Carpal fractures Angelos Assiotis SpR 06 August 2015 27 y M Fell off skateboard Spot diagnosis 06 August 2015 Objectives General principles Carpal Fractures Summary 06 August 2015 06 August 2015 ID: 233886
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Slide1
Hand and Wrist term: Carpal fractures
Angelos Assiotis (
SpR)
06 August 2015Slide2
27 y MFell off skateboard
Spot diagnosis06 August 2015Slide3
Objectives
General principlesCarpal Fractures
Summary06 August 2015Slide4
06 August 2015
General Principles
Mechanism?Incidence of carpal fractures?Correlation to distal radial fractures?Commonest carpal bone fracture?
Least common carpal bone fracture?
Scaphoid
68.2%
Triquetrum
18.3%
Trapezium
4.3%
Lunate
3.9%
Capitate
1.9%
Hamate
1.7%
Pisiform
1.3%
Trapezoid0.4%
Gelberman
et al. J Hand
Surg
1983Slide5
06 August 2015
Scaphoid Fractures (2442)
Waist > Proximal pole > Distal pole Mechanism? AVN risk based on blood supply Flexion and extension?
ClassificationSlide6
06 August 2015
Scaphoid Fractures
Symptoms and signs: snuffbox pain, thumb compression, tubercle pain, clamp sign 24 hrs after injury (100% sensitivity and 74% specificity)1 Investigations:
Scaphoid views
Should we re-
Xray
?
Humpback?
Associated injuries?
1. Hackney et al.
Curr
Rev
Musculoskelet
Med. 2011 Slide7
06 August 2015
Scaphoid Fractures
Investigations:Bone scanCT
MRISlide8
06 August 2015
Scaphoid Fractures
Treatment for acute injuries: 1. Cast immobilizationStable nondisplaced
fracture (majority of fractures, usually waist or distal pole)
What type of cast?
How long for?
Warn patients!
May opt to augment with PEMF?
Outcomes:
scaphoid fractures with <1mm displacement have union rate of >90%Slide9
06 August 2015
Scaphoid Fractures
Treatment for acute injuries: 2. ORIF vs Percutaneous
screw
Unstable fractures as shown by proximal pole fractures , displacement > 1 mm, 15 degrees of humpback deformity, scaphoid fractures associated with
perilunate
dislocation,
comminuted
fractures, vertical or oblique fractures
Reducible?
K-wires as joysticks
Dorsal approach (proximal pole, respect dorsal blood supply)
Volar
approach (entire scaphoid)
Herbert screws/
AcutrakSlide10
06 August 2015
Scaphoid Fractures
Treatment for non-union: Non-vascularised grafting:ORIF and iliac crest wedge autograft
(interposition, Fisk)
Matti-Russe
inlay
cotricocancellous
autograft
(historical)
Vascularised grafting:
PQ
pedicled
radial bone graft (
volar
)
1,2 ICSRA pedicle (dorsal)-
ZaidembergSlide11
06 August 2015
Scaphoid Fractures
Treatment for non-union and OA: Salvage procedures:Radial styloidectomy
+- denervation
+- ORIF and grafting
PRC
4 CFSlide12
06 August 2015
Triquetral Fractures (126)
‘Three faces’
1. Common avulsion injury
-Lateral XR
-
Extrinsics
2. Impingement of
ulnar
styloid
in extension and
ulnar
deviation
(USPI)
3. Shear forces
DDx
:
os
triquetrum
3 types:
Cortical dorsal
Body
Cortical palmarSlide13
06 August 2015
Triquetral Fractures
Avulsion fractures: Symptomatic relief with BE neutral POP. Role of MRI? Excision of bone flake if symptomatic?
Displaced large fractures: CT/MRI and possibly
percutaneous
fixation +/- ORIF +/- ligament repair
-
Look
for
perilunate
dislocation in body fractures
-
Look
for LTL rupture in cortical palmar (VISI)Slide14
06 August 2015
Trapezium Fractures (172)
High E Body and Ridge fractures - Body: coronal split, associated with Bennett’s fracture - Ridge (direct blow, avulsion): associated hook of
hamate fractureSlide15
06 August 2015
Trapezium Fractures
Bett’s view Carpal tunnel view CT
Treatment:
Assess CMCJ stability
BE POP (+/- thumb spica) if undisplaced avulsion
ORIF if body displaced
Excision in ridge non-unionSlide16
06 August 2015
Lunate Fractures (618)
‘Moon shaped’ The Keystone
High E or Fall with hyperextended
wrist
Associated injuries
ClassificationSlide17
06 August 2015
Lunate Fractures
Examination findings? Common missed diagnosis:Kienböck's disease
Treatment:
BE POP if undisplaced
Long term f/up with MRI
ORIF if carpus
subluxed
or
displaced bodySlide18
06 August 2015
Capitate Fractures (262)
‘Having a head’- Capitatus Largest one
Retrograde blood supply
Fall in wrist extension, pain at base of MF/RF MC
Scaphoid views
BE POP if undisplaced, headless screws if displacedSlide19
06 August 2015
Capitate Fractures
Associated with scaphoid fractures (naviculocapitate syndrome) and perilunate
dislocation
Scaphoid views
BE POP if undisplaced, headless screws if displaced (dorsal approach)Slide20
06 August 2015
Hamate Fractures (314)
‘Hook-shaped’ - Hamatus Hamate
body and hook (Milch)
Hamate
body: direct impact with clenched fist, RF/LF MC base fracture/dislocation
Hook of
hamate
: Blunt trauma in palm (golf/hockey/baseball)
Ulnar
nerve symptoms
Carpal tunnel views/CTSlide21
06 August 2015
Hamate Fractures
Dx: Hook of hamate pull test Treatment
-Non-operative: undisplaced, usually hook
- Excision in hook non-union +/-
Gyuon’s
canal decompression
-ORIF: body displaced intra-articular, small headless screws, dorsal approachSlide22
06 August 2015
Pisiform Fractures (79)
‘Pea-shaped’ Sesamoid bone, within FCU
Direct impact
Associated with DRF,
hamate
fracture
Carpal tunnel view/CTSlide23
06 August 2015
Pisiform Fractures
Treatment:POP in flexion and ulnar deviation Excision in non-union (palmar longitudinal, splitting FCU) +/-
Guyon’s canal decompressionSlide24
06 August 2015
Trapezoid Fractures (121)
Compressive force through IF MC Often associated with other carpal fractures
AP/Oblique wrist and CT
BE POP usuallySlide25
QUESTIONS?
(What were the numbers all about?)Scaphoid 2442, Lunate 618, Triquetrum
126, Pisiform 79 , Hamate 314, Capitate 262, Trapezoid 121, Trapezium 17206 August 2015Slide26
Conclusion
Difficult to diagnoseHigh index of suspicionThink about what attaches to the bone
06 August 2015Slide27
Summary
Ligaments?
IntrinsicExtrinsicPatterns of instability? MayoCID: Within a rowCIND: Between two rows
CIC: Combo, common is perilunate
dislocation
Adaptive
caprus
:
malunions
,
Madelung’s
31 December 2012Slide28
Summary
31 December 2012Slide29
Summary
Is it that difficult???Ulna to radial: trapezium to styloid
, scaphoid flexion (and proximal row)Radial to ulna: trapezium away from styloid, scaphoid
extension (and proximal row)
Lunate
will go with UNDAMAGED
carpus
, defining instability pattern
SLL injury? DISI
LTL injury? VISI
31 December 2012Slide30
Treatment options
Wrist arthroscopy:Diagnose
CartilageDebrideClassify (Geissler
)
Make a plan
31 December 2012Slide31
Treatment options
Scaphoid non-union:
ORIF + Bone graft31 December 2012Slide32
Treatment options
SLL injury:Thumb
spica, activity modification, NSAIDS: partial acute tears (uncommon presentation)31 December 2012Slide33
Treatment options
SLL injury (dynamic instability):2.
Blatt capsulodesis: 31 December 2012
With two K-wires
In concurrent distal radius #
In partial or complete tears
NO OASlide34
Treatment options
SLL injury (static or DISI):3.
Brunelli tenodesis: 31 December 2012
SL dissociation
FCR tendon
Promising early results
NO OASlide35
Treatment options
SLL injury (static or DISI):4. Reconstruction:
31 December 2012Autologous bone-ligament-boneTechnically challenging
Intercarpal
fusion:
STT fusion, SC fusion
+- Radial
styloidectomy
Slide36
Treatment options
Complex instability:
Perilunate/lunate dislocationSCL fusion (50-67% ROM)
Proximal row carpectomy
(50-75% ROM, 80% grip)
31 December 2012Slide37
Treatment options
SLAC (commonest pattern of wrist OA):
Scaphoidectomy and 4-corner fusion (CLHT)IF no
luno-radial OA (40-60% ROM, 80% grip)
+- Radial
styloid
excision
2. Proximal row
carpectomy
if no
midcarpal
OA
31 December 2012Slide38
Treatment options
SLAC:4. Total wrist
arthrodesis31 December 2012
Wrist in 10-15
degreed
extension or neutral
No movement BUT
Pain free
Long term relief
Reliable
Manual workers, young men
?
Personal hygiene
? Tight spacesSlide39
Literature review
31 December 2012
PRC vs 4-corner fusion: no difference in ROM or strength, but fusion if midcarpal OAKitay et al, 2012Slide40
Conclusion
31 December 2012
What is the pathology? Is there OA? If so, where? What functional demands?What does the patient want?
REFER TO HAND SURGEONSlide41
06 August 2015