From the Guidelines
The treatment of dorsal dislocation of the lunate requires prompt closed reduction followed by surgical stabilization to prevent long-term morbidity and mortality related to avascular necrosis and chronic instability. The initial management involves closed reduction under adequate sedation or regional anesthesia, with longitudinal traction applied to the wrist while applying direct pressure on the lunate, as suggested by the principles outlined in the assessment of carpal instability 1. Once reduced, surgical intervention is necessary in most cases to ensure stability, given that radiographs may not always show the full extent of the injury, especially in low-grade injuries where radiographs are usually normal 1.
The preferred surgical approach is open reduction and internal fixation (ORIF), typically through a dorsal approach to the wrist. Kirschner wires (K-wires) are commonly used to stabilize the lunate to adjacent carpal bones, and ligament repair or reconstruction may be necessary if there is significant ligamentous damage. The importance of careful radiographic positioning and assessment of carpal instability, as mentioned in the context of scapholunate diastasis and dorsal tilt of the lunate 1, underscores the need for precise preoperative planning and intraoperative execution to achieve optimal outcomes.
Following surgery, the wrist is immobilized in a short-arm cast for 6-8 weeks, with K-wires typically removed after 6-8 weeks. After cast removal, physical therapy focusing on range of motion exercises and gradual strengthening is essential for 2-3 months to restore function and quality of life. Prompt treatment is crucial as delayed management can lead to avascular necrosis of the lunate (Kienböck's disease), chronic instability, and post-traumatic arthritis, all of which significantly impact morbidity, mortality, and quality of life. The severity of these complications relates to the disruption of blood supply to the lunate during dislocation and the damage to surrounding ligamentous structures, highlighting the importance of timely and effective intervention.
From the Research
Treatment Options for Dorsal Dislocation of the Lunate
- Closed manipulation and percutaneous K-wire fixation followed by a short period of immobilisation in a Plaster-of-Paris cast is a possible treatment option for dorsal dislocation of the lunate, as seen in a case study where the patient had a rapid return to full duties at work 2.
- Anatomic restoration of the key elements (scaphoid, lunate, and capitate) is essential in the management of carpal dislocations, including dorsal dislocation of the lunate 3.
- Early diagnosis and treatment are crucial in the management of dorsal dislocation of the lunate, and failure to obtain or maintain anatomic position by closed methods may be an indication for open reduction and internal fixation 3, 4.
- Surgical management, most commonly via open reduction and direct ligamentous stabilisation, is often necessary to restore anatomical carpal alignment and maintain stability, allowing repair and healing of the important wrist ligaments 4.
Important Considerations
- Concomitant injuries, such as median nerve damage, osteochondral fractures of the carpal bones, and fracture of the radial styloid, should be looked for and addressed in the treatment of dorsal dislocation of the lunate 3.
- Thorough neurovascular and soft tissue examination is required to identify open wounds and median nerve dysfunction, including acute onset carpal tunnel syndrome 4.
- Imaging is undertaken to appreciate injury severity, which is graded by the Mayfield classification, and to guide treatment decisions 4.