Wrist Flashcards
1
Q
Column concept
A
Lateral - S,T,T bones (mobile)
Central - L,C,H bones (flex ext)
Medial - Triquetrum and distal carpal row , rotation
2
Q
Space of Poirier
A
Between volar RSC and volar long radiolunate (radiolunotriquetral), at the base of Capitate
3
Q
Volar radoiocarpal lig
A
RCL - Radial collateral
RSC - Radioscaphocapitate
Long radiolunate
RCL - Radioscapholunate (Testut and Kuentz) not at true lig, neurovascular
Short RL - Radiolunate
4
Q
Volar ulnocarpal lig
A
Ulnotriquetral
Ulnolunate
Ulnocapitate
5
Q
Dorsal lig
A
Radiotriquetral (disruption + lunotriquetral big rupture gives VISI)
DIC - Dorsal intercarpal
RL - Radiolunate
RS - Radioscaphoid
6
Q
Proximal row intrinsic lig
A
Scapholunate lig
Lunotriquetral lig
7
Q
distal row ligaments
A
Trapeziotrapezoid lig
trapeziocapitate lig.
Capitohamate lig.
8
Q
Palmar midcarpal lig
A
Scaphotrapeziotrapezoid STT
Scaphocapitate
Triqutralcapitate
Triguetralhamate
9
Q
Colle fracture
Indication for surgery
A
> 10-15 Degrees dorsal tilt
2-5 mm ulnar shortening
2 mm intraarticular step-off
<15 degrees radial inclination
10
Q
Lunate types
A
Type 1: One distal facett (to capitate)
Type 2: Two facettes (Capitate and Hamate)
11
Q
How does lunate type affect Kienböck disease?
A
Lunate type 2 (2 facettes) seems to be protective against DISI and coronal fractures in Kienböck
12
Q
Etiology of Kienböck
A
Avascular necrosis
1. Biomechanical factors (Ulna negative, Decreased radial inclination, repetetive trauma)
2. Anatomic factors (Lunate 1 predisposed, vascular)
13
Q
Kienböck type IIIA and B difference
A
Important difference in treatment.
A: Early collapse with no fixed scaphoid rotation (treatment to prevent further collapse)
B: Late collapse with fixed rotation (too late - only pain reducin procedures)
14
Q
Kienböck stage IV
A
Arthritis adjacent joints
15
Q
Kienböck type I and II (of IV)
A
- MRI (not visible on x-ray)
- Sclerosis
16
Q
Kienböck stage 1 treatment
A
NSAID
Immobilisation
17
Q
Kienböck stage 2 and 3A treatment (5)
A
- Joint levelling (radial shortening)
- Radial wedge osteotomy
- STT-fusion
- Distal radius core decompression
- Revascularization procedures
- Capitohamate fusion + SC fusion (66% decreased contact stress on lunate)
18
Q
Kienböck stage 3B treatment
A
- PRC
- STT-fusion
- SC-fusion
19
Q
Kienböck stage 4 treatment
A
- Wrist fusion
- PRC
- Limited intercarpal fusion
- Total wrist arthroplasty
20
Q
Role of MRI in Kienböck
A
Early diagnosis
Rule out ulnar impaction
(decreas T1 signalling)
21
Q
Role of CT in Kienböck
A
Once collapse has already occured
1. Extent of necrosis
2. Lunate geometry
3. Trabecular destruction
4. Degenerative changes
22
Q
Vascularized bone graft for Kienböck disease?
A
Many options have been described including
- transfer of pisiform
- transfer of distal radius on a vascularized pedicle of pronator quadratus
t- ransfers 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
23
Q
TFCC inj classification
A
Palmer classification
1 acute
A central
B ulnar
C distal
D radial
2 degenerative
A thinning
B chondromalac
C perforation
D LT lig perforation
E arthritis
24
Q
Ulnar impaction treatment
A
Wafer (2-4mm if no instability, open or arthroscopically
Ulnar shortening in diaphysis prox to DOB lig
25
Two typer of ulnocarpal dislocation
26
Radial inclination and palmar tilt?
27
2 dorsal and 6 volar extrinsic wrist ligaments
28
In radial deviation, does the scaphoid flex?
29
Funktion of triquetrum in the wrist
30
How do u see that its a true lateral?
The pisiform is between the capitate and the scaphoid
31
3 ulnar extrinsic volar lig
32
3 volar radial extrinsic lig
33
An importens funktion of DIC lig
34
2 dorsal extrinsic lig
35
Mechanism of SL rupture?
Volar short RL lig intact Hilda lunatum
Firat volar SL then dorsal
36
How does the lunate dislocate?
37
Tales IK type 2 is?
38
Signs of VISI in a frontal
Seagull sign, ring sign, sec SL dissociation(not true)
39
Lesser arc perilunate dislocation means?
Only ligament inj
40
Greater arc perilunate injury
41
Ulna carpal dislocation type 2?
42
Mayfield stage 1
43
Mayfield stage 2?
44
Mayfield stage 3
45
Mayfield stage IV
46
When is it possible to reconstruct SL-injury
1. Reducible SL in frontal/lateral
2. Stable lunate, not ulnarly translated(short/long RL intact)
3. Patient factors
4. Local exprience/complications
47
Unstable lunate + SL, what to do?
Spiral antipronation tenodesis (FCR borras igenom S, går dorsalt om L till T och sen volart om L till radiusstyloiden där den förankras)
48
SCAC?
Scaphoid Chondrocalcinosis Advanced Collapse (pyrofosfate deposition - extremely common)
49
SLAC 1
Arthrosis in dorsal part of scaphoid fossa
50
SLAC 2
Large dorsal damage of scaphoid fossa
51
SLAC 3
Midcarpal
Never affects SCj (as in SNAC)
But with DISI dorsal LC degenerates
52
SNAC movement of S?
Snac1
Distal fragment is flexed and rotated (pronated)
Distal fragment has more motion than unbroken
SNAC1 - affects radial styloid fossa not proximal S - fossa
53
SNAC 2
Between proxiaml fragment and Capitate not distal fragment. The distal fragment moves together with C. The proximal fragment moves together with L (not affecting l and prox S fossa)
54
SNAC 3 and SLAC 3
Affecting LC joint dorsally with DISI
55
SNAC and SLAC 4
THj osteoarthritis - extremely uncommon
56
SCAC pattern
Difference from SLAC is calcinosis, no Scaphoid flexion, Scapiod is usually digging into radius (often Sl injury - missdiagnosed as SLAC)
57
Factors influencing outcomes of PRC
>40y
Not heavy job
Type of capitate/lunate did not affect clinical outsomes
58
PRC indications
ONLY in SLAC 1 and 2 and SNAC 1 (all others affect head of capitate)
Otherwise 4CF in stage 3 SLAC, stage 2 SNAC
59
PRC and 4CF tips
- Preserve RSC radioscaphocapitate lig
- Small radial styloidectomy prevents radio-trapezoid impingement
- 4CF derotate lunate
60
Tips RSL fusion
Inspect midcarpal
Excise distal 1/4 Scaphoid (improves unoin rates, maximises DTM)
POP 4 weeks, Wires out later
61
2 STT fusion tips
Restorenormal hight!
Scaphoid angle 55-60 degrees important
62
Why is total arthroplasty not a winner?
- Closer to the body better results (cannot be compared to other joints)
- Strong rivals (Fusion, PRC..)
- Limited indications (gives less money to develop)
63
3 Types of wrist implants now?
1. Freedom
2. Re-motion
Cementless - distal polyethyleene, ellipoid,
3. Motec (Ball and socket, no cement into radius, capitate and 3rd MC)
64
Most common cause of failiure in implants
Distal component loosening,
often stuck proximal and difficult to take away
65
Lunate vascular necroris cause
Stress fracture in subchondral bone gives a compartment syndrome in the bone with damaged venous drainage - but cartilage is preserved in early disease! It's a bone disease
66
Morphologic causes of Kienböck
-Short ulna (stress fracture in the radial half of lunate)
- Viegas type 1 (1 distal facet)
- Zapico 1 (<130gr)
67
Kienböck mechanical effects?
- Collapse of lunate gives prox migration of Capitate - like cracker into SL and collapse of central column
- Kissing lesions LC and RL osteoarthritis
- S flexion
- T extension
- Carpal ulnar translation
68
Kienböck classifications
1. Lichtmann (MRI nad radiography)
2. Schmitt (staging viability with MR + gadolineum)
3. Bain (arthroscopic assessment (0-4)
4. 4D CT
69
<15y Keinböck treatment?
1. Konservative 6m
If proceeds surgical levelling procedure:
2. Epiphysiodesis with or/without carpal central loading decompression
3. STT pinning temporary
70
>70y Kienböck treatment
Conservative since good clinical outcome even if the disease progresses
Arthroscopic synovectomy for pain
71
Kienböck with intact lunate treatment - protect fr loading
Only extraarticular procedures
If short ulna -> radial wedge osteotomy 2-3mm +/- STT pinning
Not short ulna but increased radial tilt - radial wedge osteotomy
Not short ulna -> 2-3mm Capitate shortening +/- STT-pinning
72
Kienböck with compromised lunate - treatment (still reconstructable 2 and 3A)
Reconstruction - intraarticular procedures
1. Cancellous graft
2. Vascularized graft
3. Tissue transfer
73
Kienböck not reconstructible lunate - treatment
Salvage to reduce pain and restore hand function after athroscopic assessment:
1. intact RLj -> PRC
2. damaged RLj but intact RSj -> SC-arthrodesis
74
Static forearm stabilizers
- PRUj lig
- Proximal oblique cord
- Central band (most important) & accessory bands
- Distal oblique bundle
- DRUj & ulnocarpal lig
75
Central band of Interosseous lig direction and origin?
When walking on hands - load and prox migration of radius- Central band prevents this (orientation prox radius 1/3 to distal ulnae 2/3). often obvious tubercles on the bone
76
Distal oblique bundle function?
Static stabilizer DRUJ (not everyone has it)
77
Axis of forearm rotation?
Oblique from enter of radial head to basistyloid fovea of ulnar head
78
Is ulna still under pro/sup?
No - slight motion (moves a little bit to the other side of the radius ex pronation moves ulnarly..)
79
Where do you need congreuncy for forearm movement
Congruency of the whole forearm joint PRUJ, radial pronation so the radius can go over the ulna and DRUJ
The whole forearm is a joint
80
Load transfer in wrist and elbow
20% ulna, 80% radius
20% goes from radius to ulna through the central band of interosseous membrane
In elbow 40% through ulna and 60% through radius
Depends on ulna +/i and pronation/supination
More equal load in supination to ulna and radius
81
What is most important of longitudinal forearm stability
1. Radial head most important
2. CB central band sec stabilizer
3. TFCC less important
If no radial head the interosseous lig will have less tension since the bones are close together
82
DRUJ stabilizers?
TFCC
Ulocarpal lig
IOM
Dynamic stabilizers:
ECU tendon and sheath
PQ
arm & forearm muscles
83
DRUj LAXITY exams?
1. Piano key sign (man ska tryck på ulna som en piano tangent)
2. Dimple test (det jag tidigare trodde var piano key
3. Distal ulna ballottement test (neutr, pro, sup, radial incl testing ulnocarpal lig)
If patient can dynamically stabilize the DRUj it can have laxity but still be stable.
84
How to treath DRUJ arthropaty
1. Resection
2. Fusion (Sauve-Kampandji)
3. Arthroplasty (Herbert, Schecker)
85
Ulnar pain exams
1. TFCC/ulnar grinding test (wrist extension, load and rotate to uln dev)
2. Press test (ställa sig upp o belasta)
3. Radioulnar compression test
85
6 groups of ulnar sided wrist pain (Lluch and Garcia Elias)?
Intracapsular
1. DJUR articular (synovitis, arthropathy, stiffness
2. Lig inj
3. Impaction syndr
4. Carpal instab
5. Other carpal conditions
6. Extracapsular causes
86
Treatment of DRUj artropathy?
1. Resection or hemiresection (Darrach)
2. Fusion (sauve Kampandji)
3. Arthoplasty (Herbert, Schecker
87
Impaction syndromes types and treatment
Ulnocarpal
- Constitutional or aquired
Ulnar styloid-triquetrum impaction syndrome
- Megastyloid
- Non-union of ulna styloid
Luno-hamate and triquetro-hamate
Radio-ulnar impaction after Darrach resection
88
Ulnar shortening tnesion what?
1. Ulnocarpal lig (UTr and UL)
2. Distal oblique bundle of IOM (not always present)
89
Ulnar styloid triquetrum impaction test
Supination - extension - ulnar deviation
Puts styloid the closes to triquetrum
Can be impingement of bony part or the ulnocarpal soft tissues a.k.a. ulnocarpal meniscoid
90
Ulnocarpal meniscoid impingement test
press fovea and ulnarly deviate wrist
91
Ulnocarpal impingement treatment
Ulnocarpal
- Constiutional och acquired (secondary to DRF malunion)
Treatment if no osteoarthritis?
- Radial lengthening
- Ulnar shortening (if not secondary abutment)
- Distal ulnar resection (Wafer by Feldon et al -92) keeping DRUj
92
Carpal instabilities
CIND - Carpal Instability Non Dissociative - between carpal rows (Palmar midcarpal instability) - often with clunk
CID - Carpal Instability Dissociative (Lunotriquetral instability)
93
Difference betweend CIND and CID
CIND is between carpal rows
CID is within a carpal row
94
Mention 3 "other" intracapsular conditions caousing ulnar sided wrist pain
1. Kienböck
2. Chondrocalcinosis
3. Painful tumours like osteoid osteoma
95
Extracapsular causes of ulnar sided wrist pain
25%
1. Tendinopathies (mostly ECU and sheet that is very innervated, or FCU pisiform insertion)
2. Other joints and bones (pisiform, hamate hook fx, PTr joint
3. Nerve and vascular (nerve inj or in Guyon canal)
96
ECU tests
1. ECU synergy test (Supinate and abduct fingers)
2. ECU tendon subluxation test "Sand scoop test" (supinate ulnar dev and palpate ECU)
97
Where does the limbs of TFCC attach
Deep limb to fovea
Superficial to ulnar styloid
98
How much pro/supination is radiocarpal
30 degree
| 150-180 in DRUj
99
Stabilizers of DRUj
TFSS
IOM
DRUj capsule
Articular disk
Dynamic: PQ & ECU
100
Meniscus Homologue
Structure prox to and attached totriquetrum. Well vascularized loose connective tissue fr synovium
101
How to confirm correct lateral x-ray view
SPC-lateral
From palmar the palmar surface´s of Scaphoid, Pisiform, Capitate should come in this order
102
TFCC reconstruction if repair not possible
103
Sigmoid notch osteoplasty
+ bone graft
104
Difference of ulnar vaiance in pro/supination
Only 0,6mm
| But still most ulna plus in pronation, power grip or combo
105
When is ulnar shortening a good option for DRUj problems?
If radial shortening is the only substantial deformity and articular alignment of the radius and carpus is satisfactory
106
How many cadavers have TFCC perforationin normal and ulna + wrist compared to ulna minus
73% vs 17%
| Radiography in pronation and powergrip - can give 2mm ulnar variance
107
How much of the distal head should be wxcised in Wafer procedure
by Feldon and co
2 - 4 mm
| Concider ulna-shortening osteotomy - doeas not violate joint
108
Hemiresection- Interposition arthroplasty
Bowers arthroplasty
If intact TFCC
DRUj osteoarthritis
And ulnar head shortening osteotomy is possible. They prefer metafyseal with good healing attached with anchor
109
How many mm ulna-shortening
Ulna + -> 0 och -1
Ulna neutral -> 2-3 mm
110
Approach to DRUj
and to TFCC
5th compartment
between FCU and ECU
111
How much excise in Sauve-Kapandji?
1cm
If ulna positiv -> correct it and resect more so 1cm gap in pseudoarthrosis
| FCU distal tenodesis + Interpose detached ulnar PQ in pseudoarthrosis
112
Stabilization of respected distal ulna
FCU and ECU strips by Breen and Jupiter
113
Where ostotomy for Darrach
At margin of sigmoid notch approx 3cm
Ulnar styloid + attachments left in situ
| Risk ulnocarpal translation - considor RL fusion
114
Ecu sheet reconstruction
Do not suture to itself but proximal to create a loose sling
115
Oblique or transverse osteotomy in dorsal opening wedge DR osteotomy
116
Volar marginal fragment
5 mm or less. Needs hook plate added, can be avascular. Watershed line is 2mm from joint but because of hardware thickness 5mm away is needed
117
How to prevent going distal to water shed line
Make incision in PQ at the side and along the palpated water shed line to elevate all soft tissues
118
Incision for volar plating
Extended FCR approach crossing the flexor sheet and follow FCR distally. Split FCR insertion to trapezium. Move FCR and FPL ulnarly. Maybe release FPL radial insertion. Release 1st compartment and BR step wise for suture afterwards.
119
Why often problem intraop reduce dorsal tilted DRF fx
Dorsal organized hematoma inside periosteum. PRONATE the whole pro fragment. Lift periosteum if needed
120
How to see proper reduction in DRF perop in PA
Use wires, the ulnar should exit in the ulnar corner and also a radial wire - before screws. Use additional x-ray angel
121
How to see proper PLATE PLACEMENT in lateral
2mm from osteochondral limit.
122
What is this view called and how to do it
For viewing DRUj screw penetration
123
Blatt capsulodesis
If reducible SL dissociation
Dorsal capsular flap leaving radius origion, 1cm wide capsular flap insicion in scaphoid axis full length, developed from ulnar side
Reduce scaphoid Eric with wire to capitate and MC3- pill our suture trough fine drill Holes to volar tubercle.
124
Bain and Begg classification
1 prox lugnare
2 lugnate fossa
2B fracture
3 distal lunate
4 próx capitate
125
Zaidemberg
Mist common for avascular necrosis
1,2 iC SRA
126
Approachens to both bone midshaft fracture
127
Antipronation spiral tenodesis
If reducible ulnar translation in SL injury (3LT if only reducible SL gap)
128
Staging SL-disability
Modified by Garcia Elias
1. Partial
2. Still Repairable but total
3. Not repairable
4. RS angle bad
5. Is reducible but lunate malaligned
6. Is not reducible
7. Bad cartilage
129
EWAS
1. Elongation- probe no passage
2. Tip of probe inside (próx membrane rupture)
3A. 2 + volar SL (volar widening with probe)
3B. 2 + dorsal (dorsal)
3C. 2 + dorsal + volar (global widening but reduces when probe is out)
4. + SL gap but no radiographic abnormalities (arthroscope through)
5. + rtg anomalies
130
Kienbock 3A and B difference measure
RS angle over 60 degrees by Goldfarb et al
131
How to make osteotomy in distal radius malunion
Parallell to joint surface
132
CIND surgery
Rehab, proprioception!
Volar CIND: RL fusion, but if good cartilage and easy reducible reconstruction with ECRB strip tunneled in C and Trq. No longer TrqH fusion because RS impingement.
Dorsal: No longer suture space of poirer because stops extension of wrist. Instead ex Mayo capsulodesis reinforcing DIC.
133
Prognosis of conservative treatment of Kienböck
Kristensen et al, 46 pat mean 20y: 66% arthritis but 20% significant symptoms
Taniguchi - worse rig in 70% of 20 pat 25y but 20% sign symptoms
Keith 33 pat predictable pattern of worsening incl DASH
