wrist
          • dorsal or volar radiocarpal wrist dislocation
            • loss of colinearity of the lunate with the articular surface of the radius
        • "tear-drop view"
          • 10 degree proximal view on a lateral
          • evaluate for lunate facet fracture
    • CT
      • indications
        • to evaluate articular surface in cases of severe comminution and articular depression
    • MRI
      • indications
        • to evaluate for the integrity of the scapholunate and lunotriquetral
  • Differential 
    • Lunate Dislocation (Perilunate dissociation)
    • Distal radius fracture
  • Treatment
    • Nonoperative
      • closed reduction and cast immobilization
        • indications
          • not medically stable for surgery
          • stable radiocarpal joint after closed reduction
        • outcomes
          • historically satisfactory outcomes for purely ligamentous injuries
    • Operative
      • open reduction, internal fixation, radiocarpal pinning and ligament repair
        • indications
          • irreducible radiocarpal dislocation
          • unstable radiocarpal joint after reduction
        • outcomes
          • good outcomes can be achieved with concentric reduction of the radiocarpal joint, treatment of intercarpal injuries and sound repair of the osseousligamentous injuries
  • Techniques
    • Closed reduction and cast immobilization
      • technique
        • longitudinal axial traction of the digits
        • casting for up to 6 weeks to allow ligamentous scarring
    • Open reduction, internal fixation, radiocarpal pinning and ligament repair
      • approach
        • volar approach to distal radius
        • dorsal approach to distal radius
      • technique
        • provisional radiocarpal joint reduction
        • three-column fixation
          • radial column (radial styloid)
            • K-wire, compression screw, or plate fixation (dorsal, volar, or radial) of radial styloid
            • soft tissue or possible suture anchor repair if ligamentous, comminuted, or fragment too small for fracture fixation
          • intermediate column (lunate facet)
            • screw or tension band wire loop fixation of lunate facet
            • soft tissue or possible suture anchor repair if ligamentous, comminuted or too small for fracture fixation
            • short radiolunate and radioscaphocapitate ligament repair
          • ulnar column (controversial)
            • indicated for DRUJ injury or persistent instability following after fixation of radial and intermediate column screw or tension band wiring of ulnar styloid fracture, or ligament repair
            • DRUJ closed or open reduction, percutaneous pinning in mid-supination
        • decompression of neurovascular structures
        • addition of external fixation, radiolunar pin x 4-6 weeks for unstable injuries after fixation
          • can use a dorsal spanning bridge plate instead for additional fixation
  • Complications
    • Acute carpal tunnel syndrome
      • risk factors
        • delay in treatment
      • treatment
        • carpal tunnel release
    • Stiffness
      • incidence
        • 30-40% of total arc of wrist flexion/extension
      • risk factors
        • prolonged immobilization
      • treatment
        • manipulation under anesthesia
        • hardware removal
    • Post-traumatic arthritis
      • risk factors
        • non-anatomic reduction of articular surface
    • Chronic radiocarpal instability
    • Late intercarpal disruption
      • risk factors
        • occult injury to the intercarpal ligaments
  • Prognosis
    • With early treatment and appropriate management, good outcomes can be expected.
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