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. What additional data is most necessary to obtain before a reduction is attempted? Carpal dislocations: pathomechanics and progressive perilunar instability. Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. 1. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; A 17-year-old male falls from a retaining wall onto his left arm. 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. Scaphoid Lunate Advanced Collapse (SLAC) d. escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. In this condition, the lunate bone loses its blood supply, leading to death of the bone. Copyright 2023 Lineage Medical, Inc. All rights reserved. (SBQ17SE.12) Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 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. The mechanism of injury is typically a fall onto an outstretched hand with a hyperextended wrist or during a . A radiograph is shown in figure A. A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. Treatment requires urgent closed versus open reduction and stabilization. Radiographs obtained at the time of injury are shown in Figure A. whilst on the lateral the capitate no longer sits in the lunate. - it is palpable just distal to radial tubercle; It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. A 25-year-old female falls from her horse and injures her left wrist. This medication is given in an effort to decrease the incidence of which of the following? In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. Thank you. 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). Lunate Dislocation (Perilunate dissociation). Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Treatment requires urgent closed versus open reduction and stabilization. What is the next most appropriate step in management? Volar wrist swelling is usually prominent. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. 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. A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms. Diagnosis requires careful evaluation of plain radiographs. Lunate. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 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. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). Medical Information Search Thank you. Which of the following interventions should be taken? Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Radiographs are shown in Figures A and B. 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? 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. A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Towson, MD 21204 A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. MR arthrogram of the wrist to assess ligamentous injuries, Type in at least one full word to see suggestions list, Transscaphoid perilunate fracture dislocation management, AO Trauma Hand: Must Know Series HOW I DO IT Perilunate FX-Dislocations, Open reduction of volar lunate dislocation (through dorsal Cape Town approach), Hand Lunate Dislocation (Perilunate dissociation), University of Illinois Orthopaedic Surgery, Lunate Dislocation and Acute Carpal Tunnel Syndrome in 23M. J Hand Surg Am. How do you counsel him about his post-operative period? The rest of the carpal bones are in a normal anatomic position in relation to the radius. (OBQ17.87) Inability to flex the thumb interphalangeal joint. Two-point discrimination is now >10mm in these fingers. Summary. Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. - w/ flexion and extension lunate/capitate articulation may be felt; 2. A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. Evaluation of volar compartment pressures with a needle monitor, Icing and elevation of the arm with follow-up evaluation in 8 hours, Immediate EMG evaluation of the left upper extremity, Closed reduction, carpal tunnel release, and sugar tong splinting, Emergent open reduction internal fixation with carpal tunnel release. (SBQ17SE.75) 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. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. Mayfield JK, Johnson RP, Kilcoyne RK. (OBQ05.195) 4. immobilization in a short arm thumb spica cast. A 56-year-old woman sustains the closed injury depicted in Figures A-B. 1980;5 (3): 226-41. (OBQ04.38) toe phalanx fracture orthobullets The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. (SBQ07SM.38) - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: Find a hand surgeon near you. A fracture to the lunate may also be associated with injury to the TFCC. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. (OBQ18.177) The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. You can rate this topic again in 12 months. (SBQ17SE.67) Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. 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. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. Electromyography and nerve conduction velocity studies, AP and lateral radiographs of the forearm, (SAE07SM.78) Both images from . The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? not be relevant to the changes that were made. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; 73% (1391/1911) 3. Thank you. He sustains the injury shown in Figure A. The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). A 65-year-old man fell and injured his right wrist. The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). Treatment involves observation, NSAIDs and splinting in early stages of disease. Capitate fractures are most commonly due to high-energy, hyperextension forces 2. 2023 Lineage Medical, Inc. All rights reserved. Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. Which of the following tendons is most commonly transferred to address the patient's deficiency? - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. Changes for Fat Loss by with a free trial. Radiographs are provided in Figures A-C. The scaphoid accounts for 95% of degenerative/traumatic arthri- . Summary. 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). immobilization in a long arm thumb spica cast. educational laws affecting teachers. The latter mechanism frequently occurs . 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? 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). 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. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Type in at least one full word to see suggestions list, Hand Scaphoid Lunate Advanced Collapse (SLAC). The patient undergoes open reduction internal fixation (ORIF). 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. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. The lunate is displaced and rotated volarly. Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. Perilunate fracture-dislocations of the wrist. There is no single cause of Kienbocks disease. {"url":"/signup-modal-props.json?lang=us"}, Dixon A, Hacking C, El-Feky M, et al. Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . These should not be confused with perilunate dislocations in which the radiolunate articulation is . What is the appropriate surgical treatment at this time? Inability to flex the index finger proximal interphalangeal joint. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. She was seen in the emergency department at the time of injury and was told she had a sprain. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. arthroscopic repair and percutaneous pinning. (OBQ09.254) 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. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. It can be difficult to diagnose in its earlier stages. A normal wrist without Kienbock's disease. After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view? Which of the following injuries is the most likely cause of this finding? Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated hand. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. Ulnar side of hand. Patients often prefer to hold their fingers in partial flexion due to pain on extension. Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Scaphoid Lunate Advanced Collapse (S-LAC) - Hand - Orthobullets Scapholunate ligament - Wikipedia positive test seen in patients with scaphol-unate ligament injury or patients with liga-mentous laxity, where the scaphoid is no longer constrained proximally and sublux-ates out of the scaphoid fossa resulting in pain; when pressure removed from the The rest of the carpal bones are in a normal anatomic position in relation to the radius. Epidemiology. (OBQ05.25) Wheeless' Textbook of Orthopaedics. The lunate is displaced and rotated volarly. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). A 65-year-old female sustains a fall onto her outstretched right hand.
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