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Name:
Perilunate Injuries
Description:
Perilunate Injuries
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
MICHAEL B. GOTTSCHALK: Welcome to the Hand. e Hand 50 Series. This presentation is on perilunate injuries, including perilunate fracture dislocations and lunate dislocations. It is intended to give you a foundation of which to build off of in the future.
MICHAEL B. GOTTSCHALK: I have the following disclosures. The only one relevant to this topic is that I am a co-investigator on a research grant, evaluating the biomechanical strength of suture augmentation of SL injuries. The nomenclature for describing injuries about the carpus can often be confusing. The term perilunate dislocation or perilunate fracture dislocation describes an injury whereby the carpus dislocates about the lunate, but the lunate stays reduced within the lunate fossa of the radius.
MICHAEL B. GOTTSCHALK: This can be depicted in the figure to the right. In contrast, a lunate dislocation is whereby the carpus remains reduced and the lunate is the only bone to dislocate. Sometimes these injuries represent a continuum of pathology encompassing a very broad range of entities. The epidemiology of these injuries is truly unknown. However, we currently recognize that they are relatively infrequent.
MICHAEL B. GOTTSCHALK: They are the result of a high energy injury and comprise approximately 5% to 10% of all carpal injuries. Approximately 25% of these injuries are missed upon initial presentation or present in a delayed fashion. Understanding the anatomy of the carpus is imperative to the treatment of these injuries. Both the interosseous and ligamentous structures about the risks can be implicated and may require surgical repair or reconstruction.
MICHAEL B. GOTTSCHALK: To restore the function of the wrist,
MICHAEL B. GOTTSCHALK: it is paramount to have a strong grasp of the injured anatomy. The scaphoid represents a twisted peanut. The scaphoid has a tendency to want to flex, and this is thought to be secondary to the applied trapezius forces that are enacted distally on the distal aspect of the scaphoid as depicted here. The lunate has two common bony morphologies which are distinguished from each other based on the presence or absence of a facet for the hamate.
MICHAEL B. GOTTSCHALK: This may play a role in ensuring the injury has been properly reduced. In addition, the lunate has a tendency to extend which must be corrected prior to definitive surgical correction. In addition to understanding the bone morphology, the complex anatomy of the ligamentous structures are even more important to comprehend. Ligaments are static structures that guide and/or constrain the motion of the carpal bones.
MICHAEL B. GOTTSCHALK: We describe the ligaments about the carpus as either intrinsic or extrinsic. An intrinsic ligament is one that originates and inserts within one of the eight carpal bones. In contrast, an extrinsic ligament is one that originates outside of the carpus and inserts onto one of the carpal bones. The ligaments about the wrist are named by their sites of attachment from a radial to ulnar direction and a proximal to distal direction.
MICHAEL B. GOTTSCHALK: The intrinsic ligaments about the carpus have been well studied. There are a few classic articles that will lay a strong foundation for the understanding of these ligaments, and I strongly recommend that you read them. They are at the end of this lecture under recommended reading.
MICHAEL B. GOTTSCHALK: The scapholunate interosseous ligament has three components, with the dorsal component being the strongest sub-region. In contrast, the palmar aspect of the lunotriquetral interosseous ligament is the strongest. Thus, when repairing these ligaments, the SL is often repaired dorsally and the LT volar. The dorsal volar
MICHAEL B. GOTTSCHALK: extrinsic ligaments are often also associated with perilunate dislocations. These ligaments are also important secondary stabilizers about the wrist. As such, several pioneering thought leaders believe that when these ligaments are not part of the injury complex, that they should be spared during exposure of the wrist. These ligaments include the dorsal radial carpal ligament as depicted here, as well as the dorsal intercarpal ligament as depicted here.
MICHAEL B. GOTTSCHALK: The volar capsular structures are often also injured during a lunate dislocation. Specifically, the space of Poirier is a weak area devoid of ligamentous attachments between the capitate and lunate that is often injured during dorsal dislocations as depicted by the yellow circle on the left. A classic transverse rent may be seen as indicated here.
MICHAEL B. GOTTSCHALK: This rent may be enlarged to gain access for volar repairs of the LT ligament as depicted here. It remains controversial to repair this rent absent the signs of neurological compromise. The kinematics of the wrist are often very complex. However, they can be simplified into three basic tenets.
MICHAEL B. GOTTSCHALK: First, all motion is centered about the head of the capitate. Second, the proximal carpal row has no tendinous attachments and acts as a free intercalated segment. Lastly, radial deviation of the wrist flexes the scaphoid while ulnar deviation extends it. As with all radiographs, they are two dimensional representations of a 3D object. This is certainly true of the wrist.
MICHAEL B. GOTTSCHALK: Probably the most well known and simplest method for detecting a perilunate injury is the evaluation of Gilula's lines on a PA and lateral radiograph as depicted here. There are several known signs that can be indicative of a perilunate dislocation or lunate dislocation. These include a break in Gilula's lines, as previously mentioned,
MICHAEL B. GOTTSCHALK: capitate and lunate overlap on a PA radiograph. The piece of pie sign as depicted here by the red triangle and the spilled teacup sign as seen on the far right of the screen. When evaluating the reduction of a perilunate or lunate dislocation, radiographic parameters do matter. There are a series of parameters that should be evaluated. First is the scapholunate angle as measured on a lateral radiograph.
MICHAEL B. GOTTSCHALK: The average is 47 with a range of 30 to 60 degrees. Higher numbers are indicative of SL dissociation. The second parameter is the capitolunate angle, which is often easier to evaluate and measure. This is completely disrupted during perilunate and lunate injuries and should be corrected to match the contralateral side. As such, it is wise to consider getting radiographs of the contralateral wrist to evaluate these radiographic parameters prior to surgical correction.
MICHAEL B. GOTTSCHALK: The third parameter is measuring the carpel height ratio. This is often seen in later stages of carpal instability. In addition to arthrosis of the carpal joints. In addition to static radiographs, advanced imaging has an important role in the workup of a perilunate and lunate dislocations. First, when possible, a reduction should be attempted prior to any advanced imaging.
MICHAEL B. GOTTSCHALK: When a reduction is not permitted or has failed, a CT scan is recommended to evaluate for associated fractures prior to taking the patient to the operating room in an urgent fashion. Both MRIs and arthroscopy, in my opinion, are less useful in the acute traumatic setting and are more useful in the incomplete perilunate dislocations. With that said, in the appropriate surgeon's hands, arthroscopy may be utilized to repair or reconstruct the ligaments.
MICHAEL B. GOTTSCHALK: For me, I still use an open approach as it is less technically demanding. Carpal instability has been categorized into four broad categories, categories. These include carpal instability dissociative, carpal instability non dissociative, carpal instability complex and carpal instability adaptive. Perilunate dislocations and lunate dislocations are categorized under carpal instability complex.
MICHAEL B. GOTTSCHALK: The theories behind how these injuries occur are reasonably understood owing to the work of Mayfield and Murray. The classic perilunate injury is thought to be due to a hyperextension and supination force of the wrist. The reverse perilunate injury is thought to be due to a hyperextension and pronation force.
MICHAEL B. GOTTSCHALK: As previously discussed, I would recommend reading Mayfield's classic two articles and the one by Murray listed below. Mayfield's classic article demonstrated progressive perilunate, lunate instability into four stages. These can be seen here in writing. In addition, the four stages are depicted here on a right wrist and on a left wrist, respectively.
MICHAEL B. GOTTSCHALK: Please note in the middle that there are extra lines denoting whether or not there is bony involvement. In addition to the classification by Mayfield, the injuries may also be classified by how the force is transferred through the carpus. The terminology utilized is referred to as a lesser arc injury, which is purely ligamentous or a greater arc injury whereby the interosseous structures have been injured.
MICHAEL B. GOTTSCHALK: The various arcs of injury are noted here, as well as the various nomenclature for greater arc injuries. As with all injuries, a thorough history and physical exam is important. Often in these cases, there is an acute trauma that brings these patients to the ER or office. Hand dominance, work status and subjective paresthesis are important.
MICHAEL B. GOTTSCHALK: Questions to ask. The examination should include evaluating for open injuries, swelling and their neurovascular status of the hand. For severe injuries like these is it, it is important to have a preoperative documented neurological exam and vascular exam.
MICHAEL B. GOTTSCHALK: I recommend the use of Doppler probes two point discriminations and Semmes-Weinstein monofilaments. Once an examination has been performed and the diagnosis made on radiographs, a reduction should be attempted. The goal of the reduction is to improve or prevent neurological injury and to reduce swelling.
MICHAEL B. GOTTSCHALK: It is not for definitive management. If a reduction cannot be obtained, the patient warrants an emergency trip to the operating room for relocation and fixation of the injury. For non hand surgeons, a relocation and delayed fixation may be necessary. If a closed reduction is possible and the patient does not have evidence of neurovascular compromise, the timing to definitive fixation is controversial.
MICHAEL B. GOTTSCHALK: Some experts will tell you up to 1 to 2 weeks, while others will say the night or the next day. Unfortunately, there is no good level of evidence to help elucidate, elucidate this dilemma. I use the adage that often what is least convenient for the surgeon is often the best for the patient. Those patients with neurologic compromise or who fail a closed reduction, warrant an immediate procedure. In addition to the timing of the procedure.
MICHAEL B. GOTTSCHALK: The approach may also be controversial. There is good evidence to suggest that these injuries cannot be treated closed as a definitive treatment. The optimal surgical approach remains to be seen. The standard dorsal approach is often used in almost all cases, but the controversy as to whether to also perform a volar approach is less straightforward. The addition of a volar approach to the standard dorsal approach has several pros and cons.
MICHAEL B. GOTTSCHALK: First, there are two absolute indications for proceeding with the volar approach, which include neurological compromise or failure to reduce a dislocation from a dorsal approach. An additional reason would be if there's an open wound requiring irrigation on the volar aspect of the wrist. The remaining pros and cons are listed here. In my opinion, in the absence of either nerve symptoms or irreducibility, I do not perform a volar approach as I believe the stiffness that ensues after surgery to be worse than the benefits of the approach itself.
MICHAEL B. GOTTSCHALK: When performing the volar approach, my approach includes an extended carpal tunnel approach. The standard carpal tunnel incision is utilized and drawn proximally. A Bruner like incision can be made at the wrist crease in either an ulnar or radial direction. As depicted on the far left I choose to make an ulnar directed incision in the case
MICHAEL B. GOTTSCHALK: that the ulnar nerve vascular bundle needs to be evaluated and to ensure that the palmar cutaneous nerve is not injured. In short, if a radial incision is utilized, one must be careful not to injure the palmar cutaneous nerve. The repair through a volar approach requires an extensile incision and retraction of the finger flexors and nerve.
MICHAEL B. GOTTSCHALK: Typically, a transverse rent can be identified, which often corresponds to the space of Poirier as identified here by the yellow arrow. This can be elevated approximately to allow access to the LT. In some instances, the lunate is still protruded volarly and there is a much larger rent in the capsule. I often recommend repairing the volar restrictions only after a dorsal approach has been undertaken and the carpus has been pinned in adequate alignment.
MICHAEL B. GOTTSCHALK: Once this has been done, the LT ligament or volar SL ligament can be repaired with suture anchors and the capsule can be imbricated. The dorsal approach starts with- [VOICEROVER] So here's the extensor retinaculum in here. We've gone nice down here. It ends right in around in here. As I turn right, this is how mobile the window is so you don't have to make a super large incision,
MICHAEL B. GOTTSCHALK: it's mobile with you. We will make our incision here, find the tendons, and then make our longitudinal cut over the continuation of the extensor retinaculum here. As discussed, the midline incision is centered over the third metacarpal and is traced proximally just ulnar to Lister's tubercle. The epidermis and dermis are incised and dissection is carried down to the extensor retinaculum.
MICHAEL B. GOTTSCHALK: In this video, the dissection is down to the retinaculum already. As can be seen here, the retinaculum has a continued fascia into the dorsum of the hand. This can, the skin can be a very pliable mobile window as also depicted here. Once dissection has been carried down to the retinaculum, the third compartment should be identified and may be entered. The second, third and fourth dorsal compartment should be identified and protected.
MICHAEL B. GOTTSCHALK: If a wider exposure is necessary, the third compartment can be completely elevated out of its compartment and a sub-periosteal dissection underneath the second and fourth compartments can be made. The capsular arthrotomy is very important. I utilize the incision as described by Dr. Berger, which spares the secondary stabilizers of the wrist. In the operative photos to the right, I have placed a self retractor to protect the second, third and fourth compartments.
MICHAEL B. GOTTSCHALK: The red and yellow lines depict the drawing of the dorsum of the capsule whereby the DRC and DIC are incised. To gain further radial access to the scaphoid, the capsule underneath the second compartment can be incised and repaired later as well. The reduction of the deformity can be quite difficult. If the wrist was not previously reduced, a freer may be utilized to help shoehorn the capitate back into the lunate with an associated axial traction.
MICHAEL B. GOTTSCHALK: Once the carpus is back in the general vicinity, joysticks may be placed into the scaphoid and lunate to aid reduction as depicted here. I have a few tricks that I try to employ when doing this. First, I try and place the joysticks where I think I may want my anchors placed for ligament repair. This is done so that when I place the temporary k-wires to hold the reduction, I still will have room for my anchors without hitting any hardware.
MICHAEL B. GOTTSCHALK: In addition, I will use k-wires that correspond closely to the drill size I am considering or are smaller. Lastly, I will recognize that the scaphoid is often flexed and align my k-wire with the flex scaphoid. I will do something similar for the lunate whereby the k-wire will align with the extended lunate. I will then bring the two k-wires together that are then parallel and hold them with a Coker clamp.
MICHAEL B. GOTTSCHALK: If the reduction is not perfect, I will try and reposition my joysticks based on fluoroscopic imaging. While I have my reduction perfect as checked under fluoroscopy, I will then place several temporizing k-wires to hold the reduction. When the injury allows, I recommend a diamond type configuration of pins.
MICHAEL B. GOTTSCHALK: I first start with the scapholunate k-wire as depicted here. I then do a scaphocapitate pin, then I do a triquetral lunate k-wire, followed by a triquetral hamate k-wire. I find that an 0.054 k-wire works well without taking up too much, too much space yet it is less likely to break inside the patient. If smaller k-wires are used,
MICHAEL B. GOTTSCHALK: I recommend placing two across the SL gap as if patients have any motion post-operatively these can often break if only one is used. When fracture fixation is required and held with internal hardware, k-wires may not always necessarily be utilized, I will demonstrate in later slides. Once the temporary fixation has been placed, I then remove my joysticks and place my anchors where the joysticks used to be located.
MICHAEL B. GOTTSCHALK: As depicted here, I'm using suture to repair the injured SL back down to the bone using a horizontal mattress stitch. I will provisionally pull on the sutures to ensure that. number two fiber wire, I believe. Does that sound correct? 2.0? 2.0 fiberwire? Yeah cool.
MICHAEL B. GOTTSCHALK: Very good. And then now we will tie this back down. It looks really good. As discussed, I will provisionally pull on the sutures to ensure that the ligament lays down back anatomically to where the avulsion occurred. For the SL, this should occur off the scaphoid lunate or in rare instances, both areas.
MICHAEL B. GOTTSCHALK: If the SL tissue is non repairable, there are several options. First, you can use a graft, such as the palmaris or a 1 or 2 millimeter segment from the ECRB or ECRL. Alternatively, if the SL is repairable but attenuated, you can perform a capsulodesis. There are several types of capsulodesis described in the literature, with the most common, in my opinion, listed here. In lieu of a capsulodesis,
MICHAEL B. GOTTSCHALK: there are newer techniques utilizing suture augmentation of the repair. Some surgeons will utilize compression screws to perform the equivalency of, of a capsulodesis such as an acute RASL. The first capsulodesis method is the Blatt. This method incorporates a proximally based capsular piece at the distal aspect of the scaphoid, tethering it in an extended position.
MICHAEL B. GOTTSCHALK: I no longer perform this owing to the loss of wrist flexion that often ensues. The second technique, the Szabo capsulodesis uses the distal aspect of the DIC and transfers it to the distal aspect of the scaphoid in an aim to help keep the scaphoid extended. In a similar fashion, The MAYO capsulodesis uses the proximal aspect of the DIC and transfers it to the lunate.
MICHAEL B. GOTTSCHALK: Just as a repair of the ligaments is important, the closure is equally as important. An anatomical dissection accompanied by an anatomic closure reduces the risk, in my opinion, of significant scarring. The left intraoperative photo depicts the ligament sparing capsulotomy once it is closed, with the fourth compartment retracted to the left and the second compartment visible within the wound.
MICHAEL B. GOTTSCHALK: The right photo demonstrates the closure of the fascia and distal extent of the retinaculum. The next set of slides are some case examples of patients with a variety of perilunate and lunate injuries. This first example is a Mayfield type III with a perilunate dislocation of the capitate relative to the lunate.
MICHAEL B. GOTTSCHALK: The patient is a young male who has injured their non-dominant hand with no parathesis or neurological injury. An attempted reduction, failed in the emergency room and a CT scan revealed no fractures. The patient was taken to the OR immediately for reduction. I performed a dorsal approach and was able to reduce the injury. I then placed my joysticks and temporarily pinned the carpus. As the SL was attenuated,
MICHAEL B. GOTTSCHALK: I reinforced my repair with suture, which is why metal anchors can be seen in the scaphoid lunate and distal scaphoid. Our biomechanical lab has recent data demonstrating improved strength of suture augmentation over the discussed capsulodesis methods. These radiographs demonstrate a reasonable reduction of the dislocation with near anatomical alignment. Notice the k-wires have been cut below the skin for removal at a later date.
MICHAEL B. GOTTSCHALK: On the lateral, the SL angle can be seen and is less than 60 degrees. This second example is an example of a greater arc injury, including the radial styloid and scaphoid. The patient is a young male status post a motorcycle collision. The patient had no neurological compromise and a reduction was performed in the ED.
MICHAEL B. GOTTSCHALK: After successful reduction, as seen here, the patient underwent a CT scan to evaluate for the pattern of the fractures. It should be noted that the reductions are often easier in greater arc injuries. The patient was taken to the OR in an urgent but delayed fashion.
MICHAEL B. GOTTSCHALK: Again, I performed an all dorsal approach. For these types of injuries, it is important to evaluate the SL. Typically, for transcaphoid perilunate injuries, the SL will be intact. As such, once you reduce the scaphoid, the wrist is relatively stable. In this particular case, the patient had avulsed the SL off the lunate as well and had also injured
MICHAEL B. GOTTSCHALK: the dorsal radiocarpal ligament off of the radius. Two commonly asked questions in the in-train exam or boards are listed below, and I would commit these to memory. Notice that there are no radial sided k-wires although an SL k-wire would have been prudent to protect the repair off the lunate as the SL angle, at the SL angle was deemed reasonable, I did not place one of these k-wires.
MICHAEL B. GOTTSCHALK: The main reason for this is just due to lack of real estate. However, if the SL was not injured, I do not believe radial sided k-wires would have been warranted as previously discussed. Case example number 3 is probably one of the worst perilunate fracture dislocations
MICHAEL B. GOTTSCHALK: I have seen in my history s a hand surgeon. This is a transscaphoid, transcapitate, perilunate fracture dislocation. The patient was a young male on a scooter and sustained the injury to his non-dominant hand. Surprisingly, there was no neurological compromise. An attempted reduction was performed in the ER and a CT scan was later obtained. Notice the location of the head of the capitate.
MICHAEL B. GOTTSCHALK: As such, the patient was taken in an emergent fashion to the operating room. Intra operatively, the capitate head was noted to be subcutaneous outside the wrist capsule as depicted here in the photos. A dorsal arthrotomy was then made. An attempted reduction of the capitate and scaphoid was performed.
MICHAEL B. GOTTSCHALK: It should be noted in the top left corner that this was the scaphoid reduction and it was not perfect. The capitate reduction is in the bottom right corner and I felt more confident about this. Despite our best efforts, there was a persistent SL gap. As I tell our residents and Fellows, it is always important when presenting to show the good and the bad.
MICHAEL B. GOTTSCHALK: In my opinion, this is not an ideal reduction or fixation. Some of the possibilities for failure of reduction include scaphoid comminution, loss of bone or poor reduction of the capitate head. To this day, I'm still not sure whether or not the capitate head should not have been flipped 180 degrees. It should be noted, regardless, that this patient is at high risk for the need of a second surgery owing to the risk of AVN of the capitate and scaphoid.
MICHAEL B. GOTTSCHALK: Upon further follow up, the patient subsequently did not heal at capitate and developed midcarpal arthrosis. I have such, I have therefore recommended a pan carpal arthrodesis. This next case is a demonstration of a complete lunate dislocation with associated radial carpal subluxation. The patient was a young male, non-dominant hand with associated parasthesis in the ER.
MICHAEL B. GOTTSCHALK: He was taken for immediate operative intervention. As mentioned, he had nerve parasthesis and it was irreducible in the ER. As such, we performed a volar and dorsal approach with repair of the SL, DRC and volar soft tissues. This is an intraoperative photo depicting the lunate within the carpal tunnel with a median nerve adjacent to the bone.
MICHAEL B. GOTTSCHALK: Post-operative radiographs depict the reduction in fixation here. It should be noted that the short radial lunate ligament often is intact and that the lunate has flipped or rotated about that ligament. One must monitor these patients for lunate avascular necrosis
MICHAEL B. GOTTSCHALK: which may mean that the patient has a high risk for a secondary surgery. This next case is an older, right hand dominant female who is in a motor vehicle collision with a purely ligamentous perilunate. She had a small open wound at the volar aspect of her wrist in addition to paresthesias. She was still subsequently reduced in the ER as depicted here.
MICHAEL B. GOTTSCHALK: These are her post images and a CT confirmed no related fractures. As discussed, she had an open injury with associated medial nerve paresthesias. Despite the excellent reduction, we took her to the OR. Please note the small transverse laceration on the proximal aspect of the wrist, which did probe down to the wrist. This can see this can be seen at the most proximal aspect of the incision.
MICHAEL B. GOTTSCHALK: We then utilized standard incisions as depicted here. We repaired the SL and volar capsule ligamentous structures as well both with suture. In addition, given how unstable she was, we performed a Szabo capsulodesis whereby you can see the distal anchor in the scaphoid.
MICHAEL B. GOTTSCHALK: Note that the k-wires are smaller, so we used two k-wires within the SL interval. This last example is somewhat of a controversial case. This is a young, 30-year-old manual laborer. With his dominant hand, he presented several weeks after falling off of a roof. The initial emergency room physician and other physician missed the lunate dislocation, which is fairly subtle on these x-rays.
MICHAEL B. GOTTSCHALK: For a young male who is a laborer and has injured his dominant hand, what would you do? In my opinion, there are few options and these include attempted reconstruction/repair of the ligaments, an acute PRC or an acute arthrodesis. Some of these may depend on the vascularity and status of the cartilage of the dislocated lunate. Regardless of the procedure, a volar approach will also be necessary to free up the lunate, as the chronicity will make relocation next to impossible from an all dorsal approach.
MICHAEL B. GOTTSCHALK: Given his age, and after evaluating the lunate intraoperatively, we elected to proceed with the reconstruction of his ligaments. His cartilage appeared intact and the lunate bled when we let the tourniquet down. We used a portion of his ECRB and reconstructed the ligaments both volarly and dorsally with suture augmentation dorsally.
MICHAEL B. GOTTSCHALK: The patient ultimately recovered approximately 50% of his range of motion and 75% of his grip as compared to the contralateral side. Now that you have seen a myriad of cases, it is prudent to discuss the post op rehabilitation for these injuries. First, stiffness is one of the most common complications following these injuries.
MICHAEL B. GOTTSCHALK: As such, it is imperative to start early range of motion of the digits immediately. A certified hand therapist is a must to ensure compliance and the chance for a reasonable outcome. I will often splint the patients for two weeks and then convert them to a cast. The temporary k-wires will stay in between 8 to 12 weeks, depending on the injury pattern.
MICHAEL B. GOTTSCHALK: As I bury my pins to prevent infection, I will take patients back to the OR to remove the k-wires. I have done this in the office in very stoic individuals, but do recommend the OR as the preferred location. Following removal, patients are to start an aggressive regimen with the therapist. Once motion has been restored, strengthening may then begin.
MICHAEL B. GOTTSCHALK: There is a relative paucity of data in regards to the outcomes after these injuries. This is due to the low incidence of the injury, difficulty with trauma follow up and that there are no two similar injuries. With that said, here are some relatively recent retrospective long term studies that demonstrate mediocre results after relatively devastating injuries. I often tell my patients that their wrists will never be normal again, but that we are aiming for a stiff, non painful functional wrist.
MICHAEL B. GOTTSCHALK: This is a list of references and recommended reading on the topic we discussed. It is certainly not exhaustive, but I find that these references are often very good for a quick understanding of the anatomy as well as some general review principles about these injuries. I have found that these articles, in addition to the book chapters from the ASSH and Greens operative textbooks, have helped my understanding of the topic significantly.
MICHAEL B. GOTTSCHALK: Thank you for tuning in and feel free to come visit us at the Emery Upper Extremity Center here in Atlanta, Georgia.
Segment:0 .
MICHAEL B. GOTTSCHALK: Welcome to the Hand. e Hand 50 Series. This presentation is on perilunate injuries, including perilunate fracture dislocations and lunate dislocations. It is intended to give you a foundation of which to build off of in the future.
MICHAEL B. GOTTSCHALK: I have the following disclosures. The only one relevant to this topic is that I am a co-investigator on a research grant, evaluating the biomechanical strength of suture augmentation of SL injuries. The nomenclature for describing injuries about the carpus can often be confusing. The term perilunate dislocation or perilunate fracture dislocation describes an injury whereby the carpus dislocates about the lunate, but the lunate stays reduced within the lunate fossa of the radius.
MICHAEL B. GOTTSCHALK: This can be depicted in the figure to the right. In contrast, a lunate dislocation is whereby the carpus remains reduced and the lunate is the only bone to dislocate. Sometimes these injuries represent a continuum of pathology encompassing a very broad range of entities. The epidemiology of these injuries is truly unknown. However, we currently recognize that they are relatively infrequent.
MICHAEL B. GOTTSCHALK: They are the result of a high energy injury and comprise approximately 5% to 10% of all carpal injuries. Approximately 25% of these injuries are missed upon initial presentation or present in a delayed fashion. Understanding the anatomy of the carpus is imperative to the treatment of these injuries. Both the interosseous and ligamentous structures about the risks can be implicated and may require surgical repair or reconstruction.
MICHAEL B. GOTTSCHALK: To restore the function of the wrist,
MICHAEL B. GOTTSCHALK: it is paramount to have a strong grasp of the injured anatomy. The scaphoid represents a twisted peanut. The scaphoid has a tendency to want to flex, and this is thought to be secondary to the applied trapezius forces that are enacted distally on the distal aspect of the scaphoid as depicted here. The lunate has two common bony morphologies which are distinguished from each other based on the presence or absence of a facet for the hamate.
MICHAEL B. GOTTSCHALK: This may play a role in ensuring the injury has been properly reduced. In addition, the lunate has a tendency to extend which must be corrected prior to definitive surgical correction. In addition to understanding the bone morphology, the complex anatomy of the ligamentous structures are even more important to comprehend. Ligaments are static structures that guide and/or constrain the motion of the carpal bones.
MICHAEL B. GOTTSCHALK: We describe the ligaments about the carpus as either intrinsic or extrinsic. An intrinsic ligament is one that originates and inserts within one of the eight carpal bones. In contrast, an extrinsic ligament is one that originates outside of the carpus and inserts onto one of the carpal bones. The ligaments about the wrist are named by their sites of attachment from a radial to ulnar direction and a proximal to distal direction.
MICHAEL B. GOTTSCHALK: The intrinsic ligaments about the carpus have been well studied. There are a few classic articles that will lay a strong foundation for the understanding of these ligaments, and I strongly recommend that you read them. They are at the end of this lecture under recommended reading.
MICHAEL B. GOTTSCHALK: The scapholunate interosseous ligament has three components, with the dorsal component being the strongest sub-region. In contrast, the palmar aspect of the lunotriquetral interosseous ligament is the strongest. Thus, when repairing these ligaments, the SL is often repaired dorsally and the LT volar. The dorsal volar
MICHAEL B. GOTTSCHALK: extrinsic ligaments are often also associated with perilunate dislocations. These ligaments are also important secondary stabilizers about the wrist. As such, several pioneering thought leaders believe that when these ligaments are not part of the injury complex, that they should be spared during exposure of the wrist. These ligaments include the dorsal radial carpal ligament as depicted here, as well as the dorsal intercarpal ligament as depicted here.
MICHAEL B. GOTTSCHALK: The volar capsular structures are often also injured during a lunate dislocation. Specifically, the space of Poirier is a weak area devoid of ligamentous attachments between the capitate and lunate that is often injured during dorsal dislocations as depicted by the yellow circle on the left. A classic transverse rent may be seen as indicated here.
MICHAEL B. GOTTSCHALK: This rent may be enlarged to gain access for volar repairs of the LT ligament as depicted here. It remains controversial to repair this rent absent the signs of neurological compromise. The kinematics of the wrist are often very complex. However, they can be simplified into three basic tenets.
MICHAEL B. GOTTSCHALK: First, all motion is centered about the head of the capitate. Second, the proximal carpal row has no tendinous attachments and acts as a free intercalated segment. Lastly, radial deviation of the wrist flexes the scaphoid while ulnar deviation extends it. As with all radiographs, they are two dimensional representations of a 3D object. This is certainly true of the wrist.
MICHAEL B. GOTTSCHALK: Probably the most well known and simplest method for detecting a perilunate injury is the evaluation of Gilula's lines on a PA and lateral radiograph as depicted here. There are several known signs that can be indicative of a perilunate dislocation or lunate dislocation. These include a break in Gilula's lines, as previously mentioned,
MICHAEL B. GOTTSCHALK: capitate and lunate overlap on a PA radiograph. The piece of pie sign as depicted here by the red triangle and the spilled teacup sign as seen on the far right of the screen. When evaluating the reduction of a perilunate or lunate dislocation, radiographic parameters do matter. There are a series of parameters that should be evaluated. First is the scapholunate angle as measured on a lateral radiograph.
MICHAEL B. GOTTSCHALK: The average is 47 with a range of 30 to 60 degrees. Higher numbers are indicative of SL dissociation. The second parameter is the capitolunate angle, which is often easier to evaluate and measure. This is completely disrupted during perilunate and lunate injuries and should be corrected to match the contralateral side. As such, it is wise to consider getting radiographs of the contralateral wrist to evaluate these radiographic parameters prior to surgical correction.
MICHAEL B. GOTTSCHALK: The third parameter is measuring the carpel height ratio. This is often seen in later stages of carpal instability. In addition to arthrosis of the carpal joints. In addition to static radiographs, advanced imaging has an important role in the workup of a perilunate and lunate dislocations. First, when possible, a reduction should be attempted prior to any advanced imaging.
MICHAEL B. GOTTSCHALK: When a reduction is not permitted or has failed, a CT scan is recommended to evaluate for associated fractures prior to taking the patient to the operating room in an urgent fashion. Both MRIs and arthroscopy, in my opinion, are less useful in the acute traumatic setting and are more useful in the incomplete perilunate dislocations. With that said, in the appropriate surgeon's hands, arthroscopy may be utilized to repair or reconstruct the ligaments.
MICHAEL B. GOTTSCHALK: For me, I still use an open approach as it is less technically demanding. Carpal instability has been categorized into four broad categories, categories. These include carpal instability dissociative, carpal instability non dissociative, carpal instability complex and carpal instability adaptive. Perilunate dislocations and lunate dislocations are categorized under carpal instability complex.
MICHAEL B. GOTTSCHALK: The theories behind how these injuries occur are reasonably understood owing to the work of Mayfield and Murray. The classic perilunate injury is thought to be due to a hyperextension and supination force of the wrist. The reverse perilunate injury is thought to be due to a hyperextension and pronation force.
MICHAEL B. GOTTSCHALK: As previously discussed, I would recommend reading Mayfield's classic two articles and the one by Murray listed below. Mayfield's classic article demonstrated progressive perilunate, lunate instability into four stages. These can be seen here in writing. In addition, the four stages are depicted here on a right wrist and on a left wrist, respectively.
MICHAEL B. GOTTSCHALK: Please note in the middle that there are extra lines denoting whether or not there is bony involvement. In addition to the classification by Mayfield, the injuries may also be classified by how the force is transferred through the carpus. The terminology utilized is referred to as a lesser arc injury, which is purely ligamentous or a greater arc injury whereby the interosseous structures have been injured.
MICHAEL B. GOTTSCHALK: The various arcs of injury are noted here, as well as the various nomenclature for greater arc injuries. As with all injuries, a thorough history and physical exam is important. Often in these cases, there is an acute trauma that brings these patients to the ER or office. Hand dominance, work status and subjective paresthesis are important.
MICHAEL B. GOTTSCHALK: Questions to ask. The examination should include evaluating for open injuries, swelling and their neurovascular status of the hand. For severe injuries like these is it, it is important to have a preoperative documented neurological exam and vascular exam.
MICHAEL B. GOTTSCHALK: I recommend the use of Doppler probes two point discriminations and Semmes-Weinstein monofilaments. Once an examination has been performed and the diagnosis made on radiographs, a reduction should be attempted. The goal of the reduction is to improve or prevent neurological injury and to reduce swelling.
MICHAEL B. GOTTSCHALK: It is not for definitive management. If a reduction cannot be obtained, the patient warrants an emergency trip to the operating room for relocation and fixation of the injury. For non hand surgeons, a relocation and delayed fixation may be necessary. If a closed reduction is possible and the patient does not have evidence of neurovascular compromise, the timing to definitive fixation is controversial.
MICHAEL B. GOTTSCHALK: Some experts will tell you up to 1 to 2 weeks, while others will say the night or the next day. Unfortunately, there is no good level of evidence to help elucidate, elucidate this dilemma. I use the adage that often what is least convenient for the surgeon is often the best for the patient. Those patients with neurologic compromise or who fail a closed reduction, warrant an immediate procedure. In addition to the timing of the procedure.
MICHAEL B. GOTTSCHALK: The approach may also be controversial. There is good evidence to suggest that these injuries cannot be treated closed as a definitive treatment. The optimal surgical approach remains to be seen. The standard dorsal approach is often used in almost all cases, but the controversy as to whether to also perform a volar approach is less straightforward. The addition of a volar approach to the standard dorsal approach has several pros and cons.
MICHAEL B. GOTTSCHALK: First, there are two absolute indications for proceeding with the volar approach, which include neurological compromise or failure to reduce a dislocation from a dorsal approach. An additional reason would be if there's an open wound requiring irrigation on the volar aspect of the wrist. The remaining pros and cons are listed here. In my opinion, in the absence of either nerve symptoms or irreducibility, I do not perform a volar approach as I believe the stiffness that ensues after surgery to be worse than the benefits of the approach itself.
MICHAEL B. GOTTSCHALK: When performing the volar approach, my approach includes an extended carpal tunnel approach. The standard carpal tunnel incision is utilized and drawn proximally. A Bruner like incision can be made at the wrist crease in either an ulnar or radial direction. As depicted on the far left I choose to make an ulnar directed incision in the case
MICHAEL B. GOTTSCHALK: that the ulnar nerve vascular bundle needs to be evaluated and to ensure that the palmar cutaneous nerve is not injured. In short, if a radial incision is utilized, one must be careful not to injure the palmar cutaneous nerve. The repair through a volar approach requires an extensile incision and retraction of the finger flexors and nerve.
MICHAEL B. GOTTSCHALK: Typically, a transverse rent can be identified, which often corresponds to the space of Poirier as identified here by the yellow arrow. This can be elevated approximately to allow access to the LT. In some instances, the lunate is still protruded volarly and there is a much larger rent in the capsule. I often recommend repairing the volar restrictions only after a dorsal approach has been undertaken and the carpus has been pinned in adequate alignment.
MICHAEL B. GOTTSCHALK: Once this has been done, the LT ligament or volar SL ligament can be repaired with suture anchors and the capsule can be imbricated. The dorsal approach starts with- [VOICEROVER] So here's the extensor retinaculum in here. We've gone nice down here. It ends right in around in here. As I turn right, this is how mobile the window is so you don't have to make a super large incision,
MICHAEL B. GOTTSCHALK: it's mobile with you. We will make our incision here, find the tendons, and then make our longitudinal cut over the continuation of the extensor retinaculum here. As discussed, the midline incision is centered over the third metacarpal and is traced proximally just ulnar to Lister's tubercle. The epidermis and dermis are incised and dissection is carried down to the extensor retinaculum.
MICHAEL B. GOTTSCHALK: In this video, the dissection is down to the retinaculum already. As can be seen here, the retinaculum has a continued fascia into the dorsum of the hand. This can, the skin can be a very pliable mobile window as also depicted here. Once dissection has been carried down to the retinaculum, the third compartment should be identified and may be entered. The second, third and fourth dorsal compartment should be identified and protected.
MICHAEL B. GOTTSCHALK: If a wider exposure is necessary, the third compartment can be completely elevated out of its compartment and a sub-periosteal dissection underneath the second and fourth compartments can be made. The capsular arthrotomy is very important. I utilize the incision as described by Dr. Berger, which spares the secondary stabilizers of the wrist. In the operative photos to the right, I have placed a self retractor to protect the second, third and fourth compartments.
MICHAEL B. GOTTSCHALK: The red and yellow lines depict the drawing of the dorsum of the capsule whereby the DRC and DIC are incised. To gain further radial access to the scaphoid, the capsule underneath the second compartment can be incised and repaired later as well. The reduction of the deformity can be quite difficult. If the wrist was not previously reduced, a freer may be utilized to help shoehorn the capitate back into the lunate with an associated axial traction.
MICHAEL B. GOTTSCHALK: Once the carpus is back in the general vicinity, joysticks may be placed into the scaphoid and lunate to aid reduction as depicted here. I have a few tricks that I try to employ when doing this. First, I try and place the joysticks where I think I may want my anchors placed for ligament repair. This is done so that when I place the temporary k-wires to hold the reduction, I still will have room for my anchors without hitting any hardware.
MICHAEL B. GOTTSCHALK: In addition, I will use k-wires that correspond closely to the drill size I am considering or are smaller. Lastly, I will recognize that the scaphoid is often flexed and align my k-wire with the flex scaphoid. I will do something similar for the lunate whereby the k-wire will align with the extended lunate. I will then bring the two k-wires together that are then parallel and hold them with a Coker clamp.
MICHAEL B. GOTTSCHALK: If the reduction is not perfect, I will try and reposition my joysticks based on fluoroscopic imaging. While I have my reduction perfect as checked under fluoroscopy, I will then place several temporizing k-wires to hold the reduction. When the injury allows, I recommend a diamond type configuration of pins.
MICHAEL B. GOTTSCHALK: I first start with the scapholunate k-wire as depicted here. I then do a scaphocapitate pin, then I do a triquetral lunate k-wire, followed by a triquetral hamate k-wire. I find that an 0.054 k-wire works well without taking up too much, too much space yet it is less likely to break inside the patient. If smaller k-wires are used,
MICHAEL B. GOTTSCHALK: I recommend placing two across the SL gap as if patients have any motion post-operatively these can often break if only one is used. When fracture fixation is required and held with internal hardware, k-wires may not always necessarily be utilized, I will demonstrate in later slides. Once the temporary fixation has been placed, I then remove my joysticks and place my anchors where the joysticks used to be located.
MICHAEL B. GOTTSCHALK: As depicted here, I'm using suture to repair the injured SL back down to the bone using a horizontal mattress stitch. I will provisionally pull on the sutures to ensure that. number two fiber wire, I believe. Does that sound correct? 2.0? 2.0 fiberwire? Yeah cool.
MICHAEL B. GOTTSCHALK: Very good. And then now we will tie this back down. It looks really good. As discussed, I will provisionally pull on the sutures to ensure that the ligament lays down back anatomically to where the avulsion occurred. For the SL, this should occur off the scaphoid lunate or in rare instances, both areas.
MICHAEL B. GOTTSCHALK: If the SL tissue is non repairable, there are several options. First, you can use a graft, such as the palmaris or a 1 or 2 millimeter segment from the ECRB or ECRL. Alternatively, if the SL is repairable but attenuated, you can perform a capsulodesis. There are several types of capsulodesis described in the literature, with the most common, in my opinion, listed here. In lieu of a capsulodesis,
MICHAEL B. GOTTSCHALK: there are newer techniques utilizing suture augmentation of the repair. Some surgeons will utilize compression screws to perform the equivalency of, of a capsulodesis such as an acute RASL. The first capsulodesis method is the Blatt. This method incorporates a proximally based capsular piece at the distal aspect of the scaphoid, tethering it in an extended position.
MICHAEL B. GOTTSCHALK: I no longer perform this owing to the loss of wrist flexion that often ensues. The second technique, the Szabo capsulodesis uses the distal aspect of the DIC and transfers it to the distal aspect of the scaphoid in an aim to help keep the scaphoid extended. In a similar fashion, The MAYO capsulodesis uses the proximal aspect of the DIC and transfers it to the lunate.
MICHAEL B. GOTTSCHALK: Just as a repair of the ligaments is important, the closure is equally as important. An anatomical dissection accompanied by an anatomic closure reduces the risk, in my opinion, of significant scarring. The left intraoperative photo depicts the ligament sparing capsulotomy once it is closed, with the fourth compartment retracted to the left and the second compartment visible within the wound.
MICHAEL B. GOTTSCHALK: The right photo demonstrates the closure of the fascia and distal extent of the retinaculum. The next set of slides are some case examples of patients with a variety of perilunate and lunate injuries. This first example is a Mayfield type III with a perilunate dislocation of the capitate relative to the lunate.
MICHAEL B. GOTTSCHALK: The patient is a young male who has injured their non-dominant hand with no parathesis or neurological injury. An attempted reduction, failed in the emergency room and a CT scan revealed no fractures. The patient was taken to the OR immediately for reduction. I performed a dorsal approach and was able to reduce the injury. I then placed my joysticks and temporarily pinned the carpus. As the SL was attenuated,
MICHAEL B. GOTTSCHALK: I reinforced my repair with suture, which is why metal anchors can be seen in the scaphoid lunate and distal scaphoid. Our biomechanical lab has recent data demonstrating improved strength of suture augmentation over the discussed capsulodesis methods. These radiographs demonstrate a reasonable reduction of the dislocation with near anatomical alignment. Notice the k-wires have been cut below the skin for removal at a later date.
MICHAEL B. GOTTSCHALK: On the lateral, the SL angle can be seen and is less than 60 degrees. This second example is an example of a greater arc injury, including the radial styloid and scaphoid. The patient is a young male status post a motorcycle collision. The patient had no neurological compromise and a reduction was performed in the ED.
MICHAEL B. GOTTSCHALK: After successful reduction, as seen here, the patient underwent a CT scan to evaluate for the pattern of the fractures. It should be noted that the reductions are often easier in greater arc injuries. The patient was taken to the OR in an urgent but delayed fashion.
MICHAEL B. GOTTSCHALK: Again, I performed an all dorsal approach. For these types of injuries, it is important to evaluate the SL. Typically, for transcaphoid perilunate injuries, the SL will be intact. As such, once you reduce the scaphoid, the wrist is relatively stable. In this particular case, the patient had avulsed the SL off the lunate as well and had also injured
MICHAEL B. GOTTSCHALK: the dorsal radiocarpal ligament off of the radius. Two commonly asked questions in the in-train exam or boards are listed below, and I would commit these to memory. Notice that there are no radial sided k-wires although an SL k-wire would have been prudent to protect the repair off the lunate as the SL angle, at the SL angle was deemed reasonable, I did not place one of these k-wires.
MICHAEL B. GOTTSCHALK: The main reason for this is just due to lack of real estate. However, if the SL was not injured, I do not believe radial sided k-wires would have been warranted as previously discussed. Case example number 3 is probably one of the worst perilunate fracture dislocations
MICHAEL B. GOTTSCHALK: I have seen in my history s a hand surgeon. This is a transscaphoid, transcapitate, perilunate fracture dislocation. The patient was a young male on a scooter and sustained the injury to his non-dominant hand. Surprisingly, there was no neurological compromise. An attempted reduction was performed in the ER and a CT scan was later obtained. Notice the location of the head of the capitate.
MICHAEL B. GOTTSCHALK: As such, the patient was taken in an emergent fashion to the operating room. Intra operatively, the capitate head was noted to be subcutaneous outside the wrist capsule as depicted here in the photos. A dorsal arthrotomy was then made. An attempted reduction of the capitate and scaphoid was performed.
MICHAEL B. GOTTSCHALK: It should be noted in the top left corner that this was the scaphoid reduction and it was not perfect. The capitate reduction is in the bottom right corner and I felt more confident about this. Despite our best efforts, there was a persistent SL gap. As I tell our residents and Fellows, it is always important when presenting to show the good and the bad.
MICHAEL B. GOTTSCHALK: In my opinion, this is not an ideal reduction or fixation. Some of the possibilities for failure of reduction include scaphoid comminution, loss of bone or poor reduction of the capitate head. To this day, I'm still not sure whether or not the capitate head should not have been flipped 180 degrees. It should be noted, regardless, that this patient is at high risk for the need of a second surgery owing to the risk of AVN of the capitate and scaphoid.
MICHAEL B. GOTTSCHALK: Upon further follow up, the patient subsequently did not heal at capitate and developed midcarpal arthrosis. I have such, I have therefore recommended a pan carpal arthrodesis. This next case is a demonstration of a complete lunate dislocation with associated radial carpal subluxation. The patient was a young male, non-dominant hand with associated parasthesis in the ER.
MICHAEL B. GOTTSCHALK: He was taken for immediate operative intervention. As mentioned, he had nerve parasthesis and it was irreducible in the ER. As such, we performed a volar and dorsal approach with repair of the SL, DRC and volar soft tissues. This is an intraoperative photo depicting the lunate within the carpal tunnel with a median nerve adjacent to the bone.
MICHAEL B. GOTTSCHALK: Post-operative radiographs depict the reduction in fixation here. It should be noted that the short radial lunate ligament often is intact and that the lunate has flipped or rotated about that ligament. One must monitor these patients for lunate avascular necrosis
MICHAEL B. GOTTSCHALK: which may mean that the patient has a high risk for a secondary surgery. This next case is an older, right hand dominant female who is in a motor vehicle collision with a purely ligamentous perilunate. She had a small open wound at the volar aspect of her wrist in addition to paresthesias. She was still subsequently reduced in the ER as depicted here.
MICHAEL B. GOTTSCHALK: These are her post images and a CT confirmed no related fractures. As discussed, she had an open injury with associated medial nerve paresthesias. Despite the excellent reduction, we took her to the OR. Please note the small transverse laceration on the proximal aspect of the wrist, which did probe down to the wrist. This can see this can be seen at the most proximal aspect of the incision.
MICHAEL B. GOTTSCHALK: We then utilized standard incisions as depicted here. We repaired the SL and volar capsule ligamentous structures as well both with suture. In addition, given how unstable she was, we performed a Szabo capsulodesis whereby you can see the distal anchor in the scaphoid.
MICHAEL B. GOTTSCHALK: Note that the k-wires are smaller, so we used two k-wires within the SL interval. This last example is somewhat of a controversial case. This is a young, 30-year-old manual laborer. With his dominant hand, he presented several weeks after falling off of a roof. The initial emergency room physician and other physician missed the lunate dislocation, which is fairly subtle on these x-rays.
MICHAEL B. GOTTSCHALK: For a young male who is a laborer and has injured his dominant hand, what would you do? In my opinion, there are few options and these include attempted reconstruction/repair of the ligaments, an acute PRC or an acute arthrodesis. Some of these may depend on the vascularity and status of the cartilage of the dislocated lunate. Regardless of the procedure, a volar approach will also be necessary to free up the lunate, as the chronicity will make relocation next to impossible from an all dorsal approach.
MICHAEL B. GOTTSCHALK: Given his age, and after evaluating the lunate intraoperatively, we elected to proceed with the reconstruction of his ligaments. His cartilage appeared intact and the lunate bled when we let the tourniquet down. We used a portion of his ECRB and reconstructed the ligaments both volarly and dorsally with suture augmentation dorsally.
MICHAEL B. GOTTSCHALK: The patient ultimately recovered approximately 50% of his range of motion and 75% of his grip as compared to the contralateral side. Now that you have seen a myriad of cases, it is prudent to discuss the post op rehabilitation for these injuries. First, stiffness is one of the most common complications following these injuries.
MICHAEL B. GOTTSCHALK: As such, it is imperative to start early range of motion of the digits immediately. A certified hand therapist is a must to ensure compliance and the chance for a reasonable outcome. I will often splint the patients for two weeks and then convert them to a cast. The temporary k-wires will stay in between 8 to 12 weeks, depending on the injury pattern.
MICHAEL B. GOTTSCHALK: As I bury my pins to prevent infection, I will take patients back to the OR to remove the k-wires. I have done this in the office in very stoic individuals, but do recommend the OR as the preferred location. Following removal, patients are to start an aggressive regimen with the therapist. Once motion has been restored, strengthening may then begin.
MICHAEL B. GOTTSCHALK: There is a relative paucity of data in regards to the outcomes after these injuries. This is due to the low incidence of the injury, difficulty with trauma follow up and that there are no two similar injuries. With that said, here are some relatively recent retrospective long term studies that demonstrate mediocre results after relatively devastating injuries. I often tell my patients that their wrists will never be normal again, but that we are aiming for a stiff, non painful functional wrist.
MICHAEL B. GOTTSCHALK: This is a list of references and recommended reading on the topic we discussed. It is certainly not exhaustive, but I find that these references are often very good for a quick understanding of the anatomy as well as some general review principles about these injuries. I have found that these articles, in addition to the book chapters from the ASSH and Greens operative textbooks, have helped my understanding of the topic significantly.
MICHAEL B. GOTTSCHALK: Thank you for tuning in and feel free to come visit us at the Emery Upper Extremity Center here in Atlanta, Georgia.
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