Systematic review for treatment modalities and timing for wrist injuries

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