Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. The scaphoid accounts for 95% of degenerative/traumatic arthri- . A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Upper extremity deep vein thrombosis (DVT), Lower extremity deep vein thrombosis (DVT). Capitate fractures are most commonly due to high-energy, hyperextension forces 2. A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. The rest of the carpal bones are in a normal anatomic position in relation to the radius. A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms. Which of the following distal radius fractures is associated with volar translation of carpus relative to the radial articulation? Philadelphia : Lippincott Williams & Wilkins, c2005. Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. Volar wrist swelling is usually prominent. 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. Treatment involves observation, NSAIDs and splinting in early stages of disease. His radiograph is shown in Figure A. Perilunate fracture-dislocations of the wrist. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. The lunate is an important stabilizer of the wrist . Other common causes include: car . immobilization in a long arm thumb spica cast. Adhesions within the first and third dorsal wrist compartments. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to 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? Wheeless' Textbook of Orthopaedics. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Find a hand surgeon near you. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Perilunate dislocations and fracture-dislocations are relatively uncommon injury patterns in acute wrist trauma. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. (OBQ09.254) immobilization in a short arm thumb spica cast. 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. Greenberg's text-atlas of emergency medicine. What complication is most likely to occur in this patient? 14% (259/1911) 2. (OBQ09.227) On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. whilst on the lateral the capitate no longer sits in the lunate. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. If you are unsure, it is best to err on the safe side and call for help. (OBQ16.228) Fractures of the normal lunate--isolated or associated with fractures of the scaphoid or radius--are very rare. (2017) Journal of Hand Surgery (European Volume). Treatment requires urgent closed versus open reduction and stabilization. Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . 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. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. The injury pattern may involve a crush injury, a FOOSH injury (Figure 18.21), or a direct blow to the dorsal aspect of the wrist. (SBQ17SE.28) He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Lunate fractures are often secondary to axial loading of the head capitate bone,this is seen in forceful hyperextension with ulnar deviation 2. Inability to extend the index finger proximal interphalangeal joint. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). Radiographs taken in the emergency room are seen in Figure A. 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. - it differs from Colles' or Smith's Fracture in that the dislocation is the most striking radiographic finding; - volar Barton's is more common than dorsal Barton frxs; - mechanism: - usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; You can rate this topic again in 12 months. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. 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). At the time the article was created Andrew Murphy had no recorded disclosures. He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. What is the appropriate surgical treatment at this time? What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist? Ulnar gutter splint/cast. The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). lunate fracture orthobullets Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. He initially thought it was a sprain, but presents due to continued pain worsened by push-ups. 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. It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. What is the most appropriate treatment at this time? 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). (OBQ18.177) Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ07.226) (OBQ05.25) 1980;5 (3): 226-41. Colles'. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . Pathology. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Pearls/pitfalls. Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. Overall, carpal dislocations comprise less than 10% of all wrist injuries. Lunate Dislocation (Perilunate dissociation). Treatment of acute SL ligament injuries may be immobilization versus operative repair/reconstruction depending on degree of displacement. (OBQ10.127) The patient shows you the lateral film in Figure A. The patient undergoes open reduction internal fixation (ORIF). Perilunate fracture-dislocations of the wrist. There are no open wounds and the hand is neurovascularly intact. 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. 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). Mayfield JK, Johnson RP, Kilcoyne RK. Two-point discrimination is now >10mm in these fingers. Summary. Proper . Difficult wrist fractures. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Diagnosis requires careful evaluation of plain radiographs. (OBQ06.60) (OBQ13.78) Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. What is the most appropriate treatment at this time? Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. 110 West Rd., Suite 227 Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Frequent questions. Inability to flex the index finger proximal interphalangeal joint. What is this structure? These should not be confused with perilunate dislocations in which the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. Patients often prefer to hold their fingers in partial flexion due to pain on extension. (SBQ17SE.67) (SBQ17SE.12) {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. Four months post-injury, he presents to the office with an inability to extend his thumb. The lunate is displaced and rotated volarly. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. Distal Radius Fracture Non-Spanning External Fixator . Die-punch. 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.