lunate fracture orthobullets

Mechanism of injury. The force of injury in this syndrome can propagate leading to perilunate dislocation as . Die-punch. lunate fracture orthobullets Colles'. The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Check for errors and try again. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient? As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. Thieme Medical Pub. 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. - lunate articulates proximally w/ radius and distally w/ capitate; Hand therapy does not change the course of the disease; however, it can help to minimize loss of motion from the disease. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. 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. (2017) Journal of Hand Surgery (European Volume). DISI (dorsal intercalated segmental instability), scapholunate dissociation causes the scaphoid to flex palmar and the lunate to dorsiflex, if left untreated the DISI deformity can progress into a, DISI deformity may also develop secondary to distal pole of the scaphoid excision for treatment of STT arthritis, DISI is a form of carpal instability dissociative, c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and lunate bones, dorsal fiber thickened (2-3mm) compared to volar fibers, dorsal component provides the greatest constraint to translation between the scaphoid and lunate bones, proximal fibers have minimal mechanical strength, Overview of wrist ligaments and biomechanics, acute FOOSH injury vs. degenerative rupture, age, nature of injury, duration since injury, degree of underlying arthritis, level of activity, pain increased with loading across the wrist (e.g. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. 2023 Lineage Medical, Inc. All rights reserved. Lunate fracture. commonly missed (~25%) on initial presentation, occurs when wrist extended and ulnarly deviated, disruption of capitolunate articulation -->, disruption of lunotriquetral articulation -->, failure of dorsal radiocarpal ligament -->, ligamentous disruptions with associated fractures of the radius, ulnar, or carpal bones, lunate stays in position while carpus dislocates, lunate forced volar or dorsal while carpus remains aligned, major stabilizers of the proximal carpal row, ligaments the both originate and insert among the carpal bones, + lunotriquetral disruption, "perilunate", Lunate dislocated from lunate fossa (usually volar), median nerve symptoms may occur in ~25% of patients, most common in Mayfield stage IV where the lunate dislocates into the carpal tunnel, due to palmar rotation from dorsal force of carpus, loss of colinearity of radius, lunate, and capitate, no indications when used as definitive management, universally poor functional outcomes with non-operative management, emergent closed reduction/splinting followed by open reduction, ligament repair, fixation, possible carpal tunnel release, decreased grip strength and stiffness are common, chronic injury (defined as >8 weeks after initial injury), not uncommon, as initial diagnosis frequently missed, chronic injuries with degenerative changes, finger traps, elbow at 90 degrees of flexion, dorsal dislocations are reduced through wrist extension, traction, and flexion of wrist, longitudinal incision centered at Lister's tubercle, excellent exposure of proximal carpal row and midcarpal joints, extended carpal tunnel incision just proximal to volar wrist crease, some believe volar ligament repair not necessary, difficulty regaining digital flexion and grip, controversy of k-wire versus intraosseous cerclage wiring, repair of lunotriquetral interosseous ligament, decision to repair based on surgeon preference as no studies have shown improved results, short arm thumb spica splint converted to short arm cast at first post-op visit, duration of casting varies, but at least 6 weeks, perform via dorsal and volar incisions if median nerve compression is present, volar approach allows median nerve decompression with excision of lunate, dorsal approach facilitates excision of the scaphoid and triquetrum, radiodense appearance of the lunate on radiograph reported in up to 12.5% of cases, usually identified 1-4 months post-injury, - 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). Copyright 2023 Lineage Medical, Inc. All rights reserved. The rest of the carpal bones are in a normal anatomic position in relation to the radius. (OBQ18.216) Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis (SAE07SM.38) Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . Radiographs are provided in Figures A-C. 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). Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. Incidence. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Surgery may be done to change forces across the lunate and wrist joint or to improve vascularity of the lunate. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Epidemiology. Perilunate fracture-dislocations of the wrist. Pearls/pitfalls. Given the lunate's position in the wrist, there is significant overlap from other carpal bones and hence these fractures can be subtle. (OBQ12.244) Type in at least one full word to see suggestions list, Hand Scaphoid Lunate Advanced Collapse (SLAC). A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. At the time the article was created Andrew Murphy had no recorded disclosures. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). Treatment involves observation, NSAIDs and splinting in early stages of disease. J Hand Surg Am. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). (OBQ07.226) He reports paresthesias in his thumb and index finger. A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. Immediate post-operative radiographs are seen in Figure A. Fractures of the normal lunate--isolated or associated with fractures of the scaphoid or radius--are very rare. -. Epidemiology. What is the next best step in management of this patient? Flashcards. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. Lunate Dislocation (Perilunate dissociation) . Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: The patient now reports increasing pain and inability to use his wrist. Medical Information Search A four-stage process to describe perilunar instability has been described,where lunate dislocation represents stage IV 2. disruption of the normally smooth line made by tracing the proximal articular surfaces of the hamate and capitate, lunate overlaps the capitate and has a 'triangular' or 'piece of pie' appearance (also seen in perilunate dislocation), signet ring sign: rounded appearance of the scaphoid tubercle due to rotatory subluxation from injury to the scapholunate ligament, lunate seen displaced and angulated volarly, lunate does not articulate with capitate or radius (as opposed to perilunate dislocation where the lunate remains aligned with the radius). Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Capitate fractures are typically seen with associated scaphoid fractures, distal radial fractures, or lunate injuries; they are rarely seen in isolation. Incompetence of which of the following anatomic structures is the most likely etiology of this finding? Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. 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. - most frequently dislocated carpal bone; A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms. Scapholunate Advanced Collapse Article - StatPearls Wrist osteoarthritis - Wikipedia Hip fracture Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? The patient undergoes open reduction and internal fixation of the fracture. Both images from . (OBQ08.179) tures, specically non-union of scaphoid fractures. Extensor carpi radialis longus transfer to extensor pollicus longus, Extensor pollicis brevis transfer to extensor pollicus longus, Extensor indicis proprius transfer to extensor pollicus longus, Primary repair of extensor pollicus longus. 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 The lunate is one of the eight small bones in the wrist. (OBQ09.254) 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). 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 combination of a capitate fracture and a scaphoid waist fractureis known as "scaphocapitate syndrome" . A fracture to the lunate may also be associated with injury to the TFCC. (OBQ06.136) 2. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. His radiograph is shown in Figure A. Inability to extend the thumb interphalangeal joint. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Distal radius fractures are themost common orthopaedic injury and generally result from fall on an outstretched hand. Thank you. 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. The lunate is an important stabilizer of the wrist, fractures can lead to ligamentous injury and overall volar intercalated segment instability. Which of the following has evidence to support its utility in this clinical situation? Distal Radius Fracture Non-Spanning External Fixator . His physical exam shows dorsal wrist tenderness and is positive for the provocative test shown in Figure V. Standard PA radiograph of the wrist is normal. At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to ORTHOBULLETS; Flashcards. immobilization in a short arm thumb spica cast. Copyright 2023 Lineage Medical, Inc. All rights reserved. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. Find a hand surgeon near you. Read 14. Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. Radiographs are shown in Figures A and B. There may be other associated injuries that require further investigation via cross-sectional imaging 1,2. immobilization in a long arm thumb spica cast. Copyright 2023 Lineage Medical, Inc. All rights reserved. Lunate fractures are often secondary to axial loading of the head capitate bone,this is seen in forceful hyperextension with ulnar deviation 2. (SBQ17SE.47) 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. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. The lunate is rotated forming a triangular shape commonly known as the "piece-of-pie" sign. Carpal dislocations: pathomechanics and progressive perilunar instability. Which of the following distal radius fractures is associated with volar translation of carpus relative to the radial articulation? You can rate this topic again in 12 months. A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. This medication is given in an effort to decrease the incidence of which of the following? The lunate is displaced and rotated volarly. How do you counsel him about his post-operative period? Ulnar side of hand. He denies any new trauma, and has followed all post-operative activity restrictions. The black dot in the photo is the capitate. You can rate this topic again in 12 months. Three months after the fracture she reports an acute loss of her ability to extend her thumb. Data Trace Publishing Company The patient shows you the lateral film in Figure A. What complication is most likely to occur in this patient? Copyright 2023 Lineage Medical, Inc. All rights reserved. There is no single cause of Kienbocks disease. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. FlashCards My DeckMaster Create Card Deck . . - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. It works closely with the two forearm bones (the radius and ulna) to help the wrist move. . A radiograph is shown in figure A. Dorsally displaced, extra-articular fracture. A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. A 57-year-old woman underwent open reduction internal fixation from a volar approach for a displaced distal radius fracture. (OBQ05.195) A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. At the time the article was created Andrew Dixon had no recorded disclosures. What is this structure? Orthobullets Team Trauma - Distal Radius Fractures Technique Guide. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Figure A is an intraoperative photo. You can rate this topic again in 12 months. Evaluation of volar compartment pressures with a needle monitor, Icing and elevation of the arm with follow-up evaluation in 8 hours, Immediate EMG evaluation of the left upper extremity, Closed reduction, carpal tunnel release, and sugar tong splinting, Emergent open reduction internal fixation with carpal tunnel release. Ulnar gutter splint/cast. (SBQ17SE.70) Due to a fall onto a flexed wrist or a blow to the back of hand. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. A 56-year-old woman sustains the closed injury depicted in Figures A-B. Unable to process the form. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. (OBQ06.102) Inability to flex the index finger proximal interphalangeal joint. Lunate fractures account for around 4% of all carpal fractures 1. Treatment requires urgent closed versus open reduction and stabilization. Clifford R. Wheeless, III, M.D. 73% (1391/1911) 3. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Perilunate dislocations and fracture-dislocations are relatively uncommon injury patterns in acute wrist trauma. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). The lunate is displaced and rotated volarly. What additional data is most necessary to obtain before a reduction is attempted? 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. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Lunate/perilunate dislocations are high energy injuries to the wrist associated with neurological injury and poor functional outcomes. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. educational laws affecting teachers. Lunate fractures and associated radiocarpal and midcarpal instabilities: a systematic review:. 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.