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. It works closely with the two forearm bones (the radius and ulna) to help the wrist move. Summary. Carpal dislocations: pathomechanics and progressive perilunar instability. 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? On physical exam she has no sensation of the volar thumb, index, and middle fingers. 1. Around 60% of perilunate dislocations are associated with a scaphoid fracture which is then termed a trans-scaphoid perilunate dislocation . Diagnosis is made with PA wrist radiographs showing widening of the SL joint. Extensor carpi radialis longus transfer to extensor pollicus longus, Extensor pollicis brevis transfer to extensor pollicus longus, Extensor indicis proprius transfer to extensor pollicus longus, Primary repair of extensor pollicus longus. 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? Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. The force of injury in this syndrome can propagate leading to perilunate dislocation as . arthroscopic repair and percutaneous pinning. The scaphoid accounts for 95% of degenerative/traumatic arthri- . (OBQ05.25) These should not be confused with perilunate dislocations in which the radiolunate articulation is . What complication is most likely to occur in this patient? (OBQ04.38) 2. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. 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. 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. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Type in at least one full word to see suggestions list, Hand Scaphoid Lunate Advanced Collapse (SLAC). The other types are perilunate, trans-radial styloid and . Treatment is designed to relieve pain and restore function.Your hand surgeon will advise you of the best treatment options and explain the risks, benefits and side-effects of various treatments for Kienbocks disease. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Ulnar side of hand. immobilization in a short arm thumb spica cast. Dorsally displaced, extra-articular fracture. (2005) ISBN:0781745861. (SBQ17SE.64) He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. What is the appropriate surgical treatment at this time? A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. Unable to process the form. (OBQ06.60) You can rate this topic again in 12 months. 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. He denies any new trauma, and has followed all post-operative activity restrictions. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. (OBQ13.140) A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. lunate fracture orthobulletswellesley, ma baby store. - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. 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. (OBQ18.223) (OBQ09.254) Lunate dislocation. He reports paresthesias in his thumb and index finger. 2023 Lineage Medical, Inc. All rights reserved. ADVERTISEMENT: Supporters see fewer/no ads. Incompetence of which of the following anatomic structures is the most likely etiology of this finding? Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. The rest of the carpal bones are in a normal anatomic position in relation to the radius. 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. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. 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. Adhesions within the first and third dorsal wrist compartments. (SBQ17SE.13) A 25-year-old female falls from her horse and injures her left wrist. Displaced impaction fracture of the lunate fossa. toe phalanx fracture orthobulletsdaniel casey ellie casey. Schmitt R, Lanz U, Buchberger W. Diagnostic Imaging of the Hand. Lunate dislocations are far less common than the less severe perilunate dislocation. (SBQ17SE.67) Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Despite treatment, there remains a high risk of future degenerative arthritis and wrist instability. The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). 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. Patients often prefer to hold their fingers in partial flexion due to pain on extension. 4. A 56-year-old woman sustains the closed injury depicted in Figures A-B. (SLAC) - Hand - Orthobullets Scapholunate Advanced Collapse Article - StatPearls Scapholunate advanced collapse (SLAC) of the wrist is a very common case of degenerative arthritis . Lunate fractures are relatively uncommon, representing about 4 percent of all carpal bone injuries [ 1-4 ]. (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. 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 . Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Make an enquiry and our team will be get in touch with you ASAP. 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. The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. Diagnosis is made with PA wrist radiographs showing widening of the SL joint. Capitate fractures are classified by the anatomic location of the fracture, along with what other concomitant injuries may be present. lunate fracture orthobullets Perilunate dislocations and fracture-dislocations are relatively uncommon injury patterns in acute wrist trauma. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. (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. 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). (OBQ07.8) A fracture to the lunate may also be associated with injury to the TFCC. Hand therapy does not change the course of the disease; however, it can help to minimize loss of motion from the disease. Overall, carpal dislocations comprise less than 10% of all wrist injuries. The proximal 2 Cs indicates the articulation between the lunate and . He sustains the injury shown in Figure A. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. (SBQ17SE.70) Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. Isolated capitate fractures are rare (scaphoid is most common associated fracture) Occurs via forceful dorsiflexion of hand (FOOSH injury) with impact on radial side; Proximal fracture fragment at risk for avascular necrosis; Clinical Features. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. 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. 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. (OBQ12.105) (OBQ12.38) His radiograph is shown in Figure A. Deciding whether a fracture needs reducing. (OBQ12.244) Pathology. The next best step in management would be: (OBQ12.163) Radiographic features Thank you. 2023 Lineage Medical, Inc. All rights reserved. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). In this condition, the lunate bone loses its blood supply, leading to death of the bone. 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. 1980;5 (3): 226-41. There are no open wounds and the hand is neurovascularly intact. Worse outcomes on the Mayo wrist score are expected without fixation, Chronic distal radioulnar joint instability can be expected to occur without fixation, Wrist function depends on the level of ulnar styloid fracture and initial displacement, Grip strength and wrist range of motion are improved with fixation, There is no adverse effect on wrist function or stability without fixation. Flashcards. A recent imaging study is seen in Figure A. A 46-year-old woman sustains an extra-articular fracture of the distal radius and undergoes open reduction and internal fixation with a volar plate and screw construct. Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. 3, Greenberg MI. Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. When performed on 18 children with distal radius-ulna fractures, P . A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. Thank you. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. The lunate is displaced and rotated volarly. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. 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. (SBQ17SE.75) The lunate is an important stabilizer of the wrist . A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. Due to a fall onto a flexed wrist or a blow to the back of hand. Diagnosis requires careful evaluation of plain radiographs. It is essentially the same sequela of . A radiograph is shown in figure A. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. Scaphoid Lunate Advanced Collapse (SLAC) d. escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. These should not be confused with perilunate dislocations in which the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. What is the next best step in management of this patient? It rarely affects both wrists. Follow-up/referral. A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. Smith's fracture: volarly displaced and extraarticular. It can be difficult to diagnose in its earlier stages. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral.

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