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The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). (OBQ12.105) Which of the following tendons is most commonly transferred to address the patient's deficiency? Two-point discrimination is now >10mm in these fingers. The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. (OBQ11.273) 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. Mayfield JK, Johnson RP, Kilcoyne RK. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? (SBQ17SE.13) 110 West Rd., Suite 227 She was seen in the emergency department at the time of injury and was told she had a sprain. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. A fracture to the lunate may also be associated with injury to the TFCC. Despite treatment, there remains a high risk of future degenerative arthritis and wrist instability. Check for errors and try again. 14% (259/1911) 2. Which of the following interventions should be taken? The instrument touches a structure that prevents ulnar translocation of the carpus after a PRC. A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. Which of the following has evidence to support its utility in this clinical situation? 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 . Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. 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. 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). Philadelphia : Lippincott Williams & Wilkins, c2005. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. immobilization in a short arm thumb spica cast. Frequent questions. Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. 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. Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. 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. FlashCards My DeckMaster Create Card Deck . A recent imaging study is seen in Figure A. This medication is given in an effort to decrease the incidence of which of the following? Diagnosis requires careful evaluation of plain radiographs. Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. A 46-year-old woman sustains an extra-articular fracture of the distal radius and undergoes open reduction and internal fixation with a volar plate and screw construct. (OBQ10.127) A radiograph is shown in Figure 21. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. The lunate is made up of the volar pole, body, and dorsal pole. Check for errors and try again. Radiographs obtained at the time of injury are shown in Figure A. Four months post-injury, he presents to the office with an inability to extend his thumb. 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. In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. Copyright 2023 Lineage Medical, Inc. All rights reserved. 43 (1): 84-92. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament; Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? 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. Scaphoid Lunate Advanced Collapse (SLAC) d. escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. 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. A radiograph is shown in figure A. It rarely affects both wrists. A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. A normal wrist without Kienbock's disease. Data Trace Publishing Company tures, specically non-union of scaphoid fractures. Hip fracture Smith's fracture: volarly displaced and extraarticular. Carpal tunnel release if no resolution at 6-12 weeks. Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ12.38) Radiographs taken in the emergency room are seen in Figure A. On physical exam she has no sensation of the volar thumb, index, and middle fingers. 2. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 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? Type in at least one full word to see suggestions list, Hand Scaphoid Lunate Advanced Collapse (SLAC). 1. - it is palpable just distal to radial tubercle; The lunate is one of the eight small bones in the wrist. Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner. The injury is closed and she is neurovascularly intact. 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. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Treatment options depend upon the severity and stage of the disease. Treatment involves observation, NSAIDs and splinting in early stages of disease. (OBQ06.102) What additional data is most necessary to obtain before a reduction is attempted? (OBQ12.244) 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). A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. 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. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? He initially thought it was a sprain, but presents due to continued pain worsened by push-ups. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. 28 (6): 1771-84. When dislocation occurs in the wrist . 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) 2023 Lineage Medical, Inc. All rights reserved. Radiographic features He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. Both images from . (OBQ08.179) Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. At the time the article was created Andrew Murphy had no recorded disclosures. (OBQ05.25) (OBQ07.8) Radiographs are provided in Figures A-C. Thank you. It is essentially the same sequela of . Three months after the fracture she reports an acute loss of her ability to extend her thumb. How do you counsel him about his post-operative period? Displaced impaction fracture of the lunate fossa. The patient recovered well initially but presents after 6 months with grip weakness. {"url":"/signup-modal-props.json?lang=us"}, Dixon A, Hacking C, El-Feky M, et al. (SBQ17SE.64) Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). A 17-year-old male falls from a retaining wall onto his left arm. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Lunate fractures are often secondary to axial loading of the head capitate bone,this is seen in forceful hyperextension with ulnar deviation 2. It is the second most common carpal bone injury in children 1. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. His radiograph is shown in Figure A. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Lunate fracture. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Wrist Dislocation by Kadeer M Halimi from emedicine.com. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. Lunate fractures and associated radiocarpal and midcarpal instabilities: a systematic review:. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. He reports paresthesias in his thumb and index finger. What complication is most likely to occur in this patient? Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Wheeless' Textbook of Orthopaedics. Perilunate fracture-dislocations of the wrist. Flashcards. - w/ flexion and extension lunate/capitate articulation may be felt; The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). Carpal dislocations: pathomechanics and progressive perilunar instability. Summary. 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. (OBQ04.233) Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. AP and lateral radiographs of the wrist are shown in figures A and B respectively. (SBQ17SE.70) Scapholunate Advanced Collapse Article - StatPearls Wrist osteoarthritis - Wikipedia