Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . 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. (OBQ13.140) The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). The patient now reports increasing pain and inability to use his wrist. Wrist Dislocation by Kadeer M Halimi from emedicine.com. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Summary. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Medical Information Search You can rate this topic again in 12 months. If time has passed since injury, it can also lead to wrist arthritis. Most hand and wrist fractures (the latter of which is basically an ulnar styloid fracture) are caused by trying to break a fall with your arm outstretched. Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. 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. Treatment options depend upon the severity and stage of the disease. Inability to extend the thumb interphalangeal joint. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. Patients often prefer to hold their fingers in partial flexion due to pain on extension. At the time the article was created Andrew Murphy had no recorded disclosures. Difficult wrist fractures. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). toe phalanx fracture orthobullets Diagnosis requires careful evaluation of plain radiographs. Data Trace is the publisher of The lunate is made up of the volar pole, body, and dorsal pole. 28 (6): 1771-84. He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. Follow-up/referral. 110 West Rd., Suite 227 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 is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Ulnar side of hand. Colles'. (OBQ12.105) Phalanx fractures of the hand are some of the most common fractures occurring in humans. Die-punch. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. The patient shows you the lateral film in Figure A. In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. Lunate fractures and associated radiocarpal and midcarpal instabilities: a systematic review:. The lunate is made up of the volar pole, body, and dorsal pole. In this condition, the lunate bone loses its blood supply, leading to death of the bone. (SBQ17SE.47) Adequate maintenance of reduction by non-operative treatment is unsuccesful. The lunate is displaced and rotated volarly. Unable to process the form. Around 20% of patients possess a single-vessel supply to their lunate hence there is an increased possibility of avascular necrosis, the remaining cohort typically has a two-vessel supply and intraosseous anastomosis 2. 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. The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. (OBQ18.223) (OBQ12.244) Diagnosis is made with PA wrist radiographs showing widening of the SL joint. Admit for acute carpal tunnel syndrome monitoring, Admit for acute open reduction/internal fixation, Place into removable soft splint and follow-up in clinic, Place into rigid splint and follow-up in clinic, Place into rigid splint and schedule for outpatient open reduction/internal fixation. Which plating option provides the most appropriate treatment of this fracture? This medication is given in an effort to decrease the incidence of which of the following? Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. The lunocapitate articulation may be disrupted resulting in a dorsal perilunate dislocation, or in the case of concomitant scaphoid fracture, the wrist may undergo a transscaphoperilunate dislocation. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Orthopaedic Specialists of North Carolina. What is the likely mechanism of her paresthesias and what is the most appropriate treatment? Two-point discrimination is now >10mm in these fingers. A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Despite treatment, there remains a high risk of future degenerative arthritis and wrist instability. (OBQ06.136) SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. When dislocation occurs in the wrist . Epidemiology. (2017) Journal of Hand Surgery (European Volume). The proximal 2 Cs indicates the articulation between the lunate and . At the time the article was last revised Craig Hacking had no recorded disclosures. - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament; Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. commonly missed (~25%) on initial presentation, occurs when wrist extended and ulnarly deviated, disruption of capitolunate articulation -->, disruption of lunotriquetral articulation -->, failure of dorsal radiocarpal ligament -->, ligamentous disruptions with associated fractures of the radius, ulnar, or carpal bones, lunate stays in position while carpus dislocates, lunate forced volar or dorsal while carpus remains aligned, major stabilizers of the proximal carpal row, ligaments the both originate and insert among the carpal bones, + lunotriquetral disruption, "perilunate", Lunate dislocated from lunate fossa (usually volar), median nerve symptoms may occur in ~25% of patients, most common in Mayfield stage IV where the lunate dislocates into the carpal tunnel, due to palmar rotation from dorsal force of carpus, loss of colinearity of radius, lunate, and capitate, no indications when used as definitive management, universally poor functional outcomes with non-operative management, emergent closed reduction/splinting followed by open reduction, ligament repair, fixation, possible carpal tunnel release, decreased grip strength and stiffness are common, chronic injury (defined as >8 weeks after initial injury), not uncommon, as initial diagnosis frequently missed, chronic injuries with degenerative changes, finger traps, elbow at 90 degrees of flexion, dorsal dislocations are reduced through wrist extension, traction, and flexion of wrist, longitudinal incision centered at Lister's tubercle, excellent exposure of proximal carpal row and midcarpal joints, extended carpal tunnel incision just proximal to volar wrist crease, some believe volar ligament repair not necessary, difficulty regaining digital flexion and grip, controversy of k-wire versus intraosseous cerclage wiring, repair of lunotriquetral interosseous ligament, decision to repair based on surgeon preference as no studies have shown improved results, short arm thumb spica splint converted to short arm cast at first post-op visit, duration of casting varies, but at least 6 weeks, perform via dorsal and volar incisions if median nerve compression is present, volar approach allows median nerve decompression with excision of lunate, dorsal approach facilitates excision of the scaphoid and triquetrum, radiodense appearance of the lunate on radiograph reported in up to 12.5% of cases, usually identified 1-4 months post-injury, - 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). Scapholunate Advanced Collapse Article - StatPearls Wrist osteoarthritis - Wikipedia 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. What is the next best step in management of this patient? 73% (1391/1911) 3. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. (OBQ06.102) (OBQ12.38) They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. lunate fracture orthobullets Like the scaphoid bone, the lunate also has a tenuous retrograde blood supply off of an interosseus arterial branch, and it has the same inherent risk of poor healing and AVN . J Hand Surg Am. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. Three months after the fracture she reports an acute loss of her ability to extend her thumb. Proper . The patient undergoes open reduction internal fixation (ORIF). 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. The patient recovered well initially but presents after 6 months with grip weakness. A 25-year-old female falls from her horse and injures her left wrist. 1. What is the appropriate surgical treatment at this time? Diagnosis requires careful evaluation of plain radiographs. Which of the following interventions should be taken? Treatment involves immobilization or surgical fixation depending on location, severity and alignment of 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). Mechanism of injury. (OBQ04.38) Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. The force of injury in this syndrome can propagate leading to perilunate dislocation as . 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. (SBQ17SE.67) It is the second most common carpal bone injury in children 1. The mechanism of injury is typically a fall onto an outstretched hand with a hyperextended wrist or during a . 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. Capitate fractures account for 1-2% of all carpal fractures 1,2. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). - it has large volar surface, & is displaced volarward w/ forceddorsiflexion of the wrist; Figure A is an intraoperative photo. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis index finger injury, The patient should undergo revision fixation as soon as possible, The plate is in appropriate position and will likely never need to be removed. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. - lunate articulates proximally w/ radius and distally w/ capitate; At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Treatment involves observation, NSAIDs and splinting in early stages of disease. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. Schmitt R, Lanz U, Buchberger W. Diagnostic Imaging of the Hand. Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist, Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands, accounts for 17.5% of all fractures in adults, younger patients due to high energy mechanisms, older patients due to low energy mechanisms (i.e. (OBQ09.254) The lunate is displaced and rotated volarly. Radiographs are provided in Figure A. push up position), may be associated with wrist instability or weakness, may see swelling over the dorsal aspect of the wrist, tenderness in the anatomical snuffbox or over the, pain increased with extreme wrist extension and radial deviation, when deviating from ulnar to radial, pressure over volar aspect of scaphoid subluxates the scaphoid dorsally out of the scaphoid fossa of the distal radius, and a clunk is palpated when pressure is released as the scaphoid reduces back over the dorsal rim of the radius, a painful clunk during this maneuver may indicate insufficiency of scapholunate ligament, clenched fist (can exaggerate the diastasis), dorsal tilt of lunate leads to SL angle > 70, may be used as screening tool for arthroscopy, always assess the contralateral wrist for comparison, may demonstrate the presence of a tear but cannot determine the size of the tear, positive finding of a tear may indicate the need for wrist arthroscopy, often overused as a screening modality for SLIL tears, requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis, Carpal instability nondissociative (CIND), splinting and close follow-up with repeat imaging and clinical response with acute injuries, most people feel casting alone is insufficient, acute scapholunate ligament injury without carpal malalignment, ligament pathoanatomy is ammenable to repair, if pathoanatomy of SL ligament injury is a scaphoid fx than repair with, small incision is made just distal to the radial styloid, care to avoid cutting the radial sensory nerve branches, often added to a ligament repair and remains a viable alternative for a chronic instability when ligament repair is not feasible, place two k-wires in parallel into the scaphoid bone, reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation, confirm reduction of the SL joint under fluoroscopy, FCR tendon transfer (direct SL joint reduction), ECRB tendonosis (indirect SL joint reduction), weave not recommended due to high incidence of late failure.
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