FRACTURE-DISLOCATION OF THE

LUNOTRIQUETRAL COALITION
Cato T. Laurencin, MD, PhD, Robert S. Cummings, MD, Timothy R. Jones, and Linda Martin, MD, MPH
Philadelphia, Pennsylvania

Bony fusions involving the carpus have a much higher prevalence in blacks relative to
whites. This article describes a case of lunotriquetral coalition fracture-dislocation in an
African American. This lesion is best treated through open reduction and pin fixation. (J Nail
Med Assoc. 1 998;90:779-78 1.)

Key words: carpal coalition
* wrist fracture-dislocation * wrist pain
Carpal coalitions are rare, asymptomatic entities
that most often present as incidental findings. The
most common coalition is of the lunotriquetral type,
which, in one study, represented 88.9% of all carpal
fusions, followed by the capitohamate coalition at
5.60/o.1
The vast majority of carpal fusions show no func-
tional deficit in range of motion; however, it has been
suggested that the absent intra-articular cartilage in
patients with incomplete carpal cavitation predispos-
es them to degenerative arthritic changes secondary
to poor stress loading tolerance or trauma.2
Cockshott3 reported that the prevalence of carpal
fusions in blacks may be as high as 100 times greater
than that of whites. Fractures through these coalitions
are extremely uncommon, and there are few reports
in the literature concerning these findings.
This article reports a case of a fracture-dislocation
of the lunotriquetral coalition and its successful treat-
From the Department of Orthopaedic Surgery, MCP-Hahnemann
School of Medicine, and the Department of Chemical Engineering,
Drexel University, Philadelphia, Pennsylvania. Requests for reprints
should be addressed to Dr Cato T. Laurencin, Dept of Chemical
Engineering, Drexel University, Philadelphia, PA 19104.
ment with open reduction, pinning, and the applica-
tion of a thumb spica cast.
CASE REPORT
A 37-year-old, right-hand dominant African-
American man sustained a closed-head injury in a
motor vehicle accident in which he was the driver.
He was not wearing a seatbelt. The initial physical
examination failed to detect any extremity injury,
and it was not until 2 weeks after the accident that the
patient began to complain of left wrist pain. He also
complained of decreased sensation in the median
nerve distribution of the left hand.
An examination at that time demonstrated mild
swelling on the volar aspect of the wrist, with point
tenderness over the lunate. The lunate was palpable
and prominent, and motor function was intact.
Preoperative radiographs revealed a lunate disloca-
tion in the volar direction with no evidence of frac-
ture (Figure 1).
The patient underwent open reduction of the
lunate dislocation through a volar approach with
carpal tunnel release. Following reduction, fluoro-
scopic radiograph revealed a reduction of the lunate
dislocation and reduction of a fracture through a pre-
viously undiscovered lunotriquetral coalition. Two
K-wires were placed through the scaphoid and
through the lunotriquetral coalition for fixation. A

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 12 779

CASE REPORT

~~.:.
taio of th atlaioshndu rcrsrdrn

Figure 1. Figure 2.
Preoperative AP (top) and lateral (bottom) radiographs of Postoperative AP (top) and lateral (bottom) radiographs of
the left wrist. the left wrist.

third wire was placed from the radius into the lunate
and hamate for further stabilization.
Postoperatively, the patient's left upper extremity
was placed in a short-arm thumb spica cast with the
wrist in neutral position (Figure 2). Eight weeks after
surgery, the splint and wire pins were removed, and
a physical therapy program was initiated. By 12
weeks postoperatively, the patient had regained full
motion at his left wristRadiographs at that time
demonstrated complete healing of the lunotriquetral
coalition (Figure 3).
DISCUSSION
While often described as carpal fusion, carpal
coalition more accurately represents a failure of cavi-

780 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 12


- ~ ~~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~
l~~~~~~~~~~~~~~~~~~~~~ l
Figure 3.
Postoperative AP (top) and lateral rcldiographs (bottom) of
the left wrist taken at the 12-week follow-up examination.
the fourth to eighth week of intrauterine life.4 The
spectrum of symptoms a patient may present with
can be attributed to the chronological stage at which
the osseous differentiation arrested. Complete fusion
of the affected carpal bones provides for no relative
motion between the structures and hence no pain.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 90, NO. 12
CASE REPORT
However, deficient cartilage formation between
incompletely separated carpal bones may result in
symptoms analogous to that of degenerative arthritis.2
Case reports of fractured carpal coalitions are
uncommon and have been described for lunotrique-
.:+.. coalitions.3'5'6 Only one
tral and trapezoid-capital
report appears in the literature describing the occur-
rence and treatment of lunate dislocation in the set-
ting of lunotriquetral coalition.7
Mechanistically, lunate dislocation can be
described using the staging of Mayfield et a18 who
reproduced perilunate dislocation in the laboratory
by forcing cadaver wrists into extension and apply-
ing a load to the thenar eminence. The sequence of
disruption that ensued was described in stages (I-IV)
of progressive perilunar instability. For dislocation
of the lunate to occur in the aforementioned case
report, fracture through a lunotriquetral coalition
would be predicted by their model.89 Treatment of
a fracture through a lunotriquetral coalition, in asso-
ciation with a lunate dislocation, includes open
reduction and wire pin fixation to correct the patho-
mechanics of the injury.
Literature Cited
1. Delaney TJ, Eswar S. Carpal coalitions. JHand Surg Am.
1992;17:28-31.
2. Gross SC, Watson HK, Strickland JW, Palmer AK,
Brenner LH. Triquetral-lunate arthritis secondary to synostosis.J
Hand Surg Am. 1989;14:95-102.
3. Cockshott WP. Carpal fusions. Am J Roentgenol.
1963;89: 1260-1271.
4. Moore KL. The Developing Human. 4th ed. Philadelphia,
Pa: WB Saunders Co; 1988:355-357.
5. Peyton RS, Moore RJ. Fracture through a congenital
carpal coalition.JHand Surg Am. 1994;19:369-371.
6. McGoey PF. Fracture-dislocation of a fused triangular
and lunate (congenital).JBoneJoint Surg. 1943;25:928-929.
7. Auerbach DM, Collins ED. An unusual fracture disloca-
tion pattern in a patient with an os lunatotriquetrum. AmJ Orthop.
1995;24:714-6.
8. MayfieldJK,Johnson RP, Kilcoyne RK. Carpal disloca-
tions: pathomechanics and progressive perilunar instability. J
Hand Surg Am. 1980;5:226-241.
9. Kozin SH. Perilunate injuries: diagnosis and treatment. J
Am Acad Orthop Surg. 1998;6:114-120.
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