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? What additional data is most necessary to obtain before a reduction is attempted? Both images from . Copyright 2023 Lineage Medical, Inc. All rights reserved. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . Check for errors and try again. (SBQ07SM.38) It rarely affects both wrists. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. lunate fracture orthobullets A radiograph is shown in figure A. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. (OBQ07.226) A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. ADVERTISEMENT: Supporters see fewer/no ads. educational laws affecting teachers. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. 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. 110 West Rd., Suite 227 Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. The other types are perilunate, trans-radial styloid and . (OBQ16.228) 43 (1): 84-92. . Check for errors and try again. Depressed fracture of the lunate fossa (articular surface) Smith's. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. Treatment options depend upon the severity and stage of the disease. Lunate Dislocation (Perilunate dissociation). Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. His radiograph is shown in Figure A. Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated hand. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. The injury is closed and she is neurovascularly intact. Clifford R. Wheeless, III, M.D. Phalanx fractures of the hand are some of the most common fractures occurring in humans. Capitate fractures account for 1-2% of all carpal fractures 1,2. Chronic DISI deformities may be indicated for fusion procedures depending on degree of arthritis and patient symptoms. - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: He sustains the injury shown in Figure A. (OBQ04.38) The lunate is one of the eight small bones in the wrist. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-80825, see full revision history and disclosures, 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. proximally and the capitate distally. A fracture to the lunate may also be associated with injury to the TFCC. (2005) ISBN:0781745861. (OBQ10.127) Immediate post-operative radiographs are seen in Figure A. The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis index finger injury, The patient should undergo revision fixation as soon as possible, The plate is in appropriate position and will likely never need to be removed. (SBQ17SE.47) Unable to process the form. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Radiographs are shown in Figures A and B. These should not be confused with perilunate dislocations in which the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. Revista dedicada a la medicina Estetica Rejuvenecimiento y AntiEdad. What is the next most appropriate step in management? Carpal dislocations: pathomechanics and progressive perilunar instability. 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. Patients present with wrist pain following a fall. - it is palpable just distal to radial tubercle; Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. Incidence. Lunate dislocationsare an uncommon traumatic wrist injury that require prompt management and surgical repair. Admit for acute carpal tunnel syndrome monitoring, Admit for acute open reduction/internal fixation, Place into removable soft splint and follow-up in clinic, Place into rigid splint and follow-up in clinic, Place into rigid splint and schedule for outpatient open reduction/internal fixation. There are no open wounds and the hand is neurovascularly intact. Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. Treatment involves observation, NSAIDs and splinting in early stages of disease. The lunate is made up of the volar pole, body, and dorsal pole. 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. commonly missed (~25%) on initial presentation, occurs when wrist extended and ulnarly deviated, disruption of capitolunate articulation -->, disruption of lunotriquetral articulation -->, failure of dorsal radiocarpal ligament -->, ligamentous disruptions with associated fractures of the radius, ulnar, or carpal bones, lunate stays in position while carpus dislocates, lunate forced volar or dorsal while carpus remains aligned, major stabilizers of the proximal carpal row, ligaments the both originate and insert among the carpal bones, + lunotriquetral disruption, "perilunate", Lunate dislocated from lunate fossa (usually volar), median nerve symptoms may occur in ~25% of patients, most common in Mayfield stage IV where the lunate dislocates into the carpal tunnel, due to palmar rotation from dorsal force of carpus, loss of colinearity of radius, lunate, and capitate, no indications when used as definitive management, universally poor functional outcomes with non-operative management, emergent closed reduction/splinting followed by open reduction, ligament repair, fixation, possible carpal tunnel release, decreased grip strength and stiffness are common, chronic injury (defined as >8 weeks after initial injury), not uncommon, as initial diagnosis frequently missed, chronic injuries with degenerative changes, finger traps, elbow at 90 degrees of flexion, dorsal dislocations are reduced through wrist extension, traction, and flexion of wrist, longitudinal incision centered at Lister's tubercle, excellent exposure of proximal carpal row and midcarpal joints, extended carpal tunnel incision just proximal to volar wrist crease, some believe volar ligament repair not necessary, difficulty regaining digital flexion and grip, controversy of k-wire versus intraosseous cerclage wiring, repair of lunotriquetral interosseous ligament, decision to repair based on surgeon preference as no studies have shown improved results, short arm thumb spica splint converted to short arm cast at first post-op visit, duration of casting varies, but at least 6 weeks, perform via dorsal and volar incisions if median nerve compression is present, volar approach allows median nerve decompression with excision of lunate, dorsal approach facilitates excision of the scaphoid and triquetrum, radiodense appearance of the lunate on radiograph reported in up to 12.5% of cases, usually identified 1-4 months post-injury, - 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). In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. Radiographic features Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. He is not able to see a physician for 4 months. Stage IV denotes a true lunate dislocation, involving a . Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. 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. These should not be confused with perilunate dislocations in which the radiolunate articulation is . Two-point discrimination is now >10mm in these fingers. (OBQ17.87) It can be difficult to diagnose in its earlier stages. (OBQ06.102) - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; 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. Difficult wrist fractures. It works closely with the two forearm bones (the radius and ulna) to help the wrist move. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Die-punch. Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment, No difference in radiographic outcomes after ORIF vs. closed treatment, No difference in functional outcomes after ORIF vs. closed treatment, Improved functional outcomes with closed treatment vs. ORIF, Improved functional outcomes with external fixation and K wire fixation vs. ORIF. Towson, MD 21204 At the time the article was created Andrew Murphy had no recorded disclosures. 73% (1391/1911) 3. 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? Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). comic book publishers accepting submissions 2022 Likes ; brady list police massachusetts Followers ; nurse injector training Followers ; transfer apple health data to samsung Subscriptores ; night shift vs overnight shift Followers ; big joe's funeral questions and answers The patient undergoes open reduction and internal fixation of the fracture. Hand therapy does not change the course of the disease; however, it can help to minimize loss of motion from the disease. Medical Information Search 14% (259/1911) 2. A normal wrist without Kienbock's disease. Which plating option provides the most appropriate treatment of this fracture? 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). 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. How do you counsel him about his post-operative period? Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . (OBQ08.179) Wrist Dislocation by Kadeer M Halimi from emedicine.com. tures, specically non-union of scaphoid fractures. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. (SAE07SM.38) Inability to extend the index finger proximal interphalangeal joint. A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms. Perilunate fracture-dislocations of the wrist, Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate, Orthopaedic Specialists of North Carolina. 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. Hook of hamate fractures are rare, often missed, injuries generally as a result of a direct blow to the hamate bone most commonly seen in athletes. Mayfield JK, Johnson RP, Kilcoyne RK. AP and lateral radiographs of the wrist are shown in figures A and B respectively. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Which of the following has evidence to support its utility in this clinical situation? Diagnosis requires careful evaluation of plain radiographs. Adequate maintenance of reduction by non-operative treatment is unsuccesful. What is the next best step in management of this patient? Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. It is essentially the same sequela of . Treatment is designed to relieve pain and restore function.Your hand surgeon will advise you of the best treatment options and explain the risks, benefits and side-effects of various treatments for Kienbocks disease. Hip fractures are strongly associated with BMD in the proximal femur, but there are also many clinical predictors of hip fracture risk that are independent of bone density. Displaced impaction fracture of the lunate fossa. (OBQ04.233) 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 17-year-old male falls from a retaining wall onto his left arm. Which of the following interventions should be taken? Radiographs are provided in Figure A. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? Overall, carpal dislocations comprise less than 10% of all wrist injuries. She complains of wrist pain and deformity. (OBQ13.78) Due to a fall onto a flexed wrist or a blow to the back of hand. 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. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. He denies any new trauma, and has followed all post-operative activity restrictions. Standard wrist radiographs are normal. 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. Treatment requires urgent closed versus open reduction and stabilization. 3, Greenberg MI. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Thank you. 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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