PMC5989276_01
AP and lateral images of the initial radiographs taken in the peripheral hospital. Note the comminuted scaphoid facet, subtle triquetral fracture (AP) as well as the obvious perilunate dislocation (lateral).
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Noting this, the consulting surgeon ordered an X-ray which revealed that the patient had a missed perilunate dislocation with a fracture of the triquetrum and a comminuted impaction fracture of the scaphoid facet (Figure 1).
Radiograph demonstrating Gilula's lines. Line I represents the proximal articular surfaces of the proximal carpal row. Line II represents the distal articular surfaces of the first carpal row. Line III represents the proximal articular surfaces of the distal carpal row. Disruption of these lines is indicative of a boney (greater arc) or ligamentous (lesser arc) injury.
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On the anterior radiograph, there was an obvious disruption of Gilula's lines (see Figure 2 for comparison), as well as an impaction injury to the scaphoid facet (Figure 3), and fracture of the triquetrum.
Examination of the comminuted scaphoid facet. (a) Obvious impaction injury. (b) Impaction fragment loose and nonadherent has a high likelihood of secondary arthrosis.
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On the anterior radiograph, there was an obvious disruption of Gilula's lines (see Figure 2 for comparison), as well as an impaction injury to the scaphoid facet (Figure 3), and fracture of the triquetrum.
Illustration of the capsular incision used in the ligamentous sparing Berger capsulotomy. Note the radially based flap created. DRC: dorsal radiocarpal ligament. DIC: dorsal intercarpal ligament. The image was reprinted with a permission from Medscape Drugs & Diseases (https://emedicine.medscape.com/) and Perilunate Fracture Dislocations, 2017, available at https://emedicine.medscape.com/article/1240108-overview.
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A dorsal approach to the wrist was used, utilizing a Berger ligamentous sparing capsulotomy (Figures 4 and 5).
Visualization of the carpal bones once the radially based flap is lifted. S: scaphoid; C: capitate; L: lunate; T: triquetrum; H: hamate. The image was reprinted with permission from Medscape Drugs & Diseases (https://emedicine.medscape.com/) and Perilunate Fracture Dislocations, 2017, available at https://emedicine.medscape.com/article/1240108-overview.
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A dorsal approach to the wrist was used, utilizing a Berger ligamentous sparing capsulotomy (Figures 4 and 5).
Intraoperative fluoroscopic images confirming screw position and proper alignment of the midcarpal fusion.
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The final screw position was confirmed on imaging (Figure 6), followed by irrigation and closure of the wound.