Radiographs are provided in Figure A. Stage IV denotes a true lunate dislocation, involving a . The lunate is displaced and rotated volarly. Chronic DISI deformities may be indicated for fusion procedures depending on degree of arthritis and patient symptoms. The rest of the carpal bones are in a normal anatomic position in relation to the radius. The next best step in management would be: (OBQ12.163) The injury pattern may involve a crush injury, a FOOSH injury (Figure 18.21), or a direct blow to the dorsal aspect of the wrist. You can rate this topic again in 12 months. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. DISI (dorsal intercalated segmental instability), scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex, if left untreated the DISI deformity can progress into a, DISI deformity may also develop secondary to distal pole of the scaphoid excision for treatment of STT arthritis, DISI is a form of carpal instability dissociative, c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and lunate bones, dorsal fiber thickened (2-3mm) compared to volar fibers, dorsal component provides the greatest constraint to translation between the scaphoid and lunate bones, proximal fibers have minimal mechanical strength, Overview of wrist ligaments and biomechanics, acute FOOSH injury vs. degenerative rupture, age, nature of injury, duration since injury, degree of underlying arthritis, level of activity, pain increased with loading across the wrist (e.g. A fracture to the lunate may also be associated with injury to the TFCC. 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. 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. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. It can be difficult to diagnose in its earlier stages. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. 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? Inability to extend the thumb interphalangeal joint. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). Patients present with wrist pain following a fall. For more advanced stages, surgery is usually considered. Data Trace is the publisher of You can rate this topic again in 12 months. Summary. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated hand. (OBQ04.233) He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. In this condition, the lunate bone loses its blood supply, leading to death of the bone. Epidemiology. Dorsally displaced, extra-articular fracture. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Alendronate 700mg once per week for 3 months, Alendronate 70mg once per week for 3 months. Schmitt R, Lanz U, Buchberger W. Diagnostic Imaging of the Hand. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. Which of the following injuries is the most likely cause of this finding? Ulnar side of hand. (OBQ05.195) Towson, MD 21204 A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. This medication is given in an effort to decrease the incidence of which of the following? Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? The force of injury in this syndrome can propagate leading to perilunate dislocation as . Classification. lunate fracture orthobullets (SBQ17SE.70) whilst on the lateral the capitate no longer sits in the lunate. As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. Lunate dislocation. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. 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 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. The mechanism of injury is typically a fall onto an outstretched hand with a hyperextended wrist or during a . (SBQ17SE.13) Cleveland Combined Hand Fellowship Lecture Series 2019-2020, Fractures of the Other Carpal Bones - Austin Pitcher, MD. 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). Two-point discrimination is now >10mm in these fingers. 28 (6): 1771-84. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? A recent imaging study is seen in Figure A. The lunate is displaced and rotated volarly. Radiographic features Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? Inability to extend the index finger proximal interphalangeal joint. Overall, carpal dislocations comprise less than 10% of all wrist injuries. A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. Carpal dislocations: pathomechanics and progressive perilunar instability. Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. 1. Lunate Dislocation (Perilunate dissociation). At the time the article was last revised Craig Hacking had no recorded disclosures. She was seen in the emergency department at the time of injury and was told she had a sprain. 2020 American Society for Surgery of the Hand. The rest of the carpal bones are in a normal anatomic position in relation to the radius. The black dot in the photo is the capitate. Proper . The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. (2005) ISBN:0781745861. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury? Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. On physical exam she has no sensation of the volar thumb, index, and middle fingers. Phalanx fractures of the hand are some of the most common fractures occurring in humans. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. (OBQ07.226) Orthopaedic Specialists of North Carolina. In this condition, the lunate bone loses its blood supply, leading to death of the bone. 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. Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. What is the most appropriate treatment at this time? ADVERTISEMENT: Supporters see fewer/no ads. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. The latter mechanism frequently occurs . A radiograph is shown in figure A. 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). 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. There is no single cause of Kienbocks disease. Smith's fracture: volarly displaced and extraarticular. - most frequently dislocated carpal bone; . Lunate Dislocation (Perilunate dissociation) . toe phalanx fracture orthobulletsdaniel casey ellie casey. She also complains of some paresthesias in her thumb and index finger. lunate fracture orthobullets 110 West Rd., Suite 227 Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. (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. Volar wrist swelling is usually prominent. His radiograph is shown in Figure A. (OBQ05.25) A 65-year-old man fell and injured his right wrist. The lunate is displaced and rotated volarly. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. 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 palpable just distal to radial tubercle; She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. 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. (SBQ17SE.28) Both images from . A 35-year-old professional football player complains of severe wrist pain after making a tackle. (SBQ17SE.47) How do you counsel him about his post-operative period? In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. 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?