lunate fracture orthobullets
Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. This medication is given in an effort to decrease the incidence of which of the following? Hand therapy does not change the course of the disease; however, it can help to minimize loss of motion from the disease. Radiographs of the affected wrist are shown in Figure A. There are no open wounds and the hand is neurovascularly intact. 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. (2017) Journal of Hand Surgery (European Volume). toe phalanx fracture orthobullets What is the most appropriate treatment at this time? A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. 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. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. A 56-year-old woman sustains the closed injury depicted in Figures A-B. MR arthrogram of the wrist to assess ligamentous injuries, Type in at least one full word to see suggestions list, Transscaphoid perilunate fracture dislocation management, AO Trauma Hand: Must Know Series HOW I DO IT Perilunate FX-Dislocations, Open reduction of volar lunate dislocation (through dorsal Cape Town approach), Hand Lunate Dislocation (Perilunate dissociation), University of Illinois Orthopaedic Surgery, Lunate Dislocation and Acute Carpal Tunnel Syndrome in 23M. There may be other associated injuries that require further investigation via cross-sectional imaging 1,2. Copyright 2023 Lineage Medical, Inc. All rights reserved. Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. ORTHOBULLETS; Flashcards. He denies any new trauma, and has followed all post-operative activity restrictions. (OBQ05.25) Radiographs are provided in Figures A-C. What complication is most likely to occur in this patient? The proximal 2 Cs indicates the articulation between the lunate and . He sustains the injury shown in Figure A. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). Perilunate dislocations and fracture-dislocations are relatively uncommon injury patterns in acute wrist trauma. Which plating option provides the most appropriate treatment of this fracture? Treatment requires urgent closed versus open reduction and stabilization. Follow-up/referral. Which of the following has evidence to support its utility in this clinical situation? - w/ flexion and extension lunate/capitate articulation may be felt; 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. Most hand and wrist fractures (the latter of which is basically an ulnar styloid fracture) are caused by trying to break a fall with your arm outstretched. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. ADVERTISEMENT: Supporters see fewer/no ads. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. (OBQ09.254) The lunate is displaced and rotated volarly. A normal wrist without Kienbock's disease. A radiograph is shown in Figure 21. The lunate is made up of the volar pole, body, and dorsal pole. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Difficult wrist fractures. A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. Changes for Fat Loss by with a free trial. 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. Lunate fracture. 1. Carpal dislocations: pathomechanics and progressive perilunar instability. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. 73% (1391/1911) 3. Towson, MD 21204 Distal Radius Fracture Non-Spanning External Fixator . On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. Treatment of acute SL ligament injuries may be immobilization versus operative repair/reconstruction depending on degree of displacement. (OBQ17.87) In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. 2.0 screw for a Scaphoid Hand Fracture How to palpate the . A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. Orthopaedic Specialists of North Carolina. 1980;5 (3): 226-41. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view? The lunate is displaced and rotated volarly. Worse outcomes on the Mayo wrist score are expected without fixation, Chronic distal radioulnar joint instability can be expected to occur without fixation, Wrist function depends on the level of ulnar styloid fracture and initial displacement, Grip strength and wrist range of motion are improved with fixation, There is no adverse effect on wrist function or stability without fixation. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Unable to process the form. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Volar wrist swelling is usually prominent. The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). Pathology. Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent.A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability. Read 14. sudden impact force applied to the hand and wrist causing SLIL injury and scapholunate dissociation, injury occurs most commonly with wrist positioned in extension, ulnar deviation and carpal supination, SLIL tearing will position the scaphoid in flexion and lunate extension. (OBQ16.228) A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. Radiographs are provided in Figure A. Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist, Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands, accounts for 17.5% of all fractures in adults, younger patients due to high energy mechanisms, older patients due to low energy mechanisms (i.e. Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. A recent imaging study is seen in Figure A. Inability to flex the thumb interphalangeal joint. Inability to flex the index finger proximal interphalangeal joint. 2023 Lineage Medical, Inc. All rights reserved. 43 (1): 84-92. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. The next best step in management would be: (OBQ12.163) Phalanx fractures of the hand are some of the most common fractures occurring in humans. lunate fracture orthobullets Clifford R. Wheeless, III, M.D. Incompetence of which of the following anatomic structures is the most likely etiology of this finding? The latter mechanism frequently occurs . You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. Lunate fractures account for around 4% of all carpal fractures 1. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. 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). Which of the following tendons is most commonly transferred to address the patient's deficiency? Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. He reports paresthesias in his thumb and index finger. 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. Thank you. main cause for these lesions is a direct impact against a hard surface with a, 4th or 5th metacarpal base fractures or dislocations, usually required to delineate fracture pattern and determine operative plan, diagnosis confirmed by history, physical exam, and, may be used for extra-articular non-displaced fracture, most fractures are intra-articular and require open reduction, interfragmentary screws +/- k-wires for temporary stabilization, fixation may be obtained with K wires or screws, 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). educational laws affecting teachers. This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Patients often prefer to hold their fingers in partial flexion due to pain on extension. Two-point discrimination is now >10mm in these fingers. Dorsally displaced, extra-articular fracture. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. The rest of the carpal bones are in a normal anatomic position in relation to the radius. (OBQ04.233) Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. {"url":"/signup-modal-props.json?lang=us"}, Dixon A, Hacking C, El-Feky M, et al. Lunate dislocation. Inability to extend the index finger proximal interphalangeal joint. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis Long arm cast above the elbow for 6 weeks, Long arm cast for 3 weeks followed by a short arm cast for 3 additional weeks, Closed reduction and percutaneous pinning. Adequate maintenance of reduction by non-operative treatment is unsuccesful. Barton's. Fracture-dislocation of radiocarpal joint (with intra-articular fracture involving the volar or dorsal lip) Chauffer's. Fracture of radial styloid. Which of the following interventions should be taken? Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Extensor carpi radialis longus transfer to extensor pollicus longus, Extensor pollicis brevis transfer to extensor pollicus longus, Extensor indicis proprius transfer to extensor pollicus longus, Primary repair of extensor pollicus longus. Lunate. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Greenberg's text-atlas of emergency medicine. Stage IV denotes a true lunate dislocation, involving a . In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Around 20% of patients possess a single-vessel supply to their lunate hence there is an increased possibility of avascular necrosis, the remaining cohort typically has a two-vessel supply and intraosseous anastomosis 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. Other common causes include: car . Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. 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. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. 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. It can be difficult to diagnose in its earlier stages. Indications. Diagnosis requires careful evaluation of plain radiographs. Radiographs show a well-fixed fracture in good alignment. (2008) RadioGraphics. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). What is the next most appropriate step in management? Die-punch. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. His radiograph is shown in Figure A. She complains of wrist pain and deformity. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? 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 . FOOSH), high incidence of distal radius fractures in women > 50 years old, DEXA scan is recommended for women with distal radius fractures, fall on outstretched hand (FOOSH) is most common in older population, higher energy mechanism more common in younger patients, includes the radial styloid and scaphoid fossa, attachment sites for the brachioradialis tendon, long radiolunate ligament, and radioscaphocapitate ligament, serves as a buttress to resist radial carpal translation, functions as a load-bearing platform for activities performed with the wrist in ulnar deviation, holds the carpus out to length radially, allowing a more uniform distribution of load across the scaphoid and lunate facets, serves as an anchor for the radioscaphocapitate ligament that prevents ulnar translation of the carpus, transmits load from the carpus to the forearm, based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fracture, divides intra-articular fractures into 4 types based on displacement, Depressed fracture of the lunate fossa of the articular surface of the distal radius, Fracture-dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx), Low energy, dorsally displaced, extra-articular fx, Low energy, volarly displaced, extra-articular fx, usually a fall onto outstretched hand (FOOSH), Dorsal angulation < 5 or within 20 of contralateral distal radius, dorsal angulation < 5 or within 20 of contralateral distal radius, extra-articular fracture with stable volar cortex, 82-90% good results if used appropriately, radiographic findings indicating instability (pre-reduction radiographs best predictor of stability), dorsal angulation > 5 or > 20 of contralateral distal radius, displaced intra-articular fractures > 2mm, associated ulnar styloid fractures do not require fixation, articular margin fractures (dorsal and volar Barton's fractures), the volar ulnar corner (critical corner) supports the volar lunate facet with its strong radiolunate ligament attachments, failure to address this fragment can result in volar carpal subluxation, comminuted and displaced extra-articular fractures (Smith's fractures), progressive loss of volar tilt and radial length following closed reduction and casting, medically unstable patients unable to undergo a lengthy procedure, important adjunct with 80-90% good/excellent results, therefore usually combined with percutaneous pinning technique or plate fixation, apply longitudinal traction and volar/dorsal pressure to the distal fracture fragment, avoid positions of extreme flexion and ulnar deviation (Cotton-Loder Position), no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization, radial shortening is the most predictive of instability, followed by dorsal comminution, dorsal comminution > 50%, palmar comminution, intraarticular comminution, higher loss of reduction with 3 or more of LaFontaine criteria, Meta-analyses and systematic reviews demonstrate no difference in functional outcomes between closed treatment versus operative methods in elderly patients (>65 years old), K wires are placed dorsally into the fracture and used as reduction tools until they are driven into the proximal radius, Rayhack technique with arthroscopically assisted reduction, distal radius extra-articular fracture ORIF with volar approach, distal radius intra-articular fracture ORIF with dorsal approach, associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons, can have hyperesthesia over the base of the thenar eminence due to palmar cutaneous nerve injury during retraction of the digital flexor tendons when plating the distal radius, new volar locking plates offer improved support to subchondral bone, intra-articular distal radius fractures with dorsal comminution, can combine with external fixation and percutaneous pinning, volar lunate facet fragments may require fragment-specific fixation to prevent early postoperative failure, screw penetration into the radiocarpal joint or DRUJ, assess intra-articular screws with a 23 degree elevated lateral view, assess dorsal cortex penetration with a skyline view, no benefit of therapist-directed physical therapy compared to home exercise program, distal radius fracture spanning external fixator, distal radius fracture non-spanning external fixator, place radial shaft pins under direct visualization to avoid injury to superficial radial nerve, and excessive volar flexion and ulnar deviation, pin site care comprising daily showers and dry dressings recommended, prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder position), progressive paresthesias, weakness in thumb opposition, paresthesias that do not respond to reduction and last > 24-48 hours, nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the EPL tendon, extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon, volar plating with screw fixation that penetrates the dorsal cortex and is proud dorsally, very distal volar plate placement on the radius (distal to watershed line) is associated with FPL rupture, due to physical contact of tendon on plate and subsequent tendinopathy, 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2mm, delayed procedure associated with higher need for bone grafting and a more difficult procedure, radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fractures, AAOS 2010 clinical practice guidelines recommend, early efforts to regain motion of wrist and fingers, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. (OBQ07.8) 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? Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. His physical exam shows dorsal wrist tenderness and is positive for the provocative test shown in Figure V. Standard PA radiograph of the wrist is normal. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; The lunate is one of the eight small bones in the wrist. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? A 35-year-old professional football player complains of severe wrist pain after making a tackle. 1. (OBQ11.273) Wheeless' Textbook of Orthopaedics. immobilization in a short arm thumb spica cast. These should not be confused with perilunate dislocations in which the radiolunate articulation is . Diagnosis is made with PA wrist radiographs showing widening of the SL joint. 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. Radiographs obtained at the time of injury are shown in Figure A. There is no single cause of Kienbocks disease. Find a hand surgeon near you. - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; Kienbocks disease is most common in men between the ages of 20 and 40. Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Despite treatment, there remains a high risk of future degenerative arthritis and wrist instability. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. diastasis of the scapholunate complex occurs with complete SLIL tears and capsule disruption. Management should consist of. 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. Check for errors and try again. A fracture to the lunate may also be associated with injury to the TFCC. Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. 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.