Check for errors and try again. A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. (SLAC) - Hand - Orthobullets Scapholunate Advanced Collapse Article - StatPearls Scapholunate advanced collapse (SLAC) of the wrist is a very common case of degenerative arthritis . (OBQ12.168) Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. SLAC (scaphoid lunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) are the most common patterns seen. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Lunate fracture. Lunate Dislocation (Perilunate dissociation) . Diagnosis is confirmed with either a radiographic carpal tunnel view or CT scan. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Dorsally displaced, extra-articular fracture. Diagnosis requires careful evaluation of plain radiographs. He is not able to see a physician for 4 months. Hip fracture When the lunate is severely fracture, collapsed, or arthritic, salvage treatments such as lunate and other wrist bone removal may be necessary. (OBQ18.216) lunate fracture orthobullets Treatment requires urgent closed versus open reduction and stabilization. - it is palpable just distal to radial tubercle; Radiographs are provided in Figures A-C. 110 West Rd., Suite 227 He sustained 2 minor falls over the next 6 years and his wrist pain recurred. J Hand Surg Am. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, 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). A 45-year-old female barista from Portland fell off her skateboard and sustained a closed distal radius fracture. Perilunate instability represents about 7 percent of all injuries to the carpus [ 5 ]. The swelling often causes a decrease in 2-point discrimination in the median nerve distribution due to acute carpal tunnel syndrome. (OBQ06.60) 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. Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. toe phalanx fracture orthobulletsdaniel casey ellie casey. Radiographs are provided in Figure A. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 2.Meenalochani Shunmugam, Joideep Phadnis, Amy Watts, Gregory I. Bain. As he tried to brace his fall, he landed directly on his extended and ulnarly deviated left hand. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. How do you counsel him about his post-operative period? 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. 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. In the early stages of this disease, the x-rays may be normal and other tests are needed to confirm the diagnosis. Patients present with wrist pain following a fall. Immediate post-operative radiographs are seen in Figure A. Displaced impaction fracture of the lunate fossa. Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture? She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. 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). 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. Which of the following injuries is the most likely cause of this finding? If time has passed since injury, it can also lead to wrist arthritis. 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). When he finally does, he is diagnosed with a perilunate dislocation and indicated for a Proximal Row Carpectomy (PRC). What complication is most likely to occur in this patient? The latter mechanism frequently occurs . Surgery may be done to change forces across the lunate and wrist joint or to improve vascularity of the lunate. Treatment involves observation, NSAIDs and splinting in early stages of disease. Find a hand surgeon near you. Four months post-injury, he presents to the office with an inability to extend his thumb. Diffuse swelling and tenderness over capitate (just proximal to 3rd metacarpal) Differential Diagnosis A 28-year-old woman fell on her right wrist while rollerblading 6 days ago. 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. Diagnosis of DISI deformity can be made with lateral wrist radiographs showing a scapholunate angle. Medical Information Search Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist, Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands, accounts for 17.5% of all fractures in adults, younger patients due to high energy mechanisms, older patients due to low energy mechanisms (i.e. Diagnosis is made clinically with progressive wrist pain and wrist instability with radiographs showing advanced arthritis of the radiocarpal and midcarpal joints (radiolunate joint spared). What is the most likely etiology of her new loss of function? Perilunate fracture-dislocations of the wrist. What is the likely mechanism of her paresthesias and what is the most appropriate treatment? When dislocation occurs in the wrist . Type in at least one full word to see suggestions list, Hand Scaphoid Lunate Advanced Collapse (SLAC). At the time the article was created Andrew Murphy had no recorded disclosures. arthroscopic repair and percutaneous pinning. There is no median nerve paresthesias. Failure to support the lunate facet with fragment specific fixation, Use of only three bicortical screws in the intact radial shaft proximally. 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. When performed on 18 children with distal radius-ulna fractures, P . Other common causes include: car . Figure A is an intraoperative photo. Copyright 2023 Lineage Medical, Inc. All rights reserved. The scaphoid accounts for 95% of de-generative/traumatic arthritis in the wrist, with 55% involving the radioscaphoid joint (SLAC pattern). (OBQ09.254) Treatment is nonoperative for non-displaced fractures but displaced or intra-articular fractures require ORIF. tures, specically non-union of scaphoid fractures. Copyright 2023 Lineage Medical, Inc. All rights reserved. At the time the article was created Andrew Dixon had no recorded disclosures. Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius. Thank you. He was taken to the local teaching hospital where radiographs were taken, shown in Figures A and B. 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? Fractures of the normal lunate--isolated or associated with fractures of the scaphoid or radius--are very rare. In this condition, the lunate bone loses its blood supply, leading to death of the bone. Both images from . 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. 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. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations1. Radiographic features whilst on the lateral the capitate no longer sits in the lunate. Phalanx fractures of the hand are some of the most common fractures occurring in humans. Inability to extend the index finger proximal interphalangeal joint. 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). 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). Smith's fracture: volarly displaced and extraarticular. Which of the following interventions should be taken? This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. A lumberjack in rural Michigan falls 10 feet from an Evergreen branch onto an outstretched arm and develops immediate wrist pain. The proximal 2 Cs indicates the articulation between the lunate and . In this condition, the lunate bone loses its blood supply, leading to death of the bone. Stage IV denotes a true lunate dislocation, involving a . diastasis of the scapholunate complex occurs with complete SLIL tears and capsule disruption. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. - w/ flexion capitate slides out from under lunate tocreate fullness where the capitate depression has been; - Radiographs: (SBQ17SE.13) He undergoes operative treatment of his fracture, and immediate post-op radiographs are shown in Figure C. Two weeks later he presents with significantly increased pain and deformity. What additional data is most necessary to obtain before a reduction is attempted? Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. Philadelphia : Lippincott Williams & Wilkins, c2005. The patient recovered well initially but presents after 6 months with grip weakness. (OBQ05.195) Which plating option provides the most appropriate treatment of this fracture? Distal Radius Fracture Non-Spanning External Fixator . 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). Diagnosis can be confirmed with orthogonal radiographs of the involve digit. This medication is given in an effort to decrease the incidence of which of the following? (OBQ18.177) Inability to extend the thumb interphalangeal joint. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. (2008) RadioGraphics. (OBQ06.102) (OBQ18.223) 1980;5 (3): 226-41. 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. Hamate Body Fractures are rare carpal fractures that can be associated with 4th or 5th metacarpal fractures. not be relevant to the changes that were made. 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 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view? (OBQ08.179) 2.0 screw for a Scaphoid Hand Fracture How to palpate the . -. 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. Radiographs show a well-fixed fracture in good alignment. Wrist with Kienbock's disease and ulna that is short compared to radius, Using this search tool means you agree to the, 2023 American Society for Surgery of the Hand, from the American Society for Surgery of the Hand, Decreased motion or stiffness of the wrist. Volar pole fractures are more commonly observed as the lunate is compressed by the capitate. Lunate dislocations typically occur in young adults with high energy trauma resulting in loading of a dorsiflexed wrist. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Radiographs of the affected wrist are shown in Figure A. Most likely, the most reliable test to assess the blood supply of the lunate is Magnetic Resonance Imaging (MRI). A normal wrist without Kienbock's disease. Scaphoid Lunate Advanced Collapse (SLAC) d escribes the specific pattern of degenerative arthritis seen in chronic dissociation between the scaphoid and lunate. Colles'. (OBQ09.227) The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. Carpal tunnel release if no resolution at 6-12 weeks. Difficult wrist fractures. proximally and the capitate distally. - lunate articulates proximally w/ radius and distally w/ capitate; Rathachai Kaewlai, Laura L. Avery, Ashwin V. Asrani, Hani H. Abujudeh, Richard Sacknoff, Robert A. Novelline. What is the next best step in management of this patient? Thank you. The lunate is made up of the volar pole, body, and dorsal pole. AP and lateral radiographs of the wrist are shown in figures A and B respectively. 2023 Lineage Medical, Inc. All rights reserved. (SBQ07SM.38) Copyright 2023 Lineage Medical, Inc. All rights reserved. 1. Lunate fractures account for around 4% of all carpal fractures 1. (OBQ16.228) (OBQ04.38) 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).
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