Carpal instability non-dissociative

Surgical Techniques in Nontraumatic Midcarpal Instability: Evaluating the Dorsal Capsulodesis and 3-Ligament Tenodesis Technique

BACKGROUND

Surgical management of midcarpal instability (MCI), also referred to as carpal instability nondissociative, remains controversial because of limited evidence on different techniques. This study aimed to assess and compare differences in patient-reported pain, hand and wrist function, satisfaction, range of motion, and return to work in patients with nontraumatic MCI who underwent surgical treatment either through dorsal wrist capsulodesis or 3-ligament tenodesis (3LT).

METHODS

Patients with MCI and persisting complaints after conservative therapy treated with 3LT or dorsal capsulodesis were included. Patients with posttraumatic instability were excluded. Primary endpoints included the Patient Rated Wrist Evaluation and Satisfaction with Treatment Result Questionnaire at 12 months postoperatively. All data were analyzed retrospectively.

RESULTS

A total of 91 patients treated with dorsal capsulodesis and 21 treated with 3LT between December of 2011 and December of 2019 were included. At 12 months postoperatively, both treatment groups reported significant improvements in pain and function scores. However, at 3 months postoperatively, the dorsal capsulodesis group exhibited significantly better outcomes, followed by a greater return-to-work rate (72%) compared with the 3LT group (50%). However, the capsulodesis group demonstrated a decreased range of motion at 3 months that was restored at 12 months postoperatively. No significant difference in satisfaction with treatment was observed.

CONCLUSIONS

Both 3LT and dorsal capsulodesis demonstrate promising results for addressing nontraumatic MCI. However, considering the quicker recovery and faster return to work associated with dorsal capsulodesis, the authors recommend favoring capsulodesis over 3LT when both surgical options are deemed suitable for the patient.

Pediatric Lunotriquetral Dissociation and Static Volar Intercalated Segmental Instability After Radial Neck Fracture

Pediatric patients can pose challenges with regard to both diagnosis and obtaining an accurate history and physical examination, as well as in treatment strategies, as options become limited when physes remain open. This case report examines a 12-year-old boy who sustained a radial neck fracture after a ground-level fall. Although his elbow injury was treated appropriately, he developed wrist pain that progressed to static volar intercalated segmental instability deformity in the context of a carpal instability nondissociative wrist. A paucity of cases of pediatric patients with open physes and static volar intercalated segmental instability deformity exists. Adult treatment typically consists of some form of arthrodesis; however, this should be approached with caution in young patients. This case highlights the importance of careful wrist examination in all elbow injuries, as well as the challenges in surgical treatment options for pediatric patients.

[Osteoarthritis of the wrist]

The term osteoarthritis (OA) of the wrist can be used as an umbrella term for various, often independent areas of OA, as the wrist is made up of several joints. Radiocarpal OA often occurs after untreated ligament injuries, incorrectly healed bone fractures in the carpus or after radius fractures involving the joint. A typical sequence of propagation is known for radiocarpal OA following scapholunate (SL) insufficiency or scaphoid pseudarthrosis. Other causes include inflammation, crystal deposits or bone necrosis. Ulnocarpal arthrosis occurs posttraumatically or primarily when there are differences in levels between the ulna and radius. When treating wrist arthrosis, after conservative measures have been exhausted a surgical procedure should be chosen that enables the best possible load-bearing and residual mobility, considering the surgical risks and individual requirements. During salvage operations, the defective cartilage areas are either fused directly or eliminated using appropriate diverting partial fusions and resection arthroplasty. An accurate analysis of the affected zones is crucial for selecting an appropriate intervention.

Palmar midcarpal instability a narrative review of the literature: Have we reached a consensus on a treatment?

Palmar midcarpal instability (PMCI) is a wrist condition that requires treatment through non-surgical rehabilitation programs or surgical stabilization. This condition's natural history is poorly understood, and the optimal treatment approach remains unknown. Non-surgical treatments are initially implemented, followed by surgical stabilization if necessary. Arthrodesis and soft tissue stabilization are the two main surgical options for PMCI, with no established gold standard for treatment. A systematic review of 12 articles comparing arthrodesis and soft tissue stabilization was conducted to identify the optimal treatment approach for PMCI. Arthrodesis techniques, such as lunotriquetral arthrodesis, showed high functional outcomes but also high reintervention rates due to nonunion. Soft tissue stabilization techniques showed superior functional outcomes with less mobility loss and lower reintervention rates compared to arthrodesis. However, more studies are required to determine the optimal soft tissue technique. Based on this review we created a treatment algorithm for PMCI starting with non-surgical treatment first, followed by surgical stabilization if needed. Soft tissue stabilization techniques are preferred over arthrodesis due to better functional outcomes and lower reintervention rates. However, each patient's treatment approach should be individualized and evaluated independently to determine the best course of action. PMCI is a rare wrist condition, and further research is needed to better understand its natural history and establish a gold standard for treatment. The lack of literature comparing the two surgical options underscores the need for further research to determine the optimal treatment approach. Nonetheless, the current evidence suggests that soft tissue stabilization is a promising alternative to arthrodesis, providing superior functional outcomes and lower reintervention rates.

Midcarpal Instability

Midcarpal instability (MCI) of the wrist represents multiple distinct clinical entities that all have in common abnormal force transmission across the midcarpal joint. This can be asymptomatic but can also result in painful wrist motion, a characteristic catch-up clunk, and symptoms of instability. The carpus is stabilized by numerous extrinsic and intrinsic ligaments. Dynamic joint reactive forces between the proximal and distal carpal rows help create reciprocal motion, which results in smooth, physiologic wrist mechanics. Diagnosis of MCI requires a thorough history, physical examination, and adequate imaging. MCI can be managed nonsurgically with activity modification, physical therapy, specialized orthotics, medications, and corticosteroid injections. A variety of surgical treatment options exists to treat symptomatic MCI. These include arthroscopic thermal capsulorrhaphy, ligament repair or reconstruction, radial osteotomies, and limited radiocarpal or intercarpal fusions. Capsulorrhaphy or ligament repair is favored for mild to moderate cases; osteotomies can be used for the correction of bony deformities contributing to instability, whereas partial wrist arthrodesis is indicated for severe or recurrent instability and fixed deformities.

Nascent Malunion of Distal Radius Fractures Treated with Fixed Angled Volar Plates without Using Bone Grafts

Purpose

Malunion of the distal radius is a common complication. Using bone grafts is common to restore the bone to an acceptable level. This study aimed to verify if it is necessary to use bone grafts in nascent malunion of distal radius fractures treated with fixed angled volar plates and which radiographic parameters are essential to obtain satisfactory outcomes.

Methods

This single-centered prospective study included 11 patients who underwent corrective osteotomy of the radius for malunion. Patients with a metaphyseal, extraarticular osteotomy stabilized by a volar fixed angle plate within 3 months after the fracture are included. Patients underwent a standard radiological evaluation at postoperative 1 month, 3 months, 6 months, 1 year, and annually thereafter. Radial inclination, radial height, ulnar variance, and palmar tilt were measured. Wrist ranges of motion are measured throughout follow-up with a goniometer. Grip strength is measured using a Jamar Hand Dynamometer. The function is evaluated via the Gartland-Werley (GW) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Results

The mean age of 11 patients, 9 (81.82%) males, included in the study was 41.45 ± 14.89 years. The mean post-fracture admission time is 39.3 ± 15.1 days. Radial inclination, radial length, and ulnar variance improved significantly after surgery (p = 0.0023, 0.0002, 0.0037). Radial inclination values are within normal limits for all patients at admission. The radial length was in the normal range for 72.73%, the ulnar variance was in the normal range for 72.73%, and palmar tilt was in the normal range for 100% of the patients. Extension 54.55%, flexion 72.73%, radial deviation 81.82%, ulnar deviation 63.64%, pronation 90.91%, and supination 72.73% were achieved after surgery. GW average was 3.09 ± 3.24 DASH score average was 12.24 ± 13.48. The mean grip strength was 29.27 ± 7.21 on the operated side, while it was 34.91 ± 5.32, on the healthy side, with a significant difference (p = 0.0108).

Conclusion

It is possible to get good results without using bone grafts in corrective osteotomy of distal radius malunions.

Midcarpal Instability: A Historical and Etymological Review

Although midcarpal instability was first described almost 45 years ago, this uncommon condition is still poorly understood by most clinicians today. Adding to the confusion, it is known by 2 different names: midcarpal instability and carpal instability nondissociative. In this article, we describe the history of the recognition of instability of the midcarpal joint, including its pathomechanics, classification, and treatment. We hope that a more complete understanding of the etymology and kinematics of the disorder will facilitate its future recognition and assist in appropriate treatment decision making.

Traumatic Nondissociative Carpal Instability: A Case Series

PURPOSE

We report 8 cases of acute or subacute unilateral nondissociative carpal instability (CIND) in the context of nondisplaced scaphoid fractures.

METHODS

Eight patients from 3 centers developed abnormal volar intercalated segment instability (VISI) or dorsal intercalated segment instability (DISI) following the diagnosis of a nondisplaced scaphoid fracture. An operative inspection in each patient confirmed intact scapholunate and lunotriquetral interosseous ligaments. We outline the demographic characteristics of our patient cohort, radiologic and operative findings of CIND-DISI and CIND-VISI, and the outcomes of acute and delayed treatment.

RESULTS

Two patients were diagnosed with CIND-DISI and 6 with CIND-VISI associated with ipsilateral nondisplaced scaphoid fractures. The average time from injury to diagnosis of CIND was 11 weeks, and the mean clinical and radiographic follow-up was 18 months. Rapid healing of the scaphoid fractures was achieved in all patients (4 open reduction internal fixation, 4 cast). All patients underwent surgery to improve proximal carpal row alignment: in 3 of the 4 patients who were diagnosed and treated surgically within 12 weeks of injury, the radiolunate angle (RLA) was successfully restored. A contracture release and ligament repair or reconstruction with tendon graft 12 or more weeks following injury was unsuccessful in restoring proximal row alignment in all 4 patients. Two patients in the delayed treatment group required secondary surgery for partial fusion.

CONCLUSIONS

Based on the arthroscopic, imaging, and operative findings, we propose that the ligamentous restraints to CIND-VISI are dorsal at the radiocarpal joint and volar at the midcarpal joint. Conversely, the ligamentous restraints to CIND-DISI are dorsal at the midcarpal joint and volar at both the radiocarpal and midcarpal joints. In our series, a delayed diagnosis and late reconstructive surgery were associated with no improvement in RLA. We recommend early recognition of traumatic CIND and prompt treatment of injured ligaments prior to the development of a fixed deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Arthroscopic-assisted radiocarpal ligaments tensioning for dynamic radiocarpal instability

Background

Dynamic radiocarpal instability is one of the causes of post-trauma radial-sided wrist pain. It is not easy to diagnose and may possibly be overlooked. The key ligaments responsible for dynamic radiocarpal instability are the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. Tensioning of these 2 ligaments could be a method of treatment for dynamic carpal instability. We proposed a method for arthroscopic thermal shrinkage of these 2 ligaments, and for setting a landmark arthroscopically to facilitate identification of these 2 ligaments during the combined open suture tensioning procedure.

Methods

Between January 2016 and May 2020, 12 patients treated with this method were enrolled. The mean age was 33.3 years (range, 18–57 years), and the mean duration from injury to operation was 7.8 months (range, 3–25 months). The diagnosis was mainly depended on the physical examinations and confirmed under arthroscopy. The mean follow-up was 17.7 months (range, 12–26 months).

Results

All the patients had marked improvement of pain, grip strength, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the radiocarpal stability. The wrist range of motion showed significant decrease around 5^o in both flexion and extension and around 4^o in the ulnar deviation at the final follow-ups. All patients were able to return to their previous full level of work and activities.

Conclusions

We conclude that arthroscopic thermal shrinkage combined with open suture tensioning can be effective in treating dynamic carpal instability, while the arthroscopic-assisted landmark setting can help identify the accurate location of the RSC and LRL ligaments without dissecting too much soft tissue.

Medium-Term Outcomes for Amandys Implant: A 5-Year Minimum Follow-Up of 63 Cases

Background  Amandys is a pyrocarbon interposition implant used as a therapeutic alternative to total wrist fusion (TWF) or total wrist arthroplasty (TWA) in painful and disabling extensive destruction of the wrist. Objective  To review mid-term outcomes in a continuous prospective series of patients who underwent wrist arthroplasty Amandys with a minimum follow-up of 5 years. Methods  Clinical evaluation included a satisfaction survey, pain, two functional scores, the short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Rated Wrist Evaluation (PRWE), active wrist mobility, and grip strength compared with the contralateral side. Radiological evaluation was used to detect implant subsidence, carpal migration, bone lysis, or implant malposition. All per- and postoperative complications were collected. Results  Fifty-nine patients (63 procedures) were evaluated with a mean follow-up of 7 years; 57% of the patients were males, and the mean age was 58 years. Among the patients, 90% were satisfied or very satisfied. Pain was significantly improved, with a gain of 4/10 ( p  < 0.001). Functional outcomes also improved between the second and fifth year of follow-up. Active mobility was preserved and grip strength was significantly improved by 7 kg ( p  < 0.001). No implant subsidence or carpal migration was observed. Ten patients (11.9%) underwent revision surgery for conflict (1%), rotation (6%), or implant dislocation (5%). All complications and revisions occurred early with no new events after 1 year of follow-up. Discussion  Mid-term clinical and radiological outcomes were stable with improvement of functional scores. The survival rate was comparable to that reported for TWF with conserved mobility. We report fewer complications compared with those reported for TWA or TWF. Early instability of the implant was the main etiology of the revisions. Repositioning of the implant was successful. No conversion to TWA or TWF was necessary. Conclusions  Mid-term outcomes of the Amandys implants were encouraging. Patients conserved good wrist motion with improved strength and functional scores. The implant was well tolerated. Functional outcomes continue to improve with the follow-up. The survival rate remains stable after 2 years. The level of evidence of this study is IV (therapeutic case series).

Four-Corner Fusion with Locking Dorsal Circular Plate versus Headless Compression Screws: A Clinico-Radiological Comparative Study

Introduction Four-corner fusion is a technique for the treatment of carpal advanced collapse. It consists of scaphoid excision and arthrodesis of the lunate, triquetrum, hamate, and capitate bones. This can be accomplished with different kinds of osteosynthesis. In the first reports of the use of a circular plate, poor outcomes are described, with high rates of non-union, which decreased in later studies, which highlight certain aspects of the surgical technique.

Objective To report our experience with four-corner fusion with the use of a dorsal locking plate (Xpode, Trimed Inc., Santa Clarita, CA, US), and compare it with another traditional fixation method (3.0-mm headless compression screws [HCSs], Synthes, Slothurn, Switzerland), with an emphasis on union, an assessment of the fincitonal outcomes, and the presence of complications.

Material and Methods A comparative study of two prospective series of patients operated on through two fixation techniques for four-corner fusion using autologous bone graft from the iliac crest.

The first group of patients, evaluated between 2010 and 2012, underwent osteosynthesis with 2 HCSs, with a minimum follow up of 18 months. The second group, evaluated between 2011 and 2014, underwent osteosynthesis with a dorsal locking plate, with a minimium foloow up of 12 months. The patients were operated on by four different surgeons in four centers.

The patients were evaluated with radiographs to establish the presence of union and the time it took to occur. In case of doubt, union was confirmed through a computed tomography (CT) scan at 8 weeks postoperatrively. We also assessed the range of motion, the presence of complications, and function through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a grip strength score.

Results We achieved a union rate of 100% in both groups at similar times. In the dorsal locking plate group, we obtained better full range of motion, particularly in wrist extension, which was statistically significant (p = 0.0016), as well as lower DASH scores, which was also statistically significant (p = 0.0066). Complications were only present in two patients in the HCS group.

Conclusion Both techniques are valid and reproducible for the treatment of wrists with scapholunate advanced collapse (SNAC) and scaphoid non-union advanced collapse (SLAC). Based on the outcomes, with the Xpode plate, the patients presented better ranges of motion and DASH scores; therefore it may be an excellent fixation option in the open four-corner fusion surgical technique. The entry point and configuration of the HCS are fundamental variables to analyze.

The union rate of 100% obtained in the present study contrasts with the high rates of non-union reported in the literature published in the early 2000s.

Posttraumatic Carpal Instability Nondissociative

Background  Posttraumatic midcarpal instability nondissociative (CIND) is an exceptional rare condition, therefore the outcome after different treatment options remains unknown. Questions  The purpose of this study was to investigate the different treatment options for posttraumatic CIND. We also describe the different radiological and magnetic resonance imaging (MRI) findings in this patient cohort. Patients and Methods  We present outcomes of 10 patients who developed CIND following acute wrist trauma between 2007 and 2018, 3 with dorsal intercalated segment instability pattern (CIND-DISI) and 7 with volar intercalated segment instability (CIND-VISI) radiographically. Results  Three patients with CIND-VISI had satisfactory outcomes with conservative treatment. Two patients with irreducible CIND-DISI and one with CIND-VISI underwent proximal row carpectomy (PRC), two with reducible CIND-VISI had radiolunate fusion, and two with secondary osteoarthritis had total wrist fusion. All patients with CIND-DISI needed surgery, whereas only four of the seven patients with CIND-VISI needed surgery. On MRI, all three patients with CIND-DISI had rupture of the radiolunate ligament. Conclusions  The data collected in this study may provide the first step toward better understanding of the pathology for this exceptionally rare finding. In CIND-VISI, we have not seen any ligament injury in four patients. Therefore, conservative therapy is more likely to be the first step. In CIND-DISI, we recommend an operative procedure: if detected early, with ligament suture, otherwise by radiolunate fusion, PRC, or total wrist fusion. Level of Evidence  This is a Level IV study.

Lunate morphology: association with the severity of scapholunate ligament injuries and carpal instability patterns

Type II lunate has been associated with a lower incidence of dorsal intercalated segment instability (DISI) in the case of scapholunate dissociation. We aimed to evaluate the frequency of different lunate types and their influence on the prevalence and severity of scapholunate ligament (SLIL) injuries and the development of DISI. The surgical records of 414 arthroscopies were reviewed retrospectively. Lunate types were diagnosed based on radiograms and MRI examinations. The Type II lunate had a facet between hamate and lunate; in the Type I lunate, this facet is lacking. We additionally included the assessment of the capitate-triquetrum distance (CTD), which defines Type I, Intermediate, and Type II lunates. We adopted the DISI when the scapholunate angle was more than 80° and/or the radiolunate angle less than -15°. Fisher's exact test was applied to compare the distribution frequency of SLIL lesions and DISI deformity of patients with different lunate types. To quantify the inter- and the intra-rater reliability of lunate type assessment Cohen's kappa was calculated and, for CTD measurements, a Bland-Altman plot was created. Up to 77.1% patients had Type II lunates. Regarding MRI and CTD classification in patients with Type I lunates, Grade 4 SLIL injuries were more common than in those with Intermediate and Type II (p < 0.05). In the case of Grade 4 SLIL lesions, DISI was more common in patients with Type I lunates (p < 0.05). There were, however, only 25 patients with Type I lunates, and Grade 4 SLIL lesions according to MRI, and 6 according to CTD measurement.

Carpal Instability: I. Pathoanatomy

The pathoanatomy of carpal instability is multifactorial and usually complex. A thorough medical history and clinical examination are essential, as well as profound knowledge of the specific instability patterns. The stability of the wrist is ensured by the carpal joint surfaces, by intact intra-articular (particularly the scapholunate interosseous ligament) and intracapsular ligaments, and by crossing extensor and flexor tendons, the latter making the proximal carpal row an "intercalated segment." An important classification feature is the distinction between dissociative and nondissociative forms of carpal instability. Among others, scapholunate dissociation, lunotriquetral dissociation, midcarpal instability, and ulnar translocation are the most common entities. Early forms of instability are considered dynamic. In the natural course, static instability of the wrist and osteoarthritis will develop. This review focuses on the pathoanatomical fundamentals of the various forms of carpal instability.

Demystifying Palmar Midcarpal Instability

Palmar midcarpal instability is an uncommon condition diagnosed clinically with a painful pathognomonic clunk on terminal ulnar deviation of the wrist. Various causes have been described, but congenital laxity of the carpal ligaments is thought to be a key contributor. Treatment commences with conservative measures. This includes proprioceptive training based on more recent concepts on the sensorimotor function of the wrist. When these measures plateau, surgery is considered. The lack of high-level evidence and consensus on its cause continue to hamper our understanding and knowledge of this condition. The purpose of this review is to examine the current evidence to conceptualize this mysterious, yet infrequent phenomenon, and to provide an algorithm on its management.

Trapeziometacarpal osteoarthritis and arthritis of the wrist

Although the simultaneous occurrence of arthritis of the wrist and the base of the thumb is rare, it is nonetheless imperative to carry out a preoperative clinical and radiological assessment of the wrist when managing trapeziometacarpal osteoarthritis. The presence of pre-arthritic lesions or established wrist arthritis, even if treated, must be taken into consideration when treating osteoarthritis at the base of the thumb. The coexistence of these lesions determines the entire surgical strategy. Failure to take them into account during the surgical treatment often results in a compromised postoperative course and it often adversely impacts the outcome of secondary surgeries.

Carpal Instability Nondissociative Following Acute Wrist Fractures

PURPOSE

Carpal malalignment following intra-articular fractures has been reported in the literature, with no clear description of possible ligamentous injury leading to the radiological appearance. This study presents a series of patients that developed carpal instability nondissociative (CIND) following acute wrist fractures. The mechanism of injury is postulated by using a cadaveric laboratory investigation.

METHOD

Twelve patients with average age of 32 years were identified with CIND, between 2013 and 2018. Ten patients with a normal carpal alignment in the initial postoperative radiographs exhibited CIND-palmar radiographically at different postoperative periods, and 2 patients showed CIND-dorsal in the initial postoperative x-rays. Four cadaveric specimens were used to validate this injury pattern.

RESULTS

In cadaveric dissections, CIND-palmar could be reproduced by applying an axial loading and dorsal shearing force on a wrist with sequential sectioning of dorsal and palmar extrinsic wrist ligaments. For the intra-articular fractures with CIND-dorsal, the cause is likely a result of volar radiocarpal extrinsic ligament injury combined with intra-articular incongruity of the scaphoid fossa. Eight out of the 12 patients had severe wrist pain and underwent additional surgery. Three patients with reducible CIND-palmar had open capsular repair, and 5 patients with fixed nonreducible malalignment were treated with radioscapholunate arthrodesis. At an average follow-up of 2.3 years, pain relief was noted, together with an improvement in grip strength and range of movement. Radiographically, the wrist alignment was corrected and maintained.

CONCLUSIONS

This article highlights the existence of possible concomitant radiocarpal ligament lesions and residual articular incongruity, associated with acute intra-articular fractures and radiocarpal fracture-dislocations, that destabilize the proximal carpal row into a pattern of nondissociative carpal instability. Early detection of this condition may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Management of Nondissociative Instability of the Wrist

Nondissociative carpal instability is instability of an entire carpal row and can lead to vague ulnar-sided wrist pain as well as a clunking wrist. The etiology of this process is most often generalized ligamentous laxity; however, it can infrequently occur as a result of trauma or malalignment of the radiocarpal joint. Whereas treatment remains controversial, the literature supports nonsurgical management and includes patient education, dynamic placement of orthoses, proprioceptive therapy, and extensor carpi ulnaris strengthening. If extensive nonsurgical therapy fails, surgical intervention includes soft tissue and bony procedures, all with high complication and failure rates and limited long-term outcome data.

Treatment of Carpal Instability and Distal Radioulnar Joint Instability

Carpal instability and distal radioulnar joint instability represent an important set of conditions responsible for pain and disability in the wrist. Either condition can occur as a result of ligamentous failure or loss of articular congruity from fractures or a combination of both. Instability itself is a clinical diagnosis supported by relevant imaging modalities. Carpal and distal radioulnar joint instability needs to be considered according to its stage and severity as well as other factors like etiology and chronicity to determine the optimal treatment option. This article summarizes the conditions most relevant to the practice of a hand surgeon, with emphasis divided equally between assessment and diagnosis, staging, and treatment. The 3 most common carpal instability conditions are outlined in this article together with a review on acute and chronic distal radioulnar joint instability.

Best Approaches in Distal Radius Fracture Malunions

PURPOSE OF REVIEW

Malunion remains a common complication in the treatment of distal radius fractures. The purpose of this review was to discuss the various approaches in planning and surgical management for extra- and intra-articular distal radius malunions.

RECENT FINDINGS

Several recent studies have reported good results with surgical correction of distal radius malunions utilizing a number of preoperative planning methods and surgical approaches. Three-dimensional models and custom cutting guides have recently become more popular, but their benefit in comparison to other methods remains unclear. Regardless of preoperative planning method or surgical approach, good results can be achieved with correction of distal radius malunion with careful attention to patient selection, indications, and surgical technique.

Palmar Capsuloligamentous Plication in Dorsal Capitolunate Instability: Technique and Preliminary Results

Midcarpal instability (MCI) is a form of the carpal instability nondissociative pattern and can be differentiated into dorsal, palmar, or extrinsic MCI. Dorsal MCI can frequently be observed in adolescent or adult patients due to trauma or hyperlaxity of the palmar intrinsic carpal ligaments. Clinical stress tests and cinematography are capable to depict the ligamentous instability centered around the capitolunate area. We describe a novel technique which aims to address palmar ligamentous hyperlaxity by plication of the radioscaphocapitate, radiolunotriquetral, and arcuate ligaments, thus closing the so-called space of Poirier. This palmar technique has been used in several cases in isolated form or in conjunction with other concomitant procedures. After the floor of the carpal tunnel and thus the palmar ligaments are exposed and the weak spot meticulously verified, 2 or rarely 3 deep FibreWire pulley sutures are used for capsuloligamentous plication. Among 11 patients, 4 cases (5 operated wrists) with isolated capitolunate capsuloligamentous plication were followed at an average of 2.6 years after surgery. The results were excellent with a mean postoperative Disabilities of the Arm, Shoulder and Hand Score of 9.7 (range, 6.9 to 15.0), mean numerical rating scale of 0 at rest and 1 (range, 0 to 2) during stress. All cases stated that they were very satisfied with the result and all would definitely elect to choose the surgery again. Palmar capsuloligamentous plication has been shown to be a quick, relatively easy and reliable procedure to reduce dorsal MCI in our patient cohort.

Four-dimensional CT Analysis of Wrist Kinematics during Radioulnar Deviation

Purpose To determine the technical feasibility of four-dimensional (4D) CT for analysis of the variation of radioscaphoid angle (RSA) and lunocapitate angle (LCA) during wrist radioulnar deviation. Materials and Methods In this prospective study, 37 participants suspected of having scapholunate instability were evaluated from January 2015 to December 2016 with 4D CT and CT arthrography (mean age ± standard deviation, 42.3 years ± 15; range, 21-75 years; 27 men [mean age, 44 years ± 15] and 10 women [mean age, 38 years ± 14]). Five angular parameters for RSA and LCA variation during radioulnar deviation were calculated by two independent readers. CT arthrography was used as the reference standard method for scapholunate ligament tear identification. Results In the control group (n = 23), the mean values for RSA were 103° ± 8 and 104° ± 9, whereas the mean values for LCA were 86° ± 9° and 90° ± 11° with a coefficient of variation of 11% and 13% for reader 1 and reader 2, respectively. The interobserver and intraobserver agreements were excellent for RSA and substantial to excellent for LCA. In the pathologic group (n = 14), LCA amplitude, standard deviation, and maximal angle were lower for both readers with respect to the control group, measuring 36% and 44% (P = .003), 37% and 44% (P = .002), and 13% and 19% (P = .003), respectively. RSA amplitude did not show statistically significant results in the pathologic group (P > .13). LCA yielded the highest sensitivity (71%-93%), whereas RSA yielded the highest specificity (87%-100%). Conclusion Semiautomatic four-dimensional CT analysis of the wrist during radioulnar deviation is technically feasible and reproducible for evaluation of carpal kinematic abnormalities. © RSNA, 2018 Online supplemental material is available for this article .

Long-Term Functional Results of a Wrist Exercise Program for Patients with Palmar Midcarpal Instability

Background  Patients with palmar midcarpal instability have symptoms of pain, combined with clinical signs of abnormal mobility on stressing the joint, an unpredictable blockade feeling, and a noticeable clunk, in the absence of an underlying trauma. No data are available on the effect of conservative treatment for these patients. Purpose  The purpose of this study was to evaluate the effect and the long-term functional outcomes of a wrist exercise program in patients with palmar midcarpal instability. Patients and Methods  All patients diagnosed with palmar midcarpal instability between 2005 and 2011 were included. Patients completed the Patient-Rated Wrist and Hand Evaluation (PRWHE) and the Short Form-36 health (SF-36) questionnaires, scaled their perceived pain before and after treatment, and indicated the effect of the received treatment. Results  A total of 119 patients diagnosed with palmar midcarpal instability were included. The median follow-up time was 6 years (IQR 4.5-7.0). The median PRWHE score after hand therapy was 35.5 and the median mental component of the SF-36 score was 53.9 and the physical component was 45.2. The median perceived pain reduced from eight to four and the median therapeutic effect of the wrist exercise program was five. Conclusion  Although palmar midcarpal instability remains to be a chronic disease, the effectiveness of our wrist exercise program is promising with acceptable long-term functional results and a good quality of life. Level of Evidence  Level IV, retrospective cohort study.

[Mediocarpal instability of the wrist]

Typical lesions of the carpal ligaments are mostly found after a fall on the wrist in hyperextension or as complex injuries after severe trauma, e. g. after a fall from a significant height, motorcycle accident or as accompanying lesions in multiple trauma. The typical mechanisms, patterns and diagnostic algorithms are well known for the common ligamentous injuries (e.g. scapholunate, lunotriquetral and perilunate); therefore, consistent diagnostic procedures and adequate therapy are increasingly performed after such lesions, e. g. by early ligament repair or by ligament reconstruction through augmentation. Within appropriate operative treatment, accompanying fractures are also treated and instabilities are addressed by transfixation of joints by Kirschner wires. If followed by immobilization with a cast or stable brace, healing can be achieved in most cases; however, more problems occur if ligamentous lesions or instabilities are not clearly due to a trauma mechanism and more the result of laxity or hypermobile situations due to a congenital predisposition. In such cases, wrist pain is often described and misdiagnosed as the result of overload or tenovaginitis.

Wrist cineradiography: a protocol for diagnosing carpal instability

Carpal instability is often related to ruptured or lax carpal ligaments. Wrist cineradiography has been shown to be a good modality for diagnosing carpal instability. To create uniformity in obtaining and assessing wrist cineradiography, a wrist cineradiography protocol is desirable. This protocol will focus on wrist cineradiography for diagnosing carpal instabilities. It describes the pathologic motions of the carpus and correlates these with a clinical diagnosis.

LEVEL OF EVIDENCE

III.

Treatment of chronic scapholunate dissociation with tenodesis: A systematic review

Scapholunate (SL) instability is the most common dissociative carpal instability condition. It is the most frequent cause of wrist osteoarthritis, defined as scapholunate advanced collapse or SLAC wrist. Familiarity with the SL ligament complex is required to understand the various features of SL instability. Damage to the SL interosseous ligament is the main prerequisite for SL instability; however the extrinsic, palmar and dorsal ligaments of the carpus also come into play. When more than 6 weeks has passed since the initial injury event, SL instability is considered chronic because ligament healing is no longer possible. Before osteoarthritis sets in and when the SL instability is still reducible (scaphoid can be reverticalized), ligament reconstruction surgery is indicated. Since the end of the 1970s, various ligament reconstruction or tenodesis techniques have been described. These techniques are used in cases of chronic, dynamic or static reducible SL instability, when no repairable ligament stump and no chondral lesions are present. The aim is to correct the SL instability using a free or pedicled tendon graft to reduce pain while limiting the loss of mobility and protecting against osteoarthritis-related collapse in the long-term. We will perform a systematic review of the various tenodesis techniques available in the literature.

Palmer Midcarpal Instability: An Algorithm of Diagnosis and Surgical Management

Background  Palmar midcarpal instability (PMCI) is an uncommon form of nondissociative carpal instability. However, it is an important cause of chronic ulnar wrist pain. Diagnosis can be difficult and high index of suspicion is mandatory. Pathomechanics and optimal treatment of PMCI remain uncertain. We propose an algorithm of clinical diagnosis and evaluate the outcome of our management. Materials and Methods  Between 2000 and 2011, 16 patients, including 7 males and 9 females, of a mean age of 33.9 diagnosed with PMCI were reviewed for their clinical, radiologic, and arthroscopic features. All patients presented with ulnar wrist pain in their dominant hands except in one. Initial management included a disease-specific anticarpal supination splint. Refractory cases were evaluated by arthroscopy and treated by arthroscopic thermal shrinkage using radiofrequency appliance as an interim or definite surgical intervention. Shrinkage was targeted at the ulnocarpal ligament at the radiocarpal joint and triquetrohamate ligament at the midcarpal joint. Nonresponsive or recurrent cases were managed by a novel technique of dorsal radiocarpal ligament reconstruction procedure using a pisiform-based split flexor carpi ulnaris (FCU) tendon graft. Results  In all cases, the midcarpal clunk test was positive with pain. Other common clinical features included lax ulnar column, carpal supination, volar sagging of the wrist, increased pisostyloid distance, wrist pain aggravated by passive hand supination and not by passive forearm supination, and increased wrist pain upon resisted pronation, which could be partially alleviated by manually supporting the pisostyloid interval. Common arthroscopic findings were excessive joint space at triquetrohamate interval and reactive synovitis over the ulnar compartments. Nine patients (56.3%) responded well to splinting alone at an average follow-up of 3.3 years. Arthroscopic thermal shrinkage was performed in five patients with recurrence in two patients. Five patients received split FCU tendon graft for ligament reconstruction. All patients showed improvement in the wrist performance score (preop 21.0, postop 36.6 out of 40) and pain score (preop 10.0, postop 2.2 out of 20) at the final follow-up of average 86 months (range: 19-155 months). Grip strength improved from 66.9 to 82.0% of the contralateral side. Wrist motion slightly decreased from a flexion/extension arc of 132 to 125 degrees. Three patients were totally pain free, one had mild pain, and one had moderate fluctuating pain. All patients returned to their original works. X-ray showed no arthrosis. Conclusion  PMCI is an uncommon but significant cause of chronic ulnar wrist pain. We have developed a clinical algorithm for diagnosis of the condition. The natural history seems to favor a benign course. Conservative treatment with an anticarpal supination splint is recommended as the initial management. Surgical options for resistant cases include arthroscopic thermal shrinkage or soft tissue reconstruction. The reconstruction of the dorsal radiocarpal ligament using a pisiform-based split FCU tendon graft provides reliable restoration of the carpal stability with good long-term outcome and few complications. This should be considered a viable alternative to limited carpal fusion.

Midcarpal Instability: The Role of Wrist Arthroscopy

The evidence behind management options for midcarpal instability (MCI) is scarce, relying solely on case series. Established treatments cause significant loss of wrist motion. As understanding of the condition has progressed, surgeons have been trying soft tissue techniques. The treatment option should be chosen for the appropriate type and grade of MCI. The Hargreaves grading system for palmar MCI aids treatment decision-making. A possible role for arthroscopy in treatment of MCI has been developed using arthroscopic thermal capsular shrinkage, appropriate for cases with dynamic instabilities. Static deformities require a soft tissue reconstruction or a partial wrist fusion.

Role of muscles in the stabilization of ligament-deficient wrists

This article reviews the results of a series of cadaver investigations aimed at clarifying the role of muscles in the stabilization of ligament-deficient wrists. According to these studies, isometric contraction of some forearm muscles induces midcarpal (MC) supination (ie, the abductor pollicis longus, extensor carpi radialis longus, and flexor carpi ulnaris), whereas other muscles induce MC pronation (ie, the extensor carpi ulnaris). Because MC supination implies tightening of the volar scaphoid-distal row ligaments, the MC supination muscles are likely to prevent scaphoid collapse of wrists with scapholunate ligament insufficiency. MC pronator muscles, by contrast, would be beneficial in stabilizing wrists with ulnar-sided ligament deficiencies owing to their ability to tighten the triquetrum-distal row ligaments. Should these laboratory findings be validated by additional clinical research, proprioceptive reeducation of selected muscles could become an important tool for the treatment of dynamic carpal instabilities.

Conservative management of midcarpal instability

Midcarpal instability is a complex condition that can present in various forms, from mild pain to debilitating subluxation. Once diagnosed, treatment guidelines for hand therapy are limited by the scarcity of high-level evidence. Evidence does exist for use of proprioceptive awareness and neuromuscular rehabilitation for instability of the knee, shoulder and ankle joint, but studies of similar programmes for the wrist joint have not been published. The purpose of this review is to examine the evidence supporting current concepts in the non-operative management of midcarpal instability, and to provide recommendations for the management of this condition with hand therapy.

Midcarpal instability

Midcarpal instability is a collective term for a number of conditions where the instability of the wrist is predominantly between the proximal and distal carpal rows. It has been regarded as relatively rare and infrequently requires surgical treatment. Palmar midcarpal instability is the most commonly found type of midcarpal instability and can be responsible for causing a clunking and painful wrist. The diagnosis is made on clinical grounds using the midcarpal instability provocative tests. Standard imaging and arthroscopic inspection do not usually confirm a definite diagnosis, but are important in excluding other pathologies. The classification and staging has been described using the extent of palmar translocation of the distal carpal row, which is elicited on passive stress tests. As this is a functional instability, it may be that a functional staging description might be better, and a proposed scheme is described. Treatment options including partial wrist fusions, tenodesis stabilizations and arthroscopic capsular shrinkage have been described in small case series with limited follow-up. There are no comparative series or randomized studies because of the relative rarity of this condition.

The role of proprioception and neuromuscular stability in carpal instabilities

Carpal stability has traditionally been defined as dependent on the articular congruity of joint surfaces, the static stability maintained by intact ligaments, and the dynamic stability caused by muscle contractions resulting in a compression of joint surfaces. In the past decade, a fourth factor in carpal stability has been proposed, involving the neuromuscular and proprioceptive control of joints. The proprioception of the wrist originates from afferent signals elicited by sensory end organs (mechanoreceptors) in ligaments and joint capsules that elicit spinal reflexes for immediate joint stability, as well as higher order neuromuscular influx to the cerebellum and sensorimotor cortices for planning and executing joint control. The aim of this review is to provide an understanding of the role of proprioception and neuromuscular control in carpal instabilities by delineating the sensory innervation and the neuromuscular control of the carpus, as well as descriptions of clinical applications of proprioception in carpal instabilities.

Carpal Ligament Injuries, Pathomechanics, and Classification

Carpal instability is a complex array of maladaptive and posttraumatic conditions that lead to the inability of the wrist to maintain anatomic relationships under normal loads. Many different classification schemes have evolved to explain the mechanistic evolution and pathophysiology of carpal instability, including 2 of the most common malalignment patterns: volar intercalated segment instability and the more common dorsal intercalated segment instability. Recent classifications emphasize the relationships within and between the rows of carpal bones. Future research is likely to unify the disparate paradigms used to describe wrist instability.

Physical Examination of the Wrist: Useful Provocative Maneuvers

Chronic wrist pain resulting from partial interosseous ligament injury remains a diagnostic dilemma for many hand and orthopedic surgeons. Overuse of costly diagnostic studies including magnetic resonance imaging, computed tomography scans, and bone scans can be further frustrating to the clinician because of their inconsistent specificity and reliability in these cases. Physical diagnosis is an effective (and underused) means of establishing a working diagnosis of partial ligament injury to the wrist. Carefully performed provocative maneuvers can be used by the clinician to reproduce the precise character of a patient's problem, reliably establish a working diagnosis, and initiate a plan of treatment. Using precise physical examination techniques, the examiner introduces energy into the wrist in a manner that puts load on specific support ligaments of the carpus, leading to an accurate diagnosis. This article provides a broad spectrum of physical diagnostic tools to help the surgeon develop a working diagnosis of partial wrist ligament injuries in the face of chronic wrist pain and normal x-rays.

A new technique for the treatment of midcarpal instability

Extensor carpi radialis brevis (ECRB) transfer to the hamate bone is a novel procedure that offers a new surgical treatment option for select patients with midcarpal instability (MCI) who do not respond to conservative treatment. We present our early experience with this procedure. In total, 12 patients (13 wrists) were reviewed with a follow-up duration ranging from 1 to 6 years. Complications and changes in active range of motion (AROM) were noted. Patient related outcome was measured using the Patient Rated Wrist/Hand Evaluation (PRWHE) questionnaire, amongst others. Two patients failed to show a positive response to the surgery. ECRB transfer to the ulnar side of the wrist is a new procedure that offers a potential option for the surgical treatment of MCI in select patients; however, further biomechanical and clinical studies are required. The level of evidence for this study is IV (therapeutic).

Soft tissue stabilization for palmar midcarpal instability using a palmaris longus tendon graft

PURPOSE

To report the results of a technique of soft tissue stabilization for palmar midcarpal instability using a palmaris longus graft.

METHODS

In patients' symptomatic wrists with palmar midcarpal instability that had failed conservative management, we used a dorsal approach and stabilized the hamate and triquetrum by reconstructing the dorsal triquetrohamate ligament. The palmaris longus tendon graft was fixed with bone anchors. Seven wrists in 6 patients were available for follow-up at a mean of 28 months (range, 17-37 mo).

RESULTS

There was an overall meaningful improvement in function (mean preoperative Disabilities of the Arm, Shoulder, and Hand score, 49 preoperatively, 28 postoperatively). There was a significant increase in grip strength from 15 to 21 kg. At final follow-up, 2 patients had moderate pain. The others had mild or no pain. Four patients returned to their previous occupation or activity. Patients retained full pronation and supination. When compared with the normal side, flexion was reduced to 71%, extension to 81%, radial deviation to 90%, and ulnar deviation to 65% of the opposite side. Although the mean results show an improvement, one patient had a poor result with deterioration in Disabilities of the Arm, Shoulder, and Hand score in spite of a clinically stable wrist, and another had clinical evidence of recurrent instability during pregnancy. One patient had residual symptoms from a prominent bone anchor.

CONCLUSIONS

Overall, this technique showed good medium-term results in most of our patients. It retained some midcarpal mobility, eliminated clunking in most patients, and provided a noteworthy improvement in grip strength and function. We continue to use this technique for patients with symptomatic midcarpal instability, but it requires further evaluation with larger patient numbers and a longer follow-up to assess its overall value.

Four-dimensional real-time cine images of wrist joint kinematics using dual source CT with minimal time increment scanning

PURPOSE

To validate the feasibility of real time kinematography with four-dimensional (4D) dynamic functional wrist joint imaging using dual source CT.

MATERIALS AND METHODS

Two healthy volunteers performed radioulnar deviation and pronation- supination wrist motions for 10 s and 4 s per cycle in a dual source CT scanner. Scan and reconstruction protocols were set to optimize temporal resolution. Cine images of the reconstructed carpal bone of the moving wrist were recorded. The quality of the images and radiation dosage were evaluated.

RESULTS

The 4D cine images obtained during 4 s and 10 s of radioulnar motion showed a smooth stream of movement with good quality and little noise or artifact. Images from the pronation-supination motion showed noise with a masked surface contour. The temporal resolution was optimized at 0.28 s.

CONCLUSION

Using dual source CT, 4D cine images of in vivo kinematics of wrist joint movement were obtained and found to have a shorter scan time, improved temporal resolution and lower radiation dosages compared with those previously reported.

Fracture-dislocations of the carpus: perilunate injury

The progressive perilunar instability model described by Mayfield is still used to predict the pattern of injury. Diagnosis of injury and clinical and radiographic findings depend on the pattern of injury. Open procedures are preferred for anatomic reduction after initial closed reduction is performed for acute injuries. A dorsal, volar, or combined dorsal/volar approach may be necessary and is often decided by surgeon preference. Loss of motion and diminished grip strength are common consequences despite appropriate treatment. Successful outcomes depend on time to treatment, open or closed nature of injury, extent of chondral damage, residual instability, and fracture union.

Triple jeopardy: transscaphoid, transcapitate, transtriquetral, perilunate fracture dislocation

Carpal injuries are frequently underdiagnosed and underreported injuries of the hand. Scapholunate perilunate dissociation is the most common perilunate instability pattern seen in clinical practice. Transscaphoid, transtriquetral, transcapitate dislocation with a volar intercalated segment instability pattern is a very rare pattern of carpal injury. We describe a case with this unique pattern of injury, explaining its mechanism and treatment. Good outcome can be achieved in these injuries following open reduction and internal fixation with ligamentous repair.

[Scaphoidectomy (instead of trapezectomy) in the treatment of rhizoarthrosis. Report of a case]

INTRODUCTION

Surgery site errors and technical errors in hand surgery are rare and not often published.

OBSERVATION

A 46-year-old patient with rhizoarthrosis of the left hand was initially treated by mistake in another center by a scaphoidectomy instead of a trapezectomy. She was seen in consultation 6months later, still suffering from her rhizoarthrosis and with carpal instability, clinically symptomatic and radiologically confirmed. The instability of the wrist was treated by a hamatocapito-lunar arthrodesis and a trapeziometacarpal arthrodesis was performed to treat the rhizoarthrosis. The clinical and radiological results were acceptable.

DISCUSSION

Besides the paradigmatic error, this observation confirms that the excision of the scaphoid quickly leads to a destabilization of the wrist, the capitatum no longer maintaining its alignment under the lunatum, and leads to a limitation of the wrist mobility and a loss of strength. The hamato-capito-lunate arthrodesis described in 1997 can treat wrist instability and only the trapeziometacarpal arthrodesis can, in the absence of scaphoid, treat the problem of rhizoarthrosis.

CONCLUSION

The authors recommend to always carry out a radiography of the wrist during trapezectomy surgery when there is doubt about the identification of the trapezium.

Midcarpal instability: a radiological perspective

Midcarpal instability (MCI) is the result of complex abnormal carpal motion at the midcarpal joint of the wrist. It is a form of non-dissociative carpal instability (CIND) and can be caused by various combinations of extrinsic ligament injuries that then result in one of several subtypes of MCI. The complex patterns of injury and the kinematics are further complicated by competing theories, terminology and classifications of MCI. Palmar, dorsal, ulna midcarpal instability, and capitolunate or chronic capitolunate instability are all descriptions of types of MCI with often overlapping features. Palmar midcarpal instability (PMCI) is the most commonly reported type of MCI. It has been described as resulting from deficiencies in the ulna limb of the palmar arcuate ligament (triquetrohamate-capitate) or the dorsal radiotriquetral ligaments, or both. Unstable carpal articulations can be treated with limited carpal arthrodesis or the ligamentous defects can be treated with capsulorrhaphy or ligament reconstruction. Conventional radiographic abnormalities are usually limited to volar intercalated segment instability (VISI) patterns of carpal alignment and are not specific. For many years stress view radiographs and videofluoroscopy have been the methods of choice for demonstrating carpal instability and abnormal carpal kinematics respectively. Dynamic US can be also used to demonstrate midcarpal dyskinesia including the characteristic triquetral "catch-up" clunk. Tears of the extrinsic ligaments can be demonstrated with MR arthrography, and probably with CT arthrography, but intact yet redundant ligaments are more difficult to identify. The exact role of these investigations in the diagnosis, categorisation and management of midcarpal instability has yet to be determined.

Controlled active mobilization after dorsal capsulodesis to correct capitolunate dissociation

STUDY DESIGN

Case Report. Capitolunate instability is a form of midcarpal instability. If conservative management is unsuccessful, surgical reconstruction is often indicated. However, the literature is limited regarding postoperative management after reconstruction. Often patients are immobilized for a 6- to 12-week period, which can produce secondary complications, including wrist stiffness, tendon adherence, and muscle atrophy. The purpose of the case report was to demonstrate that controlled early mobilization may be implemented postoperatively after dorsal capsulodesis procedures to correct capitolunate instability. This early mobilization may prevent secondary complications, which can be associated with lengthy immobilization periods. A 27-year-old female underwent a dorsal capsulodesis procedure to correct capitolunate instability. The intraoperative findings of the reconstruction and tension on the capsulodesis procedure were communicated to the therapist by the surgeon. This close communication allowed the therapist to institute early controlled mobilization immediately postoperatively using a hinged wrist splint. The patient was followed by our unit for 13 years. Early controlled mobilization using a hinged wrist splint may have maximized the subject's recovery, with no secondary complications. At 13-year follow-up, fluoroscopic and radiographic examination was normal, and no symptoms of pain or instability had reoccurred. In conclusion, early controlled mobilization using a hinged wrist splint may optimize the recovery period while retaining the desired arc of motion that is set intraoperatively.

LEVEL OF EVIDENCE

4.

Surgical treatment of pediatric posttraumatic palmar midcarpal instability: case report

We treated a 6-year-old child able to extend her wrist only to within 30 degrees of the neutral position secondary to posttraumatic palmar midcarpal instability with palmar and dorsal capsulodesis and pinning. More than 8 years after surgery, she has no complaints referable to her wrist and has 30 degrees of active wrist extension. Although unpredictable in adults, soft-tissue reconstruction is a treatment option in the pediatric patient with posttraumatic palmar midcarpal instability.

[Rotatory subluxation of the scaphoid: pathology and surgical management]

The interosseous scapholunate ligament (IOSLL) is the main stabilizer of the scapholunate (SL) couple but a static instability can appear only in the event of an associated injury of the extrinsic ligaments. Thus, SL dissociation covers a broad spectrum in which only static instability leads with certainty to osteoarthritis. Classically described as a rotatory subluxation of the scaphoid with DISI collapse, static SL instability manifests itself as a complex deformity with dorsolateral subluxation of the unit formed by the scaphoid and the distal carpal row. This deformity explains the dorsolateral radioscaphoid conflict and capitolunar decentering that is the origin of the radioscaphoid and midcarpal osteoarthritis that later appears. It is only within the first 4 to 6 weeks that a repair of the IOSLL, possibly associated with a capsulodesis, makes it possible to expect a good result and can prevent osteoarthritis. Beyond that time, no soft tissue procedure will modify the natural history of the condition. For us, surgery is indicated only for acute injuries and for symptomatic chronic instabilities. Before the occurrence of osteoarthritis, with new-found knowledge of the medium-term results of capsulodesis, it seems reasonable to favour a limited fusion. But in the event of failure, the patient is likely to remain in pain even after a total fusion. It is thus not aberrant to perform a capsulodesis in a sedentary person but it is necessary to inform the patient that osteoarthritis will occur. After occurrence of osteoarthritis, if it is symptomatic, proximal row carpectomy, SLAC procedure, total wrist fusion and denervation, can be considered, depending on the stage, the mobility of the wrist and the wishes of the patient. Denervation of the wrist can give good results with few risks, and does not jeopardize the results of a subsequent procedure.