Fractures and dislocations of the carpal bones - Punjab Orthopaedic ...

Fractures and dislocations of the carpal bones – a reviewMS Dhillon MS, MNAMS*, Sarvdeep Dhatt MS**, Vishal Kumar MS***Professor & Head, **Pool Officer, ***RegistrarDepartment of Orthopaedics,Postgraduate Institute of Medical Education and Research, Chandigarh.ABSTRACTCarpal bone injuries constitute important cause of disability of hand and wrist. These injuries are oftenmissed due to lack of awareness on the part of general orthopaedic surgeons. We have reviewed the currentconcepts in the management of these injuries including the mechanism of trauma, biomechanic, injury pattern,the role of radiography and advanced imaging in the diagnosis and the various treatment modalities beingused for them.Keywords: Wrist, carpal bones, fractures, dislcoationsINTRODUCTIONThe wrist is perhaps the most complex joint in the body, mainlydue to the multiple bones involved and the complex ligamentousstructures. It provides the final positioning for the hand at theend of a “multilinked cantilever mechanism” 1 . Injuries to thewrist are common at all ages, with metaphyseal injuries beingcommon in the elderly and scaphoid fractures being commonat almost all ages 2 . Most uninitiated orthopedists focus theirattention to these common problems, and the rarer injuries tothe lesser carpal bones are sometimes overlooked 3 . This couldresult in long term residual pain and grip weakness, and hencea high index of suspicion is mandatory if a clinical examinationshows a painful and tender wrist, but the x-ray does not showa scaphoid or a Colles’ fracture.Although the ancients were aware of wrist problems, anysignificant advances had to wait till the discovery ofroentgenograms in the 19 th century which revealed differentinjury patterns that led to better understanding. Severalauthors 1,4 recognized the fact that carpal instabilities could beproduced even by soft tissue injuries alone, and a wide varietyof injury combinations involving bone, ligaments and capsulecould be responsible for the long-term problems in the wrist.The residual effect of these injuries maybe a painful carpalinstability; the primary cause in most cases being, the fact thatCorresponding AuthorDr. M S Dhillon, Professor & HeadDepartment of Orthopaedics,Postgraduate Institute of Medical Education and Research,Chandigarh.E-mail : drdhillon@gmail.comthe injury is either not recognized at initial presentation andhad been dismissed after primary examination as “no fractureof the scaphoid detected”.MECHANISM OF TRAUMA AND INJURY PATTERNSCarpal injuries represent a vast spectrum of bony andligamentous damage. Each injury is perhaps not an isolatedinjury but part of a continuum, with the final injury beingdetermined by three factors (Mayfield, 1980) 5 – (1) The type ofthree- dimensional loading, (2) the magnitude and the durationof forces involved, and (3) the position of the hand at the timeof impact.The carpi are aligned in two rows, with the scaphoid partlybridging these two rows, and making it most susceptible tofracture at its waist. If the distal radius remains intact, there aretwo primary arcs through which the injuries at the wrist occur;one is through the scaphoid, around the lunate to thetriquetrum, with significant disruption of the proximal rowligaments. The second injury is through the scaphoid and thecapitate, without disruption of the luno-triquetral ligament 6 .Fractures of the lesser bones usually require special situations;isolated injuries can occur either because the application offorce was just right or because it was not severe enough tocause additional injury. Most of these can be injured by directblows to either the palmar or volar surfaces of the wrist, or byavulsion of the attached ligaments. Injuries to the Triquetrumwhich is the third most common group of carpal fractures, maybeof two types of fractures; a direct blow may cause a fracture ofthe body, or there maybe an avulsion of the attached ligamentsleading to a chip fracture on the dorsum. It is also commonlyPb Journal of Orthopaedics Vol-XI, No.1, 200924

Fractures and dislocations of the carpal bones – a reviewfractured as a part of perilunate dislocation.The Capitate is the largest bone in the wrist and has morearticulations than any other carpal bone; it also forms the centralportion of the perilunate disruptions. It could also be similarlyinjured in its neck, with a hyper dorsiflexion strain impingingthe capitate against the radius. A special situation is the socalled naviculo-capitate syndrome, with fractures of thescaphoid and capitate, without any dislocation being observed.The neck fracture occurs if the injuring force follows a moredistally based arc than the commoner perilunate dislocation,with a tension fracture of the scaphoid permitting acute hyperextension and impingement of the capitate against radius. Theproximal fragment often rotates 180 degrees in the plane of thepalm, as the wrist reduces spontaneously 7 .Fractures through the Trapezium are produced bycompression caused by the base of 1 st metacarpal, or as avulsionfractures due to the pull of the capsular attachments. Corderyand Ferrer-Torell 8 , after reviewing the world literature, found 37out of 75 reported fractures to be isolated injuries, and identifiedtwo major types: avulsion of the ridge and a vertical fractureassociated with dislocation of the 1 st Metacarpal and the radialfragment. The mechanism is usually a blow on the adductedthumb or a fall with the hyper extended hand in radial deviation 5.The Pisiform, being relatively more superficial, is generallyinjured by a direct injury such as a fall on the dorsiflexed hand,or the use of the hand as a hammer to strike an object. Since theflexor carpi ulnaris can potentially hold it in tension against thetriquetrum, it can also sustain an osteochondral compressionfracture at the pisotriquetral joint, or its distal pole can beavulsed. Vasilas et al 9 reported that the fractures can be linear,comminuted or chip-in type.The Hamate can be fractured through its body, with orwithout articular surface involvement, or a fracture of the hookcould occur with a fall on the dorsiflexed hand, and tensionbeing exerted through the transverse carpal and pisohamateligaments. This is perhaps a relatively common sports relatedinjury, occurring with the use of bats or racquets or clubs. Thehook is usually avulsed from its base, but avulsion fractures ofthe tip have also been reported. Fractures of the hamate bodyare perhaps only observed in direct crushing or blast injuries,and are reportedly clubbed into two main groups, those inwhich the fracture line is radial to the hook and those in whichit is ulnar to the hook. The Trapezoid is generally injured by alongitudinal force applied through the second metacarpal, anddue to its shape and protected position, is perhaps the leastcommonly fractured carpus; it could, however be dorsallydislocated by a volar directed blow on the second metacarpal,with the occasionally reported fracture.Dislocations of the other carpus in isolation are rare, withtrapezium dislocations being commoner. The triquetrum hasstrong ulnar, palmar and dorsal ligaments, minimizing thechances of dislocation in isolation being the primary injury,and the hamate and capitate are relatively protected betweenthe bases of the metacarpals and the convex shape of theproximal carpal row.The lunate is discussed separately as both fractures anddislocations of this “keystone bone” of the proximal carpalrow are frequently encountered. Isolated fractures may beavulsion injuries, or repetitive stress could lead to avascularnecrosis. Most fractures result from hyper-extension injuries,with avulsions from the dorsal pole being more frequent due tothe tension in the scapholunate ligament of a dorsally rotatinglunate.Diagnosis and radiologyThe diagnosis of these injuries is based on a thorough clinicalexamination of an acutely injured wrist, with a high index ofsuspicion once fractures of the scaphoid are ruled out. Painand tenderness are usually appropriately situated, with swelling,prominence and limited motion helping to localize the specificinjury. A good knowledge of the pertinent wrist anatomy isessential to locate the injury specifically.Radiographic examination is perhaps the most importantmodality for accurate diagnosis. The fractures or dislocations,however, may be very subtle at times, and awareness of thenormal alignments as well as the requisition of special viewsfor specific injuries is usually required. Gilula 10 , reviewedradiographic wrist relationships and particularly, emphasizedthe postero-anterior view. He analyzed the three normal arcsand their abnormalities. Arc 1 follows the convex proximalcurvatures of the scaphoid, lunate and triquetrum, Arc II outlinesthe distal curvatures of these three bones, and Arc III tracesthe main proximal curvatures of the capitate and the hamate. Inaddition to looking for breaks in these arcs, specific fracturesare picked up in specific views. Transverse triquetrum fracturesare easily identified on PA views, but dorsal chip fractures mayneed a slightly oblique, pronated lateral view. A true AP (Roberts)view may be needed to outline the body of the trapezium withoutsuperimposition, while carpal tunnel views may sometimes beneeded to identify trapezium ridge fractures as well as pisiforminjuries and fractures of the hamate hook. The pisiform is alsowell evaluated by a lateral view with the forearm in 30 degreessupination. Injuries to the hamate and the capitate are usuallyeasily identified by the PA or AP views. If a lucent line isvisualized in the neck of the capitate, the lateral view should beexamined carefully to identify the head of the bone, to assessPb Journal of Orthopaedics Vol-XI, No.1, 200925

Dhillon et alfor displacement or rotation. A trapezoid dislocation/ fracturecan be best visualized on the AP view as loss of normalrelationship between the 2 nd metacarpal and the trapezoid.Special situations may need tomography or even MRI fordetection of occult fractures and chondral injuries. Hamate hookfractures can be best defined by CT scans, but care must betaken not to confuse the Os hamulus proprium, a separatelyossified hook, as a fracture.Management of injuries of the lesser carpusIsolated carpal injuries, if undisplaced, are all similarly treatedby a regimen of POP cast support for a period of 6 weeks.Closed treatment also suffices for a variety of dislocations aswell as displaced fractures, when satisfactory reduction can beachieved by a finger trap apparatus and good muscle relaxation,followed by direct manipulation. Operative intervention isrequired only in a few special situations:Triquetrum : Chip fractures often do not heal, needing excisionof the fragment as well as ligament repair. Triquetral orientationmust be carefully scrutinized if there is doubt about volarligament injury. Osteonecrosis does not usually occur as thefracture are mostly undisplaced, and there is a good bloodsupply from the extensive ligamentous attachments.Pisiform : This is a sesamoid in the tendon of the flexorcarpi ulnaris, and is the contact point for stabilizing thehand in precise movements. Occasional excision of afragment is necessary if splinting does not help; althoughosteonecrosis has not been reported, the potential for latearthrosis as well as instability is present if there is associatedligament disruption.Hamate : Body fractures heal well with splinting, but fracturesof the hook usually need operative intervention. Open reductionhas its proponents 6 but the success rates are not reproducible.Excision of the hook has given good results in many series;tendon fraying or even rupture could occur secondary tononunion of the hamate hook, as well as the frequentlyassociated problem of ulnar neuropathy involving the deepbranch of the nerve. In late cases, mild discomfort couldnevertheless persist.Trapezium : Surgical options include primary internal fixationwith K wires or the late excision of a chip fracture if it causespain. In primary reductions, the size of the fragment as well asthe joint stability are important determinants in decisionmaking.Trapezoid : Being the keystone of its arc, long term problemslike wrist pain may occur due to arthrosis of the 2nd CM joint;this may sometimes need arthrodesis. Osteonecrosis has neverFig 1. Fracture proximal pole of Capitate in a complex wrist instabilityinjurybeen recorded with fractures, but since dislocation is morecommon, has been occasionally been reported.Capitate : Although cast support is the recommended treatmentfor undisplaced fractures, non union is common. Largerfragments may even reabsorb with non-union, leading to latecollapse and overriding. As the proximal fragment is almosttotally articular, osteonecrosis is also a frequent problem. Thisinjury should preferably be treated by open reduction of thelarger fragments. Late arthrosis may need limited intercarpalfusion.Lunate fractures : These are injuries which are frequentlyunrecognized and may only present when they becomesymptomatic as Kienbock’s disease. This produces significantdisability in relatively young people, with no totally reliabletreatment option. Lunate injuries are usually missed initiallydue to various reasons: the patient may ignore it as a simplesprain, or the doctor may not be able to pick up an occultfracture line in x-rays (like sometimes seen in the scaphoid).Most times, the vascularity of the bone is disrupted, leading tolate sclerosis and osteochondral collapse.Most cases with lunate fractures have a history ofa hyper extension injury; occasionally repetitive use of thewrist may cause a sudden “snap”. A proximally directed forcepushes the capitate against the palmar pole of the lunate, andalso shifts the lunate ulnarwards; this stresses the radio-lunateligament. Avulsion fractures on the dorsum occur by pull ofthe scapho-lunate ligament, while avulsion fractures of thepalmar pole are usually associated with a perilunar dislocationvariant.Pb Journal of Orthopaedics Vol-XI, No.1, 200926

Fractures and dislocations of the carpal bones – a reviewFig 2. Incomplete Fracture of Lunate. Note osteolytic areaFig 3. MRI confirms the articular breakMost fresh fractures are either palmar or dorsal hornavulsions, more commonly from the radial corner; bodyfractures, occurring most often between the mid and palmarthirds, are usually in the coronal plane. A fracture in the sagittalplane maybe seen in ulnar minus wrists, where the radio-ulnardifferential step may have an important role to play. Thesefractures may also be fragmented injuries, and the differentiationfrom the late fragmentation of Kienbock’s disease is usually aproblem.Radiographic assessment is usually difficult due to theoverlap of the surrounding bones in both AP and lateral views,which may hide a non displaced crack fracture. Clinicalsuspicion must take precedence over x-ray films, and insuspected cases, technetium bone scans or even MRI couldbe helpful in the early stages. Oblique views will pick up somefractures, but CT scans and polyaxial tomograms are perhapsthe best. MRI is the best modality for evaluating vascularchanges. Special note should be made on radiographs of thecarpal collapse, if any.Treatment : It is important to understand that a lunate fracturemay progress to carpal instability, non union and late AVN. Allfractures treated with POP casts should have serial follow-upwith tomography and even MRI. If the fragments are separatedby intrusion of the capitate, union is impossible. Open reductionand fixation is a possibility, but no large studies are available toprove the efficacy; distraction with an external fixator couldtheoretically allow cooptation of the lunate fragments. All POPcasts should be long arm types, with compression over thelunate.The treatment of established AVN is to be done on thelines of Kienbock’s disease.The prognosis, of body fractures, with minimaldisplacement, is relatively good, especially in younger ages.Non union is rare, as most cases will progress to Kienbock’sdisease.SCAPHOID FRACTURESThe most common, and also the most problematic, fracture inthe wrist is that of the carpal scaphoid. It accounts for 70% ofall carpal fractures and is most prevalent in the 15- to 30-yearoldpopulation 2 . The scaphoid bone has an irregular shape,and 80% of the surface is covered by articular cartilage. Bloodsupply to the scaphoid has been well documented by Panagiset al 11 , who have shown that dorsal vessels supply 70% to 80%of vascularity, the majority of which enters at the dorsal ridgeof the scaphoid. Because of the vascular anatomy, proximalpole fractures have a worse prognosis for healing than moredistal injuries.When examining a patient with a suspected scaphoidinjury, it is important to compare the injured wrist with theuninjured wrist. The classic hallmark of an anatomicsnuffbox tenderness on examination if a highlysensitive (90%) indication of scaphoid fracture, but it isnonspecific (specifically, 40%) 12 . There are variousimaging options for assessing a patient with suspectedscaphoid injury. They include plain radiographs,Magnetic resonance imaging (MRI) and bonescintigraphy. Anteroposterior, lateral and obliqueradiographic views are required for evaluation of a scaphoidfracture.Pb Journal of Orthopaedics Vol-XI, No.1, 200927

Dhillon et alFig 4. Fracture across scaphoid waist showing sclerotic lineOccasionally, a special radiograph called a scaphoid viewmay be helpful; the wrist is ulnarly deviated and extended whilethe film is shot from a dorsal-volar angle.Historically, the bone scan has been used to look for occultfractures of the scaphoid and other bones. In a studycomparing bone scan with MRI, 13 the authors found the twomethods to be equivalent. In this study, 59 patients with clinicalsuspicion of scaphoid fracture and negative radiographs atpresentation had a bone scan and MRI. Both methods foundall fractures, but the MRI found some significant ligamentousand carpal instabilities. A Cochrane review 14 of the data foundthat bone scintigraphy was a cost effective and accuratemethod for assessing occult scaphoid fractures compared withrepeat plain radiography.Fig 5. Fracture of scaphoid tuberosity, with step in distal articularsurface, best seen in oblique viewFig 6. Same case, MRI findingsInternal fixation should be regarded as the treatment ofchoice for all proximal pole fracture 15,16 . In contrast to fracturesthrough the waist, which can be classified as stable or unstableaccording to the amount of displacement and the direction ofthe fracture line, all proximal pole fractures should be regardedas unstable, whether or not they are displaced, for the reasonsmentioned above. It is essential that the fracture is completelyimmobilized in order to optimize the conditions forrevascularization and healing. This is difficult, if not impossible,to achieve with external splintage alone, because there is noextrinsic ligamentous support around the proximal part of thescaphoid, which without doubt explains why proximal polefractures have such high rates of nonunion. Internal fixation isbest carried out through a dorsal approach, using anintraosseous fixation device appropriate to the small size of theproximal fragment. The dorsal approach provides limited accesswith partial opening of the second and third extensorcompartments and the wrist capsule over the scapholunatejoint. It does not cause any further compromise to the bloodsupply of the proximal fragment and allows clear visualizationof the fracture and exact placement of the screw 16 . Thereis no real advantage to percutaneous insertion as noligaments are incised with the open technique and the risk ofincorrect positioning of the screw increases with the closedtechnique.The mini-Herbert screw, which has a shank diameter of1.5mm and small threads, can be easily inserted under directvision into the small proximal fragment using a freehandtechnique. The small size of this screw minimizes the risk ofdisplacement and disruption of the small proximal fragmentduring fixation and allows the screw to be buried beneath thecartilage. The wrist is immobilized postoperatively for 2 weeksPb Journal of Orthopaedics Vol-XI, No.1, 200928

Fractures and dislocations of the carpal bones – a reviewin a below elbow cast and heavy manual activity is restrictedduring the first 6 weeks. Full activities are resumed once X-rays demonstrate fracture union. This treatment regime has ahigh success rate in our hands, even for proximal pole fractureswhich present up to 4 months following the injury.COMPLICATIONS OF CARPAL BONE INJURIES1. Refracture: rare, commoner with scaphoid than other bones2. Nerve Injury: more common with dislocations; usuallydirect injury or stretching. Median nerve commonly injuredin lunate dislocation, but fractures of pisiform and hamatehook could injure ulnar nerve also.3. Nonunion: May occur as maintaining immobility is aproblem, and early diagnosis is frequently lacking. Willalways need open reduction and bone graft to regain carpalheight.4. Pain dysfunction syndrome: Could be associated with anycarpal/wrist trauma.DISLOCATIONS OF THE CARPAL BONESAcute fracture-dislocations of the carpus are uncommoninjuries. Although carpal bone dislocations have beenrecorded for many years, the mechanisms and classificationhave only been recently clarified. These are complex injuries,with specified patterns of trauma. Most carpal dislocations arecaused by hyper extension trauma, with fall being thecommonest mechanism. As per the simplest explanation, theprimary dislocation occurs at the midcarpal joint, with thecapitate usually displaced dorsal to the lunate. As thescaphoid bridges both the rows, it may either fracture or rotatewhen the capitate dislocates dorsally. This leads toligamentous instability, and if the injury stops at thisstage, it is classified as a Perilunate dislocation(transscaphoid, or if there is no fracture, simple perilunatedislocation). The same mechanism may occur with a volarlydirected force, leading to Volar Perilunate dislocations.Previously a lunate dislocation was thought to be an isolatedinjury, but now this is understood to be the end result of aperilunate injury, where the dislocated carpus, on relocation,pushes the lunate from its position. As in all ligamentousinjuries, there is a spectrum of damage in these injuries, rangingfrom partial tears to total disruption of the complex ligamentousstructures. These are the so called wrist instabilities, whichpresent as intercarpal segmental dissociations, and are aseparate entity in themselves. Broadly speaking, the keydistinctions from management point of view are whether thescaphoid is fractured or subluxated, and whether thedisplacement of the distal row is dorsal or volar.TABLE 11. Dorsal perilunate/volar lunate dislocation2. Dorsal trans scaphoid perilunate dislocation3. Volar perilunate/dorsal lunate dislocation4. VARIANTSTransradial styloid, perilunateNaviculocapitate syndromeTranstriquetralMiscellaneous5. Isolated rotary scaphoid subluxationAcute subluxationRecurrent subluxation6. Total dislocation of the scaphoid7. Isolated dislocations of the lesser carpal bonesThe list of potential dislocations is given in Table 1.Dorsal Perilunate/ Volar Lunate dislocationPatients with perilunate fracture-dislocations usually presentwith wrist pain, swelling, and crepitus. The digits often areheld in a semiflexed position, and passive extension is painful.There also is abnormal wrist alignment with the capitatedisplaced dorsally, which can be apparent on clinicalexamination. These patients usually also complain ofparesthesias in the median nerve distribution. Radiographicevaluation is important to evaluate the extent of injury. Ofperilunate injuries, 20% are misdiagnosed with the initialradiographic evaluation. This is best diagnosed on lateral x-rays; the capitate is seen dorsal to the lunate, with the proximalscaphoid pole being rotated dorsally. AP views demonstrateoverlap between the proximal and distal carpal rows. In caseswhere the deforming forces have relocated the distal row, thelunate will be seen volarly, and will be rotated 90 degrees onthe lateral x-ray (“Spilled tea-cup” sign). The capitate may partlyarticulate with the distal radius. In AP views the shape of thelunate becomes triangular or wedge shaped, as compared tothe normal trapezoidal shape. An additional posteroanteriorradiograph of the wrist with a loaded fist is made to rule outscapholunate instability. The presence of associated fracturesmay divert the attention of physicians away from the carpalsubluxations or dislocations. Distraction radiographs are helpfulto identify scaphocapitate syndrome or to delineate any otherassociated fracture or dislocation that was not apparent at thefirst evaluation. Tomography of the wrist is useful for evaluatingthe alignment of the carpal bones and for assessing fracturesPb Journal of Orthopaedics Vol-XI, No.1, 200929

Dhillon et aland fracture- dislocations. It also provides useful crosssectionalimages and is particularly helpful if three-dimensionalreconstruction is performed.Traditional treatment of carpal dislocations or fracturedislocations in the acute stages include reduction with fingertrap traction, open reduction and internal fixation of fracturesand primary capsular and ligament repair followed by castimmobilization for a period of 10±12 weeks. 6,17,18 . This is thestandard protocol preferred by the authors 5 for the so-calledsimple dislocations these being: the transscapho-perilunardislocations seen early and the perilunar dislocations with orwithout complete dislocation of one carpal bone. These twolast injury patterns correspond to stages I±IV of Mayfield’sprogressive perilunar instabilities of the “lesser arc” 19 .Open reduction can be done through the dorsal approach,or a combined dorsal and volar one 20 . The authors prefer atransverse dorsal skin incision, with a longitudinal incision inthe capsule. This gives adequate exposure to reduce the lunateas well as fix the scaphoid; volar ligamentous repair however isnot possible through this incision, but we have had nosubsequent instability in our experience. It is important tounderstand that restoration of the relationship between thescaphoid, lunate and capitate is essential; this should bemaintained with k-wires. In trans-scaphoid injuries, the proximalpole of the scaphoid is displaced with the lunate, and this hasto be reduced and fixed with a screw. The intercarpal k-wiresshould be left for a minimum of 8 weeks to prevent late lunatesubluxation and allow intercarpal ligamentous healing. A longarm POP cast should also be continued till this time.ROLE OF EXTERNAL FIXATORS IN THE MANAGEMENTOF CARPAL FRACTURE-DISLOCATIONSFor the so-called complex fracture dislocations represented by:(a) injuries to the “greater arc” with fracture of two or morecarpal bones, (b) complete irreducible palmar dislocationsassociated with intraarticular fractures of the distal radius, and(c) open carpal injuries, a wrist fixator is routinely used. This isnot only as a means to obtain indirect reduction byligamentotaxis, but also for protective immobilization using theframe in a neutralizing mode to block the axial load of the cartilageon the injured proximal carpal row, and to maintain normal carpalalignment during the initial stages of ligament healing 21,22 .Subsequently, external fixation was found particularly usefulin the treatment of carpal dislocations with ipsilateral fracturesof the upper extremity, especially forearm and elbow fractures.This permits cast free after treatment, providing earlyrehabilitation of forearm rotation and elbow motion. Furtherindications for external fixation include the old neglectedunreduced transscaphoperilunate dislocations, as well as thecompression fracture of the lunate as a result of an axiallydirected force on the proximal row.External fixation of the wrist as a method of immobilizationof carpal fracture dislocations was proposed in 1980 by Ballmerand Buchler (personal communication). It could be shown thatthe principle of ligamentotaxis using an external fixator acrossthe wrist was not only useful to restore the joint surface of thedistal radius 21, 22, 23 but also to reduce and maintain carpalalignment in difficult carpal fracture dislocations 24 .External fixation greatly facilitates both exposure andreduction of dislocated carpal bones. The constant distractingforce of the external fixator frees the surgeon intraoperativelyfrom the continuous struggle to move the distal carpal “out ofthe way”, allowing him to concentrate his efforts on the properrealignment, internal fixation, and bone grafting of thedislocated or fractured bones. The frame should be used duringthe operation as a distraction device, to allow indirect reduction,but after completion of bone and ligament reconstructiondistraction should be reduced allowing the fixator to functiononly as a neutralization frame. Thus normal carpal alignment ismaintained protecting the ligament repair especially at thescapholunate junction during the first 8±10 weeks. Furthermore,the use of a fixator has the advantage over conventionaltechniques, because it permits unrestricted, cast-free early activeforearm rotation and elbow motion in cases in which the carpaldislocations are associated with ipsilateral forearm or elbowfractures.CONCLUSIONSIn conclusion, this review is presented to increase theawareness of this complex problem; even today we are seeingwrist injuries which had been missed at initial presentation.This is most probably due to a lack of awareness of this problemamong the general orthopaedic surgeons.REFERENCES1. Cooney WP, Linscheid RL, Dobyns JH. Fractures and dislocationsof the wrist.In: Rockwood and Green’s Fractures in Adults, LippincottRaven Publishers, Philadelphia, 1996: pp 745-80.2. Gutierrez G. Office management of Scaphoid fractures. Phys SportsMed 1996; 24:60-70.3. Greene WB. Essentials of musculoskeletal care. 2nd ed. Rosemont,Illinois, American Academy of Orthopaedic Surgeons, 2001: pp252-54.4. Fisk GR: Carpal instability and the fractured scaphoid. Ann R. CollSurg Engl.46; 63-73, 19705. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations:Pathomechnaics and progressive perilunar instability. J Hand SurgPb Journal of Orthopaedics Vol-XI, No.1, 200930

Fractures and dislocations of the carpal bones – a review[Am] 1980; 5: 226-41.6. O’Brien ET. Acute fracture and dislocations of the carpus. OrthopClin N Am 1984; 15:237-58.7. Stein F, Siegel MW. Naviculocapitate fracture syndrome: a casereport and new thoughts on the mechanism of injury. J Bone JointSurg 1969; 51-A:391.8. Cordrey LJ, Ferrer-Torrels M: Management of fractures of thegreater multangular. J Bone Joint Surg 1960; 42-A, 1111-18.9. Vasilas A, Gireco RV, Bartone NF. Roentgen aspects of injuries tothe pisiform bone. J Bone Joint Surg. 42-A; 1317, 196010. Gilula LA. Carpal injuries: Analytic approach and case exercises.Am J Roentgenol 1979; 133:503-17.11. Panagis JS, Gelberman RH, Taleisnik J, Baumgaertner M. The arterialanatomy of the human carpus. Part II: The intraosseous vascularity.J Hand Surg [Am] 1983; 8:375-82.12. Freeland P. Scaphoid tubercle tenderness: a better indicator ofscaphoid fractures? Arch Emerg Med 1989; 6:46-50.13. Gutierrez G. Office management of Scaphoid fractures. Phys SportsMed 1996; 24:60-70.14. Tiel-van Buul MM, Broekhuizen TH, Van Beek EJ, Bossuyt PM.Choosing a strategy for the diagnostic management of suspectedscaphoid fracture: a cost-effectiveness analysis. J Nucl Med 1995;36:45-48.15. Herbert TJ. The fractured scaphoid. Quality Medical Publishing, St.Louis, 1990: pp 57.16. Rettig ME, Raskin KB. Retrograde compression screw fixation ofacute proximal pole scaphoid fractures. J Hand Surg [Am] 1999;24:1206-1210.17. Panting AL, Lamb OW, Noble J et al. Dislocations of the lunatewith or without fractures of the scaphoid. J Bone Joint Surg 1984;66-B:391-95.18. Worland RL, Dick HM. Transnavicular perilunate dislocations. JTrauma 1975; 15;407-12.19. Monheim MS, Hofmann KE, Omer GE. Transscaphoid perilunatefracture dislocation. Results of open reduction and internal fixation.Clin Orthop 1984; 190: 227.20. Green DP, O’Brien ET. Classification and Management of carpaldislocations. Clin Orthop 1980; 149:55-72.21. Fernandez DL, Jakob RP, Buchler U. External fixation of the wrist.Current indications and technique. Ann Chir Gyn 1983; 72:298-302.22. Fernandez DL, Ghillani R. External fixation of complex carpaldislocations: a preliminary report. J Hand Surg [Am] 1984; 12:335-47.23. Jakob RP, Fernandez DL. The treatment of wrist fractures with thesmall AO external fixation device. In: Uhthoff HK, ed. Currentconcepts of external fixation of fractures, Spriner Verlag, Berlin,1982; pp 307-14.24. Cooney WP, Bussey U, Dobyns JH, Linscheid RL. Difficult wristfractures: Perilunate fracture dislocations of the wrist. Clin Orthop1987; 214:136-47.Pb Journal of Orthopaedics Vol-XI, No.1, 200931