Lunate Facet Malunion with Osteotomy

Case Presentation: A 36 year old gentleman sustained a wrist injury while running and falling but xrays at the time were reportedly negative for a fracture.  He was given a splint but had continued and persistent pain and swelling.  He came to my office 6 months later and xrays and a CT scan showed a dislocated wrist with a malunited lunate facet fragment.  Based on his young age and long term function, I recommended an osteotomy to correct the bone and restore the articular surface.  The fracture healed uneventfully and he worked aggressively with therapy to regain motion which plateaued at 1 year with wrist flex/ext of 25/55 degrees and supination/pronation of 50/80 degrees.



Distal Radius 3 plates

Case Presentation: 30 year old gentleman injured his distal radius (wrist fracture) while snowboarding.  He had a severe fracture with separation of the lunate and scaphoid facet fragments.  Intra-operative fixation required individual fragment specific plating with screws, wires, and plates.  The fracture healed in a reasonable position, and the plates were taken out once healed due to some mild irritation. Once recovered he had nearly full motion and was very pleased.


  

CRPS Images

The following images represent classic signs and symptoms of Complex Regional Pain Syndrome, also known as CRPS.  Historically, this has also been referred to as sympathetic reflex dystrophy or causalgia.

I have found that the most sensitive and predictive finding is a dramatic loss in function (strength or motion) of a body part that is out of proportion to the injury.  Other common findings include:

  • changes in skin texture on the affected area; it may appear shiny and thin
  • abnormal sweating pattern in the affected area or surrounding areas
  • changes in nail and hair growth patterns
  • stiffness in affected joints
  • problems coordinating muscle movement, with decreased ability to move the affected body part
  • abnormal movement in the affected limb, most often fixed abnormal posture (called dystonia) but also tremors in or jerking of the limb.

Treatment always requires a prompt diagnosis and typically starts with therapy to improve motion and reduce discomfort.  However, some evidence suggests CRPS is propagated by a compressed nerve (ie: median nerve) and surgical intervention is sometimes recommend, such as a carpal tunnel release.

The following images show patients with an open palm, and attempted closed fist, compared to the normal side.

Median Nerve Allograft

History/Diagnosis: This patient is a 35 year old gentlement who sustained a glass puncture injury to his forearm about 3 weeks before presenting to my office for evaluation.  He initially did not think the injury was severe, but due to continued pain and numbness was concerned that it may be more involved.  His exam was consistent with numbness in the median nerve distribution and a laceration suggesting a median nerve injury. I recommended exploration and allograft repair. 

Treatment: Intra-operatively he was found to have a completed laceration of the median nerve.  I resected the nerve to healthy tissue and performed an allograft repair with suture and fibrin glue.

 

Outcome: He did very well during his recovery.  He recovered nearly 100% of his finger motion.  His sensation improved every visit and by 6 months he had sensation and tingling into the tips of his thumb, index, and middle fingers. 

 

Complex Motorcycle Accident

History/Diagnosis: This patient sustained a very severe motorcycle accident with open injuries to the forearm, wrist, hand, and fingers.  There were fractures of the ulna, radius, ulnar styloid, thumb dislocation, metacarpals, and CMC joints.  I took her to the operative room for extensive surgery to repair and reconstruct all of the injuries.  

Treatment: Complex repair of all injuries.

Outcome: She did exceptionally well, essentially regaining full function and strength.  She returned to riding motorcycles, returned to work, and was very pleased!

 

Radius Shaft Fracture ORIF

History/Diagnosis: This gentleman sustained an isolated radial shaft fracture. 

Treatment: Radial shaft ORIF

Outcome: He regained full motion and strength without any limitations

 

Bilateral Forearm ORIF

History: 22 year-old male injured in a motorcycle accident with bilateral forearm fractures of the radius and ulna.  

Diagnosis: Complex bilateral forearm fractures with comminution, open injuries, and need for repair

 

Treatment: Bilateral forearm ORIF

  

Outcome: Within 6 weeks he had near full motion. He had minimal pain and was quite pleased with the final result. 

Steroid Skin Blanching

The following images demonstrate the temporary depigmentation and atrophy effects of Kenalog injected in the hand and wrist. The follow-up image is 6 months later.

 

 

3 Phalanx IM screws

History: 39 year old gentleman came to the office after a steel beam fell on his hand, crushing his index, middle, and ring fingers.  He had fractures of the proximal phalanx to all three fingers and limited motion, swelling, and pain. 

Diagnosis: P1 fractures of index, middle, ring fingers

 

Treatment: Index and Middle fingers intramedullary screw, Ring finger pinning

Outcome: At 2.5 months he had nearly full motion and no pain.  The index and middle fingers were significantly better than the ring finger in regards to motion. 

Table Saw Skin Graft

History: 63 year old gentleman sustained a table saw injury to his right index finger.  This included a deep skin injury with full thickness loss but did not seem to involved the tendons, nerves, or vessels.  

Diagnosis: Right index full thickness loss

Treatment: Full thickness skin graft to digit

Outcome: Despite early loss of part of the graft, the entire wound quickly granulated in resulting in full coverage, full motion, and return to full activities.