Ortopedia y Traumatología
Cirugía de Mano y Microcirugía
domingo, 29 de diciembre de 2013
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miércoles, 25 de diciembre de 2013
sábado, 14 de diciembre de 2013
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SCAPHOLUNATE DISSOCIATION
FUENTE:
http://networkedblogs.com/RVf3u
http://networkedblogs.com/RVf3u
SCAPHOLUNATE DISSOCIATION
Rajesh Purushothaman, MS, Associate Professor, Govt.Medical College, Kozhikode, India
- According to Dobyns, carpal instability is “a carpal injury in which loss of normal alignment of the carpus occur early or late”. . Scapholunate dissociation (SLD) is the most common type of carpal instability. It is the most common instability pattern because the intercarpal motion during flexion and extension cross at the scapholunate interface. Another reason is that compression forces transmitted through the capitate has a tendency to separate the scaphoid and lunate.
- It occurs due to injury to scapholunate interosseous ligament (SLIL). SLIL may either be injured alone or in combination with other ligaments such as radioscaphocapitate ligament or dorsal intercarpal ligament. In addition, SLD may occur alone or in combination with other injuries such as radial styloid fracture (Chauffeurs fracture) or as a part of perilunate instability.
Kinematics
- Wrist has one of the most complex kinematics in the human body. Various concepts like row theory by Johnston in 1907, column theory by Navarro in 1921, modified column theory by Taleisnik in 1978 and oval ring theory by Lichtman in 1981 have been used to explain carpal kinematics.
- Flexion occurs mainly in the scaphotrapeziotrapezoid (STT), radiolunate and ulnotriquetral articulations. Extension occurs mainly in the radioscaphoid, lunocapitate and triquetrohamate articulations. Thus the plane of flexion and the plane of extension cross at the scapholunate interspace. Hence SLIL is highly prone for injury.
- During radial and ulnar deviation; both the carpal rows move in the same direction in the frontal plane. During radial deviation; the proximal row flexes, and the distal row extends in the coronal plane. During ulnar deviation, there is extension of the proximal row and flexion of the distal row. Such reciprocal movements help to keep the hand in the neutral position.
- Kinematically the wrist is considered to be similar to a 3-link system. The three links are the radius, lunate-triquetrum and the distal row-metacarpal complex. As it doesn’t have any tendons directly inserted to it; the proximal row acts mechanically as an intercalated segment between the radius-TFCC complex and the distal carpal row in a three joint link system. Collapse of the proximal row is prevented by the presence of scaphoid which link the proximal and distal rows as a slider crank.
Anatomy
- Anatomically the proximal surface of carpus appears similar to a condyle. But it is not a true condyle, but a composite condyle made of scaphoid, lunate and triquetrum attached to each other by interosseous ligaments.
- No tendons insert into the carpus but 3 sets each of tendons cross the carpus on the dorsal and volar aspect; influencing carpal motion. These three sets of tendons are finger extensors and flexors centrally, wrist extensors and flexors on the radial and ulnar side.
- Ligaments of the wrist may be classified into intrinsic, extrinsic ligaments. Intrinsic carpal ligaments are those between carpal bones of the same row.
- Scapholunate ligament is U shaped and is thicker dorsally. Its rupture leads to increased flexion of scaphoid, extension of lunate and dorsal translation of proximal pole of scaphoid. Secondary stabilisers of the scapholunate interface can be dorsal or volar. Volar secondary stabilisers are the radioscaphocapitate ligament and the scaphotrapezial ligament. The dorsal secondary stabilisers are the dorsal radiocarpal or dorsal intercarpal ligaments. Injury to secondary stabilisers will worsen the instability, which is likely in perilunate dislocations.
Pathomechanics of Dorsal Intercalated Segement Instability (DISI)
- Under compressive loads, the natural tendency of scaphoid is to palmar flex and the natural tendency of triquetrum is to extend. Compression of radial column during radial deviation flexes the scaphoid which in turn leads to flexion of the proximal row. Compression of ulnar column during ulnar deviation leads to extension of triquetrum which in turn leads to extension of proximal row. In the normal wrist the tendency of triquetrum to extend the proximal row is counterbalanced by the scaphoid. The dorsal horn of lunate is thinner than the palmar horn; hence under compressive forces transmitted by the capitate the lunate has a tendency to extend.
- In scapholunate dissociation, the triquetrum extends the lunate as the counterbalancing by scaphoid is absent and the scaphoid is flexed. This leads to dorsiflexion of lunate, palmar flexion of scaphoid which will increase the scapholunate angle and lunocapitate capitate creating the dorsal intercalated segment instability (DISI) pattern.
Clinical Features
- Usually it occurs due to a fall on the outstretched hand (FOOSH) leading to forced dorsiflexion and ulnar deviation of the wrist. Patients present with pain and swelling of the wrist. There may be tenderness over the dorsum of wrist just distal to the Lister’s tubercle. There will be painful restriction of wrist movements. Watson test may be positive. It is done by placing the thumb of the examiner over the scaphoid tuberosity and applying pressure in the dorsal direction. With the other hand hold the hand and move the wrist repeatedly into radial and ulnar deviation. A painful clunk is suggestive of SLD.
Imaging
- Investigations needed for evaluation are x-ray, arthrography, video fluoroscopy, MRI and arthroscopy. X-rays needed are the PA in neutral position, radial deviation and ulnar deviation, lateral view, lateral oblique view and medial oblique view and clenched fist AP view. Gilula Lines are 3 arcs to be looked for on the PA view. First arc is on the proximal surface of proximal carpal row, second arc on the distal surface of proximal row and third on the proximal surface of capitate and hamate. Any asymmetry or gap suggests carpal malalignment. Normally lunate appear rectangular on the PA view, if it is triangular it is malpositioned. Normally scaphoid lies in an oblique plane on the AP view and the proximal and distal thirds can be seen to be separated by the waist. In patients with SLD, the scaphoid is flexed leading to shortened appearance on the PA view, there may be cortical ring sign on the PA view due end on view of distal pole.
- Normal gap between scaphoid and lunate is 9 mm at 7 years of age and 3 mm after 15 years of age; a gap more than 5 mm (Terry Thomas sign) is diagnostic of SLD in presence of ring sign. It should be compared with the opposite side before confirming the diagnosis. If there is a strong clinical suspicion but the x-rays are normal; then a stress x-ray with the patient clenching the fist will show increased gap.
- The scapholunate angle should be measured on the lateral view. Draw a line connecting the centre of the convex surfaces of the proximal and distal poles of scaphoid. Draw a line connecting the dorsal and volar lips of the distal articular surface of lunate and draw a line perpendicular to it to get the lunate axis line. Normal angle is 30-600. An angle greater than 800 confirms SLD.
- Draw the axis line for lunate and capitate on the lateral view and the angle between the lines gives the lunocapitate angle. Normal is 0-150. If the lunate is dorsiflexed as in DISI, the angle is >150.
Classification
The severity of SLD may range from
The severity of SLD may range from
- SLIL strains
- Dynamic Instability
- Static Instability
- Rotatory scaphoid subluxation
- Scaphoid Dislocation
Geissler Classification
I. Attenuation or hemorrhage into SLIL on midcarpal arthroscopy. Bones congruent.
II. Scapholunate incongruency on midcarpal arthroscopy.
III. Scapholunate gap allows passage of 1 mm arthroscope from midcarpal space to radiocarpal space
IV. Gap allows passage of 2.7mm arthroscope.
Management
Depends on the duration of injury, severity, reducibility, associated injuries and whether the injury is static or dynamic.
I. Attenuation or hemorrhage into SLIL on midcarpal arthroscopy. Bones congruent.
II. Scapholunate incongruency on midcarpal arthroscopy.
III. Scapholunate gap allows passage of 1 mm arthroscope from midcarpal space to radiocarpal space
IV. Gap allows passage of 2.7mm arthroscope.
Management
Depends on the duration of injury, severity, reducibility, associated injuries and whether the injury is static or dynamic.
Factors to be considered
Duration of injury
Duration of injury
- • Acute- Less than 4 weeks duration
- • Subacute- Less than 4 weeks but greater than 24 weeks
- • Chronic- More than 6 months
• Severity of gap
• Reducible or irreducuble
• Dynamic or static deformity
• Associated carpal injuries
• Arthritic or not
Guide lines for the treatment of acute SLD
• Reducible or irreducuble
• Dynamic or static deformity
• Associated carpal injuries
• Arthritic or not
Guide lines for the treatment of acute SLD
- Injuries without incongruence are treated by immobilization.
- Injury with partial SLIL disruption with a gap that is reducible by closed manipulation or percutaneous K wire joysticks is treated by reduction and percutaneous scapholunate and scaphocapitate K wires and immobilization.
- Gap > 3 mm, scapholunate angle > 600, lunocapitate angle >150 are indications for open reduction and ligament repair.
- If the gap is more than 5 mm; repair or advancement of palmar ligaments is usually necessary.
Technique of SLIL repair
- Dorsal incision centered over the Lister’s tubercle
- Retract extensor pollicis longus radially and extensor digitorum communis medially.
- Open the capsule by a radially based flap preserving dorsal intercarpal and dorsal radiotriquetral ligaments.
- Put a K wire as joystick into the lunate in the proximal-dorsal to distal-volar direction to allow flexion of lunate during reduction.
- Put a K wire into scaphoid as joystick from dorsal-distal to volar proximal direction to allow extension of scaphoid during manipulation.
- Visualize the SLIL tear which is usually avulsed from scaphoid.
- Freshen the site of reattachment.
- Manipulate to reduce by flexing the lunate and extending and supinating the scaphoid.
- Fix by scapholunate and scaphocapitate K wires
- Reattach the ligament using intraosseous suture anchors such as G2 Mini anchors 1.9 mm (Depuy Mitek) and nonabsorbable sutures.
- In subacute tears or in the absence of poor tissue quality; the repair can be augmented by suturing a proximally based dorsal capsular flap on the scapholunate interspace and the adjacent dorsal scaphoid. (Blatt technique)
- Tendon strips from radial extensors can also be used for augmentation if the quality of tissue available for repair is poor. Almquist and Linscheid technique utilizes extensor carpi radialis brevis (ECRB) and the Brunelli technique uses extensor carpi radialis longus (ECRL).
- Close the wound in layers and immobilize for 3 months.
Subacute SLD needs ligament repair and augmentation by dorsal capsular flap. In addition palmar approach for repair and advancement of radioscaphocapitate and radiolunate ligaments to overcorrect the scaphoid flexion should also be done.
In chronic SLD without arthritis; ligament repair and augmentation is the preferred treatment if the gap is reducible. If not reducible or if there is arthritis then limited carpal fusion is preferred. In presence of advanced arthritis; wrist arthrodesis is preferred.
Further reading
- DOBYNS, J. H.; LINSCHEID, R. L., CHAO, E. Y. S.; WEBER, E. R.; and SWANSON, G. E.: Traumatic Instability of the Wrist. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 24, pp. 182-199. St. Louis, C. V. Mosby, 1975
- FISK, G. R.: Carpal Instability and the Fractured Scaphoid. Ann. Roy. Coll. Surg. England, 46: 63-76, 1970
- GILFORD, W. W.; BOLTON, R. H.; and LAMBRINUDI, C. The Mechanism of tl~ Wrist Joint. With Special Reference to Fractures of the Scaphoid. Guy’s Hosp. Rep., 22: 52-59, 1943
- LINSCHEID, R. L.; DOBYNS, J. H.; BEABOUT, J. W.; and BRYAN, R. S.: Traumatic Instability of the Wrist. Diagnosis, Classification and Pathomechanics. J. Bone and Joint Surg., 4-A: 1612-1632, Dec. 1972
lunes, 9 de diciembre de 2013
lunes, 2 de diciembre de 2013
miércoles, 27 de noviembre de 2013
Use of quantitative intra-operative electrodiagnosis during partial ulnar nerve transfer to restore elbow flexion
FUENTE:
http://www.bjj.boneandjoint.org.uk/content/93-B/3/364.abstract
http://www.bjj.boneandjoint.org.uk/content/93-B/3/364.abstract
Use of quantitative intra-operative electrodiagnosis during partial ulnar nerve transfer to restore elbow flexion
THE TREATMENT OF EIGHT PATIENTS FOLLOWING A BRACHIAL PLEXUS INJURY
- O. Suzuki, MD, PhD, Assistant Professor1;
- T. Sunagawa, MD, PhD, Professor2;
- K. Yokota, MD, PhD, Assistant Professor1;
- Y. Nakashima, MD, PhD, Orthopaedic Surgeon1;
- R. Shinomiya, MD, PhD, Orthopaedic Surgeon1;
- K. Nakanishi, MD, PhD, Assistant Professor1; and
- M. Ochi, MD, PhD, Professor1
+Author Affiliations
- Correspondence should be sent to Professor O. Suzuki; e-mail:osami@hiroshima-u.ac.jp
Abstract
The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level.
Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss.
- Received February 9, 2010.
- Accepted November 10, 2010.
- © 2011 British Editorial Society of Bone and Joint Surgery
domingo, 24 de noviembre de 2013
viernes, 22 de noviembre de 2013
Premios Semergen (I): lesiones en la práctica profesional de la guitarra
http://www.condroprotectores.es/premios-semergen-i-lesiones-en-la-practica-profesional-de-la-guitarra/
Conocer la incidencia de lesiones en la práctica profesional de la guitarra y determinar las posibles causas que contribuyen a su aparición. Este fue el objetivo de un estudio descriptivo realizado por la Dra. Milagros Lucas, Médico Residente de Medicina Familiar y Comunitaria del Centro de Salud San Fernando de Badajoz. El trabajo ha sido premiado con una de las becas a la investigación en artrosis y condroprotección que Semergen otorgó durante su congreso nacional el pasado mes de octubre.
Premios Semergen (I): lesiones en la práctica profesional de la guitarra
Conocer la incidencia de lesiones en la práctica profesional de la guitarra y determinar las posibles causas que contribuyen a su aparición. Este fue el objetivo de un estudio descriptivo realizado por la Dra. Milagros Lucas, Médico Residente de Medicina Familiar y Comunitaria del Centro de Salud San Fernando de Badajoz. El trabajo ha sido premiado con una de las becas a la investigación en artrosis y condroprotección que Semergen otorgó durante su congreso nacional el pasado mes de octubre.
Para el estudio se realizó una encuesta ad hoc para los participantes de uno de los Concursos Internacionales realizados en Extremadura en 2012. Los resultados mostraron que:
- El 88% de los encuestados había presentado alguna enfermedad relacionada con la práctica musical, predominando la patología a nivel de columna vertebral.
- El 40% realizaba estiramientos antes de tocar, el 32% a veces y el 28% nunca.
- Solamente el 64% consultó con un profesional sanitario (un 82% a su médico de atención primaria y un 36% a un fisioterapeuta).
Por todo ello, el estudio recomienda la realización de estiramientos previos a la interpretación musical desde la infancia, así como la adopción de posiciones adecuadas al toca, para evitar posibles lesiones músculo esqueléticas.
Si os ha interesado este tema, os recomendamos visitar este blog sobre la Salud del Guitarrista.
miércoles, 20 de noviembre de 2013
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miércoles, 13 de noviembre de 2013
Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial
Utilidad de las inyecciones de esteroides en los pacientes con el síndrome del túnel carpiano -> Proporcionan alivio a corto plazo del dolor del túnel carpiano, pero no alivian los síntomas a largo plazo en la mayoría de los pacientes. El 75% de los pacientes recurrió a la cirugía el plazo de 1 año para aliviar el dolor persistente.
Ann Intern Med, 03/09/2013 "Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial"
Antecedentes: Las inyecciones de esteroides se utilizan en el síndrome del túnel carpiano idiopático (STC), pero la evidencia de la eficacia más allá de 1 mes es deficiente. Objetivo: Evaluar la eficacia de las inyecciones de metilprednisolona locales del STC. Diseño: Ensayo aleatorizado, controlado con placebo. ( ClinicalTrials.gov : NCT00806871 ). Marco: Departamento de ortopedia de referencia regional en Suecia. Pacientes: Pacientes de 18 a 70 años con el STC, pero sin inyecciones de esteroides anteriores. Intervención: Tres grupos (37 pacientes cada uno) recibieron 80 mg de metilprednisolona, 40 mg de metilprednisolona o placebo. Los pacientes y los cirujanos que tratan estaban cegados. Medidas: Los puntos finales primarios fueron el cambio en los síntomas del STC, las puntuaciones de gravedad a las 10 semanas (rango, 1 a 5) y la tasa de cirugía al 1 año. A tres pacientes les faltaban datos de 10 semanas. Todos los pacientes tenían datos del 1 año. Resultados: Los resultados de mejora de los síntomas de gravedad del STC a las 10 semanas fue mayor en los pacientes que recibieron 80 mg de metilprednisolona y 40 mg de metilprednisolona que en los que recibieron placebo (diferencia en cambio desde el inicio, -0,64 [ IC del 95%, -1,06 a - 0,21, p = 0,003 ] y -0,88 [IC, -1,30 a -0,46 , p < 0,001 ], respectivamente ), pero no hubo diferencias significativas al año. Las tasas de cirugía al año fueron de 73 %, 81 % y 92 % para de 80 mg de metilprednisolona, 40 mg de metilprednisolona y placebo, respectivamente. En comparación con los pacientes que recibieron placebo, los que recibieron 80 mg de metilprednisolona fueron menos propensos a tener una cirugía (odds ratio, 0,24 [IC , 0,06 a 0,95 ], p = 0,042). Con el tiempo de la cirugía incorporado, tanto el grupo de 80mg de metilprednisolona como el de 40 mg tuvieron menor probabilidad de cirugía (razón de riesgo, 0,46 [IC, 0,27 hasta 0,77 , p = 0,003 ] y 0,57 [IC , 0,35 a 0,94 , p = 0,026 ], respectivamente ). Limitación: El estudio se realizó en 1 centro y las férulas de muñeca habían fracasado previamente para todos los pacientes. Conclusión: Aunque las inyecciones de metilprednisolona durante STC tienen beneficios significativos en el alivio de los síntomas a las 10 semanas y reducen la tasa de cirugía al año después del tratamiento, 3 de cada 4 pacientes fue operado el plazo de 1 año.
Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial
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