Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture
Jorge Jimenez Lopez1, Anastasia Boptsi1, Konstantinos Kalousis1
- 1Universitätsklinikum Schleswig-Holstein Lübeck
Abstract
Keywords: Hand surgery; wrist; carpectomy; scaphoid; lunate dislocation Authors: Jorge Jimenez Lopez, MD; Anastasia Boptsi, MD; Konstantinos Kalousis, MD Institution: Universitätsklinikum Schleswig-Holstein Lübeck Abstract Carpal dislocation fractures are uncommon injuries, most frequently associated with high-energy trauma. Combined carpal dislocations without associated bone fractures are even rarer. Delayed treatment can have serious consequences. The case presented here involves an 86-year-old man with dislocation of the scaphoid and lunate bones, as well as acute carpal tunnel syndrome resulting from the injury. PRC is mostly a salvage operation but given the severity of ligamentous disruption, the need to restore the patient's mobility and also the fact, that scaphoid was irreducible, a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). Patient medical history The 86-year-old patient crashed the car into the wall of his garage at a speed of 30 km/h. As a result, the patient presented a dislocation of the lunate bone and the scaphoid. The patient lived alone and was completely independent. Regarding other conditions, he suffered from arterial hypertension and prostate cancer. Before and After Patient examination There was a visible deformity at the right wrist with bruising, and swelling. Additionally, a positive Hoffman-Tinel sign was observed with paresthesia in the median nerve area. A radiological examination of the hand was then performed, which revealed a dislocation of the scaphoid and lunate bones. No bone fractures were detected. Pre-operative considerations Given the severity of ligamentous disruption and the need to restore the patient’s mobility a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). 1 Surgical Dorsal Exposure The surgical procedure involved exposing and splitting the 4th and 3rd extensor tendon compartments to facilitate access. The extensor pollicis longus (EPL) tend
BeforeAfterThe 86-year-old patient crashed the car into the wall of his garage at a speed of 30 km/h. As a result, the patient presented a dislocation of the lunate bone and the scaphoid. The patient lived alone and was completely independent. Regarding other conditions, he suffered from arterial hypertension and prostate cancer.
The surgical procedure involved exposing and splitting the 4th and 3rd extensor tendon compartments to facilitate access. The extensor pollicis longus (EPL) tendon was transposed subcutaneously, and the extensor tendons were luxated out of the 4th extensor tendon compartment. The posterior interosseous nerve was identified and divided. Additionally, the dorsal joint capsule was found to be torn, and the scaphoid and lunate bones were luxated ventrally, with the lunate bone rotated 90°
A skin incision was made along the Linea vitalis, extending proximally to the distal forearm. The palmar aponeurosis, flexor brevis muscle (which was coagulated), and the flexor retinaculum were divided. The median nerve was exposed and underwent neurolysis, and the palmar branch of the median nerve was also identified and neurolyzed. Both the median nerve and the flexor tendons were retracted to the side. The palmar joint capsule was found to be torn. The scaphoid and lunate bones were displaced into the carpal tunnel. A carpal tunnel release was performed. The lunate and scaphoid bones were only secured by the ventral ligaments. The remaining ligaments, including the SL and LT ligaments, were torn. The lunate and scaphoid bones were then resected from the palmar side.
2
Further steps were performed dorsally, including the resection of the triquetral bone. The second row of carpal bones was then moved proximally, forming a new joint between the capitate bone and the lunate fossa. The joint was mobilized. An impingement was observed during radial abduction, so the tip of the styloid process of the radius was resected using an oscillating saw. The joint capsule was closed both palmar and dorsal using PDS 2.0 continuous sutures. The extensor retinaculum was closed using PDS 3.0 continuous sutures.
3
The postoperative result was controlled under X-ray, showing full range of motion of the wrist in all planes, with normal articulation of the capitate bone at the lunate fossa.
4
Immobilization in a splint for 6 weeks and physiotherapy performed without the splint.
How to cite this article
Jorge Jimenez Lopez, Anastasia Boptsi, Konstantinos Kalousis. Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
Open access. © 2025 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
Keep reading
Related cases
Case 16: Utilizing the reverse radial forearm flap for burn wound management of the hypothenar part of hand
David Salim, MD, Msc
Keywords: Reverse radial forearm flap, Burn wound management, Hand surgery Authors: David Salim, MD and Taiba Alrasheed, MD, FRCSC, Msc. Institution: Department of Plastic- & Breast Surgery , Zealand University Hospital Roskilde, Denmark Abstract A 55-year-old man had sought and was admitted to the emergency department one week after sustaining a superficial second degree burn wound on the hypothenar region of the right hand after accidentally placing it on a hot stove. At first sight, the burn wound seemed quite superficial and conservative healing and bandaging was initially deemed sufficient with the aim of spontaneous healing. One week after the initial assessment in the emergency department, the patient was seen for a routine clinical control of the wound. At this consultation, the patient scored 4/4 positive Kanavel’s signs and flexor tenosynovitis was suspected. Afterwards immediate wound revision of the right hypothenar was conducted. During wound revision, considerable amounts pus was noted and furthermore the musculus abductor digiti minimi was avital and excised. Suitable wound dressing was applied, pus was sent for culture and sensitivity testing and the patient was gives appropriate peroral antibiotics. After numerous wound revisions and debridement, control of the infection at the orthopedic surgery department was achieved. The patient was then referred to the plastic surgery department for planning of soft tissue coverage with a reverse radial forearm flap. Patient medical history The patient was known to have substantial unregulated diabetes mellitus type two, but no other known medical comorbidities. Before and After Patient examination The patient was seen in an outpatient setting in the plastic surgery department for planning of surgery. The defect was located to the whole hypothenar region of the right hand. Substantial soft tissue loss was noted and the 3-5th flexor tendons were exposed. Pre-operative considerations A reverse radial forearm
Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face
Dr. Guillermo Alvarez-Sanchez, Ignacio Lugo-Beltran
Keywords: Cheek reconstruction, face, cheek, forearm, free flap, Neurorrhaphy , radial forearm flap Authors: Dr. Guillermo Alvarez-Sanchez, MD ; Ignacio Lugo-Beltran, MD, Chief, Dr. Haro-Cruz Jorge Said, MD. Institution: Plastic and Reconstructive Surgery Division of Microsurgery, Hospital Angeles Metropolitano, Cuauhtémoc, Mexico. Abstract A 52 year old female who presents to the emergency room after receiving a dog bite in her right face, the defect is managed with a free radial forearm flap. Patient medical history 52 year old female, without past medical history, presented to the emergency room, referring she was attacked by her dog at her house, suffering a bite on her right cheek, with bleeding and loss of skin Before and After 1 Before photo - Arrival at the ER Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups. Patient examination Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups. Pre-operative considerations Given the circumstance of tissue loss, active bleeding and section of the nerve branches, also being a contaminated wound, we decided to go to the operating room immediately Due to tissue loss dimensions, we planned a radial free flap for tissue coverage 2 Debridement and assessing damages we cleansed, remodeled the irregular borders and clos
Case 14: Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction
Sophie Osenegg, Oliver Didzun, Amir K. Bigdeli, Chief
Keywords: Latissimus dorsi flap, sliding flap, thoracic wall reconstruction Authors: Sophie Osenegg, MD, Oliver Didzun, MD, Amir K. Bigdeli, MD, Chief. Institution: Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Klinikum Kassel, Teaching Hospital of Philipps University Marburg, Kassel, Germany Abstract A 78-year-old multimorbid patient with chronic osteomyelitis and a full-thickness soft tissue defect (12 × 6 × 5 cm) of the right flank required flap reconstruction following multiple debridements. Given the absence of nearby recipient vessels and perforators, an ipsilateral myocutaneous latissimus dorsi sliding flap was selected. The thoracodorsal pedicle was extended by 30 cm using autologous venous grafts to achieve cranial reach while preserving anterograde arterial flow. This case illustrates the rarely described use of a latissimus dorsi sliding flap in complex reconstructions, emphasizing vascular adaptation techniques. Patient medical history A 78-year-old male had undergone right-sided nephrectomy in 1970 for renal cell carcinoma. Following initially uneventful wound healing, a chronic wound developed at the nephrectomy site, which the patient managed conservatively over the subsequent decades. In September 2024, he presented with spontaneous purulent discharge from the right flank, attributable to chronic osteomyelitis of the adjacent ribs. In addition, intraperitoneal infection with Staphylococcus aureus was confirmed. Serial debridements were performed by the departments of general and thoracic surgery, including partial rib resections and an atypical laparotomy. These interventions resulted in a full-thickness soft tissue defect of the right flank, measuring 12 × 6 × 5 cm, with exposed ribs and peritoneum. The patient was subsequently referred to our department for reconstructive management under ongoing open wound therapy. At the time of presentation, his medical history included stage V chronic kidney disease with initiation of hemod