The other types are perilunate, trans-radial styloid and . Two-point discrimination is now >10mm in these fingers. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Which of the following has evidence to support its utility in this clinical situation? Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. Perilunate fracture-dislocations of the wrist. 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. (2005) ISBN:0781745861. Lunate fracture. Wheeless' Textbook of Orthopaedics. Summary. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. Deciding whether a fracture needs reducing. 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. What is the next best step in management of this patient? His radiograph is shown in Figure A. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. (OBQ12.38) She complains of wrist pain and deformity. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. 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 is palpable just distal to radial tubercle; Classification. 28 (6): 1771-84. 1980;5 (3): 226-41. ORTHOBULLETS; Flashcards. This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. not be relevant to the changes that were made. (OBQ12.244) Lunate Dislocation (Perilunate dissociation). 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. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of, Anterior and posterior interosseous neurectomy. 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. AP and lateral radiographs of the wrist are shown in figures A and B respectively. Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent.A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability. A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. Adhesions within the first and third dorsal wrist compartments. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. Pearls/pitfalls. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. Diagnosis is made with PA wrist radiographs showing widening of the SL joint. (OBQ13.140) Greenberg's text-atlas of emergency medicine. It rarely affects both wrists. There is no single cause of Kienbocks disease. Inability to flex the thumb interphalangeal joint. In this condition, the lunate bone loses its blood supply, leading to death of the bone. Inability to extend the thumb interphalangeal joint. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. 3, Greenberg MI. 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. Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner. Which of the following interventions should be taken? A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: When dislocation occurs in the wrist . Dorsally displaced, extra-articular fracture. Radiographs of the affected wrist are shown in Figure A. 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. The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. - Discussion: A 17-year-old male falls from a retaining wall onto his left arm. What additional data is most necessary to obtain before a reduction is attempted? Data Trace is the publisher of Copyright 2023 Lineage Medical, Inc. All rights reserved. There is no median nerve paresthesias. - w/ flexion and extension lunate/capitate articulation may be felt; Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. (SBQ17SE.70) Lunate dislocationsare an uncommon traumatic wrist injury that require prompt management and surgical repair. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Immediate post-operative radiographs are seen in Figure A. These should not be confused with perilunate dislocations in which the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis A 32-year-old professional baseball player presents with wrist pain after a fall on his outstretched wrist 10 days ago. A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. (OBQ16.228) Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Which of the following distal radius fractures is associated with volar translation of carpus relative to the radial articulation? Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). For more advanced stages, surgery is usually considered. In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. Capitate fractures account for 1-2% of all carpal fractures 1,2. The lunate is displaced and rotated volarly. At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to Depressed fracture of the lunate fossa (articular surface) Smith's. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? The patient now reports increasing pain and inability to use his wrist. Treatment involves observation, NSAIDs and splinting in early stages of disease. immobilization in a long arm thumb spica cast. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Thank you. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. He denies any new trauma, and has followed all post-operative activity restrictions. There is injury of all of the perilunate ligaments, most significantly the dorsal radiolunate ligament. Proper . Lunate fractures account for around 4% of all carpal fractures 1. (SBQ17SE.64) A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. The patient undergoes open reduction internal fixation (ORIF). After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view? 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. What complication is most likely to occur in this patient? Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). Capitate fractures are most commonly due to high-energy, hyperextension forces 2. Scapholunate Advanced Collapse Article - StatPearls Wrist osteoarthritis - Wikipedia The patient recovered well initially but presents after 6 months with grip weakness. (SBQ17SE.75) Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . Most patients with Kienbocks disease have the following symptoms: The diagnosis of Kienbocks disease can often be made by reviewing your history, performing a physical examination, and taking x-rays. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. Epidemiology. Cleveland Combined Hand Fellowship Lecture Series 2019-2020, Fractures of the Other Carpal Bones - Austin Pitcher, MD. immobilization in a short arm thumb spica cast. 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. (OBQ06.102) Thieme Medical Pub. He was treated as a sprain and no further follow-up was planned. (OBQ06.136) Copyright 2023 Lineage Medical, Inc. All rights reserved. The lunate is an important stabilizer of the wrist . 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. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. The most important differential is of other carpal dislocations, particularly: In addition to stating that a lunate dislocation is present, a number of features should be sought and commented upon: ensure that radiolunate alignment is disrupted, and that you are not looking at a perilunate dislocation(stage II carpal dislocation), evaluate and comment on the degree or palmar rotation of the lunate (this can be up to 270 degrees)4, ensure that the capitate remains co-linear with the long axis of the radius, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys.