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 lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. Summary. 3, Greenberg MI. Thank you. 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. There is no median nerve paresthesias. Copyright 2023 Lineage Medical, Inc. All rights reserved. Perilunate dislocations and fracture-dislocations are relatively uncommon injury patterns in acute wrist trauma. A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. Around 60% of perilunate dislocations are associated with a scaphoid fracture which is then termed a trans-scaphoid perilunate dislocation . 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. 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). Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. 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. Overall, carpal dislocations comprise less than 10% of all wrist injuries. Incidence. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? She also complains of some paresthesias in her thumb and index finger. (OBQ07.8) A 65-year-old man fell and injured his right wrist. Thieme Medical Pub. - most frequently dislocated carpal bone; (OBQ04.38) In this condition, the lunate bone loses its blood supply, leading to death of the bone. Ulnar side of hand. What complication is most likely to occur in this patient? The injury is closed and she is neurovascularly intact. In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. 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). Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. (OBQ08.179) What additional data is most necessary to obtain before a reduction is attempted? 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). A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. immobilization in a long arm thumb spica cast. Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. Treatment requires urgent closed versus open reduction and stabilization. Lunate dislocations typically occur due to a fall on an outstretched hand (or during a motor vehicle injury) where there is forceful dorsiflexion of the wrist 3. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. Dorsally displaced, extra-articular fracture. toe phalanx fracture orthobulletsdaniel casey ellie casey. Treatment of acute SL ligament injuries may be immobilization versus operative repair/reconstruction depending on degree of displacement. A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. 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. Lunate fracture. Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. The lunate is made up of the volar pole, body, and dorsal pole. tures, specically non-union of scaphoid fractures. Diagnosis requires careful evaluation of plain radiographs. 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. Volar wrist swelling is usually prominent. The lunate is one of the eight small bones in the wrist. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. 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. 14% (259/1911) 2. Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. At the time the article was last revised Craig Hacking had no recorded disclosures. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. Check for errors and try again. The patient now reports increasing pain and inability to use his wrist.

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