LUNATE

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LUNATE
AP and lateral radiograph of a transscaphoid
perilunate dislocation.
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The lunate is facing directly volar and is
located in the carpal canal.
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LUNATE
CAPITATE
After attempt at closed reduction in the
emergency room, the patients lunate was
repositioned against the distal radius, however
the midcarpus is still dislocated as the capitate
remains dorsal to the capitate fossa of the
lunate.
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LUNATE
CAPITATE
The patients neurologic status was intact, with
normal peripheral nerve sensation, including 2
point discrimination.
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INCISION
EPL
LISTERS TUBERCLE
Dorsal view of the wrist showing the extensor
pollicus longus (EPL) tendon. The EPL tendon
passes ulnarward of Listers tubercle before
angling toward the thumb. The incision is based
as seen (between the third and fourth dorsal
compartment).
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EXTENSOR RETINACULUM
The incision is brought down through the soft
tissue and the extensor retinaculum is identified.
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2nd DORSAL COMPARTMENT
EPL
After the release of the extensor retinaculum
between the third and fourth dorsal compartments,
the extensor pollicus longus and second dorsal
compartment tendons are visualized.
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The EPL and second compartment are retracted
radially, while the common extensor tendons are
retracted laterally, exposed the wrist capsule.
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LUNATE
CAPITATE
EPL
SCAPHOID (PROXIMAL FRAGMENT)
SCAPHOID (DISTAL FRAGMENT)
After the capsule is incised, the carpal bones
are visualized. The lunate is visualized
adjacent to the distal radius. The capitate is
seen dorsally dislocated from the lunate.
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SCAPHOID (PROXIMAL FRAGMENT)
SCAPHOID (DISTAL FRAGMENT)
Using a Freer elevator, luno-capitate joint is
reduced.
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LUNATE
CAPITATE
SCAPHOID FRACTURE
SCAPHOID
The capitate is now within the confines of the
lunate. The lunate and proximal scaphoid are in
their normal relationship as this interval is not
interrupted. The scaphoid fracture is visualized
adjacent to the capitate.
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CAPITATE
As visualized from distally, looking down at the
articular surface of the scaphoid that
articulates with the capitate, the reduction is
achieved.
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SCAPHOID (REDUCED)
CAPITATE
As visualized from distally, looking down at the
articular surface of the scaphoid that
articulates with the capitate, the reduction is
achieved.
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After reduction of the scaphoid and radiographic
confirmation, K-wires are placed at the radial
and ulnar border of the scaphoid, allowing a
central screw to be positioned between the two
K-wires.
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These K-wires are necessary, as without two
points of K-wire stabilization the fragments will
rotate on one another during screw placement
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A P and lateral radiographs of the scaphoid
reduction, with K-wires and cannulated screw
guidewire.
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After appropriate drilling and tapping, the
cannulated screw is placed into the scaphoid,
maintaining the reduction.
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The screw is seated below the articulate surface
of the scaphoid.
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PROXIMAL
DISTAL RADIUS
TRIQUETRUM
CAPITATE
SCAPHOID
DISTAL
Next, the lunotriquetral interval is explored and
cleaned. Notice that the scaphoid to capitate
relationship is normal. By holding the
triquetrum away from the lunate, a pin can be
placed retrograde through the center of the
triquetral articular surface that will articulate
with the lunate once it is reduced.
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VIEW IS FROM ULNAR SIDE OF HAND
A K-wire is driven through the center of the
articular surface of the triquetrum.
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VIEW IS FROM ULNAR SIDE OF HAND
The K-wire is then driven through skin and
withdrawn such that it lies completely within the
triquetrum.
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TRIQUETRUM
LUNATE
CAPITATE
SCAPHOID
After reduction of the triquetrum to the lunate
under direction vision, the previously placed
K-wire is then driven back across the lunate,
holding stability.
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TRIQUETRUM
LUNATE
CAPITATE
SCAPHOID
A second K-wire should be placed so that there
are two fixation points across the triquetrum to
the lunate.
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The closure includes the capsule as well as the
extensor retinaculum. The patient is then placed
into a short-arm thumb-spiked cast.
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AP and lateral radiographs demonstrating the
reduction of the transscaphoid perilunate
fracture dislocation.