Carpal instability - Orthopedic
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i present this lovely topic at Notional Guard Hospital in Al-Ahsa in the Orthopedic department. hope you enjoy Fahad Al Hulaibi Orthopedic Resident NGH-A
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Carpal instability - Orthopedic
- 1. Carpal Instability By: Fahad Al Hulaibi Orthopedic Resident National Guard Hospital - 2015
- 2. - Definitions - DISI - VISI - Mid-carpal CIND - Radio-carpal dislocation - Peri-lunate dislocation Objective:
- 3. definitions
- 4. Definitions: Dynamic instability - (incomplete injury) maintains normal alignment at rest but will collapse under applied load. Carpal Instability
- 5. Static Instability - (complete injury) abnormal intercarpal alignment on static radiographs. Carpal Instability
- 6. Carpal Instability – Dissociative: Instability occurs between the individual bones. (in the same row) E.g: DISI & VISI Carpal Instability
- 7. Carpal Instability – Non-Dissociative: Instability occurs between the row of bones Carpal Instability
- 8. DISI “Dorsal intercalated segmental instability”
- 10. DISI Scapholunate ligament disruption. Dorsal ligaments are stronger. scaphoid will hyperflex. and the lunate will hyperextend. Carpal Instability
- 11. Presentation Hx: acute FOOSH injury vs. degenerative rupture Symptoms: dorsal and radial-sided wrist pain Carpal Instability
- 12. Examination: - Dorsal wrist pain. - Diminished grip strength. - pain increased with extreme wrist extension and radial deviation Carpal Instability
- 13. Watson test Palpable clunk Carpal Instability
- 14. Terry Thomas sign Static & Dynamic >3 mm Carpal Instability
- 15. Terry Thomas sign Static & Dynamic >3 mm Clenched-fist Carpal Instability
- 16. cortical ring sign Duo to frontal projection of volar tubercle Carpal Instability
- 18. Treatment • acute, undisplaced • chronic, asymptomatic NSAIDS, rest +/- immobilization • SL ligament injury W/o carpal malalignment • reducible SL ligament injuries SL reconstruction • rigid and unreducible • DISI with severe DJDwrist fusion Carpal Instability
- 19. Scapholunate advanced collapse (SLAC) untreated DISI deformity Carpal Instability
- 20. VISI “Volar intercalated segmental instability”
- 21. VISI Instability of the lunotriquetral ligament. Volar ligaments are stronger. scaphoid & Lunate will hyperflex. Carpal Instability
- 22. Presentation Symptoms: Ulnar side wrist pain Increase with ulnar deviation Carpal Instability
- 23. Ballottement test Laxity, crepitation or reproduction of pain Carpal Instability
- 24. Gilula arc on AP Break this line Carpal Instability
- 25. < SL angel on Lateral Carpal Instability
- 26. Treatment • acute instabilityCRPP with lunotriquetral repair • chronic instability LT fusion • chronic instability secondary to ulnar positive variance arthroscopic debridement with ulnar shortening Carpal Instability
- 29. Extrinsic ligamentous disruption. - radioscaphocapitate (SRC) - long radiolunate - short radiolunate - radioscapholunate Carpal Instability
- 31. Associated conditions: Intracarpal injury (scapholunate or lunotriquetral ligament) acute carpal tunnel syndrome compartment syndrome Carpal Instability
- 32. Prognosis: Volar dislocation more severe than dorsal. Carpal Instability
- 33. Presentation: No history of trauma (midcarpal) High energy trauma (radiocarpal) generalized ligamentous laxity irritating clunking sign complain of wrist giving way Carpal Instability
- 36. Treatment • first line of treatmentimmobilization +/- splinting • ulnar translation with styloid fractures open repair, reduction, and pinning • failed nonoperative management midcarpal joint fusion • distal radius malunion Osteotomy • failure of above treatments wrist arthrodesis Carpal Instability
- 39. 25% are missed in the ER diagnosed 75% missed 25% Carpal Instability
- 40. Mayfield commonly associated with a scaphoid fracture Carpal Instability Stage I : scapholunate dissociation Stage II: + lunocapitate disruption Stage III: + lunotriquetral disruption, "perilunate“ Stage VI: Lunate Dislocation Most severe of carpal instabilities
- 42. space of Poirier
- 43. break in Gilula's arc Carpal Instability triangular lunate "piece-of-pie sign"
- 44. Treatment • definitive management Closed reduction and casting • all acute injuries <8 weeks old closed reduction/splinting followed by open reduction, ligament repair, fixation, possible carpal tunnel release • chronic injury (defined as >8 weeks after initial injury) Proximal row carpectomy • chronic injuries with degenerative changes Total wrist arthrodesis Carpal Instability
- 46. Case 1
- 49. Sources: Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012 AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009 Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011 Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009 Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012 Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012