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Isolated Scaphoid DislocationAssociated With Axial Carpal

Dissociation: An Unusual InjuryReport

Todd Horton, MD, San Diego, CA, Alexander Y. Shin, MD,William P. Cooney III, MD, Rochester, MN

We present a report of a patient with an isolated scaphoid dislocation associated with a hyperex-tension and axial loading injury of the carpus required a careful and extensive clinical andradiographic evaluation leading to surgical intervention to reduce and stabilize the scaphoid andto reduce and hold internally the axial carpal injury. Knowledge of the anatomy and the potentialinjury patterns of the carpus will aid the hand surgeon with injury recognition and propertreatment. (J Hand Surg 2004;29A:1102–1108. Copyright © 2004 by the American Society forSurgery of the Hand.)

Key words: Scaphoid dislocation, axial carpal dissociation, acute injury, diagnosis, treatment.

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caphoid dislocations have been described since930, usually as individual case reports and rarelys a series.1– 47 Scaphoid dislocations can be clas-ified as either isolated to the periscaphoid liga-ents or as an element of a more complex carpal

njury. The dislocation can also be subdivided intoubluxation, proximal dislocation, or total disloca-ion.

Axial carpal injuries31,48,49 involve typically mas-ive soft tissue trauma to the hand and present oftens open injuries. The combination of an isolated

rom the Naval Medical Center San Diego, Department of Orthopaedicurgery, San Diego, CA; and Department of Orthopedic Surgery, Handivision, Mayo Clinic, Rochester, MN.Received for publication February 24, 2004; accepted in revised form

une 18, 2004.No benefits in any form have been received or will be received fromcommercial party related directly or indirectly to the subject of this

rticle.Correspondence: Alexander Y. Shin, MD, Mayo Clinic, Division of

and Surgery, 200 First St SW, Rochester, MN 55905.Copyright © 2004 by the American Society for Surgery of the Hand0363-5023/04/29A06-0019$30.00/0

idoi:10.1016/j.jhsa.2004.06.018

102 The Journal of Hand Surgery

caphoid dislocation and axial carpal dissociation isxceedingly rare. We found only 11 cases report-d.5,9,15,16,26,29,31,37,40,42,46 Only 6 of those cases aren the English-language literature.5,9,16,31,37,42 Theon-English literature has described and discussedhe injury pattern; however, the English literature isimited.

The purpose of this case report is to describe thisare injury pattern and the associated injuries and toescribe the surgical treatment of this injury.

ase Report33-year-old man presented after sustaining an axial

oading and hyperextension injury to his wrist. Heeported immediate pain and deformity without neu-ovascular symptoms. He was evaluated initiallylinically and radiographically and was diagnosedith a dislocation of the scaphoid (Fig. 1).The patient was treated with closed reduction un-

er anesthesia (Fig. 2), was immobilized in a shortrm splint, and was referred to us for definitive care0 days after injury. After careful review and exam-

nation of the radiographs we were concerned that

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ignificant ligamentous injury had occurred to therist. We obtained a magnetic resonance image

MRI) that showed complete disruption of the inter-arpal capitohamate and scapholunate ligaments andhe extrinsic dorsal radiocarpal, dorsal intercarpal,adioscaphocapitate, and long radiolunate ligaments.here was also a partial tear of the short radiolunate

igament and laxity of the palmar and dorsal radio-lnar ligaments. The MRI also showed edema withinhe radial styloid, diastasis of the capitohamate andcapholunate joints, and diffuse edema about therist. The triangular fibrocartilage complex was in-

act and there was no evidence of osteonecrosis of thecaphoid (Fig. 3).

The patient was examined under anesthesia withuoroscopy and wrist arthroscopy. The presurgicallan included repair of the scapholunate ligament andtabilization of the capitohamate diastasis.

Examination with fluoroscopy showed scapholu-ate diastasis with radial and ulnar deviation. Withxial loading there was a capitohamate diastasisnd middle- and ring-finger metacarpal base dias-asis.

Radiocarpal and midcarpal arthroscopy confirmedhe scapholunate, radioscaphocapitate, and long ra-

igure 1. (A,B) Anteroposterior and lateral radiographs showvidenced by the capitohamate incongruity.

iolunate ligament injuries and showed a complete p

isruption (Geissler grade IV) of the scapholunateigament. The short radiolunate ligament was tornartially and the lunotriquetral ligaments were stable.he radioscaphocapitate ligament could be reducedolarly with resultant reduction of the scaphocapitateoint.

Based on the clinical imaging and arthroscopicvaluations we decided to stabilize the capitohamateisruption with a capitohamate arthrodesis (K-wirexation with distal radius bone graft), reduce thecaphoid and repair the scapholunate ligament viauture anchors, and supplement the repair with aorsal capsulodesis of the dorsal intercarpal ligamentxed to the dorsal lunate (Fig. 4).After surgery the wrist was immobilized in a long

rm splint for 2 weeks and then in a short arm cast forweeks. The K-wires were removed at 6 weeks and

ange of motion therapy commenced.At the 6-month follow-up evaluation the patient

as re-examined clinically and radiographicallyFig. 5). Measurements of the wrist showed wristexion and extension of 55° and 65°, respectively,ith symmetric grip strength. The patient is liftingeights, doing push-ups, and playing rugby withoutifficulty. Radiographs show maintenance of the car-

ation of the scaphoid with an associated axial carpal injury

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1104 The Journal of Hand Surgery / Vol. 29A No. 6 November 2004

iscussioncaphoid dislocations are uncommon, with only 60ases reported,1–47,50,51 usually as case reports or asimited case series. The combined injury of scaphoidislocation with axial carpal instability is rare andas first described in 1934 by Buzby.7 Nearly aecade later this injury pattern was reintroduced byoodd-Walker45 and Russell,33 who described case

eports of scaphoid subluxations and dislocations as-ociated with other carpal and radius fractures.

In 1973 Nigst52 elaborated on Bindi’s6 1964 clas-ification of isolated scaphoid dislocations and sub-uxations as purely palmar or dorsal or radial palmarnd radial dorsal. He also described the mechanismf axial disruption of the distal carpal row that allowshe capitate to collapse into the scaphoid fossa.

In 1993 Richards et al31 categorized injury pat-erns as simple (isolated to the scaphoid with anntact distal carpal row) or complex (scaphoid dislo-

igure 2. (A,B) Anteroposterior lateral and oblique radiographhe capitohamate joints were reduced; however, the wrist rlignment.

ation with axial carpal dislocation). The complex w

njury classification of Richards was similar to that ofarcia-Elias et al,48,53 who classified axial carpalislocation into an axial-ulnar, axial-radial, or com-ined axial-radial-ulnar injury pattern. Garcia-Elias,owever, did not include scaphoid dislocations in hislassification.

Connell and Dyson9 and McNamara and Corley23

eported on scaphoid dislocations before Richards31

ut did not recognize formally the association be-ween their reported scaphoid dislocations and theoncomitant axial dissociation. Connell, however,roposed a mechanism of injury, describing a diver-ent force that traveled proximally between the mid-le and ring metacarpals splitting the capitohamateoint and dislocating the scaphoid from the radius andunate.

Sakada et al34 in 1998 described a case of com-ined scaphoid and hamate dislocations withoutroximal migration of the capitate, which can be seen

n after closed reduction under anesthesia. The scaphoid anded unstable despite the near anatomic restoration of carpal

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caphoid dislocation. No mechanism of injury wasroposed.Leung et al20 in 1998 described simple and com-

lex injury patterns associated with scaphoid dislo-ation and added primary versus secondary and par-ial versus total to the classifications. Primaryislocations result directly from the injury whereasecondary dislocations are persistent dislocations af-er closed reduction of the proximal carpus. Simpleislocations involve only the radioscaphoid andcapholunate articulations whereas complex disloca-ions involve also the capitohamate and middle-ringetacarpal articulations. Partial dislocations retain

ome soft tissue attachments (usually distal) andomplete dislocations have loss of all soft tissuettachments.

Gilula54 described 3 radiographic arcs of the car-us. The first arc is along the proximal border of theroximal carpal row, the second along the distalorder of the proximal carpal row, and the thirdlong the proximal border of the distal carpal row.e suggested that if these arcs are disrupted ligamen-

ous injury of the carpus must be investigated.Andre et al2 proposed that with hyperdorsiflexion

he proximal pole of the scaphoid slides down theolar slope of the radius and is ejected volarly. If thenergy of injury is not dissipated the capitate thenbuts the radial dorsal rim and is forced to fall intohe scaphoid fossa. The lunate, triquetrum, andamate maintain their ligamentous integrity and thehearing force between the capitate and hamate isransmitted distally between the middle and ringetacarpals. Polveche et al29 reported a case in 1995

nd also supported this injury mechanism in theiriscussion and literature review.The mechanisms of injury attributed to both

caphoid dislocations and axial carpal dislocation

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™igure 3. (A,B) Anteroposterior and axial MRI show com-lete disruption of the intercarpal capitohamate (gray arrowsn A show edema in the capitate and hamate where theigament had been avulsed and white arrow in B showsncongruity of capitate and hamate articulation) andcapholunate ligaments (A, white arrow) and the extrinsicorsal radiocarpal, dorsal intercarpal (C, white arrow), ra-ioscaphocapitate, and long radiolunate ligaments. (C) Thereas also a partial tear of the short radiolunate ligament (gray

rrow) and laxity of the palmar and dorsal radioulnar liga-ents. The MRI also shows edema within the radial styloid,iastasis of the capitohamate and scapholunate joints, andiffuse edema about the wrist. The triangular fibrocartilageomplex was intact and there was no evidence of osteone-

rosis of the scaphoid.

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igure 4. After capitohamate arthrodesis with distal radius bone graft and K-wire fixation and reduction of the scaphoid withcapholunate ligament repair and dorsal capsulodesis, the anteroposterior and lateral radiographs show realignment of the

arpus and reduction of the axial carpal instability.

igure 5. Follow-up radiographs obtained 6 months after surgery. The anteroposterior and lateral radiographs show adequate

arpal alignment and maintenance of the scapholunate interval with fusion of the capitohamate joint.

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Horton, Shin, and Cooney / Scaphoid Dislocation With Axial Carpal Dissociation 1107

nclude hyperextension injury with axial loading ofhe wrist. Initial diagnostic evaluation must in-lude standard anteroposterior, lateral, oblique,nd radioulnar deviation radiographs. Arthrogramr MRI can be used to assess the ligamentousntegrity of the intercarpal joints if gross subluxa-ion is not obvious. Arthroscopy may be used asoth a diagnostic and therapeutic modality if im-ging modalities are nondiagnostic.

Treatment has ranged historically from closed re-uction and casting to percutaneous fixation afterlosed or open reduction and to open reduction andigament reconstruction with internal fixation.

In almost all reported cases, after proper treat-ent the patients have returned to their prior ac-

ivities with only moderate limitations. There is aearly universal loss of range of wrist motion.vascular injury to the scaphoid has not been

eported with this injury pattern, possibly becausef the frequent retention of the distal scaphoidigamentous structures and possible preservationf some of the vascular supply.In the present case the patient sustained a fall withhyperextension and axial load injury. The injury

attern followed loosely Richards’s,31 Leung’s,20

nd Garcia-Elias’s48,53 primary complex axial-radialcaphoid dislocation with axial carpal instability. Thenjury involved a disruption of the distal carpus at theapitohamate joint and then extended proximallyith disruption of the radioscaphocapitate, scapholu-ate, and long radiolunate ligaments allowing theroximal scaphoid dislocation. There was also dorsalisruption of the dorsal radiocarpal ligament andorsal intercarpal ligament when the carpus dividedxially. After open reduction, scapholunate ligamentepair, and capsulodesis and capitohamate arthrode-is the patient has returned to prior activity withlight loss of motion and by his own report is “doingery well.”

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