lunate fracture orthobullets

A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. (2017) Journal of Hand Surgery (European Volume). The lunocapitate articulation may be disrupted resulting in a dorsal perilunate dislocation, or in the case of concomitant scaphoid fracture, the wrist may undergo a transscaphoperilunate dislocation. The lunate is displaced and rotated volarly. There is injury of all of the perilunate ligaments, most significantly the dorsal radiolunate ligament. A fracture to the lunate may also be associated with injury to the TFCC. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. Which of the following interventions should be taken? Urgent reduction and surgical repair of disrupted ligaments is required to prevent long-term joint dysfunction. What is the likely mechanism of her paresthesias and what is the most appropriate treatment? - lunate articulates proximally w/ radius and distally w/ capitate; Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. Epidemiology. Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? (2005) ISBN:0781745861. Diagnosis is made with PA wrist radiographs showing widening of the SL joint. It can be difficult to diagnose in its earlier stages. Despite treatment, there remains a high risk of future degenerative arthritis and wrist instability. Hip fracture The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). Treatment requires urgent closed versus open reduction and stabilization. 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. Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment, No difference in radiographic outcomes after ORIF vs. closed treatment, No difference in functional outcomes after ORIF vs. closed treatment, Improved functional outcomes with closed treatment vs. ORIF, Improved functional outcomes with external fixation and K wire fixation vs. ORIF. The lunate is the fourth most fractures carpal bone (following the scaphoid, triquetrum, and trapezium). There is no single cause of Kienbocks disease. Check for errors and try again. 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). In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. Immediate post-operative radiographs are seen in Figure A. In lunate dislocations, disruption of Gilula's arcs can be appreciated with disruption of spaces between the proximal and distal carpal bones. The lunate bone articulates with the scaphoid, the distal radius, and the TFCC. Lunate fracture. Three months after the fracture she reports an acute loss of her ability to extend her thumb. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Lunate dislocationsare an uncommon traumatic wrist injury that require prompt management and surgical repair. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Adequate maintenance of reduction by non-operative treatment is unsuccesful. Colles'. What additional data is most necessary to obtain before a reduction is attempted? Radiographs are provided in Figure A. Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. Patients present with wrist pain following a fall. Lunate fractures are often secondary to axial loading of the head capitate bone,this is seen in forceful hyperextension with ulnar deviation 2. There is no median nerve paresthesias. 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). At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to 2023 Lineage Medical, Inc. All rights reserved. (OBQ09.254) A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. What is the most appropriate treatment at this time? educational laws affecting teachers. - w/ flexion and extension lunate/capitate articulation may be felt; Displaced impaction fracture of the lunate fossa. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. Patients often prefer to hold their fingers in partial flexion due to pain on extension. CT and bone scans may also be used.This is a slow-progressing disease, and patients often have the condition for months or even years before they seek treatment. It is essentially the same sequela of . Philadelphia : Lippincott Williams & Wilkins, c2005. 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. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. (OBQ05.195) Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. (OBQ04.233) The table below lists normal and acceptable ranges for these measurements (from orthobullets), but it is impossible to be proscriptive. Lunate Dislocation (Perilunate dissociation) . SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. Check for errors and try again. Carpal tunnel release if no resolution at 6-12 weeks. 43 (1): 84-92. Proper . Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. He was treated as a sprain and no further follow-up was planned. Admit for acute carpal tunnel syndrome monitoring, Admit for acute open reduction/internal fixation, Place into removable soft splint and follow-up in clinic, Place into rigid splint and follow-up in clinic, Place into rigid splint and schedule for outpatient open reduction/internal fixation. If you are unsure, it is best to err on the safe side and call for help. Which of the following tendons is most commonly transferred to address the patient's deficiency? Radiographs are provided in Figures A-C. A 56-year-old male presents to your clinic with a 4-month history of inability to extend the IP joint of his thumb. What is the most likely etiology of her new loss of function? Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of, Anterior and posterior interosseous neurectomy. (SBQ17SE.75) ADVERTISEMENT: Supporters see fewer/no ads. (OBQ12.38) 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). How do you counsel him about his post-operative period? Difficult wrist fractures. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. toe phalanx fracture orthobulletsdaniel casey ellie casey. 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. What is the next best step in management of this patient? The other types are perilunate, trans-radial styloid and . Medical Information Search 2.0 screw for a Scaphoid Hand Fracture How to palpate the . Kienbock's disease is also known as avascular necrosis (AVN) of the lunate. (OBQ18.223) Data Trace Publishing Company Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: Both images from . What is the next most appropriate step in management? arthroscopic repair and percutaneous pinning. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. (OBQ18.177) Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. (OBQ13.140) In the Traumatological Hospital Meidling/Vienna, 12 patients with acute fractures of the lunate bone were treated between 1983 and 1993. Displaced intra-articular fracture with a fragment consisting of the volar-ulnar corner. In this condition, the lunate bone loses its blood supply, leading to death of the bone. ORTHOBULLETS; Flashcards. 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. Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. (SBQ17SE.13) A radiograph is shown in figure A. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. 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. - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. Barton's. Fracture-dislocation of radiocarpal joint (with intra-articular fracture involving the volar or dorsal lip) Chauffer's. Fracture of radial styloid. Most hand and wrist fractures (the latter of which is basically an ulnar styloid fracture) are caused by trying to break a fall with your arm outstretched. scaphoid is flexed and lunate is extended as scapholunate ligament no longer restrains this articulation, lunate extended > 10 degrees past neutral, resultant scaphoid flexion and lunate extension creates, abnormal distribution of forces across midcarpal and radiocarpal joints, malalignment of concentric joint surfaces, describes predictable progression of degenerative changes from the radial styloid to the entire scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on the lunate, key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal radius, Arthritis between scaphoid and radial styloid, Arthritis between scaphoid and entire scaphoid facet of the radius, While original Watson classification describes preservation of radiolunate joint in all stages of SLAC wrist, subsequent description by other surgeons of "stage IV" pancarpal arthritis observed in rare cases where radiolunate joint is affected, validity of "stage IV" changes in SLAC wrist remains controversial and presence pancarpal arthritis should alert the clinician of a different etiology of wrist arthritis, patients localize pain in region of scapholunate interval, tenderness directly over scapholunate ligament dorsally, will not be positive in more advanced cases as arthritic changes stabilize the scaphoid, with firm pressure over the palmar tuberosity of the scaphoid, wrist is moved from ulnar to radial deviation, positive test seen in patients with scapholunate ligament injury or patients with ligamentous laxity, where the scaphoid is no longer constrained proximally and subluxates out of the scaphoid fossa resulting in pain, when pressure removed from the scaphoid, the scaphoid relocates back into the scaphoid fossa, and typical snapping or clicking occurs, obtain standard PA and lateral radiographs, PA radiograph will reveal greater than 3mm diastasis between the scaphoid and lunate, PA radiograph shows sclerosis and joint space narrowing between scaphoid and the entire scaphoid fossa of distal radius, PA radiograph shows sclerosis and joint space narrowing between the lunate and capitate, and the capitate will eventually migrate proximally into the space created by the scapholunate dissociation, thinning of articular surfaces of the proximal scaphoid, scaphoid facet of distal radius and capitatolunate joint with synovitis in radiocarpal and midcarpal joints, NSAIDs, wrist splinting, and possible corticosteroid injections, prevents impingement between proximal scaphoid and radial styloid, may be performed open or arthroscopically via 1,2 portal for instrumentation, since posterior and anterior interosseous nerve only provide proprioception and sensation to wrist capsule at their most distal branches, they can be safely dennervated to provide pain relief, can be used in combination with below procedures for Stage II or III, contraindicated with caputolunate arthritis (Stage III SLAC) because capitate articulates with lunate fossa of the distal radius, contraindicated if there is an incompetent radioscaphocapitate ligament, excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while preserving, provides relative preservation of strength and motion, also provides relative preservation of strength and motion, wrist motion occurs through the preserved articulation between lunate and distal radius (lunate fossa), similar long term clinical results between scaphoid excision/ four corner fusion and proximal row carpectomy, wrist fusion gives best pain relief and good grip strength at the cost of wrist motion, - Scaphoid Lunate Advanced Collapse (SLAC), 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 patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. The instrument touches a structure that prevents ulnar translocation of the carpus after a PRC. Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. His radiograph is shown in Figure A. Worse outcomes on the Mayo wrist score are expected without fixation, Chronic distal radioulnar joint instability can be expected to occur without fixation, Wrist function depends on the level of ulnar styloid fracture and initial displacement, Grip strength and wrist range of motion are improved with fixation, There is no adverse effect on wrist function or stability without fixation. 2023 Lineage Medical, Inc. All rights reserved. (SBQ17SE.70) A recent imaging study is seen in Figure A. Unable to process the form. 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. 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. Lunate. The patient undergoes open reduction and internal fixation of the fracture. (OBQ07.226) (OBQ17.87) 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. (SBQ17SE.12) Perilunate dislocations typically occur in young adults with high energy trauma resulting in the loading of a hyperextended, ulnarly deviated hand. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. 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 (OBQ13.78) At the time the article was created Andrew Dixon had no recorded disclosures. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). Perilunate fracture-dislocations of the wrist. lunate fracture orthobulletswellesley, ma baby store. 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.

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