Acute carpal tunnel syndrome secondary to chronic trans-scaphoid perilunate fracture dislocation. Case report

Abstract

Introduction: Perilunate injuries are rare, and their severity and frequent underdiagnosis favor the onset of complications such as carpal tunnel syndrome (CTS) or compartment syndrome (CS).

Case presentation: A 53-year-old male was admitted to the emergency department of a secondary care hospital in a rural area of Antioquia (Colombia) due to a crush injury (600 kg) to his right hand. Since bone and joint injuries were ruled out during the initial assessment by means of an X-ray of the hand, he was discharged without being immobilized and with instructions to take pain medication and attend a follow-up appointment with the general medicine service. During the follow-up appointment, two weeks after the accident, the patient reported persistent pain and paresthesia in the first three fingers. In addition, a decrease in the range of motion of the wrist was observed, so a CT scan was requested and the patient was referred to the hand surgery unit, where he was evaluated two weeks later. On physical examination, a positive Tinel's sign was reported, with no findings suggestive of CS, resulting in a diagnosis of CTS. After reviewing previous imaging tests, a dorsal trans-scaphoid perilunate fracture dislocation was identified. Six weeks after the injury, open reduction with internal fixation, reconstruction of the dorsal trans-scaphoid perilunate and dorsal intercarpal ligaments, and carpal tunnel release were performed. Four weeks later, the percutaneous fixation was removed. At the 16-week postoperative follow-up, the patient reported complete resolution of pain and neuropathic symptoms and adequate reintegration to his work activities; there was also complete mobility of the fingers and wrist.

Conclusion: Trans-scaphoid perilunate fracture dislocations are rare injuries that should be suspected after sustaining a high-energy trauma to the carpus, as timely diagnosis and treatment are essential to avoid severe complications such as CTS. Since surgery with open reduction and internal fixation, ligament reconstruction, and carpal tunnel release showed good outcomes in our case, it could be considered a treatment option for patients with chronic trans-scaphoid perilunate fracture dislocations with associated CTS.