sudden impact force applied to the hand and wrist causing SLIL injury and scapholunate dissociation, injury occurs most commonly with wrist positioned in extension, ulnar deviation and carpal supination, SLIL tearing will position the scaphoid in flexion and lunate extension. 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. (OBQ17.87)
(OBQ06.60)
The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Unable to process the form. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. She complains of wrist pain and deformity. Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. Kienbocks disease is most common in men between the ages of 20 and 40. It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? lunate fracture orthobulletswellesley, ma baby store. Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. There is no median nerve paresthesias. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Standard wrist radiographs are normal. . Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. - most frequently dislocated carpal bone; Capitate fractures account for 1-2% of all carpal fractures 1,2. (OBQ12.38)
Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner. Both images from . Perilunate fracture-dislocations of the wrist. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. 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. (2017) Journal of Hand Surgery (European Volume). - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament;
In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. Radiographs of the affected wrist are shown in Figure A. 2. Lunate fracture. Check for errors and try again. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. 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. (SBQ17SE.28)
Figure A is an intraoperative photo. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. 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). Inability to extend the index finger proximal interphalangeal joint. Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. Read 14. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. Thieme Medical Pub.
The patient undergoes open reduction internal fixation (ORIF). The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). Treatment options depend upon the severity and stage of the disease.
Towson, MD 21204
Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. (OBQ05.25)
Die-punch. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. - it is palpable just distal to radial tubercle; If time has passed since injury, it can also lead to wrist arthritis. J Hand Surg Am. 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. not be relevant to the changes that were made. Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. 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.
Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture? 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. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. (SBQ17SE.47)
Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: The patient now reports increasing pain and inability to use his wrist. What is the most appropriate treatment at this time? 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. Which of the following injuries is the most likely cause of this finding? The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. He denies any new trauma, and has followed all post-operative activity restrictions. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-80825, see full revision history and disclosures, Mayfield classification of carpal instability, dorsal intercalated segment instability (DISI), volar intercalated segment instability (VISI), scaphoid nonunion advanced collapse (SNAC), triangular fibrocartilaginous complex (TFCC) injuries, ulnar-sided wrist impaction and impingement syndromes, calcium pyrophosphate dihydrate deposition disease. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. (OBQ18.223)
A 56-year-old woman sustains the closed injury depicted in Figures A-B. Diagnosis requires careful evaluation of plain radiographs. He is not able to see a physician for 4 months. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). 1980;5 (3): 226-41. Data Trace is the publisher of
(SBQ17SE.13)
- w/ flexion and extension lunate/capitate articulation may be felt; lunate fracture orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. 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. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . 4.
The instrument touches a structure that prevents ulnar translocation of the carpus after a PRC. A radiograph is shown in Figure 21. A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. 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). Pearls/pitfalls.
A 17-year-old male falls from a retaining wall onto his left arm. (2008) ISBN:1588904539. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. He sustained 2 minor falls over the next 6 years and his wrist pain recurred.
At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to (OBQ08.179)
14% (259/1911) 2. They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening.
Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Unable to process the form. diastasis of the scapholunate complex occurs with complete SLIL tears and capsule disruption. Dorsally displaced, extra-articular fracture. AP and lateral radiographs of the wrist are shown in figures A and B respectively.
Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ04.38)
There may be other associated injuries that require further investigation via cross-sectional imaging 1,2. 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). Check for errors and try again. A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. 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.
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. The injury is closed and she is neurovascularly intact.
1. (OBQ18.177)
The lunate is one of the eight small bones in the wrist. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient?
Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. 28 (6): 1771-84. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? Epidemiology. Adhesions within the first and third dorsal wrist compartments. What is the next best step in management of this patient? Immediate post-operative radiographs are seen in Figure A. When dislocation occurs in the wrist . Perilunate fracture-dislocations of the wrist. (2005) ISBN:0781745861. Lunate fractures are relatively uncommon, representing about 4 percent of all carpal bone injuries [ 1-4 ]. A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. Revista dedicada a la medicina Estetica Rejuvenecimiento y AntiEdad. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. 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 . (OBQ04.233)
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. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures.
lunate fracture orthobullets A 35-year-old professional football player complains of severe wrist pain after making a tackle.
It works closely with the two forearm bones (the radius and ulna) to help the wrist move. (SLAC) - Hand - Orthobullets Scapholunate Advanced Collapse Article - StatPearls Scapholunate advanced collapse (SLAC) of the wrist is a very common case of degenerative arthritis . Upper extremity deep vein thrombosis (DVT), Lower extremity deep vein thrombosis (DVT).
The rest of the carpal bones are in a normal anatomic position in relation to the radius. 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. A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand.