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Wrist problems Flashcards

1
Q

List the ligaments of the wrist

A

INTRINSIC

  • VOLAR: SL, LTq, VIC
  • DORSAL: SL, LTq, DIC
  • Midcarpal: THC, SC, Strapezial

Dorsal SL and Volar LTq are most important for stability

EXTRINSIC

  • VOLAR: RL (Long and short), RS, RSC, RU, UTq, UL, UC
  • DORSAL: RS, RL, RTq (DRC), RU
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2
Q

What is the space of poirier

A
  • located between RL long and RSC
  • space where perilunate dislocations can occur
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3
Q

what is the TFCC, location and function

A

Triangulofibrous Cartilage complex

  • located between ulna, carpus, contained wihtin RU ligaments, UL, UTq, ECU
  • Function
    • primary stabilizer of DRUJ
    • stabilizer of ulnocarpal joint
    • gliding surface of pronation/supination
    • suspends ulnar wrist from radius
      *
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4
Q

aDescribe the vascular supply to the carpal bones and specific scaphoid blood supply

A
  • Derived from radial and ulnar palmar and carpal arches/branches
  • single Intraosseous vessel: scaphoid, lunate, capitate
  • Dual supply, no anast; hamate trapezoid
  • Dual supply with anast: Trap Triq, Pisiform, lunate

SCAPHOID

  • Dorsal scaphoid branch of radial artery -> retrograde flow to the scaphoid proximal pole **80% of blood flow
  • Volar scaphoid branch of radial artery -> anterograde flow to tubercle
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5
Q

Describe your physical exam of the wrist

A

compare BOTH sides with elbow resting on the table

  • point of maximal tenderness
    • scaphoid tubercle - radial to FCR, prominent in radial devaition
    • scaphoid waist - snuff box, prominent in ulnar
    • scaphoid proximal pole - b/w 2nd and 4th compartment, distal to listers tubercle
    • Sl lig - b/w 2nd and 4th compartments
    • lunate - valley distal to lister’s tubercle, check w wrist flexion
    • Tq - distal to ulnar head on dorsum
    • capitate - base of D3 MC
    • Trapezoid - base D2 MC
    • Hamate - base D4/5
    • TFCC - valley distal to ulnar head
    • STT - base of D2MC
  • ROM
    • ​dorsi/palmar flexion 75’
    • radial deviation 35’
    • ulnar deviation 25’
    • pronation/supination 75’/80’
  • Special Tests
    • ​1st CMC arthritis - grind test, shoulder sign
    • STT arthitis - thumb immobilized, wrist flex/ext moves ST - if painful, STT not CMC arthr.
    • scaphoid instability/SL lig - Watson’s test: wrist movement from ulnar to radial, with thumb applying pressure on tubercle - with deviation and release will have clunk/pain when scaphoid clunks back
    • Lq instability
      • ballottment with dorsal pressure on Lunate and volar on Tq
      • Kleinmann sheer test - dorsal pressure on Tq is painful
    • Dequervains - Finkelsteins
    • MIdcarpal instability - Lichtman test
      • axial pressure into radial deviation, look for proximal clunk when in extension (catch up clunk)
    • DRUJ
      • pain/crepitus w pron/sup
      • ballottment- stabilize radius with elbow in neutral and trasnlate ulna back and forth- 5mm normal - none in extreme pron/sup
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6
Q

What is your DDX for radial sided wrist pain?

A
  • FCR tendonitis
  • Dequervains
  • intersection syndrome
  • ECRB/ECRL tenosynovitis
  • SL instability, tear
  • carpal F#: scaphoid, Tp, Tm
  • radial styloid F#
  • Kienbocks (lunate AVN)
  • Preiser’s (scaphoid AVN)
  • Arthritis 1st CMC, STT, RC
  • Ganglion
  • Vascular lesion - AVM/ischemia
  • Neuroma- wartenberg syndrome (DSRN neuritis)
  • Carpal Tunnel
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7
Q

What are normal features to identify on a wrist xray series

A
  • Series: PA, lateral, 45’ oblique
  • pencil grip, scaphoid views
  • Alignment
    • ​Radial inclination 22’ +/- 2
    • Radial volar tilt 11’ +/- 22
    • Radial height 11mm +/-2
    • Ulnar variance 0-2mm
    • Gilula’s lines
    • SL joint space<2mm
    • carpal height: capitate = 1/2 D3MC
    • ulnar translocation = >1/2 lunate ulnar to radius, occurs in SLAC wirst
    • CL angle <30
    • SL angle <60
      • based on volar max concexity of scaphoid, max convexity of lunate, max distal/proximal pt of capitate
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8
Q

DDX of ulnar sided wrist pain

A
  • FCU tendonitis
  • ECU subluxation
  • Arthritis PT, DRUJ, ulnar styloid
  • DRUJ instability (TFCC tear/injury)
  • L-Tq instability
  • Ulnar styloid F#, hamate/Tq#
  • ulnar carpal abutment
  • TILT (Triquetrail impingement lgament tear) (fibrous cuff displaced distally that impinges on Tq - need ot remove fibrous cuff
  • hypothenar hammer syndrome
  • DSUbr neuritis
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9
Q

How do you tell if it is a true lateral xray

A

<3mm ulna showing beyond radius

SPC - pisiform lies beteen volar edge of scaphoid and dorsal edge of capitate

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10
Q

What is diagnostic for DISI and VISI on xray

A
  • DISI - lunate cup is pointed dorsal (extended) and capitate is dorsal, SL>60
  • VISI - lunate cup is pointed volar (flexed) and capitate is volar, SL <30
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11
Q

What F# is difficult to spot on xray

A
  • hook of hamate F#
  • Triquetrium F# in proximal radial corner =>key for mayfield class of periL dislocation
  • Trapezium - dorsal ulnar border
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12
Q

What are normal variations to see on xray for carpal bones?

A
  • carpal coalitiion (lunate/Tq)
  • Lunate facets - type 1 - capitate only, type 2 - capitate and hamate
  • bipartite scaphoid (often bilateral)Os carpi centrale - accessory carpal bone adj to scaphoid/capitate
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13
Q

How do you classify distal radius fractures?

A
  • Barton - INTRA-articular fracture with radiocarpal displacement - dorsal or volar
  • shearing force with strong radiocarpal ligaments causing radiocarpal dislocation
  • Colles - EXTRA-articular fracture with dorsal disaplcement
  • Smith - EXTRA-articular or juxta-articular fractur with VOLAR displacmeent
  • for smith/colles, one cortex fails and other undergoes comminution
  • Chaffeur - INTRA-articular radial styloid F# ***associated with SL injury, Perilunate dislocation, ulnar styloid fracture ***must assess
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14
Q

How do you manage distal radius fractures?

A

Indications for non-operative Tx

  • loss of radius height >5mm
  • dorsal tilt >10’
  • articular incongruity

Indication for operative Tx

  • displaced, irreducible, unstblae F#
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15
Q

How do you perform a closed reduction of a colles fracture

A
  • extension of wrist to disengage fracture segment, volar pronated force
  • splint in 20’ulnar 20’flexion position for 3wks w wkly checks
  • early AROM 4-6wks
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16
Q

What are complications of a distal radius fracture?

A

ACUTE

  • nerve injruy: median, ulnar, radial sensory
  • compartment syndrome
  • DRUJ instability

CHRONIC

  • Arthritis
  • CRPS
  • stiffness
  • Malunion
    • ulnocarpal abutment syndrome (shortened radius)
    • midcarpal intability (excessive volar tilt)
    • Arthritis (excessive volar tilt)
    • DISI (excessive volar tilt)
  • Tendon rupture
    • EPL rupture (2’ attrition/ischemia post hematoma)
    • flexor/extensor 2’ attrition post hardware
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17
Q

WHat is the incidence of carpal bone F#

A
  • scaphoid 60-80%
  • triquetrum 15%
  • rest 1%
  • trapezoid most infrequent
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18
Q

What anaotmic location of the scaphoid is most likely to fracture

A
  • waist 70%
  • tubercle 20%
  • proximal pole 10%
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19
Q

What are clinical features of a scaphoid fracture

A
  • tenderness in snuffbox (waist), tubercle or proximal pole
  • tenderness worsened with resisted supination or axial compression of thumb
  • may have assocated + watsons test (SL tear)
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20
Q

How do you classify scaphoid fractures?

A

Herbert

  • Type A= acute stable
    • tubercle
    • incomplete waist
  • Type B = Acute unstable
    • distal oblique
    • complete waist
    • proximal pole
    • trasnscaphoid perilunate F# dislocation
  • Type C = Delayed union
  • Type D = non-union (fibrous union or pseudoarthrosis
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21
Q

What xray view would you order for radial sided wrist pain?

A
  • PA, lateral, oblique, scphoid views
  • repeat in 10-21days as F# will not be evident until then
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22
Q

What are scaphoid/SL views?

A
  • ulnar deviation and extension of wrist
  • pencil grip view
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23
Q

How do you manage a pt w a suspected scaphoid fracture and neagtive xray?

A
  • short arm thumb spica x14days
  • re-xray 10-21days
  • if second xray negative and strong suspicion, CT scan
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24
Q

What are signs on imaging of a scaphoid fracture and DISI?

A
  • SL angle >60
  • CL angle >15
  • dorsal translation of capitate
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25
Q

How do you define an UNSTABLE scaphoid fracture?

A
  • >1mm displacement
  • fracture angulation
  • carpal malalingment
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26
Q

What % of scaphoid fractures will go on to unite?

A
  • 95% of tubercle F#
  • 90% of waist fracture
  • 60% of proximal pole F#
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27
Q

How do you manage an acute scaphoid fracture (Type A/B herber classification)?

A

NON-OPERATIVE (type A)

  • tubercle F# -> 2wks short arm thumb spica splint, IPj free, then 6wks cast. Xray q4wk
  • non-displaced waist F# -> 2wks short arm thumb spica splint, IPj free, then 6wks cast. Xray q4wk
  • *most require 8-12wks of immoblization
  • *if not healed at 6-8wks, (tender/xray showing sclerosis/cystic changes/resorption => ORIF
  • return to sports 6mths

OPERATIVE (type B)

  • proximal pole F#
  • displaced waist F# (angulation, >1mm displaced, carpal malalignment)
  • also for nondisplaced if athelete/refusal/inability to immoblize for 8-12wk
  • communited F# (requires BG)

OPERATIVE OPTIONS

kwire, compression scrw osteosynthesis (herbert screw), percutaneous screw fixation

volar approach if F# in distal 1/2, dorsal appraoch if F# in proximal 1/2

aim to place screw in central 1/3 of scaphoid

  • Volar approach (for distal 1/2 F#)
    • divide volar carpal ligaments
    • reduce fracture with joysticks
    • ST jt opened and segment of T removed to allow screw placement
    • alignment jig, drill guide, drill, tapp, screw
    • repair volar carpal ligament
    • xray check
    • 1wk thumb spica immobilization, then splint early ROM
  • contact sports 3-6mths
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28
Q

How do you manage scaphoid delayed union? Type c -

A
  • Defined as INCOMLPETE BONE UNION/ persistent symptoms after 4mths of adequate immobilization
  • If not yet 4mths, continue up to 4mth w cast immobilization
  • at 4-12mths wihtout union, ORIF + BG
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29
Q

How do you manage scaphoid nonunion (type d?)

A
  • Defined as failure of trabeculation across fracture site and sclerosis of bone ends
  • AVN of proximal pole can co-exist w non-union

INVESTIGATION

  • XRAY
    • sclerosis, cysts, flexion deformity (humpback for waist F#), resorption, DISI
  • CT
    • to measure extent of collapse
  • MRI
    • to assess for AVN **** low signal on T1 and T2 images

TREATMENT

  • Goal: restore alignment and unite fracture
  • ORIF with Bone graft
  • Plan dependent on
    • location of non-union
      • proximal -> dorsal approach
      • waist ->volar approach
    • AVN
      • if present, vascularized BG
      • if no AVN, corticocancellous IC bone with wedge (Fisk-Fernandez)
    • presence of SNAC
      • no restoration of scaphoid
      • PRC or 4corner fusion

SUMMARY

  • displaced Waist non-union with humpback deformity=> volar approach, ICBG wedge
  • Proximal pole - dorsal approach:
    • vascularized: ICBG and internal fixation
    • AVN: vascularized BG (1,2ICSRA)
  • AVN + SNAC or fragmentation
    • PRC or Four corner fusion
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30
Q

What are risk factors for scaphoid non-union?

A
  • Delayed diagnosis >4wks
  • inadeqaute immobilization
  • proximal pole fracure
  • waist fracture with displacement >1mm
  • smoker
  • asssociated ligamentous injury
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31
Q

What is the sequalae of unrecognized scaphoid non-union

A

SNAC - scaphoid non-union advanced collapse:

  • radiocarpal arthrosis
  • carpal collapse
  • AVN
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32
Q

What type of Triquetrium fractures occur and how is it treated?

A
  • Body
  • Proximal-radial - LT ligament bony avulsion
  • Dorsal cortical - insertion of DRC and DIC

Tx- immobilization 4-6wks - cant ignore dorsal cortical F#

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33
Q

WHat type of Hamate fractures occur and the treatment

A
  • Body
  • Hook - common in racket/golfers - deep ulnar pain
  • Treatment:
    • excision of hook if non-union and tender
    • immobilize 4-6wks if presenting acutely
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34
Q

What type of capitate fracture can occur and what is treatment

A
  • Scaphocapitate syndrome - fracture of capitate along w scaphoid
  • capitate can rotate 90 or 180 degrees
  • risk of AVN
  • Treatment - ORIF w compression screw
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35
Q

List carpal instbaility patterns and provide an example of each

A
  • Dissociative (CID) = istability wihtin a carpal row due to intrinsic ligament injury (v/d SL, v/d LTq v/d IC)
    • Sl, LTq tear
    • Scaphoid F#
    • Kienbocks
  • Non-dissociative (CIND) = instability between carpal row due to extrinsic ligament injury (volar; RL, RSL, RSC, RU, Utq, UL, UC, dorsal RS, RL, RTq (~DRC), RU)
    • Midcapal instability
  • Complex (CIC) = combination of both intrinsic an dextrinsic ligament injury and instability
    • perilunate dislocation
  • Adaptive (CIA) = injury proximal or distal to carpus causing carpal malalignment
    • distal radius fracture malunion
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36
Q

What are the degrees of instability

A
  • Static = ligament RUPTURE - on static non stress xrays, abnormality visible
    • eg. scaphoid flexed on PA
  • Dynamic = ligament COMPLETE tear - only on stress xrays is abnormality visible
    • eg. SL widening on stressviews
  • Predynamic = ligament PARTIAL tear - normal stress adn resting xrays - clinically tender
37
Q

List directions of instability with respect to the lunate

A
  • DISI - lunate in extended position
    • caused by SL tear, Lunate extends w Tq
  • VISI -lunate in flexed poition
    • caused by LTq tear, lunate flexes w S
  • Ulnar translocation
    • lunate displaced ulnar w/r/t radius
  • Radial translocation
    • lunate displaced radial w/r/t radius
  • Dorsal translocation
    • carpus subluxed dorsally
38
Q

What is the greater and lesser arc force trasnmissions?

A
  • Great er arc: force transmitted hrough ilgaments and bones leading to fracture dislocations
    • eg. transscaphoid perilunate dislocation
  • Lesser arc: force trasnmitted thoguht ST and ligaments only
39
Q

Whow does ulnar variance change with wrist pronation and supination?

A
  • pronation increases ulnar variance
  • supination decreases ulnar variance
  • as seen radiographically
40
Q

Describe your management of SL injury (excluding Tx options)

A
  • Hx: MOI hyperextension injury, tenderness distal to listers tubercle, swelling and pain dorsoradial wrist. worse with ROM. Previous distal radius F#/scaphoid F#/dorsal ganglion, RA. Weak grip
  • PE: tender distal to lister’s tubercle, + Watson’s test, + SL ballotment

Clinical types

  • Predynamic: pain as described above, normal xrays. PARTIAL SL tear
  • Dynamic: pain as bove, SL gap on provocative Xray, normal on routine Xray = COMPLETE Tear BUT secondary stabilizers intact (STT, RSC)
  • Static, Reducible; SL degenerated, failed 2’ stabilizers, scaphoid flexion on xray. Reducible.
  • Static Irreducible: Chronic complete SL tear, DISI deformity
  • SLAC: IRreducible, Degenrative OA

Investigations

  • XRAY: 3views + scaphoid view (ulnar deviation and extension) => look for wide SL gap, DISI, arthristis:
    • increased SL gap (terry thomas sign >3mm)
    • lunate extension
    • Scaphoid flexion (ring sign)
    • CL >15’
    • SL >60’
    • = DISI
  • CT/MRI

Procedures

  • Wrist arthroscopy (GOLD STANDARD) for diagnostic and therapeutic
41
Q

Describe the stages of SLAC wrist

A
  1. Arthritis at radial styloid
  2. Arthritis at radioscaphoid jt
  3. Arthritis at scaphocapitate, lunocapitate (midcarpus)
  4. collapse of capitate

Note: NO arthritic changes to radiolunate

Note: SLAC wrist with radioscaphoid degenerative jt disease and scaphoid erosions is CPPD until proven otherwise???

42
Q

Describe the operative treatment options for SL injury

A

ACUTE SL - PARTIAL - PREDYNAMIC (<3WKS)

  • Arthroscopic debridment, CR + Kwire pins Sc, LTq, SL
  • Immobilize 6-8wks short arm thumb spica cast, then protective splint 4wks, sports 6mth

ACUTE SL- COMPLETE - DYNAMIC (<3WKS)

  • ORIF + Direct SL repair + stabilization of repair (Blatt dorsal capsulodesis or Brunelli tenodesis)
    • Dorsal approach (base of 4th compart) or volar (base of CT)
    • reduce S and L w joystick, Kwire fixation
    • Repair SL with anchors/intraosseous suture
    • Stabilize repair:
      • Capsulodesis: Blatt (proximally based Dcapsular flap inserted into S.tubercle.)
      • Capsulodesis: Mayo (radially based flap from DIC inserted into scaphoid/radius/lunate)
      • Tenodesis: Linscheid ECRB (distally based segment of ECRB weaved through C,S,L,radius)
      • Tenodesis: modified Burnelli FCR (distally anchored FCR passed from tubercle to dorsal scaphoid and secured to SL lig repair

SUBACUTE/CHRONIC - COMPLETE - STATIC REDUCIBLE (>6WKS) **AS LONG AS ITS REDUCIBLE, WKS DONT MATTER

  • Reduction&Association of SL(Herbert screw)+stabilization
  • RASL
    • ​open/arthroscopic, debride articular surfcae b/w S-L
    • Herbert screw S->L to allow for pseudoarthrosis to form
    • Stabilization with Blatt capsulodesis or Brunelli FCR
    • short arm thumb spica cast 6wks

CHRONIC- COMPLETE - STATIC IRREDUCIBLE

  • Partial arthrodesis
    • STT + radial styloidectomy
    • SLC arthrodesis, SC arthrodesis

SLAC WRIST (arthritis at radial styloid, RS, SC/CL, capitate collapse)

  • Salvage procedures
  • Stage 1-2 SLAC (radial styloid, RS arthritis, preserve RC)
    • ​PRC +/- radial styloidectomy
      • Dorsal approach
      • excise S, L, Tq
      • Closure of dorsal capsule
      • Good pain control, ROM, no risk of non-union, conversion to total wrist if required
      • contraindicated if LC OA
    • Scaphoidectomy & 4corner fusion (C, H, Tq, L)
      • excise scaphoid, remove articular surfaces C-L-H-Tq, fix with kwire, BG (IC or scaphoid)
      • ?better longterm outcome
      • indicated when Lcapitate OA identified
    • Total wrist arthroplasty
      • only in RA, not posttraumatic pt
  • Stage 3-4 ( SC or CL arthritis, capitate collapse)
    • ​Total wirst arthrodesis
    • good option for high demand hand
43
Q

Describe your management of L-Tq ligament injury

A
  • Def: Mayfield stage 3 -part of progressive perilunate instbaility=> disruption of L-Tq ligament from capitate hyperextension disrupting strong volar L-Tq ligament=>may lead to CTS with lunate sitting in CT
  • Clinical presentation
    • pain on ulnar wrist, tender directly over LTq deep to EDM
    • hx of FOUSH w rdial deviation/pronation
      • ballotment/shear test
    • +/- CTS
  • Investigations
    • Xrays - VISI deformity (lunate flexes, SL <30)
  • Procedure
    • Wrist arthroscopy - gold standard Dx and Tx
  • Treatment
    • predynamic/dynamic acute/chronic (no VISI on xray)
      • conservative acutely - NSAID, immoblize, steroid
      • Operative - CRIF + stabilization (Kwire fixation SL, LTq, Ligament recon w FCU strip)
    • chronic static (VISI on xray)
      • LTq arthrodesis w 8weeks immobilization
44
Q

What are 3 examples of CIND (non-dissociative)? Due to extrinsic ligaments??

A
  • Radiocarpal CIND
    • madelung deformity
  • Ulnocarpal CIND
  • Midcarpal CIND
45
Q

Describe your management of radiocarpal CIND

A

Caused by Madelung deformity, excessive ulnar head resection, RA

Madelung defomrity - congenital growth disturbance of the volar ulnar aspct of the distal radius

  • resulting palmar radial angulation
  • Xray: tear drop defomrity of radius below lunate, +ulnar variance
  • Tx: USO + wedge osteomtomy of radius w corticocancellous interpositional BG
46
Q

Describe your management of midcarpal instbility (extrinsic ligament disruption )

A

TqHC ligament - critical to pull Tq into extension

  • Clinical presentation
    • female, lax jts
    • pain with ulnar translation
    • catchup clunk
    • Midcarpal shift test
  • Imaging
    • normal xray usually
    • may have VISI deformity
  • Treatment
    • Split, NSAID, activity modified
    • Operative: Capsulodesis, tenodesis for lig recon
47
Q

Classify CIC carpal dislocations = Progressive perilunate Instability (PPI) (5total)

A
  • Dorsal PL dislolcations (lesser arc - ligamentous only)
  • Dorsal PL fracture dislocations (greater-arc)
  • Volar PL dislocations (rare)
  • Axial dislocations
  • Isolated carpal bone dislocation
48
Q

What is your differential for radial and ulnar sided wrist pain?

A
  • radial
    • osseous: sequellae of # (MU/NU) & degenerative arthritis like: scaphoid #/MU/NU/SNAC, Bennett, OA (1st CMC, STT, MCP), AVN (Lunate/Keinbocks, Scaphoid/Preiser’s), radial styloid #
    • ligamentous: SL injury (pre/dynamic/static/slac), UCL,
    • tendinous: tendinitis: deQuervain’s, intersection, FCR
    • vascular: aneurysm, anomalies, ischemia
    • neurogenic: CTS, Wartenberg (entrapments RSN)
    • misc: tumours including ganglion (volar/radial), crps
  • ulnar
    • osseous: sequellae of # (MU/NU) & degenerative arthritis like: OA (PTq, 5th CMC), HoH #/NU, baby-Bennett, ulno-carpal abutment, ulnar styloid
    • ligamentous: LTq injury (pre/dynamic/static/VISI), TFCC tear, DRUJ instability
    • tendinous: tendinitis including ECU (& subluxation), FCU
    • vascular: hypothenar hammer, other anomalie, ischemia
    • neurogenic: entrapment/compression/neuroal dorsal sens br ulnar n, guyon’s canal
    • misc: other space occupying lesion, tumour, crps
49
Q

What are mayfield’s 4 stages of progressive Perilunate Instability (PPI)?

A
  • I - SL lig. disruption + RSC lig. disruption (or scaphoid F#)
  • II - LC dislocation (opening space of poirier)
  • III - LTq lig. disruption (or Tq F#)
  • IV - DRC lig. disruption => volar dislocation of lunate
50
Q

What are clinical features, xray findings and tretament options of a perilunate or lunate dislocation

A

CLINICAL FEATURES

  • Young men, high velocity injuries
  • assocaited CTS (25%)

XRAY findings

  • Lunate has triangular shape, disruption of Gilula line1/2
  • Ass. scaphoid/Tq/distal rad F#
  • Lateral:
    • Spilled tea cup (flexed, volar dislcoation of lunate)
    • Radio-lunate-capitate axis disrupted

TREATMENT

  • STEP 1 - Closed Reduction + immobilization
    • NV examination
    • ​Watson Jones / Tavernier method
      • longitudinal traction 15min w slight WE, then continue long. traction AND apply volar pressure on lunate and gradual flexion of wrist until snap/clunk when capitate relocates over dorsal lip of lunate
    • Immobilize cast 8 wk then splint 4
    • MOST/ALL need lig. repair/ORIF
  • STEP 2 - ORIF + SL/LTq lig repair + stabilization (capsulodesis/tenodesis) + ORIF associated F# +/- CTR +/- volar lig repair
    • ​Dorsal approach at 3rd compartment
    • reduce Lunate, kwire fixation R-L, L- Tq
    • RASL to recon S-L or ORIF w herbert screw if F#
    • Stabilize w blatt capsulodesis/brunelli tenodesis FCR
    • +/- CTR, +/- volar capsule repair
    • immoblize cast 8wks, splint 4wks, kwire total 12wk
51
Q

describe the use of imaging in hand problems

A
  • always XR: 3 views (PA, LAT, OBLIQUE)
    • often scaphoid view: PA w ulnar deviation
    • carpal tunnel view is good for hamate (hook), trapezial ridge, pisiform, but requires hyperextension of wrist so can be difficult in acute injury
  • consider CT if need to clarify # pattern, displacement, sequellae/healing, reduction/subluxation/dislocation
  • consider MRI if need to clarify soft tissue injuries
  • consider arthroscopy to clarify ligamentous injuries & TFCC pathology
52
Q

List and briefly describe the eponymous fractures of the distal radius

A
  • colles - dorsally displaced extra-articular DR # (apex volar)
  • smiths - reverse colles; volarly displaced extra-articular DR # (apex dorsal)
  • bartons - intra-articular DR # with dislocation of the radiocarpal joint, can be dorsal or volar
  • chauffeur - intraarticular radial styloid #
  • die-punch - depressed fracture of lunate fossa of distal radius
53
Q

what are indications for ORIF of distal radius?

A
  • comminuted
  • open
  • loss of height by > 2mm
  • loss of volar tilt of > 10mm (ie to neutral)
  • loss of radial inclination of > 5mm
  • displaced intra articular # step of > 1mm
  • unable to obtain/maintain reduction of DRUJ
54
Q

what are complications to DR #?

A
  • acute:
    • infection, pain, hematoma, compartment syndrome, median nerve compression (CTS), concomitant tendon/nerve injury, radial sensory nerve injury during perc pinning
  • chronic
    • non-union, malunion, chronic pain, CRPS, ulnar abutment syndrome (from loss of radial height / inclination), decreased ROM/stiffness, degenerative radiocarpal / DRUJ arthritis, DRUJ instability, tendinopathies (EPL attrition/ischemia rupture after CR, dorsal or volar attrition ruptures 2’ rubbing on hardware), hardware infection/loosening
55
Q

which scaphoid fractures can have non-operative fractures and which fractures should have ORIF?

A
  • Non-operative
    • non-displaced distal tubercle & scaphoid waist
    • incomplete #
    • low demand pt / high operative risk
  • Operative
    • peri-lunate dislocation/scaphoid #
    • comminuted
    • delayed presentation > 4 wks
    • delayed union @ 4 months
    • displaced waist or distal scaphoid fracture (including flexed position)
    • any proximal pole fracture
    • high demand patient or athlete
56
Q

How do you define a distal radius malunion

A

malunion = bony union in inadeqaute anatomic position

  • ulnar variance >5mm compared to contralat wrist
  • radial inclination <15’ (normal 22)
  • Outside of 15’ Volar tilt 15’ - 20’dorsal tilt 20’ (normal palmar tilt 11’)
57
Q

What are indications for surgical treatment of a distal radius malunion

A
  • Dorsal angulation >20’
  • volar angulation >15’
  • ulnar variance >5mm compared to contralat side
  • DRUJ incongruity
  • pain in RC, MC, distal RU joint
  • intraarticular incongruity >1-2mm
58
Q

What are treatment options for distal radius malunion

A

EXTRA-ARTICULAR

DORSAL ANGULATION

  • opening wedge dorsal radius osteotomy

VOLAR ANGUALTION

  • opening wedge dorsal radius osteotomy

+ DRUJ INTRA-ARTICULAR INCONGRUITY

  • Young pt => Sauve-Kapandji (DRUJ fusion w proximal ulna pseudoarthrosis
  • resection arthroplasty
  • Old pt => Darrach, Bowers hemiresection arthroplasty

+ DRUJ EXTRA-ARTICULAR INCONGRUITY

  • USO /wafer procedure

INTRAARTICULAR

  • RSL arthrodesis
59
Q

What is the etiology, clinical features, and epidemiology of kienbocks disease?

A

AVN lunate

Etiology

  • unclear
  • decrease perfusion
  • abnormal lunate shape
  • altered biomechanical forces (- ulnar variance)
  • repetitive trauma

Epidemiology

  • M:F 2:1, 20-40s

Clinical features

  • dorsal wrist pain, over lunate (distal to listers, base of D3 w wrist inflexion)
  • decreased ROM
60
Q

HOw is kienbocks dx made?

A

Imaging

  • Xray: Lunate may appear normal or show signs of
    • hyperdensity (sclerosis)
    • fragmentation
    • fratures
    • collapse
    • proximal migration of capitate
  • MRI
    • decreased signal - low signal T1 and T2
61
Q

How is kiebocks disease classified ?

A

Lichtman classification

STAGE 0

  • XRAY normal
  • MRI lunate density abnormality

STAGE 1

  • XRAY Linear/compression F#
  • MRI lunate low T1/2 signal

STAGE 2

  • XRAY lunate sclerosis

STAGE 3 A

  • XRAY lunate collapse, NO scaphoid rotation deformity

STAGE 3 B

  • XRAY lunate collapse
    • + SCAPHOID FLEXED
    • Capitate proximal migration
    • decreased carpal height

STAGE 3 C

  • Lateral XRAY lunate F#

STAGE 4

  • XRAY lunate collapse + perilunate degenerative change
62
Q

What are considerations for treatment of Kienbocks disease and what treatment options are offered according to LIchtman stage?

A

Considerations

  • Stage
  • Ulnar variance
  • presence of arthritis
  • age and fxnal level

TREATMENT ACORDING TO LICHTMAN STAGES

STAGE 0-1 = MRI signal changes, +/- xray lunate linear f#

  • immobilization 12weeks (to reduce synoviitis and work load on lunate+/- arthroscopy

STAGE 2-3A = Lunate sclerosis->collapse, no scaphoid flex

  • immobilization 12weeks +/- arthroscopy
  • RSO (if ulnar var -) or radial wedge osteotomy (if ulna neutral)
  • Others rare: vascularized BG, temporary SCor STT pin

STAGE 3B = lunate collapse, scaphoid flexion

  • SC or STT arthrodesis +/- lunate excision
  • RSO
  • Vascularized BG

STAGE 3C = Lunate FRacture

  • PRC

STAGE 4 = lunate collapse w perilunate degenrative change

  • PRC
  • wrist fusion
  • wrist denervation
63
Q

Describe the operative interventions for kienbock disease

A
  • RSO
    • designed to offload lunate
    • 2mm shortening
    • indications: ulnar -variance/neutral, Lunocapitate preservation. Stage 2-3A
  • Radial wedge
    • designed to reduce radial inclination to offload lunate
    • indications: ulnar neutral, +, -, stage 2-3A
  • Vascularized bone graft
    • promotes primary bone healing
    • Extensor compartmental artery 4,5 (ECA45)
    • intercompartmental supraretinacular artery (ICSRA23)
    • indicated for 2, 3A, 3b (lunate sclerosis or collapse but not fracture (3c)
  • PRC
    • useful is stage 3b/c and ulnar neutral
64
Q

How do you manage TFCC injury?

A

Clinical features

  • ulnar sided wrist pain
    • DRUJ instability, ulnocarpal stress +

Investigations

  • XRAY- ulnocarpal abutment, Ulnar + var
  • MRI - central perforations
  • CT - DRUJ instability
  • BEST in wrist arthroscopy

On Arthroscopy

  • small central TFCC tear - immobilize
  • large central TFCC tear - debride
  • peripheral TFCC tear - immobilize
  • large TFCC tear and normal DRUJ -> debride + USO
  • large TFCC tear and degenerative DRUJ -> Deridement and Bowers
65
Q

which scaphoid fractures are approached dorsally? which scaphoid fractures are approached volarly?

A
  • dorsal: proximal pole fractures (from proximal pole to waist), pattern w/ concommitant SL injury
  • volar: waist fractures, distal pole fractures, humpback deformity
66
Q

what imaging modalities are used to investigate a patient for ? scaphoid #?

A
  • initial imaging modality: XR: 3 standard views + scaphoid view (PA w ulnar deviation and slight wrist extension)
  • at 2 wks after TS splint, repeat XR - if still negative then:
    • CT scan - if still negative then consider MRI to r/o SL injury; consider arthroscopy to rule out acute SL injury
  • if XR reveals #, but there is a gap, displacement, flexion deformity/DISI, then do a CT scan to characterize the fracture anatomy - guides treamtent to non-operative vs. operative
67
Q

what are the union rates by locatio of fracture for non-displaced scaphoid # when managed appropriately with early immobilization?

A
  • distal tubercle: 90-95%
  • waist: varies 80 - 90%
  • proximal pole: <60%
68
Q

which scaphoid fractures / fracture sequellae require bone graft?

A
  • comminuted - cancellous vs. corticocancellous bone graft
  • non-union, no resorption - cancellous
  • non-union, resportion, proximal extent vascularized - corticocancellous
  • malunion, humpback deformity - tricortical corticocancellous bone graft (standard from iliac crest)
  • non-union, resportion, proximal extent avascular - vascuarlized bone graft - pedicled 1,2 intercompartmental supraretinacular artery vs. free femoral condyle osseous flap
69
Q

discuss the protocol for an initially XR negative, subsequently XR positive non-displaced scaphoid waist #

A
  • initially thumb spika splint x 2 wks, forearm only, reassess at 2 wks clinically and w XR
    • (if XR normal at 2 wks but still clinically tender, then consider 2 wks cast and reassess, CT scan, consider SL pathology & MRI)
  • at 2 wks w/ positive XR of non-displaced stable scaphoid waist #, then TS cast x 6 more weeks, reassess every 4 wks
  • at 6-8 weeks, if patient still tender and XR still positive (or any signs of cyst, resorption, sclerosis) then take CT scan and strongly consider ORIF at this stage for presumed low potential to heal
  • would be within acceptable standards to cast for up to 3 months prior to moving onto ORIF for delayed/non-union
70
Q

why does the humpback deformity occur in scaphoid fracture - acute or in context of malunion?

A
  • a fracture of the scaphoid waist distal to the majority of the dorsal SL ligament can interrupt the influence of the SL ligament to the distal aspect of the bone
  • therefore the proximal aspect acts physio-anatomically, moving with the lunate and triquetrum and eventually maintains and extended or “upright” posture, whereas the distal portion of the scaphoid is no longer acted on by the stronger dorsal SL ligament, and is allowed to fall into the fixed posture

SHORT ANSWER:

  • bc the # is distal to the action of the stronger dorsal SL ligament, so the proximal scaphoid follows the position of the lunate, triquetrum whereas the distal portion falls into flexion unimpeded by ligamentous supports
71
Q

describe ORIF for scaphoid waist displaced fracture using the volar approach

A
  • volar approach is common for waist # (dorsal is possible)
  • landmark the FCR & scaphoid tubercle and palpate the radial artery prior to insufflation of tourniquet
  • mark hockey stick incision along FCR 2cm proximal to wrist crease then obliquely distally to base of thumb
  • incise skin and FCR sheath; retract FCR ulnarly and protect/retract radial artery radially
  • divide a superficial radial arterby branch if present
  • identify the wrist capsule, divide with a longitudinal or ulnarly based flap
  • expose the scaphoid, identify fracture, debride hematoma
  • reduce fracture using clamp, bone reduction forceps or 2 K-wire joysticks
  • place guide wire down central part of scaphoid (aim 45’ dorsal, 45’ medial/ulnar) from distal to proximal
  • image to confirm placement, measure screw length by subtraction of guidewire from k-wire - 2mm (for cartilage caps)
  • drill/ream over guidewire
  • tap if not using self-taping screws
  • insert headless compression screw (self-tapping if possible)
  • confirm using fluoroscan
  • close capsule & skin
  • immobilize in TS splint until 1st FU (1 wk)
  • protected range in splint x 3-4 wks; full activities at 3-4 months
    *
72
Q

describe dorsal approach for ORIF of scaphoid proximal pole non-union with avascular necrosis

A
  • use CT or MRI to accurately identify fracture anatomy and non-union and avascular necrosis of proximal pole
  • arm table and non-sterile tourniquet
  • dorsal approach - distal incision is 3-4cm distal to lister’s tubercle; proximal 4cm component S-shaped to come more radially between 1st adn 2nd compartments
  • make incision, distally identify dorsal capsule between EPL and second compartment, more proximally between 4th and 2nd compartments
  • make longitudinal or inverted T incision in capsule and elevate capsule, but maintain dorsal scapular blood supply at waist
  • flex wrist to ID # and debride #, non-union
  • debride avascular bone within the cartilaginous cap
  • now move to harvesting VBG - incise proximally between 1st and 2nd compartments, see the 1,2 intercompartmental supraretinacular artery just proximal to radiocarpal joint
  • incise the periosteum around the 1,2 ICSRA (pedicle within/on this periosteum)
  • use drill and osteotome to harvest small square of bone, and elevate w distal peristeal sleeve of pedicle
  • turn the VBG under the 2nd compartment tendons & inset into defect
  • hold reduction using bone reduction clamps
  • drive guidewire from proximal to distal
  • confirm placement w fluoroscan
  • measure screw length
  • ream with cannulated drill
  • use self-tapping headless compression screw
  • pack donor site w bone substitute if available
  • close capsule, skin
  • immobilize in TS x 3 wks then start aROM
73
Q

what is the long-term sequallae of scaphoid non-union?

A
  • scaphoid non-union advanced collapse
  • a pathological state where the non-union progresses to scaphoid flexion deformity, carpal collapse, +/- avascular necrosis of scaphoid, varying degrees of radiocarpal and intercarpal degenerative arthritis
74
Q

how would you classify scaphoid non-union advanced collapse to guide treatment? how would you approach treatment to SNAC wrist?

A
  • i would classify based on extent of radiocarpal and intercarpal arthritis, and use this classification to guide treatment options
  • stage 1: arthritis isolated to radial styloid
    • distal scaphoid excision and radial styloidectomy
  • stage 2: radial styloid and radioscaphoid arthritis
    • options: preferred: scaphoidectomy, radial styloidectomy, proximal row carpectomy
    • alternative: scaphoidectomy, radial styloidectomy, 4-corner fusion
    • how do you choose between the 2 operations: I choose PRC in this situation because it is easy, it is a motion-preserving operation, avoids risk of non-union of arthrodesis, avoids long duration immobilization
    • would choose 4-corner if young, heavy labourer, or at risk for ulnar translation of carpus (concomittant inflammatory arthritis)
  • Stage 3: radial styloid and radioscaphoid scaphocapitate +/- capitolunate arthritis
    • options: preferred scaphoidectomy, radial styloidectomy, 4-corner fusion - preserves some motion and strength vs. total wrist arthrodesis
    • alternative: total wrist arthrodesis
  • Stage 4: pan-carpal arthritis, including at radio-lunate interface
    • primary option is total wrist arthrodesis (arthroplasty is an option, but I would not recommend this as I have little experience w this operation)
75
Q

what type of stability pattern is SL injury?

A
  • CID - carpal instability dissociative - ie between carpal bones of same row
76
Q

Describe history and physical exam findings for pt w acute, complete SL tear

A
  • History
    • radial sided wirst pain, aggravated by use, occassional snapping w movement, c/o weak grip, limited motion
    • mechanism like FOOSH or hyperextension injury (or s/p ganglion excision, scaphoid or DR #, RA, wrist infection)
  • Physical
    • dorsoradial swelling, weak grip strenth, limited ROM 2’ pain (esp radial deviation and extension)
    • tender proximal pole (dorsal), distal tubercle (volar), waist (snuffbox)
    • +ve Watson shift test
    • +ve SL ballottment test
77
Q

how is SL injury classified clinically? How does this correspond to findings on XR?

A
  • Pre-dynamic
    • often acute, partial vs. complete injury
    • by definition, normal XR - +ve findnigs seen on arthroscopy
    • occassionally with complete tear, a gap can manifest acutely however this does not reflect static and secondary changes
  • Dynamic
    • often acute or subacute complete SL injury; 2’ stabilizers intact
    • resting XR are normal, but stress (clenched fist) XR demonstrate a gap on injured side when compared to C/L side
  • Static, reducible
    • chronic changes of flexed posture of scaphoid, reflect alteration to secondary stabilizers, but would find that SL can be anatomically reduced
      • resting XR: terry thomas sign (gap > 3mm), signet ring (or cortical ring) sign: double ring indicating flexed posture of scaphoid, increased SL angle
  • Static irreducible
    • chronic changes of flexed posture of scaphoid with secondary alteration to proximal row biomechanics of dorsal extension of lunate (disi)
    • resting XR as above plus DISI deformity (increased SL angle, increase CL angle, extended posture of lunate)
  • Scapho-lunate advanced collapse
    • chronic degenerative changes to articular surfaces secondary to chronic changes in biomechanics
78
Q

how is SLAC wrist classified? How does the classification ifluence treatment decisions?

A

§ Stage I: arthritic changes at radial styloid

§ Stage II: arthritic changes at radioscaphoid joint

  • stages I/II - PRC vs. scaphoidectomy & 4-corner fusion (vs. rarely arthroplasty)

§ Stage III: progression to midcarpal OA (capitolunate and scaphocapitate)

§ Stage IV: collapse of capitate secondary to midcarpal arthritis; + radiocarpal arthritis

  • stages III/IV: capitate not preserved, therefore total wrist fusion
79
Q

what is your management of suspected acute SL injury?

A
  • History (often mis-diagnosed as wrist sprain; radial sided wrist pain & swelling)
  • Physical (may or may not have +ve Watson shift test)
  • Imaging: will likely have normal XR
  • MRI: may identify SL injury
  • Arthroscopy - allows for definitive diagnosis (and treatment)
  • Treatment
    • on arthroscopy, partial injury, then debride, reduce (can use k-wire to joy-stick reduction) and immobilize with intercarpal k-wire (SL, SC, LT) + splint immobilization x 4-6 wks
    • if complete injury seen, no OA, ligament is INTACT, then consider a direct repair following a combined arthroscopic (diagnosis, debridement, faciliate reduction) and open (dorsal longitudinal incision distal to lister’s tubercle, enter capsule via longitudinal incision or via developing a proximally based capsular flap)
    • direct repair avulsed SL to scaphoid w suture anchor
    • consider augmenting repair w proximally based dorsal capsular flap to scaphoid - Blatt capsulodesis
    • immobilize repair using percutaneous k-wire
    • immobilize w/ splint
80
Q

what are the treatment options available for dynamic and static SL injury without evidence of intercarpal or radiocarpal arthritis?

A
  • DYNAMIC
    • Capsulodesis: Blatt (proximally based dorsal capsule flap), Mayo (partial DIC ligament to lunate, distal radius)
    • Tenodesis: Modified Brunelli (total/partial FCR through scaphoid tubercle, to SL/lunate) vs. ECRB/Linsheid (through scaphoid, capitate, lunate)
    • some add RASL to this group
  • Static reducible
    • RASL (open vs. arthroscopic reduction association scapholunate) - debride articulation, reduce, apply herbert/headless compression screw, create pseudarthrosis
    • consider augmenting w capsulodesis
    • consider capsulodesis vs tenodesis alone
  • Static irreducible
    • limited intercarpal fusion (usually STT, occassionally SLC)
      *
81
Q

for SLAC wrist with preserved capitolunate joint, how do you decide between available surgical procedures?

A
  • stage i/ii SLAC wrist have preserved luno-capitate joint
  • options are PRC vs. scaphoidectomy + 4-corner fusion (SLAC wrist procedure)
  • PRC advantages: better preservation ROM, lower risk bc no risk for non-union, less immobilization, easy procedure, easily converted to total wrist fusion
  • PRC disadvantages: nearly all progress to radiographic +/- clinical radiocapitate arthritis (new radiocarpal articulation) and may require total wrist fusion
  • Best indications: older patients, lower demand
  • vs. scaphoidectomy + 4-corner fusion advantages: radiolunate joint is nearly always preserved, has longer-term pain-free result
  • disadvantages: less ROM than PRC, more difficult to convert to total wrist fusion later, more technically challenging operation, risk of non-union, immobilization
  • Best indications: younger patient, more high-demand activities
82
Q

how do you diagnose LTq ligament injury?

A
  • History: ulnar sided wrist pain
  • Physical: pain over LTq; may find LTq ballottment test / shear test positive
  • XR: normal; may find abn gilula’s lines; may find gap (uncommon); +ve on stress view
  • arthroscopy becomes gold standard
83
Q

what are treatment options for LTq ligament injury?

A
  • start non-operative
    • activity modification
    • short course splint immobilization
    • corticosteroids
    • non-op can fail bc there is still ulnar sided carpal motion (ie @ LTq) w pronosupionation, would require above elbow cast for full immobilization
  • operative
    • dynamic, subacute, reducible (no VISI)
      • LTq reconstruction using slip of ECU, passed via drill hole btwn L and Tq (Mayo)
      • LTq arthrodesis
    • Chronic instability (VISI seen)
      • controversy regarding ideal treatment option, not well studied
      • LTq arthrodesis will not correct visi
      • LTq + TH +/- LR limited arthrodesis; USO if symptoms of abutment
84
Q

what is the pathomechanics of symptoms in mid-carpal instability?

A
  • intra- and inter carpal row STT, THC, SC ligament laxity
  • laxity causes late extension of proximal carpal row until wrist is in extreme ulnar deviation - late (and not smooth) flexion to extension motion causes pain & clunk during extreme ulnar deviation; also prevents appropriate extension of proximal carpal row during loading, leading to a dynamic or static visi deformity
85
Q

what is a treatment approach to mid-carpal instability?

A
  • manh patients respond well to non-operative treatment
    • activity modification
    • short course splint immobilization
    • exercises to strengthen ulnar wrist stabilizers including FCU and ECU to become 2’ stabilizers
  • operative
    • 1st choice is capsulodesis / capsule plication
    • consider tenodesis
    • consider limited carpal arthrodesis or 4-corner fusion
86
Q

discuss your management of perilunate dislocation, with actual dislocation of lunate

A
  • ATLS/ABCs first; as injury often occurs during high-velocity injury and there are concomitant injuries
  • History & Physical: evaluate and document concomitant CTS
  • Closed reduction of lunate in emerg
    • local (or regional) block w IV sedation
    • wrist traction in slight extension x 10-15 mins, then apply dorsal pressure on volar surface at lunate, while bringing wrist into flexion - clunk is reduction of capitate over dorsal lip of lunate
  • Post-reduction films indicate adequate reduction and CTS symptoms temporarily resolve
  • Urgent trip to OR for open reduction, internal fixation, direct ligament repair +/- CTR
    • dorsal approach through 3rd compartment (or btwn 3rd and 4th), volarly based capsular flap to enter joint, k-wire to joystick lunate reduction, fixation of reduction w k-wire between SL, SC, LT (some ppl will use headless compression screw/rasl at SL here), direct ligament repair (suture anchor to scaphoid [SL] and triquetrum [LT]) +/- Blatt capsulodesis
    • Consider volar approach if unable to reduce lunate or ongoing symptoms of median nerve compression after reduction, carpal tunnel release and to repair volar extrinsic ligaments
  • Immobilization in splint then case x 8 wks, then splint and protected ROM x 4 wks
87
Q

define keinbock’s disease

what is the etiology of keinbock’s disease

A
  • avn of lunate, spontaneous, usually M>F, c/o central wrist pain, decr ROM, occas + Watson
  • abn vasc anatomy
    • single vascular pedicle with little intraosseous branching in ~ 20%
    • increased intraosseous pressure and venous congestion
  • combination of abnormal lunate geometry (smaller, greater axial loading w ulnar + variance) plus repetitive trauma (micro/macro #, ligament disruption)
88
Q

what is classification of Keinbock disease

how does this inform treatment?

A
  • Lichtman classification
  • stage 1: XR N; MRI edema
    • treatment is conservative: 3 wks immobilization in neutral position; consider elective RSO if ulnar negative variance
  • stage 2: Lunate sclerosis, fracture +/- fragmentation present, but no lunate collapse
  • stage 3a: Lunate sclerosis, fracture +/- fragmentation present, but +ve lunate collapse
    • treatment for stage 2/3a similar:
    • to decrease axial load use joint leveling procedures
      • if ulnar -ve variance - RSO
      • if ulnar +ve or neutral variance - capitate shortening or CH fusion
    • revascularization using VBG
      • debride avascular lunate but maintain available articular surfaces
      • use 1,2 or 4,5 ICSRA pedicle VBG or pedicle pisiform VBG
      • can combine w load reduction strategies, immobilize STT/SC temporarilty to permit revascularization
  • stage 3b: Lunate sclerosis, fracture +/- fragmentation present, +ve lunate collapse, +ve carpal collapse
    • STT/SC fusion +/- excision of lunate
    • still consider above arthrodesis w maintain lunate w revascularization proceudre
    • consider PRC
  • stage 4: radiocarpal and midcarpal arthritism
    • PRC vs. total wrist fusion (if gross RL OA)
89
Q
A

injured hand and fractures (21 decks)

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