Injuries of the scapholunate ligament in children

Wrist arthroscopy was performed in three children (9, 11 and 12 years old) after persisting pain over the dorsal scapholunate region and revealed intraligamentous tear of the scapholunate ligament in two cases and its avulsion from the scaphoid border in one case. Open surgical repair of all lesions was performed after arthroscopy during the same session. After an average follow-up of 2.4 years all patients were pain free and resumed all sports activities. This study shows that different kind of injuries can occur to the scapholunate ligament in the skeletally immature carpus. Surgical repair leads to good results.

[The "Shoulder, Arms and Hand Disability Questionnaire" as a scale for identification of the diagnosis-specific activity profile]

Functional disabilities of the upper extremities have a considerable social and economic impact so that interest was aroused in developing a valid and reliable instrument suitable for international use. The Disabilities of the Arm, Shoulder, and Hand questionnaire is a self-report measure recording functional limitations in the upper extremity. A German version is now available in German-speaking countries. Previous studies have been concerned with the evaluation of DASH scores. Based on the data of four diagnostic groups, this study explores DASH's ability to identify diagnosis-specific limitations at the item level. The data were pooled and examined with regard to significant differences within the groups. Diagnosis-specific limitations could be identified within all groups, indicating that DASH is capable of expressing diagnostic entities as well as summed scores. Consideration of the individual profiles opens the possibility of using DASH as a prognostic tool to anticipate functional problems arising during rehabilitation following surgical interventions.

Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire

PURPOSE

To determine the clinical outcome of patients with perilunate and lunate dislocations treated with a combined dorsal and volar approach and intraosseous cerclage wire.

METHODS

A combined dorsal and volar approach with an intraosseous wiring technique was used to treat 22 isolated perilunate and lunate dislocations. The mean interval between injury and surgery was 3 days. Outcome was assessed after an average of 49 months. Patients were assessed subjectively with a Disabilities of the Arm, Shoulder, and Hand questionnaire and were asked to rate their overall satisfaction, pain relief, problems with activities of daily living, and return to work and previous activity status. Results were assessed objectively by range of motion and grip-strength measurements and initial postsurgical radiographs were compared with final radiographs with regard to scapholunate angle and gap.

RESULTS

Patient satisfaction was high in 15 of 22 patients. Seven patients stated they had problems with activities of daily living after their injury. Only 10 patients returned to the same job they had before their injury; however, all 22 patients were able to return to some type of work. Sixteen of the patients stated they were able to return to their previous level of activity. The wrist flexion-extension arc and grip strength averaged 80% and 77%, respectively, compared with the opposite side. Follow-up radiographs showed no significant change in scapholunate angle or gap with time. As expected the scapholunate cerclage wire broke frequently. The cerclage wire was removed in 16 patients, 12 because of broken hardware and 4 because of pain.

CONCLUSIONS

Our results show that a combined dorsal and volar approach with an intraosseous wiring technique can restore effectively normal intercarpal relationships, providing acceptable pain relief, functional motion, and grip strength.

Preliminary lunate reduction and pinning facilitates restoration of carpal height when treating perilunate dislocation, scaphoid fracture and nonunion, and scapholunate dissociation

Carpal collapse potentially accompanies greater and lesser arc perilunate injuries; unstable, acute scaphoid fracture; scaphoid nonunion with humpback deformity; and scapholunate dissociation. When surgical treatment is elected, preliminary reduction of the lunate from extension to neutral--to correct dorsal intercalated segment instability deformity--facilitates restoration of carpal height and decreases the risk of carpal malalignment and scapholunate advanced-collapse arthritis. This simple technique is described.

Failure to diagnose--fractures

'Failure to diagnose' claims are the most common cause of medical negligence claims in general practice. This article examines a claim involving a failure to diagnose a fracture and outlines some risk management strategies for general practitioners to minimise the possibility of a claim arising from a failure to diagnose orthopaedic problems. Case histories are based on actual medical negligence claims, however, certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved.

Bildgebende Verfahren am Handgelenk

Injuries of the wrist are difficult to diagnose because of the complex and narrow anatomic structures. Based on precise clinical examination, X-rays, CT, and MRI are valuable additional tools that can be used. If a fracture is suspected a CT scan is preferable. In the case of a suspected soft tissue or ligamentous injury and non-vital fragments or necrosis MRI is suitable. Other diagnostic tools are presently of minor importance for the wrist. Technical innovations allow better visualization and classification of lesions. However, exact knowledge of the tools is important.

[Preliminary results with Cuénod's osteoligamentoplasty and capsulodesis for treatment of chronic scapholunate dissociation]

Until now, the ideal treatment of scapholunate dissociation has not yet been found. Cuénod described an operation with reconstruction of the dorsal part of the scapholunate ligament using a bone-ligament-bone autograft (dorsal trapezoidometacarpal II ligament) and an additional dorsal capsulodesis using the dorsal intercarpal ligament. From December 2000 until January 2002, we operated on twelve patients with symptomatic chronic scapholunate dissociation without signs of osteoarthrosis using Cuénod's procedure. Preoperatively as well as at follow-up patients were evaluated using a traditional wrist score and a DASH-questionnaire in addition to clinical examination. X-rays of both wrists in two planes each and additional stress radiographs were done. All patients had an arthroscopy preoperatively and a CT scan before K-wire removal. The mean follow-up time was twelve months. Clinical follow-up showed good results (traditional wrist score: 77 points; DASH-score: 27 points), but with regard to the good preoperative findings (traditional wrist score: 73 points; DASH-score: 28 points) no significant improvement. Postoperative X-rays showed a correction of static instability in three cases; in four cases we found a recurrent SL gap, which was interpreted as failure of the transplanted ligament. Until now, one patient had to be reoperated by STT-fusion. In our patients, Cuénod's operation showed different results. So, further studies are necessary to find the correct indications for applying this procedure.

Teil-Arthrodesen von Skaphoid, Trapezium und Trapezoideum (STT-Fusion)

BACKGROUND

Scapho-trapezio-trapezoid (STT)/triscaphe fusion is used to stabilize the radial column of the wrist. However the reported results are controversial.

MATERIAL AND METHODS

111 patients were treated with STT fusion from 1992 to 1997. Indications were chronic dissociation of the scapholunate joint (n = 15), idiopathic arthrosis of the scaphotrapeziotrapezoid joint (n = 11), Kienböck's disease in advanced stage (n = 84) and dislocation of the trapezium (n = 1). This study reviews the results after an average follow-up period of four years (range, two to eight years).

RESULTS

Patients showed an average wrist motion (ROM) in extension and flexion of 81 % of the preoperative range and in radial and ulnar deviation of 68 % of the preoperative range. Preoperative pain values (VAS) were reduced 76 % (non-stress) and 55 % (stress). The average grip strength improved to 65 % of the contra-lateral side. Good results were reached according to the modified Mayo wrist score with a score of 66 points (71 points in arthritis of the STT joint; 62 points in Kienböck's disease, 60 points in SL-dissociation). The patients described low disability in the DASH scores, with an average of 27 points.

CONCLUSIONS

Our data show that STT fusion is reliable and effective for treatment and pain relief and offers reasonable functional results in the above mentioned indications.

Resektion der proximalen Handwurzelreihe bei karpalem Kollaps

Proximal row carpectomy (PRC) is a generally accepted procedure in the treatment of an advanced radiocarpal arthrosis. The aim of this retrospective study was the evaluation of individual, functional and radiological results after proximal row carpectomy. Seventeen patients (15 male, two female) who had undergone proximal row carpectomy between 1991 and 1999, were reviewed. The most common indication was degenerative arthrosis secondary to carpal collapse associated with chronic scaphoid nonunion (SNAC), scapholunate advanced collapse (SLAC) deformity, late Kienböck's disease or perilunate dislocations. Clinical and subjective results were assessed using different scores (DASH-, modified Mayo wrist-score) and evaluating the individual wrist range of motion. Anteroposterior and lateral X-rays were obtained for radiological analysis. At follow-up evaluation (mean 65.4 months), the majority of patients reported pain relief and a significant increased range of motion for the operated wrist. Radiographical analysis showed degenerative changes at the radiocapitate articulation in ten patients. The intermediate-term results of this review would suggest that proximal row carpectomy is an effective procedure providing pain relief and a satisfactory range of motion in a variety of pathologic wrist disorders. Because of eventual radiocapitate arthrosis, we suggest PRC only in patients without significant degenerative changes at the proximal pole of the capitate or the lunate fossa.

Okkulte skapholunäre Dissoziation bei distaler Radiusfraktur

INTRODUCTION

The aim of this study was to investigate the clinical consequences of scapholunate dissociation associated with fractures of the distal radius and the impact on wrist function. Fractures of the distal radius and scapholunate dissociation overlap in pathomechanics. The diagnosis however is frequently missed initially.

PATIENTS AND METHODS

We reviewed 45 consecutive patients with closed distal radius fractures with a mean follow up of 48 months. Ten patients underwent surgery and 35 patients were treated by fracture reduction and cast immobilization during 4.5 (range 3 to 8) weeks. All patients were re-examined clinically and radiographs of both wrists were compared.

RESULTS

Four patients showed evidence of SLD in the scapholunate joint region based on specific criteria (scapholunate gaps > 2 mm on anterior-posterior radiograph and the scapholunate angle > 60 degrees on lateral radiograph). All patients with SLD showed a poor radioulnar deviation. Three patients reported mild to moderate pain.

DISCUSSION

The difficulties in management of SLD may be avoided by early detection and treatment. In all investigated patients the diagnosis was missed after the initial trauma. Untreated SLD can lead to carpal collapse and arthrosis of the wrist, and ultimately to scapholunate advanced collapse.

Oblique shear fractures of the lunate

Traumatic fractures of the lunate are rare. This article presents two patients who had displaced oblique lunate fractures and distal radius fractures. Both fractures achieved union; however, transient avascular necrosis occurred in the proximal healing of one patient.

The natural history of an untreated isolated scapholunate interosseus ligament injury

The natural history of an untreated isolated scapholunate interosseus ligament injury remains unclear, although it is commonly assumed that patients continue to suffer with pain, stiffness and weakness of the wrist and ultimately develop secondary osteoarthritis (SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with an arthroscopically proven interosseus scapholunate ligament injury, but without any radiological signs of either DISI deformity or scapholunate gapping, who had declined further treatment at an average follow-up of 7 years. Whilst there was on going pain and functional limitation in all cases, there was no rapid progression to degenerative change (SLAC wrist).

Treatment of scapholunate dissociation: ligamentous repair associated with modified dorsal capsulodesis

We previously reported that our repair and/or reconstruction of the scapholunate interosseous ligament reduced the scapholunate dissociation and improved the clinical results. Re-evaluation of these patients after three years revealed that malrotation of the scaphoid advanced significantly although the clinical results declined only slightly. To prevent progression of scaphoid malrotation, a modified dorsal capsulodesis was subsequently added to the ligamentous repair of scapholunate dissociation. The records of 17 patients were available for this study. The time lapse from injury to surgical treatment ranged from four days to one year and six months. All but three patients were operated less than two months after the injury. All patients were followed for more than one year, with an average of 49 months. Clinical results were expressed by a modification of the point score method of Green and O'Brien. Scapholunate angles were measured on lateral X-ray films with the wrist in neutral position. Overall clinical results averaged 83 points (range: 25-100). The scapholunate angles averaged 49 degrees (range: 45-60). In the three patients, in whom the operation was performed more than 11 months after the injury, the clinical results averaged 38 points and scapholunate angles averaged 54 degrees, respectively. These clinical and X-ray results suggest that early repair of the scapholunate interosseous ligament along with a modified dorsal capsulodesis is a useful procedure in the treatment of scapholunate dissociation.

Transscaphoid-transtriquetral perilunate fracture dislocation: report of a case and review of the literature

INTRODUCTION

A transscaphoid and transtriquetral perilunate fracture dislocation is fairly rare among the known cases of perilunate fracture dislocations, and the details of the initial treatment and outcome of this injury have never been reported.

MATERIALS AND METHODS

A 21-year-old, right-handed man presented with fractures at the proximal third of the scaphoid and at the mid-body of the triquetrum with an associated dorsal perilunate dislocation after a fall onto his outstretched hand. Under general anesthesia, closed reduction was attempted with 3 kg of traction applied by means of finger traps. After anatomical reduction was achieved, percutaneous fixation was applied to both the triquetrum and scaphoid using cannulated screws. A short arm thumb spica splint was applied for 2 weeks, and part-time splinting was continued for an additional 3 weeks. The patient subsequently underwent 3 months of intensive range-of-motion and muscle-strengthening exercises.

RESULTS

At the final follow-up examination 68 months after the initial operation, the arc of motion of the right wrist, 150 degrees (extension plus flexion arc), and grip strength, 41 kg, were 94% and 103% of the values for the unaffected wrist, respectively. Radiographs showed a bony union of the scaphoid and triquetrum, and no sign of avascular necrosis in the proximal scaphoid fragment, as well as other carpi. No midcarpal or radiocarpal degenerative arthritis was observed, and the normal carpal bone relationships were still maintained, with a scapholunate angle of 48 degrees and a scapholunate gap of 2 mm.

CONCLUSION

We recommend closed reduction and percutaneous screw fixation of the scaphoid, as well as the triquetrum in this case, to minimize the interruption of the blood supply to the carpus and also to obtain rigid fixation during the procedure.

Proximal row carpectomy: a worthwhile salvage procedure

After proximal row carpectomy 11 patients were evaluated in the six ensuing years for pain relief, satisfaction, ranges of movement, grip and precision grip strength, and radiographic picture. The median follow-up period was 3.1 years (range 4 months to 6 years). They were operated on for scaphoid non-union with radiocarpal arthritis, late stage Kienböck's disease, chronic scapholunate dissociation and scapholunate advanced collapse wrist deformity. The mean disabilities of the arm, shoulder and hand (DASH) scoring list, which indicates the patient's degree of disability 28% (range 2%-64%) of maximum disability for the function and symptom score. Flexion, extension, and radial and ulnar deviation of the wrist improved to 47% (range 21%-76%), 67% (range 41%-81%), 39% (range 25%-55%), and 81% (range 44%-90%) of the opposite wrist. Mean grip strength, 70% (range 22%-117%) of the opposite site, while the three precision grips improved between 72% and 79%. A review of previous studies of proximal row carpectomy showed results comparable with those of our study. Compared with other treatments, it is a dependable, relatively-simple procedure that gives reliable relief of pain, preserves functional ranges of movement and grip strength, and allows most patients to return to work.

Static scapholunate dissociation diagnosed by scapholunate gap view in wrists with or without distal radius fractures

This prospective study investigated static scapholunate dissociation (SLD) in wrists associated with distal radius fractures. SLD was detected as a widening of the scapholunate (SL) joint interval by SL gap view. Ninety-six distal radius fractures and 154 normal wrists were investigated by SL gap view, which is better for detecting SLD than the standard posteroanterior (PA) view. Incidences of non-symptomatic SLD detected by SL gap view in normal wrists increased by age. In the young age bracket, incidences of SLD in distal radius fractures were significantly higher than in normal wrists. Our results indicated that in patients younger than 30 years old, SLD in distal radius fractures was a fracture-caused abnormality. In those over 30, ascribing SLD to the fracture was difficult. Close examinations, like arthroscopy and dynamic cineradiography, need to be made in patients with SLD associated with distal radius fractures, especially in those younger than 30.

[Palmar lunate dislocation]

Palmar lunate dislocation as the end stage of a perilunate dislocation is a very uncommon injury. Having treated 19,534 hospitalized patients between 1 January 1986 and 1 October 2001 the diagnosis was recorded in four male trauma patients (33, 36, 37 and 62 years old). Among the operatively treated carpal dislocations and carpal fracture dislocations those of the lunate were seen in five per cent. The dislocation was caused in by an acute hyperextension injury resulting of falls from heights in three cases, and of a motorcycle accident in a further case. In two of these cases a complete palmar lunate dislocation was analysed that were produced by fall from seven meters heights of a young craftsman and by accident of a motorcyclist. First using a longitudinal palmar approach in both cases a revision of the hemorrhagic carpal canal was performed urgently, the largely denuded lunate was reduced and the repair of identified ligamentous structures was performed by means of sutures respectively suture anchors. Reduction was stabilized with Kirschner wires. Afterwards performed computed tomography identified the result of reduction and associated defects (subluxation distal radioulnar joint). In one patient a soft tissue infection prevented the dorsal ligamentous repair. In spite of a consequent after-treatment and a good functional result a scapho-lunate dissociation was proved. An avascular defect of the lunate could be excluded by magnetic resonance imaging. In case of a secondary performed dorsal repair a persisting carpal stabilization with a satisfactory functional result could achieved. At second hand an advanced carpal collapse was proved.

CONCLUSIONS

If reduction cannot be achieved by closed manipulation or a loss of reduction is shown, open reduction is indicated first by a palmar approach. An additional dorsal ligamentous repair seems to be necessary. Transfixation by Kirschner wires and suture anchors stabilize the restored anatomic relationships. Wrist immobilization in a cast for at least eight weeks is recommended. Although ligamentous insufficiency, osteoarthrosis and avascular necrosis are often proved, functional results are satisfactory.

Dorsal intercarpal ligament capsulodesis for chronic, static scapholunate dissociation: clinical results

The purpose of this study was to review and report the results of using a new procedure, the dorsal intercarpal ligament capsulodesis (DILC), to treat a group of patients with chronic flexible scapholunate dissociation. This was a prospective study of 21 patients (22 wrists), ranging in age from 16 to 62 years followed up for 1 to 4 years. For this study all patients returned to complete a questionnaire and have a physical examination performed by physicians and therapists independent of the treating surgeons and to obtain standardized radiographs of the wrists. Patient demographics, mechanism of injury, range of motion, and grip strength were recorded. Patients completed the Mayo wrist, Short-Form (SF)-12, and Disabilities of Arm, Shoulder and Hand (DASH) questionnaires. Results showed there were significant improvements in scapholunate angle and scapholunate gap at final follow-up examination, with minor loss of range of motion and grip strength. Patients were satisfied with the outcomes, showing an average score of 17 on the DASH and 83 on the SF-12. The DILC procedure is a reasonable option for treating chronic scapholunate dissociation. The procedure has conceptual advantages to recommend it: it avoids a tether between radius and scaphoid and keeps the proximal carpal row linked as a functional unit. It reduces the scapholunate angle and gap. Overall the results to date are quite encouraging.

Stage 3 Kienböck's disease: reconstruction of the fractured lunate using a free vascularized iliac bone graft and external fixation

Eighteen patients with stage 3 Kienböck's disease were treated by débridement of the necrotic core of the lunate and implantation of a free vascularized corticocancellous iliac bone. The wrist was stabilized with an external fixator during healing. The efficiency of the procedure for restoring the structure of the fractured lunate, preventing carpal collapse and improving the clinical outcome was assessed at a mean follow-up of 5 years. The graft became incorporated in the lunate in 16 of the 18 patients and no fracture of the reconstructed lunate or carpal collapse occurred in these cases. The graft did not integrate and was resorbed in the other two patients.