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Lunate Instability for Orthopaedic Exams
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Lunate Instability for Orthopaedic Exams
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Language: EN.
Segment:0 .
Guys, this one is this teaching is kindly delivered by kashif, is a speciality doctor from firmly, and he's going to tell us about lunate instability and associated disorders and injuries. And this is no doubt high yield topic in first year exam. So please, I'm sure this is going to be fantastic presentation. So please listen carefully and we will discuss some of these issues also in more depth in the hot seat session.
So please pay attention to kashif. Go ahead, please. OK, look, guys, thank you for listening. So I'm going to present a little bit about loonette and Luna dislocations. If you have any questions, please just write down and ask and. So tenotomy of the carpus carpus is a divided couple. Bones are divided into the proximal and distal carpal growth, and each row has four bones, you already know that.
So on this diagram that the pink line show greater art and then blue and red lines show the lesser. The injuries are divided, according to the according to the. You already know about the ligaments around the carpets, which is divided into two ligaments, which runs between the carpal bones, and they are major stabilizers of the proximal row and that intrinsic ligaments, which is divided into dorsal and volar and then extrinsic ligaments, which connects the forearm both to the bones, which is again divided into the Bowler and dorsal.
You already know the tenotomy of the carcass due to the types of these dislocations, they are divided into eluded dislocation where it stay in the position. While carpal dislocates and Leonid dislocation, where unit is forced out of the car was either volar or dorsal volar is the most common. So the mechanism is usually is dramatic, high energy type of trauma.
It occurs when they went behind, falls on risk with extension and ulnar deviation that leads into the entire purpose of. The injuries are divided, as I told you earlier, into the greater arc injury, which is represented by the blue line here, which involved the fractures and the lesser of which is purely ligamentous injury, which which is shown by the red line.
The sequence of events in this injury, would you start from the scaffold ligament disruption and then followed by the disruption of the capitellum unit articulation? Subsequently, there is a disruption of lunar typekit lunar articulation and then that is followed by a failure of the dorsal radiocarbon ligament that leaves the unit to rotate and dislocate, usually into the carpal tunnel, which is volar.
So you don't need to remember the certification, but for the path of completion. So it divided into four stages the stage one when there is a skillful unit dissociation. Stage two is for lunar dissociation plus lunar disruption, and then stage 3 is a skillful unit dissociation plus lunar capital disruption and plus lunar regular disruption that is mentioned a baby unit in the Soviet Union and stage four where lunar is completely dislocated from the lunar fossa, usually in the karpel, usually on the volar side, and the stage 4 is usually associated with median nerve compression.
You can usually, as I mentioned earlier, high energy trauma patients present with acute risk swelling and pain media ulnar nerve symptoms as mentioned in the literature, around 25% of the patients usually may feel a stage four. But from the reality point of view, you will go for AP and lateral radiograph in the AP radiograph. You can see there the break in the arc.
And there is a story and usually there is a. Usually there is a unit and it will overlap, and you can see sometimes it appears triangular, as in the second radiograph, which is called piece of the pie sign. And on the lateral radiograph, you usually see there is a loss of linearity of the radius unit and computed in normal radiograph, you see, then all three bones are aligned in one line or in this type of injury.
You will see there is a disruption of this opportunity. So management is divided into the according to the acute, whether it's the acute injury, which is less than 8 weeks, whether it's a chronic injury, which is more than eight weeks, and whether this chronic injury with a degenerative changes. So management is divided into three different categories in acute injuries.
Beauty management is urgent, further action followed by a splinting and subsequently there will be open edition with the ligament ligament repair and then fixation if there is any fractures and carpal tunnel. It is usually done by the hand surgeon. So for the emergency emergency, you need to just do the closed reduction possible, followed by sprinting.
If you can't do the clothes reduction, then you have to get advice from your hand surgeon, but then patient need it open. Open addiction and carpal tunnel release. Then then second stage will be open. Open addiction along with ligament repair with fixation. So then dilemma is whether you need to go for volar approach or Darcell approach. If there is carpal if there is a median or compression, then you will go for volar approach.
If there is no medial nerve symptoms, then most of head surgeons they will prefer dorsal approach. But again, it depends on the surgeon choice. And then in secondly, say, while you are doing so, you need to fix the associated fractures, then you need to repair the scaffold union ligament, usually with the suture anchor fixation. And then you have to protect your ligaments repair with a temporary fixation.
Most of the time, they use the temporary wires, which need to be taken out in around four weeks time and then repair of the lunar tracheal ligament. That again, depends on the surgeon choice. Sometimes I just go for repair of the lunar ligament. Some surgeons don't. As I mentioned earlier, slide for electronic injuries, which is more than eight weeks, so options is proximal to me.
While chronic injuries with degenerative changes, optional wrist auto braces. Then post-operative management for this type of injury, really post-operatively patient will be in the. COVID spike spilling from theaters and subsequently patients will be coming back to one management clinic where there will be a head drop, which usually apply the thermoplastic splint, which is usually below elbow below elbow type of the splint and duration of the splinting varies, but usually between four to six weeks is sufficient for these type of injuries.
Usually, they say a patient day had if this. Injuries managed appropriately, usually patient, a good outcome, but most of the time these are injuries, so you need to be very. You should have very high suspicion of index with these type of injuries because sometimes x-rays are deceiving and you may require further imaging.
So any questions over you? I haven't gone into details. I don't think you need it in detail more than this presentation to exams. There's one question, which I think you already answered. Yeah, is what do you do if you there is a closed dislocation? Yeah, patient comes in the evening and showing signs of median nerve compression.
And I think you already answered that your I don't know if you want to add anything to it. Yes so answer to your question if patient is coming in the evening with a close injury, whatever the median nerve symptoms. So the options are you need to try closed reduction once in the knee. So you will give a direction, counter direction with a hand in the hand in the dotted flexion.
And then you will push the unit into the force and bring the hand into the palmar flexion. So if the median are symptoms already, so you don't need to push too hard and no second attempt in the area, then you need to prepare the patient for theaters, for opting for open induction along with the carpal tunnel. In the meantime, you have to discuss with your hand surgeon or upper limb colleague because some hand surgeon what they want.
Just carpal tunnel release and relocation of the unit. No wires. Some head surgeons are. They are quite happy to put the wire for temporary stabilization and then patient will go for second stage repair of the repair of the ligaments if needed. Do you think kashif has, for example, purposes as a general, orthopedic surgeon and trauma approach?
Do you think we should be talking about ligament reconstruction or should we be safe and just say, I think you need to keep it simple that you need to just deal with the emergency? Yes, your medien symptoms? Yeah, I'm sure everyone knows how to do that. How to relieve the carpal tunnel. So you have both carpal tunnel approach. Once you have retracted that study, you will see that loonette will be lying over there.
So you need to just push the unit back. And that's it. And then you will close the wound. And as I mentioned earlier, temporary stabilization with wires are no wires. That depends on your hand surgery. If they want, if they like wire, then you put a couple of wires to hold the bones together and close the wound and then splint if they don't like wires.
Then once it is reduced, it is quite stable, then I think it is now. Welcome after he has a question to you. So can somebody. I have been told on various occasions that there is a very valid role of Chinese finger trap and this is again is a repeated, repeated scenario in can be in any exam setting in terms of where you say or patient just had a burger or a patient just had a lucozade bottle.
What will you do? Patient is developing medium no symptoms and the answer is that. What are your thoughts about it? Yes, you are right. If patient had median nerve symptoms. And if a patient had like, as you mentioned, leukocyte or Burger or whatever, the patient can be put in the Chinese strip with around two to 3 pounds weight on the opposite side.
So you put a Chinese trap and with a pulley system, you will put a 2 to 3 pounds sweat and with the weight of the arm, usually get to reduce it. But to be honest with you, I have not seen personally myself while I was working in my head unit, so I've done three in the evening and a. Fortunately, all three patients were male Bible. Sure what do you think? What do you think?
I think the trouble here, if you see in the exam, if you suggest you're going to put a patient who is developing media nerfs in terms of finger attraction, you can do it temporarily while you're waiting to go to theater. But patients who are even if they've got a full stomach, you can do rapid sequencing in patients. And it's a little saving emergency. So therefore you are justified to go ahead and do this.
Yeah, I agree. I agree with you. One, I think for the exam purposes, this is the limit threat is if a patient started to develop median nerve symptoms, this is limbs becoming limb threatening. And then for rapid sequence discussion, whether it's a limb threatening condition situation. Because because it might not be just the median nerve, he might be developing compartment syndrome.
Absolutely so there are three different scenarios in this situation. Yeah so if your status is busy, for example, laparotomy is going out or whatever, so you need to open second theater. This should be answer. You need to open the second theater and you need to bring the second team to do the decompression. Yeah, I think make it clear to the examiners I want to operate on this patient.
He keep asking you this and that the patient is a patient. I don't know. Not ready. Theater is busy as far as you concerned. You you're concerned for the safety of the patient of the viability of his limb. Any further comment? Sure there is one other scenario where you have a patient who is unable to go to theater for whatever reason.
Stuck in ICU, intubated for other injuries. But you've got the X-ray confirming the neck dislocation. If you leave this patient for 24 hours, they will have median nerve symptoms. So your options and this was going to be a hot seat question for me. But since we brought this up, you might as well talk about it.
You can do a carpal tunnel release while the patient's in ECU or even on the Ward. It's the safest thing to do for this patient, and that's how you would argue you would be reluctant to do it in any other situation. But in a last resort, you can do a carpal tunnel release while you're waiting to get the patient into theater while the patient is fit for later on. One more question.
Kashif is there a vein? A common problem with dislocation as a complication of the injury is a complete. It is a problem because if you have a unit dislocation, blood supply is disrupted. It is a problem. I'm not sure how much is a percentage. I'm sorry. I haven't.
I haven't. I don't know what the exact percentage I think. I think we might. Yeah, we might never know the exact because not all avian is symptomatic and therefore we might not down the line years, down the line, patients could be at discharge. So we don't know exactly. But I think that it is. It's a recognized complication.
Look, long term or short term complication, but absolutely, Yeah. Well, do you know, if anything more about it? No how about you exact percentages there? I'm sure there's somebody that's written a paper on it, to be honest with you, it's irrelevant to managing the patient in an emergency situation. If if, if you're down to discussing AVM rates, you're quoting papers at that stage.
So it's unlikely you're ever going to reach that in an emergency discussion of this situation. More important is that you've saved this patient's limb. Any further comment? I thought about this topic. No, I think the scenarios, the three scenarios that has been covered is covered, but I've been told by the examiners about the Chinese trap scenario as well.
But I will be absolutely right. But sometimes if you haven't seen anything because what they want you what you are going to do. Yes, exactly. So the safe answer is, as you guys have suggested, and that's what you're going to do and you're going to stick to your guns, it inspector, whatever, whatever you. Yeah, I think overall, overall, my general advice is for this FARC.
But one priority, always any questions you ask is safety. Absolutely safety glass more important than any fancy treatments that you might know about? Yeah, exactly. Yeah which could, you know, could look very impressive. I know a lot of it. Sometimes just simple things. Sticking to your guns is what will pass. You get you through the exam.
I just review it again. You want me, I don't think you need anything more to pass. No, no. I just did know the principles, the anatomy, and we will recap a little bit more on this during the hot seat session. Absolutely with this topic and any relevant topics, I mean, obviously, guys, some guys want to know about dizzy and Dizzy.
Yeah, I think it should I discuss it, they say in the hot seat with the visa entity? Yeah, good. That's a good idea. I think that's a good idea. OK, so that was a very good catch. Again, another very good presentation from you. We had 36 people attended today and that we would collect feedback, but that was very good.
As I said, there is hot seat session will follow in two minutes. OK, so we thought I thought rashwan, kashif and myself will be here asking you questions, guys. So please, as soon as you relocate.
Segment:0 .
Guys, this one is this teaching is kindly delivered by kashif, is a speciality doctor from firmly, and he's going to tell us about lunate instability and associated disorders and injuries. And this is no doubt high yield topic in first year exam. So please, I'm sure this is going to be fantastic presentation. So please listen carefully and we will discuss some of these issues also in more depth in the hot seat session.
So please pay attention to kashif. Go ahead, please. OK, look, guys, thank you for listening. So I'm going to present a little bit about loonette and Luna dislocations. If you have any questions, please just write down and ask and. So tenotomy of the carpus carpus is a divided couple. Bones are divided into the proximal and distal carpal growth, and each row has four bones, you already know that.
So on this diagram that the pink line show greater art and then blue and red lines show the lesser. The injuries are divided, according to the according to the. You already know about the ligaments around the carpets, which is divided into two ligaments, which runs between the carpal bones, and they are major stabilizers of the proximal row and that intrinsic ligaments, which is divided into dorsal and volar and then extrinsic ligaments, which connects the forearm both to the bones, which is again divided into the Bowler and dorsal.
You already know the tenotomy of the carcass due to the types of these dislocations, they are divided into eluded dislocation where it stay in the position. While carpal dislocates and Leonid dislocation, where unit is forced out of the car was either volar or dorsal volar is the most common. So the mechanism is usually is dramatic, high energy type of trauma.
It occurs when they went behind, falls on risk with extension and ulnar deviation that leads into the entire purpose of. The injuries are divided, as I told you earlier, into the greater arc injury, which is represented by the blue line here, which involved the fractures and the lesser of which is purely ligamentous injury, which which is shown by the red line.
The sequence of events in this injury, would you start from the scaffold ligament disruption and then followed by the disruption of the capitellum unit articulation? Subsequently, there is a disruption of lunar typekit lunar articulation and then that is followed by a failure of the dorsal radiocarbon ligament that leaves the unit to rotate and dislocate, usually into the carpal tunnel, which is volar.
So you don't need to remember the certification, but for the path of completion. So it divided into four stages the stage one when there is a skillful unit dissociation. Stage two is for lunar dissociation plus lunar disruption, and then stage 3 is a skillful unit dissociation plus lunar capital disruption and plus lunar regular disruption that is mentioned a baby unit in the Soviet Union and stage four where lunar is completely dislocated from the lunar fossa, usually in the karpel, usually on the volar side, and the stage 4 is usually associated with median nerve compression.
You can usually, as I mentioned earlier, high energy trauma patients present with acute risk swelling and pain media ulnar nerve symptoms as mentioned in the literature, around 25% of the patients usually may feel a stage four. But from the reality point of view, you will go for AP and lateral radiograph in the AP radiograph. You can see there the break in the arc.
And there is a story and usually there is a. Usually there is a unit and it will overlap, and you can see sometimes it appears triangular, as in the second radiograph, which is called piece of the pie sign. And on the lateral radiograph, you usually see there is a loss of linearity of the radius unit and computed in normal radiograph, you see, then all three bones are aligned in one line or in this type of injury.
You will see there is a disruption of this opportunity. So management is divided into the according to the acute, whether it's the acute injury, which is less than 8 weeks, whether it's a chronic injury, which is more than eight weeks, and whether this chronic injury with a degenerative changes. So management is divided into three different categories in acute injuries.
Beauty management is urgent, further action followed by a splinting and subsequently there will be open edition with the ligament ligament repair and then fixation if there is any fractures and carpal tunnel. It is usually done by the hand surgeon. So for the emergency emergency, you need to just do the closed reduction possible, followed by sprinting.
If you can't do the clothes reduction, then you have to get advice from your hand surgeon, but then patient need it open. Open addiction and carpal tunnel release. Then then second stage will be open. Open addiction along with ligament repair with fixation. So then dilemma is whether you need to go for volar approach or Darcell approach. If there is carpal if there is a median or compression, then you will go for volar approach.
If there is no medial nerve symptoms, then most of head surgeons they will prefer dorsal approach. But again, it depends on the surgeon choice. And then in secondly, say, while you are doing so, you need to fix the associated fractures, then you need to repair the scaffold union ligament, usually with the suture anchor fixation. And then you have to protect your ligaments repair with a temporary fixation.
Most of the time, they use the temporary wires, which need to be taken out in around four weeks time and then repair of the lunar tracheal ligament. That again, depends on the surgeon choice. Sometimes I just go for repair of the lunar ligament. Some surgeons don't. As I mentioned earlier, slide for electronic injuries, which is more than eight weeks, so options is proximal to me.
While chronic injuries with degenerative changes, optional wrist auto braces. Then post-operative management for this type of injury, really post-operatively patient will be in the. COVID spike spilling from theaters and subsequently patients will be coming back to one management clinic where there will be a head drop, which usually apply the thermoplastic splint, which is usually below elbow below elbow type of the splint and duration of the splinting varies, but usually between four to six weeks is sufficient for these type of injuries.
Usually, they say a patient day had if this. Injuries managed appropriately, usually patient, a good outcome, but most of the time these are injuries, so you need to be very. You should have very high suspicion of index with these type of injuries because sometimes x-rays are deceiving and you may require further imaging.
So any questions over you? I haven't gone into details. I don't think you need it in detail more than this presentation to exams. There's one question, which I think you already answered. Yeah, is what do you do if you there is a closed dislocation? Yeah, patient comes in the evening and showing signs of median nerve compression.
And I think you already answered that your I don't know if you want to add anything to it. Yes so answer to your question if patient is coming in the evening with a close injury, whatever the median nerve symptoms. So the options are you need to try closed reduction once in the knee. So you will give a direction, counter direction with a hand in the hand in the dotted flexion.
And then you will push the unit into the force and bring the hand into the palmar flexion. So if the median are symptoms already, so you don't need to push too hard and no second attempt in the area, then you need to prepare the patient for theaters, for opting for open induction along with the carpal tunnel. In the meantime, you have to discuss with your hand surgeon or upper limb colleague because some hand surgeon what they want.
Just carpal tunnel release and relocation of the unit. No wires. Some head surgeons are. They are quite happy to put the wire for temporary stabilization and then patient will go for second stage repair of the repair of the ligaments if needed. Do you think kashif has, for example, purposes as a general, orthopedic surgeon and trauma approach?
Do you think we should be talking about ligament reconstruction or should we be safe and just say, I think you need to keep it simple that you need to just deal with the emergency? Yes, your medien symptoms? Yeah, I'm sure everyone knows how to do that. How to relieve the carpal tunnel. So you have both carpal tunnel approach. Once you have retracted that study, you will see that loonette will be lying over there.
So you need to just push the unit back. And that's it. And then you will close the wound. And as I mentioned earlier, temporary stabilization with wires are no wires. That depends on your hand surgery. If they want, if they like wire, then you put a couple of wires to hold the bones together and close the wound and then splint if they don't like wires.
Then once it is reduced, it is quite stable, then I think it is now. Welcome after he has a question to you. So can somebody. I have been told on various occasions that there is a very valid role of Chinese finger trap and this is again is a repeated, repeated scenario in can be in any exam setting in terms of where you say or patient just had a burger or a patient just had a lucozade bottle.
What will you do? Patient is developing medium no symptoms and the answer is that. What are your thoughts about it? Yes, you are right. If patient had median nerve symptoms. And if a patient had like, as you mentioned, leukocyte or Burger or whatever, the patient can be put in the Chinese strip with around two to 3 pounds weight on the opposite side.
So you put a Chinese trap and with a pulley system, you will put a 2 to 3 pounds sweat and with the weight of the arm, usually get to reduce it. But to be honest with you, I have not seen personally myself while I was working in my head unit, so I've done three in the evening and a. Fortunately, all three patients were male Bible. Sure what do you think? What do you think?
I think the trouble here, if you see in the exam, if you suggest you're going to put a patient who is developing media nerfs in terms of finger attraction, you can do it temporarily while you're waiting to go to theater. But patients who are even if they've got a full stomach, you can do rapid sequencing in patients. And it's a little saving emergency. So therefore you are justified to go ahead and do this.
Yeah, I agree. I agree with you. One, I think for the exam purposes, this is the limit threat is if a patient started to develop median nerve symptoms, this is limbs becoming limb threatening. And then for rapid sequence discussion, whether it's a limb threatening condition situation. Because because it might not be just the median nerve, he might be developing compartment syndrome.
Absolutely so there are three different scenarios in this situation. Yeah so if your status is busy, for example, laparotomy is going out or whatever, so you need to open second theater. This should be answer. You need to open the second theater and you need to bring the second team to do the decompression. Yeah, I think make it clear to the examiners I want to operate on this patient.
He keep asking you this and that the patient is a patient. I don't know. Not ready. Theater is busy as far as you concerned. You you're concerned for the safety of the patient of the viability of his limb. Any further comment? Sure there is one other scenario where you have a patient who is unable to go to theater for whatever reason.
Stuck in ICU, intubated for other injuries. But you've got the X-ray confirming the neck dislocation. If you leave this patient for 24 hours, they will have median nerve symptoms. So your options and this was going to be a hot seat question for me. But since we brought this up, you might as well talk about it.
You can do a carpal tunnel release while the patient's in ECU or even on the Ward. It's the safest thing to do for this patient, and that's how you would argue you would be reluctant to do it in any other situation. But in a last resort, you can do a carpal tunnel release while you're waiting to get the patient into theater while the patient is fit for later on. One more question.
Kashif is there a vein? A common problem with dislocation as a complication of the injury is a complete. It is a problem because if you have a unit dislocation, blood supply is disrupted. It is a problem. I'm not sure how much is a percentage. I'm sorry. I haven't.
I haven't. I don't know what the exact percentage I think. I think we might. Yeah, we might never know the exact because not all avian is symptomatic and therefore we might not down the line years, down the line, patients could be at discharge. So we don't know exactly. But I think that it is. It's a recognized complication.
Look, long term or short term complication, but absolutely, Yeah. Well, do you know, if anything more about it? No how about you exact percentages there? I'm sure there's somebody that's written a paper on it, to be honest with you, it's irrelevant to managing the patient in an emergency situation. If if, if you're down to discussing AVM rates, you're quoting papers at that stage.
So it's unlikely you're ever going to reach that in an emergency discussion of this situation. More important is that you've saved this patient's limb. Any further comment? I thought about this topic. No, I think the scenarios, the three scenarios that has been covered is covered, but I've been told by the examiners about the Chinese trap scenario as well.
But I will be absolutely right. But sometimes if you haven't seen anything because what they want you what you are going to do. Yes, exactly. So the safe answer is, as you guys have suggested, and that's what you're going to do and you're going to stick to your guns, it inspector, whatever, whatever you. Yeah, I think overall, overall, my general advice is for this FARC.
But one priority, always any questions you ask is safety. Absolutely safety glass more important than any fancy treatments that you might know about? Yeah, exactly. Yeah which could, you know, could look very impressive. I know a lot of it. Sometimes just simple things. Sticking to your guns is what will pass. You get you through the exam.
I just review it again. You want me, I don't think you need anything more to pass. No, no. I just did know the principles, the anatomy, and we will recap a little bit more on this during the hot seat session. Absolutely with this topic and any relevant topics, I mean, obviously, guys, some guys want to know about dizzy and Dizzy.
Yeah, I think it should I discuss it, they say in the hot seat with the visa entity? Yeah, good. That's a good idea. I think that's a good idea. OK, so that was a very good catch. Again, another very good presentation from you. We had 36 people attended today and that we would collect feedback, but that was very good.
As I said, there is hot seat session will follow in two minutes. OK, so we thought I thought rashwan, kashif and myself will be here asking you questions, guys. So please, as soon as you relocate.
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