Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? - it has large volar surface, & is displaced volarward w/ forceddorsiflexion of the wrist; You can rate this topic again in 12 months. 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. Access Free Scapholunate Advanced Collapse And Scaphoid Nonunion FlashCards My DeckMaster Create Card Deck . Treatment involves observation, NSAIDs and splinting in early stages of disease. 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. Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. Standard wrist radiographs are normal. The lunate is made up of the volar pole, body, and dorsal pole. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Follow-up/referral. In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets (OBQ06.136) (SBQ17SE.67) Carpal tunnel release if no resolution at 6-12 weeks. (OBQ07.226) Incidence. Figure A is an intraoperative photo. Summary. Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. (OBQ12.105) Frequent questions. The latter mechanism frequently occurs . Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. lunate fracture orthobulletswellesley, ma baby store. Capitate fracture - WikEM A recent imaging study is seen in Figure A. Check for errors and try again. arthroscopic repair and percutaneous pinning. - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament; 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. Clifford R. Wheeless, III, M.D. 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. What additional data is most necessary to obtain before a reduction is attempted? There is injury of all of the perilunate ligaments, most significantly the dorsal radiolunate ligament. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). Difficult wrist fractures. 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. 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. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. immobilization in a short arm thumb spica cast. Which plating option provides the most appropriate treatment of this fracture? Dorsally displaced, extra-articular fracture. Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner. 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. Difficult wrist fractures. 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. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Cleveland Combined Hand Fellowship Lecture Series 2019-2020, Fractures of the Other Carpal Bones - Austin Pitcher, MD. Lunate dislocations typically occur due to a fall on an outstretched hand (or during a motor vehicle injury) where there is forceful dorsiflexion of the wrist 3. Surgery may be done to change forces across the lunate and wrist joint or to improve vascularity of the lunate. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. Diagnosis requires careful evaluation of plain radiographs. Greenberg's text-atlas of emergency medicine. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. The patient undergoes open reduction internal fixation (ORIF). Lunate fractures - OrthopaedicsOne Articles - OrthopaedicsOne Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). 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. Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint spared). Lunate fractures account for around 4% of all carpal fractures 1. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. (OBQ08.179) 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? Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. 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. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Epidemiology. The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. (OBQ05.195) A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. (OBQ16.228) Other common causes include: car . toe phalanx fracture orthobullets The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; Pathology. 110 West Rd., Suite 227 (OBQ04.38) What is the likely mechanism of her paresthesias and what is the most appropriate treatment? (OBQ06.60) 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. (OBQ06.102) 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. The next best step in management would be: (OBQ12.163) A 25-year-old female falls from her horse and injures her left wrist. 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). Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. immobilization in a long arm thumb spica cast. There is no single cause of Kienbocks disease. 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. (SAE07SM.38) (OBQ11.273) Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. 2.0 screw for a Scaphoid Hand Fracture How to palpate the . At the time the article was created Andrew Dixon had no recorded disclosures. Proper . 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. You can rate this topic again in 12 months. - w/ flexion and extension lunate/capitate articulation may be felt; ORTHOBULLETS; Flashcards. not be relevant to the changes that were made. 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. (OBQ10.127) Radiographs show a well-fixed fracture in good alignment. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Smith's fracture: volarly displaced and extraarticular. Nerve compression; open reduction internal fixation with open carpal tunnel release, Nerve laceration; open reduction internal fixation with primary nerve repair or grafting, Decreased arterial inflow; fasciotomy with open reduction internal fixation, Nerve compression; repeat closed reduction. He reports paresthesias in his thumb and index finger. - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; It rarely affects both wrists. What is this structure? A 35-year-old professional football player complains of severe wrist pain after making a tackle. Check for errors and try again. Which of the following injuries is the most likely cause of this finding? Hamate Body Fracture - Hand - Orthobullets Type in at least one full word to see suggestions list, Hand Scaphoid Lunate Advanced Collapse (SLAC). Treatment options depend upon the severity and stage of the disease. Inability to flex the index finger proximal interphalangeal joint. In this condition, the lunate bone loses its blood supply, leading to death of the bone. Around 60% of perilunate dislocations are associated with a scaphoid fracture which is then termed a trans-scaphoid perilunate dislocation . Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Flashcards. Treatment requires urgent closed versus open reduction and stabilization. Electromyography and nerve conduction velocity studies, AP and lateral radiographs of the forearm, (SAE07SM.78) - lunate articulates proximally w/ radius and distally w/ capitate; (SBQ17SE.28) Towson, MD 21204 Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Acces PDF Scapholunate Advanced Collapse And Scaphoid Nonunion toe phalanx fracture orthobullets - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: AP and lateral radiographs of the wrist are shown in figures A and B respectively. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation?