2011/1/17

Intra-carpal Fracture Carpal Instability

2011-1-15 CME Course

Carpal instability
z The carpal bones are misaligned. z CID: carpal instability dissociated break in the proximal or distal carpal row (S_L dissociation) z CIND: non-dissociated carpal instability, between carpal row (mal-united distal radius fx)

Carpal Instability
z Instability = abnormal kinematics
during physiologic load z Collapse = fixed malalignment (may/may not be stable)

Timing :Carpal Instability

z Static instability: abnormal carpal alignment at rest. z Dynamic instability: normal at rest, but abnormal under load in carpal alignment. z Predynamic instability: with symptoms, without deformity

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Location: Carpal Instability

z Midcarpal instability: abnormal kinematics between proximal and distal carpal row. z Radiocarpal instability: abnormal translation of the entire carpus. z Axial instability: separation of carpal columns.
z

Etiology: Carpal Instability

Primary: Trauma: most frequent Secondary : Inflammatory arthropathy Congenital ligamentous laxity Connective tissue disease

Mechanism of injury
Force applied to the thenar area with wrist in hyperextension, ulnar deviation and midcarpal supination
Mayfield JK Mechanism of carpal injuries Clin Orthop 149:45-54 1980

Trauma
z Traffic accident: motorcycle z Fall from height z Sport injury

Pattern of injury
zLigamentous disruption starts radially progresses ulnarwards (distally and around the lunate) zWeakest ligaments of the wrist on the radial side
Mayfield, JHS 1980

Perilunar dislocation
Type of injury: z Lesser arc injuries (Mayo Clinic Type I) Pure ligamentous z Greater arc injuries (Mayo Clinic Type II) Trans-scaphoid, transcapitate Transhamate, transtriquetral Johnson, 1980

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Progressive Perilunate Instability (PLI)

z Stage I: z Stage II: z Stage I: z Stage I:

Progression of injury

Scapholunate Lunocapitate Lunotriquestral Lunate Dislocation

z Mayfield et al Anat Rec 186:417-428,1976

Models for carpal Instability

CID , CIND CIC , CIA . *&%$, (*@#

DISI, VISI
%$&*,##@&

Carpal Bone: Balance

Dorsal Intercalated Segment Instability (DISI)

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Volar Intercalated Segment Instability (VISI)

Carpal Dislocation

Transcaphoid Perilunate Fracture Dislocation (TSPD)

Trans-Scaphoid Perilunate Fracture Dislocation (Great Arc)

z Perilunate Dislocation z Scaphoid Fracture z Lunotriquestral Injury

z Perilunate Dislocation
z As early as possible z Closed Reduction Manipulation in ER Traction reduction Pinning augmentation Joystick manipulation z Open Reduction Dorsal ? Volar ? Combined ?

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z Lunotriquestral Injury
z Axial load and wrist hyperextension z Ulnar positive variance/impaction. z Clinical: click with RU deviation. Ulnar side wrist pain z Positve TL ballottement , shear test. z Arthrogram, bone scan: low specificity z Arthroscopy diagnostic

z LT separation treatment
z Pinning fixation z Dynamic :shrinkage ulno-carpal ligament,ulna shortening z LT ligament repair z LT ligament reconstruction z LT fusion z Ulnar colum fusion

z Scaphoid Fracture
z Minimal invasive z Percutaneous z Open : anti/retrograde

Treatments of TSPD
z Perilunate Dislcation: must be reduced better in closed method z Scaphoid Fracture:
screw fixation percutaneous for simple open for comlicated

z Lunotriquestral Injury
Pinning Vs Open

Perilunate Dislocation (Lesser Arc)

z Perilunate Dislocation

Perilunate Dislocation

z Scapholunate Dissocation z Lunotriquestral Injury

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zScapholunate dissociation
z Etiology: hyperextension, ulnar deviation, intercarpal supination. z Scaphoid shift test positive. z S-L gap>2 mm,S-L angle >70 . z Cortical ring sign, foreshortened scaphoid. z Carpal stretch test z Arthrogram. MRI. Arthroscope.

PA Radiography

Lack of paralelism

PA Radiography
Signet ring sign

PA Radiography
Scapholunate gap > 3mm Terry Thomas sign

Lateral Radiography
60
o

Treatment S-L dissociation

z Closed reduction and pin fix. z Arthroscopic exam and reduction , pin fix. z Open reduction , lig repair, pin fix, possible dorsal capsulodesis or Brunelli procedure z Ligament reconstruction with tendon graft, bone lig bone graft z Trans-scapholunate screw fixation z STT fusion or SC fusion, SCL fusion. z PRC

95
o

Normal SL angle 30-60o

SL > 80o DISI deformity

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S-L repair and ligamentoplasty

S-L Repair and Modified Dorsal Capsulodesis

Reduction and Association of S-L

Treatments of Lesser Arc

z Perilunate Dislcation: must be reduced better in closed method z Scapholunate Dissociation: repair to reconstruction capsulodesis to fusion z Lunotriquestral Injury
Pinning Vs Open

Clinical Comparison:
z Perilunate Dislocation with Trasscaphoid: without Transcaphoid :

z Different Treatment Techniques z Different Outcomes

z 1997 J Hand Surg A z Pittsburgh z 11 cases of PLD and PLFD

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z Both Volar and dorsal approach

z 2000 J Hand Surg A z London 23 cases of PLD or PLFD z Combine dorsal and volar approach

z 2002 J Hand B z G Herzberg France z 14 cases TSPD z dorsal approach

z Mayo score: average 79% z Radiographic result VS Score

z 2004 J Hand Surg A z Seattle z 22 isolated PLD z Combined dorsal and volar approach

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z 12 cases broken of wire

z 2005 J Hand Surg A z Seattle WA z 25 cases: TSPD z Dorsal appraoch

z 2007 J Hand Surg A z Massachusetts ,Harvard z 18 cased PLD z 9 screws VS 9 K-wires

Results
z Flexion Arc: Screw :97 % K-wire :73 % z Grip 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

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z 2008: Review Article : PLD z Houston TX z Repair /Reconstruction of lignament z Screw fixation cross joint

z 2008 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

z 2008 Hand Surgery: z Hong Kong : Reference of Rookwood z 21 cases TSPLD z Percutaneous 3.5 screw for scaphoid z Percutaneous k-wire for LT

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z 2010 J Hand B z Korea 4 cases TSPD z Arthroscopic assisted MIS

Summary of Papers Review

TSPD
z Comibned with PLD z Double incision z Dorsal incision z Screws for scaphoid z Miniinvasive z Arthroscopic

PLD
z Combined with TSPD z Double incision z Ligament reconstruction z Suture repair z Screws cross bone

z Identification of ligament injury z Chip bone grafting

Conclusion:
Based on our findings we conclude : signs of posttraumatic arthritis static carpal instability increase progressively but are well tolerated at an average follow-up of 13 years.

z 2010: J Hand Surg A z France z 18 cases : 11 PLD , 7 TSPD z at least : 13 years

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