The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Ulnar side of hand. A 65-year-old man fell and injured his right wrist. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. (SBQ17SE.13) Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. A radiograph is shown in Figure 21. Lunate fracture. Copyright 2023 Lineage Medical, Inc. All rights reserved. Radiographs are shown in Figures A and B. What is the appropriate surgical treatment at this time? Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. Capitate fractures account for 1-2% of all carpal fractures 1,2. Treatment of acute SL ligament injuries may be immobilization versus operative repair/reconstruction depending on degree of displacement. Treatment involves observation, NSAIDs and splinting in early stages of disease. They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. 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. Smith's fracture: volarly displaced and extraarticular. (2017) Journal of Hand Surgery (European Volume). (OBQ09.227) Inability to flex the index finger proximal interphalangeal joint. A 17-year-old male falls from a retaining wall onto his left arm. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Wheeless' Textbook of Orthopaedics. Immediate post-operative radiographs are seen in Figure A. Copyright 2023 Lineage Medical, Inc. All rights reserved. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. For more advanced stages, surgery is usually considered. Thank you. Fractures of the normal lunate--isolated or associated with fractures of the scaphoid or radius--are very rare. - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; He is not able to see a physician for 4 months. 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. Summary. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. 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). (OBQ11.273) 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. 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 . 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). (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Medical Information Search (OBQ13.140) These should not be confused with perilunate dislocations in which the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . Stage IV denotes a true lunate dislocation, involving a . A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. - it differs from Colles' or Smith's Fracture in that the dislocation is the most striking radiographic finding; - volar Barton's is more common than dorsal Barton frxs; - mechanism: - usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; (OBQ04.233) (SLAC) - Hand - Orthobullets Scapholunate Advanced Collapse Article - StatPearls Scapholunate advanced collapse (SLAC) of the wrist is a very common case of degenerative arthritis . Distal Radius Fracture Non-Spanning External Fixator . Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. The patient now reports increasing pain and inability to use his wrist. Scapholunate Advanced Collapse Article - StatPearls Wrist osteoarthritis - Wikipedia The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. What is the most appropriate treatment at this time? Colles'. Which plating option provides the most appropriate treatment of this fracture? The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. Radiographic features lunate fracture orthobullets Lunate. - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. What is the most likely etiology of her new loss of function? Changes for Fat Loss by with a free trial. (OBQ06.136) The lunate is displaced and rotated volarly. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Inability to flex the thumb interphalangeal joint. not be relevant to the changes that were made. Diagnosis is made with PA wrist radiographs showing widening of the SL joint. (OBQ18.177) (SBQ17SE.12) The patient shows you the lateral film in Figure A. ORTHOBULLETS; Flashcards. Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Diagnosis requires careful evaluation of plain radiographs. (OBQ17.87) Perilunate fracture-dislocations of the wrist. The injury is closed and she is neurovascularly intact. (OBQ09.254) Incidence. Orthopaedic Specialists of North Carolina. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. The proximal 2 Cs indicates the articulation between the lunate and . Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. 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. toe phalanx fracture orthobullets FlashCards My DeckMaster Create Card Deck . At the time the article was last revised Craig Hacking had no recorded disclosures. The black dot in the photo is the capitate. (OBQ18.223) 1980;5 (3): 226-41. What is this structure? A 65-year-old female sustains a fall onto her outstretched right hand. Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. (SBQ17SE.70) A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. whilst on the lateral the capitate no longer sits in the lunate. 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. Difficult wrist fractures. Unable to process the form. Which of the following has evidence to support its utility in this clinical situation? Data Trace Publishing Company 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. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Capitate fractures are most commonly due to high-energy, hyperextension forces 2. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. She complains of wrist pain and deformity. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Greenberg's text-atlas of emergency medicine. Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. A fracture to the lunate may also be associated with injury to the TFCC. lunate fracture orthobullets Die-punch. These should not be confused with perilunate dislocations in which the radiolunate articulation is . He initially thought it was a sprain, but presents due to continued pain worsened by push-ups. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. Thank you. Radiographs are provided in Figures A-C. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Make an enquiry and our team will be get in touch with you ASAP. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. On physical exam she has no sensation of the volar thumb, index, and middle fingers. A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. Due to a fall onto a flexed wrist or a blow to the back of hand. (SBQ17SE.28) J Hand Surg Am. Lunate fractures account for around 4% of all carpal fractures 1. Unable to process the form. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? The scaphoid accounts for 95% of degenerative/traumatic arthri- . If time has passed since injury, it can also lead to wrist arthritis.