As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. (OBQ16.228) Like the scaphoid bone, the lunate also has a tenuous retrograde blood supply off of an interosseus arterial branch, and it has the same inherent risk of poor healing and AVN . On physical exam she has no sensation of the volar thumb, index, and middle fingers. Copyright 2023 Lineage Medical, Inc. All rights reserved. He is not able to see a physician for 4 months. Perilunate fracture-dislocations of the wrist. Proper . Find a hand surgeon near you. She complains of wrist pain and deformity. Which plating option provides the most appropriate treatment of this fracture? If you are unsure, it is best to err on the safe side and call for help. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? arthroscopic repair and percutaneous pinning. - it differs from Colles' or Smith's Fracture in that the dislocation is the most striking radiographic finding; - volar Barton's is more common than dorsal Barton frxs; - mechanism: - usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; Deciding whether a fracture needs reducing. ADVERTISEMENT: Supporters see fewer/no ads. A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. The lunate is one of the eight small bones in the wrist. (2017) Journal of Hand Surgery (European Volume). Lunate fracture. Overall, carpal dislocations comprise less than 10% of all wrist injuries. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. Orthopaedic Specialists of North Carolina. - lunate articulates proximally w/ radius and distally w/ capitate; Lunate fractures are relatively uncommon, representing about 4 percent of all carpal bone injuries [ 1-4 ]. Carpal tunnel release if no resolution at 6-12 weeks. Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Radiographs are shown in Figures A and B. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Upper extremity deep vein thrombosis (DVT), Lower extremity deep vein thrombosis (DVT). A 17-year-old male falls from a retaining wall onto his left arm. Treatment involves observation, NSAIDs and splinting in early stages of disease. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient? What complication is most likely to occur in this patient? (OBQ18.177) Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Ulnar side of hand. A recent imaging study is seen in Figure A. A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. Electromyography and nerve conduction velocity studies, AP and lateral radiographs of the forearm, (SAE07SM.78) Radiographic features You can rate this topic again in 12 months. - most frequently dislocated carpal bone; These should not be confused with perilunate dislocations in which the radiolunate articulation is . Immediate post-operative radiographs are seen in Figure A. Both images from . In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Fracture Non-Spanning External Fixator, Distal Radius Fracture Spanning External Fixator, Type in at least one full word to see suggestions list, 7th Annual Frontiers in Upper Extremity Surgery, Nonoperative Treatment of Distal Radius Fractures - Michael Bednar, MD, Dorsal Plating of Radius Fractures - Nader Paksima, DO, MPH, Fragment Specific Fixation Distal Radius Fractures - Mark Rekant, MD, 12th Annual Orthopaedic Trauma: Pushing The Envelope. (OBQ06.136) scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this articulation, lunate extended > 10 degrees past neutral, resultant scaphoid flexion and lunate extension creates, abnormal distribution of forces across midcarpal and radiocarpal joints, malalignment of concentric joint surfaces, describes predictable progression of degenerative changes from the radial styloid to the entire scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on the lunate, key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal radius, Arthritis between scaphoid and radial styloid, Arthritis between scaphoid and entire scaphoid facet of the radius, While original Watson classification describes preservation of radiolunate joint in all stages of SLAC wrist, subsequent description by other surgeons of "stage IV" pancarpal arthritis observed in rare cases where radiolunate joint is affected, validity of "stage IV" changes in SLAC wrist remains controversial and presence pancarpal arthritis should alert the clinician of a different etiology of wrist arthritis, patients localize pain in region of scapholunate interval, tenderness directly over scapholunate ligament dorsally, will not be positive in more advanced cases as arthritic changes stabilize the scaphoid, with firm pressure over the palmar tuberosity of the scaphoid, wrist is moved from ulnar to radial deviation, positive test seen in patients with scapholunate ligament injury or patients with ligamentous laxity, where the scaphoid is no longer constrained proximally and subluxates out of the scaphoid fossa resulting in pain, when pressure removed from the scaphoid, the scaphoid relocates back into the scaphoid fossa, and typical snapping or clicking occurs, obtain standard PA and lateral radiographs, PA radiograph will reveal greater than 3mm diastasis between the scaphoid and lunate, PA radiograph shows sclerosis and joint space narrowing between scaphoid and the entire scaphoid fossa of distal radius, PA radiograph shows sclerosis and joint space narrowing between the lunate and capitate, and the capitate will eventually migrate proximally into the space created by the scapholunate dissociation, thinning of articular surfaces of the proximal scaphoid, scaphoid facet of distal radius and capitatolunate joint with synovitis in radiocarpal and midcarpal joints, NSAIDs, wrist splinting, and possible corticosteroid injections, prevents impingement between proximal scaphoid and radial styloid, may be performed open or arthroscopically via 1,2 portal for instrumentation, since posterior and anterior interosseous nerve only provide proprioception and sensation to wrist capsule at their most distal branches, they can be safely dennervated to provide pain relief, can be used in combination with below procedures for Stage II or III, contraindicated with caputolunate arthritis (Stage III SLAC) because capitate articulates with lunate fossa of the distal radius, contraindicated if there is an incompetent radioscaphocapitate ligament, excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while preserving, provides relative preservation of strength and motion, also provides relative preservation of strength and motion, wrist motion occurs through the preserved articulation between lunate and distal radius (lunate fossa), similar long term clinical results between scaphoid excision/ four corner fusion and proximal row carpectomy, wrist fusion gives best pain relief and good grip strength at the cost of wrist motion, - Scaphoid Lunate Advanced Collapse (SLAC), Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). 14% (259/1911) 2. Wrist Dislocation by Kadeer M Halimi from emedicine.com. Capitate fractures account for 1-2% of all carpal fractures 1,2. He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. Which of the regions on the patient's injury AP radiograph in Figure A, if not addressed properly during surgery, represents a risk for radiocarpal instability? Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. push up position), may be associated with wrist instability or weakness, may see swelling over the dorsal aspect of the wrist, tenderness in the anatomical snuffbox or over the, pain increased with extreme wrist extension and radial deviation, when deviating from ulnar to radial, pressure over volar aspect of scaphoid subluxates the scaphoid dorsally out of the scaphoid fossa of the distal radius, and a clunk is palpated when pressure is released as the scaphoid reduces back over the dorsal rim of the radius, a painful clunk during this maneuver may indicate insufficiency of scapholunate ligament, clenched fist (can exaggerate the diastasis), dorsal tilt of lunate leads to SL angle > 70, may be used as screening tool for arthroscopy, always assess the contralateral wrist for comparison, may demonstrate the presence of a tear but cannot determine the size of the tear, positive finding of a tear may indicate the need for wrist arthroscopy, often overused as a screening modality for SLIL tears, requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis, Carpal instability nondissociative (CIND), splinting and close follow-up with repeat imaging and clinical response with acute injuries, most people feel casting alone is insufficient, acute scapholunate ligament injury without carpal malalignment, ligament pathoanatomy is ammenable to repair, if pathoanatomy of SL ligament injury is a scaphoid fx than repair with, small incision is made just distal to the radial styloid, care to avoid cutting the radial sensory nerve branches, often added to a ligament repair and remains a viable alternative for a chronic instability when ligament repair is not feasible, place two k-wires in parallel into the scaphoid bone, reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation, confirm reduction of the SL joint under fluoroscopy, FCR tendon transfer (direct SL joint reduction), ECRB tendonosis (indirect SL joint reduction), weave not recommended due to high incidence of late failure.

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