To The Editor:
We are writing with regard to the article "Radiocarpal
Dislocations: Classification and Proposal for Treatment. A Review
of Twenty-seven Cases" (83-A: 212-18, Feb. 2001), by Dumontier
et al. The authors retrospectively reviewed twenty-seven patients
with radiocarpal dislocations, which is the largest series reported
to date. They classified the series into two groups. Group 1 included
all patients with pure radiocarpal dislocations and patients with
only a fracture of the tip of the radial styloid process. Group
2 included patients with a radiocarpal dislocation and an associated
fracture of the radial styloid process that involved more than one-third of
the width of the scaphoid fossa.
The authors cited the series by Moneim et al., in which seven
patients with radiocarpal dislocations were reviewed1. Moneim et al. classified these injuries according
to the presence or absence of associated intercarpal instability
and found that three of the seven patients in their series had associated
intercarpal ligamentous disruption. Most importantly, the authors
noted a poor prognosis for those injuries with an associated intercarpal
dislocation1. Bilos et al. reported
on five patients with radiocarpal dislocations, four of whom were
found to have intercarpal ligamentous injuries2.
In our experience with these injuries, we reported that one of two
patients with radiocarpal dislocations also sustained intercarpal
ligamentous disruption, which again was associated with a poor outcome3.
In the series reported by Dumontier et al., only one of twenty-seven
patients was noted to have intercarpal ligamentous disruption. Did
any other patients in the series have an associated intercarpal
injury that was noted radiographically or intraoperatively? Do the authors
believe that intercarpal instability should be included in the classification
of radiocarpal dislocations and, if not, how do they account for
the findings of other authors?
A second concern is that the validity of the classification system
and treatment algorithm (based on the presence or absence of a radial
styloid fracture) presented by the authors is not substantiated
by their findings. The authors present a series of twenty-seven patients
treated over a time-period of twenty-three years. These patients
were treated with a variety of modalities: closed reduction and
cast immobilization in four patients, percutaneous Kirschner-wire
fixation and cast immobilization in five patients, external fixation
in two patients, and open reduction with Kirschner-wire fixation and
cast immobilization in eleven patients. Strikingly, details of treatment were
not known for five patients, which represents almost 20% of
the study group. The authors’ recommendations for surgical
treatment are not based on the results of treatment for their series but
merely on assumptions as to the probable site of osseous or ligamentous disruption.
We would agree that the presence of a large radial styloid fracture
appears to be an important factor to consider in the treatment of
these patients. We suggest that there are other important factors
to consider, including the direction of instability (dorsal vs. volar),
the presence of associated neurovascular injury (specifically, the median
nerve at the wrist), and the presence of associated intercarpal
ligamentous injuries.
C. Dumontier, G.M. zu Reckendorf, A. Sautet, E. Lenoble,
P. Saffar, and Y. Allieu reply:
We thank Dr. Bozentka and Dr. Beredjiklian for their interest
in our article concerning radiocarpal dislocations.
Regarding the associated intercarpal injuries, we were fortunate
to have only one patient with associated radiocarpal and intercarpal
injuries. Our main concern was to avoid imprecision in the article.
Many papers, especially those written in the 1960s and 1970s, fail
to define the exact nature of the lesions. In Dunn’s article,
at least two cases did not involve radiocarpal dislocations4. We believe that a posterior perilunate dislocation
with a radial styloid fracture is not a radiocarpal dislocation,
even if the radiographs of the two injuries may look similar.
We believe that radiocarpal dislocations and perilunate dislocations
are different injuries with different mechanisms. Perilunate dislocations
are thought to be produced by a hyperextension injury with ulnar
inclination. Radiocarpal dislocations seem to be produced by a rotation
injury. We do think that it is important not to mix these two different lesions
(which may be associated in high-energy trauma).
We disagree with Dr. Bozentka and Dr. Beredjiklian regarding
their second concern. Of course, there are many statistical concerns
in a series of twenty-seven patients who received various treatments
over a span of more than twenty years. We cannot answer which treatment
would be the best for anterior dislocations as all patients were
lost to follow-up. However, our classification system is the result
of a lengthy clinical experience. In 1992, we wrote a book chapter
in which we classified these lesions into three groups. As we gained experience,
we found that two of the three classifications more precisely corresponded
to the injuries seen. We have operated on the more recent patients and
each time have found a "Bankart-type" lesion with
all of the ligaments avulsed from the radius in the Group-1 patients.
In contrast, in the Group-2 patients, the ligaments were still attached
to the radial styloid fragment.
Follow-up showed, as in other cases reported in the literature,
that ulnar translation of the carpus was observed only in Group-1
patients and never in Group-2 patients. We do believe that the ligamentous
lesion is the most important element to consider when planning treatment.
Stabilization of the lesion is the primary goal of treatment of
every orthopaedic injury and should be the goal of the treatment
of radiocarpal dislocation. Group-1 patients should have their ligaments
sutured, and Group-2 patients should have their fractures fixed.
The techniques used may vary from patient to patient, but this principle
of differential treatment for the two groups remains. Nerve lesions,
the direction of instability, and/or intercarpal ligamentous
lesions are only additional problems that may require specific,
additional treatments.