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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of
Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
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Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis. Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Answer 1. Neurectomy of AIN and PIN is performed for Stage I disease and can also be done in addition to other bony procedures for Stages II-III.
Answer 2. STT fusion is indicated for chronic scapholunate instability, STT arthritis and Kienbock's disease. It is not appropriate for Stage III SLAC wrist as it does not address capitolunate arthritis.
Answer 3. Complete wrist arthrodesis is indicated for pancarpal arthritis in a young patient. It is less appropriate for this 71-year-old patient. It sacrifices wrist motion. Wrist arthrodesis would be performed if BOTH capitolunate and radiolunate arthritis were present
Answer 4. Proximal row carpectomy is indicated for Stage II disease. It is contraindicated where capitolunate arthritis is present (Stage III).
Cohen MS, Kozin SH
J Hand Surg Am. 2001 Jan;26(1):94-104. PMID: 11172374 (Link to Abstract)
Cohen, JHS 2001
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A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. A radiograph is shown in figure A. What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist?
The clinical presentation is consistent with a SLAC wrist. The radioscaphoid joint is the first to be affected in this process.
The radiographs of the right wrist demonstrate a scapholunate dissociation, as evidenced by an increased scapholunate joint space, referred to as scapholunate diastasis (abnormal when the gap is greater than 2 mm and increased from the opposite extremity and other intercarpal spaces).
If left untreated, the wrist may progress to a "SLAC" wrist, as originally described by Watson and Ballet in 1984, which is the most common form of wrist arthritis. The repetitive sequence of degenerative changes is based on and caused by articular alignment problems between the scaphoid, the lunate and the radius.
Kuo et al. review the stages of SLAC wrist. They report stage I SLAC wrist involves changes limited to an area of abnormal contact between the abnormally rotated scaphoid and the radial styloid. In stage II the remaining radioscaphoid joint is affected, as persistent abnormal load transfer and shear across the cartilaginous surfaces leads to degeneration of the proximal scaphoid facet. In stage III, the dorsally translated capitate migrates proximally into the widened scapholunate interval, and degenerative changes occur at the capitolunate joint. The relative congruency of the radiolunate joint in all positions of lunate rotation due to the spherical shape of the lunate facet preserves this articulation, and at all stages of SLAC wrist the radiolunate joint is not involved. The lunate is congruently loaded in every position and, thus, highly resistant to degenerative changes.
Illustration A below shows the stages of involvement in the SLAC wrist.
Watson HK, Ballet FL
J Hand Surg Am. 1984 May;9(3):358-65. PMID: 6725894 (Link to Abstract)
Watson, JHS 1984
Kuo CE, Wolfe SW
J Hand Surg Am. 2008 Jul-Aug;33(6):998-1013. PMID: 18656780 (Link to Abstract)
Kuo, JHS 2008
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