MacintoshPICTimageformatisnotsupportedLUNATEAPandlateralradiographofatransscaphoidperilunatedislocation.Thelunateisfacingdirectlyvolarandislocatedinthecarpalcanal.LUNATECAPITATEAfterattemptatclosedreductionintheemergencyroom,thepatient’slunatewasrepositionedagainstthedistalradius,howeverthemidcarpusisstilldislocatedasthecapitateremainsdorsaltothecapitatefossaofthelunate.LUNATECAPITATEThepatient’sneurologicstatuswasintact,withnormalperipheralnervesensation,including2pointdiscrimination.EPLLISTER’STUBERCLEINCISIONDorsalviewofthewristshowingtheextensorpollicuslongus(EPL)tendon.TheEPLtendonpassesulnarwardofLister’stuberclebeforeanglingtowardthethumb.Theincisionisbasedasseen(betweenthethirdandfourthdorsalcompartment).EXTENSORRETINACULUMTheincisionisbroughtdownthroughthesofttissueandtheextensorretinaculumisidentified.EPL2ndDORSALCOMPARTMENTAfterthereleaseoftheextensorretinaculumbetweenthethirdandfourthdorsalcompartments,theextensorpollicuslongusandseconddorsalcompartmenttendonsarevisualized.TheEPLandsecondcompartmentareretractedradially,whilethecommonextensortendonsareretractedlaterally,exposedthewristcapsule.LUNATECAPITATESCAPHOID(PROXIMALFRAGMENT)SCAPHOID(DISTALFRAGMENT)Afterthecapsuleisincised,thecarpalbonesarevisualized.Thelunateisvisualizedadjacenttothedistalradius.Thecapitateisseendorsallydislocatedfromthelunate.EPLSCAPHOID(PROXIMALFRAGMENT)SCAPHOID(DISTALFRAGMENT)UsingaFreerelevator,luno-capitatejointisreduced.Thecapitateisnowwithintheconfinesofthelunate.Thelunateandproximalscaphoidareintheirnormalrelationshipasthisintervalisnotinterrupted.Thescaphoidfractureisvisualizedadjacenttothecapitate.LUNATECAPITATESCAPHOIDSCAPHOIDFRACTUREAsvisualizedfromdistally,lookingdownatthearticularsurfaceofthescaphoidthatarticulateswiththecapitate,thereductionisachieved.CAPITATEAsvisualizedfromdistally,lookingdownatthearticularsurfaceofthescaphoidthatarticulateswiththecapitate,thereductionisachieved.SCAPHOID(REDUCED)CAPITATEAfterreductionofthescaphoidandradiographicconfirmation,K-wiresareplacedattheradialandulnarborderofthescaphoid,allowingacentralscrewtobepositionedbetweenthetwoK-wires.TheseK-wiresarenecessary,aswithouttwopointsofK-wirestabilizationthefragmentswillrotateononeanotherduringscrewplacementAPandlateralradiographsofthescaphoidreduction,withK-wiresandcannulatedscrewguidewire.Afterappropriatedrillingandtapping,thecannulatedscrewisplacedintothescaphoid,maintainingthereduction.Thescrewisseatedbelowthearticulatesurfaceofthescaphoid.Next,thelunotriquetralintervalisexploredandcleaned.Noticethatthescaphoidtocapitaterelationshipisnormal.Byholdingthetriquetrumawayfromthelunate,apincanbeplacedretrogradethroughthecenterofthetriquetralarticularsurfacethatwillarticulatewiththelunateonceitisreduced.SCAPHOIDTRIQUETRUMCAPITATEPROXIMALDISTALDISTALRADIUSVIEWISFROMULNARSIDEOFHANDAK-wireisdriventhroughthecenterofthearticularsurfaceofthetriquetrum.TheK-wireisthendriventhroughskinandwithdrawnsuchthatitliescompletelywithinthetriquetrum.VIEWISFROMULNARSIDEOFHANDAfterreductionofthetriquetrumtothelunateunderdirectionvision,thepreviouslyplacedK-wireisthendrivenbackacrossthelunate,holdingstability.SCAPHOIDLUNATETRIQUETRUMCAPITATEAsecondK-wireshouldbeplacedsothattherearetwofixationpointsacrossthetriquetrumtothelunate.SCAPHOIDLUNATETRIQUETRUMCAPITATETheclosureincludesthecapsuleaswellastheextensorretinaculum.Thepatientisthenplacedintoashort-armthumb-spikedcast.APandlateralradiographsdemonstratingthereductionofthetransscaphoidperilunatefracturedislocation.
