7/28/2019 Intra-Carpal Fracture Instability

1/12

2011/1/17

1

Intra-carpal Fracture

Carpal Instability

2011-1-15 CMECourse

Carpal instability

zThe carpal bones are misaligned.

zCID: carpal instability dissociated

break in the proximal or distal carpal row

(S_L dissociation)

zCIND: non-dissociated carpal instability,

between carpal row

(mal-united distal radius fx)

Carpal Instabilityz Instability = abnormal kinematics

during physiologic load

z Collapse =fixed malalignment

(may/may not be stable)

Timing :Carpal Instability

zStatic instability: abnormal carpalalignment at rest.

zDynamic instability: normal at rest, butabnormal under load in carpalalignment.

zPredynamic instability:

with symptoms, without deformity

7/28/2019 Intra-Carpal Fracture Instability

2/12

2011/1/17

2

Location: Carpal Instability

zMidcarpal instability: abnormalkinematics between proximal anddistal carpal row.

zRadiocarpal instability: abnormaltranslation of the entire carpus.

zAxial instability: separation of carpalcolumns.

Etiology: Carpal Instability

z

Primary:Trauma: most frequent

z Secondary :

Inflammatory arthropathy

Congenital ligamentous laxity

Connective tissue disease

Force applied to the thenar area withwrist in hyperextension, ulnar deviation

and midcarpal supination

Mayfield JKMechanism of carpal injuriesClin Orthop 149:45-54 1980

Mechanism of injuryMechanism of injury Trauma

zTraffic accident: motorcycle

zFall from height

zSport injury

Pattern of injuryzLigamentous disruption

starts radially

progresses ulnarwards

(distally and around the lunate)

zWeakest ligaments of the wrist

on the radial side

Mayfield,

JHS 1980

Perilunar dislocationType of injury:

z Lesser arc injuries

(Mayo Clinic Type I)

Pure ligamentous

z Greater arc injuries

(Mayo Clinic Type II)

Trans-scaphoid, transcapitate

Transhamate, tr anstriquetral

Johnson, 1980

7/28/2019 Intra-Carpal Fracture Instability

3/12

2011/1/17

3

Progressive Perilunate Instability(PLI)

z Stage I: Scapholunate

z Stage II: Lunocapitate

z Stage I: Lunotriquestral

z Stage I: Lunate Dislocation

z Mayfield et alAnat Rec 186:417-428,1976

Progression of injury

CID , CINDCIC ,CIA .

*&%$, (*@#

DISI,VISI

%$&*,##@&

Models for carpal Instability

Carpal Bone: Balance

Dorsal Intercalated Segment

Instability (DISI)

7/28/2019 Intra-Carpal Fracture Instability

4/12

2011/1/17

4

Volar Intercalated SegmentInstability (VISI)

Carpal Dislocation

Transcaphoid Perilunate

Fracture Dislocation

(TSPD)

Trans-Scaphoid Perilunate

Fracture Dislocation (Great Arc)

zPerilunate Dislocation

zScaphoid Fracture

z Lunotriquestral Injury

z Perilunate Dislocation

z As early as possible

z Closed Reduction

Manipulation in ER

Traction reduction

Pinning augmentation

J oystick manipulation

z Open Reduction

Dorsal ? Volar ?

Combined ?

7/28/2019 Intra-Carpal Fracture Instability

5/12

2011/1/17

5

z Lunotriquestral Injury

zAxial load and wrist hyperextension

zUlnar positive variance/impaction.

zClinical: click with RU deviation. Ulnarside wrist pain

zPositve TL ballottement , shear test.

zArthrogram, bone scan: low specificity

zArthroscopy diagnostic

z LT separation treatment

zPinning fixation

zDynamic :shrinkage ulno-carpalligament,ulnashortening

zLT ligament repair

zLT ligament reconstruction

zLT fusion

zUlnar columfusion

z Scaphoid Fracture

zMinimal invasive

zPercutaneous

zOpen : anti/retrograde

Treatments of TSPDzPerilunate Dislcation:

must be reduced

better in closed method

zScaphoid Fracture:

screw fixation

percutaneous for simple

open for coml icated

z Lunotriquestral Injury

Pinning Vs Open

Perilunate Dislocation

Perilunate Dislocation

(Lesser Arc)

z Perilunate Dislocation

z Scapholunate

Dissocation

z Lunotriquestral Injury

7/28/2019 Intra-Carpal Fracture Instability

6/12

2011/1/17

6

zScapholunate dissociation

zEtiology: hyperextension, ulnardeviation, intercarpal supination.

zScaphoid shift test positive.

zS-L gap>2 mm,S-L angle >70 .

zCortical ring sign, foreshortenedscaphoid.

zCarpal stretch test

zArthrogram. MRI. Arthroscope.

PA Radiography

Lack of paralelism

PA Radiography

Signet ring sign

PA RadiographyScapholunate gap >3mm

Terry Thomas sign

Lateral Radiography

95o

SL > 80o

DISI deformity

60o

Normal SL angle 30-60o

Treatment S-L dissociationzClosed reduction and pin fix.

zArthroscopic exam and reduction , pin fix.

zOpen reduction , lig repair, pin fix, possibledorsal capsulodesis or Brunelli procedure

zLigament reconstruction with tendon graft,bone lig bone graft

zTrans-scapholunate screw fixation

zSTT fusion or SC fusion, SCL fusion.

zPRC

7/28/2019 Intra-Carpal Fracture Instability

7/12

2011/1/17

7

S-L repair and ligamentoplasty S-L Repair and ModifiedDorsal Capsulodesis

Reduction and Associationof S-L

Treatments of Lesser ArczPerilunate Dislcation:

must be reduced

better in closed method

zScapholunate Dissociation:

repair to reconstruction

capsulodesis to fusion

z Lunotriquestral Injury

Pinning Vs Open

Clinical Comparison:

zPerilunate Dislocation

with Trasscaphoid:

without Transcaphoid :

z Different Treatment Techniques

z Different Outcomes

z1997J Hand Surg A

zPittsburgh

z 11 cases of PLD and PLFD

7/28/2019 Intra-Carpal Fracture Instability

8/12

2011/1/17

8

zBoth Volar and dorsal approach

z2000 J Hand Surg A

zLondon 23 cases of PLD or PLFD

zCombine dorsal and volar approach

z2002J Hand B

zG Herzberg France

z14 cases TSPD

z dorsal approach

zMayo score: average 79%

zRadiographic result VS Score

z2004J Hand Surg A

zSeattle

z22 isolated PLD

zCombined dorsal and volar approach

7/28/2019 Intra-Carpal Fracture Instability

9/12

2011/1/17

9

z12 cases broken

of wire

z2005J Hand Surg A

zSeattle WA

z25 cases: TSPD

zDorsal appraoch

z2007J Hand Surg A

zMassachusetts ,Harvard

z18 cased PLD

z 9 screws VS 9 K-wires

Results

zFlexion Arc: Screw :97 %

K-wire :73 %

zGrip strength: screw: 74 %

K-wire: 67 %

z Mayo score: E: 1 screw

G: 1 screw,1 wire

F: 3 screw, 3 wire

P: 4 screw, 5 wire

7/28/2019 Intra-Carpal Fracture Instability

10/12

2011/1/17

10

z2008: Review Article : PLD

zHouston TX

zRepair /Reconstruction of lignament

zScrew fixation cross joint

z2008 J Otrthop Trauma

z 12 cases TSPD Turkey

z 6 cases acute: 3 days(0-7)

z 6 cases delayed : 26 days (10-26)

8 dorsal approach

LT: k-wire fixation

z2008 Hand Surgery:

zHong Kong : Reference of Rookwood

z21 cases TSPLD

zPercutaneous 3.5 screw for scaphoid

zPercutaneous k-wire for LT

7/28/2019 Intra-Carpal Fracture Instability

11/12

2011/1/17

11

z2010J Hand B

zKorea 4 cases TSPD

zArthroscopic assisted MIS

z Identification of

ligament injury

zChip bone grafting

Summary of Papers Review

TSPDz Comibned with PLD

z Double incision

z Dorsal incision

z Screws for scaphoid

z Miniinvasive

z Arthroscop ic

PLDz Combined with TSPD

z Double incision

z Ligament

reconstruction

z Suture repair

z Screws cross bone

z2010: J Hand Surg A

z France

z18 cases : 11 PLD , 7 TSPD

z at least : 13 years

Conclusion:Based on our findings

we conclude :

signs of posttraumatic arthritis

static carpal instability

increase progressively

but are well tolerated at an averagefollow-up of 13 years.

7/28/2019 Intra-Carpal Fracture Instability

12/12

2011/1/17

12