A Rare Case of Complex Carpal Injury: Divergent Trapezium-Trapezoid Fracture Dislocation

Abstract

Background Divergent trapezium-trapezoid fracture dislocation is a rare and complex injury. The authors present an unusual case of dislocation of the trapezium-trapezoid complex with scaphoid fracture.

Case Description A 25-year-old man suffered a road traffic accident leading to complex carpal injury due to axial and rotation forces (steer wheel injury) on the left wrist. X-rays and computed tomographic (CT) scan were done showing trapezium-trapezoid dissociation with fracture of distal pole of scaphoid and ulna styloid. The second metacarpal base was fractured with many ligamentous injuries in the wrist.

Methods Volar flexor carpi radialis (FCR) approach was used to reduce and fix scaphoid fracture with 2.7-mm cannulated screw. Dorsal approach was used to fix fracture of second metacarpal base and perform reduction in trapezium-trapezoid complex with help of 0.8-mm K-wires, and suspension wiring of first to second and second to third metacarpal was done using 1.5-mm K-wires. The transverse flexor retinaculum (TFR) in this case was avulsed.

Discussion The divergent trapezium-trapezoid joint with scaphoid fracture is not described in the literature yet. The authors implicate steering wheel injury pattern for such complex carpal fracture dislocations. CT scan is imperative to diagnose and plan treatment of such fracture morphology. Early fracture reduction and stabilization of carpal dislocations are essential for proper functioning of wrist.

Keywords

complex carpal injuries - divergent axial-radial-ulnar - steering wheel injury - scaphoid fracture - divergent trapezium-trapezoid dissociation

• References

• 1 Garcia-Elias M. Axial fracture dislocations. In: Cooney WP. ed. The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA: Lippincott Williams & Wilkins; 2010: 579-589
• 2 Garcia-Elias M, Dobyns JH, Cooney III WP, Linscheid RL. Traumatic axial dislocations of the carpus. J Hand Surg Am 1989; 14 (03) 446-457
• 3 Apergis E. Axial dislocations or fracture-dislocations. In: Apergis E. ed. Fracture-Dislocations of the Wrist. 1st ed.. Italy: Springer-Verlag; 2013: 275-286
• 4 Reinsmith LE, Garcia-Elias M, Gilula LA. Traumatic axial dislocation injuries of the wrist. Radiology 2013; 267 (03) 680-689
• 5 Clarke SE, Raphael JR. Combined dislocation of the trapezium and the trapezoid: a case report with review of the literature. Hand (NY) 2010; 5 (01) 111-115
• 6 Maxwell HA, Morris MA. Scaphotrapezio-trapezoidal dislocation. A case report. Acta Orthop Scand 1993; 64 (03) 385-386
• 7 Keith J, Wollstein R. Combined dislocation of the trapezoid and finger carpometacarpal joints-the steering wheel injury: case report. J Hand Surg Am 2010; 35 (09) 1454-1456
• 8 Chim H, Yam AK, Chin AY, Teoh LC. Complex carpal dissociation with open, complete, and divergent trapezium, capitate, and hamate dislocation: a case report. J Hand Surg Am 2007; 32 (09) 1363-1366
• 9 Shorbe HB. Carpometacarpal dislocations: report of a case. J Bone Joint Surg 1938; 20: 454-457
• 10 Waugh RL, Yancey AG. Carpometacarpal dislocations with particular reference to simultaneous dislocation of the bases of the fourth and fifth metacarpals. J Bone Joint Surg Am 1948; 30A [phone]
• 11 Gunther SF. The carpometacarpal joints. Orthop Clin North Am 1984; 15 (02) 259-277
• 12 Kumar S, Arora A, Jain AK, Agarwal A. Volar dislocation of multiple carpometacarpal joints: report of four cases. J Orthop Trauma 1998; 12 (07) 523-526