At the time the article was last revised Craig Hacking had no recorded disclosures. (OBQ12.38) He sustained 2 minor falls over the next 6 years and his wrist pain recurred. (2017) Journal of Hand Surgery (European Volume). Four months post-injury, he presents to the office with an inability to extend his thumb. In this condition, the lunate bone loses its blood supply, leading to death of the bone. arthroscopic repair and percutaneous pinning. It can be difficult to diagnose in its earlier stages. A recent imaging study is seen in Figure A. Radiographs are shown in Figures A and B. Hand therapy does not change the course of the disease; however, it can help to minimize loss of motion from the disease. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. A 45-year-old male sustained a fall onto his right wrist 2 weeks ago. 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. The instrument touches a structure that prevents ulnar translocation of the carpus after a PRC. A 65-year-old female sustains a fall onto her outstretched right hand. The lunate is made up of the volar pole, body, and dorsal pole. Fractures of the normal lunate--isolated or associated with fractures of the scaphoid or radius--are very rare. Lunate fracture. Capitate fractures are most commonly due to high-energy, hyperextension forces 2. There are no open wounds and the hand is neurovascularly intact. Which of the following tendons is most commonly transferred to address the patient's deficiency? Scapho-lunate advanced collapse arthritis or SLAC occurs as the result of unrecognised injury to the . Treatment options depend upon the severity and stage of the disease. Around 20% of patients possess a single-vessel supply to their lunate hence there is an increased possibility of avascular necrosis, the remaining cohort typically has a two-vessel supply and intraosseous anastomosis 2. The mechanism of injury is typically a fall onto an outstretched hand with a hyperextended wrist or during a . Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Diagnosis requires careful evaluation of plain radiographs. The patient undergoes open reduction internal fixation (ORIF). 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. - most frequently dislocated carpal bone; In very early stages, the treatment can be as simple as observation, activity changes, and/or immobilization. In this condition, the lunate bone loses its blood supply, leading to death of the bone. 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. It is the second most common carpal bone injury in children 1. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. (SBQ17SE.12) A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. Treatment of acute SL ligament injuries may be immobilization versus operative repair/reconstruction depending on degree of displacement. 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. Lunate. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist? 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). FlashCards My DeckMaster Create Card Deck . A 65-year-old man fell and injured his right wrist. Both images from . A 25-year-old female falls from her horse and injures her left wrist. Treatment requires urgent closed versus open reduction and stabilization. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Indications. Mechanism of injury. His radiograph is shown in Figure A. (OBQ04.38) Adhesions within the first and third dorsal wrist compartments. When dislocation occurs in the wrist . Wheeless' Textbook of Orthopaedics. (SBQ07SM.38) A fracture to the lunate may also be associated with injury to the TFCC. When performed on 18 children with distal radius-ulna fractures, P . Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint . Proper . Scaphoid Lunate Advanced Collapse (SLAC) - Hand - Orthobullets SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. (OBQ06.102) He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking plate fixation. What additional data is most necessary to obtain before a reduction is attempted? Which of the following injuries is the most likely cause of this finding? - knowing position of ECU & ulnar styloid helds to differentiate ECU tendinitisfrom distal radioulnar problems. The other types are perilunate, trans-radial styloid and . - Discussion: Diagnosis is generally made with radiographs of the wrist but may require CT for confirmation. 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. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. A normal wrist without Kienbock's disease. Stage III involves disruption of the the lunotriquetral ligament or triquetral fractures. Treatment involves observation, NSAIDs and splinting in early stages of disease. (SBQ17SE.67) Data Trace Publishing Company 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. lunate fracture orthobullets Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. He initially thought it was a sprain, but presents due to continued pain worsened by push-ups. Revista dedicada a la medicina Estetica Rejuvenecimiento y AntiEdad. Barton's. Fracture-dislocation of radiocarpal joint (with intra-articular fracture involving the volar or dorsal lip) Chauffer's. Fracture of radial styloid. The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). 1980;5 (3): 226-41. whilst on the lateral the capitate no longer sits in the lunate. Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. Late treatment of a dorsal transscaphoid, transtriquetral perilunate wrist dislocation with avascular changes of the lunate. Radiographs are provided in Figures A-C. 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). Displaced impaction fracture of the lunate fossa. The lunate is a central bone in the wrist that is important for proper movement and support of the joint (Figure 1). Which plating option provides the most appropriate treatment of this fracture? Telephone: 410.494.4994, Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius, Difficult wrist fractures. 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. Lunate fracture. You can rate this topic again in 12 months. Incidence. 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. 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. Summary. (SBQ17SE.75) A radiograph is shown in figure A. A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. Radiographs show a well-fixed fracture in good alignment. A 35-year-old professional football player complains of severe wrist pain after making a tackle. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle > 70 degrees. Classification. (OBQ09.227) What is the likely mechanism of her paresthesias and what is the most appropriate treatment? Hook of hamate fractures are rare, often missed, injuries generally as a result of a direct blow to the hamate bone most commonly seen in athletes. Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. What is this structure? Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Check for errors and try again. Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent.A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability. Phalanx fractures of the hand are some of the most common fractures occurring in humans. 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. Carpal tunnel release if no resolution at 6-12 weeks. A 52-year-old farmers periodic wrist pain has been managed with non-operative modalities to include two injections in the last 8 months. Copyright 2023 Lineage Medical, Inc. All rights reserved. (SBQ17SE.13) - tenderness of dorsal lunate may suggest Keinbock's dz, while moreulnar tenderness suggests tears of TFC or lunotriquetral ligament; Data Trace is the publisher of What joint is first affected if left untreated with subsequent development of a SLAC (scapholunate advanced collapse) wrist? Die-Punch: Depressed fracture of lunate fossa of distal radius due to an axial loading injury. 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. Which of the following interventions should be taken? 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? - colinear alignment of: radius, lunate, capitate, & 3rd metacarpal; At the time the article was last revised Craig Hacking had the following disclosures: These were assessed during peer review and were determined to A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. The injury pattern may involve a crush injury, a FOOSH injury (Figure 18.21), or a direct blow to the dorsal aspect of the wrist. - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: A radiograph is shown in Figure 21. The patient undergoes open reduction and internal fixation of the fracture. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. Wrist Dislocation by Kadeer M Halimi from emedicine.com. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. Hip fracture . Radiographic features (OBQ16.228) Inability to flex the thumb interphalangeal joint. not be relevant to the changes that were made. Unable to process the form. The rest of the carpal bones are in a normal anatomic position in relation to the radius. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). (OBQ13.140) Which of the following has evidence to support its utility in this clinical situation? Isolated fractures without displacement or subluxation can be managed conservatively, however fractures that possess joint subluxation are unstable and require surgical intervention 2. Post-operatively she is given a prescription with the goal of mitigating a potential adverse outcome. Perilunate fracture-dislocations of the wrist. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. Copyright 2023 Lineage Medical, Inc. All rights reserved. (OBQ04.233) The patient now reports increasing pain and inability to use his wrist. Philadelphia : Lippincott Williams & Wilkins, c2005. Lunate fracturesare a carpal injury that if left untreated, can result in significant carpal instability. Greenberg's text-atlas of emergency medicine. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. A 76-year-old male sustains a minimally displaced distal radius fracture and undergoes closed treatment with a cast. Mayfield JK, Johnson RP, Kilcoyne RK. - w/ flexion and extension lunate/capitate articulation may be felt; Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, 23-Year-Old Skateboarder Falls On An Outstretched Arm With A Scapholunate Full-Thickness Tear: All Those Procedures To Repair Don't Work, I Have The Answer: 'RASL' Dazzle: I Am Not Dead Yet, Look At My Long-Term Results - Melvin P. Rosenwasser, MD, Modified Brunelli for Scapholunate Reconstruction, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Wrist Scapholunate (SL) Ligament Injury in 52M. ADVERTISEMENT: Supporters see fewer/no ads. - it has large volar surface, & is displaced volarward w/ forceddorsiflexion of the wrist; Adequate maintenance of reduction by non-operative treatment is unsuccesful. 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. Scapholunate Ligament Injury is a source of dorsoradial wrist pain with chronic injuries leading to a form of wrist instability (DISI deformity). 4. 2.0 screw for a Scaphoid Hand Fracture How to palpate the . A variety of operative procedures may be indicated depending on severity of disease and patient's symptoms. Clifford R. Wheeless, III, M.D. The proximal 2 Cs indicates the articulation between the lunate and . The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. - lunate, capitate, and the base of the 3rd metacarpal are in line w/each other & is covered by base of ECRB; Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. educational laws affecting teachers. He was treated as a sprain and no further follow-up was planned. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. The lunate is displaced and rotated volarly. The next best step in management would be: (OBQ12.163) The most important differential is of other carpal dislocations, particularly: In addition to stating that a lunate dislocation is present, a number of features should be sought and commented upon: ensure that radiolunate alignment is disrupted, and that you are not looking at a perilunate dislocation(stage II carpal dislocation), evaluate and comment on the degree or palmar rotation of the lunate (this can be up to 270 degrees)4, ensure that the capitate remains co-linear with the long axis of the radius, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Barton's fracture: Dorsal intraarticular fracture which is often associated with dislocation at the radiocarpal joint. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Find a hand surgeon near you. Dependent on the fracture-line and the intraosseous vascularity, partial or total avascular . She was seen in the emergency department at the time of injury and was told she had a sprain. If time has passed since injury, it can also lead to wrist arthritis. When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. 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 As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. ADVERTISEMENT: Supporters see fewer/no ads. 43 (1): 84-92. Epidemiology. 3, Greenberg MI. He reports having undergone open reduction and internal fixation of a distal radius fracture 1 year prior that healed uneventfully. Like the scaphoid bone, the lunate also has a tenuous retrograde blood supply off of an interosseus arterial branch, and it has the same inherent risk of poor healing and AVN . He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 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. Diagnosis requires careful evaluation of plain radiographs. A 17-year-old male falls from a retaining wall onto his left arm. 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. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Kienbocks disease is also known as avascular necrosis (AVN) of the lunate. 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).

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