WEBVTT 00:00:00.000 --> 00:00:02.220 Welcome back to Deep Dive Ortho, where we pull 00:00:02.220 --> 00:00:04.860 apart complex orthopedic topics to get to the 00:00:04.860 --> 00:00:07.519 core insights. Today, we're zeroing in on the 00:00:07.519 --> 00:00:10.080 wrist an absolute engineering marvel, isn't it? 00:00:10.160 --> 00:00:12.699 So intricate, allowing incredible precision, 00:00:12.820 --> 00:00:15.599 yet incredibly vulnerable to some truly devastating 00:00:15.599 --> 00:00:18.480 injuries. Our focus for this deep dive is on 00:00:18.480 --> 00:00:21.359 radiocarpal fracture dislocations. These are 00:00:21.359 --> 00:00:23.960 far beyond your everyday sprains or simple breaks. 00:00:24.320 --> 00:00:26.300 They're uncommon, yes, but when they do occur, 00:00:26.440 --> 00:00:28.500 the impact on a patient's life, their function, 00:00:28.640 --> 00:00:31.800 their future, Well, it can be profound and long 00:00:31.800 --> 00:00:34.659 -lasting. Our mission today is to truly unpack 00:00:34.659 --> 00:00:37.200 the intricacies of these severe injuries. We'll 00:00:37.200 --> 00:00:39.520 explore everything from the subtle diagnostic 00:00:39.520 --> 00:00:41.759 clues that can be missed to the sophisticated 00:00:41.759 --> 00:00:44.020 surgical strategies and the long -term realities 00:00:44.020 --> 00:00:46.520 for these patients. We're aiming for a comprehensive, 00:00:46.740 --> 00:00:49.100 nuanced understanding tailored specifically for 00:00:49.100 --> 00:00:50.979 you, our mid -senior medical professionals who 00:00:50.979 --> 00:00:53.380 often face these challenging cases. To guide 00:00:53.380 --> 00:00:55.500 us through this complex anatomical and clinical 00:00:55.500 --> 00:00:57.520 landscape, we're honored to have our expert guest 00:00:57.520 --> 00:00:59.280 with us today. Thank you. It's a pleasure to 00:00:59.280 --> 00:01:01.130 be here. You've hit the nail on the head. Radiocarpal 00:01:01.130 --> 00:01:03.329 fractured dislocations are, without question, 00:01:03.530 --> 00:01:05.909 at the more severe end of the wrist injury spectrum. 00:01:06.650 --> 00:01:08.989 They almost invariably result from high energy 00:01:08.989 --> 00:01:11.689 trauma, and their potential for significant, 00:01:11.849 --> 00:01:14.469 even permanent functional impairment means that 00:01:14.469 --> 00:01:17.230 a truly deep understanding is absolutely crucial. 00:01:17.390 --> 00:01:19.909 It's not just about fixing a bone. It's about 00:01:19.909 --> 00:01:22.349 meticulous planning and execution, really, to 00:01:22.349 --> 00:01:24.989 preserve a patient's long -term quality of life. 00:01:25.250 --> 00:01:27.670 Absolutely. And that meticulous approach begins 00:01:27.670 --> 00:01:29.980 right at the foundation. You know when we talk 00:01:29.980 --> 00:01:32.459 about such profound disruptions, it always circles 00:01:32.459 --> 00:01:35.280 back to the anatomical foundation. This injury 00:01:35.280 --> 00:01:38.180 is so devastating because of how perfectly engineered 00:01:38.180 --> 00:01:40.560 the wrist is. Could you start us off by reminding 00:01:40.560 --> 00:01:42.680 us of its critical components, especially those 00:01:42.680 --> 00:01:45.519 that bear the brunt of these forces? Of course. 00:01:46.180 --> 00:01:48.340 Yes, to appreciate the scale of disruption in 00:01:48.340 --> 00:01:51.040 these injuries, we must first briefly recap the 00:01:51.040 --> 00:01:53.909 wrist's intricate architecture. At its core, 00:01:54.109 --> 00:01:55.950 we have the radiocurple joint. It's the primary 00:01:55.950 --> 00:01:58.469 articulation where the distal end of the radius, 00:01:58.730 --> 00:02:00.670 along with its crucial articular disc, meets 00:02:00.670 --> 00:02:04.310 three key bones of the proximal carpus. The scaphoid, 00:02:04.430 --> 00:02:06.489 the lunate, and the tricotral. Functionally, 00:02:06.510 --> 00:02:08.669 it's classified as a synovial ellipsoid joint, 00:02:09.069 --> 00:02:10.789 which is what grants the wrist its incredible 00:02:10.789 --> 00:02:13.210 range of two -axis movement, flexion extension, 00:02:14.050 --> 00:02:17.550 and abduction. It's vital to remember the radius 00:02:17.550 --> 00:02:20.069 directly articulates with the scaphoid and lunate, 00:02:20.229 --> 00:02:22.550 while its connection to the trichetrol is indirect, 00:02:22.889 --> 00:02:25.830 through that biconcave articular disc. And that 00:02:25.830 --> 00:02:27.810 disc is actually part of the larger triangular 00:02:27.810 --> 00:02:31.129 fibrocartilaginous complex of TFCC. Adjacent 00:02:31.129 --> 00:02:33.610 to this, and equally critical, is the distal 00:02:33.610 --> 00:02:37.069 radial nar joint, or DRUJ. This is a synovial 00:02:37.069 --> 00:02:39.250 pivot joint formed between the ulnar head and 00:02:39.250 --> 00:02:41.669 the sigmoid notch of the radius. Now here's a 00:02:41.669 --> 00:02:44.030 truly remarkable insight. While bones obviously 00:02:44.030 --> 00:02:46.150 provide structure, the osseous components of 00:02:46.150 --> 00:02:48.409 the DRU -J contribute only about 20 % to its 00:02:48.409 --> 00:02:50.870 overall stability. Only 20%. Yes, only about 00:02:50.870 --> 00:02:54.169 20%. The vast majority, a staggering 80%, comes 00:02:54.169 --> 00:02:57.310 from its soft tissues, most notably the triangular 00:02:57.310 --> 00:03:00.990 fibrocartilaginous complex, or TFCC. This isn't 00:03:00.990 --> 00:03:03.169 just a simple disc, it's a sophisticated complex 00:03:03.169 --> 00:03:05.469 that acts as a major stabilizer for both the 00:03:05.469 --> 00:03:08.310 radiocarpal and ulna -carpal joints. It plays 00:03:08.310 --> 00:03:10.729 a critical role in preventing the ulna from impacting 00:03:10.729 --> 00:03:13.689 the carpus, a condition known as ulnocarpal abutment, 00:03:14.169 --> 00:03:16.889 and critically, it facilitates the complex pronation 00:03:16.889 --> 00:03:19.430 and supination movements of the forearm and wrist. 00:03:20.050 --> 00:03:22.270 Its key components include the central articular 00:03:22.270 --> 00:03:24.870 disc itself, the dorsal and palmar radial gnar 00:03:24.870 --> 00:03:27.210 ligaments that tether the radius and ulna, the 00:03:27.210 --> 00:03:29.349 ulnomenescal homolog, and the ulnar collateral 00:03:29.349 --> 00:03:31.879 and ulnocarpal ligaments. You see, even a seemingly 00:03:31.879 --> 00:03:34.300 minor tear here can lead to profound functional 00:03:34.300 --> 00:03:36.759 deficits down the line, far beyond what SC's 00:03:36.759 --> 00:03:39.139 injury alone might cause. That's a really important 00:03:39.139 --> 00:03:42.439 point about the TFCC. It is. Then beyond these 00:03:42.439 --> 00:03:44.340 primary articulations, we have the intricate 00:03:44.340 --> 00:03:46.780 arrangement of the eight carpal bones organized 00:03:46.780 --> 00:03:49.930 into two rows. These bones, along with a dense 00:03:49.930 --> 00:03:52.009 network of intrinsic and extrinsic ligaments, 00:03:52.409 --> 00:03:54.770 function as both static and dynamic stabilizers, 00:03:55.110 --> 00:03:57.110 enabling the wrist's wide range of movements. 00:03:57.550 --> 00:03:59.129 From a clinical perspective, in these severe 00:03:59.129 --> 00:04:02.110 injuries, the intrinsic ligaments of most concern 00:04:02.110 --> 00:04:05.090 are the scaphalunate and lino -trichotral ligaments. 00:04:05.610 --> 00:04:08.750 Each has dorsal, volar, and interosseous fibrocartilaginous 00:04:08.750 --> 00:04:10.990 components, and their integrity is paramount 00:04:10.990 --> 00:04:13.099 to maintaining carpal alignment. And how do we 00:04:13.099 --> 00:04:14.900 check that alignment? You mentioned radiographs 00:04:14.900 --> 00:04:17.319 earlier. Yes. For assessing carpal alignment 00:04:17.319 --> 00:04:20.480 on standard radiographs, we heavily rely on what 00:04:20.480 --> 00:04:23.839 we call the jalula arcs. When we look at a PA 00:04:23.839 --> 00:04:26.660 wrist x -ray, we're almost looking for a specific 00:04:26.660 --> 00:04:29.180 set of curves. Think of it like a finely tuned 00:04:29.180 --> 00:04:32.639 machine. You expect three perfectly smooth concentric 00:04:32.639 --> 00:04:35.470 arches formed by the carpal bones. The first 00:04:35.470 --> 00:04:37.730 arc outlines the proximal margin of the proximal 00:04:37.730 --> 00:04:40.370 carpus, the second outlines its distal margin, 00:04:40.610 --> 00:04:42.529 and the third outlines the proximal margin of 00:04:42.529 --> 00:04:45.379 the capitate and hamet. If any of those arcs 00:04:45.379 --> 00:04:47.980 are broken, jagged, or discontinuous, a loss 00:04:47.980 --> 00:04:50.540 of congruency is a huge red flag. It's a simple 00:04:50.540 --> 00:04:52.319 visual cue that immediately tells you something 00:04:52.319 --> 00:04:54.480 is profoundly out of alignment within the carpus, 00:04:54.860 --> 00:04:56.600 often the first hint of a serious injury. Right, 00:04:56.699 --> 00:04:59.459 a break in the pattern. Exactly. Now, when we 00:04:59.459 --> 00:05:02.160 discuss the extrinsic ligaments, their role in 00:05:02.160 --> 00:05:04.899 preventing radiocarpal dislocation is truly paramount. 00:05:05.300 --> 00:05:08.139 What's truly eye -opening is the sheer biomechanical 00:05:08.139 --> 00:05:10.839 dominance of the Volar Capsular Ligamentus Complex. 00:05:11.100 --> 00:05:13.600 This complex includes critical structures like 00:05:13.600 --> 00:05:16.420 the radioscapocapitate, the long and short radiolunate 00:05:16.420 --> 00:05:18.699 ligaments, and the Palmar capsule. They are not 00:05:18.699 --> 00:05:20.980 just supporting players. They are the primary 00:05:20.980 --> 00:05:23.920 restraint against radiocarvel dislocation. Research 00:05:23.920 --> 00:05:26.560 demonstrates they contribute a substantial 61 00:05:26.560 --> 00:05:29.879 % of resistance to dorsal translation and 48 00:05:29.879 --> 00:05:33.180 % to Palmar translation of the carpus. 61 % for 00:05:33.180 --> 00:05:36.279 dorsal? That's huge! It is. In stark contrast, 00:05:36.459 --> 00:05:39.100 the dorsal ligaments contribute a minor 2 % and 00:05:39.100 --> 00:05:42.000 6 % respectively under the same conditions. This 00:05:42.000 --> 00:05:44.360 isn't just a number. It's a direct roadmap for 00:05:44.360 --> 00:05:47.439 our surgical priorities. Robust repair of these 00:05:47.439 --> 00:05:50.319 holostructures and any associated radial styloid 00:05:50.319 --> 00:05:52.639 fracture isn't an option. It's the absolute non 00:05:52.639 --> 00:05:54.740 -negotiable cornerstone for restoring stability. 00:05:55.040 --> 00:05:57.040 So the Volar site is really the key player in 00:05:57.040 --> 00:05:59.879 preventing dislocation. Absolutely. Finally, 00:06:00.000 --> 00:06:01.899 just briefly on innervation and blood supply. 00:06:02.189 --> 00:06:04.670 The radiocarpal joint receives its nerve supply 00:06:04.670 --> 00:06:07.490 from articular branches of the anterior interosseous 00:06:07.490 --> 00:06:10.490 nerve from the median, the posterior interosseous 00:06:10.490 --> 00:06:12.730 nerve from the radial, and the deep endorsal 00:06:12.730 --> 00:06:15.189 branches of the ulnar nerve. Blood supply is 00:06:15.189 --> 00:06:17.470 primarily from branches of the dorsal and palmar 00:06:17.470 --> 00:06:20.470 carpal arches. However, for these high energy 00:06:20.470 --> 00:06:23.810 injuries, it's a potential for traction neuropraxia 00:06:23.810 --> 00:06:26.670 to these nerves due to the severe deformity. 00:06:27.029 --> 00:06:29.649 That's the real clinical concern we must vigilantly 00:06:29.649 --> 00:06:32.259 monitor. That foundational understanding of the 00:06:32.259 --> 00:06:34.560 wrist's intricate design truly highlights how 00:06:34.560 --> 00:06:37.339 disruptive a radiocarpal fracture dislocation 00:06:37.339 --> 00:06:39.600 can be. It's like a complex machine suddenly 00:06:39.600 --> 00:06:41.959 losing its core alignment, especially when you 00:06:41.959 --> 00:06:43.839 consider how much stability comes from those 00:06:43.839 --> 00:06:46.040 volar ligaments. Knowing that they are the primary 00:06:46.040 --> 00:06:48.300 restraints really puts the severity into perspective. 00:06:48.839 --> 00:06:50.699 So what does this all mean when we talk about 00:06:50.699 --> 00:06:53.040 the injury itself? How does such a severe disruption 00:06:53.040 --> 00:06:55.519 occur, and what exactly defines it, beyond just 00:06:55.519 --> 00:06:57.699 the general idea of a wrist injury? You're right 00:06:57.699 --> 00:07:00.480 to connect the two. The anatomical complexity 00:07:00.480 --> 00:07:02.459 makes these injuries particularly challenging. 00:07:03.160 --> 00:07:06.879 To define it precisely, a radiocarpal dislocation 00:07:06.879 --> 00:07:10.720 or RCD refers to the total loss of contact between 00:07:10.720 --> 00:07:13.600 the carpus and the distal radius. This is a key 00:07:13.600 --> 00:07:16.199 differentiator from simpler intraarticular shear 00:07:16.199 --> 00:07:18.420 or rim fractures of the distal radius, where 00:07:18.420 --> 00:07:20.519 a piece of the articular surface may break off. 00:07:20.860 --> 00:07:22.939 But the main articular fragment still maintains 00:07:22.939 --> 00:07:26.100 contact with the carpus. When we speak of a radiocarpal 00:07:26.100 --> 00:07:28.939 fracture dislocation, or RCFD, we're talking 00:07:28.939 --> 00:07:31.240 of this total loss of contact along with associated 00:07:31.240 --> 00:07:33.620 bony fractures. It's a combined injury of both 00:07:33.620 --> 00:07:36.360 the articulation and bone. Okay, total loss of 00:07:36.360 --> 00:07:38.660 contact. And how common are these? Well, in terms 00:07:38.660 --> 00:07:41.220 of how often we see these, RCFEs are, thankfully, 00:07:41.439 --> 00:07:44.279 rare. They account for only about 0 .2 % of all 00:07:44.279 --> 00:07:46.560 wrist injuries annually. Tiny fraction. Very 00:07:46.560 --> 00:07:49.500 small. Epidemiologically, we tend to see them 00:07:49.500 --> 00:07:52.420 more frequently in males than females, and dorsal 00:07:52.420 --> 00:07:54.819 dislocations are somewhat more common than volar 00:07:54.819 --> 00:07:57.579 dislocations. The most significant demographic 00:07:57.579 --> 00:08:00.199 trend, though, is their strong association with 00:08:00.199 --> 00:08:03.060 high -energy trauma. These aren't typically simple 00:08:03.060 --> 00:08:06.240 slips. They demand significant force. We're talking 00:08:06.240 --> 00:08:09.000 about mechanisms like falls from a significant 00:08:09.000 --> 00:08:11.439 height, high -speed motor vehicle accidents, 00:08:11.759 --> 00:08:14.480 or industrial accidents. Right, serious mechanisms. 00:08:14.680 --> 00:08:17.079 Exactly. The typical mechanism of injury involves 00:08:17.079 --> 00:08:20.259 a high -energy shear or rotational force applying 00:08:20.259 --> 00:08:22.920 to a wrist that is both hyperextended and pronated. 00:08:23.480 --> 00:08:25.980 This classic scenario is often described as a 00:08:25.980 --> 00:08:28.839 foosh injury, a fall on an outstretched hand. 00:08:29.069 --> 00:08:32.029 The sheer force involved in such an event means 00:08:32.029 --> 00:08:34.129 that the damage isn't limited to just the bony 00:08:34.129 --> 00:08:36.690 structures. It also extends to the crucial ligaments 00:08:36.690 --> 00:08:38.970 and can frequently involve vessels and nerves. 00:08:39.690 --> 00:08:41.929 It's truly a domino effect of destruction. A 00:08:41.929 --> 00:08:44.029 domino effect. That's a good way to put it. And 00:08:44.029 --> 00:08:46.250 this brings us to the profound importance of 00:08:46.250 --> 00:08:48.809 identifying concomitant injuries as they are 00:08:48.809 --> 00:08:52.220 exceedingly common with RCFDs. From an orthopedic 00:08:52.220 --> 00:08:54.980 perspective, we frequently find various types 00:08:54.980 --> 00:08:57.600 of distal radius fractures, particularly radial 00:08:57.600 --> 00:09:00.240 styloid avulsion fractures. These are highly 00:09:00.240 --> 00:09:02.500 significant because they often involve the direct 00:09:02.500 --> 00:09:05.620 attachment point of the radioscapocapitate ligament, 00:09:06.120 --> 00:09:08.600 a primary stabilizer we just discussed. Oh, back 00:09:08.600 --> 00:09:11.740 to that key ligament. Precisely. We also commonly 00:09:11.740 --> 00:09:14.519 see volar lunate facet fractures, which are where 00:09:14.519 --> 00:09:17.139 the short radiolunate ligament attaches, and 00:09:17.139 --> 00:09:19.860 ulnar styloid fractures. Beyond the radius and 00:09:19.860 --> 00:09:22.139 ulna, other carpal bone fractures are regrettably 00:09:22.139 --> 00:09:25.039 common, including the scaphoid, lunate trapezium, 00:09:25.159 --> 00:09:28.480 trichotrol hamate, pisiform, and capitate. It's 00:09:28.480 --> 00:09:30.950 a whole cascade. It's also critical to assess 00:09:30.950 --> 00:09:33.690 for an irreducible DRUJ, which can occur due 00:09:33.690 --> 00:09:36.409 to soft tissue interposition and for intercarpal 00:09:36.409 --> 00:09:39.009 injuries, such as capillunate or lunatric control 00:09:39.009 --> 00:09:41.690 dissociation, which further complicate the overall 00:09:41.690 --> 00:09:44.110 stability and long -term prognosis. And what 00:09:44.110 --> 00:09:46.230 about nerves and vessels? You mentioned neuropraxia 00:09:46.230 --> 00:09:48.870 earlier. Yes, neurological involvement is also 00:09:48.870 --> 00:09:51.169 a significant concern, often presenting with 00:09:51.169 --> 00:09:54.029 a patient reporting numbness or weakness. Median 00:09:54.029 --> 00:09:56.230 nerve injuries are more frequent than ulnar nerve 00:09:56.230 --> 00:09:58.429 injuries in these cases. These are typically 00:09:58.429 --> 00:10:01.909 due to a mechanical traction neuropraxia, where 00:10:01.909 --> 00:10:03.970 the nerve is stretched or pulled over the deformed 00:10:03.970 --> 00:10:06.769 wrist during the injury. It's not necessarily 00:10:06.769 --> 00:10:08.970 a direct laceration, but the nerve is functionally 00:10:08.970 --> 00:10:11.169 compromised by the extreme distortion of the 00:10:11.169 --> 00:10:14.370 anatomy. Additionally, radial and ulnar artery 00:10:14.370 --> 00:10:16.970 injuries are not uncommon due to the severe deformity 00:10:16.970 --> 00:10:19.629 that occurs, sometimes requiring immediate vascular 00:10:19.629 --> 00:10:22.679 assessment and potentially repair. That cascade 00:10:22.679 --> 00:10:24.440 of associated injuries you mentioned, it really 00:10:24.440 --> 00:10:26.419 drives home how much is at stake. It's not just 00:10:26.419 --> 00:10:29.460 a bone break, it's a systemic disruption affecting 00:10:29.460 --> 00:10:32.659 bones, ligaments, nerves, vessels. Here's where 00:10:32.659 --> 00:10:35.529 it gets really interesting. The sheer force required 00:10:35.529 --> 00:10:38.210 and the cascade of associated injuries underscore 00:10:38.210 --> 00:10:40.169 the critical need for a meticulous approach. 00:10:40.730 --> 00:10:42.730 So when a patient presents with this level of 00:10:42.730 --> 00:10:45.750 trauma, how do we as clinicians effectively cut 00:10:45.750 --> 00:10:47.909 through the noise and get a definitive diagnosis? 00:10:48.470 --> 00:10:50.429 What are your go -to imaging strategies and what 00:10:50.429 --> 00:10:51.909 are the critical findings we should be looking 00:10:51.909 --> 00:10:55.419 for? Indeed, diagnosis is foundational. and it 00:10:55.419 --> 00:10:58.159 starts with the most accessible tools. Conventional 00:10:58.159 --> 00:11:00.539 radiography, or X -ray as it's commonly called, 00:11:01.019 --> 00:11:03.340 is always the primary radiological investigation 00:11:03.340 --> 00:11:07.000 for acute wrist trauma. For suspected wrist fractures, 00:11:07.399 --> 00:11:09.320 it's essential to obtain at least three views. 00:11:09.820 --> 00:11:12.659 The posterior anterior, or PA view, the lateral 00:11:12.659 --> 00:11:16.639 view, and a 45 degree oblique view. For increased 00:11:16.639 --> 00:11:19.440 sensitivity, particularly when a scaphoid fracture 00:11:19.440 --> 00:11:21.820 is suspected given their high incidence in FUSH 00:11:21.820 --> 00:11:24.220 injuries, we'll often place the hand in ulnar 00:11:24.220 --> 00:11:27.519 deviation for the PA scaphoid views as this elongates 00:11:27.519 --> 00:11:30.759 the scaphoid bone and can unmask subtle fractures. 00:11:31.259 --> 00:11:33.539 High quality radiographs with standardized positioning 00:11:33.539 --> 00:11:36.299 are key. Poor images can lead to significant 00:11:36.299 --> 00:11:38.860 misdiagnoses. Right, good quality views are essential. 00:11:39.000 --> 00:11:41.539 What are the signs on x -ray? On the PA view, 00:11:41.679 --> 00:11:45.000 crucial radiographic signs of a radiocarpal dislocation 00:11:45.000 --> 00:11:47.179 include a total loss of contact between the carpus 00:11:47.179 --> 00:11:49.419 and the radius, often with ulnar translation 00:11:49.419 --> 00:11:51.240 of the carpus and widening of the inner carpal 00:11:51.240 --> 00:11:54.059 spaces. As we discussed, a clear sign is the 00:11:54.059 --> 00:11:56.700 disruption of the jalula arcs, those three concentric 00:11:56.700 --> 00:11:59.340 arcs that define normal carpal alignment, losing 00:11:59.340 --> 00:12:02.220 their coloniality. The broken arcs again. Exactly. 00:12:02.379 --> 00:12:05.340 If you see breaks in those smooth curves, it's 00:12:05.340 --> 00:12:08.399 an immediate red flag. On the lateral view, we 00:12:08.399 --> 00:12:11.200 look for obvious dorsal or volar radiocarpal 00:12:11.200 --> 00:12:13.639 wrist dislocation and a loss of collinearity 00:12:13.639 --> 00:12:15.679 of the lunate with the articular surface of the 00:12:15.679 --> 00:12:18.289 radius. If there's a lunate dislocation, you'll 00:12:18.289 --> 00:12:20.429 specifically see what's often referred to as 00:12:20.429 --> 00:12:23.210 the spilled teacup sign, where the lunate displaces 00:12:23.210 --> 00:12:25.669 vularly, resembling an overturned teacup. Ah, 00:12:25.830 --> 00:12:29.110 the spilled teacup. Classic sign. It is. When 00:12:29.110 --> 00:12:31.409 evaluating associated disco -radius fractures 00:12:31.409 --> 00:12:33.830 on x -ray, we also measure several parameters 00:12:33.830 --> 00:12:36.029 that correlate strongly with long -term patient 00:12:36.029 --> 00:12:38.690 outcomes. These include radial length, normally 00:12:38.690 --> 00:12:41.590 11 to 22 millimeters, radial inclination, normally 00:12:41.590 --> 00:12:44.950 13 to 30 degrees, And the volar, or dorsal tilt, 00:12:45.289 --> 00:12:47.330 measured on the lateral view, normally ranges 00:12:47.330 --> 00:12:50.269 from 4 degrees dorsal to 11 degrees volar tilt. 00:12:50.710 --> 00:12:53.250 Significant deviations, for example, a decrease 00:12:53.250 --> 00:12:55.850 in radial length by more than 2 mm, a dorsal 00:12:55.850 --> 00:12:58.470 tilt greater than 20 degrees, or radial inclination 00:12:58.470 --> 00:13:00.389 less than 10 degrees are all associated with 00:13:00.389 --> 00:13:02.730 decreased long -term risk function and alert 00:13:02.730 --> 00:13:04.669 us to the need for more aggressive intervention. 00:13:05.310 --> 00:13:07.909 Subtle clues on initial radiographs, such as 00:13:07.909 --> 00:13:10.230 soft tissue swelling or the obliteration of the 00:13:10.230 --> 00:13:12.750 pronator quadratus fat stripe, can also hint 00:13:12.750 --> 00:13:15.450 at a fracture. However, it's important to remember 00:13:15.450 --> 00:13:18.690 a critical limitation. Approximately 30 % of 00:13:18.690 --> 00:13:21.070 wrist fractures, especially scaphoid fractures, 00:13:21.389 --> 00:13:23.769 can be radiographically occult on initial x -rays. 00:13:24.149 --> 00:13:26.570 30 % missed on initial x -ray. That's significant. 00:13:26.990 --> 00:13:29.590 It is. A negative x -ray, especially with high 00:13:29.590 --> 00:13:32.049 clinical suspicion, should never rule out a fracture 00:13:32.049 --> 00:13:34.840 definitively. So what's next if the x -ray isn't 00:13:34.840 --> 00:13:37.679 clear or you suspect more? This is precisely 00:13:37.679 --> 00:13:41.340 where computed tomography, or CT, becomes the 00:13:41.340 --> 00:13:43.740 modality of choice for more detailed evaluation. 00:13:44.679 --> 00:13:47.080 CT is invaluable for suspected bony injuries, 00:13:47.580 --> 00:13:49.679 particularly when radiographs are negative or 00:13:49.679 --> 00:13:52.779 indeterminate. It excels at visualizing complex, 00:13:53.039 --> 00:13:56.059 comminuted fractures, and, crucially, it allows 00:13:56.059 --> 00:13:58.519 us to identify and measure intraarticular step 00:13:58.519 --> 00:14:00.860 -offs, especially those greater than 2 millimeters. 00:14:01.129 --> 00:14:03.690 We know these strongly correlate with late development 00:14:03.690 --> 00:14:06.210 of osteoarthritis and typically warrant open 00:14:06.210 --> 00:14:09.250 reduction and internal fixation to restore articular 00:14:09.250 --> 00:14:12.909 congruity. CT also provides multiplanar and volumetric 00:14:12.909 --> 00:14:14.929 reformations, which are incredibly useful for 00:14:14.929 --> 00:14:17.250 comprehensive preoperative planning, allowing 00:14:17.250 --> 00:14:19.350 us to virtually reconstruct the injury before 00:14:19.350 --> 00:14:21.769 we even enter the operating theater. So CT for 00:14:21.769 --> 00:14:24.710 the bone detail and planning. Exactly. It's also 00:14:24.710 --> 00:14:27.070 superior for detecting subtle, non -displaced 00:14:27.070 --> 00:14:29.649 scaphoid fractures and other associated carpal 00:14:29.649 --> 00:14:31.309 injuries that might be missed on conventional 00:14:31.309 --> 00:14:34.289 x -rays. Furthermore, CT is the gold standard 00:14:34.289 --> 00:14:37.649 for evaluating DRUJ dislocations, with the epicenter 00:14:37.649 --> 00:14:39.710 method being the preferred technique for its 00:14:39.710 --> 00:14:42.370 instability and guiding reduction. Okay, and 00:14:42.370 --> 00:14:45.370 where does MRI fit into this picture? Magnetic 00:14:45.370 --> 00:14:48.250 resonance imaging, or MRI, has a more limited 00:14:48.250 --> 00:14:50.889 role in the acute phase of fractures and dislocations 00:14:50.889 --> 00:14:53.309 due to its availability, time constraints, and 00:14:53.309 --> 00:14:56.460 cost. However, its critical role lies in evaluating 00:14:56.460 --> 00:14:59.279 soft tissue injuries, such as damage to tendons, 00:14:59.519 --> 00:15:02.100 ligaments, and muscles components often severely 00:15:02.100 --> 00:15:04.620 compromised in these high -energy traumas. It's 00:15:04.620 --> 00:15:07.179 also excellent for detecting truly occult fractures, 00:15:07.580 --> 00:15:09.600 particularly trabecular fractures without cortical 00:15:09.600 --> 00:15:12.240 breach, which CT you're going to miss. For instance, 00:15:12.559 --> 00:15:14.919 a short protocol MRI can be used effectively 00:15:14.919 --> 00:15:17.600 in the emergency setting specifically for suspected 00:15:17.600 --> 00:15:20.549 occult scaphoid fractures. Optimized parameters 00:15:20.549 --> 00:15:23.590 for wrist MRI typically involve an 8 -12 cm field 00:15:23.590 --> 00:15:26.669 of view, 3 mm slice thickness, and dedicated 00:15:26.669 --> 00:15:29.490 phased array extremity coils. Sequences like 00:15:29.490 --> 00:15:32.049 T2 weighted or proton density with fat suppression 00:15:32.049 --> 00:15:34.350 are ideal for detecting bone meridima and fracture 00:15:34.350 --> 00:15:36.590 lines, while T1 weighted sequences are added 00:15:36.590 --> 00:15:39.210 for assessing bony alignment. It truly provides 00:15:39.210 --> 00:15:40.950 the missing pieces of the puzzle when the soft 00:15:40.950 --> 00:15:43.250 tissue injury is extensive or unclear. That's 00:15:43.250 --> 00:15:46.350 a powerful toolkit for diagnosis. It really underscores 00:15:46.350 --> 00:15:48.409 the importance of choosing the right imaging 00:15:48.409 --> 00:15:51.710 at the right time to get the full picture, especially 00:15:51.710 --> 00:15:55.090 when so much can be missed on initial radiographs. 00:15:55.230 --> 00:15:57.230 It's not just about seeing a break. It's about 00:15:57.230 --> 00:15:59.809 truly understanding the extent of the damage 00:15:59.809 --> 00:16:03.070 to both bone and soft tissue. Once we've identified 00:16:03.070 --> 00:16:05.789 and fully characterized the injury, how do we 00:16:05.789 --> 00:16:08.549 categorize these complex fragments? dislocations. 00:16:08.809 --> 00:16:11.309 Are there classification systems that help guide 00:16:11.309 --> 00:16:13.750 prognosis and management? That's an excellent 00:16:13.750 --> 00:16:15.950 point, as classification helps us both understand 00:16:15.950 --> 00:16:18.309 the severity and plan our approach. While we 00:16:18.309 --> 00:16:20.669 have several classification systems, it's worth 00:16:20.669 --> 00:16:23.190 briefly acknowledging some of the eponymous distal 00:16:23.190 --> 00:16:25.789 radius fractures first. For those of you regularly 00:16:25.789 --> 00:16:28.610 in clinic, terms like collis fracture or Smith 00:16:28.610 --> 00:16:31.190 fracture are second nature. Very familiar names. 00:16:31.409 --> 00:16:34.309 Indeed. They describe specific patterns collis 00:16:34.309 --> 00:16:37.500 with dorsal displacement. often from a fall on 00:16:37.500 --> 00:16:40.080 a dorsiflexed hand, common in older patients 00:16:40.080 --> 00:16:43.700 with osteoporosis. Smith's, the reverse, with 00:16:43.700 --> 00:16:46.159 voller displacement, often from higher energy 00:16:46.159 --> 00:16:48.860 onto a flexed wrist, perhaps in younger individuals. 00:16:49.120 --> 00:16:51.320 Then there's Barton's fracture, an intra -articular 00:16:51.320 --> 00:16:53.980 shear fracture with carpal displacement, either 00:16:53.980 --> 00:16:56.629 voller or dorsal. and the Hutchinson fracture, 00:16:56.870 --> 00:16:59.049 or Chauffeur's fracture, involving the radial 00:16:59.049 --> 00:17:01.750 styloid, again intraarticular. While these terms 00:17:01.750 --> 00:17:03.850 are deeply ingrained in practice, their universal 00:17:03.850 --> 00:17:07.250 reproducibility on radiographs or CT scans is 00:17:07.250 --> 00:17:09.450 actually quite limited, as studies have shown. 00:17:09.630 --> 00:17:12.529 Ah, so maybe less reliable than we think. Potentially. 00:17:12.910 --> 00:17:15.109 Therefore, when assessing the severity of radial 00:17:15.109 --> 00:17:17.690 fractures in the context of our CFDs, the most 00:17:17.690 --> 00:17:19.549 important considerations for us are the precise 00:17:19.549 --> 00:17:21.910 displacement of the fracture fragments, the extent 00:17:21.910 --> 00:17:24.410 of intraarticular extension, and any step off. 00:17:24.589 --> 00:17:27.809 particularly the DRUJ or radiocarpal joint, the 00:17:27.809 --> 00:17:30.509 degree of comminution, and critically, the presence 00:17:30.509 --> 00:17:33.069 of any associated ulnar, other carpal bone, or 00:17:33.069 --> 00:17:35.329 soft tissue injuries. These factors directly 00:17:35.329 --> 00:17:37.349 dictate prognosis and the surgical approach, 00:17:37.589 --> 00:17:39.829 perhaps more than the epinome itself. Okay, focus 00:17:39.829 --> 00:17:41.710 on the specifics of the injury pattern rather 00:17:41.710 --> 00:17:44.269 than just the name. What about classification 00:17:44.269 --> 00:17:47.309 specifically for the radiocarpal fracture dislocations 00:17:47.309 --> 00:17:51.089 themselves? Yes. Moving specifically to radiocarpal 00:17:51.089 --> 00:17:53.690 fracture dislocations, there are a couple of 00:17:53.690 --> 00:17:56.809 classifications we refer to. The monium classification 00:17:56.809 --> 00:17:58.750 divides these injuries based on the presence 00:17:58.750 --> 00:18:01.730 of intercarpal involvement. Type 1 injuries are 00:18:01.730 --> 00:18:05.589 RCFDs without associated intercarpal dissociation. 00:18:06.450 --> 00:18:08.930 So the dislocation is at the radiocarpal joint, 00:18:09.289 --> 00:18:11.730 maybe with a radial styloid fracture, but the 00:18:11.730 --> 00:18:14.910 carpus itself remains intact as a unit. Type 00:18:14.910 --> 00:18:18.349 2, on the other hand, involves an RCFD with associated 00:18:18.349 --> 00:18:21.190 intercarpal dissociation, maybe a carpal bone 00:18:21.190 --> 00:18:24.109 fracture or an intercarpal ligament tear. This 00:18:24.109 --> 00:18:25.990 means the injury has propagated further into 00:18:25.990 --> 00:18:27.890 the carpus. And does that distinction matter 00:18:27.890 --> 00:18:30.769 clinically? It does. It's generally accepted 00:18:30.769 --> 00:18:33.069 that type 2 injuries are typically more severe 00:18:33.069 --> 00:18:35.329 and are associated with worse outcomes, often 00:18:35.329 --> 00:18:37.390 necessitating open reduction and more extensive 00:18:37.390 --> 00:18:39.869 repair. They demand a heightened level of vigilance. 00:18:39.930 --> 00:18:42.089 Right, more complex repair needed. Then there's 00:18:42.089 --> 00:18:45.049 the dumontia classification. This classifies 00:18:45.049 --> 00:18:47.990 RCFDs into two groups, historically attempting 00:18:47.990 --> 00:18:51.470 to guide the surgical approach. Type 1 is a purely 00:18:51.470 --> 00:18:55.049 ligamentous RCFD, or one involving only a small 00:18:55.049 --> 00:18:57.890 cortical evulsion off the radius. The key here 00:18:57.890 --> 00:19:01.009 is primary ligamentous failure. Type 2 refers 00:19:01.009 --> 00:19:03.930 to an RCFD associated with a large radial styloid 00:19:03.930 --> 00:19:06.650 fracture fragment, involving at least one third 00:19:06.650 --> 00:19:09.349 of the scaphoid fossa. The implication is the 00:19:09.349 --> 00:19:11.329 crucial ligaments are attached to that displaced 00:19:11.329 --> 00:19:14.000 styloid fragment. Historically, this suggested 00:19:14.000 --> 00:19:16.460 maybe a volar approach for type 1 and dorsal 00:19:16.460 --> 00:19:19.019 for type 2. However, clinical experience has 00:19:19.019 --> 00:19:21.279 shown that outcomes varied, and current thinking 00:19:21.279 --> 00:19:23.759 often requires a more combined, comprehensive 00:19:23.759 --> 00:19:26.119 approach regardless of this classification to 00:19:26.119 --> 00:19:28.960 ensure full anatomical restoration. So the Dumontier 00:19:28.960 --> 00:19:31.059 type might not dictate the approach as much anymore? 00:19:31.339 --> 00:19:34.140 Not rigidly, no. The injury itself dictates the 00:19:34.140 --> 00:19:36.259 approach needed for full reduction and fixation. 00:19:37.019 --> 00:19:39.039 Finally, it's also important to consider the 00:19:39.039 --> 00:19:41.400 Mayfield classification for perilunate instability, 00:19:41.859 --> 00:19:44.099 as RCFDs can be part of this progressive spectrum, 00:19:44.700 --> 00:19:47.299 especially with high -energy trauma. This describes 00:19:47.299 --> 00:19:49.539 a sequential pattern of ligament disruption around 00:19:49.539 --> 00:19:52.920 the lunate. Stage 1. Scaffolunate dissociation 00:19:52.920 --> 00:19:55.440 widening of that interval. A lesser arc injury. 00:19:55.960 --> 00:19:59.559 Stage 2. Perilunate dislocation. The lunate stays 00:19:59.559 --> 00:20:01.380 aligned with the radius, but the rest of the 00:20:01.380 --> 00:20:04.220 carpus dislocates, usually dorsally. This is 00:20:04.220 --> 00:20:06.789 often a greater arc injury. potentially involving 00:20:06.789 --> 00:20:10.069 fractures like a transcephoid perilunate dislocation. 00:20:10.450 --> 00:20:13.250 Stage 3 adds lunotricatural joint disruption. 00:20:13.769 --> 00:20:16.069 Stage 4, complete disruption of radial lunate 00:20:16.069 --> 00:20:18.529 ligaments, allowing the lunate itself to displace 00:20:18.529 --> 00:20:21.069 volarely that classic spilled teacup sign again. 00:20:21.190 --> 00:20:23.329 The whole carpus sort of unravels sequentially. 00:20:23.730 --> 00:20:26.049 Precisely. And it's worth noting that transcephoid 00:20:26.049 --> 00:20:28.750 perilunate dislocation is actually the most common 00:20:28.750 --> 00:20:31.009 pattern of perilunate fracture dislocation we 00:20:31.009 --> 00:20:33.539 encounter. These stages highlight the extensive 00:20:33.539 --> 00:20:36.420 damage possible beyond just the primary RCFD, 00:20:36.759 --> 00:20:38.980 profoundly impacting function if not addressed 00:20:38.980 --> 00:20:41.339 comprehensively. So, what does this all mean 00:20:41.339 --> 00:20:44.380 for the clinician? These classifications, while 00:20:44.380 --> 00:20:46.700 imperfect perhaps, clearly highlight the need 00:20:46.700 --> 00:20:49.319 to look beyond the obvious and consider the full 00:20:49.319 --> 00:20:51.720 spectrum of injury. It's not just a dislocation, 00:20:51.799 --> 00:20:53.880 it's what else has been disrupted and the sequence 00:20:53.880 --> 00:20:56.660 of that disruption. Once the injury is thoroughly 00:20:56.660 --> 00:20:59.180 assessed and classified, the next critical step 00:20:59.180 --> 00:21:01.720 is management. What are the current approaches, 00:21:01.920 --> 00:21:04.140 both conservative and operative, and what evidence 00:21:04.140 --> 00:21:07.380 guides these often complex decisions? Precisely. 00:21:07.819 --> 00:21:09.759 The initial management is immediate and critical, 00:21:09.960 --> 00:21:12.460 often in the emergency department. The primary 00:21:12.460 --> 00:21:14.880 goal, as soon as the patient presents, is to 00:21:14.880 --> 00:21:17.140 perform an immediate reduction of the dislocation. 00:21:18.119 --> 00:21:20.880 This is paramount, not just to alleviate pain, 00:21:21.339 --> 00:21:23.500 but to prevent further neurovascular injury. 00:21:24.199 --> 00:21:26.779 Remember, those nerves and vessels are stretched 00:21:26.779 --> 00:21:29.740 and to facilitate subsequent imaging by normalizing 00:21:29.740 --> 00:21:32.460 the anatomy somewhat. Immediate reduction can 00:21:32.460 --> 00:21:34.980 make a real difference to nerve recovery. Our 00:21:34.980 --> 00:21:37.259 overarching objective is meticulous restoration 00:21:37.259 --> 00:21:39.759 of wrist anatomy, paying particular attention 00:21:39.759 --> 00:21:42.619 to the radial and ulnar styloids, and crucially, 00:21:43.000 --> 00:21:44.619 restoring the precise length of the attached 00:21:44.619 --> 00:21:47.359 ligaments. This anatomical restoration confers 00:21:47.359 --> 00:21:49.740 stability and is directly linked to positive 00:21:49.740 --> 00:21:52.119 long -term outcomes. Good results are achievable 00:21:52.119 --> 00:21:54.519 with concentric reduction, treatment of intracarpal 00:21:54.519 --> 00:21:56.640 injuries, and sound repair of bone and ligament 00:21:56.640 --> 00:21:59.099 damage. So immediate reduction first. Is non 00:21:59.099 --> 00:22:01.359 -operative management ever an option? Well... 00:22:01.369 --> 00:22:03.289 For non -operative management, the indications 00:22:03.289 --> 00:22:05.910 are quite specific and, frankly, limited for 00:22:05.910 --> 00:22:08.990 true RCFDs. It's typically reserved for patients 00:22:08.990 --> 00:22:12.069 not medically stable for surgery, or in those 00:22:12.069 --> 00:22:14.390 exceptionally rare cases where a truly stable 00:22:14.390 --> 00:22:16.670 radiocarple joint is achieved after a perfect 00:22:16.670 --> 00:22:19.230 closed reduction, confirmed by stress imaging. 00:22:19.970 --> 00:22:22.470 The technique involves longitudinal axial traction, 00:22:22.670 --> 00:22:25.289 then casting for up to six weeks, usually a sugar 00:22:25.289 --> 00:22:28.170 tongue or long arm cast, allowing ligamentous 00:22:28.170 --> 00:22:31.460 scarring. While historically some purely ligamentous 00:22:31.460 --> 00:22:33.819 injuries did okay with this, especially in older, 00:22:34.099 --> 00:22:36.619 low -demand patients, it's associated with common 00:22:36.619 --> 00:22:39.480 persistent instability, like ulnar translation 00:22:39.480 --> 00:22:42.500 and reduced range of motion. So generally not 00:22:42.500 --> 00:22:44.640 the first choice for these high -energy injuries? 00:22:44.880 --> 00:22:48.039 Generally not. For a high -energy RCFD, non -operative 00:22:48.039 --> 00:22:50.319 management is almost always considered suboptimal 00:22:50.319 --> 00:22:52.079 due to the high risk of chronic instability, 00:22:52.299 --> 00:22:54.380 stiffness, and post -traumatic arthritis. Which 00:22:54.380 --> 00:22:56.880 leads us to surgery. It's exactly. Operative 00:22:56.880 --> 00:22:58.880 management is widely considered the standard 00:22:58.880 --> 00:23:02.460 of care for virtually all RCFDs. The main indications 00:23:02.460 --> 00:23:05.529 are an irreducible dislocation, We can't get 00:23:05.529 --> 00:23:08.210 it back in place closed or an unstable joint 00:23:08.210 --> 00:23:10.890 after attempted closed reduction, where it simply 00:23:10.890 --> 00:23:13.549 won't stay reduced. The general approach involves 00:23:13.549 --> 00:23:17.349 open reduction, internal fixation, or RRF, often 00:23:17.349 --> 00:23:19.950 with radiocarpal pinning and meticulous ligament 00:23:19.950 --> 00:23:23.130 repair. The goal is stable fixation, allowing 00:23:23.130 --> 00:23:25.549 early, protected motion. Okay, let's get on to 00:23:25.549 --> 00:23:27.569 the surgical techniques. What approaches do you 00:23:27.569 --> 00:23:30.029 typically use? When it comes to surgical approaches, 00:23:30.109 --> 00:23:32.349 we often utilize a Voller -Henry approach to 00:23:32.349 --> 00:23:35.730 the distal radius. This offers advantages. Nerve 00:23:35.730 --> 00:23:38.789 decompression if needed, fasciotomy access, direct 00:23:38.789 --> 00:23:41.089 repair of those crucial volar ligaments, and 00:23:41.089 --> 00:23:44.009 good access for radial styloid fixation. However, 00:23:44.329 --> 00:23:46.940 it's often not sufficient alone. A dorsal approach 00:23:46.940 --> 00:23:49.220 may also be necessary, particularly for dorsal 00:23:49.220 --> 00:23:51.960 buttress plating, or to elevate impacted articular 00:23:51.960 --> 00:23:54.460 fragments. In fact, a combined volar and dorsal 00:23:54.460 --> 00:23:56.960 approach is frequently required. Surgeons shouldn't 00:23:56.960 --> 00:23:58.799 hesitate to make that second dorsal incision 00:23:58.799 --> 00:24:01.180 for adequate exposure and precise reduction of 00:24:01.180 --> 00:24:03.640 all fragments. An inadequate approach risks a 00:24:03.640 --> 00:24:06.259 poor outcome. Right. Do what's needed for full 00:24:06.259 --> 00:24:08.920 visualization and reduction. What about external 00:24:08.920 --> 00:24:11.559 fixation? Provisional stability can be achieved 00:24:11.559 --> 00:24:15.140 with external fixation. This is incredibly useful 00:24:15.140 --> 00:24:17.740 acutely for restoring length, controlling an 00:24:17.740 --> 00:24:20.420 unstable limb, protecting repairs, and allowing 00:24:20.420 --> 00:24:22.799 early elbow forearm motion while the wrist is 00:24:22.799 --> 00:24:25.220 held. It can be provisional before definitive 00:24:25.220 --> 00:24:28.200 internal fixation, or sometimes definitive immobilization 00:24:28.200 --> 00:24:31.200 for four to six weeks in complex cases or those 00:24:31.200 --> 00:24:33.839 with significant soft tissue injury. And the 00:24:33.839 --> 00:24:35.640 internal fixation itself. You mentioned three 00:24:35.640 --> 00:24:38.059 columns earlier. Yes, a key principle is often 00:24:38.059 --> 00:24:40.380 three -column fixation, addressing the radial, 00:24:40.559 --> 00:24:44.029 intermediate, and ulnar columns. For the radial 00:24:44.029 --> 00:24:47.410 column, radial styloid, robust fixation is crucial 00:24:47.410 --> 00:24:49.710 due to that radioscapacitate ligament attachment. 00:24:50.410 --> 00:24:52.509 We might use K -wires, compression screws, or 00:24:52.509 --> 00:24:55.589 small plates, dorsal, volar, or radial. If it's 00:24:55.589 --> 00:24:58.269 a small fragment or ligament avulsion, soft tissue 00:24:58.269 --> 00:25:01.099 repair with suture anchors may be needed. Robust 00:25:01.099 --> 00:25:03.759 repair here is paramount for stability. The intermediate 00:25:03.759 --> 00:25:07.079 column lunity fast fixation typically uses interfragmentary 00:25:07.079 --> 00:25:10.519 screws or tension band wires. Again, suture anchors 00:25:10.519 --> 00:25:13.200 for ligamentous issues. Anatomical reduction 00:25:13.200 --> 00:25:15.500 here is critical. Even a one two millimeter step 00:25:15.500 --> 00:25:18.759 off risks significant arthritis. The ulnar column 00:25:18.759 --> 00:25:21.440 distal ulnar styloid fixation is more controversial, 00:25:21.779 --> 00:25:25.160 but indicated for DRUJ injury or persistent instability. 00:25:25.420 --> 00:25:27.980 This might involve fixing an onostyloid fracture, 00:25:28.259 --> 00:25:30.960 K -wire screw, tension band, or TSCC repair. 00:25:31.700 --> 00:25:33.980 If the DRUJ is dislocated, it needs meticulous 00:25:33.980 --> 00:25:36.079 reduction and often pinning in mid -supination 00:25:36.079 --> 00:25:39.180 to maintain it while the TSCC heals. The DRUJ 00:25:39.180 --> 00:25:40.980 is often the forgotten joint, but instability 00:25:40.980 --> 00:25:43.339 there is debilitating. It sounds like addressing 00:25:43.339 --> 00:25:45.500 all three columns comprehensively is key. It 00:25:45.500 --> 00:25:48.720 often is. And ligament repair itself is a cornerstone, 00:25:48.920 --> 00:25:52.380 often needing magnification. For volar extrinsic 00:25:52.380 --> 00:25:54.940 ligaments, suture anchors can reattach them. 00:25:55.019 --> 00:25:57.420 It's critical not to overtighten, which could 00:25:57.420 --> 00:25:59.940 limit extension and cause stiffness. We must 00:25:59.940 --> 00:26:02.420 also evaluate and repair other significant ligaments 00:26:02.420 --> 00:26:04.940 if disrupted, like this scaffolding, leaving 00:26:04.940 --> 00:26:07.319 that unstable leads to poor outcomes despite 00:26:07.319 --> 00:26:10.880 good radiocarble repair. For impacted articular 00:26:10.880 --> 00:26:13.400 fragments, bone grafting, examined from iliac 00:26:13.400 --> 00:26:16.140 crest, might be needed to restore the joint surface. 00:26:16.349 --> 00:26:18.329 And you mentioned nerve decompression earlier 00:26:18.329 --> 00:26:20.529 too. Absolutely. Neurovascular decompression 00:26:20.529 --> 00:26:23.029 is essential if there are neurological signs 00:26:23.029 --> 00:26:24.869 pre -op or concern for compartment syndrome. 00:26:25.589 --> 00:26:27.769 Typically achieved via the Palmer approach with 00:26:27.769 --> 00:26:30.109 flexor retinaculum release. Critical for these 00:26:30.109 --> 00:26:32.589 high energy injuries. That's a powerful combination 00:26:32.589 --> 00:26:35.160 of techniques. really customizing the approach 00:26:35.160 --> 00:26:38.079 to the specific injury. It sounds like the emphasis 00:26:38.079 --> 00:26:40.940 is always on restoring that precise anatomical 00:26:40.940 --> 00:26:43.740 alignment and stability. However, even with the 00:26:43.740 --> 00:26:46.279 most meticulous surgical intervention, the journey 00:26:46.279 --> 00:26:48.960 doesn't end there. What are the common complications 00:26:48.960 --> 00:26:51.240 we need to anticipate, and what does the post 00:26:51.240 --> 00:26:53.079 -treatment rehabilitation look like? It sounds 00:26:53.079 --> 00:26:55.299 like it could be a long road. You're absolutely 00:26:55.299 --> 00:26:58.480 right. Surgery is often just the beginning, and 00:26:58.480 --> 00:27:01.500 vigilant post -treatment care is vital. After 00:27:01.500 --> 00:27:03.579 operative repair, patients typically undergo 00:27:03.579 --> 00:27:06.359 immobilization, averaging maybe five weeks, range 00:27:06.359 --> 00:27:09.119 four to eight weeks, often in a splint or cast, 00:27:09.339 --> 00:27:11.220 depending on surgical stability and soft tissue 00:27:11.220 --> 00:27:13.980 repair. But even during immobilization, it's 00:27:13.980 --> 00:27:16.880 crucial to start immediate, gentle, regular movement 00:27:16.880 --> 00:27:19.900 of all uninvolved joints, shoulder, elbow, fingers, 00:27:20.019 --> 00:27:22.480 thumb, to reduce swelling and prevent stiffness 00:27:22.480 --> 00:27:25.240 elsewhere. Early motion is key. Keeping everything 00:27:25.240 --> 00:27:27.910 else moving. Exactly. Once stability allows, 00:27:28.230 --> 00:27:30.369 usually after pin removal or early radiographic 00:27:30.369 --> 00:27:33.529 union, critical early hand exercises begin. Simple 00:27:33.529 --> 00:27:36.769 finger curls, hook fist, tabletop position. For 00:27:36.769 --> 00:27:38.950 the wrist itself, gentle, active and assisted 00:27:38.950 --> 00:27:41.049 range of motion, flexion, extension, deviation, 00:27:41.529 --> 00:27:43.769 pronation, supination introduced as soon as safe, 00:27:44.289 --> 00:27:47.210 avoiding severe discomfort. Move to slight stretch, 00:27:47.430 --> 00:27:50.890 not pain. Early on, we can begin isometric strengthening 00:27:50.890 --> 00:27:52.630 contracting muscles without moving the joint. 00:27:52.779 --> 00:27:55.380 As strength and comfort improve, typically 8 00:27:55.380 --> 00:27:58.480 -12 weeks post -op, progress to isotonic exercises 00:27:58.480 --> 00:28:01.000 with light weights or bands, gradually increasing 00:28:01.000 --> 00:28:03.859 load. Controlled progressive loading is vital. 00:28:04.039 --> 00:28:06.140 Sounds like a carefully staged rehab process. 00:28:06.259 --> 00:28:08.680 What about potential pitfalls, complications? 00:28:09.160 --> 00:28:11.400 Despite best efforts, complications can arise. 00:28:12.079 --> 00:28:14.359 Acute carpal tunnel syndrome is frequent, especially 00:28:14.359 --> 00:28:16.930 with delayed presentation or reduction. Persistent 00:28:16.930 --> 00:28:19.390 or worsening nerve signs often need urgent carpal 00:28:19.390 --> 00:28:21.910 tunnel release. Stiffness is also highly common. 00:28:22.109 --> 00:28:24.809 Maybe 30 -40 % loss in wrist motion are reported. 00:28:25.190 --> 00:28:27.170 Prolonged immobilization is a risk factor, but 00:28:27.170 --> 00:28:29.589 also scarring. Treatment involves intensive hand 00:28:29.589 --> 00:28:31.930 therapy, maybe manipulation under anesthesia, 00:28:32.269 --> 00:28:34.049 or hardware removal if it's impeding motion. 00:28:34.390 --> 00:28:36.710 That's a significant loss of motion potentially. 00:28:36.970 --> 00:28:40.250 It can be. Post -traumatic arthritis is a significant 00:28:40.250 --> 00:28:43.329 long -term risk, especially with non -anatomic 00:28:43.329 --> 00:28:46.359 reduction or chronic instability. That articular 00:28:46.359 --> 00:28:48.960 step -off greater than 2 millimeters is strongly 00:28:48.960 --> 00:28:52.119 associated with late osteoarthritis. We also 00:28:52.119 --> 00:28:54.160 need awareness of late intercarpal disruption 00:28:54.160 --> 00:28:56.299 from occult injuries becoming apparent later. 00:28:57.099 --> 00:28:59.160 While many neurological deficits resolve after 00:28:59.160 --> 00:29:01.740 reduction decompression, some may persist, like 00:29:01.740 --> 00:29:05.180 residual numbness. And non -union or osteonecrosis 00:29:05.180 --> 00:29:07.279 is a concern for associated scapoid fractures 00:29:07.279 --> 00:29:09.519 due to its blood supply and neglected hook of 00:29:09.519 --> 00:29:11.559 Hammett fractures. A lot to watch out for long 00:29:11.559 --> 00:29:13.380 -term. What's the overall prognosis typically? 00:29:13.609 --> 00:29:15.549 Turning to long -term outcomes, the good news 00:29:15.549 --> 00:29:18.309 is that with early diagnosis, precise anatomical 00:29:18.309 --> 00:29:21.089 repair, stable fixation, and good rehab, good 00:29:21.089 --> 00:29:23.130 functional outcomes can generally be expected. 00:29:24.470 --> 00:29:27.109 Reviews show promising results. One study reported 00:29:27.109 --> 00:29:29.890 mean flexion extension arc of 100 degrees, grip 00:29:29.890 --> 00:29:33.109 strength 86 % of the other side. That's excellent 00:29:33.109 --> 00:29:35.900 given the injury severity. Many patients resume 00:29:35.900 --> 00:29:39.079 prior occupations, even high demand ones. However, 00:29:39.279 --> 00:29:41.799 open injuries and dumontia type 2 injuries historically 00:29:41.799 --> 00:29:44.640 show less favorable results, often needing more 00:29:44.640 --> 00:29:47.380 rehab and having higher complication rates. We 00:29:47.380 --> 00:29:50.579 use outcome scores like quick dash, PWRE to assess 00:29:50.579 --> 00:29:53.880 function, pain, motion, grip strength. Scores 00:29:53.880 --> 00:29:57.470 over 65 often considered satisfactory. Interestingly, 00:29:57.809 --> 00:29:59.609 clinical scores and x -ray changes don't always 00:29:59.609 --> 00:30:01.650 correlate perfectly with patient -reported function. 00:30:02.329 --> 00:30:04.130 Someone might have arthritis on x -ray but feel 00:30:04.130 --> 00:30:06.309 fine functionally or vice versa. That's an interesting 00:30:06.309 --> 00:30:08.289 point about the disconnect sometimes between 00:30:08.289 --> 00:30:11.029 imaging and function. It is. And in some refractory 00:30:11.029 --> 00:30:13.890 cases with persistent instability or severe arthritis, 00:30:14.490 --> 00:30:16.269 secondary interventions like radial loon fusion 00:30:16.269 --> 00:30:18.809 or even total wrist fusion might be needed as 00:30:18.809 --> 00:30:21.240 a salvage procedure later on. That's a truly 00:30:21.240 --> 00:30:23.759 comprehensive overview, highlighting both the 00:30:23.759 --> 00:30:25.779 successes we can aim for and the significant 00:30:25.779 --> 00:30:29.400 challenges demanding ongoing vigilance. This 00:30:29.400 --> 00:30:32.140 raises an important question. For our listeners 00:30:32.140 --> 00:30:34.400 working with these patients, what's the key takeaway 00:30:34.400 --> 00:30:37.220 or perhaps a thought to provoke deeper consideration 00:30:37.220 --> 00:30:39.420 on this challenging topic? What's the one thing 00:30:39.420 --> 00:30:42.180 you'd want them to carry forward? For our colleagues, 00:30:42.460 --> 00:30:44.880 I think the critical importance lies in a thorough, 00:30:45.140 --> 00:30:47.279 really deep understanding of the wrist anatomy. 00:30:47.470 --> 00:30:50.369 A judicious, multimodality imaging approach, 00:30:50.569 --> 00:30:53.630 remembering x -rays, are just the start and implementing 00:30:53.630 --> 00:30:56.710 tailored, meticulous surgical strategies. While 00:30:56.710 --> 00:30:59.230 these injuries are rare and complex, precise 00:30:59.230 --> 00:31:01.690 diagnosis and rigorous anatomical restoration 00:31:01.690 --> 00:31:04.190 are absolutely paramount to mitigating those 00:31:04.190 --> 00:31:06.089 long -term problems like post -traumatic arthritis 00:31:06.089 --> 00:31:08.529 and chronic instability. It's about restoring 00:31:08.529 --> 00:31:11.109 not just form but critical function and remembering 00:31:11.109 --> 00:31:13.420 the long game for the patient. That's a powerful 00:31:13.420 --> 00:31:16.319 message, thank you. This deep dive has truly 00:31:16.319 --> 00:31:18.900 laid bare the complexities and the critical pathways 00:31:18.900 --> 00:31:21.140 for managing these significant wrist injuries. 00:31:22.220 --> 00:31:25.140 As we move forward in orthopedic practice, perhaps 00:31:25.140 --> 00:31:27.500 the next frontier lies not just in achieving 00:31:27.500 --> 00:31:30.839 perfect initial reduction, but in truly understanding 00:31:30.839 --> 00:31:34.099 the subtle individual biomechanical responses 00:31:34.099 --> 00:31:37.019 to these high -energy traumas, allowing us to 00:31:37.019 --> 00:31:39.819 predict and prevent long -term functional impairments 00:31:39.819 --> 00:31:42.849 with even greater precision. What more can we 00:31:42.849 --> 00:31:44.950 learn from the patient journey beyond the initial 00:31:44.950 --> 00:31:48.049 fracture? And how can we leverage emerging technologies 00:31:48.049 --> 00:31:50.710 to better understand those long -term adaptations? 00:31:51.609 --> 00:31:53.950 If you found this discussion insightful, please 00:31:53.950 --> 00:31:56.089 take a moment to rate and share Deep Dive Ortho 00:31:56.089 --> 00:31:57.950 with your colleagues. It helps us reach more 00:31:57.950 --> 00:32:00.150 dedicated professionals like yourselves. Thank 00:32:00.150 --> 00:32:02.549 you again for your invaluable expertise and insights 00:32:02.549 --> 00:32:04.549 today. My pleasure entirely. Thank you for having 00:32:04.549 --> 00:32:06.430 me. And thank you for joining us on Deep Dive 00:32:06.430 --> 00:32:08.730 Ortho. We'll be back soon with another exploration 00:32:08.730 --> 00:32:10.869 into the fascinating world of orthopedics.