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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

Publicada em: Saúde e medicina
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Carpal instability - Orthopedic

  1. 1. Carpal Instability By: Fahad Al Hulaibi Orthopedic Resident National Guard Hospital - 2015
  2. 2. - Definitions - DISI - VISI - Mid-carpal CIND - Radio-carpal dislocation - Peri-lunate dislocation Objective:
  3. 3. definitions
  4. 4. Definitions:  Dynamic instability - (incomplete injury) maintains normal alignment at rest but will collapse under applied load. Carpal Instability
  5. 5.  Static Instability - (complete injury) abnormal intercarpal alignment on static radiographs. Carpal Instability
  6. 6.  Carpal Instability – Dissociative: Instability occurs between the individual bones. (in the same row) E.g: DISI & VISI Carpal Instability
  7. 7.  Carpal Instability – Non-Dissociative: Instability occurs between the row of bones Carpal Instability
  8. 8. DISI “Dorsal intercalated segmental instability”
  9. 9. Carpal Instability
  10. 10. DISI  Scapholunate ligament disruption.  Dorsal ligaments are stronger.  scaphoid will hyperflex. and the lunate will hyperextend. Carpal Instability
  11. 11. Presentation  Hx: acute FOOSH injury vs. degenerative rupture  Symptoms: dorsal and radial-sided wrist pain Carpal Instability
  12. 12.  Examination: - Dorsal wrist pain. - Diminished grip strength. - pain increased with extreme wrist extension and radial deviation Carpal Instability
  13. 13. Watson test Palpable clunk Carpal Instability
  14. 14. Terry Thomas sign Static & Dynamic >3 mm Carpal Instability
  15. 15. Terry Thomas sign Static & Dynamic >3 mm Clenched-fist Carpal Instability
  16. 16. cortical ring sign Duo to frontal projection of volar tubercle Carpal Instability
  17. 17. SL angel: Carpal Instability
  18. 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. 19. Scapholunate advanced collapse (SLAC)  untreated DISI deformity Carpal Instability
  20. 20. VISI “Volar intercalated segmental instability”
  21. 21. VISI  Instability of the lunotriquetral ligament.  Volar ligaments are stronger.  scaphoid & Lunate will hyperflex. Carpal Instability
  22. 22. Presentation  Symptoms: Ulnar side wrist pain Increase with ulnar deviation Carpal Instability
  23. 23. Ballottement test Laxity, crepitation or reproduction of pain Carpal Instability
  24. 24. Gilula arc on AP Break this line Carpal Instability
  25. 25. < SL angel on Lateral Carpal Instability
  26. 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
  27. 27. Carpal instaability Dissociative(CIND)
  28. 28. CIND Midcarpal instability Radiocarpal dislocation Carpal Instability
  29. 29.  Extrinsic ligamentous disruption. - radioscaphocapitate (SRC) - long radiolunate - short radiolunate - radioscapholunate Carpal Instability
  30. 30. Carpal Instability
  31. 31. Associated conditions:  Intracarpal injury (scapholunate or lunotriquetral ligament)  acute carpal tunnel syndrome  compartment syndrome Carpal Instability
  32. 32. Prognosis:  Volar dislocation more severe than dorsal. Carpal Instability
  33. 33. Presentation:  No history of trauma (midcarpal)  High energy trauma (radiocarpal)  generalized ligamentous laxity  irritating clunking sign  complain of wrist giving way Carpal Instability
  34. 34. Radiocarpal dislocation Carpal Instability
  35. 35. Carpal Instability
  36. 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
  37. 37. Peri-lunate dislocation
  38. 38. mechanism Forced dorsflextion, Ulnar deviation Supination. Carpal Instability
  39. 39. 25% are missed in the ER diagnosed 75% missed 25% Carpal Instability
  40. 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
  41. 41. space of Poirier
  42. 42. break in Gilula's arc Carpal Instability triangular lunate "piece-of-pie sign"
  43. 43. 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
  44. 44. Summery: Carpal Instability
  45. 45. Case 1
  46. 46. Lunate dislocation
  47. 47. 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

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