The document discusses carpal instability, including lunotriquetral dissociation and scapholunate dissociation. Lunotriquetral dissociation typically results from a fall on an outstretched hand with wrist extension and radial deviation. Scapholunate dissociation usually occurs from a fall onto an outstretched, ulnarly deviated wrist. Both injuries can cause wrist pain and decreased grip strength. Treatment depends on the injury severity and includes immobilization, arthroscopy, and ligament repair or reconstruction.
Vincenzo: Arthrogryposis w/ Lower Limb Deformities, Severe Contractures, & Pt...David S. Feldman, MD
Vincenzo is a young man from Bari, Italy who had been diagnosed with arthrogryposis at birth and had been wheelchair bound since the age of six. His family had sought treatment in Altamura and Milano Italy but doctors had not provided any treatment and told the family that nothing could be done to improve his condition. At age 14, he traveled with his family to America to seek treatment.
During our consultation I found that while Vincenzo’s arthrogryposis had caused severe contractures and lower limb deformities, many of these issues could be resolved with surgery and therapy. Over the course of two years, I performed muscles and tendon releases to allow for improved range of motion. By the end of treatment, Vincenzo was able to walk without assistance and had greater control of his arms which allowed him to use his hands in ways he could not before.
http://www.davidsfeldmanmd.com/patient-education/case-studies/vincenzo-arthrogryposis-lower-limb-deformity-contractures-pterygium
Anthony was diagnosed with Legg-Calve-Perthes disease at the age of four and was treated by me until the age of 10. His multi-faceted and individualized course of treatment consisted of therapy, non-weight bearing, and surgery. Five years after his last procedure, Anthony’s Legg-Calve-Perthes is completely resolved and he should continue to enjoy normal hip function for many decades to come.
www.davidsfeldmanmd.com/patient-education/case-studies/anthony-legg-calve-perthes-disease
Vincenzo: Arthrogryposis w/ Lower Limb Deformities, Severe Contractures, & Pt...David S. Feldman, MD
Vincenzo is a young man from Bari, Italy who had been diagnosed with arthrogryposis at birth and had been wheelchair bound since the age of six. His family had sought treatment in Altamura and Milano Italy but doctors had not provided any treatment and told the family that nothing could be done to improve his condition. At age 14, he traveled with his family to America to seek treatment.
During our consultation I found that while Vincenzo’s arthrogryposis had caused severe contractures and lower limb deformities, many of these issues could be resolved with surgery and therapy. Over the course of two years, I performed muscles and tendon releases to allow for improved range of motion. By the end of treatment, Vincenzo was able to walk without assistance and had greater control of his arms which allowed him to use his hands in ways he could not before.
http://www.davidsfeldmanmd.com/patient-education/case-studies/vincenzo-arthrogryposis-lower-limb-deformity-contractures-pterygium
Anthony was diagnosed with Legg-Calve-Perthes disease at the age of four and was treated by me until the age of 10. His multi-faceted and individualized course of treatment consisted of therapy, non-weight bearing, and surgery. Five years after his last procedure, Anthony’s Legg-Calve-Perthes is completely resolved and he should continue to enjoy normal hip function for many decades to come.
www.davidsfeldmanmd.com/patient-education/case-studies/anthony-legg-calve-perthes-disease
Prof Anisuddin Bhatti Paediatric orthopaedic surgeon Dr. Ziauddin University Hospital Clifton, Karachi delivered Lectures to trainees and Junior consultants on PERTHES' part-1, [Pathogenesis, Diagnosis, Classification and case discussion] on 20th February 2021, through Dr. Ziauddin Hospital Clifton Webinar series. Part-2 on Perthes' management to be delivered on 6th March 2021. he declares few pictures & material taken from Google.com and mostly his own patients
Adult Scoliosis Indications for Operative TreatmentAlexander Bardis
Primary degenerative scoliosis (‘‘de novo’’ form), mostly located in the thoracolumbar or lumbar spine.
Progressive idiopathic scoliosis in adult life of the thoracic, thoracolumbar, and/or lumbar spine
Prof. Anisuddin Bhatti, Paediatric Orthopaedic Surgeon, Dr. Ziauddin University Hospital, Clifton campus Karachi, presented lecture on Congenital Clubfoot and PPV deformity evaluation & treatment. On 31 May 2021 to Resident's of AKUH and others. Acknowledged text & picture source as indicated in reference list.
Prof. Anisuddin Bhatti gave lectures to residents & Junior consultants on PostPolio Residual Paralysis part2 lower limb Reconstructive surgery on 17.04.202. Acknowledged for text and figures as such in reference list.
Background: Distal femur fractures make up 6 to 7% of all femur fractures. Various plating options for distal femur fracture are conventional buttress plates, fixed-angle devices, and locking plates. This study was planned to evaluate and explore locking compression plate fixation in distal end femur fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, less complications and a better quality of life.
Methods: The study was conducted as prospective clinical study in 20 skeletally mature patients with x-ray evidence of distal femur fracture fulfilling inclusion and exclusion criteria, operated with distal femur LCP plating. Patients were assessed radiologically and classified according to distal femur fracture classification and outcome graded as excellent, good, fair and poor based on Lysholm Knee Score.
Results: Out of 15 excellent outcome cases, 3 cases were type A1 fracture, 1 case had type A3, 2 cases had type B1 and B2 each, 5 cases had type C2 and 2 cases had type C3 fracture. 1 case with good outcome was type C3. 1 case with fair outcome was type B2. While 3 cases with poor outcome were type A1, A2 and C3.
Conclusions: The DF-LCP is an ideal implant to use for fractures of the distal femur. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A and C, osteoporotic and periprosthetic fractures.
Keywords: Distal femur, DF-LCP, Lysholm score, Periprosthetic fracture
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: September C...Sean M. Fox
Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Buckle Fracture
- Greenstick Fracture
- Displaced Radial and Ulnar Fractures
- Non-Displaced Radial and Ulnar Fractures
- Comminuted Radial Fractures
- Monteggia Fracture
Prof Anisuddin Bhatti Paediatric orthopaedic surgeon Dr. Ziauddin University Hospital Clifton, Karachi delivered Lectures to trainees and Junior consultants on PERTHES' part-1, [Pathogenesis, Diagnosis, Classification and case discussion] on 20th February 2021, through Dr. Ziauddin Hospital Clifton Webinar series. Part-2 on Perthes' management to be delivered on 6th March 2021. he declares few pictures & material taken from Google.com and mostly his own patients
Adult Scoliosis Indications for Operative TreatmentAlexander Bardis
Primary degenerative scoliosis (‘‘de novo’’ form), mostly located in the thoracolumbar or lumbar spine.
Progressive idiopathic scoliosis in adult life of the thoracic, thoracolumbar, and/or lumbar spine
Prof. Anisuddin Bhatti, Paediatric Orthopaedic Surgeon, Dr. Ziauddin University Hospital, Clifton campus Karachi, presented lecture on Congenital Clubfoot and PPV deformity evaluation & treatment. On 31 May 2021 to Resident's of AKUH and others. Acknowledged text & picture source as indicated in reference list.
Prof. Anisuddin Bhatti gave lectures to residents & Junior consultants on PostPolio Residual Paralysis part2 lower limb Reconstructive surgery on 17.04.202. Acknowledged for text and figures as such in reference list.
Background: Distal femur fractures make up 6 to 7% of all femur fractures. Various plating options for distal femur fracture are conventional buttress plates, fixed-angle devices, and locking plates. This study was planned to evaluate and explore locking compression plate fixation in distal end femur fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, less complications and a better quality of life.
Methods: The study was conducted as prospective clinical study in 20 skeletally mature patients with x-ray evidence of distal femur fracture fulfilling inclusion and exclusion criteria, operated with distal femur LCP plating. Patients were assessed radiologically and classified according to distal femur fracture classification and outcome graded as excellent, good, fair and poor based on Lysholm Knee Score.
Results: Out of 15 excellent outcome cases, 3 cases were type A1 fracture, 1 case had type A3, 2 cases had type B1 and B2 each, 5 cases had type C2 and 2 cases had type C3 fracture. 1 case with good outcome was type C3. 1 case with fair outcome was type B2. While 3 cases with poor outcome were type A1, A2 and C3.
Conclusions: The DF-LCP is an ideal implant to use for fractures of the distal femur. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A and C, osteoporotic and periprosthetic fractures.
Keywords: Distal femur, DF-LCP, Lysholm score, Periprosthetic fracture
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: September C...Sean M. Fox
Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Buckle Fracture
- Greenstick Fracture
- Displaced Radial and Ulnar Fractures
- Non-Displaced Radial and Ulnar Fractures
- Comminuted Radial Fractures
- Monteggia Fracture
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: August CasesSean M. Fox
Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Supracondylar Fracture Type I
- Supracondylar Fracture Type II
- Supracondylar Fracture Type III
- Supracondylar Fracture Type IV
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: October CasesSean M. Fox
Dr. Kelsey Lena is Emergency Medicine Resident and interested in pediatric emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and supervision of Dr. Danielle Sutton, a Pediatric Emergency Medicine specialist, and Dr. Virginia Casey, a Pediatric Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Femur Fractures
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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12. Lunotriquetral Dissociation
• Occur with a fall on an
outstretched hand with
the wrist in extension and
radial deviation
• Atraumatic causes include
inflammatory arthritis
and ulnar abutment
Scapholunate Dissociation
• Trauma : injury results
from a fall onto an
outstretched, ulnar
deviated hand
• Atraumatic causes such as
infection and
inflammatory arthritis
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
13. Lunotriquetral Dissociation
• A cadaveric study observed
lunotriquetral ligament tears in
36% of the specimens
• It is also apparent that age-related
tears of the proximal membranous
component of the lunotriquetral
ligament are common findings
Scapholunate Dissociation
• Evidence of scapholunate ligament
injury was observed in 35% of
cadaveric wrists.
• 29% of the specimens with
scapholunate ligament injuries had
associated degenerative changes.
• 30% of intra-articular distal radius
fractures are associated with
scapholunate ligament complex
injuries.
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
14. From : Green’s operative hand surgery 7th edition,2017
Scapholunate
Dissociation
15.
16. Lunotriquetral Dissociation
• A history of falling on the wrist and
landing on the hypothenar area with
continued wrist pain
• Ulnar sided wrist pain and decreased
grip strength
Scapholunate Dissociation
• Persistent wrist pain following a fall
onto an outstretched hand
• Decreased grip strength
• Experience popping or clicking during
activities
• Exacerbated when the wrist is placed
into extension and radial deviation
• Wrist motion may be limited
secondary to pain
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
17. Lunotriquetral Dissociation
• Pain can be elicited by palpation
over the lunotriquetral joint
• Ulnar deviation with pronation
and axial compression of the
wrist can result in a painful snap
• The lunotriquetral ballottement
test
• Kleinman's shear test
Scapholunate Dissociation
• Tender to palpation dorsally
over the scapholunate joint
• The scaphoid shift test
• Watson shift test
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
20. Lunotriquetral Dissociation
• AP and lateral view radiographs
• Arthroscopy helpful in making
diagnosis, as radiographs may be
normal
Scapholunate Dissociation
• AP and lateral view radiographs
• Arthrography indications
• may be used as screening tool for
arthroscopy
• MRI indications
• often overused as a screening
modality for SLIL tears
• Arthroscopy indications
• considered the gold standard for
diagnosis
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
24. From : Green’s operative hand surgery 7th edition,2017 and orthobullet
25. Lunotriquetral Dissociation
• Ulnar impaction syndrome
• Triangular fibrocartilage complex tears
• Kienbock disease (lunate avascular
necrosis)
• Triquetral avulsion fracture
• Pisotriquetral arthrosis
• ECU tendon subluxation/ tenosynovitis
• DRUJ arthrosis
• CIND-VISI
Scapholunate Dissociation
• Scaphoid fracture
• Kienbock disease (avascular
necrosis of the lunate)
• Ganglion cyst
• Flexor carpi radialis tendinopathy
• Extensor carpi radialis
brevis/longus tendinopathy
• CIND-DISI
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
26. Stage I: partial ligament injury
immobilization
physical therapy with reeducation of wrist
proprioception
arthroscopic ligament debridement with or
without thermal shrinkage
percutaneous K-wire fixation of the scapholunate
joint
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
27. Stage III: complete ligament injury with static
scapholunate interval widening
>repairable ligament
open dorsal scapholunate ligament repair +
reduction of interval
>nonrepairable ligament
dorsal ligament reconstruction
dorsal scapholunate capsulodesis
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
28. Acute injury with failed conservative management[19]
arthroscopy and injury classification[64]
Grade I: ligament attenuation, no gap between lunate and
triquetrum - > ligament debridement
Grade II: ligament attenuation, <2 mm gap - > ligament
debridement + K-wire fixation
Grade III: ligament disruption, >2 mm gap - > ligament
debridement + K-wire fixation
Grade IV: complete ligament disruption, able to pass arthroscope
between lunate and triquetrum - > open ligament repair
From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
29. From : Carpal Ligament Instability, NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.2020
30. From : Orthobullet : https://www.orthobullets.com/hand/6041/scapholunate-ligament-injury-and-disi
31. From : Green’s operative hand surgery 7th edition,2017
Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
34. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
35. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
36. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
37. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
38. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
39. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
40. Wolfe, Scott W. MD; Garcia-Elias, Marc MD; Kitay, Alison MD Carpal Instability Nondissociative, Journal of the American
Academy of Orthopaedic Surgeons: September 2012 - Volume 20 - Issue 9 - p 575-585 doi: 10.5435/JAAOS-20-09-575
Editor's Notes
The proximal carpal row, truly an intercalated segment between the radius and distal carpal row, is inherently unstable. If not for the capsule, ligaments, and muscles, the three bones would collapse when compressed by the distal carpal row against the radius. The obliquely oriented scaphoid would rotate into flexion and pronation, while the wedge-shaped (thinner dorsally than palmarly) lunate and triquetrum would collapse into extension and supination
Until recently, muscles were considered to have a negative influence on carpal stability. Instability was assumed to be a ligament insufficiency problem made worse by muscle contraction. Now we know that the assumption is wrong: muscles play an important stabilizing role
Chronicity: Traditionally, ligament injuries have been classified depending on the time elapsed from injury to diagnosis into three categories: acute, subacute, and chronic
Severity: Any carpal instability can be analyzed according to the severity of the resulting subluxation. If carpal misalignment appears only under high stress in specific wrist positions, the case is less severe than if it were permanently present. Based on this idea, three groups of instabilities exist: occult (partial ligament tears with no misalignment under stress), dynamic (complete ruptures exhibiting carpal misalignment only under certain loading conditions), and static (complete ruptures with permanent alteration of carpal alignment).
Etiology: Although most instability problems are caused by trauma, certain diseases (e.g., inflammatory arthritis) may also be responsible for a similar constellation of radiographic findings. In traumatic cases, especially if diagnosed early, effective repair of the ruptured ligaments is possible. If ligament rupture results from rheumatoid arthritis, strong remaining ligament tissue is unlikely.
Location: It is important to investigate the location of the most important dysfunctions (e.g., subluxation or joint gapping), which may or may not coincide with the location
of the primary lesion.
Direction: When present, the direction of the carpal misalignment is an important factor to consider; several patterns have been recognized. (3) ulnar translocation, when a portion of, or the entire proximal row, is (or can be) displaced ulnarly beyond normal limits; (4) radial translocation, when the proximal row can be passively displaced radially beyond normal, usually in the context of a radially malunited distal radius fracture; (5) dorsal translocation, when the carpal condyle, often as a result of a dorsally malunited fracture of the radius, is (or can be) displaced in a dorsal direction
-carpal instability dissociative (CID), in which the predominant dysfunction (i.e., ligament rupture or insufficiency) occurs between bones of the same carpal row. Most CIDs occur between the scaphoid and lunate, and less often between the lunate and triquetrum. Dissociative instabilities between the bones of the distal carpal row are rare, usually the result of a violent dorsopalmar crushing mechanism
- also known as carpal instability nondissociative (CIND).This group includes radiocarpal, midcarpal, and combined radiocarpal–midcarpal instabilities. If the entire carpus is malaligned (translocated) with respect to the radius in any direction, this is radiocarpal instability. If the proximal carpal row as a unit collapses and becomes unstable, either in
flexion or e
-“carpal instability complex” (CIC), where there are features ofxtension, this is a combined radiocarpal–midcarpal instability, a condition that is also known as nondissociative instability of the proximal carpal row both CID and CIND types. Carpal dislocations, if treated inadequately, may generate complex (i.e., CIC) patterns of instability where the dysfunction affects both the radiocarpal and the proximal intercarpal joint.
Various classification schemes have been proposed to aid in the diagnosis and treatment of carpal instability.
Two of the most common malalignment patterns are volar intercalated segment instability (VISI) and the more common dorsal intercalated segment instability (DISI)
DISI, when the lunate is regarded as an intercalated segment and appears abnormally extended relative to the radius and capitate;
VISI, when the lunate appears abnormally flexed
SLD : A fall on the outstretched hand with the wrist in extension and ulnar inclination and associated with midcarpal supination may cause a wide spectrum of injuries, from minor SL sprains to complete perilunar dislocations.
LTD : Most isolated injuries to the LTq ligaments are secondary to a backward fall onto the outstretched hand, with the arm externally rotated, the forearm supinated, and the wrist extended and radially inclined. In such circumstances, the impact is concentrated on the hypothenar area, and particularly on the pisiform, which acts as a punch against the extended triquetrum
DISI
AP radiographs,SL gap > 3mm with clenched fist view (Terry Thomas sign) ,cortical ring sign (caused by scaphoid malalignment) ,humpback deformity with DISI associated with an unstable scaphoid fracture, scaphoid shortening. Lateral radiographs ,dorsal tilt of lunate leads to SL angle > 70° on neutral rotation lateral ,capitolunate angle > 20°
Arthrography : 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
MRI : requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis, low sensitivity for tears
VISI
Lateral,volar flexion of lunate leads to SL angle < 30° (normal is 47°) and VISI deformity ,capitolunate zigzag deformity seen with capitolunate angle increase to > 15° (lunate and capitate normally co-linear), AP unlike scapholunate dissociation, may not be widening of LT interval break in Gilula's arc may see proximal translation of triquetrum and/or LT overlap
Increased SL joint space. The “Terry Thomas sign,” white arrow named by Frankel after the English film comedian’s dental diastema, is considered positive when the space between the scaphoid and lunate appears abnormally wide compared with the contralateral side The SL gap should be measured in the middle of the flat ulnar facet of the scaphoid.120 A unilateral gap greater than 5 mm is diagnostic of SL dissociation. If there is no history of a specific traumatic episode, and yet there is an obvious SL diastasis, one must consider either a constitutionally increased SL gap, usually bilateral, with or without hyperlax ligaments.
To rule out the presence of an occult asymptomatic SL ligament injury, a comparative radiographic examination is critical (Figure 13.22).
Scaphoid ring sign. Black arrow When the scaphoid has collapsed into flexion, it has a foreshortened appearance in the anteroposterior view. In such circumstances, the scaphoid tuberosity is shown in the PA projection in the form of a radiodense circle or ring over the distal two-thirds of the scaphoid
Increased SL angle. In the lateral view, if the scaphoid lies more perpendicular to the long axis of the radius and the lunate appears normally aligned or abnormally extended, SL dissociation should be suspected. In such circumstances, the SL angle is greater than the usual 45 to 60 degrees (Figure 13.23). This angle will progressively increase as the lunate extends to accommodate the loss of height of the radial column, causing a dorsal subluxation of the capitate.
Palmar V sign. In the lateral view of a normal wrist, a wide “C”-shaped line can be drawn by joining the palmar margins of the scaphoid and radius. When the scaphoid is abnormally flexed, the palmar outline of it intersects the palmar margin of the radial styloid at an acute angle, forming a sharper, “V”- shaped pattern
Lateral radiographs : right pic dorsal tilt of lunate leads to SL angle > 70° on neutral rotation lateral , capitolunate angle > 20°
In such cases, the lunate’s dorsal pole is superimposed on the distal part of the capitate, implying an abnormal flexion of the bone. It is also pathognomonic of this problem, the so-called “seagull sign”—the distal outlines of the lunate and triquetrum adopt the form of a flying seagull (Figure 13.40). A widened SL joint is paradoxically common in LTq dissociations
Disruption in the proximal Gilula line (PA view) due to proximal translation of the triquetrum and/or lunotriquetral overlap
Lunotriquetral interval narrowing/subchondral cyst formation (PA view) suggestive of chronic injury
In the lateral projection, aside from the VISI pattern of misalignment, it is sometimes possible to find a decreased LTq angle. According to Reagan et al,79 the average LTq angle is 14 degrees. Assessment of this angular measurement requires films of excellent quality and considerable practice taking them because the longitudinal axis of the triquetrum is difficult to identify. Yet, identifying the relative position of the triquetrum axis relative to the lunate axis may help
Lunotriquetral angle (lateral view) : normal -3 to 31 degrees, becomes more negative (average -16 degrees) with lunotriquetral dissociation
Lateral right pic : volar flexion of lunate leads to SL angle < 30° (normal is 47°) and VISI deformity ,capitolunate zigzag deformity seen with capitolunate angle increase to > 15° (lunate and capitate normally co-linear)
