The lunate is made up of the volar pole, body, and dorsal pole. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? 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). Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Capitate fractures account for 1-2% of all carpal fractures 1,2. Hook of hamate fractures are rare, often missed, injuries generally as a result of a direct blow to the hamate bone most commonly seen in athletes. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. (OBQ05.25) Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? - w/ flexion and extension lunate/capitate articulation may be felt; The black dot in the photo is the capitate. Figure A is an intraoperative photo. 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. (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. In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. Other common causes include: car . Inability to extend the thumb interphalangeal joint. Overall, carpal dislocations comprise less than 10% of all wrist injuries. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Epidemiology. Summary. (OBQ10.127) 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. He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. 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. Mechanism of injury. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Perilunate fracture-dislocations of the wrist. Carpal dislocations: pathomechanics and progressive perilunar instability. He was treated as a sprain and no further follow-up was planned. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Which of the following interventions should be taken? 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. (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. It is essentially the same sequela of . A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. A radiograph is shown in figure A. Incidence. Depressed fracture of the lunate fossa (articular surface) Smith's. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. What is the next best step in management of this patient? Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? Summary. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? - lunate articulates proximally w/ radius and distally w/ capitate; Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist? 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. There is injury of all of the perilunate ligaments, most significantly the dorsal radiolunate ligament. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. (OBQ06.136) In this condition, the lunate bone loses its blood supply, leading to death of the bone. Radiographs of the affected wrist are shown in Figure A. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . tures, specically non-union of scaphoid fractures. (OBQ12.105) Summary. Perilunate fracture-dislocations of the wrist. The patient shows you the lateral film in Figure A. 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? What is the appropriate surgical treatment at this time? What is the most appropriate treatment at this time? 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. A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. Pearls/pitfalls. Philadelphia : Lippincott Williams & Wilkins, c2005. (SBQ17SE.75) Copyright 2023 Lineage Medical, Inc. All rights reserved. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; A fracture to the lunate may also be associated with injury to the TFCC. Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. (OBQ08.179) A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. (SBQ07SM.38) Four months post-injury, he presents to the office with an inability to extend his thumb. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . Copyright 2023 Lineage Medical, Inc. All rights reserved. How do you counsel him about his post-operative period? The lunate is displaced and rotated volarly. Patients present with wrist pain following a fall. The injury is closed and she is neurovascularly intact. Radiographs are provided in Figures A-C. What is the most appropriate next step in management? Smith's fracture: volarly displaced and extraarticular. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. 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. 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. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. (SBQ17SE.67) 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). (OBQ06.60) Radiographs obtained at the time of injury are shown in Figure A. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. A 56-year-old woman sustains the closed injury depicted in Figures A-B. Lunate dislocation. Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated hand. When performed on 18 children with distal radius-ulna fractures, P . 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). 2. 2020 American Society for Surgery of the Hand. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. Thank you. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). He denies any new trauma, and has followed all post-operative activity restrictions. - it is palpable just distal to radial tubercle; 2.0 screw for a Scaphoid Hand Fracture How to palpate the . (OBQ18.216) He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. Management should consist of. - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. You can rate this topic again in 12 months. There may be other associated injuries that require further investigation via cross-sectional imaging 1,2. A radiograph is shown in Figure 21. 3, Greenberg MI.
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