Emergency bilateral proximal row carpectomy for Mayfield stage IV greater arc injuries: a case report in a restricted social environment

INTRODUCTION

Perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD) are severe injuries resulting from high-energy mechanisms.^1,2 Mayfield described a progression of perilunar instability (Stages I-IV) involving the purely ligamentous "lesser arc." By analogy, Stage IV-equivalent displacement in "greater arc" injuries involves lunate enucleation into the carpal tunnel.^1,3

Standard acute management typically involves open reduction and internal fixation (ORIF).^2-4 However, 50% to 100% of patients develop osteoarthritis regardless of treatment.⁴ Alternatives include arthroscopy-assisted reduction, four-corner fusion, or partial wrist arthrodesis.^4,5 PRC, initially a salvage procedure, is increasingly proposed as a first-line treatment for irreparable trauma due to its simplicity and shorter recovery.^1,4,6

This case has been reported in accordance with the updated SCARE 2025 criteria.⁷

CASE REPORT

A 22-year-old right-handed male presented after a high-energy 4^th-story fall. Initial imaging confirmed bilateral trans-scaphoid PLFD with complete volar lunate enucleation (Figure 1 and 2) (characterized as Mayfield IV-equivalent) and a scaphoid fragment displaced proximally on the left (Figure 2 A-C). A concomitant subarachnoid hemorrhage was identified and stabilized medically. Neurovascular examination was normal, specifically showing no clinical signs of acute median nerve compression despite the carpal tunnel displacement.

The patient actively participated in the decision-making process. Given his imminent incarceration, which presented a documented barrier to accessing specialized postoperative physical therapy, and intraoperative findings of irreparable, devitalized lunates (showing 360° ligamentous disconnection and total cartilage erosion), a salvage procedure was selected.

Surgery was performed 24 hours after injury by a professor at a tertiary university hospital once neurological stability was achieved. The patient was in a supine position under general anesthesia, with both limbs prepared and operated on simultaneously. No pneumatic tourniquet was utilized. Through a 4 cm dorsal longitudinal incision, a ligament-sparing capsulotomy (Berger type) was performed. The scaphoid fragments, enucleated lunate, and triquetrum were excised (Figure 1 D and 2 D) while meticulously preserving the radioscaphocapitate (RSC) ligament to maintain stability, no temporary K-wire fixation was used, allowing for early mobilization. Operative times were 25 minutes for the right wrist and 37 minutes for the left.

Postoperatively, wrists were immobilized in volar splints for 10 days.

To address the limited access to postope physical therapy" in a custodial environment., the patient’s hospital stay was intentionally extended to 2 weeks, to provide supervised training in an autonomous rehabilitation protocol, ensuring he mastered passive, active, and isometric exercises before his transfer.

At 6-month follow-up, patient expressed satisfaction with the surgical outcome, specifically the relief of his initial debilitating pain. He stated that he is now able to perform the majority of his activities of daily living autonomously, which was his primary goal.

The QuickDASH score was 25 points, which reflects a moderate disability (population norm being approximately 10). The functional arc of motion was reported separately for each side: the dominant right wrist achieved an 80° arc (50° flexion/30° extension), whereas left wrist achieved a 50° arc (40° flexion/10° extension). Bilateral radiographs showed well-centered and congruent capitate within the radial lunate fossa on both sides without evidence of ulnar translocation (Figure 3 A-C).

DISCUSSION

The complexity of this case comes from an unusual combination of medical and environmental factors: the high-energy bilateral nature of the trauma, the complete volar enucleation of both lunates, the proximal displacement of the scaphoid on the left side, and the systemic restriction to postoperative therapy.

While the Mayfield classification was designed for ligamentous "lesser arc" injuries, we apply the framework here by analogy to describe the terminal stage of carpal instability (Stage IV-equivalent) resulting from a high-energy trans-scaphoid mechanism.

Anatomical reconstruction (ORIF) is the traditional gold standard for young patients to preserve carpal height, but its success is inherently dependent on the viability of the carpal bones and strict adherence to a multi-stage rehabilitation protocol.^2,8 In this case, the decision to proceed with bilateral irreversible salvage was primarily dictated by the anatomical irreparability of the injuries. Intraoperative findings, specifically 360° ligamentous disconnection, eroded cartilage, and devitalized lunates, validated the preoperative choice, confirming that the proximal row was not reconstructable.

The team also considered other published alternatives, such as arthroscopy- and fluoroscopy-assisted percutaneous reduction and fixation, which has shown promising functional results in acute perilunate injuries.⁴ However, the severity of bone displacement and soft-tissue disruption in this case made percutaneous options unfeasible. Four-corner fusion (4CA) is another motion-sparing alternative, particularly when midcarpal arthritis is present.^6,9,10 While Wagner et al and others note that 4CA may provide superior grip strength (65% of the opposite side compared to 54% for PRC), it also carries a higher complication rate (30% vs 11%), including risks of nonunion (12%) and hardware irritation.^8,11 Total wrist arthrodesis reliably eliminates pain but at the cost of complete motion sacrifice, often making it a secondary salvage for failed primary procedures.^6,12,13 Lunate excision, once used historically for pure dislocations, is now rarely indicated as a primary solution due to the risk of subsequent carpal collapse.³

The efficacy of acute PRC for irreparable trauma is well-supported. Della Santa et al. found that patients treated in the emergency phase achieved significantly higher satisfaction and grip strength compared to those undergoing elective salvage for chronic conditions.^3,13,14 Furthermore, Muller et al and Smeraglia et al demonstrated that acute PRC yields results comparable to ORIF while offering significantly shorter operative times and reduced immobilization.^2,4

We report the bilateral outcomes separately to maintain transparency regarding recovery; at 6 months, the 80° total arc achieved on the right side meets high-performance thresholds, whereas the left wrist was more restricted at 50°.¹⁵ This 37% difference and the limited 10° extension on the left likely stem from the patient’s honest prioritization of his dominant hand during self-rehabilitation.

This early report has limitations, including the 6-month follow-up and the lack of grip strength values due to the absence of a dynamometer. Although early results show excellent analgesia, radiocapitate degeneration typically manifests between 5 and 20 years postoperatively.^5,16 While studies by Wall et al and Bijon et al suggest that functional scores often stabilize despite these radiographic changes, the risk of failure remains higher in younger patients.^5,16 Vigilance is also required for rare complications such as atraumatic volar carpus dislocation. Consequently, this patient requires mandatory long-term radiocapitate surveillance to monitor for progressive arthritis, which remains the primary concern for any young individual undergoing this irreversible salvage procedure

CONCLUSION

This report indicates that emergency bilateral PRC can provide a satisfactory early outcome for patients with irreparable carpal disruptions, particularly in limited access to postoperative physical therapy. Given the patient's young age and the known risk of progressive degenerative changes in the neo-radiocapitate joint, mandatory long-term radiocapitate surveillance is essential to monitor for symptomatic arthritis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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