Carpal rows injuries!

Transcription

1 Carpal rows injuries! Michael Papaloïzos! Center for Hand Surgery and Therapy Geneva, Switzerland

2 no conflict of interest to declare

3 Fractures of carpal bones! The fractured scaphoid! Fracture-dislocations of the wrist! Scapholunate injuries!

4 Fractures of carpal bones scaphoid 90% other carpal bones 10% Triquetrum Hamatum Trapezium Lunatum Capitatum Pisiforme Trapezoid fracture-dislocations rares

5 Fractures of carpal bones A positive ulna variance increased the frequency of ulnar-sided lesions (triquetrum, hamatum)

6 Fractures of carpal bones CLASSIFICATION Body or apophysis Intra- vs. extra-articular Avulsion «chip fracture» Displaced / undisplaced Associated lesions

7 Fractures of carpal bones DIAGNOSIS Symptoms may be very light > high suspicion level Functional impairement varies Meticulous palpation mandatory

8 Fractures of carpal bones IMAGING Standard wrist x-rays Specific views according to clinics CT scan for bones MRI more sensitive for soft tissues lesions

9 Triquetrum fractures most often dorsal avulsion fracture! body fractures usually require MRI or scan to be diagnosed

10 Triquetrum fractures TREATMENT! Conservative in most instances wrist cast 4 to 6 weeks Screw or K-wire fixation for large dorsal fragments in athletes

11 Triquetrum fractures TREATMENT! Conservative in most instances wrist cast 4 to 6 weeks Screw or K-wire fixation for large dorsal fragments in athletes

12 Hamatum fractures Mainly processus hamati «Contusion-like symptoms» Ø Late diagnosis usual Ø Elective pain on hamulus Ø Pain on ulnar deviation + resisted flexion on tendons D4-D5 is typical

13 Hamatum fractures TREATMENT! Conservative Percutaneous screw fixation Hamulus resection

14 Other carpal fractures Trapezium ± 2% Lunatum 1-2% Capitatum 1% Pisiform/trapezoid <1% Difficult diagnosis, frequently associated or combined lesions

15 Fractures of carpal bones The fractured scaphoid fracture nonunion SNAC

16 The fractured scaphoid 90% of carpal bones fractures circa 2000 new cases/year in Switzerland most frequent in young adults 90% are men malunion or nonunion when untreated

17 The fractured scaphoid CLASSIFICATION! Level distal third middle third proximal Fracture orientation transverse horizontal oblique vertical oblique

18 The fractured scaphoid CLASSIFICATION! undisplaced (A) stability displaced (B) nonunions (C, D)

19 The fractured scaphoid DIAGNOSIS! clinically suspected fracture visible on x-rays NO MRI (short protocol) YES

20 The fractured scaphoid TREATMENT! a)..is necessary b)..until union is obtained. c) conservative or operative?

21 The fractured scaphoid INDICATIONS for TREATMENT! Every fractured scaphoid can be fixed operatively.... the surgeon s role is to help the patient making the optimal decision.

22 The fractured scaphoid GUIDELINES! Elderly, not much active or demanding patient OR for Undisplaced distal fractures (tubercle) Ø Forearm cast 4-6 weeks Young or active patient Undisplaced middle third fractures Ø Mini-access fixation or forearm cast (until union) Young or active patient Displaced middle third or proximal pole fractures Ø Operative treatment (open or mini-access)

23 The fractured scaphoid Mini-access TECHNIQUE! 2 1 3

24 The fractured scaphoid Mini-access TECHNIQUE! 10 mm skin incision «to the bone» by blunt dissection locate the ST joint KW: 45 to front and side axes

25 The fractured scaphoid Mini-access TECHNIQUE! Check the KW position Insert the screw while checking progression under fluoroscopy

26 The fractured scaphoid Mini-access TECHNIQUE! Beware of Fracture line / screw direction Screw position Screw length Thread beyond the fracture line

27 The fractured scaphoid Mini-access TECHNIQUE! Remember all scaphoids are not the same both in size and shape

28 The fractured scaphoid SIZE VARIATIONS! Mean length (mm) author year women men all Viegas et al Patterson et al ± ± ± 3 Ceri et al ± 2 Heinzelmann et al ± ± ± 2 Guo and Tian ± ± 2 28 ± 2 ALL 27.4 ± 2 29 ± ± 2

29 The fractured scaphoid MORPHOTYPES! Shape varies 3 types: A. Equal pole sizes Compson et al, JHSb, 1994 A B C B. Undersized proximal pole C. Undersized distal pole 58% 19% 23%

30 The fractured scaphoid Mini-access TECHNIQUE! n good technique > good results > few complications n not easy but reliable once mastered n Critical attention at each step warranted

31 Scaphoid nonunion RISK factors! extrinsic Ø late diagnosis late treatment Ø inappropriate treatment /follow-up intrinsic Ø displacement >1mm Ø associated ligament injury (dislocations) Ø compromised vascular supply

32 Scaphoid nonunion BASIC RULE! By definition, bone pieces must be a) vascularized b) in stable contact in order to achieve bony union.

33 Scaphoid nonunion CLASSIFICATION (treatment oriented)! 1 simple nonunion 2 unstable nonunion or malunion no shortening little sclerosis middle third vascular supply ok bone shortening flexion deformity SL angle > 70 3 avascular nonunion (proximal pole) å vascular supply bone fragmentation 4 late nonunion Limited degenerative changes à SNAC wrist

34 Scaphoid nonunion TREATMENT! 1 simple nonunion Ø Stabilize + insure viability Ø Compression screw + bone marrow autograft

35 Scaphoid nonunion TREATMENT! 2 unstable nonunion or malunion Ø Correct deformity and length Ø Cortico-spongious autograft Ø Stabilize

36 Scaphoid nonunion TREATMENT! 3 avascular nonunion (proximal pole) Ø preserve the pole if possible Ø bone marrow autograft (radius or iliac) Ø anterograde stabilization Ø small screws

37 Scaphoid nonunion TREATMENT! 3 avascular nonunion (proximal pole) Alternative 1 Ø pedicled vascularized graft Ø requires adequate fixation as well

38 Scaphoid nonunion TREATMENT! 3 avascular nonunion (non viable, fragmented pole) Alternative 2 Ø proximal pole resection Ø pyrocarbone implant

39 Scaphoid nonunion TREATMENT! 4 late nonunion with arthritis «save what can be saved» Limited arthritis Ø bone graft as required Ø stabilization Ø radial styloidectomy Scaphoid Nonunion Advanced Collapse Ø Four corner fusion Ø Total wrist fusion Ø Wrist denervation

40 Scaphoid nonunion to conclude! challenging but not desperate issue! equivalent to scapholunate dissociation same evolution! treatment oriented classification! keypoints: insure both biologically active tissue and stability! fragmented pole: resect and replace!

41 Fracture-dislocations highly variable injuries! è adapt strategies and repair all damaged structures

42 Perilunate dislocation Axial traction Lunate in place Anchors in 1st row

43 Perilunate dislocation Sutures through the dorsal capsule Dorsal flap in place Completed repair

44 Fracture-dislocations Know the problem - much hardware usually not required to solve it.

45 Scapholunate injuries fibrocartilaginous membrane dorsal ligament (stronger) volar ligament (weaker)

46 Scapholunate injuries Spectrum of lesions

47 Scapholunate injuries Two clinical presentations 1 Young men (20-30 years) Single high energy trauma Acute injury Frequently associated injuries (distal radius, LT) 2 Older men (40-50 years) Repeated injuries at low energies (manual workers) Chronic injury, late presentation, pain on load Isolated injury ± arthritis

48 Scapholunate injuries scaphoid shift test

49 Scapholunate injuries Typical radiographic signs! dorsal tilt Ring sign SL gap

50 Scapholunate injuries Lunate relocation!

51 Scapholunate injuries SL reconstruction (or repair)!

52 TAKE HOME MESSAGE! Know the problem Repair or reconstruct according to treatmentoriented injury grades and patients needs Save what can be saved Follow-up until healing Be calm Smile

53 thanks.