Updated: 3/18/2020

Radiocarpal Fracture Dislocation

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https://upload.orthobullets.com/topic/422863/images/tear-drop_view..jpg
https://upload.orthobullets.com/topic/422863/images/radiocarpal_dislocation..jpg
Introduction
  • Overview
    • A radiocarpal dislocation (RCD) is the total loss of contact between the carpus and the radius 
      • can be purely ligamentous (rare) or associated with a fracture
      • 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
    • demographics
      • male > females
      • dorsal dislocation > volar dislocation
    • risk factors
      • high-energy trauma
  • 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 radioscapholunate 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)
    • medical condition
      • associated injuries to other organ systems very common due to high energy mechanism of these injuries. 
  • Prognosis
    • with early treatment and appropriate management, good outcomes can be expected
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
      • radioscapholunate ligament (RSC) provides restraint against ulnar translation of the carpus
        • RSL 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
Tested 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 repairof 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
 

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