Wrist problems Flashcards

Question

How do you define an UNSTABLE scaphoid fracture?

Answer 1

* \>1mm displacement * fracture angulation * carpal malalingment

Answer 2

* 95% of tubercle F# * 90% of waist fracture * 60% of proximal pole F#

Answer 3

**NON-OPERATIVE (type A)** * tubercle F# -\> 2wks short arm thumb spica splint, IPj free, then 6wks cast. Xray q4wk * non-displaced waist F# -\> 2wks short arm thumb spica splint, IPj free, then 6wks cast. Xray q4wk * \*most require 8-12wks of immoblization * \*if not healed at 6-8wks, (tender/xray showing sclerosis/cystic changes/resorption =\> ORIF * return to sports 6mths **OPERATIVE (type B)** * proximal pole F# * displaced waist F# (angulation, \>1mm displaced, carpal malalignment) * also for nondisplaced if athelete/refusal/inability to immoblize for 8-12wk * communited F# (requires BG) ***_OPERATIVE OPTIONS_*** kwire, compression scrw osteosynthesis (herbert screw), percutaneous screw fixation volar approach if F# in distal 1/2, dorsal appraoch if F# in proximal 1/2 aim to place screw in central 1/3 of scaphoid * Volar approach (for distal 1/2 F#) * divide volar carpal ligaments * reduce fracture with joysticks * ST jt opened and segment of T removed to allow screw placement * alignment jig, drill guide, drill, tapp, screw * repair volar carpal ligament * xray check * 1wk thumb spica immobilization, then splint early ROM * contact sports 3-6mths

Answer 4

* Defined as INCOMLPETE BONE UNION/ persistent symptoms after 4mths of adequate immobilization * If not yet 4mths, continue up to 4mth w cast immobilization * at 4-12mths wihtout union, ORIF + BG

Answer 5

* Defined as failure of trabeculation across fracture site and sclerosis of bone ends * AVN of proximal pole can co-exist w non-union INVESTIGATION * XRAY * sclerosis, cysts, flexion deformity (humpback for waist F#), resorption, DISI * CT * to measure extent of collapse * MRI * to assess for AVN \*\*\*\* low signal on T1 and T2 images TREATMENT * Goal: restore alignment and unite fracture * ORIF with Bone graft * Plan dependent on * location of non-union * proximal -\> dorsal approach * waist -\>volar approach * AVN * if present, vascularized BG * if no AVN, corticocancellous IC bone with wedge (Fisk-Fernandez) * presence of SNAC * no restoration of scaphoid * PRC or 4corner fusion SUMMARY * displaced Waist non-union with humpback deformity=\> volar approach, ICBG wedge * Proximal pole - dorsal approach: * vascularized: ICBG and internal fixation * AVN: vascularized BG (1,2ICSRA) * AVN + SNAC or fragmentation * PRC or Four corner fusion

Answer 6

* Delayed diagnosis \>4wks * inadeqaute immobilization * proximal pole fracure * waist fracture with displacement \>1mm * smoker * asssociated ligamentous injury

Answer 7

SNAC - scaphoid non-union advanced collapse: * radiocarpal arthrosis * carpal collapse * AVN

Answer 8

* Body * Proximal-radial - LT ligament bony avulsion * Dorsal cortical - insertion of DRC and DIC Tx- immobilization 4-6wks - cant ignore dorsal cortical F#

Answer 9

* Body * Hook - common in racket/golfers - deep ulnar pain * Treatment: * excision of hook if non-union and tender * immobilize 4-6wks if presenting acutely

Answer 10

* Scaphocapitate syndrome - fracture of capitate along w scaphoid * capitate can rotate 90 or 180 degrees * risk of AVN * Treatment - ORIF w compression screw

Answer 11

* Dissociative (CID) = istability wihtin a carpal row due to **intrinsic ligament injury (v/d SL, v/d LTq v/d IC)** * Sl, LTq tear * Scaphoid F# * Kienbocks * Non-dissociative (CIND) = instability between carpal row due to extrinsic ligament injury (volar; RL, RSL, RSC, RU, Utq, UL, UC, dorsal RS, RL, RTq (~DRC), RU) * Midcapal instability * Complex (CIC) = combination of both intrinsic an dextrinsic ligament injury and instability * perilunate dislocation * Adaptive (CIA) = injury proximal or distal to carpus causing carpal malalignment * distal radius fracture malunion

Answer 12

* Static = ligament RUPTURE - on static non stress xrays, abnormality visible * eg. scaphoid flexed on PA * Dynamic = ligament COMPLETE tear - only on stress xrays is abnormality visible * eg. SL widening on stressviews * Predynamic = ligament PARTIAL tear - normal stress adn resting xrays - clinically tender

Answer 13

* DISI - lunate in extended position * caused by SL tear, Lunate extends w Tq * VISI -lunate in flexed poition * caused by LTq tear, lunate flexes w S * Ulnar translocation * lunate displaced ulnar w/r/t radius * Radial translocation * lunate displaced radial w/r/t radius * Dorsal translocation * carpus subluxed dorsally

Answer 14

* Great er arc: force transmitted hrough ilgaments and bones leading to fracture dislocations * eg. transscaphoid perilunate dislocation * Lesser arc: force trasnmitted thoguht ST and ligaments only

Answer 15

* pronation increases ulnar variance * supination decreases ulnar variance * as seen radiographically

Answer 16

* Hx: MOI hyperextension injury, tenderness distal to listers tubercle, swelling and pain dorsoradial wrist. worse with ROM. Previous distal radius F#/scaphoid F#/dorsal ganglion, RA. Weak grip * PE: tender distal to lister’s tubercle, + Watson’s test, + SL ballotment **Clinical types** * Predynamic: pain as described above, normal xrays. PARTIAL SL tear * Dynamic: pain as bove, SL gap on provocative Xray, normal on routine Xray = COMPLETE Tear BUT secondary stabilizers intact (STT, RSC) * Static, Reducible; SL degenerated, failed 2’ stabilizers, scaphoid flexion on xray. Reducible. * Static Irreducible: Chronic complete SL tear, DISI deformity * SLAC: IRreducible, Degenrative OA **Investigations** * **XRAY**: 3views + scaphoid view (ulnar deviation and extension) =\> look for wide SL gap, DISI, arthristis: * increased SL gap (terry thomas sign \>3mm) * lunate extension * Scaphoid flexion (ring sign) * CL \>15' * SL \>60' * = DISI * CT/MRI **Procedures** * **Wrist arthroscopy (GOLD STANDARD) for diagnostic and therapeutic**

Answer 17

1. Arthritis at radial styloid 2. Arthritis at radioscaphoid jt 3. Arthritis at scaphocapitate, lunocapitate (midcarpus) 4. collapse of **capitate** **Note: NO arthritic changes to radiolunate** **Note: SLAC wrist with radioscaphoid degenerative jt disease and scaphoid erosions is CPPD until proven otherwise???**

Answer 18

**ACUTE SL - PARTIAL - PREDYNAMIC (\<3WKS)** * Arthroscopic debridment, CR + Kwire pins Sc, LTq, SL * Immobilize 6-8wks short arm thumb spica cast, then protective splint 4wks, sports 6mth **ACUTE SL- COMPLETE - DYNAMIC (\<3WKS)** * ORIF + Direct SL repair + stabilization of repair (Blatt dorsal capsulodesis or Brunelli tenodesis) * Dorsal approach (base of 4th compart) or volar (base of CT) * reduce S and L w joystick, Kwire fixation * Repair SL with anchors/intraosseous suture * Stabilize repair: * Capsulodesis: **Blatt** (proximally based Dcapsular flap inserted into S.tubercle.) * Capsulodesis: **Mayo** (radially based flap from DIC inserted into scaphoid/radius/lunate) * Tenodesis: **Linscheid ECRB** (distally based segment of ECRB weaved through C,S,L,radius) * Tenodesis: **modified Burnelli FCR** (distally anchored FCR passed from tubercle to dorsal scaphoid and secured to SL lig repair **SUBACUTE/CHRONIC - COMPLETE - STATIC _REDUCIBLE_** *(\>6WKS) \*\*AS LONG AS ITS REDUCIBLE, WKS DONT MATTER* * Reduction&Association of SL(Herbert screw)+stabilization * **RASL** * open/arthroscopic, debride articular surfcae b/w S-L * Herbert screw S-\>L to allow for pseudoarthrosis to form * Stabilization with Blatt capsulodesis or Brunelli FCR * short arm thumb spica cast 6wks **CHRONIC- COMPLETE - STATIC IRREDUCIBLE** * Partial arthrodesis * STT + radial styloidectomy * SLC arthrodesis, SC arthrodesis **SLAC WRIST (arthritis at radial styloid, RS, SC/CL, capitate collapse)** * **Salvage procedures** * **Stage 1-2 SLAC (radial styloid, RS arthritis, preserve RC)** * ****PRC +/- radial styloidectomy * Dorsal approach * excise S, L, Tq * Closure of dorsal capsule * Good pain control, ROM, no risk of non-union, conversion to total wrist if required * contraindicated if LC OA * Scaphoidectomy & 4corner fusion (C, H, Tq, L) * excise scaphoid, remove articular surfaces C-L-H-Tq, fix with kwire, BG (IC or scaphoid) * ?better longterm outcome * indicated when Lcapitate OA identified * Total wrist arthroplasty * only in RA, not posttraumatic pt * **Stage 3-4 ( SC or CL arthritis, capitate collapse)** * **Total wirst arthrodesis** * good option for high demand hand

Answer 19

* Def: Mayfield stage 3 -part of progressive perilunate instbaility=\> disruption of L-Tq ligament from capitate hyperextension disrupting strong volar L-Tq ligament=\>may lead to CTS with lunate sitting in CT * Clinical presentation * pain on ulnar wrist, tender directly over LTq deep to EDM * hx of FOUSH w rdial deviation/pronation * + ballotment/shear test * +/- CTS * Investigations * **Xrays** - VISI deformity (lunate flexes, SL \<30) * Procedure * **Wrist arthroscopy** - gold standard Dx and Tx * Treatment * predynamic/dynamic acute/chronic (no VISI on xray) * conservative acutely - NSAID, immoblize, steroid * Operative - CRIF + stabilization (Kwire fixation SL, LTq, Ligament recon w FCU strip) * chronic static (VISI on xray) * LTq arthrodesis w 8weeks immobilization

Answer 20

* Radiocarpal CIND * madelung deformity * Ulnocarpal CIND * Midcarpal CIND

Answer 21

Caused by Madelung deformity, excessive ulnar head resection, RA **Madelung defomrity - congenital growth disturbance of the volar ulnar aspct of the distal radius** * resulting palmar radial angulation * Xray: tear drop defomrity of radius below lunate, +ulnar variance * Tx: USO + wedge osteomtomy of radius w corticocancellous interpositional BG

Answer 22

**TqHC ligament - critical to pull Tq into extension** * Clinical presentation * female, lax jts * pain with ulnar translation * catchup clunk * Midcarpal shift test * Imaging * normal xray usually * may have VISI deformity * Treatment * Split, NSAID, activity modified * Operative: Capsulodesis, tenodesis for lig recon

Answer 23

* Dorsal PL dislolcations (lesser arc - ligamentous only) * Dorsal PL fracture dislocations (greater-arc) * Volar PL dislocations (rare) * Axial dislocations * Isolated carpal bone dislocation

Answer 24

* radial * osseous: sequellae of # (MU/NU) & degenerative arthritis like: scaphoid #/MU/NU/SNAC, Bennett, OA (1st CMC, STT, MCP), AVN (Lunate/Keinbocks, Scaphoid/Preiser's), radial styloid # * ligamentous: SL injury (pre/dynamic/static/slac), UCL, * tendinous: tendinitis: deQuervain's, intersection, FCR * vascular: aneurysm, anomalies, ischemia * neurogenic: CTS, Wartenberg (entrapments RSN) * misc: tumours including ganglion (volar/radial), crps * ulnar * osseous: sequellae of # (MU/NU) & degenerative arthritis like: OA (PTq, 5th CMC), HoH #/NU, baby-Bennett, ulno-carpal abutment, ulnar styloid * ligamentous: LTq injury (pre/dynamic/static/VISI), TFCC tear, DRUJ instability * tendinous: tendinitis including ECU (& subluxation), FCU * vascular: hypothenar hammer, other anomalie, ischemia * neurogenic: entrapment/compression/neuroal dorsal sens br ulnar n, guyon's canal * misc: other space occupying lesion, tumour, crps

Answer 25

* I - SL lig. disruption + RSC lig. disruption (or scaphoid F#) * II - LC **dislocation** (opening space of poirier) * III - LTq lig. disruption (or Tq F#) * IV - DRC lig. disruption =\> volar dislocation of lunate

Answer 26

CLINICAL FEATURES * Young men, high velocity injuries * assocaited CTS (25%) XRAY findings * Lunate has triangular shape, disruption of Gilula line1/2 * Ass. scaphoid/Tq/distal rad F# * Lateral: * Spilled tea cup (flexed, volar dislcoation of lunate) * Radio-lunate-capitate axis disrupted TREATMENT * STEP 1 - **Closed Reduction + immobilization** * NV examination * ****Watson Jones / Tavernier method * longitudinal traction 15min w slight WE, then continue long. traction AND apply volar pressure on lunate and gradual flexion of wrist until snap/clunk when capitate relocates over dorsal lip of lunate * Immobilize cast 8 wk then splint 4 * MOST/ALL need lig. repair/ORIF * STEP 2 - **ORIF + SL/LTq lig repair + stabilization (capsulodesis/tenodesis) + ORIF associated F# +/- CTR +/- volar lig repair** * ****Dorsal approach at 3rd compartment * reduce Lunate, kwire fixation R-L, L- Tq * RASL to recon S-L or ORIF w herbert screw if F# * Stabilize w blatt capsulodesis/brunelli tenodesis FCR * +/- CTR, +/- volar capsule repair * immoblize cast 8wks, splint 4wks, kwire total 12wk

Answer 27

* always XR: 3 views (PA, LAT, OBLIQUE) * often scaphoid view: PA w ulnar deviation * carpal tunnel view is good for hamate (hook), trapezial ridge, pisiform, but requires hyperextension of wrist so can be difficult in acute injury * consider CT if need to clarify # pattern, displacement, sequellae/healing, reduction/subluxation/dislocation * consider MRI if need to clarify soft tissue injuries * consider arthroscopy to clarify ligamentous injuries & TFCC pathology

Answer 28

* colles - dorsally displaced extra-articular DR # (apex volar) * smiths - reverse colles; volarly displaced extra-articular DR # (apex dorsal) * bartons - intra-articular DR # with dislocation of the radiocarpal joint, can be dorsal or volar * chauffeur - intraarticular radial styloid # * die-punch - depressed fracture of lunate fossa of distal radius

Answer 29

* comminuted * open * loss of height by \> 2mm * loss of volar tilt of \> 10mm (ie to neutral) * loss of radial inclination of \> 5mm * displaced intra articular # step of \> 1mm * unable to obtain/maintain reduction of DRUJ

Answer 30

* acute: * infection, pain, hematoma, compartment syndrome, median nerve compression (CTS), concomitant tendon/nerve injury, radial sensory nerve injury during perc pinning * chronic * non-union, malunion, chronic pain, CRPS, ulnar abutment syndrome (from loss of radial height / inclination), decreased ROM/stiffness, degenerative radiocarpal / DRUJ arthritis, DRUJ instability, tendinopathies (EPL attrition/ischemia rupture after CR, dorsal or volar attrition ruptures 2' rubbing on hardware), hardware infection/loosening

Answer 31

* Non-operative * non-displaced distal tubercle & scaphoid waist * incomplete # * low demand pt / high operative risk * Operative * peri-lunate dislocation/scaphoid # * comminuted * delayed presentation \> 4 wks * delayed union @ 4 months * displaced waist or distal scaphoid fracture (including flexed position) * any proximal pole fracture * high demand patient or athlete

Answer 32

malunion = bony union in inadeqaute anatomic position * ulnar variance \>5mm compared to contralat wrist * radial inclination \<15’ (normal 22) * Outside of 15' Volar tilt 15’ - 20'dorsal tilt 20’ (normal palmar tilt 11’)

Answer 33

* Dorsal angulation \>20' * volar angulation \>15' * ulnar variance \>5mm compared to contralat side * DRUJ incongruity * pain in RC, MC, distal RU joint * intraarticular incongruity \>1-2mm

Answer 34

EXTRA-ARTICULAR **DORSAL ANGULATION** * opening wedge dorsal radius osteotomy **VOLAR ANGUALTION** * opening wedge dorsal radius osteotomy **+ DRUJ INTRA-ARTICULAR INCONGRUITY** * Young pt =\> Sauve-Kapandji (DRUJ fusion w proximal ulna pseudoarthrosis * resection arthroplasty * Old pt =\> Darrach, Bowers hemiresection arthroplasty **+ DRUJ EXTRA-ARTICULAR INCONGRUITY** * USO /wafer procedure INTRAARTICULAR * RSL arthrodesis

Answer 35

AVN lunate Etiology * unclear * decrease perfusion * abnormal lunate shape * altered biomechanical forces (- ulnar variance) * repetitive trauma Epidemiology * M:F 2:1, 20-40s Clinical features * dorsal wrist pain, over lunate (distal to listers, base of D3 w wrist inflexion) * decreased ROM

Answer 36

Imaging * Xray: Lunate may appear normal or show signs of * hyperdensity (sclerosis) * fragmentation * fratures * collapse * proximal migration of capitate * MRI * decreased signal - low signal T1 and T2

Answer 37

Lichtman classification STAGE 0 * XRAY **normal** * MRI lunate density abnormality STAGE 1 * XRAY **Linear/compression F#** * MRI lunate low T1/2 signal STAGE 2 * XRAY **lunate sclerosis** STAGE 3 A * XRAY **lunate collapse, NO scaphoid rotation deformity** STAGE 3 B * XRAY **lunate collapse** * **+ SCAPHOID FLEXED** * **Capitate proximal migration** * **decreased carpal height** STAGE 3 C * Lateral XRAY **lunate F#** STAGE 4 * XRAY **lunate collapse + perilunate degenerative change**

Answer 38

Considerations * Stage * Ulnar variance * presence of arthritis * age and fxnal level TREATMENT ACORDING TO LICHTMAN STAGES **STAGE 0-1 = MRI signal changes, +/- xray lunate linear f#** * immobilization 12weeks (to reduce synoviitis and work load on lunate+/- arthroscopy **STAGE 2-3A = Lunate sclerosis-\>collapse, no scaphoid flex** * immobilization 12weeks +/- arthroscopy * RSO (if ulnar var -) or radial wedge osteotomy (if ulna neutral) * Others rare: vascularized BG, temporary SCor STT pin **STAGE 3B = lunate collapse, scaphoid flexion** * SC or STT arthrodesis +/- lunate excision * RSO * Vascularized BG **STAGE 3C = Lunate FRacture** * PRC **STAGE 4 = lunate collapse w perilunate degenrative change** * PRC * wrist fusion * wrist denervation

Answer 39

* RSO * designed to offload lunate * 2mm shortening * indications: ulnar -variance/neutral, Lunocapitate preservation. Stage 2-3A * Radial wedge * designed to reduce radial inclination to offload lunate * indications: ulnar neutral, +, -, stage 2-3A * Vascularized bone graft * promotes primary bone healing * Extensor compartmental artery 4,5 (ECA45) * intercompartmental supraretinacular artery (ICSRA23) * indicated for 2, 3A, 3b (lunate sclerosis or collapse but not fracture (3c) * PRC * useful is stage 3b/c and ulnar neutral

Answer 40

Clinical features * ulnar sided wrist pain * + DRUJ instability, ulnocarpal stress + Investigations * XRAY- ulnocarpal abutment, Ulnar + var * MRI - central perforations * CT - DRUJ instability * BEST in wrist arthroscopy On Arthroscopy * small central TFCC tear - immobilize * large central TFCC tear - debride * peripheral TFCC tear - immobilize * large TFCC tear and normal DRUJ -\> debride + USO * large TFCC tear and degenerative DRUJ -\> Deridement and Bowers

Answer 41

* dorsal: proximal pole fractures (from proximal pole to waist), pattern w/ concommitant SL injury * volar: waist fractures, distal pole fractures, humpback deformity

Answer 42

* initial imaging modality: XR: 3 standard views + scaphoid view (PA w ulnar deviation and slight wrist extension) * at 2 wks after TS splint, repeat XR - if still negative then: * CT scan - if still negative then consider MRI to r/o SL injury; consider arthroscopy to rule out acute SL injury * if XR reveals #, but there is a gap, displacement, flexion deformity/DISI, then do a CT scan to characterize the fracture anatomy - guides treamtent to non-operative vs. operative

Answer 43

* distal tubercle: 90-95% * waist: varies 80 - 90% * proximal pole: \<60%

Answer 44

* comminuted - cancellous vs. corticocancellous bone graft * non-union, no resorption - cancellous * non-union, resportion, proximal extent vascularized - corticocancellous * malunion, humpback deformity - tricortical corticocancellous bone graft (standard from iliac crest) * non-union, resportion, proximal extent avascular - vascuarlized bone graft - pedicled 1,2 intercompartmental supraretinacular artery vs. free femoral condyle osseous flap

Answer 45

* initially thumb spika splint x 2 wks, forearm only, reassess at 2 wks clinically and w XR * (if XR normal at 2 wks but still clinically tender, then consider 2 wks cast and reassess, CT scan, consider SL pathology & MRI) * at 2 wks w/ positive XR of non-displaced stable scaphoid waist #, then TS cast x 6 more weeks, reassess every 4 wks * at 6-8 weeks, if patient still tender and XR still positive (or any signs of cyst, resorption, sclerosis) then take CT scan and strongly consider ORIF at this stage for presumed low potential to heal * would be within acceptable standards to cast for up to 3 months prior to moving onto ORIF for delayed/non-union

Answer 46

* a fracture of the scaphoid waist distal to the majority of the dorsal SL ligament can interrupt the influence of the SL ligament to the distal aspect of the bone * therefore the proximal aspect acts physio-anatomically, moving with the lunate and triquetrum and eventually maintains and extended or "upright" posture, whereas the distal portion of the scaphoid is no longer acted on by the stronger dorsal SL ligament, and is allowed to fall into the fixed posture SHORT ANSWER: * bc the # is distal to the action of the stronger dorsal SL ligament, so the proximal scaphoid follows the position of the lunate, triquetrum whereas the distal portion falls into flexion unimpeded by ligamentous supports

Answer 47

* volar approach is common for waist # (dorsal is possible) * landmark the FCR & scaphoid tubercle and palpate the radial artery prior to insufflation of tourniquet * mark hockey stick incision along FCR 2cm proximal to wrist crease then obliquely distally to base of thumb * incise skin and FCR sheath; retract FCR ulnarly and protect/retract radial artery radially * divide a superficial radial arterby branch if present * identify the wrist capsule, divide with a longitudinal or ulnarly based flap * expose the scaphoid, identify fracture, debride hematoma * reduce fracture using clamp, bone reduction forceps or 2 K-wire joysticks * place guide wire down central part of scaphoid (aim 45' dorsal, 45' medial/ulnar) from distal to proximal * image to confirm placement, measure screw length by subtraction of guidewire from k-wire - 2mm (for cartilage caps) * drill/ream over guidewire * tap if not using self-taping screws * insert headless compression screw (self-tapping if possible) * confirm using fluoroscan * close capsule & skin * immobilize in TS splint until 1st FU (1 wk) * protected range in splint x 3-4 wks; full activities at 3-4 months *

Answer 48

* use CT or MRI to accurately identify fracture anatomy and non-union and avascular necrosis of proximal pole * arm table and non-sterile tourniquet * dorsal approach - distal incision is 3-4cm distal to lister's tubercle; proximal 4cm component S-shaped to come more radially between 1st adn 2nd compartments * make incision, distally identify dorsal capsule between EPL and second compartment, more proximally between 4th and 2nd compartments * make longitudinal or inverted T incision in capsule and elevate capsule, but maintain dorsal scapular blood supply at waist * flex wrist to ID # and debride #, non-union * debride avascular bone within the cartilaginous cap * now move to harvesting VBG - incise proximally between 1st and 2nd compartments, see the 1,2 intercompartmental supraretinacular artery just proximal to radiocarpal joint * incise the periosteum around the 1,2 ICSRA (pedicle within/on this periosteum) * use drill and osteotome to harvest small square of bone, and elevate w distal peristeal sleeve of pedicle * turn the VBG under the 2nd compartment tendons & inset into defect * hold reduction using bone reduction clamps * drive guidewire from proximal to distal * confirm placement w fluoroscan * measure screw length * ream with cannulated drill * use self-tapping headless compression screw * pack donor site w bone substitute if available * close capsule, skin * immobilize in TS x 3 wks then start aROM

Answer 49

* scaphoid non-union advanced collapse * a pathological state where the non-union progresses to scaphoid flexion deformity, carpal collapse, +/- avascular necrosis of scaphoid, varying degrees of radiocarpal and intercarpal degenerative arthritis

Answer 50

* i would classify based on extent of radiocarpal and intercarpal arthritis, and use this classification to guide treatment options * stage 1: arthritis isolated to radial styloid * distal scaphoid excision and radial styloidectomy * stage 2: radial styloid and radioscaphoid arthritis * options: preferred: scaphoidectomy, radial styloidectomy, proximal row carpectomy * alternative: scaphoidectomy, radial styloidectomy, 4-corner fusion * how do you choose between the 2 operations: I choose PRC in this situation because it is easy, it is a motion-preserving operation, avoids risk of non-union of arthrodesis, avoids long duration immobilization * would choose 4-corner if young, heavy labourer, or at risk for ulnar translation of carpus (concomittant inflammatory arthritis) * Stage 3: radial styloid and radioscaphoid scaphocapitate +/- capitolunate arthritis * options: preferred scaphoidectomy, radial styloidectomy, 4-corner fusion - preserves some motion and strength vs. total wrist arthrodesis * alternative: total wrist arthrodesis * Stage 4: pan-carpal arthritis, including at radio-lunate interface * primary option is total wrist arthrodesis (arthroplasty is an option, but I would not recommend this as I have little experience w this operation)

Answer 51

* CID - carpal instability dissociative - ie between carpal bones of same row

Answer 52

* History * radial sided wirst pain, aggravated by use, occassional snapping w movement, c/o weak grip, limited motion * mechanism like FOOSH or hyperextension injury (or s/p ganglion excision, scaphoid or DR #, RA, wrist infection) * Physical * dorsoradial swelling, weak grip strenth, limited ROM 2' pain (esp radial deviation and extension) * tender proximal pole (dorsal), distal tubercle (volar), waist (snuffbox) * +ve Watson shift test * +ve SL ballottment test

Answer 53

* Pre-dynamic * often acute, partial vs. complete injury * by definition, normal XR - +ve findnigs seen on arthroscopy * occassionally with complete tear, a gap can manifest acutely however this does not reflect static and secondary changes * Dynamic * often acute or subacute complete SL injury; 2' stabilizers intact * resting XR are normal, but stress (clenched fist) XR demonstrate a gap on injured side when compared to C/L side * Static, reducible * chronic changes of flexed posture of scaphoid, reflect alteration to secondary stabilizers, but would find that SL can be anatomically reduced * + resting XR: terry thomas sign (gap \> 3mm), signet ring (or cortical ring) sign: double ring indicating flexed posture of scaphoid, increased SL angle * Static irreducible * chronic changes of flexed posture of scaphoid with secondary alteration to proximal row biomechanics of dorsal extension of lunate (disi) * resting XR as above plus DISI deformity (increased SL angle, increase CL angle, extended posture of lunate) * Scapho-lunate advanced collapse * chronic degenerative changes to articular surfaces secondary to chronic changes in biomechanics

Answer 54

§ Stage I: arthritic changes at radial styloid § Stage II: arthritic changes at radioscaphoid joint * stages I/II - PRC vs. scaphoidectomy & 4-corner fusion (vs. rarely arthroplasty) § Stage III: progression to midcarpal OA (capitolunate and scaphocapitate) § Stage IV: collapse of capitate secondary to midcarpal arthritis; + radiocarpal arthritis * stages III/IV: capitate not preserved, therefore total wrist fusion

Answer 55

* History (often mis-diagnosed as wrist sprain; radial sided wrist pain & swelling) * Physical (may or may not have +ve Watson shift test) * Imaging: will likely have normal XR * MRI: may identify SL injury * Arthroscopy - allows for definitive diagnosis (and treatment) * Treatment * on arthroscopy, partial injury, then debride, reduce (can use k-wire to joy-stick reduction) and immobilize with intercarpal k-wire (SL, SC, LT) + splint immobilization x 4-6 wks * if complete injury seen, no OA, ligament is INTACT, then consider a direct repair following a combined arthroscopic (diagnosis, debridement, faciliate reduction) and open (dorsal longitudinal incision distal to lister's tubercle, enter capsule via longitudinal incision or via developing a proximally based capsular flap) * direct repair avulsed SL to scaphoid w suture anchor * consider augmenting repair w proximally based dorsal capsular flap to scaphoid - Blatt capsulodesis * immobilize repair using percutaneous k-wire * immobilize w/ splint

Answer 56

* DYNAMIC * Capsulodesis: Blatt (proximally based dorsal capsule flap), Mayo (partial DIC ligament to lunate, distal radius) * Tenodesis: Modified Brunelli (total/partial FCR through scaphoid tubercle, to SL/lunate) vs. ECRB/Linsheid (through scaphoid, capitate, lunate) * some add RASL to this group * Static reducible * RASL (open vs. arthroscopic reduction association scapholunate) - debride articulation, reduce, apply herbert/headless compression screw, create pseudarthrosis * consider augmenting w capsulodesis * consider capsulodesis vs tenodesis alone * Static irreducible * limited intercarpal fusion (usually STT, occassionally SLC) *

Answer 57

* stage i/ii SLAC wrist have preserved luno-capitate joint * options are PRC vs. scaphoidectomy + 4-corner fusion (SLAC wrist procedure) * PRC advantages: better preservation ROM, lower risk bc no risk for non-union, less immobilization, easy procedure, easily converted to total wrist fusion * PRC disadvantages: nearly all progress to radiographic +/- clinical radiocapitate arthritis (new radiocarpal articulation) and may require total wrist fusion * Best indications: older patients, lower demand * vs. scaphoidectomy + 4-corner fusion advantages: radiolunate joint is nearly always preserved, has longer-term pain-free result * disadvantages: less ROM than PRC, more difficult to convert to total wrist fusion later, more technically challenging operation, risk of non-union, immobilization * Best indications: younger patient, more high-demand activities

Answer 58

* History: ulnar sided wrist pain * Physical: pain over LTq; may find LTq ballottment test / shear test positive * XR: normal; may find abn gilula's lines; may find gap (uncommon); +ve on stress view * arthroscopy becomes gold standard

Answer 59

* start non-operative * activity modification * short course splint immobilization * corticosteroids * non-op can fail bc there is still ulnar sided carpal motion (ie @ LTq) w pronosupionation, would require above elbow cast for full immobilization * operative * dynamic, subacute, reducible (no VISI) * LTq reconstruction using slip of ECU, passed via drill hole btwn L and Tq (Mayo) * LTq arthrodesis * Chronic instability (VISI seen) * controversy regarding ideal treatment option, not well studied * LTq arthrodesis will not correct visi * LTq + TH +/- LR limited arthrodesis; USO if symptoms of abutment

Answer 60

* intra- and inter carpal row STT, THC, SC ligament laxity * laxity causes late extension of proximal carpal row until wrist is in extreme ulnar deviation - late (and not smooth) flexion to extension motion causes pain & clunk during extreme ulnar deviation; also prevents appropriate extension of proximal carpal row during loading, leading to a dynamic or static visi deformity

Answer 61

* manh patients respond well to non-operative treatment * activity modification * short course splint immobilization * exercises to strengthen ulnar wrist stabilizers including FCU and ECU to become 2' stabilizers * operative * 1st choice is capsulodesis / capsule plication * consider tenodesis * consider limited carpal arthrodesis or 4-corner fusion

Answer 62

* ATLS/ABCs first; as injury often occurs during high-velocity injury and there are concomitant injuries * History & Physical: evaluate and document concomitant CTS * Closed reduction of lunate in emerg * local (or regional) block w IV sedation * wrist traction in slight extension x 10-15 mins, then apply dorsal pressure on volar surface at lunate, while bringing wrist into flexion - clunk is reduction of capitate over dorsal lip of lunate * Post-reduction films indicate adequate reduction and CTS symptoms temporarily resolve * Urgent trip to OR for open reduction, internal fixation, direct ligament repair +/- CTR * dorsal approach through 3rd compartment (or btwn 3rd and 4th), volarly based capsular flap to enter joint, k-wire to joystick lunate reduction, fixation of reduction w k-wire between SL, SC, LT (some ppl will use headless compression screw/rasl at SL here), direct ligament repair (suture anchor to scaphoid [SL] and triquetrum [LT]) +/- Blatt capsulodesis * Consider volar approach if unable to reduce lunate or ongoing symptoms of median nerve compression after reduction, carpal tunnel release and to repair volar extrinsic ligaments * Immobilization in splint then case x 8 wks, then splint and protected ROM x 4 wks

Answer 63

* avn of lunate, spontaneous, usually M\>F, c/o central wrist pain, decr ROM, occas + Watson * abn vasc anatomy * single vascular pedicle with little intraosseous branching in ~ 20% * increased intraosseous pressure and venous congestion * combination of abnormal lunate geometry (smaller, greater axial loading w ulnar + variance) plus repetitive trauma (micro/macro #, ligament disruption)

Answer 64

* Lichtman classification * stage 1: XR N; MRI edema * treatment is conservative: 3 wks immobilization in neutral position; consider elective RSO if ulnar negative variance * stage 2: Lunate sclerosis, fracture +/- fragmentation present, but no lunate collapse * stage 3a: Lunate sclerosis, fracture +/- fragmentation present, but +ve lunate collapse * treatment for stage 2/3a similar: * to decrease axial load use joint leveling procedures * if ulnar -ve variance - RSO * if ulnar +ve or neutral variance - capitate shortening or CH fusion * revascularization using VBG * debride avascular lunate but maintain available articular surfaces * use 1,2 or 4,5 ICSRA pedicle VBG or pedicle pisiform VBG * can combine w load reduction strategies, immobilize STT/SC temporarilty to permit revascularization * stage 3b: Lunate sclerosis, fracture +/- fragmentation present, +ve lunate collapse, +ve carpal collapse * STT/SC fusion +/- excision of lunate * still consider above arthrodesis w maintain lunate w revascularization proceudre * consider PRC * stage 4: radiocarpal and midcarpal arthritism * PRC vs. total wrist fusion (if gross RL OA)

Wrist problems Flashcards

(89 cards)