Current concepts review: carpal injuries - fractures, ligaments, dislocations.

An overview about current concepts in treating carpal injuries is presented. These injuries are more commonly seen in young, active individuals after a fall on an outstretched hand. Conventional radiographs and a thorough examination are important. The scaphoid is the most affected bone. Scaphoid fractures can be classified in accordance to OTA, AO, and other classification systems, but mostly to Herbert. It can be treated non-operatively if undisplaced, however a percutaneous internal fixation can be discussed to achieve earlier return to work and shorter time to union, but hazarding the consequences of an operation. Unstable, proximal pole, or delayed diagnosed scaphoid fractures should be treated surgically. Nonunion is seen in 5 - 40% of scaphoid fractures depending mainly on displacement and localization of the fracture. The gold standard in non-osteoarthritic scaphoid nonunion is debridement of the nonunion site, bone grafting, realignment, stable fixation and rehabilitation. The treatment of scaphoid-nonunion advanced collapse is more complex. Proximal row carpectomy or arthrodesis (four-corner or complete wrist) can be mandatory. Other carpal bone fractures are rare. Perilunate dislocations are also uncommon but can be disabling. They usually originate in high-energy trauma. The Mayfield stages help to understand the injury pattern. Open reduction through both volar and dorsal approaches, repair of the volar capsule as well as volar and dorsal ligaments, and internal fixation is commonly the standard treatment. However osteoarthritis and carpal instability are often encountered.