(OBQ12.38) A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Lunate fractures and associated radiocarpal and midcarpal instabilities: a systematic review:. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. A 46-year-old woman sustains an extra-articular fracture of the distal radius and undergoes open reduction and internal fixation with a volar plate and screw construct. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. Smith's fracture: volarly displaced and extraarticular. You can rate this topic again in 12 months. He denies any new trauma, and has followed all post-operative activity restrictions. sudden impact force applied to the hand and wrist causing SLIL injury and scapholunate dissociation, injury occurs most commonly with wrist positioned in extension, ulnar deviation and carpal supination, SLIL tearing will position the scaphoid in flexion and lunate extension. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Find a hand surgeon near you. The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injury, The plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis index finger injury, The patient should undergo revision fixation as soon as possible, The plate is in appropriate position and will likely never need to be removed. Pathology. The latter mechanism frequently occurs . (OBQ18.177) Displaced impaction fracture of the lunate fossa, Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner, Displaced extra-articular fracture with apex volar, Displaced extra-articular fracture with apex dorsal. dorsal fractures commonly axial fracture healing. Read millions of eBooks and audiobooks on the web, iPad, iPhone and Android. A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. He reports paresthesias in his thumb and index finger. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). ORTHOBULLETS; Flashcards. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). Distal Radius Fracture Non-Spanning External Fixator . A normal wrist without Kienbock's disease. Thank you. Which of the regions on the patient's injury AP radiograph in Figure A, if not addressed properly during surgery, represents a risk for radiocarpal instability? (OBQ04.38) Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. There is no median nerve paresthesias. (2005) ISBN:0781745861. Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. What additional data is most necessary to obtain before a reduction is attempted? Orthopaedic Specialists of North Carolina. (OBQ13.78) Philadelphia : Lippincott Williams & Wilkins, c2005. -. The injury is closed and she is neurovascularly intact. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. Mechanism of injury. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. Chronic DISI deformities may be indicated for fusion procedures depending on degree of arthritis and patient symptoms. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Greenberg's text-atlas of emergency medicine. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Lunate. Treatment involves observation, NSAIDs and splinting in early stages of disease. - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). You review his operative note in which the surgeon reports having to apply a volar locking plate in a distal position to secure the difficult intra-articular fracture. Long arm cast above the elbow for 6 weeks, Long arm cast for 3 weeks followed by a short arm cast for 3 additional weeks, Closed reduction and percutaneous pinning. . Inability to flex the thumb interphalangeal joint. A 25-year-old female falls from her horse and injures her left wrist. Radiographs are shown in Figures A and B. Epidemiology. This is an AAOS Self Assessment Exam (SAE) question. Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Fracture Non-Spanning External Fixator, Distal Radius Fracture Spanning External Fixator, Type in at least one full word to see suggestions list, 7th Annual Frontiers in Upper Extremity Surgery, Nonoperative Treatment of Distal Radius Fractures - Michael Bednar, MD, Dorsal Plating of Radius Fractures - Nader Paksima, DO, MPH, Fragment Specific Fixation Distal Radius Fractures - Mark Rekant, MD, 12th Annual Orthopaedic Trauma: Pushing The Envelope. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. There is injury of all of the perilunate ligaments, most significantly the dorsal radiolunate ligament. Volar wrist swelling is usually prominent. Displaced impaction fracture of the lunate fossa. Electromyography and nerve conduction velocity studies, AP and lateral radiographs of the forearm, (SAE07SM.78) A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. What is the next most appropriate step in management? - it differs from Colles' or Smith's Fracture in that the dislocation is the most striking radiographic finding; - volar Barton's is more common than dorsal Barton frxs; - mechanism: - usually result from a fall upon an outstretched arm, leading to dorsiflexion stress and tension failure of volar lip of radius; (2017) Journal of Hand Surgery (European Volume). Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). AP and lateral radiographs of the wrist are shown in figures A and B respectively. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. {"url":"/signup-modal-props.json?lang=us"}, Dixon A, Hacking C, El-Feky M, et al. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. It is essentially the same sequela of . toe phalanx fracture orthobullets (OBQ18.223) Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. 110 West Rd., Suite 227 Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to Nerve compression; open reduction internal fixation with open carpal tunnel release, Nerve laceration; open reduction internal fixation with primary nerve repair or grafting, Decreased arterial inflow; fasciotomy with open reduction internal fixation, Nerve compression; repeat closed reduction. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-80825, see full revision history and disclosures, Mayfield classification of carpal instability, dorsal intercalated segment instability (DISI), volar intercalated segment instability (VISI), scaphoid nonunion advanced collapse (SNAC), triangular fibrocartilaginous complex (TFCC) injuries, ulnar-sided wrist impaction and impingement syndromes, calcium pyrophosphate dihydrate deposition disease. Data Trace Publishing Company A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. not be relevant to the changes that were made. whilst on the lateral the capitate no longer sits in the lunate. The patient shows you the lateral film in Figure A. Dorsally displaced, extra-articular fracture. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. main cause for these lesions is a direct impact against a hard surface with a, 4th or 5th metacarpal base fractures or dislocations, usually required to delineate fracture pattern and determine operative plan, diagnosis confirmed by history, physical exam, and, may be used for extra-articular non-displaced fracture, most fractures are intra-articular and require open reduction, interfragmentary screws +/- k-wires for temporary stabilization, fixation may be obtained with K wires or screws, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). 1980;5 (3): 226-41. Other common causes include: car . In this condition, the lunate bone loses its blood supply, leading to death of the bone. - deviation of more than 15 deg either way between the links of chain may be viewed as lax, diseased, or damaged; - Exam: The patient undergoes open reduction internal fixation (ORIF). Medical Information Search Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ11.273) FOOSH), high incidence of distal radius fractures in women > 50 years old, DEXA scan is recommended for women with distal radius fractures, fall on outstretched hand (FOOSH) is most common in older population, higher energy mechanism more common in younger patients, includes the radial styloid and scaphoid fossa, attachment sites for the brachioradialis tendon, long radiolunate ligament, and radioscaphocapitate ligament, serves as a buttress to resist radial carpal translation, functions as a load-bearing platform for activities performed with the wrist in ulnar deviation, holds the carpus out to length radially, allowing a more uniform distribution of load across the scaphoid and lunate facets, serves as an anchor for the radioscaphocapitate ligament that prevents ulnar translation of the carpus, transmits load from the carpus to the forearm, based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fracture, divides intra-articular fractures into 4 types based on displacement, Depressed fracture of the lunate fossa of the articular surface of the distal radius, Fracture-dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx), Low energy, dorsally displaced, extra-articular fx, Low energy, volarly displaced, extra-articular fx, usually a fall onto outstretched hand (FOOSH), Dorsal angulation < 5 or within 20 of contralateral distal radius, dorsal angulation < 5 or within 20 of contralateral distal radius, extra-articular fracture with stable volar cortex, 82-90% good results if used appropriately, radiographic findings indicating instability (pre-reduction radiographs best predictor of stability), dorsal angulation > 5 or > 20 of contralateral distal radius, displaced intra-articular fractures > 2mm, associated ulnar styloid fractures do not require fixation, articular margin fractures (dorsal and volar Barton's fractures), the volar ulnar corner (critical corner) supports the volar lunate facet with its strong radiolunate ligament attachments, failure to address this fragment can result in volar carpal subluxation, comminuted and displaced extra-articular fractures (Smith's fractures), progressive loss of volar tilt and radial length following closed reduction and casting, medically unstable patients unable to undergo a lengthy procedure, important adjunct with 80-90% good/excellent results, therefore usually combined with percutaneous pinning technique or plate fixation, apply longitudinal traction and volar/dorsal pressure to the distal fracture fragment, avoid positions of extreme flexion and ulnar deviation (Cotton-Loder Position), no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization, radial shortening is the most predictive of instability, followed by dorsal comminution, dorsal comminution > 50%, palmar comminution, intraarticular comminution, higher loss of reduction with 3 or more of LaFontaine criteria, Meta-analyses and systematic reviews demonstrate no difference in functional outcomes between closed treatment versus operative methods in elderly patients (>65 years old), K wires are placed dorsally into the fracture and used as reduction tools until they are driven into the proximal radius, Rayhack technique with arthroscopically assisted reduction, distal radius extra-articular fracture ORIF with volar approach, distal radius intra-articular fracture ORIF with dorsal approach, associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons, can have hyperesthesia over the base of the thenar eminence due to palmar cutaneous nerve injury during retraction of the digital flexor tendons when plating the distal radius, new volar locking plates offer improved support to subchondral bone, intra-articular distal radius fractures with dorsal comminution, can combine with external fixation and percutaneous pinning, volar lunate facet fragments may require fragment-specific fixation to prevent early postoperative failure, screw penetration into the radiocarpal joint or DRUJ, assess intra-articular screws with a 23 degree elevated lateral view, assess dorsal cortex penetration with a skyline view, no benefit of therapist-directed physical therapy compared to home exercise program, distal radius fracture spanning external fixator, distal radius fracture non-spanning external fixator, place radial shaft pins under direct visualization to avoid injury to superficial radial nerve, and excessive volar flexion and ulnar deviation, pin site care comprising daily showers and dry dressings recommended, prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder position), progressive paresthesias, weakness in thumb opposition, paresthesias that do not respond to reduction and last > 24-48 hours, nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the EPL tendon, extensor mechanism is thought to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition or a local area of ischemia in the tendon, volar plating with screw fixation that penetrates the dorsal cortex and is proud dorsally, very distal volar plate placement on the radius (distal to watershed line) is associated with FPL rupture, due to physical contact of tendon on plate and subsequent tendinopathy, 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2mm, delayed procedure associated with higher need for bone grafting and a more difficult procedure, radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fractures, AAOS 2010 clinical practice guidelines recommend, early efforts to regain motion of wrist and fingers, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Lunate dislocations typically occur due to a fall on an outstretched hand (or during a motor vehicle injury) where there is forceful dorsiflexion of the wrist 3. His radiograph is shown in Figure A. (OBQ12.244) Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. Isolated capitate fractures are rare (scaphoid is most common associated fracture) Occurs via forceful dorsiflexion of hand (FOOSH injury) with impact on radial side; Proximal fracture fragment at risk for avascular necrosis; Clinical Features. Wrist Dislocation by Kadeer M Halimi from emedicine.com. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-10010, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":10010,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/lunate-dislocation/questions/1703?lang=us"}, Figure 1: Stage 4 of progressive perilunate, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, Mayfield classification of carpal instability, dorsal intercalated segment instability (DISI), volar intercalated segment instability (VISI), scaphoid nonunion advanced collapse (SNAC), triangular fibrocartilaginous complex (TFCC) injuries, ulnar-sided wrist impaction and impingement syndromes, calcium pyrophosphate dihydrate deposition disease, Philips Australia, Paid speaker at Philips Spectral CT events (ongoing). Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Copyright 2023 Lineage Medical, Inc. All rights reserved. Phalanx fractures of the hand are some of the most common fractures occurring in humans. The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Diagnosis is made with PA wrist radiographs showing widening of the SL joint. Both images from . 43 (1): 84-92. A 32-year-old professional baseball player presents with wrist pain after a fall on his outstretched wrist 10 days ago. A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. For more advanced stages, surgery is usually considered. Scaphoid Lunate Advanced Collapse (S-LAC) - Hand - Orthobullets Scapholunate ligament - Wikipedia positive test seen in patients with scaphol-unate ligament injury or patients with liga-mentous laxity, where the scaphoid is no longer constrained proximally and sublux-ates out of the scaphoid fossa resulting in pain; when pressure removed from the - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms. Difficult wrist fractures. Patients often prefer to hold their fingers in partial flexion due to pain on extension. She was seen in the emergency department at the time of injury and was told she had a sprain. push up position), may be associated with wrist instability or weakness, may see swelling over the dorsal aspect of the wrist, tenderness in the anatomical snuffbox or over the, pain increased with extreme wrist extension and radial deviation, when deviating from ulnar to radial, pressure over volar aspect of scaphoid subluxates the scaphoid dorsally out of the scaphoid fossa of the distal radius, and a clunk is palpated when pressure is released as the scaphoid reduces back over the dorsal rim of the radius, a painful clunk during this maneuver may indicate insufficiency of scapholunate ligament, clenched fist (can exaggerate the diastasis), dorsal tilt of lunate leads to SL angle > 70, may be used as screening tool for arthroscopy, always assess the contralateral wrist for comparison, may demonstrate the presence of a tear but cannot determine the size of the tear, positive finding of a tear may indicate the need for wrist arthroscopy, often overused as a screening modality for SLIL tears, requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis, Carpal instability nondissociative (CIND), splinting and close follow-up with repeat imaging and clinical response with acute injuries, most people feel casting alone is insufficient, acute scapholunate ligament injury without carpal malalignment, ligament pathoanatomy is ammenable to repair, if pathoanatomy of SL ligament injury is a scaphoid fx than repair with, small incision is made just distal to the radial styloid, care to avoid cutting the radial sensory nerve branches, often added to a ligament repair and remains a viable alternative for a chronic instability when ligament repair is not feasible, place two k-wires in parallel into the scaphoid bone, reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation, confirm reduction of the SL joint under fluoroscopy, FCR tendon transfer (direct SL joint reduction), ECRB tendonosis (indirect SL joint reduction), weave not recommended due to high incidence of late failure. He is not able to see a physician for 4 months. 28 (6): 1771-84. Lunate dislocations are an uncommon traumatic wrist injury that require prompt management and surgical repair. (SBQ17SE.47) This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. Carpal tunnel release if no resolution at 6-12 weeks. ADVERTISEMENT: Supporters see fewer/no ads. Deciding whether a fracture needs reducing. - w/ flexion and extension lunate/capitate articulation may be felt; J Hand Surg Am. Radiographic features Inability to extend the index finger proximal interphalangeal joint. Diagnosis requires careful evaluation of plain radiographs. The combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? At the time the article was created Andrew Dixon had no recorded disclosures. Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. Thank you. Radiographs obtained at the time of injury are shown in Figure A. Summary. (OBQ07.8) Three months after the fracture she reports an acute loss of her ability to extend her thumb. The lunate is made up of the volar pole, body, and dorsal pole. It is the second most common carpal bone injury in children 1. - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament; Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . The black dot in the photo is the capitate. Kienbocks disease is most common in men between the ages of 20 and 40. (OBQ08.179) He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. (OBQ09.227) A 17-year-old male falls from a retaining wall onto his left arm. Depressed fracture of the lunate fossa (articular surface) Smith's. Unable to process the form. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. Lunate Dislocation (Perilunate dissociation). Unable to process the form. A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. Mayfield JK, Johnson RP, Kilcoyne RK. Patients present with wrist pain following a fall. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Which of the following injuries is the most likely cause of this finding? The rest of the carpal bones are in a normal anatomic position in relation to the radius. Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. diastasis of the scapholunate complex occurs with complete SLIL tears and capsule disruption. Cleveland Combined Hand Fellowship Lecture Series 2019-2020, Fractures of the Other Carpal Bones - Austin Pitcher, MD. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Surgery may be done to change forces across the lunate and wrist joint or to improve vascularity of the lunate. (SBQ17SE.70) They often are not diagnosed initially and present delayed as lunate osteonecrosis, which is also known as Kienbock disease. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. On physical exam she has no sensation of the volar thumb, index, and middle fingers. What is the next best step in management of this patient? Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. shepherd school of music notable alumni,
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