Incidence of dorsal radiocarpal ligament tears in the presence of other intercarpal derangements

Outcomes Following Surgical Interventions for Isolated Lunotriquetral Interosseous Ligament Injuries: A Systematic Review

Ulnar-sided wrist pain can be attributed to various bony and ligamentous structures. The purpose of this review is to compare outcomes following surgical interventions for isolated lunotriquetral (LT) interosseous ligament injuries in adults. We assessed 202 procedures from 9 retrospective case series studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The comparative outcomes (ie, range of motion, pain, strength, quality of life, complications, return to work, and patient satisfaction) were aggregated and categorized under arthrodesis, capsulodesis, ligament repairs and reconstruction, and ulna shortening osteotomy procedures. Although the comparison of outcomes was largely inconclusive due to the heterogeneity and the omission of preoperative characteristic data, we did observe higher complications and reoperation rates post LT arthrodesis. It is recommended that all outcomes be standardized and presented uniformly with best practices developed to better characterize the injury's severity and integrity in future studies.

Wrist Trauma: More Than Bones

Acute and subacute wrist trauma predominantly consist of fractures of the distal radius in elderly patients and most frequently carpal fractures (scaphoid, followed by triquetrum and hamatum) and avulsion fractures of the ulnar styloid in younger patients, especially in sports-related injuries but also in work activities. The initial radiographs may miss the fractures and result when untreated in complications as nonunion, osteonecrosis, and degenerative osteoarthritis.

Fractures of the distal radius and of the scaphoid may be associated with ligament injuries, most frequently the scapholunate complex, which are often overlooked at the emergency department. Patients without osseous injuries may present intrinsic and extrinsic ligament tears that may lead to carpal instability when they are clinically and/or radiologically missed.

Therefore, in acute and subacute setting, computed tomography may be helpful for the detection of subtle fractures, and magnetic resonance imaging, for the early diagnosis of occult fractures and ligament injuries.

Extrinsic and Intrinsic Ligaments of the Wrist

Carpal stability depends on the integrity of both intra-articular and intracapsular carpal ligaments. In this review, the role of the radial-sided and ulnar-sided extrinsic and intrinsic ligaments is described, as well as their advanced imaging using magnetic resonance arthrography (MRA) and contrast-enhanced magnetic resonance imaging (MRI) with three-dimensional (3D) scapholunate complex sequences and thin slices. In the last decade, the new concept of a so-called "scapholunate complex" has emerged among hand surgeons, just as the triangular ligament became known as the triangular fibrocartilage complex (TFCC).The scapholunate ligament complex comprises the intrinsic scapholunate (SL), the extrinsic palmar radiocarpal: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL) ligaments, the extrinsic dorsal radiocarpal (DRC) ligament, the dorsal intercarpal (DIC) ligament, as well as the dorsal capsular scapholunate septum (DCSS), a more recently described anatomical structure, and the intrinsic palmar midcarpal scaphotrapeziotrapezoid (STT) ligament complex. The scapholunate (SL) ligament complex is one of the most involved in wrist injuries. Its stability depends on primary (SL ligament) and secondary (RSC, DRC, DIC, STT ligaments) stabilizers.The gold standard for carpal ligament assessment is still diagnostic arthroscopy for many hand surgeons. To avoid surgery as a diagnostic procedure, advanced MRI is needed to detect associated lesions (sprains, midsubstance tears, avulsions and chronic fibrous infiltrations) of the extrinsic, midcarpal and intrinsic wrist ligaments, which are demonstrated in this article using 3D and two-dimensional sequences with thin slices (0.4 and 2 mm thick, respectively).

MRI of the Wrist Ligaments

Technological advances in magnetic resonance imaging (MRI) have improved radiologists' ability to evaluate wrist ligaments. MRI interpretation often guides clinical management. This article aims to review the normal and pathologic appearance of intrinsic and extrinsic wrist ligaments with a focus on MRI. Variant anatomy, imaging pearls, and clinical significance are also discussed. Special attention is paid to key wrist ligaments that play a role in carpal stability.

Dorsal Wrist Extrinsic Carpal Ligament Injury Exacerbates Volar Radiocarpal Instability After Intra-Articular Distal Radius Fracture

Background: Volar radiocarpal instability is often seen after loss of fixation of volar lunate facet fragments. The pathogenesis of post-traumatic volar radiocarpal instability is poorly understood. The purpose of this study was to determine if injury to the dorsal wrist extrinsic carpal ligaments contributes to volar radiocarpal instability. Methods: Six matched pairs of cadaveric upper extremities were tested using a dynamic hand testing system. In group 1, the intact wrist, the wrist with a volar lunate facet fracture, and the fractured wrist after 500 cycles of grip were tested. In group 2, in addition to the intact and fractured wrist, the fractured wrist with the dorsal extrinsic carpal ligaments cut and the fractured wrist with the dorsal extrinsic carpal ligaments cut after 500 cycles of grip were also tested. Volar-dorsal displacement of the lunate was measured from 45° wrist flexion to 45° wrist extension in 22.5° increments with the wrist flexors/extensors loaded for each condition. Results: Volar lunate translation did not significantly increase after the volar lunate facet fracture alone, and was not evident to a significant extent until the dorsal wrist extrinsic carpal ligaments were cut. Further instability of the lunate occurred after grip cycling only with the dorsal extrinsic capsular ligaments cut. Conclusions: Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability. Unrecognized dorsal sided injury may be a contributing factor to why stable fixation of volar lunate facet fragments remains problematic after volar plating of intra-articular distal radius fractures with displaced volar lunate facet fragments.

Narrative Review of Ligamentous Wrist Injuries

Ligamentous wrist injuries are common occurrences that require complex anatomical mastery and extensive understanding of diagnostic and treatment modalities. The purpose of this educational review article is to delve into the most clinically relevant wrist ligaments in an organized manner to provide the reader with an overview of relevant anatomy, function, clinical examination findings, imaging modalities, and options for management. Emphasis is placed on elucidating reported diagnostic accuracies and treatment outcomes to encourage evidence-based practice.

Arthroscopic Assisted Reconstruction of LT-Ligament: A Description of a New Technique

Background  Injuries of the lunotrirquetral ligament (LT lig) could be part of an extensive carpal injury and are then often treated at the time of the injury. However, when an injury of the LT ligament occurs alone, the injury is often missed. Treatment of this injury has traditionally been by open surgery, such as reattachment of the LT ligament, ligament reconstruction, or arthrodesis of the LT joint. These procedures needed a large exposure to the carpus running the risk of damaging the external ligaments, the nerves important for proprioception, and the capsule with the potential of scarring and adhesions. Materials and Methods  We describe a novel arthroscopic assisted technique for reconstruction of the LT ligament. Using this less invasive technique, there is a possible advantage of lesser scarring and faster mobilization. Results  We have performed this technique in two patients with more than 30 months follow-up. They both have great improvement of the functional scores. Conclusion  The novel arthroscopic assisted technique for LT lig reconstruction is a technically demanding procedure; however, this obtains good clinical results with more than 30 months follow-up due to less exposure of the carpus. Level of Evidence  This is a Level IV, case series study.

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

[Pathology of the triangular fibrocartilaginous complex in distal radius fractures]

Distal radius fracture is actually quite rarely isolated and triangular fibrocartilaginous complex (TFCC) is often involved with the same mechanism of injury. A contemporary management of the treatment of the initial fracture is ideal and so benefits from a routine arthroscopic management. Nevertheless, in the absence of diagnosis and therefore early treatment, the symptoms may be located at the ulnar crossroads and justify specific treatment of TFCC. It is generally conducted after an accurate arthroscopic lesion classification guiding a procedure, depending on the lesion vascularization as well as its possible destabilization potential (debridement, capsular suture or foveal reattachment). Unfortunately, too often the radius fracture is insufficiently stabilized by an inadequate fixation process or inappropriate orthopedic management with a positive ulnar variance consequence and an ulnar plus syndrome. A "wafer procedure" may then sometimes be proposed if a shortening of less than 3mm is needed and that the distal radio-ulnar joint is not too disorganized.

Arthroscopic grading of common wrist disorders and its role in management

Palmer devised a classification system to guide treatment of triangular fibrocartilage complex tears in 1989. The main division is between traumatic Type I and atraumatic Type II tears. The wrist arthroscopy makes diagnosis and treatment of ulnar impaction syndrome possible in a less invasive way. Arthroscopy is the most valuable tool for diagnosis and treatment of acute scapholunate and lunotriquetral dissociation. Arthroscopic grading of Kienböck's disease better describes articular damage compared with plain radiographs and can help surgical treatment. The wrist arthroscopy generally makes it possible to make the diagnosis of the chondral lesion before they are visible by the usual imaging.

Ulnar impaction syndrome: incidence of lunotriquetral ligament degeneration and outcome of ulnar-shortening osteotomy

PURPOSE

We hypothesized that most patients with ulnar impaction syndrome have degenerative changes of the proximal lunotriquetral (LT) membrane and that ulnar-shortening osteotomy is an effective procedure in these patients.

METHODS

We retrospectively reviewed 50 wrists of 49 patients with idiopathic ulnar impaction syndrome who underwent an arthroscopic evaluation at the time of ulnar-shortening osteotomy, and subsequently at plate removal. Based on the Geissler classification, patients were divided into group A, normal, and group B, grades I to IV. The degree of degeneration of the proximal LT membrane at first-look arthroscopy was compared with that at second-look arthroscopy.

RESULTS

After ulnar-shortening osteotomy, both groups improved significantly in wrist range of motion and grip strength. According to the Mayo wrist score, 29, 18, and 3 patients showed excellent, good, and fair results, respectively. Of the 50 wrists, 25 had degenerative changes (group B) in the proximal LT membrane at the time of first-look arthroscopy. Of the 25 wrists in group B, 11 wrists improved based on the Geissler grade, 9 wrists showed no changes, and 2 wrists became worse. Clinically, patients demonstrated improvement after ulnar-shortening osteotomy regardless of the degree of degenerative LT ligament changes.

CONCLUSIONS

Degenerative LT membrane changes that were seen in about half of our patients were mostly of a mild nature, and the clinical outcomes of ulnar-shortening osteotomy were acceptable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Imaging of radial wrist pain. I. Imaging modalities and anatomy

Radial wrist pain is a common clinical complaint. The relatively complex anatomy in this region, combined with the small size of the anatomical structures and occasionally subtle imaging findings, can pose problems when trying to localize the exact cause of pain. To fully comprehend the underlying pathology, one needs a good understanding of both radial-sided wrist anatomy and the relative merits of the different imaging techniques used to assess these structures. In part I of this review, these aspects will be discussed.

A systematic method of arthroscopic testing of extrinsic carpal ligaments: implication in carpal stability

Several biomechanical studies have shown that the scapholunate and lunotriquetral ligaments are not the only stabilizers of the proximal carpal row. However, no study has yet analyzed the spectrum of ligamentous lesions in vivo, leading to instability. We describe an arthroscopic technique for evaluating the extrinsic carpal ligaments. The testing relies on visualization and palpation of different ligaments. Their integrity is assessed with a 4-stage scale. Radiocarpal arthroscopy enables assessment of the following ligaments: the radiocarpal part of the radio-scapho-capitate, the long radiolunate, the short radiolunate, the ulnolunate, the ulnotriquetral, and the dorsal radiocarpal. Midcarpal arthroscopy enables assessment of the mid part of the radio-scapho-capitate, the triquetrocapitate, the scaphotrapezial, and the dorsal intercarpal. Above assessment is proposed in addition to assessing the articular cartilage, scapholunate, and lunotriquetral ligaments. This method allows a precise arthroscopic assessment of the extrinsic ligaments of the wrist. It could give an important help in the understanding of carpal instability.

Current innovations in wrist arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.

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.

Scaphoid kinematics before and after scaphotrapeziotrapezoidal ligament section. Assessment by radiostereometric analysis and computed tomography in a cadaver study

The purpose of this study was to measure changes in scaphoid kinematics after division of scaphotrapeziotrapezoidal ligaments, with the intention of determining a clinical measure that could be detected by computed tomography. Twelve freshly frozen cadaver upper extremities were marked with tantalum beads and fixed in positions of neutral, 30° extension, and 40° ulnar deviation. Stereoradiographs for bone migration analysis by radiostereometric analysis and computed tomography scans for visible assessment were obtained before and after scaphotrapeziotrapezoidal ligament section. After ligament resection there was a scaphoid supination of 5° and a small (less than 1 mm) radial, distal, and dorsal translation of the distal pole in 30° of wrist extension. In computed tomography reconstructions, the ligament section appeared as a 1 to 2 mm gap in the scaphotrapeziotrapezoidal corner, with loss of articulation between the distal scaphoid pole and the trapezoid bone and increased scaphoid flexion.