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. 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. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. (SBQ17SE.28) Summary. It is the second most common carpal bone injury in children 1. Summary. (OBQ05.25) The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . educational laws affecting teachers. A 35-year-old professional football player complains of severe wrist pain after making a tackle. (OBQ12.105) Make an enquiry and our team will be get in touch with you ASAP. immobilization in a short arm thumb spica cast. 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. Perilunate fracture-dislocations of the wrist. Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. 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? What is the most appropriate treatment at this time? A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. Kienbocks disease is most common in men between the ages of 20 and 40. Unable to process the form. 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. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . Which of the following tendons is most commonly transferred to address the patient's deficiency? Displaced impaction fracture of the lunate fossa. A 65-year-old female sustains a fall onto her outstretched right hand. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. 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). Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. He sustains the injury shown in Figure A. Lunate Dislocation (Perilunate dissociation). 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. - w/ flexion and extension lunate/capitate articulation may be felt; Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. -. AP and lateral radiographs of the wrist are shown in figures A and B respectively. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. A recent imaging study is seen in Figure A. Figure A is an intraoperative photo. Lunate fracture. The patient undergoes open reduction internal fixation (ORIF). The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. When performed on 18 children with distal radius-ulna fractures, P . tures, specically non-union of scaphoid fractures. 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. (OBQ16.228) Despite treatment, there remains a high risk of future degenerative arthritis and wrist instability. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. What is the most likely etiology of her new loss of function? (SBQ17SE.70) Barton's. Fracture-dislocation of radiocarpal joint (with intra-articular fracture involving the volar or dorsal lip) Chauffer's. Fracture of radial styloid. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. (OBQ04.233) Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). The lunate is one of the eight small bones in the wrist. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Radiographs obtained at the time of injury are shown in Figure A. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Treatment involves observation, NSAIDs and splinting in early stages of disease. Incidence. Both images from . In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. Wrist Dislocation by Kadeer M Halimi from emedicine.com. After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view? Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. 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 patient shows you the lateral film in Figure A. 4. Chronic DISI deformities may be indicated for fusion procedures depending on degree of arthritis and patient symptoms. Which of the following has evidence to support its utility in this clinical situation? main cause for these lesions is a direct impact against a hard surface with a, 4th or 5th metacarpal base fractures or dislocations, usually required to delineate fracture pattern and determine operative plan, diagnosis confirmed by history, physical exam, and, may be used for extra-articular non-displaced fracture, most fractures are intra-articular and require open reduction, interfragmentary screws +/- k-wires for temporary stabilization, fixation may be obtained with K wires or screws, 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). When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Radiographs are provided in Figures A-C. 110 West Rd., Suite 227 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. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. 3, Greenberg MI. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Colles'. (OBQ08.179) Admit for acute carpal tunnel syndrome monitoring, Admit for acute open reduction/internal fixation, Place into removable soft splint and follow-up in clinic, Place into rigid splint and follow-up in clinic, Place into rigid splint and schedule for outpatient open reduction/internal fixation. Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. Lunate dislocations typically occur due to a fall on an outstretched hand (or during a motor vehicle injury) where there is forceful dorsiflexion of the wrist 3. 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. . Two-point discrimination is now >10mm in these fingers. 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. The instrument touches a structure that prevents ulnar translocation of the carpus after a PRC. - it is palpable just distal to radial tubercle; Frequent questions. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. (SBQ17SE.67) (SBQ17SE.12) Changes for Fat Loss by with a free trial. The rest of the carpal bones are in a normal anatomic position in relation to the radius. 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. It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. In this condition, the lunate bone loses its blood supply, leading to death of the bone. Which of the following interventions should be taken? He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Three months after the fracture she reports an acute loss of her ability to extend her thumb. 2. Inability to extend the thumb interphalangeal joint. 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. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint spared). (SAE07SM.38) This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist, Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands, accounts for 17.5% of all fractures in adults, younger patients due to high energy mechanisms, older patients due to low energy mechanisms (i.e. A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. The lunate is an important stabilizer of the wrist . 2.0 screw for a Scaphoid Hand Fracture How to palpate the . Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Incompetence of which of the following anatomic structures is the most likely etiology of this finding? (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Standard wrist radiographs are normal. Radiographs are shown in Figures A and B. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. The force of injury in this syndrome can propagate leading to perilunate dislocation as . Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Fractures of the normal lunate--isolated or associated with fractures of the scaphoid or radius--are very rare. Summary. The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. The lunate is made up of the volar pole, body, and dorsal pole. You can rate this topic again in 12 months. A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. He was treated as a sprain and no further follow-up was planned. 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. (OBQ06.60) Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. 2020 American Society for Surgery of the Hand. A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. Medical Information Search Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. 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 . Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. (OBQ13.78) Diagnosis is made with PA wrist radiographs showing widening of the SL joint. Overall, carpal dislocations comprise less than 10% of all wrist injuries. Hip fractures are strongly associated with BMD in the proximal femur, but there are also many clinical predictors of hip fracture risk that are independent of bone density. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. On physical exam she has no sensation of the volar thumb, index, and middle fingers. Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . If you are unsure, it is best to err on the safe side and call for help. 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. 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. Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. She was seen in the emergency department at the time of injury and was told she had a sprain. Inability to extend the index finger proximal interphalangeal joint. The lunate is one of the eight small bones in the wrist. Epidemiology. The black dot in the photo is the capitate. What is the most appropriate treatment at this time? What is the next most appropriate step in management? Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Check for errors and try again. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. The next best step in management would be: (OBQ12.163) What is this structure? 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).

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