Keywords
carpal bone - joint dislocations - radius fractures - wrist injuries
Introduction
Radiocarpal fracture-dislocation is an uncommon traumatic disorder associated with
injuries to the radiocarpal (RC) and radioulnar ligaments (RU). Diagnosis is delayed
because of the lack of radiographic findings, and is made following chronic failure
(instability) of the joint and wrist pain. Treatment of acute dislocation usually
involves stabilization and ligament suture. In this patient, we stabilized the radiocarpal
joint by RC reconstruction using a brachiorradialis tendon graft.
Case Description
A 21-year-old patient with motorcycle injury (politrauma) was presented with pain
and deformity on the left dominant forearm. Initial radiographs revealed Radio carpal
and DRUJ incongruence with radial styloid fracture ([Fig. 1]). The patient had received treatment with closed reduction and percutaneous fixation
(Headless compression screw HCS®, Synthes®, Davos, Switzerland) in styloid radial.
After, physical examination revealed RC/DRUJ unstables, and the ulnar head had dorsal
prominence. We decided (intra-operative) to perform wrist arthroscopy and diagnosed
complex lesion: radio carpal ligaments and TFCC foveal avulsion (hook and trampolim
tests were positive). Therefore, addressed the radio carpal instability by reconstruction
of the radio carpal ligaments (RSC,RLL) using BR tendon.
Fig. 1 Wrist radiographic preoperative aspect – radiocarpal fractures dislocation.
The patient was kept with a long removable splint above the elbow for two weeks after
the surgery, with his wrist in a neutral position for the improvement of the natural
regain of pronation and supination. We started occupational therapy for the improvement
of the forearm range in the first week after surgery. Four months after, the patient
achieved with no pain and a stable radio carpal joint and DRUJ, exhibited good range
of motion (ROM) for wrist, forearm, elbow and all digits. DASH score of 6, a VAS score
of 0, and grip strength of 96% as compared with the opposite wrist. X-ray images revealed
the articular congruency of DRUJ, styloid radial healing, and better bone attachment
to the implants ([Video 1]).
Surgical Technique
Wrist radial approach, wherein the BR tendon was identified, harvested, and shared
in two parts: to RSC and other part to RLL. Therefore, we prepared with an internal
brace (FiberTape® wire suture, Arthrex Inc., Naples, FL) by sectioning the tendon
on its muscle transition and preserving the insertion on the radius styloid. After,
we employed a medial ulnar approach for the reinsertion of TFCC in ulna by using the
DX® anchor, through transverse tunnel, according the technique recommended by the
manufacturer. After, we created three tunnels (scaphoid, lunate and capitate) by using
a 3.5-mm cannulated drill, according the technique described by the authors, assisted
by arthroscopy. We passed the BR tendon graft through the tunnel and kept it tensed
on the palmar face on the lunate first ([Fig. 2]) and, scaphoid and capitate ([Fig. 3]) after, thereby providing stability between the radiocarpal joint. The definitive
implants on the scaphoid, capitate and lunate were only inserted after accomplishing
stability (DX®). ([Figs. 4], [5] and [Video 1]).
Fig. 2 Schematic draw: reconstruction of radiolunate ligament.
Fig. 3 Schematic draw: reconstruction of radio scaphocapitate ligament.
Fig. 4 Postoperative aspects of anteroposterior wrist radiography.
Fig. 5 Postoperative aspects of wrist radiography in lateral view.
Discussion
Conventional treatment suggests open reduction and fixation of the styloid radial
(screw, k-wires or specific plate) and direct suture repair the radio carpal and TFCC
ligaments with k-wires.[1]
In acute lesions, it is possible directly repair the radio carpal ligaments and TFCC,
however, there is no consensus to the overall management.
In chronic lesions (the most common), we often need to reduce RC / DRUJ. Moreover,
there is a need for procedures such as: Wrist partial arthrodesis, shortening the
ulna and reconstructing the radio carpal ligaments. Aita et al.[2] published reconstruction of the RSC and obtained promising results for the stabilization
of wrist and prevention of the osteoarthritis.
Aita and Mantovani[3] suggested algorithm for treating ligament lesions and introduced the wrist arthroscopy
and internal brace® for the repair/reconstruction of intrinsic/extrinsic wrist carpal
ligaments. It was advantageous as a direct view of the articular structures, avoid
wrist dorsal capsule incision, to preserve upper limb proprioception, thereby avoiding
other surgical sites.
Potter et al.[4] described the “spanning” as a stabilizer of the radio carpal joint, as opposed direction
to that treat here, using the specific radio carpal plate with temporary arthrodesis
and achieved positive results.
Here, we suggest that “internal brace” is also sufficient to treat RC and DRUJ traumatic
instabilities, as this is an anatomical repair/reconstruction similar to that of the
RSC/RLL or TFCC reconstruction. All procedures preserve the stability and mobility
of the wrist and to increase the strength of the reconstruction and its protection.[3]
The authors have a wide range of experience of using the BR tendon graft, offered
a promising and efficient solution on this case and appears to be reproducible for
future surgical interventions.[5]
We agree that a long-term result, especially on a young patient as this one, is uncertain,
and there will be some known and unknown complications in the future. There might
be an additional need of another salvage procedure; however, the excellent functional
outcome on this mid-term follow-up seems to justify this indication on these special
circumstances.
