Bellot F, Tran Van F, Leroy N, Blejwas D, Mertl P
Service d'Orthopédie-Traumatologie, CHU Nord, place Victor-Pauchet, 80054 Amiens Cedex 1.
Rev Chir Orthop Reparatrice Appar Mot. 2003 Jun;89(4):320-32.
We report our experience with 25 peri-lunate posterior wrist dislocations and compare outcome with data in the literature searching for prognostic factors.
Our series included 24 men and one woman, mean age 36 years. Twenty-three patient were less than 50 years old at the time of the accident. Diagnosis was established late in five patients. All patients were reviewed clinically and radiologically with a mean follow-up of 57 months. We differentiated pure dislocations (n=16) from trans-scapho-lunate dislocations (n=9). The pure dislocations included six type 1 and ten type 2 in the Witvoët and Allieu classification. We also distinguished groups by open or closed treatment, with or without pinning, and with or without suture of the scapho-lunate ligament. Screw fixation was used in case of scaphoid fracture. Post-operative cast immobilization was 45 days on the average, followed by three months of rehabilitation exercises.
Residual pain of variable intensity was reported by 22 patients but subjectively, 21 patients considered outcome to be good or very good. Wrist movement was greatly impaired in eight patient with a 60 degrees flexion-extension arc. All patients had a 20% reduction in force compared with the healthy side. According to the Green and O'Brian functional score, outcome was poor in four wrists. The scapholunate space and the sapholunate angles were abnormal in seven wrists. Reduction was insufficient in only one case with the scapholunate space measuring 5 mm after trans-scapho-lunate dislocation. In most of the cases, these poor functional and/or radiographic results coincided with carpal instability which developed early or late after trauma. The most bothersome element in other cases was wrist stiffness. The trans-scapho-lunate dislocations appeared to evolve more favorably than the pure dislocations, but could also cause carpal instability.
There is a real functional impairment after posterior peri-lunate dislocation. The differences in outcome we observed were not statistically correlated with type of treatment, probably because of the small number of patients, but did reveal certain tendencies. Closed reduction did not always avoid the development of carpal instability and gave only average results. Percutaneous pinning or open reduction did not improve outcome in pure dislocations. It might be good to use scapho-lunate suture more often to obtain better healing and reduce the risk of carpal instability, as has been suggested by certain teams.
我们报告了25例月骨周围腕关节后脱位的治疗经验，并将结果与文献数据进行比较以寻找预后因素。
我们的病例系列包括24名男性和1名女性，平均年龄36岁。23例患者在事故发生时年龄小于50岁。5例患者诊断较晚。所有患者均接受了临床和影像学检查，平均随访57个月。我们将单纯脱位（n = 16）与经舟月骨脱位（n = 9）区分开来。单纯脱位在Witvoët和Allieu分类中包括6例1型和10例2型。我们还根据开放或闭合治疗、有无克氏针固定以及有无舟月韧带缝合来区分组别。舟骨骨折时采用螺钉固定。术后平均石膏固定45天，随后进行三个月的康复锻炼。
22例患者报告有不同程度的残留疼痛，但主观上，21例患者认为结果良好或非常好。8例患者腕关节活动严重受限，屈伸弧为60度。所有患者与健侧相比力量均下降20%。根据Green和O'Brian功能评分，4例腕关节结果较差。7例腕关节的舟月间隙和舟月角异常。仅1例经舟月骨脱位后舟月间隙为5mm，复位不充分。在大多数情况下，这些功能和/或影像学结果不佳与创伤后早期或晚期出现的腕关节不稳定同时存在。在其他情况下，最困扰的因素是腕关节僵硬。经舟月骨脱位似乎比单纯脱位的预后更好，但也可能导致腕关节不稳定。
月骨周围后脱位后存在明显的功能损害。我们观察到的结果差异与治疗方式无统计学相关性，可能是因为患者数量较少，但确实显示出某些趋势。闭合复位并不总是能避免腕关节不稳定的发生，结果仅为中等。经皮克氏针固定或切开复位在单纯脱位中并未改善结果。如某些研究团队所建议的，更频繁地使用舟月韧带缝合可能有助于获得更好的愈合并降低腕关节不稳定的风险。
