月骨脱位手术图解.ppt

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