Mechanism of injury. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. (SBQ17SE.47) Radiographs obtained at the time of injury are shown in Figure A. Epidemiology. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. When performed on 18 children with distal radius-ulna fractures, P . When dislocation occurs in the wrist . (OBQ18.216) 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. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. Difficult wrist fractures. 43 (1): 84-92. 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 rest of the carpal bones are in a normal anatomic position in relation to the radius. If you are unsure, it is best to err on the safe side and call for help. Lunate fracture. Perilunate dislocations and fracture-dislocations are relatively uncommon injury patterns in acute wrist trauma. Deciding whether a fracture needs reducing. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. It can be caused by multiple factors such as: Damage to the lunate can lead to pain and stiffness. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Treatment options depend upon the severity and stage of the disease. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. Electromyography and nerve conduction velocity studies, AP and lateral radiographs of the forearm, (SAE07SM.78) The patient recovered well initially but presents after 6 months with grip weakness. Adequate maintenance of reduction by non-operative treatment is unsuccesful. 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). 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. Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . 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). Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Die-punch. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. Radiographs taken in the emergency room are seen in Figure A. Wrist Dislocation by Kadeer M Halimi from emedicine.com. (OBQ06.60) Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. Lunate dislocations are far less common than the less severe perilunate dislocation. (OBQ04.233) Dorsally displaced, extra-articular fracture. What is the most appropriate treatment at this time? It works closely with the two forearm bones (the radius and ulna) to help the wrist move. It is the second most common carpal bone injury in children 1. {"url":"/signup-modal-props.json?lang=us"}, Dixon A, Hacking C, El-Feky M, et al. 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. (SBQ17SE.13) A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. The scaphoid accounts for 95% of degenerative/traumatic arthri- . Standard wrist radiographs are normal. 1980;5 (3): 226-41. Overall, carpal dislocations comprise less than 10% of all wrist injuries. Lunate dislocation. There are no open wounds and the hand is neurovascularly intact. A fracture to the lunate may also be associated with injury to the TFCC. These should not be confused with perilunate dislocations in which the radiolunate articulation is . - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament; Copyright 2023 Lineage Medical, Inc. All rights reserved. Radiographs of the affected wrist are shown in Figure A. Frequent questions. Due to a fall onto a flexed wrist or a blow to the back of hand. What is the most appropriate next step in management? 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. The rest of the carpal bones are in a normal anatomic position in relation to the radius. The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. Summary. The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). The lunate is displaced and rotated volarly. ORTHOBULLETS; Flashcards. The most important differential is of other carpal dislocations, particularly: In addition to stating that a lunate dislocation is present, a number of features should be sought and commented upon: ensure that radiolunate alignment is disrupted, and that you are not looking at a perilunate dislocation(stage II carpal dislocation), evaluate and comment on the degree or palmar rotation of the lunate (this can be up to 270 degrees)4, ensure that the capitate remains co-linear with the long axis of the radius, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Ulnar side of hand. He initially thought it was a sprain, but presents due to continued pain worsened by push-ups. A 24-year-old stagehand fell 12 feet off of a ladder while preparing a set. Medical Information Search (SAE07SM.38) (OBQ12.244) Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. (OBQ04.38) 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. You can rate this topic again in 12 months. 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. Colles'. The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. - w/ flexion and extension lunate/capitate articulation may be felt; 1. He was treated as a sprain and no further follow-up was planned. (OBQ07.226) Radiographs are provided in Figure A. It is essentially the same sequela of . Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated 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. 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. Difficult wrist fractures. Depressed fracture of the lunate fossa (articular surface) Smith's. The injury is closed and she is neurovascularly intact. toe phalanx fracture orthobullets Three months after the fracture she reports an acute loss of her ability to extend her thumb. Data Trace Publishing Company (OBQ13.140) The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). - it is palpable just distal to radial tubercle; Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. A 25-year-old female falls from her horse and injures her left wrist. (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. (SBQ17SE.28) A radiograph is shown in figure A. Treatment requires urgent closed versus open reduction and stabilization. They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. Thank you. Extensor carpi radialis longus transfer to extensor pollicus longus, Extensor pollicis brevis transfer to extensor pollicus longus, Extensor indicis proprius transfer to extensor pollicus longus, Primary repair of extensor pollicus longus. Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. Patients often prefer to hold their fingers in partial flexion due to pain on extension. In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. 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. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. Check for errors and try again. A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. 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). Capitate fractures are classified by the anatomic location of the fracture, along with what other concomitant injuries may be present. She was seen in the emergency department at the time of injury and was told she had a sprain. 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. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. 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. This is an AAOS Self Assessment Exam (SAE) question. 2. Pearls/pitfalls. Four months post-injury, he presents to the office with an inability to extend his thumb. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. A fracture to the lunate may also be associated with injury to the TFCC. ADVERTISEMENT: Supporters see fewer/no ads. Follow-up/referral. Smith's fracture: volarly displaced and extraarticular. - it differs from Colles' or Smith's Fracture in that the dislocation is the most striking radiographic finding; - volar Barton's is more common than dorsal Barton frxs; - mechanism: - usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. Lunate fractures and associated radiocarpal and midcarpal instabilities: a systematic review:. What is the next most appropriate step in management? Which of the following injuries is the most likely cause of this finding? A four-stage process to describe perilunar instability has been described,where lunate dislocation represents stage IV 2. disruption of the normally smooth line made by tracing the proximal articular surfaces of the hamate and capitate, lunate overlaps the capitate and has a 'triangular' or 'piece of pie' appearance (also seen in perilunate dislocation), signet ring sign: rounded appearance of the scaphoid tubercle due to rotatory subluxation from injury to the scapholunate ligament, lunate seen displaced and angulated volarly, lunate does not articulate with capitate or radius (as opposed to perilunate dislocation where the lunate remains aligned with the radius). Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). Thank you. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. The mechanism of injury is typically a fall onto an outstretched hand with a hyperextended wrist or during a . Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-10010, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10010,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lunate-dislocation/questions/1703?lang=us"}, Figure 1: Stage 4 of progressive perilunate, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, Mayfield classification of carpal instability, dorsal intercalated segment instability (DISI), volar intercalated segment instability (VISI), scaphoid nonunion advanced collapse (SNAC), triangular fibrocartilaginous complex (TFCC) injuries, ulnar-sided wrist impaction and impingement syndromes, calcium pyrophosphate dihydrate deposition disease, Philips Australia, Paid speaker at Philips Spectral CT events (ongoing).