Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Patients often prefer to hold their fingers in partial flexion due to pain on extension. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. (OBQ11.273) This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. Radiographs obtained at the time of injury are shown in Figure A. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. What is the most appropriate next step in management? He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. The latter mechanism frequently occurs . On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. What is the likely mechanism of her paresthesias and what is the most appropriate treatment? ORTHOBULLETS; Flashcards. Check for errors and try again. Clifford R. Wheeless, III, M.D. Patients present with wrist pain following a fall. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. (OBQ10.127) The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). Adhesions within the first and third dorsal wrist compartments. (SBQ17SE.13) . Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Summary. The lunate is displaced and rotated volarly. A 32-year-old professional baseball player presents with wrist pain after a fall on his outstretched wrist 10 days ago. ADVERTISEMENT: Supporters see fewer/no ads. What is the most appropriate treatment at this time? He undergoes operative treatment of his fracture, and immediate post-op radiographs are shown in Figure C. Two weeks later he presents with significantly increased pain and deformity. AP and lateral radiographs of the wrist are shown in figures A and B respectively. Unable to process the form. The next best step in management would be: (OBQ12.163) A fracture to the lunate may also be associated with injury to the TFCC. Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. (OBQ06.102) CT and bone scans may also be used.This is a slow-progressing disease, and patients often have the condition for months or even years before they seek treatment. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. dorsal fractures commonly axial fracture healing. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 17-year-old male falls from a retaining wall onto his left arm. Kienbocks disease is most common in men between the ages of 20 and 40. It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. Inability to flex the thumb interphalangeal joint. Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, 23-Year-Old Skateboarder Falls On An Outstretched Arm With A Scapholunate Full-Thickness Tear: All Those Procedures To Repair Don't Work, I Have The Answer: 'RASL' Dazzle: I Am Not Dead Yet, Look At My Long-Term Results - Melvin P. Rosenwasser, MD, Modified Brunelli for Scapholunate Reconstruction, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Wrist Scapholunate (SL) Ligament Injury in 52M. A 65-year-old man fell and injured his right wrist. (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. (OBQ17.87) The lunocapitate articulation may be disrupted resulting in a dorsal perilunate dislocation, or in the case of concomitant scaphoid fracture, the wrist may undergo a transscaphoperilunate dislocation. (OBQ06.60) Summary. A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). You can rate this topic again in 12 months. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture? lunate fracture orthobulletswellesley, ma baby store. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of, Anterior and posterior interosseous neurectomy. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. (2008) ISBN:1588904539. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. Lunate fracture. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. proximally and the capitate distally. The lunate is made up of the volar pole, body, and dorsal pole. Evaluation of volar compartment pressures with a needle monitor, Icing and elevation of the arm with follow-up evaluation in 8 hours, Immediate EMG evaluation of the left upper extremity, Closed reduction, carpal tunnel release, and sugar tong splinting, Emergent open reduction internal fixation with carpal tunnel release. Displaced impaction fracture of the lunate fossa, Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner, Displaced extra-articular fracture with apex volar, Displaced extra-articular fracture with apex dorsal. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Lunate Dislocation (Perilunate dissociation). Which of the following radiographic views shown in Figures A to E would be most helpful in establishing the diagnosis? 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 . Which plating option provides the most appropriate treatment of this fracture? Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; The patient undergoes open reduction internal fixation (ORIF). A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. immobilization in a long arm thumb spica cast. You can rate this topic again in 12 months. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 25-year-old female falls from her horse and injures her left wrist. 2023 Lineage Medical, Inc. All rights reserved. The lunate is displaced and rotated volarly. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? It is essentially the same sequela of . Thank you. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). toe phalanx fracture orthobulletsdaniel casey ellie casey. Standard wrist radiographs are normal. At the time the article was created Andrew Murphy had no recorded disclosures. A radiograph is shown in figure A. Wrist with Kienbock's disease and ulna that is short compared to radius, Using this search tool means you agree to the, 2023 American Society for Surgery of the Hand, from the American Society for Surgery of the Hand, Decreased motion or stiffness of the wrist. (OBQ04.233) Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . The patient shows you the lateral film in Figure A. 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? You review his operative note in which the surgeon reports having to apply a volar locking plate in a distal position to secure the difficult intra-articular fracture. 1980;5 (3): 226-41. What additional data is most necessary to obtain before a reduction is attempted? Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. A fracture to the lunate may also be associated with injury to the TFCC. On physical exam she has no sensation of the volar thumb, index, and middle fingers. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. Which of the following distal radius fractures is associated with volar translation of carpus relative to the radial articulation? If time has passed since injury, it can also lead to wrist arthritis. Radiographs show a well-fixed fracture in good alignment. Depressed fracture of the lunate fossa (articular surface) Smith's. The rest of the carpal bones are in a normal anatomic position in relation to the radius. There is no single cause of Kienbocks disease. The most important differential is of other carpal dislocations, particularly: In addition to stating that a lunate dislocation is present, a number of features should be sought and commented upon: ensure that radiolunate alignment is disrupted, and that you are not looking at a perilunate dislocation(stage II carpal dislocation), evaluate and comment on the degree or palmar rotation of the lunate (this can be up to 270 degrees)4, ensure that the capitate remains co-linear with the long axis of the radius, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The scaphoid accounts for 95% of degenerative/traumatic arthri- . Most patients with Kienbocks disease have the following symptoms: The diagnosis of Kienbocks disease can often be made by reviewing your history, performing a physical examination, and taking x-rays. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . Lunate fractures are relatively uncommon, representing about 4 percent of all carpal bone injuries [ 1-4 ]. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. - Discussion: She complains of wrist pain and deformity. Isolated capitate fractures are rare (scaphoid is most common associated fracture) Occurs via forceful dorsiflexion of hand (FOOSH injury) with impact on radial side; Proximal fracture fragment at risk for avascular necrosis; Clinical Features. (SBQ17SE.28) 3, Greenberg MI. Distal Radius Fracture Non-Spanning External Fixator . He was treated as a sprain and no further follow-up was planned. The force of injury in this syndrome can propagate leading to perilunate dislocation as . A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Stage IV denotes a true lunate dislocation, involving a . diastasis of the scapholunate complex occurs with complete SLIL tears and capsule disruption. Perilunate fracture-dislocations of the wrist. Which of the following injuries is the most likely cause of this finding? In this condition, the lunate bone loses its blood supply, leading to death of the bone. Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. What is the most appropriate treatment at this time? Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. What is the most likely etiology of her new loss of function? During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Carpal tunnel release if no resolution at 6-12 weeks. Radiographs are provided in Figures A-C. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . tures, specically non-union of scaphoid fractures. Revista dedicada a la medicina Estetica Rejuvenecimiento y AntiEdad. Lunate fracture. A normal wrist without Kienbock's disease. Find a hand surgeon near you. He reports paresthesias in his thumb and index finger. Unable to process the form. Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, 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). Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Capitate fractures are most commonly due to high-energy, hyperextension forces 2. It is the second most common carpal bone injury in children 1. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: Read 14. (OBQ08.179) The patient recovered well initially but presents after 6 months with grip weakness. Incompetence of which of the following anatomic structures is the most likely etiology of this finding? Colles'. A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. DISI (dorsal intercalated segmental instability), scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex, if left untreated the DISI deformity can progress into a, DISI deformity may also develop secondary to distal pole of the scaphoid excision for treatment of STT arthritis, DISI is a form of carpal instability dissociative, c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and lunate bones, dorsal fiber thickened (2-3mm) compared to volar fibers, dorsal component provides the greatest constraint to translation between the scaphoid and lunate bones, proximal fibers have minimal mechanical strength, Overview of wrist ligaments and biomechanics, acute FOOSH injury vs. degenerative rupture, age, nature of injury, duration since injury, degree of underlying arthritis, level of activity, pain increased with loading across the wrist (e.g. The lunate is an important stabilizer of the wrist . Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Summary. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . Ulnar side of hand. 2020 American Society for Surgery of the Hand. Philadelphia : Lippincott Williams & Wilkins, c2005. - w/ flexion and extension lunate/capitate articulation may be felt; A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). (2008) RadioGraphics. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-10010, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10010,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lunate-dislocation/questions/1703?lang=us"}, Figure 1: Stage 4 of progressive perilunate, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, Mayfield classification of carpal instability, dorsal intercalated segment instability (DISI), volar intercalated segment instability (VISI), scaphoid nonunion advanced collapse (SNAC), triangular fibrocartilaginous complex (TFCC) injuries, ulnar-sided wrist impaction and impingement syndromes, calcium pyrophosphate dihydrate deposition disease, Philips Australia, Paid speaker at Philips Spectral CT events (ongoing). Other common causes include: car . In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Capitate fractures are classified by the anatomic location of the fracture, along with what other concomitant injuries may be present. It works closely with the two forearm bones (the radius and ulna) to help the wrist move. She also complains of some paresthesias in her thumb and index finger. Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. A recent imaging study is seen in Figure A. (SBQ17SE.12) Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. 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).

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