21-7). The late stages of SLAC are irreversible and result ultimately in unsalvageable osteoarthritis of the wrist joint. At the distal end (the part farthest away from the body), the articular disc binds the radius to the ulna and carpal bones, and separates the distal ulna from the carpal bones. The radiocarpal joint is made up of four bones: Radius. The patient is placed supine, with the upper extremity extended on a hand table in a neutral position with a roll under the ulnar side of the wrist. Equipment includes a headless cannulated compression screw for scaphoid fixation to permit percutaneous fixation and some type of distal radius fixation system that can provide rigid fixation with the least complications. 21-9, Fractures and Injuries of the Distal Radius and Carpus The Cutti. Once the decision has been made to surgically treat these injuries, the question arises on the order of treatment of these combined fractures. The joint occurs proximally between the concave surface of the distal end of the radius and the articular disc of the distal radioulnar joint, and distally by the oval shaped convex surface of the proximal carpal row (the scaphoid, lunate and triquetral bones). The techniques presented in this chapter will describe in a step-by-step manner the evaluation and fixation of a specific case to help provide clarity. Historical references site the primacy of addressing the distal radius fracture, but this predated the operative treatment of acute scaphoid fractures. When the dorsal joysticks are brought together, the flexion deformity of the scaphoid is corrected. The radius lies towards the thumb and the ulna towards the little finger. The distal scaphoid is covered by the trapezium and obstructs direct line of sight, making central axis wire placement difficult. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Presurgical Functional MappingAndrew C. Papanicolaou, Roozbeh Rezaie, Shalini Narayana, Marina Kilintari, Asim F. Choudhri, Frederick A. Boop, and James W. Wheless, the Child With SeizureDon K. Mathew and Lawrence D. Morton, and Pharmacologic Consequences of SeizuresShilpa D. Kadam and Michael V. Johnston, Self-Limited EpilepsiesDouglas R. Nordli, Jr., Colin D. Ferrie, and Chrysostomos P. Panayiotopoulos, in Epilepsy: A Network and Neurodevelopmental PerspectiveRaman Sankar and Edward C. Cooper, Hematology, Oncology and Palliative Medicine. Also overlapping of the hamate and the lunate. Arthroscopy is used to confirm fracture reduction and identify occult injuries. The rare isolated stable nondisplaced scaphoid fracture and distal radius fracture might be safely managed with plaster immobilization for periods of 3 to 4 months. 3. Treatment of pediatric patients with nondisplaced fractures is relatively contraindicated because in these patients the scaphoid fracture will usually heal in a reasonable amount of time and there are not as many problems with joint stiffness. Radio-scaphoid arthrodesis is rarely performed but can be considered when degenerative changes from wrist arthritis involve the entire radio-carpal joint with sparing of the mid-carpal joint, such as happens after distal radius fractures. The distal radioulnar joint is a pivot joint located between the bones of the forearm, the radius and ulna. A Hand Surgeon is the best qualified specialist doctor to diagnose and manage the entire spectrum of this injury. Any patient with combined fractures with displacement of either the scaphoid or distal radius greater than 1 mm would be an operative candidate. As the wire is advanced, its position in two planes is confirmed using fluoroscopy (Fig. In cases of scapholunate ligament sprain or minor tears, non-surgical management involves rest immobilization of the wrist in a custom-molded thermoplastic splint for a period of 6 weeks. The patient is a 19-year-old skateboarder. Historical references site the primacy of addressing the distal radius fracture, but this predated the operative treatment of acute scaphoid fractures.5,8,9 We now understand that both fractures must be adequately reduced and treated. Unfortunately, this period of immobilization for the treatment of distal radius fractures, at best, results in delay in recovery of hand and wrist function and, at worst, permanent stiffness. Unfortunately, this period of immobilization for the treatment of distal radius fractures, at best, results in delay in recovery of hand and wrist function and, at worst, permanent stiffness.6,7. Accessory ossicles of the wrist are commonly seen on plain radiographs of the wrist and associated cross-sectional imaging.Over 20 were originally described 2, although the more common include 1:. In a complete tear, the connection between the scaphoid and the lunate is lost, and it is termed scapholunate dissociation (Figure 2). 21-3). Wire placement in a displaced fracture is crucial in the distal fragment but initially less important in the proximal fragment until reduction is performed. Typically, these are treated within 2 weeks, although treatment after that date is not necessarily contraindicated. fracture of distal radius with dorsal displacement of distal fragment. The articular surface of the distal radius is roughly triangular and concave in appearance, presenting two articular facets separated by a slight anteroposterior ridge. This forms part of the essential articulation in the wrist joint. Hove LM(1). Sequential images of the technique for fixation of this injury form the basis for discussion of this chapter. By way of repetition of anatomical terminology: volar/palmar (palm of hand), dorsal (back of hand), ulnar (side of little finger) and radial (side of thumb). between radius and scaphoid. Once fixation is achieved in one fracture, the treatment of the second fracture risks disruption of fixation of the first fracture. A review of the relatively few published reports on combined scaphoid and distal radius fractures demonstrates that treatments have evolved over the past decade. CHAPTER 21 Simultaneous Fractures of the Scaphoid and Distal Radius, Greg A. Merrell, MD, Joseph F. Slade, III, MD. Anteroposterior radiograph demonstrating distal radius fracture and a combined scaphoid nonunion with a new fracture at the distal edge of the nonunion site. 2013 Aug 21;95(16):1517-26. doi: 10.2106/JBJS.9516icl. It should be understood that adolescents have similar healing potential as adults and should be provided the same treatment as adults. The incidence of combined injuries varies from 0.7% to 6.5% of all distal radius fractures.1–4 The mechanism is a high-energy injury with rapid forced loading of an outstretched radial-deviated dorsiflexed wrist.1,3,5,6 These injuries are often associated with a displaced and angulated scaphoid fracture. The scapholunate ligament injury occurs in axial overloading of the hyperextended wrist joint. 21-1 and 21-2). shaft increases the ability to resist lateral displacement forces. This may cause pain, swelling, clicking, loss of grip strength and loss of range of motion in the wrist joint. Sequential images of the technique for fixation of this injury form the basis for discussion of this chapter. It is located on the radial side of the wrist, and articulates with the radius, lunate, trapezoid, trapezium and capitate. Simultaneous fractures of the distal radius and scaphoid are uncommon. The wrist is maintained in a flexed position to avoid bending the guidewire. It can also happen in a car accident, a bike … The part of the radius connected to the wrist joint is called the distal radius. This dorsal approach permits easy access to the central scaphoid axis because the base of the scaphoid is covered only by soft tissue. … Again, like the scaphoid, the distal radius is percutaneously reduced using mini-fluoroscopy, 19-gauge needles to locate the fracture site, a small curved hemostat placed percutaneously to achieve reduction, and K-wires to provide provisional fixation (Fig. This surgery is done as a Day Surgery procedure under general anaesthesia. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. Deformity of the scaphoid and distal radius (red arrow) is due to remodeling related to the arthropathy. ulnar collateral ligament of wrist. 2. This injury occurred in a 22-year-old right-handed skateboarder who had a fracture through an old scaphoid nonunion and a distal radius fracture (Figs. The radioulnar joints are two locations in which the radius and ulna articulate in the forearm:. FIGURE 21-5 Central axis wire is withdrawn volarly all the way to the fracture site to allow reduction of the fracture. In recent studies, it has also been discovered that the scapholunate ligament is injured concomitantly in patients with fractures of the wrist. Scaphoid Fracture Reduction and Dorsal Guidewire Placement along the Scaphoid Central Axis, The wrist is in an ulnarly deviated position extended on the arm table with a mini-fluoroscopy unit placed horizontal on the arm table and perpendicular to the wrist. Once the scaphoid fracture is reduced and provisionally stabilized, attention is turned to the distal radius fracture. Plain radiographs of both wrists in specific clenched fist views will help to determine the presence and severity of the dissociation between the scaphoid and the lunate bones. Lateral radiograph demonstrating dorsal comminution of the distal radius fracture and a flexion deformity of the scaphoid. In complete scapholunate ligament tears resulting in scapholunate dissociation, rotatory subluxation of the scaphoid and carpal collapse before the onset of osteoarthritis, surgical reconstruction of the scapholunate ligament is indicated. No parallelism at the TL joint since there is overlapping of the triquetrum and the lunate. Send us an email or enquire directly at the respective clinics for prompt assistance. The wrist consists of several synovial articulations among the distal radius, the distal ulna, the proximal carpal row (scaphoid, lunate, triquetrum, pisiform), and the distal carpal row (trapezium, trapezoid, capitate, and hamate). Distal wrist joint dislocation may occur between trapezium and head of metacarpal bone. Boutonniere deformity. The scaphoid fracture is reduced percutaneously using dorsally placed 0.062-inch K-wires as joysticks in each fracture fragment. Reconstruction of both the dorsal and volar aspects of the scapholunate ligament truly replicates normal anatomy and closely restores normal biomechanics in the scapholunate joint. Condyloid What kind of joint is located at the wrist (between the radius and the scaphoid bone)? Central axis wire in correct position on the anteroposterior view. With acute fractures, there is usually no loss of volar cortex because the volar scaphoid fails in tension in a hyperextension injury. This bone, shaped similar to that of a cashew nut or kidney bean, is located between the base of the thumb and the radius bone of the forearm. Constant feedback between the patient, doctor and hand therapist allows for a bespoke rehabilitation process and optimized outcome. The joystick is used to extend the distal pole of the scaphoid while the two axis wires are driven retrograde to capture the reduction. FIGURE 21-8 The joystick is used to extend the distal pole of the scaphoid while the two axis wires are driven retrograde to capture the reduction. a-b) Pre-operative radiographs in a 23 year-old female who fell from a height. Once reduction is achieved, the previously placed wire in the distal fragment is driven from its volar position into the proximal fragment to capture and secure reduction. So these bones form a unit. Although uncommon, simultaneous fractures of the distal radius and scaphoid can be challenging to treat. Additionally, non-steroidal anti-inflammatory medications are prescribed to reduce pain and inflammation resulting from the injury. Distal radius fracture (Colles fracture) – a fracture of the end of the radius bone in the forearm. The scaphoid and the lunate are 2 very important carpal bones sitting atop the distal end of the radius bone (Figure 1). The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. Hand Surgery centres with dedicated hand therapists who work hand-in-hand with the surgeons will give an additional advantage in patients’ recovery. The scaphoid coordinates the motion and position of all of the other wrist bones. If the scaphoid is displaced, the proximal pole is ignored and the guidewire is placed through the distal scaphoid fragment along its central axis and withdrawn volarly beyond the fracture site (Fig. The wrist is in an ulnarly deviated position extended on the arm table with a mini-fluoroscopy unit placed horizontal on the arm table and perpendicular to the wrist. This injury occurred in a 22-year-old right-handed skateboarder who had a fracture through an old scaphoid nonunion and a distal radius fracture (. The incidence of combined injuries varies from 0.7% to 6.5% of all distal radius fractures. Simultaneous scaphoid and distal radial fractures. Clinical examination of the affected wrist will reveal tenderness over the dorsal aspect of the scapholunate joint. In the absence of any fracture, pain and swelling over the dorso-radial aspect of the wrist which persist despite adequate rest and immobilization are key symptoms which may suggest the presence of this injury. Buy Membership for Orthopaedics Category to continue reading. The hemostat is introduced through a midcarpal or an accessory portal. We prefer screws of standard size for scaphoid fractures of the middle third, because the larger core shaft increases the ability to resist lateral displacement forces.14 Mini-fluoroscopy permits real-time imaging during surgery. Once the decision has been made to surgically treat these injuries, the question arises on the order of treatment of these combined fractures. The percutaneous/arthroscopic reduction of the scaphoid fracture and provisional stabilization with a guidewire placed along its central axis, The reduction and rigid fixation of the distal radius fracture to permit early motion, The fixation of the scaphoid fracture by the percutaneous implantation of a cannulated headless compression screw along the central scaphoid axis, Equipment includes a headless cannulated compression screw for scaphoid fixation to permit percutaneous fixation and some type of distal radius fixation system that can provide rigid fixation with the least complications. Finally, a magnetic resonance imaging (MRI) scan of the affect wrist may be necessary to distinguish between a sprain and a partial tear of the scapholunate ligaments. Strong ligaments between the carpal bones (intercarpal ligaments) hold these components together. Often the lunate sits in a dorsiflexed intercalated segment instability (DISI) position. The scapholunate ligament injury in these cases is commonly overlooked. The scaphoid and the lunate are 2 very important carpal bones sitting atop the distal end of the radius bone (Figure 1). The scaphoid (or carpal navicular) is one of the eight small bones of the wrist joint. The scaphoid fracture line is visualized and reduction with joysticks initiated. considered as the three centimeters proximal to the radiocarpal joint, The energy is absorbed by the scapholunate joint and can result in a sprain, partial tear or complete tear of the scapholunate ligament (Figure 3). Scaphoid fracture – a fracture to the carpal bone in the wrist called the Scaphoid. The starting position for the guidewire is the proximal scaphoid pole at the 3-4 arthroscopic portal (Fig. The scaphoid bone and the lunate bone connect with the radius at the wrist joint. When the radius breaks near the wrist, it is called a distal radius fracture. Most common carpal wrist joint dislocation is between scaphoid and lunate bone. confirm scaphoid fracture alignment and correct positioning of the guidewire. A fluoroscopic survey of the wrist and carpus is performed to evaluate the personality of the fractures, including the direction of displacement, the presence and degree of comminution, and associated ligamentous injuries. The previously placed distal wires are driven retrograde to capture the reduction. Anatomy associated with distal radius fractures is the: radioulnar joint, the sigmoid notch, lunate fossa, the scaphoid fossa, and the ridge between the two fossa. The goal of surgical treatment is rigid fixation. This forms part of the essential articulation in the wrist joint. Wire placement in a displaced fracture is crucial in the distal fragment but initially less important in the proximal fragment until reduction is performed. FIGURE 21-7 The wrist is hyperflexed to correct the lunate DISI position, and a 0.062-inch wire is driven from radius to lunate to hold this position. The typical patient who presents with these injuries is male in his 20s or 30s after a fall, motor vehicle accident, or sports injury. In a prospective 3-year study we registered 2,330 distal radial fractures and 390 scaphoid fractures, and 12 were combined. The ligament between the scaphoid and the lunate bone, known as the scapholunate ligament, is the most commonly injured of all the intercarpal ligaments. ; Distal radioulnar joint – located near the wrist.It is an articulation between the ulnar notch of the radius and the ulnar head. There is obliteration the radiocarpal joint between radius and scaphoid (yellow arrow). Proximal radioulnar joint – located near the elbow.It is articulation between the head of the radius and the radial notch of the ulna. 21-4). A second antirotation wire is usually added, particularly in less stable displaced fractures (Fig. A joystick is also placed in the distal scaphoid. The techniques presented in this chapter will describe in a step-by-step manner the evaluation and fixation of a specific case to help provide clarity. The arthroscopic care of both distal radius and scaphoid fractures and the use of percutaneous techniques have permitted the rigid fixation of these fractures while preserving uninjured tissues.10–13 This has allowed for the early recovery of hand function with minimal complications. Ulnar collateral ligament. FIGURE 21-2 Lateral radiograph demonstrating dorsal comminution of the distal radius fracture and a flexion deformity of the scaphoid. Dislocation also occurs between carpal bones. Post-operatively, the wrist is again immobilized and rested for 6 weeks before rehabilitation is started with the hand therapist. Author information: (1)Bergen Accident and Emergency Department, Bergen Legevakt, Norway. The radius has facets for articulation with the scaphoid and lunate; the ulna articulates with the triquetrum through the triangular fibrocartilage complex. The break usually happens due to falling on an outstretched or flexed hand. If the patient is going to benefit from operative intervention of one fracture and the other is nondisplaced, then stable fixation of the other fracture while in the operating room probably makes sense to allow for the earliest possible mobilization of the extremity. This is corrected by hyperflexing the wrist and driving a 0.062-inch wire from the distal radius into the lunate to capture the lunate in a corrected position (Fig. There is parallelism between radius, lunate, proximal pole of scaphoid and proximal pole of capitate. flexion of PIP joint and hyperextension of DIP joint. The capsule of the joint is lax and extends from the inferior sacciform recess to the ulnar shaft. Often the lunate sits in a dorsiflexed intercalated segment instability (DISI) position. The scaphoid and lunate are neighbors and both have seats in the distal radius and together form the radiocarpal joint (wrist joint). A common problem today with the treatment protocol of children is that many caregivers neglect to utilize a cast or limit casting in children, resulting in nonunions. The key to success is a three-step process: This surgical staging permits reduction of both fractures without compromising the final rigid fixation of either fracture. This is best confirmed on lateral fluoroscopy (. Again, like the scaphoid, the distal radius is percutaneously reduced using mini-fluoroscopy, 19-gauge needles to locate the fracture site, a small curved hemostat placed percutaneously to achieve reduction, and K-wires to provide provisional fixation (, Ligament Reconstruction/Sigmoid Notch Plasty for DRUJ Instability, Sauvé-Kapandji Procedure after Distal Radius Fractures, Arthroscopic Diagnosis of Carpal Ligament Injuries with Distal Radius Fractures, Arthroscopic-Assisted Treatment of Distal Radius Fractures, Bridge Plating of Distal Radius Fractures, Radiographic Evaluation and Classification of Distal Radius Fractures. When asked to confirm or exclude a fracture, the wrist should be imaged in at least two directions, as in any conventional image. We prefer screws of standard size for scaphoid fractures of the middle third, because the larger core. FIGURE 21-3 Driving the central axis wire. If this treatment modality fails to resolve the symptoms, arthroscopic wrist surgery may be indicated. This upsets the balance in the wrist joint and results in asynchronous and uncoordinated motion between the carpal bones during wrist movement. Exploration and debridement of inflammatory tissue around the scapholunate joint, followed by thermal shrinkage of the injured scapholunate ligament using a radiofrequency probe is then performed. The triangular fibrocartilage complex (TFCC) stabilizes the distal radioulnar joint and is a load-bearing structure between the carpus and the ulna ( … @article{Kim2012IpsilateralDR, title={Ipsilateral Distal Radius and Scaphoid Fractures Associated with Posteromedial Dislocation of the Elbow Joint: A Case Report. Additional equipment includes 0.045-inch and 0.062-inch double-cut Kirschner wires (K-wires), a wire driver, and a small joint arthroscopy setup, including a traction system. Dynamic stress tests, such as the Watson shift test, will enable the Hand Surgeon to clinch the diagnosis. The wrist is suspended for the arthroscopic component of this procedure and the radial-carpal and mid-carpal joints are visualized. The scapho-trapezial joint is exposed through a T-shaped incisiion and the volar tubercle is then excised. The wrist joint is made up of several joints.. Radiocarpal joint – the 2 long bones of the forearm are the radius and ulna. 1. Copyright © 2007-2021 Management Corporation Strata Title Plan No. It links the two rows of carpal bones together and actually helps to stabilise them. 21-6). During the consultation, a detailed history will be taken. lunula: between TFCC and triquetrum; os styloideum (carpal boss): on dorsal surface of 2 nd or 3 rd metacarpal bases; os triangulare: just distal to ulnar fovea If the scaphoid is fixed first, there is potential for screw pullout or loosening during the substantial forces applied during reduction of the distal radius. If both fractures are nondisplaced and the scaphoid fracture is mid to distal, one could make a case for either operative or nonoperative intervention depending on the specific circumstances of the patient (e.g., age, comorbidities, tolerance of a cast). A consultation with a qualified Hand Surgeon is essential. Joints. All rights reserved, 9:00am to 5:00pm on Weekdays 9:00am to 1:00pm on Saturdays, Common Questions About Carpal Tunnel Syndrome, Radial-Sided Wrist Pain: The Scapholunate Ligament Injury, What you need to know about gum (periodontal) disease. The treatment of combined fractures of the scaphoid and distal radius includes the arthroscopic-assisted/percutaneous reduction of both fractures and their rigid fixation. The rare isolated stable nondisplaced scaphoid fracture and distal radius fracture might be safely managed with plaster immobilization for periods of 3 to 4 months. Together with the proximal radioulnar joint, the distal radioulnar joint permits pronation and supination. FIGURE 21-1 Anteroposterior radiograph demonstrating distal radius fracture and a combined scaphoid nonunion with a new fracture at the distal edge of the nonunion site. This is best confirmed on lateral fluoroscopy (Fig. If the scaphoid is displaced, the proximal pole is ignored and the guidewire is placed through the distal scaphoid fragment along its central axis and withdrawn volarly beyond the fracture site (. Ipsilateral Distal Radius and Scaphoid Fractures Associated with Posteromedial Dislocation of the Elbow Joint: A Case Report. In the elderly or osteoporotic person, such a fall usually results in a wrist fracture and the scapholunate ligament may or may not be affected in these cases. J Bone Joint Surg Am. The volar end of the wire exits from the radial base of the thumb, which is a safe zone devoid of tendons and neurovascular structures. The patient is a 19-year-old skateboarder. Most common wrist joint dislocation is between scaphoid and radius bone. Longitudinal traction is then applied to the wrist, and a second fluoroscopic survey is conducted through a 90-degree arc. The radiocarpal joint is an articulation between the distal portion of the radius and three of the four proximal carpal bones; the scaphoid, lunate and triquetrum. near ulna styloid. Lunate — The lunate bone, immediately medial to the scaphoid, has a crescent shape, hence the reference to the moon (luna) in its name. This is corrected by hyperflexing the wrist and driving a 0.062-inch wire from the distal radius into the lunate to capture the lunate in a corrected position (, neously using dorsally placed 0.062-inch K-wires as joysticks in each fracture fragment.
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