The patient undergoes open reduction internal fixation (ORIF). Epidemiology. Wrist with Kienbock's disease and ulna that is short compared to radius, Using this search tool means you agree to the, 2023 American Society for Surgery of the Hand, from the American Society for Surgery of the Hand, Decreased motion or stiffness of 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. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. Around 60% of perilunate dislocations are associated with a scaphoid fracture which is then termed a trans-scaphoid perilunate dislocation . You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. He reports paresthesias in his thumb and index finger. Unable to process the form. Copyright 2023 Lineage Medical, Inc. All rights reserved. Lunate fractures are often secondary to axial loading of the head capitate bone,this is seen in forceful hyperextension with ulnar deviation 2. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. 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? Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. (OBQ13.140) 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. Both images from . Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. 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. Distal Radius Fracture Non-Spanning External Fixator . In this condition, the lunate bone loses its blood supply, leading to death of the bone. (OBQ12.105) What is the next most appropriate step in management? 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). Adhesions within the first and third dorsal wrist compartments. (OBQ05.195) The lunate is an important stabilizer of the wrist . At the time the article was created Andrew Murphy had no recorded disclosures. Dorsally displaced, extra-articular fracture. It is the second most common carpal bone injury in children 1. 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. There is no median nerve paresthesias. Medical Information Search Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? 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. (OBQ09.227) Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Radiographs taken in the emergency room are seen in Figure A. How do you counsel him about his post-operative period? The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). Lunate dislocations are far less common than the less severe perilunate dislocation. The next best step in management would be: (OBQ12.163) 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. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. educational laws affecting teachers. lunate fracture orthobullets Which plating option provides the most appropriate treatment of this fracture? If time has passed since injury, it can also lead to wrist arthritis. Treatment requires urgent closed versus open reduction and stabilization. arthroscopic repair and percutaneous pinning. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. ORTHOBULLETS; Flashcards. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? The patient shows you the lateral film in Figure A. (OBQ07.8) Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. A fracture to the lunate may also be associated with injury to the TFCC. comic book publishers accepting submissions 2022 Likes ; brady list police massachusetts Followers ; nurse injector training Followers ; transfer apple health data to samsung Subscriptores ; night shift vs overnight shift Followers ; big joe's funeral questions and answers Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. Which of the following interventions should be taken? Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . At the time the article was last revised Craig Hacking had no recorded disclosures. 4. Incidence. (OBQ18.223) Diagnosis requires careful evaluation of plain radiographs. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. (SLAC) - Hand - Orthobullets Scapholunate Advanced Collapse Article - StatPearls Scapholunate advanced collapse (SLAC) of the wrist is a very common case of degenerative arthritis . 2020 American Society for Surgery of the Hand. - it has large volar surface, & is displaced volarward w/ forceddorsiflexion of the wrist; Lunate Dislocation (Perilunate dissociation). A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. What is this structure? A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. (SBQ17SE.64) The lunate is displaced and rotated volarly. 2023 Lineage Medical, Inc. All rights reserved. Smith's fracture: volarly displaced and extraarticular. 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.
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