Rev. bras. ortop. vol.51 número4

r e v b r a s o r t o p . 2016;51(4):471–474

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Transtriquetral

perihamate

fracture-dislocation:

case

report

夽

Frederico

Barra

de

Moraes

_,

_Rodrigo

_Cunha

_Ferreira,

_Stéphanie

_Zago

_Geraldino,

Renato

Silva

Farias,

Ricardo

Pereira

da

Silva,

Mário

Yoshihide

Kuwae

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received24October2014

Accepted1December2014

Availableonline4July2016

Keywords:

Carpalbones/injuries

Bonefractures

Dislocations/radiography

Handtrauma/radiography

a

b

s

t

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Thewristisaregionthatisveryvulnerabletoinjuriesoftheextremities.Amongthese

injuries,fracturesofthepyramidalbone(ortriquetrum)inassociationwithdislocationof

thehamateandcarpalinstabilityareuncommon.Theyaregenerallycorrelatedwith

high-energytraumaandmaybeassociatedwithneurovasculardeficits,muscle-tendondisorders,

skinlesionsorinjuriestoothercarpalbones.Thus,inthisreport,oneoftheserarecases

oftranstriquetralperihamatefracture-dislocationwithcarpalinstabilityispresented,

diag-nosedbymeansofradiographyontherightwristofthepatientwhopresentedpain,edema

andlimitationofflexion-extensionofthecarpusaftertraumatotheregion.Thestagesof

attendingtothecasearedescribed,fromtheinitialconsultationtothesurgicaltreatment

andphysiotherapy,whichculminatedinrestorationofthestrengthandrangeofmotionof

thewrist.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Fratura-luxac¸ão

transtriquetral

peri-hamato:

relato

de

caso

Palavras-chave:

Ossosdocarpo/lesões

Fraturasósseas

Luxac¸ões/radiografia

Traumatismosdamão/radiografia

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e

s

u

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o

Opunhoéumaregiãomuitovulnerávelatraumasdeextremidade.Entretaislesões,as

frat-urasdopiramidal(outriquetrum),associadasàluxac¸ãodohamatoeàinstabilidadecarpal,

sãopoucofrequentes.Geralmenterelacionadasatraumatismosdealtaenergia,podemestar

associadasadéficitneurovascular,miotendíneo,lesõesdepeleouemoutrosossosdocarpo.

Assim,nesterelato,apresenta-seumdessescasosrarosdefratura-luxac¸ãotranstriquetral

peri-hamatocominstabilidadecarpal,diagnosticadasporradiografiasdopunhodireitode

umpacientequeapresentavador,edemaelimitac¸ãodaflexoextensãodocarpoapóstrauma

夽

StudyconductedattheUniversidadeFederaldeGoiás(UFG),FaculdadedeMedicina,HospitaldasClínicas,DepartamentodeOrtopedia

eTraumatologia,Goiânia,GO,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](F.B.Moraes).

http://dx.doi.org/10.1016/j.rboe.2016.06.006

2255-4971/©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle

472

naregião.Asetapasdoatendimentoforamdescritasdesdeaconsultainicialatéo

trata-mentocirúrgicoeafisioterapia,queculminaramcomarestaurac¸ãodaforc¸aedaamplitude

demovimentodopunho.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier

EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Fractures of the pyramidal bone(or triquetrum) in

associ-ation withdislocationofthe hamateand carpal instability

areuncommon,usuallyrelatedtohigh-energytrauma,and

may beassociatedwithneurovascular deficit, skinlesions,

myotendinous or even other carpal bones injuries. Early

diagnosis and treatment of these injuries can prevent

complications.1 _{Indeed, the stability of the bone-ligament}

structureofthecarpusisessentialforitsproperfunctioning.2

Thisstudyaimedtoreportararecaseoftranstriquetral

peri-hamatefracture-dislocationanditstreatment.

Case

report

A27year-oldmalemanuallaborer,right-handed,presented

totheemergencyroomwithseverepain(VAS=7)intheright

wrist, edema ++/4+, with limited carpal flexion-extension

withoutskinlesionsorneurovasculardeficit.Hereported

hav-ingsufferedadirecttraumatotherightwristonthesameday,

whichhadbeencrushedbetweentwoironbarsatwork.Pain

wasmoreintenseonpalpationoftheulnarregionofthewrist,

withaslightcrackleandinstability.

Rightwristradiographsweremadeintrueanteroposterior,

ulnardeviation,andprofileviews,whichindicatedfractureof

thepyramidalandinstabilityofthehamate(Fig.1).

Patientunderwent surgery; a dorsal incision wasmade,

followedbyanopenreductionofthehamate-capitate

insta-bilityandreductionofpyramidalfracture,whichwerefixed

withKirschnerwires.Capsulorrhaphyandrepairof

hamate-capitate and lunotriquetral ligaments were alsoperformed

(Fig.2).Thewristwasimmobilizedinashortarmcastforfour

Fig.1–RightwristX-raysintrueanteroposterior(A),ulnardeviation(B),andprofileincidences(C),showingpyramidal

fractureandinstabilityofthehamate.

weeks,andK-wireswereremovedaftereightweeks.

Physi-caltherapywasinitiatedafterthefourthweek.Eightmonths

aftersurgery,patientwasasymptomatic,withrestoredrange

ofmotionandstrength,comparabletothecontralateralside,

withadecreaseinthelast10◦_{inextensionandflexiononthe}

rightwrist(Fig.3).

Discussion

Thewristhasacomplexanatomy,developedforahighly

spe-cializedfunction,andatthesametimeitisveryexposedto

extremity traumathroughvariousmechanisms. Thecarpal

bones and ligaments promote a multiplanar mobility and

maintainstabilityinthevariousmovementsperformedbythe

wrist,suchasflexion,extension,radialandulnardeviation,

pronosupination,andcircumduction.3,4

Traumamechanismofthisinjurydiffersfromthetheoryby

Mayfieldetal.5,6_{ofprogressiveperilunateinstabilityingreater}

arc injuries, wherethe trauma energypasses through the

carpalbonesandligamentsfromtheradialtotheulnarside

instages,whichwouldbeexplainedinstage3,with

lunotri-quetralligamentrupturewithoutsemilunardislocation.The

injurydescribedinthepresentpatientindicatestheexistence

ofagreater arcinjuryinreverse, from ulnartoradial.The

radialcarpalboneswerespared.7

Moreover,itiscertainthatthepatienthadcarpal

instabil-ity,whichisadisturbanceofthestaticanddynamicbalance

between joints under physiological loads and movements.

This lossofstability, whichis relatedto boneand/or

liga-ment injuries, leads to alterations in the joint anatomical

relationships,affectingthebiomechanicalactivity,aswellas

rev bras ortop.2016;51(4):471–474

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Fig.2–Radiographsoftherightwristinanteroposteriorincidencewithcastimmobilization(A),transtriquetralperihamate

fracture-dislocationfixedwithK-wires(B),andinprofile(C),showinggoodshaftandsatisfactoryreductionofthelesion.

Fig.3–Imageseightmonthspostoperativelyshowingrestoredrangeofmotionandstrength,butwithadecreaseinthelast

10◦_{inextensionandflexionoftherightwrist.}

Thispattern ofcarpal injury was studied byGarci-Elias

etal.,9_{whoidentifiedlongitudinalandaxialcarpal}

instabil-ities,subdivided intothreegroups: axial-ulnar,axial-radial,

andaxial-radial-ulnar.Thus,thereportedcasewouldbe

clas-sifiedasalongitudinalcarpalinstability,axial-ulnarsubtype,

specificallytranstriquetralperihamate.Itisimportanttonote

thatthecleavagelineinthediastasisbetweenthecapitate

andthehamatemaybesubtleandthediagnosismaybe

over-looked.

Wrist X-rays are usually sufficient for the diagnosis of

theselesions;indoubtfulcases,CTcanbetterassessfracture

lines, and magnetic resonance imaging can identify

liga-mentinjury.8,10 _{Impairmentofthemediannerveisfrequent}

andcantriggercarpaltunnelsyndrome(compressionofthe

median nerve in the carpal tunnel area), characterized by

painwithburning,paresthesia,thenaratrophy,and

limita-tionofactivity.Nervedecompressionisrequired.Althougha

closedreductionandimmobilizationareinitiallypossible,

sur-gicaltreatmentshouldeventuallybeperformedtorestorethe

anatomyandstabilityofthecarpus,aswasdoneinthecase

reported.3–6,10–13

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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3.TrumbleTE.Principlesofhandsurgeryandtreatment. Philadelphia:Saunders;2000.

4.YeagerBA,DalinkaMK.Radiologyoftraumatothewrist: dislocations,fracturedislocations,andinstabilitypatterns. SkeletRadiol.1985;13(2):120–30.

5.MayfieldJK.Mechanismofcarpalinjuries.ClinOrthopRelat Res.1980;149:45–54.

6.MayfieldJK,JohnsonRP,KilcoyneRK.Carpaldislocations: pathomechanicsandprogressiveperilunarinstability.JHand SurgAm.1980;5(3):226–41.

7.LeungYF,IpSP,WongA,IpWY.Trans-triquetraldorsal perilunatefracturedislocation.JHandSurgEur. 2007;32(6):647–8.

8.SugawaraLM,YanaguizawaM,IkawaMH,TakahashiRD, NatourJ,FernandesARC.Instabilidadedocarpo.RevBras Reumatol.2008;48(1):34–8.

9.Garcia-EliasM,DobynsJH,CooneyWP3rd,LinscheidRL. Traumaticaxialdislocationsofthecarpus.JHandSurgAm. 1989;14(3):446–57.

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11.GrahamTJ.Theinferiorarcinjury:anadditiontothefamily ofcomplexcarpalfracture-dislocationpatterns.AmJOrthop (BelleMeadNJ).2003;32Suppl.9:10–9.

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