Incidence of ligament lesions and associated degenerative changes in the elderly wrist

An algorithmic diagnostic approach to scapholunate ligament injuries based on comparison of X-ray examinations and arthroscopy in 414 patients

Conventional X-ray imaging is usually the first diagnostic assessment after clinical examination in case of suspected scapholunate interosseous ligament (SLIL) injury. Nevertheless, there is no consensus on the norms of the scapholunate distance (SLD) or carpal angles. Therefore, we aimed to determine the utility of static and dynamic radiographs in the diagnostic of an SLIL injury in comparison with the reference standard arthroscopy. We retrospectively analyzed the preoperative X-ray series and surgical records of arthroscopies of 414 patients. Radiological assessment included conventional static X-rays in the posteroanterior (PA) projection, clenched fist views in ulnar and radial deviations, in which the SLD at the midportion of the scapholunate (SL) joint was measured. The scapholunate angle (SLA) and radiolunate angle (RLA) were measured on lateral wrist radiographs. Receiver operating characteristic (ROC) curves were created to determine possible cut-off points of the radiological indices for the diagnosis of SLIL injury. Further, a logistic regression with the parameters having the highest area under the curve (AUC) was calculated. We found that SLD in ulnar inclination (AUC= 0.774), SLD in PA projection (AUC = 0.748), and SLA (AUC = 0.737) had the highest diagnostic value. The AUC of the combination of these three parameters was 0.822 for all patients with any SLIL lesion and 0.850 for patients with SLIL lesions of 3-4 Geissler grade. Further investigation of SLIL pathology would be appropriate in the case of SLD in ulnar inclination of 2.7 mm, SLD in PA projection of 1.9 mm and SLA of 63°.

Radiographic Incidence and Functional Outcomes of Distal Radius Fractures Undergoing Volar Plate Fixation With Concomitant Scapholunate Widening: A Prospective Analysis

Background: Scapholunate (SL) ligament injuries can occur concomitantly with distal radius fractures (DRFs), and the management of acute SL injury in the setting of DRFs remains controversial. The purpose of the study is to identify the radiographic incidence of SL widening in DRF treated with volar plate fixation and to determine the functional outcomes of DRF with concomitant radiographic SL-widening. Methods: One hundred and seventeen patients with DRFs, with and without radiographic SL-widening, and treated with volar locked plating, were prospectively enrolled. No SL ligament repairs or reconstructions were performed in any cases. Patients with DRFs with radiographic criteria for SL widening were compared to those without. Patients were evaluated at 3 months and 1 year postoperatively with Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation (PRWE) questionnaires. Results: Thirty-one patients (26.5%) were found to have radiographic evidence of SL widening. Patients with concomitant SL widening had less wrist extension at 3 months (52.4 degrees vs 60.8, P = .034) and at 1 year (64.5 degrees vs 71.8, P = .023). The group with SL widening had greater articular step off at 3 months (0.33 vs 0.06, P = .042), but no difference at 1 year (0.11 vs 0.05, P = .348). There were no differences in wrist flexion, supination, pronation, volar tilt, radial inclination, radial height, ulnar variance, PRWE scores, and Quick Dash scores at 3 months and 1 year. Conclusions: Radiographic SL-widening is a common finding associated with DRFs undergoing surgical repair. There are similar clinical outcomes between those with untreated SL widening compared to those without an SL widening at 1-year postoperatively.

Assessment of distal radioulnar joint stability in healthy subjects: Changes with dominant hand, sex, and age

This study aimed to elucidate the differences in distal radioulnar stability in dominant/nondominant hand, sex, and age. Bilateral wrists of 60 healthy subjects were evaluated using force-monitoring ultrasonography. This apparatus was developed to apply cyclic compression and measure applied force to displacement during an ultrasound exam. The transducer was placed on the dorsal side of the distal radioulnar joint, and the center of the ulnar head was displayed on the monitor. The distance between the dorsal surface of the distal radius and the ulnar head was measured at an initial and at a pressed-down position. The radioulnar displacement, applied force to displacement, and displacement-to-force ratio were evaluated. The results were compared between the dominant and nondominant hands, and between males and females, and among different age groups. There were no significant differences in the parameters between the dominant and nondominant hands. The applied force to displacement was significantly greater in the male group compared with the female group. There were significant effects for the different age groups in all parameters (displacement: F = 3.67, p = .008; applied-force: F = 3.08, p = .019; displacement-to-force ratio: F = 4.66, p = .002). Our results indicated that the stability of distal radioulnar joint differed depending on age and sex. Age and sex should be considered when assessing distal radioulnar joint stability.

Early Outcomes of Scapholunate Injuries With Concomitant Distal Radius Fractures

Background: There is limited literature regarding the treatment of concomitant scapholunate ligament (SL) injuries in acute distal radius fractures (DRFs). We hypothesized that surgical treatment of SL injuries in adult patients with DRFs leads to improved functional outcomes. Methods: A retrospective review was made of 42 adult patients who underwent surgical treatment of a DRF with a SL injury between 2005 and 2013. In all, 39 of the 42 patients sustained an intra-articular DRF (AO B or C). SL injury was diagnosed by SL diastasis > 3 mm on posteroanterior (PA) radiographs, magnetic resonance imaging, or with wrist arthroscopy. Patients were divided into 3 groups: 23 had a SL repair and were treated within 21 days of injury (acute), 8 underwent SL repair greater than 21 days from injury (subacute/chronic), and 11 did not undergo repair (non-operative). Median overall time to clinical follow-up was 5.1 years. Mayo Wrist Scores (MWS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were used to evaluate functional outcome. Results: Clinical outcomes measured by the MWS at final follow-up (6 months-12 years) showed no significant differences between the 3 groups. Of patients treated acutely, 17.3% had good to excellent MWS. MWS at 1-year follow-up was 68.4, 70, and 64 in the acute, subacute/chronic, and non-operative groups, respectively. DASH scores were 16.7, 14.3, and 11.8 in the acute, subacute/chronic, and nonoperative groups, respectively, at a mean of 7.8 years. Conclusions: At mid-term follow-up, all 3 treatment groups had similar DASH scores to the general population. There were no statistical functional differences between any of the groups based upon MWS or DASH scores.

Accuracy of magnetic resonance imaging of the wrist for clinically important lesions of the major interosseous ligaments and triangular fibrocartilage complex; correlation with radiocarpal arthroscopy

OBJECTIVE

To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist.

MATERIALS AND METHODS

In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions-central and radial-or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions.

RESULTS

For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears.

CONCLUSIONS

The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.

Assessing the scapholunate and lunotriquetral interosseous ligament in MR arthrography: Diagnostic advantages of paraxial reformatting

PURPOSE

The scapholunate (SLIL) and lunotriquetral interosseous ligament (LTIL) function as the main stabilizers of the proximal carpal row. Even with MR arthrography, component assessability is often limited in orthogonal standard planes due to their horseshoe-like shape and resulting partial volume effects. This study aims to investigate the diagnostic value of reformatting isotropic 3D sequences with respect to the anatomical orientation of the intrinsic carpal ligaments.

METHOD

In 110 MR arthrograms of the wrist, we investigated the diagnostic accuracy of two radiologists (R1/R2) for SLIL and LTIL injuries in orthogonal standard planes vs. ancillary angulated reformatting of isotropic 3D dual echo steady state sequence. Component assessability and diagnostic confidence were compared between datasets.

RESULTS

The addition of paraxial reformations improved diagnostic accuracy for lesions of the palmar (R1: 0.87 vs. 0.93; R2: 0.86 vs. 0.93; all p < 0.05) and dorsal LTIL (R1: 0.85 vs. 0.93; R2: 0.82 vs. 0.90; all p < 0.05). No significant increase in accuracy could be ascertained for palmar (R1: 0.92 vs. 0.94, p = 0.50; R2: 0.86 vs. 0.92, p = 0.07) and dorsal (R1: 0.95 vs. 0.95, p = 1.00; R2: 0.90 vs. 0.94, p = 0.29) lesions of the SLIL. Interrater reliability was almost perfect with and without angulated planes for SLIL (κ = 0.88 vs. 0.82) and LTIL assessment (κ = 0.88 vs. 0.86). For the LTIL, observer confidence and component assessability were superior with anatomical reformations available (all p < 0.05).

CONCLUSIONS

In contrast to SLIL injuries, diagnosis of LTIL lesions benefits from ancillary paraxial reformations of 3D sequences in MR wrist arthrography.

Intercarpal Ligament Injuries Associated With Distal Radius Fractures

Injuries to the scapholunate (SL) and lunotriquetral (LT) interosseous ligaments occur in approximately one third of distal radius fractures. The diagnosis of these injuries is challenging because plain radiographs are not reliably diagnostic. Wrist arthroscopy may be the most accurate way to examine and diagnose soft-tissue injuries of the carpus adjacent to a distal radius fracture. Treatment options for SL and LT ligament injuries include open repair and/or percutaneous pinning. Because the natural history of these injuries is unclear, the necessity of diagnosing and treating these SL and LT interosseous ligament defects remains speculative.

Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists

Background

Management of chronic isolated scapholunate interosseous ligament (SLIL) injuries has generated a substantial volume of low-quality literature with descriptions of multiple new surgical techniques, and the impact of instability pattern and the optimal surgical technique remain unclear. The primary goal of this review was to compare clinical, radiographic and patient-rated outcomes between current surgical techniques.

Methods

We performed a systematic literature search using multiple databases. We analyzed clinical, radiographic and patient-reported outcomes. We used a fixed-effects model weighted by sample size with combined outcomes estimated via least squares means with 95% confidence intervals. We also performed a subgroup analysis of static versus dynamic instability.

Results

We assessed 805 procedures from 37 study groups, with 429 procedures used in subgroup analysis. There were no statistically significant differences in outcomes between surgical techniques or in subgroup analysis. Overall, postoperative wrist flexion and pain scores decreased, and grip strength and patient-rated outcomes improved.

Conclusion

Compared to overall preoperative values, modest improvements in pain score, grip strength and functional outcome scores were obtained from a range of reconstructive procedures performed for chronic isolated SLIL injuries. No significant differences could be ascertained between surgical techniques, potentially owing to the low quality of evidence and procedure heterogeneity. This study provides accurate preoperative reference values for future studies, highlights the controversial clinical impact of instability classification, and the need for higher-quality multicentre or collaborative trials to improve our understanding and management of this common injury.

The Prevalence of Triangular Fibrocartilage Complex Signal Abnormalities on Magnetic Resonance Imaging Relative to Clinical Suspicion of Pathology

PURPOSE

To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes.

METHODS

In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group.

RESULTS

A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age.

CONCLUSIONS

The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Radiographic Diagnosis of Scapholunate Diastasis in Distal Radius Fractures: Implications for Surgical Practice

Background  Radiographic diagnosis of scapholunate ligament injury (SLI) in the setting of distal radius fractures (DRFs) is challenging. It remains unclear to what extent radiographic diagnosis of SLI by a radiologist influences surgical decision-making regarding treatment of SLI. Purpose  We aimed to (1) identify the number of times that concerns for the possibility of concurrent SLI in the setting of a DRF had been raised by the radiologists, (2) identify how often the radiologist's diagnosis was confirmed by the treating surgeon, and (3) how many of the patients with a radiographic concern for SLI by the radiologist received operative treatment for the SLI. Patients and Methods  Based on Current Procedural Terminology codes, we identified 2,923 patients that were operatively treated for their DRF in 1 of 3 participating institutions in an urban city in the United States. We reviewed the medical charts of 654 patients who had a mention of scapholunate ligament (SL) distance in their radiography, surgery, or clinical notes. We then measured the SL distance and recorded patient, diagnosis, and treatment characteristics of all these patients. Results  A total of 200 out of 2,923 patients (6.8%) received a radiological diagnosis of SLI. In seven of these patients (3.5%), the surgeon confirmed the diagnosis of the radiologist. Four patients (2%) had operative repair of their SLI. Conclusion  Radiologists demonstrate a low threshold to identify SLI in the setting of DRFs, while the number of SLIs identified by the treating surgeon is a remarkably smaller number. Level of Evidence  Level II, prognostic study.

Chondrocalcinosis of the Wrist

Calcium pyrophosphate dihydrate deposition (CPDD) disease has characteristic radiographic features including soft tissue calcification, joint space narrowing, bone sclerosis, subchondral cyst formation without osteophyte formation, and large intraosseous geodes. Triangular fibrocartilage calcification is frequently found and isolated scapho-trapezio-trapezoid (STT) arthritis is specific for CPDD. Distal radio-ulnar (DRUJ), isolated midcarpal joint and piso-triquetral joint involvement also occur. 127 patients were reviewed. Seventy-eight had symptomatic STT joint arthritis, for which 36 underwent surgery. Twenty-two patients had a SLAC wrist deformity for which ten underwent surgery. Eight patients had isolated midcarpal arthritis for which three midcarpal arthrodeses, two four-bone arthrodeses and two carpal tunnel releases were performed. Nineteen patients had a generalized arthritis and seven of the patients underwent surgery: fourcorner arthrodesis+scaphoidectomy (one case), carpal tunnel relaease (two cases) extensor synovectomy (two cases) and trigger finger release (two cases).

Ulna-Shortening Osteotomy: Outcome and Repercussion of the Distal Radioulnar Joint Osteoarthritis

BACKGROUND

Ulnocarpal impaction syndrome occurs mostly in patients with positive ulnar variance. Ulnar-shortening osteotomy is a commonly used method to correct it, but degenerative changes may appear in the distal radioulnar joint. The authors evaluated outcome after ulnar-shortening osteotomy, particularly the impact of distal radioulnar joint osteoarthritis.

METHODS

A 10-year study was performed of patients who underwent ulnar-shortening osteotomy.

RESULTS

Forty-six patients were available for clinical examination and radiography. Twenty-nine wrists showed worsening or new osteoarthritis. A difference of preulnar variance and resection was noted: 4.64 mm and 4.48 mm, respectively, in the osteoarthritis group versus 3.50 mm and 3.38 mm in the group without osteoarthitis. Comparison of patients with osteoarthritis revealed a significant limitation of range of motion in flexion-extension (p = 0.009) and pronosupination (p = 0.028): 102 degrees and 138 degrees, respectively, in the osteroarthritis group versus 124 degrees and 155 degreees in the group without osterarthritis. The type of distal radioulnar joint differed significantly (p = 0.038), with a predominance of type I in the osterarthritis group and type II in the group without osterarthritis. Functional outcome was significantly worse in the osterarthritis group versus the group without osteoarthritis concerning the Patient-Rated Wrist Evaluation score (39.07 versus 22.59, p = 0.031), the Quick Disabilities of the Arm, Shoulder, and Hand score (27.38 versus 19.59, p = 0.017), and the modified Gartland-Werley score (76.72 versus 85.14, p = 0.027).

CONCLUSIONS

Ulnar-shortening osteotomy modifies the congruence of the distal radioulnar joint, and the type I joint may be at increased risk of arthrosis. Osteoarthritis has a clinical impact, and the amount of ulnar shortening should be limited to what is needed to avoid altering the functional outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Scapholunate instability after distal radius volar plating

BACKGROUND

Prior to volar locked plating and early motion protocols, ligamentous injuries incidentally associated with distal radius fractures may have been indirectly treated with immobilization. Our goal was to determine the prevalence of scapholunate instability in our population, while identifying those who may have had progression of instability.

METHODS

We retrospectively reviewed 221 distal radius fractures treated with a volar locking plate during a 6-year period. Average patient age was 59 years. Standard posteroanterior and lateral radiographs from the first and last postoperative visits were analyzed for scapholunate instability, using the criteria of scapholunate gap ≥3 mm and scapholunate angle ≥60°.

RESULTS

Six patients (3 %) met neither or only one criterion for instability at the first postoperative visit and did not have ligament repair and then went on to meet both criteria at the last postoperative visit after an early motion protocol. Seven patients (3 %) met both criteria at the first and last postoperative visits and did not have ligament repair. Five patients (2 %) underwent primary scapholunate ligament repair at the time of distal radius fixation.

CONCLUSIONS

In our representative population, scapholunate instability was uncommon, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. Thus, we did not find strong evidence for routinely delaying motion or pursuing further workup. When early radiographs clearly demonstrate acute scapholunate instability, more aggressive treatment may be appropriate for selected patients.

Injuries of the Scapholunate Interosseous Ligament: An Update

The scapholunate ligament is both a key ligament in the stability of the carpus and one of the most frequently injured. Thorough understanding of the anatomy, biomechanics, and pathophysiology of the wrist is important in treating injuries to the scapholunate ligament. The presentation of scapholunate instability often includes a vague injury history and pain with grip, wrist extension, and sport or labor. Identified injuries are classified based on dynamic and static radiographic findings, chronicity, and the presence or absence of arthrosis. Surgical options for the treatment of low- and high-grade injuries include both open and arthroscopic procedures and can be broadly classified into four categories: limited arthroscopic procedures, primary ligament repair, reconstructive procedures, and salvage procedures. No strong evidence currently supports any one treatment. Decision making is largely based on expert opinion and surgeon experience. Prognosis is often guarded, and patient expectations should be tempered.

Scapholunate Ligament Tears: Acute Reconstructive Options

Left untreated, scapholunate dissociation can lead to posttraumatic wrist arthritis. Multiple surgical procedures have been designed to reduce the scapholunate interval, restore normal wrist kinematics, and prevent the development of arthritis. Unfortunately, current surgical procedures have not been shown to consistently maintain radiographic alignment at long-term follow-up and result in decreased wrist range of motion and strength compared with the contralateral side. The purpose of this article is to review the current reconstructive options for scapholunate ligament tears without evidence of radiographic arthritis.

Cine MRI: a new approach to the diagnosis of scapholunate dissociation

OBJECTIVE

To evaluate the feasibility of cine MRI for the detection of scapholunate dissociation (SLD) and to compare the sensitivity and specificity of cine MRI with those of cineradiography and arthroscopy.

MATERIALS AND METHODS

To evaluate feasibility, healthy subjects underwent cine MRI of the wrist. To evaluate sensitivity and specificity, patients with clinically suspected scapholunate ligament (SLL) injury after trauma to the wrist were prospectively included and underwent radiographic examination, cineradiography, and cine MRI. In 25 out of 38 patients, subsequent arthroscopy was performed. Results of cineradiography and cine MRI correlated with those of arthroscopy.

RESULTS

Cine MRI was of diagnostic quality in all healthy subjects and patients with good interrater agreement. There was excellent correlation between cineradiography and cine MRI. Scapholunate distance differed significantly between healthy subjects and patients with scapholunate dissociation (p < 0.001), but not between imaging modalities in the patient group. Cine MRI had 85% sensitivity and 90% specificity for the detection of SLD.

CONCLUSION

Cine MRI of the wrist is a fast and reliable technique for the detection of SLD with diagnostic accuracy comparable to cineradiography. It can be easily implemented as a routine clinical MRI examination, facilitating diagnostic workup of patients with suspected SLD while avoiding radiation exposure.

Analysis of soft tissue injuries associated with distal radius fractures

BACKGROUND

Soft tissue injuries associated with distal radius fractures have been reported by some authors. Arthroscopy can be used to evaluate the condition of the articular surface and intracarpal soft tissues and as an aid to treatment. There are three intracarpal soft tissues of particular importance: the triangular fibrocartilage complex (TFCC), the scapholunate interosseous ligament (SLIL), and the lunotriquetral interosseous ligament (LTIL). The purpose of this study was to evaluate intracarpal soft tissue injuries and their relationships with fracture types during arthroscopic surgical treatment of distal radius fractures.

METHODS

Eighty-nine patients in our hospital underwent surgical treatment by arthroscopy for a fracture of the distal end of the radius. They ranged in age from 17 to 92 years (mean, 62.2 years), and comprised 20 men (mean age, 45.6 years) and 69 women (mean age, 66.5 years). The AO classification data on plain radiographs indicated A2 fracture in four patients, A3 fracture in 10 patients, C1 fracture in two patients, C2 fracture in 24 patients, and C3 fracture in 49 patients. Wrist arthroscopy was performed with vertical traction, and intracarpal soft tissues were examined. For assessment of the TFCC in the radiocarpal space, the Palmar classification was used. For assessment of the SLIL and LTIL in the midcarpal space, the Geissler classification was used.

RESULTS

TFCC injury was present in 59% of cases, SLIL injury in 54.5% of cases, and LTIL injury in 34.5% of cases. Only 17.1% of patients (14/82 patients) were negative for all three types of injury. In 81% of cases (72/89 patients), some intracarpal soft tissue injury was present in association with the fracture.

CONCLUSIONS

The fracture was complicated by TFCC injury in 59% of patients, SLIL injury in 54.5% of patients, and LTIL injury in 34.5% of patients, irrespective of the fracture type.

Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography

PURPOSE

This study compares the diagnostic performance of multidetector CT arthrography (CTA), conventional 3-T MR and MR arthrography (MRA) in detecting intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist.

MATERIALS AND METHODS

Ten cadaveric wrists of five male subjects with an average age 49.6years (range 26-59years) were evaluated using CTA, conventional 3-T MR and MRA. We assessed the presence of scapholunate ligament (SLL), lunotriquetral ligament (LTL), and TFCC tears using a combination of conventional arthrography and arthroscopy as a gold standard. All images were evaluated in consensus by two musculoskeletal radiologists with sensitivity, specificity, and accuracy being calculated.

RESULTS

Sensitivities/specificity/accuracy of CTA, conventional MRI, and MRA were 100%/100%/100%, 66%/86%/80%, 100%/86%/90% for the detection of SLL tear, 100%/80%/90%, 60%/80%/70%, 100%/80%/90% for the detection of LTL tear, and 100%/100%/100%, 100%/86%/90%, 100%/100%/100% for the detection of TFCC tear. Overall CTA had the highest sensitivity, specificity, and accuracy among the three investigations while MRA performed better than conventional MR. CTA also had the highest sensitivity, specificity, and accuracy for identifying which component of the SLL and LTL was torn. Membranous tears of both SLL and LTL were better visualized than dorsal or volar tears on all three imaging modalities.

CONCLUSION

Both CT and MR arthrography have a very high degree of accuracy for diagnosing tears of the SLL, LTL, and TFCC with both being more accurate than conventional MR imaging.

The role of MDCT arthrography in the follow-up of scapholunate stabilisation

PURPOSE

The aim of this study was to assess outcomes in a group of patients with scapholunate dissociation treated with stabilisation surgery (Brunelli-Stanley) and to compare arthrography with multidetector computed tomography (MDCT) with conventional radiography, the gold standard in the follow-up of wrist surgery.

MATERIALS AND METHODS

Twelve patients (13 wrists) underwent surgery for scapholunate dissociation and were followed up with clinical (visual analogue scale, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Disabilities of the Arm, Shoulder, and Hand) and radiological assessment (conventional radiography and CT arthrography). Conventional radiography was assessed for: the scapholunate gap, scapholunate angle, radiolunate angle, capitate-lunate angle, and carpal height index; the CT arthrography images were also evaluated for: the distance between the dorsal exit hole of the bone tunnel and the proximal scaphoid pole, the thickness and tension of the flexor carpi radialis (FCR) strip, and any signs of joint degeneration.

RESULTS

Analysis of the data from conventional radiography and MDCT arthrography demonstrated a significant statistical correlation among the measurements obtained on the radiograms and multiplanar CT reconstructions and the patients' clinical outcome.

CONCLUSIONS

Our results show that MDCT arthrography has the same value as conventional radiography in the evaluation of standard parameters (scapholunate gap, scapholunate angle, radiolunate angle, capitolunate angle, carpal height index), but in addition provides an accurate delineation of the FCR tendon graft, allowing differentiation of its thickness, direction and degree of tension.

Will the untreated ulnar styloid fracture influence the outcome of unstable distal radial fracture treated with external fixation when the distal radioulnar joint is stable

BACKGROUND

The ulnar styloid is an important supportive structure for the triangular fibrocartilage complex. However, it remains inconclusive whether or not a fractured ulnar styloid should be fixed in an unstable distal radius fracture (DRF) with a stable distal radioulnar joint (DRUJ). The purpose of this study is to evaluate the effect of an untreated ulnar styloid fracture on the outcome of unstable DRF treated with transarticular external fixation when the DRUJ is stable.

METHODS

106 patients with an unstable DRF and a stable DRUJ were included in this study following external fixation. The patients were divided into the non-fracture, the tip-fracture and the base-fracture groups according to the location of the ulnar styloid fracture at the time of injury. Postoperative evaluation included the range of wrist motion, the radiological index, the grip strength, the PRWE-HK scores, the wrist pain scores, and the instability of DRUJ at the external fixator removal time, three months postoperatively and the final follow-up visit.

RESULTS

The patients were followed for 12 to 24 months (15 months in average). Sixty-two of 106 patients (58%) had ulnar styloid fracture and 16 patients (26%) showed radiographic evidence of union of ulnar styloid fractures at the final follow-up visit. No significant difference in the radiological findings, the range of wrist motion, the grip strength, the PRWE-HK scores, and the wrist pain scores among three patient groups was detected at the external fixator removal time, three months postoperatively, or the final follow-up visit. Six of the 106 patients (5.7%) complained of persistent ulnar-side wrist pain during daily activities. One patient (0.9%) showed a positive sign in a stress-test, three patients (2.8%) showed a positive sign in a provocative-test, and five patients (4.7%) showed a positive sign in a press-test. There was no significant difference in the percentages of patients who complained of persistent ulnar-side wrist pain or showed a positive sign in the physical examination of the distal radioulnar joint among the three groups at the final follow-up time points.

CONCLUSION

When the DRUJ is stable, an untreated ulnar styloid fracture does not affect the wrist outcome of the patient with an unstable DRF treated with external fixation.

RADIOGRAPHIC SIGNS OF STATIC CARPAL INSTABILITY WITH DISTAL END RADIUS FRACTURES: IS CURRENT TREATMENT ADEQUATE?

Patients presenting with distal end radius fractures may have concomitant carpal instability due to disruption of the scapholunate ligament. This study examined the incidence of static radiographic signs of carpal instability in patients with distal radial fractures before and after fracture treatment. We performed a retrospective radiographic study of 141 patients presenting to Central Middlesex Hospital, London between January 2002–May 2004 with distal end radius fractures. We used abnormal scapholunate angle as the primary indicator of possible carpal dissociation. Abnormal scapholunate angles were noted in 39% of patients at presentation and 35% of patients after treatment with no statistically significant intra-patient variability. Persistent static radiographic signs of carpal instability are high in this subset of patients. The long-term morbidity of persistent wrist instability may be avoided by early radiological diagnosis with clinical correlation to identify carpal ligament injuries and initiate treatment that addresses both the bony and ligamentous components of the injury.

[Dorsal radiocarpal joint dislocation for an 85-years-old woman]

The authors report the case of a dorsal, closed, radiocarpal dislocation with a small posterior marginal fracture of the radius, in an 85-year-old woman, without violent trauma (fall from her height). The dislocation was reduced by traction and the wrist immobilized in a plaster cast for 6 weeks. Six months after the accident, the patient had resumed her activities without pain with a diminished range of motion. This dislocation is exceptional at this age. In our case, the functional outcome was good after orthopaedic treatment.

The aging athlete: part 2, "boomeritis" of the upper extremity

OBJECTIVE

The purpose of this review is to describe the upper extremity injuries that frequently accompany aging, the typical clinical presentations, and the differential diagnoses with an emphasis on the injury most likely encountered with each presentation.

CONCLUSION

Expectation of continued participation in exercise and sports activities by the baby boomer population has presented new challenges to the medical field. The concepts behind factors that predispose older athletes to certain pathologic conditions that affect the muscles, tendons, and bones of the upper extremity must be understood.

Immunohistochemical composition of the human lunotriquetral interosseous ligament

PURPOSE

The human lunotriquetral ligament (LTL) is a functionally important intrinsic hand ligament, which is assumedly subjected to insertion angle changes at the entheses during movement. To clarify whether the current model of the ligament's mechanical environment is reflected in its structural composition, we determined the regional distribution of extracellular matrix-related antigens.

METHODS

The extracellular matrix was immunohistochemically investigated in 12 LTLs from both wrists of 6 human donors (Mean age: 60 y).

RESULTS

The dorsal, proximal, and volar portions of the ligament immunolabeled for type I, III collagen and versican. Both entheses labeled strongly for type II collagen, aggrecan, and link protein and were distinctly cartilaginous. The ligament midsubstance was positive for collagen II in 30%, for aggrecan in 40%, and for keratocan and lumican in 100% of specimens. In contrast, keratocan and lumican were absent from the fibrocartilaginous entheses and the articular cartilage. Ligament insertion at a carpal bone occurs either directly through fibrocartilage or indirectly through a bilayered configuration of fibrocartilage and hyaline-like cartilage. The hyaline-like cartilage is continuous with the neighboring articular cartilage.

CONCLUSIONS

The LTL has an extracellular matrix comparable with that of ligaments experiencing a combination of tensile and shear/compressive load at the attachment sites. All regions of the LTL exhibit fibrocartilaginous entheses; purely fibrous attachment sites are rare. The ligament midsubstance shows a more fibrous phenotype than the entheses and expresses keratocan and lumican, which previously have not been recorded in any human hand ligament.

Intercarpal ligamentous laxity in cadaveric wrists

The purposes of this study were to define the range of laxity of the interosseous ligaments in cadaveric wrists and to determine whether this correlated with age, the morphology of the lunate, the scapholunate (SL) gap or the SL angle. We evaluated 83 fresh-frozen cadaveric wrists and recorded the SL gap and SL angle. Standard arthroscopy of the wrist was then performed and the grades of laxity of the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) and the morphology of the lunate were recorded. Arthroscopic evaluation of the SLIL revealed four (5%) grade I specimens, 28 (34%) grade II, 40 (48%) grade III and 11 (13%) grade IV. Evaluation of the LTIL showed 17 (20%) grade I specimens, 40 (48%) grade II, 28 (30%) grade III and one (1%) grade IV. On both bivariate and multivariate analysis, the grade of both the SLIL and LTIL increased with age, but decreased with female gender. The grades of SLIL or LTIL did not correlate with the morphology of the lunate, the SL gap or the SL angle. The physiological range of laxity at the SL and lunotriquetral joints is wider than originally described. The intercarpal ligaments demonstrate an age-related progression of laxity of the SL and lunotriquetral joints. There is no correlation between the grades of laxity of the SLIL or LTIL and the morphology of the lunate, the SL gap or the SL grade. Based on our results, we believe that the Geissler classification has a role in describing intercarpal laxity, but if used alone it cannot adequately diagnose pathological instability. We suggest a modified classification with a mechanism that may distinguish physiological laxity from pathological instability.

MR arthrography of the wrist: controversies and concepts

Magnetic resonance arthrography (MRA) has become the preferred modality for imaging patients with internal derangement of the wrist. However, several aspects of MRA use need to be clarified before a standardized approach to the imaging of internal derangement of the wrist can be developed. The objective of the study is to evaluate the efficiency of different magnetic resonance (MR) sequences in the detection of lesions of the triangular fibrocartilage complex (TFCC) and scapholunate and lunotriquetral ligaments on direct MRA. Thirty-one consecutive direct magnetic resonance arthrographic examinations of the wrist using a wrist surface coil were performed for the assessment of the TFCC and intrinsic ligaments on a 1.5-T MR imaging system (Signa; 16 channel, Excite, GE Healthcare, Milwaukee, WI, USA). All patients had wrist pain, and in six cases, there was associated clinical carpal instability. The presence, location, and extent of TFCC, scapholunate ligament (SLL), and lunotriquetral ligament (LTL) lesions on T1 fat-saturated, multiplanar gradient recalled (MPGR) and short tau inversion recovery (STIR) images were identified, compared, and analyzed. Forty-one lesions of the TFCC, SLL, and LTL were visualized on contrast-sensitive (T1 fat-saturated) images in 23/31 (74.2%) patients. Twenty-one lesions of the TFCC and intrinsic ligaments were visualized on noncontrast-sensitive (MPGR and STIR) images (15 tears of the TFCC and six tears of the SLL and LTL). All of these lesions were seen on T1 fat-saturated images; 48.8% (20/41) lesions seen on T1 fat-saturated images (eight tears of TFCC and 12 tears of SLL and LTT) were not seen on MPGR and/or STIR images. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences making MRA the preferred modality for imaging internal derangements of the wrist. Little agreement exists regarding the value and location of perforations of the intrinsic ligaments given that both traumatic and degenerative perforations may be symptomatic. Noncommunicating defects of the ulnar attachments of the triangular fibrocartilage (TFC), tears of the dorsal segment of the SLL, and defects at the lunate attachment of the SLL have a higher likelihood of being symptomatic and caused by trauma rather than by degenerative perforation. Although no consensus exists, it would appear that most arthrographies should be started with a radiocarpal injection. Injection into the distal radioulnar joint should be added if no communicational defects are visualized following radiocarpal injection in patients with ulnar-sided wrist pain.

Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation

OBJECTIVE

Missed tears of the scapholunate ligament (SLL) and scapholunate dissociation (SLD) after wrist injuries pose a high risk of post-traumatic osteoarthritis of the carpus. Plain X-rays and dynamic radiographic studies are frequently used for initial diagnostic work-up. Given the limited evidence of their accuracy, we retrospectively compared the radiographic findings of patients with suspected traumatic SLD with wrist arthroscopy as the accepted reference standard.

DESIGN AND METHODS

During a 6-year period, plain radiographs and DSA cineradiography scans were obtained from 198 patients who had sustained a hyperextension injury to their hand. Of those, 102 (72 men, 30 women, mean age of 42+/-12 years) subsequently underwent diagnostic arthroscopy. Digital images were reevaluated by experienced radiologists unaware of the arthroscopic findings for the presence or absence of SLD. We calculated the sensitivity (SN) and specificity (SP) with 95% confidence intervals (CI), and computed areas under the receiver operating characteristic curves (AUC/ROC).

RESULTS

Arthroscopy revealed 42 SLL ruptures, 13, 10, and 19 of which were classified as grade I (partial), II (complete with dynamic instability), or III (complete with static instability) respectively. Plain radiographs correctly identified 24 injuries (SN 57.1%, 95% CI 41.0-72.3%), and produced 1 false-positive result (SP 98.3%, 95% CI 91.1-100.0%). The scapholunate distance and the SL angle contributed independently to the diagnostic variance, with an AUC/ROC of 85.7% (95% CI 76.8-92.2%). Cineradiography had a sensitivity of 36 out of 42 (85.7%, 95% CI 71.5-94.6%), and a specificity of 57 out of 60 (95.0%, 95% CI 86.1-99.0%).

CONCLUSION

Pathological results on plain radiographs and cineradiography reliably indicate the presence of SLD after wrist trauma. Although non-conclusive, a negative dynamic study markedly reduces the pre-test probability of disease. Both methods remain key elements of primary diagnostic strategies for suspected traumatic SLD, and may facilitate the selection of additional tests.

Axial oblique MR imaging of the intrinsic ligaments of the wrist: initial experience

OBJECTIVE

To evaluate two separate MR sequences acquired in the axial oblique plane, parallel to the long axis of the scapholunate (SL) and lunotriquetral (LT) ligaments, to determine whether the addition of these sequences to the standard MR wrist examination improves visualization of the intrinsic ligaments, and the evaluation of their integrity. To our knowledge, this plane has not been described in the literature previously.

DESIGN AND PATIENTS

In total we evaluated 26 patients with chronic wrist pain or instability, referred for MR imaging following assessment by an orthopedic surgeon or physiatrist. All patients underwent initial conventional tri-compartment wrist arthrography, which served as the reference standard. This was immediately followed by MR arthrography, in the standard coronal and true axial planes, as well as in the axial oblique plane. The SL and LT ligaments were initially assessed for the presence or absence of tear, using the standard coronal and true axial sequences, and subsequently re-evaluated with the addition of the axial oblique planes.

RESULTS

A total of ten intrinsic ligament tears were identified with conventional arthrography: six SL and four LT tears. Five of the six SL tears were identified on the standard sequences. All six were diagnosed with the addition of the oblique sequences. There were three false-positive SL tears identified using standard MR imaging, and two false-positives with the addition of the oblique sequences. No LT tear was identified on standard sequences, whereas all four were confidently seen with the addition of oblique images. No false-positives of the LT ligament were recorded with either standard or axial oblique sequences.

CONCLUSION

The study suggests that the addition of axial oblique MR sequences helps identify tears to the intrinsic ligaments of the wrist, particularly the LT ligament. In addition, the axial oblique images assist in localization of the tear.

[Frequency of acute and chronic scapholunate dissociation in distal radius fractures. Different treatment plans]

BACKGROUND

Early diagnosis and appropriate treatment of acute scapholunate dissociation (SLD) is crucial for obtaining a favorable result in fractures of the distal radius. The aim of this study was to determine the incidence of acute SLD in a prospective study and to differentiate this entity from chronic SLD.

PATIENTS AND METHODS

A total of 120 patients with unilateral distal radius fractures were prospectively evaluated for SLD. Stress radiographs were obtained for all patients on the injured side after fixation of the distal radius fractures. In cases of SLD the unaffected side was examined to rule out chronic, bilateral SLD.

RESULTS

Acute SLD was detected in 13 patients (11%), 11 (9.1%) of whom had stage 3 injury. Chronic SLD with bilateral asymptomatic instability was seen in three patients (2.5%).

CONCLUSION

When treating fractures of the distal radius, acute SLD has to be ruled out and to be discriminated from chronic SLD. While acute SLD requires appropriate treatment, immediate treatment of chronic SLD is not indicated.

Interosseous Ligament Tears of the Wrist: Comparison of Multi–Detector Row CT Arthrography and MR Imaging

PURPOSE

To compare the accuracy of multi-detector row computed tomographic (CT) arthrography and magnetic resonance (MR) imaging in depicting tears of dorsal, central, and palmar segments of scapholunate (SL) and lunotriquetral (LT) ligaments in cadavers.

MATERIALS AND METHODS

Cadaver wrists were obtained and used according to institutional guidelines and with informed consent of donors prior to death. Nine cadaver wrists of eight subjects were evaluated. MR images were obtained with a 1.5-T MR unit. Imaging protocol included intermediate-weighted coronal and transverse fast spin-echo and coronal three-dimensional gradient-echo sequences. Multi-detector row CT arthrography was performed after tricompartmental injection of 3-6 mL of contrast material with a concentration of 160 mg per milliliter of iodine. Palmar, dorsal, and central segments of both ligaments were analyzed on transverse and coronal MR images and multiplanar multi-detector row CT reconstructions by two musculoskeletal radiologists working independently. Open inspection of the wrists was the reference standard. Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated from the imaging and gross pathologic readings. Statistical significance was calculated with the McNemar test. Weighted kappa values for interobserver agreement were calculated for both imaging modalities.

RESULTS

All ligament segments could be visualized in all cases with both imaging modalities. CT arthrography was more sensitive (100%) than MR imaging (60%) in detection of palmar segment tears (P = .62); specificity of both imaging modalities was 77%. Sensitivity (CT arthrography, 86%; MR imaging, 79%) and specificity (CT arthrography, 50%; MR imaging, 25%) for detection of the central segment tears were determined. Dorsal segment tears were detected only with CT arthrography, while all tears were missed with MR imaging (P = .02). Interobserver agreement was better for multi-detector row CT arthrography (kappa = 0.37-0.78) than for MR imaging (kappa = -0.33 to -0.10).

CONCLUSION

Performance in depiction of palmar and central segment tears of SL and LT ligaments is almost equal for multi-detector row CT arthrography and MR imaging, with much higher interobserver reliability for CT arthrography. CT arthrography is significantly superior to MR imaging in the detection of dorsal segment tears of SL and LT ligaments.

Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience

OBJECTIVE

To determine normal anatomy of extrinsic and intrinsic carpal ligaments at ultrasonography (US).

DESIGN AND VOLUNTEERS

In the first part of the study, two musculoskeletal radiologists retrospectively reviewed in consensus the photographs of anatomic sections and dissections derived from 20 cadaveric wrists. This cadaveric study gave the two readers the opportunity to learn the anatomy and orientation of the various extrinsic and intrinsic carpal ligaments and, thus, to develop a US protocol to facilitate the recognition of each carpal ligament. In the second part of the study, these two radiologists prospectively and independently evaluated the visibility of extrinsic and intrinsic carpal ligaments in 30 wrists of volunteers, using the same US protocol.

RESULTS

With regard to extrinsic carpal ligaments, the radioscaphocapitate ligament (partially visible, 38%; completely visible, 62%), the radiolunotriquetral ligament (partially visible, 27%; completely visible, 73%), the palmar ulnotriquetral ligament (partially visible, 12%; completely visible, 88%), and the dorsal radiotriquetral ligament (partially visible, 7%; completely visible, 93%) were visualized at US. The dorsal ulnotriquetral ligament (partially visible, 21%; completely visible, 74%), the ulnolunate ligament (partially visible, 5%; completely visible, 70%), and the radial collateral ligament (partially visible, 18%; completely visible, 12%) were more difficult to recognize. The radioscapholunate ligament was never seen. With regard to intrinsic carpal ligaments, the dorsal (partially visible, 11%; completely visible, 89%) and palmar (partially visible, 38%; completely visible, 62%) scaphotriquetral ligaments as well as the dorsal scapholunate ligament (partially visible, 3%; completely visible, 97%) were visualized at US. The dorsal lunotriquetral ligament (partially visible, 39%; completely visible, 61%) and the palmar scapholunate ligaments (partially visible, 12%; completely visible, 81%) were more difficult to recognize.

CONCLUSION

US may be helpful in identifying the major extrinsic and intrinsic carpal ligaments.

Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage

PURPOSE

To present the early results of arthroscopic debridement and thermal shrinkage using radiofrequency probes for partial (Geissler grades I and II) scapholunate (SL) interosseous ligament injuries of the wrist.

METHODS

Sixteen patients with a mean age of 34 years (range, 18-54 y) presenting with chronic dorsoradial wrist pain unresponsive to initial conservative treatment for a mean period of 12 weeks were included in this study. No patient showed radiologic signs of static dissociation (SL interval, <3.5 mm; mean SL angle, 49 degrees ) before surgery. Diagnostic arthroscopy showed a partial SL tear in 14 patients and redundancy of the ligament in 2. Partial SL tears involved the membranous (proximal) and volar part of the ligament. All lesions were debrided and treated with thermal shrinkage using a bipolar radiofrequency probe.

RESULTS

The mean follow-up period was 19 months (range, 9-34 mo). Fourteen patients experienced substantial pain relief whereas in 2 the pain remained unchanged. Eight patients were completely pain free. The mean flexion-extension arc was 142 degrees and the mean grip strength was 78% that of the unaffected side. No patient showed radiologic signs of arthritis or static or dynamic instability after surgery (SL interval remained <3.5 mm; mean SL angle, 53 degrees ). Based on the modified Mayo wrist score there were 8 excellent, 6 good, 1 fair, and 1 poor result.

CONCLUSIONS

Partial SL ligament tears can be a source of radial-sided wrist pain. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. Stability was maintained radiographically. No complications were noted from the use of radiofrequency probes. These reasonably favorable short-term results should be viewed cautiously. A longer follow-up study is necessary to determine the ultimate efficacy of this procedure.

A survey of the surgical management of acute and chronic scapholunate instability

PURPOSE

Scapholunate instability is a challenging problem and controversy persists among hand surgeons with respect to treatment choice. The purpose of this study was to evaluate the pattern of practice among specialized hand surgeons in the management of both acute and chronic scapholunate instability.

METHODS

A mailed survey study was sent to the 1,628 members of the American and Canadian Societies for Surgery of the Hand. Hand surgeons were asked to complete a comprehensive management questionnaire that examined a surgeon's treatment algorithm in the clinical case of acute and chronic scapholunate instability. The algorithm included the choices of further investigation, timing of surgery, surgical approach, surgical procedure, fixation, and predicted outcome.

RESULTS

Of the 468 hand surgeons who responded to the survey the vast majority elected to perform surgery when confronted with a case of scapholunate instability. Early surgical intervention within 6 weeks of injury using an open dorsal approach was favored in both acute and chronic cases. The preferred surgical procedure in the acute case was scapholunate repair combined with a capsulodesis followed by scapholunate ligament repair alone. Favored management of the chronic case included Blatt capsulodesis alone, capsulodesis combined with a scapholunate ligament repair, or scaphotrapezium-trapezoid arthrodesis. A majority of surgeons used K-wire fixation, especially of the scapholunate and scaphocapitate in both acute and chronic cases.

CONCLUSIONS

This survey confirms a consensus for the early soft tissue surgical management of acute scapholunate instability using a scapholunate ligament repair with or without a capsulodesis. The management of chronic scapholunate instability is highly variable among respondents and the choice of either a soft tissue or bony procedure may depend to a large extent on intraoperative findings.

The incidence of wrist interosseous ligament and triangular fibrocartilage articular disc disruptions: a cadaveric study

PURPOSE

The purpose of this cadaveric wrist study was to determine the incidence and size of defects of the scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), and triangular fibrocartilage (TFC) articular disc, and to determine their relationship to wrist arthrosis.

METHODS

The status of the SLIL, LTIL, and the TFC articular disc was determined in 96 cadaveric wrists with an average age of 75 years (range, 61-92 y). The location and length of the SLIL and LTIL ligament disruptions and the site of ligament detachment were noted. Ligament disruptions were classified into 1 of 3 grades based on the size of the ligament disruption and the absence (grade 1 and 2 disruptions) or presence (grade 3 disruption) of wrist arthrosis. The location, size, and configuration of the TFC articular disc disruptions also were noted.

RESULTS

Disruptions of the SLIL were noted in 34 wrists (35%). There were 20 grade 1, 4 grade 2, and 10 grade 3 ligament disruptions. The average length of ligament disruption was 10.9 mm, or 40% of the length of the ligament. Twenty-four of 34 SLIL disruptions occurred without wrist arthrosis. Disruptions of the LTIL were noted in 47 wrists (49%). There were 23 grade 1, 10 grade 2, and 14 grade 3 ligament disruptions. The average length of ligament disruption was 7.6 mm, or 52% of the ligament length. Thirty-three of 47 LTIL disruptions occurred without wrist arthrosis. Disruptions of the TFC articular disc were noted in 58 wrists (60%). The most common patterns of disruption were either a linear defect at the radial attachment of the articular disc or a centrally located oval defect. Thirty-seven of the 58 TFC articular disc disruptions were noted in wrists without distal radioulnar joint (DRUJ) arthrosis.

CONCLUSIONS

There is a high incidence of SLIL, LTIL, and TFC articular disc disruptions in the cadaveric model. Large ligament and TFC articular disc disruptions without wrist arthrosis are very common.

[Lesions of the wrist disc. Pathology, diagnosis and treatment]

Lesions of the TFCC are currently a diagnostic and therapeutic challenge. Disc-injuries are often not identified and, therefore, acute ruptures are unfortunately not always immediately repaired. Moreover, therapeutic measures are still sparse and informative trial results are lacking. An anatomical, pathological, diagnostic and therapeutic comparison with the meniscus of the knee is possible.

[Ulnar instability of the carpus]

Ulnar instabilities of the carpus are rare findings depending on a dissociation of the lunotriquetral (LT-) junction. They are frequently not recognized or confused with ulnocarpal complaints of other origin due to missing typical clinical or radiological indications. The central structures are the os triquetrum and its connections to the os lunatum, the distal carpal row, radius and ulna. The most important causes are injuries, but degeneration, ulnar impaction syndrome or the ulna plus variant can also be involved. The symptoms are ulnar-sided pain, sensations of instability and weakness as well as "clunking" sensations in the ulnar wrist. Clinical examination may reveal tenderness in the LT-interval, between the ECU- and FCU-tendons, and displacement of the triquetrum on palpation. The LT-interval is rarely extended in conventional X-rays. A VISI position of the os lunatum is found in instabilities of higher degree. A distinct diagnosis is only achieved by arthroscopy. Conservative treatment consists of 4-8 weeks of arm immobilization. Diagnostic arthroscopy can be combined with débridement and/or closed reduction of the LT-interval with consecutive percutaneous k-wire fixation. If a repair of the LT-ligament is not possible, reconstructive methods are indicated. They include extrinsic tenodesis with part of the extensor carpi ulnaris tendon, ligamentoplasty or osteoligamentous autografts. The role of lunotriquetral arthrodesis is considered to be controversial, due to a high rate of non-fusions. Simple correction of the LT-dissociation does not resolve the static instability of the proximal row (VISI-position of the lunatum). In these cases, salvage procedures such as limited arthrodesis of the wrist, proximal row carpectomy or complete arthrodesis are indicated.

The prevalence and characteristics of nerve compression symptoms in the general population

The purpose of this cross-sectional study was to evaluate the prevalence and intensity of nerve compression symptoms and to estimate the prevalence of carpal tunnel syndrome (CTS) in the general population. A survey that included the Katz hand diagram, the Carpal Tunnel Instrument (CTI), and the Short Form-36 questionnaire was sent to 1,559 people. A short telephone survey was conducted to a random sample of 110 nonresponders to determine if they were systematically different from the responders. Of the responders 35.1% had a symptom severity (CTI subscale) score of > or =1.5. Of the responders and the nonresponders 23.2% and 14.5%, respectively, reported waking at least once per night with numbness; 37.3% of the responders and 33.6% of the nonresponders experienced pain in the hand at least once per day. As determined by the Katz hand diagrams, 58 (16.3%) of the responders had classic or probable distributions of symptoms (likely to have CTS) and 298 (83.7%) had possible and unlikely distributions. After correcting for nonresponders our lowest possible estimate of CTS prevalence in the general US population is 3.72%, indicating a larger pool of symptomatic people than previously reported.

Osteoligamentoplasty and limited dorsal capsulodesis for chronic scapholunate dissociation

Treatment of chronic scapholunate dissociation remains unsatisfactory. As the dorsal part of scapholunate interosseous ligament (SLIL) seems to be the "critical corner" of the scapholunate stability, its replacement by an analogous structure could restore scapholunate stability. A procedure is described which combines reconstruction of the dorsal region of the SLIL by means of an osteoligamentous autograft, harvested at the carpus (dorsal trapezoidometacarpal II ligament) and limited dorsal capsulodesis. The limited dorsal capsulodesis is performed using the scaphotriquetral head of the dorsal intercarpal ligament left attached to the distal pole of the scaphoid and fixed with a bone anchor on the dorsal aspect of the lunate. The osteoligamentous autograft prevents scapholunate dissociation and dorsal scaphoid subluxation. The dorsal capsulodesis limits scaphoid flexion and allows synergistic scapholunate mobility. This combination should stabilize the scaphoid in the horizontal as well as sagittal planes. The advantages of this technique are: 1) a single incision; 2) replacement of a ligament by an analogous autograft; 3) faster healing by bone-to-bone apposition; 4) more anatomic and physiologic reconstruction. Three patients are presented to illustrate the technique.

Scapholunate ligamentous communicating defects in symptomatic and asymptomatic wrists: characteristics

PURPOSE

To determine whether the sizes and locations of scapholunate ligamentous communicating defects are different in symptomatic and asymptomatic cases.

MATERIALS AND METHODS

Bilateral wrist arthrograms were reviewed for 30 consecutive patients with a history of wrist trauma and unilateral wrist pain who had at least one scapholunate ligamentous communicating defect and unremarkable conventional radiographs. The location and size of each ligamentous defect was recorded. Differences between symptomatic and asymptomatic wrists were analyzed with the chi(2) or Fisher exact test.

RESULTS

Most communicating defects in both groups were incomplete and ranged from pinhole size to large. There was a higher frequency of complete disruption in the symptomatic wrists (nine [32%] of 28 wrists) than in the asymptomatic wrists (two [10%] of 20 wrists; P: =.092). Communicating defects involved the dorsal portion in 18 (64%) of the 28 symptomatic cases and in five (25%) of the 20 asymptomatic cases (P: =.007).

CONCLUSION

The data suggest that the demonstration of a complete ligamentous disruption or involvement of the dorsal portion of the ligament may indicate a traumatic cause rather than a degenerative change.

Magnetic resonance imaging of the wrist

MR imaging of the wrist has the unique capability of simultaneously demonstrating bone and soft tissue structures. Its exquisite sensitivity for detecting bone marrow edema makes it and ideal screening tool for diagnosing radiographically occult osseous injuries and areas of AVN. This, together with its ability to provide a comprehensive, non-invasive assessment of the ligaments, tendons, nerves, and components of the TFC make MRI a very powerful tool for evaluating patients with wrist pain of uncertain etiology. Its exact role in the work-up of these patients has not been entirely established, but with further advances in technology and the radiologist's understanding of wrist anatomy and pathology, MRI is assuming a more central role in this clinical setting.