Timing and treatment options for carpal injuries and their outcomes. A systematic review. Implications Treatment delays of 7 to 45 days, outcomes are inferior to those in the acute setting Acute setting, CRIF seems to offer better outcomes than ORIF. Chronic (>45 days) lesser arc peri lunate injuries - worst results PLFD injuries - ORIF has superior results CRIF group for PLFD and PLD no evidence inferior to the ORIF group. CRIF without repair of the SL and LT did not show inferior results as compared with the ORIF studies which repaired the SL and LT ligaments Treatment of peri lunate injuries in a delayed (7–45 days) or chronic (> 45 days) ORIF or a salvage procedures like PRC or wrist arthrodesis.

2. • uncommon - 7% of carpal traumas
• Often missed misdiagnosed (1 in 4)
• Acute treatment - better outcomes ?
• Immediate reduction
• reduce the pressure - median nerve
• Carpal cartilage
• Surgical fixation ASAP
Background

3. Classification
Lesser arc - Ligamentous injury perilunate dislocation (PLD)
Greater arc injury - Dislocation with fractures- perilunate fracture
dislocation (PLFD).
Mayfield classification
Stage I: scapholunate dissociation; stage II: + lunocapitate
disruption; stage III: + lunotriquetral disruption, also
referred as perilunate; stage IV: lunate dislocation

4. Aim
(Perilunate injuries)
Which surgical treatment is
superior for perilunate injuries?
When is best time for treatment?
What are the outcomes for late
treatment ?
What is the consensus regarding
postoperative treatment, period of
immobilization and hand therapy

5. Selection criteria
Inclusion:
• had patients with either PLD or PLFD.
• any form of surgical intervention, irrespective of the time of
surgery from injury.
• had reported physician-rated clinical outcome scores (e.g.,
Mayo wrist score).
• sample size of more than five.
Exclusion
• No physician rated clinical scores
• contained authors opinions
• letters or literature reviews
• included patients < 18 years,
• non-English
• full text - not available

6. Methods
Literature
search
•April 23, 2020
Databases
•Embase, Medline,
Cochrane, Web of
Science, and
Google Scholar
The PICOS
framework
Search strategy
•(’wrist
dislocation’/de OR
(’lunate bone’/de
AND
(’dislocation’/de
OR ’fracture
dislocation’/de))
OR ((’wrist’/de OR
’wrist fracture’/de
OR ’lunate
PRISMA
guidelines
Selection Data Extraction Synthesis

7. • PLD or PLFD
Population
• Any surgical management for
injury
Intervention
• No comparator
Control
• Physician reported outcome
measure – Mayo wrist score
Outcome
• Clinical studies > 5
Study design

10. Results
365 patients (203 were acute, 55 were delayed, and 107 were chronic treatments)
• CRIF - Seventy patients (11 an arthroscopically assisted CRIF)
• ORIF - 261 and
• Other type of treatment - 23
Majority of cases concerned facture dislocations (PLFD).
The postoperative regiment varied greatly.
Most studies reported immobilization of at least 4 weeks

14. Implications
• Treatment delays of 7 to 45 days, outcomes are inferior to those in the
acute setting
• Acute setting, CRIF seems to offer better outcomes than ORIF.
• Chronic (>45 days) lesser arc peri lunate injuries - worst results
• PLFD injuries - ORIF has superior results
• CRIF group for PLFD and PLD no evidence inferior to the ORIF group.
• CRIF without repair of the SL and LT did not show inferior results as
compared with the ORIF studies which repaired the SL and LT ligaments
• Treatment of peri lunate injuries in a delayed (7–45 days) or chronic (> 45
days)
• ORIF or a salvage procedures like PRC or wrist arthrodesis.

15. Discussion
• PLFD’s, - greater arc injury pattern,
• SL and LT remain intact
• fracture fixation- stable vs PLD, - lesser arc injury pattern where the SL and LT
are injured
• PRC - acute phase, because of the shorter operation time and shorter
immobilization
• Earlier hand therapy does not seem to result in worse outcome

16. Limitations
• Observational, retrospective nature of the included studies
• Heterogenicity - Imbalance in injury severity
• Include only studies - physician-reported scores