Introduction Avascular necrosis of the lunate leading to abnormal carpal motion Epidemiology incidence most common in males between 20-40 years old risk factors history of trauma Pathophysiology thought to be caused by multiple factors biomechanical factors ulnar negative variance leads to increased radial-lunate contact stress decreased radial inclination repetitive trauma anatomic factors geometry of lunate vascular supply to lunate patterns of arterial blood supply have differential incidences of AVN disruption of venous outflow leading to increased intraosseous pressure Prognosis progressive and potentially debilitating condition if unrecognized and untreated Anatomy Blood supply to lunate 3 variations Y-pattern X-pattern I-pattern 31% of patients postulated to be at the highest risk for avascular necrosis Classification Lichtman Classification Stage Description Treatment Image Stage I No visible changes on xray, changes seen on MRI Immobilization and NSAIDS Stage II Sclerosis of lunate Joint leveling procedure (ulnar negative patients) Radial wedge osteotomy or STT fusion (ulnar neutral patients) Distal radius core decompression Revascularization procedures Stage IIIA Lunate collapse, no scaphoid rotation Same as Stage II above Stage IIIB Lunate collapse, fixed scaphoid rotation Proximal row carpectomy, STT fusion, or SC fusion Stage IV Degenerated adjacent intercarpal joints Wrist fusion, proximal row carpectomy, or limited intercarpal fusion Presentation Symptoms dorsal wrist pain usually activity related more often in dominant hand Physical exam inspection and palpation +/- wrist swelling often tender over radiocarpal joint range of motion decreased flexion/extension arc decreased grip strength Imaging Radiographs recommended views AP, lateral, oblique views of wrist findings (see table above) CT most useful once lunate collapse has already occurred best for showing extent of necrosis trabecular destruction lunate geometry MRI best for diagnosing early disease rule out ulnar impaction findings decreased T1 signal intensity reduced vascularity of lunate Treatment Nonoperative observation, immobilization, NSAIDS indications initial management for Stage I disease outcomes a majority of these patients will undergo further degeneration and require operative management Operative temporary scaphotrapeziotrapezoidal pinning indications adolescent with radiographic evidence of Kienbock's and progressive wrist pain joint leveling procedure indications Stage I, II, IIIA disease with ulnar negative variance initial operative managment technique can be radial shortening osteotomy or ulnar lengthening more evidence on radial shortening radial wedge osteotomy indications Stage I, II, IIIA disease with ulnar positive or neutral variance vascularized bone grafts indications Stage I, II, IIIA, IIIB disease outcomes early results promising, but long-term data lacking best results in Stage III patients distal radius core decompression indications Stage I, II, IIIA disease technique creates a local vascular healing response partial wrist fusions STT capitate shortening osteotomy +/- capitohamate fusion scaphocapitate indications Stage II disease with ulnar neutral or positive variance Stage IIIA or IIIB disease must address internal collapse pattern (DISI) proximal row carpectomy (PRC) indications stage IIIB disease stage IV disease outcomes some studies have shown superior results of STT fusion over PRC for stage IIIB disease wrist fusion indications stage IV disease technique must remove arthritic part of joint total wrist arthroplasty indications Stage IV disease outcomes long-term results not available Techniques Vascularized bone grafts technique many options have been described including transfer of pisiform transfer of distal radius on a vascularized pedicle of pronator quadratus transfers of branches of the first, second, or third dorsal metacarpal arteries 4 + 5 extensor compartment artery (ECA) temporary pinning of the STT joint, SC joint or external fixation may be used to unload lunate after revascularization Impact of surgical procedure on radiolunate contact stress Operative Procedure % decrease on radiolunate contact stress STT fusion 3% Scaphocapitate fusion 12% Capitohamate fusion 0% Ulnar lengthening of 4mm 45% Radial shortening of 4mm 45% Capitate shortening and capitohamate fusion 66%, but 26% increase in radioscaphoid load
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Four Corner Wrist Fusion Orthobullets Team Hand - SLAC (Scaphoid Lunate Advanced Collapse)
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next (OBQ10.61) A 32-year-old carpenter complains of progressively worsening wrist pain for the last 2 months. He denies any recent history of trauma to the wrist or hand. An MRI is obtained and a representative image is provided in Figure A. Which of the following surgical interventions is thought to be effective for this condition by inciting a local vascular healing response? Review Topic QID: 3149 FIGURES: A 1 Wrist fusion 1% (14/2694) 2 Ulnar shortening osteotomy 10% (276/2694) 3 Distal radius core decompression 82% (2207/2694) 4 Proximal row carpectomy 2% (63/2694) 5 Scapholunate ligament reconstruction 4% (119/2694) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ07.244) A 37-year-old man has a 2-year history of increasing right wrist pain that is worse at night and aggravated by activity. He denies systemic symptoms, history of trauma, or recent weight loss. On physical exam he has tenderness over the dorsal radiocarpal joint. Radiographs of the right wrist are shown in Figure A. Which of the following imaging studies would be most sensitive for determining the stage of this patient's underlying condition? Review Topic QID: 905 FIGURES: A 1 Ultrasound 1% (51/4377) 2 Angiography 5% (230/4377) 3 CT scan of the wrist 66% (2873/4377) 4 Clenched fist AP radiograph of wrist 8% (362/4377) 5 Bone scan of the wrist 19% (836/4377) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ11.112) Figures A through E depict various conditions affecting the pediatric hand and wrist. For which of the depicted conditions is temporary scaphotrapeziotrapezoidal pinning most indicated? Review Topic QID: 3535 FIGURES: A B C D E 1 A 4% (133/3033) 2 B 33% (1004/3033) 3 C 5% (143/3033) 4 D 50% (1519/3033) 5 E 7% (207/3033) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.74) A 30-year-old female undergoes arthroscopy for a chronically painful right wrist that failed to improve with 4 months of immobilization and NSAIDS. Her clinical examination revealed point tenderness dorsally over the lunate but no tenderness elsewhere in the wrist. A picture from the procedure is shown in Figure A where 'R' identifies the distal radius, 'L' the lunate, and '*' represents a chondral flap. The articular surface of the lunate is stable to probing. A radiograph and MRI image of the patients wrist are shown in Figures B and C respectively. What is the most appropriate next step in treatment? Review Topic QID: 3162 FIGURES: A B C 1 Continue Immobilization and NSAIDS 8% (275/3288) 2 Radial shortening osteotomy 69% (2266/3288) 3 Proximal row carpectomy 10% (339/3288) 4 Scaphotrapeziotrapezoid fusion 9% (300/3288) 5 Wrist fusion 3% (85/3288) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ11.144) A 39-year-old male presents with longstanding right wrist pain. He has failed conservative measures including prolonged immobilization. His radiographs and MRI are seen in figures A and B. Which of the following options is an accepted treatment option? Review Topic QID: 3567 FIGURES: A B 1 Ulnar shortening osteotomy 5% (146/2925) 2 TFCC repair 1% (30/2925) 3 Radius core decompression 78% (2269/2925) 4 Arthroscopic lunate chondroplasty and debridement 15% (433/2925) 5 Scapholunate ligament reconstruction 1% (36/2925) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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