Carpal dislocation and instability pattern腕關(guān)節(jié)不穩(wěn)及腕關(guān)節(jié)脫位課件

CarpaldislocationandinstabilitypatternoverviewTheboneandligamentofthewristformacomplexmechanismInjuryresultinlossoffunctionandinstabilityAnatomyandkinematicsofwristGeneralconcept

RowtheoryProximalrow(scaphoid,lunate,triquetrum)Distalrow(trapezium,trapezoid,capitate,hamate)intrinsicandextrinsicligamentFormmidcarpaljoint50~60%oftotalwristmotionScaphoidlinktworow,integratingmotionandstabilityDorsal:ZshapeGeneralconcepts

kinematicsRadiocarpalandmidcarpaljoint:3planesmovementProximalrow:flexwithradialdeviationextendwithulnardeviationImpairedincertaininstabilitypatternPatternsofinjury1.Progressiveperilunardisruption2.Lesserarcandgreaterarcpatterns3.AxialdisruptionpatternsProgressiveperilunardisruptionFourstagesofsequentialligamentousfailureStageI,scapholunateligamenttear(scapholunatedissociation)StageII,capitolunateligamenttearStageIII,lunotriquetralligamenttear(perilunatedislocation)StageIV,dorsalradiolunateligamenttear(lunatedislocation)PerilunateinjuryresultinlunatedislocationStageIVStageIIILesserarcandgreaterarcpatternsPerilunarinjuryinvolveligament,carpalfractureorbothLesserarcpattern:pureligamentousinjuryGreatarcpattern:carpalfractureCombinationoftwopatternMostcommon:transcaphoidperilunatefracture-dislocationPatternsofinstability1.Dorsalandvolarinstabilitypatterns2.Dissociativeandnon-dissociativeandcomplexandadaptiveinstabilitypatterns3.StaticanddynamicinstabilitypatternsDorsalandvolarinstabilitypatternsDorsalintercalatedsegmentalinstability(DISI)Scaphoidfxorscapholunateligamenttear→scaphoidandlunatedisconnected→lunaterotatedorsally,scaphoidrotateintoflexionRotatorysubluxationofthescaphoid

Dorsalintercalatedsegmentalinstability(DISI)

Lateralview:Increasedscapholunateangle>60degree(normal30o~60o)Increasedcapitolunateangle(normal15o)andradiolunateangle(normal15o)PAview:widenofscapholunateinterval>3mmCorticalringsignVolarsideDissociativeandnon-dissociativeandcomplexandadaptiveinstabilitypatternsCarpalinstabilitydissociative(CID):intrinsicligamentdisruptioninthesamerowExample:scapholunateligamenttear→scapholunatedissociationCarpalinstabilitycomplex(CIC)Combinationofbothdissociativeandnon-dissociationandalltypeofperilunatedislocationCarpalinstabilityadaptive(CIA)AdaptiveresponsetosomepriormalalignmentExp:distalradiusfxmal-united→dorsalarticulartilt→midcarpalinstabilityEvaluationAcuteinjury:history,PE,r/oneurovascularorcompartmentsyndromeofhand,x-ray,stressviewforoccultinjuryChronicinjury:needadditionalstudyArthrogram:tripleinjectiontechnique,onlyforintrinsicligament,missedextrinsicligament,70%ofasymptomatichasabnormality

EvaluationchronicinjuryMRICineradiographyandfluoroscope:fordynamicinstabilityWristarthroscopy:comprehensiveanddirectionevaluationandtreatment,articularwear,chondralfx,synovialhypertrophyEvaluation-specialtestsWatsontest:scapholunatedissociationPressonvolarscaphoidtubercleduringradiaandulnardeviation→palpableclunkorpainBallottementorshucktest:lunotriquetraldissociationtriquetrumandlunateshiftedvolaranddorsally→instabilityorpainTestbothwrist

LesserarcinjuryPureligament,intrinsicorextrinsic1.Scapholunatedissociation2.lunotriquetraldissociation3.perilunatedissociationScapholunatedissociationMostcommoncarpalinjury:TearscapholunateinterosseousligamentEarlyDxandTx:preventDISIorcollapseAcutetreatment:ORIFwithligamentrepair3rdand4thdorsalcompartmentapproachPressscaphoid(volar),K-wirederotatePinspassfromschaphoidintolunateandcapitateLigamentrepairedtobone(sutureanchorsordrillhole)Ifinsufficientligamentusecapsule(Blattcapsulodesis)Post-OP:periodofimmobilization,pinsremoveafter8~12wks

Chronic(>8weeksold)withoutarthrosistreatment:OPwithsofttissueprocedureorlimitedarthrodesisReductionscaphoidLigamentrepairedwithcapsularaugmentationK-wirefor8~12weeksIfsofttissueinsufficientorirreducibility→limitedarthrodesisScaphotrapezial-trapezoidfusionScapholunatefusionScaphocapitatefusionScapholunateadvancedcollapse(SLAC)witharthrosistreatment:salvageprocedureScphoidexcisionmidcarpal(fourcorner)fusionProximalrowcarpectomyWristarthroplastyCompletewristfusionLunotriquetraldissociationLunotriquetralligamenttear,rareStageI,withoutmidcarpal(VISI):splint,NSAID,localinjectionStageII,withdynamicVISIStageIII,withstaticVISIcollapseTreatmentofStageII,IIIcontroversial:softtissuereconstruction,limitedarthrodesisPerilunatedislocationPerilunateinjurystagingI~IVStageIIIperilunatedislocation,stageIVlunatedislocationaretreatedasoneDorsalperilunateandvolarlunatedislocation(mostcommon)VolarperilunateanddorsallunatedislocationDorsalperilunateandvolarlunatedislocation:Treatment:emergentclosedreductionandsplintingfollowbyORIF.Combinedvolaranddorsalapproach.Volarapproach:throughcarpalcanal,reducedlunate,volarcapsuleandligamentrepaired.K-pinforrestoredalignmentofboneLunatemayinitsfossa(stageIII)orincarpalcanal(stageIV)

LigamentrepairedandaugmentedwithcapsulePinsremainedforatleast8weeksROMmaynotreach50%ofnormalVolarperilunateanddorsallunatedislocationLesscommonTreatmentasaboveGreaterarcinjuryTransscaphoidperilunatefracture-dislocation(mostcommon)TransradialstyloidperilunatefractureScaphocapitatesyndromeTranstriquetralperilunatefracturedislocationTransscaphoidperilunatefracture-dislocation(mostcommon)EmergentclosedreductionandsplintfollowedbyORIFVolarapproach,fixedscaphoidwithscreworK-pins,attentionalignmentIfVISI,adddorsalapproachVolardislocationrequiredtwoapproachComplicationnonunionandAVNofscaphoid

Transradialst