Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? (OBQ16.228) 2023 Lineage Medical, Inc. All rights reserved. Which of the following tendons is most commonly transferred to address the patient's deficiency? A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. What complication is most likely to occur in this patient? Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Acces PDF Scapholunate Advanced Collapse And Scaphoid Nonunion Radiographs are provided in Figures A-C. They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. Surgery may be done to change forces across the lunate and wrist joint or to improve vascularity of the lunate. A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. A four-stage process to describe perilunar instability has been described,where lunate dislocation represents stage IV 2. disruption of the normally smooth line made by tracing the proximal articular surfaces of the hamate and capitate, lunate overlaps the capitate and has a 'triangular' or 'piece of pie' appearance (also seen in perilunate dislocation), signet ring sign: rounded appearance of the scaphoid tubercle due to rotatory subluxation from injury to the scapholunate ligament, lunate seen displaced and angulated volarly, lunate does not articulate with capitate or radius (as opposed to perilunate dislocation where the lunate remains aligned with the radius). Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. Hip fracture The scaphoid accounts for 95% of degenerative/traumatic arthri- . 110 West Rd., Suite 227 (OBQ13.140) Difficult wrist fractures. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. 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 . A 32-year-old professional baseball player presents with wrist pain after a fall on his outstretched wrist 10 days ago. In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Summary. Wrist Dislocation by Kadeer M Halimi from emedicine.com. Medical Information Search Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. A fracture to the lunate may also be associated with injury to the TFCC. - lunate articulates proximally w/ radius and distally w/ capitate; Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. Summary. Check for errors and try again. Orthopaedic Specialists of North Carolina. Radiographs are provided in Figure A. 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. 1. In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. Dorsal fractures commonly axial fracture healing. Medical search According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . If time has passed since injury, it can also lead to wrist arthritis. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Radiographs obtained at the time of injury are shown in Figure A. The lunate is one of the eight small bones in the wrist. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). You can rate this topic again in 12 months. Carpal tunnel release if no resolution at 6-12 weeks. FlashCards My DeckMaster Create Card Deck . 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. (SBQ17SE.70) 28 (6): 1771-84. ORTHOBULLETS; Flashcards. Hamate Body Fracture - Hand - Orthobullets A 56-year-old woman sustains the closed injury depicted in Figures A-B. Lunate Fracture - an overview | ScienceDirect Topics 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. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. ADVERTISEMENT: Supporters see fewer/no ads. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. - w/ flexion and extension lunate/capitate articulation may be felt; (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. Deciding whether a fracture needs reducing. 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. toe phalanx fracture orthobullets - sportsnt.com.tw Capitate fractures account for 1-2% of all carpal fractures 1,2. The lunate is displaced and rotated volarly. A 65-year-old man fell and injured his right wrist. Chronic DISI deformities may be indicated for fusion procedures depending on degree of arthritis and patient symptoms. A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Lunate dislocationsare an uncommon traumatic wrist injury that require prompt management and surgical repair. Radiographs of the affected wrist are shown in Figure A. Patients often prefer to hold their fingers in partial flexion due to pain on extension. Proper . Perilunate dislocation | Radiology Reference Article | Radiopaedia.org - Discussion: These should not be confused with perilunate dislocations in which the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Diagnosis requires careful evaluation of plain radiographs. - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: 14% (259/1911) 2. Which of the following radiographic views shown in Figures A to E would be most helpful in establishing the diagnosis? (SBQ17SE.47) Difficult wrist fractures. It rarely affects both wrists. 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). Phalanx Fractures - Hand - Orthobullets The rest of the carpal bones are in a normal anatomic position in relation to the radius. Treatment of acute SL ligament injuries may be immobilization versus operative repair/reconstruction depending on degree of displacement. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Distal Radius Fractures - Trauma - Orthobullets Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . A radiograph is shown in figure A. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets 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. The patient undergoes open reduction internal fixation (ORIF). 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. The lunate is made up of the volar pole, body, and dorsal pole. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). Find a hand surgeon near you. 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 .