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

Abstract

Bilateral trans-scaphoid perilunate fracture-dislocations (PLFD) with complete lunate enucleation (Mayfield IV-equivalent) represent a terminal stage of carpal instability. While anatomical reconstruction is traditionally favored in young patients, its success depends on intensive, long-term specialized hand therapy. We report a unique case where primary salvage was selected to ensure functional autonomy despite intraoperative findings of irreparability and systemic barriers to rehabilitation. A 22-year-old right-handed male smoker presented with bilateral trans-scaphoid PLFD following a 4-story fall. Intraoperative assessment revealed irreparable, devitalized lunates with 360° ligamentous disconnection and eroded cartilage. Given the lesion severity and documented barriers to accessing specialized physical therapy, bilateral emergency proximal row carpectomy (PRC) was performed 24 hours after trauma. At the 6-month follow-up, the patient was pain-free (VAS 1/10). The right wrist achieved 50° flexion/30° extension (80° arc), while the left achieved 40° flexion/10° extension (50° arc). The QuickDASH score of 25 points reflects moderate disability, influenced by the patient’s prioritization of his dominant side during autonomous rehabilitation. Early radiographic evaluation confirmed stable alignment. Emergency bilateral PRC is a pragmatic solution for severe carpal instability when anatomical repair is unattainable or when external constraints preclude standard reconstruction protocols. Long-term surveillance remains mandatory.