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Crowe CS, Emanuels AF, Kakar S, Moran SL. Etiology and Diagnostic Challenges of Ulnar Wrist Pain in Pediatric and Adolescent Patients. J Hand Surg Am 2024:S0363-5023(24)00207-7. [PMID: 38934985 DOI: 10.1016/j.jhsa.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/06/2024] [Accepted: 04/24/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Diagnosing the cause of ulnar-sided wrist pain can be difficult in the pediatric and adolescent age group. While frequently used, the diagnostic accuracy of magnetic resonance image (MRI), as compared with intraoperative arthroscopic findings, is not well-described in this population. This study aimed to determine concordance rates between magnetic resonance and arthroscopic findings depending on the specific ulnar wrist pathology. METHODS A retrospective review was performed to identify pediatric and adolescent patients who underwent operative treatment of ulnar wrist pain between 2004 and 2021. Patients were included in the analysis if they were <18 years of age, complained of ulnar-sided wrist pain, underwent MRI of the affected wrist with an available report interpreted by a consultant radiologist, and had a diagnostic arthroscopy procedure within one year of imaging. Ulnar pathologies analyzed included triangular fibrocartilage (TFCC) tears, ulnotriquetral (UT) ligament tears, lunotriquetral ligament abnormalities, and ulnocarpal impaction. RESULTS A total of 40 patients with a mean age of 15-years-old (range 11 to 17) were included in the analysis. Twenty-four were female, and approximately half had their dominant extremity affected. Most had a history of antecedent trauma (n = 34, 85%), but only 15/40 (38%) had a history of fracture. The mean duration of symptoms prior to presentation was six months (standard deviation, 7). The most common etiologies were Palmer 1B TFCC tears (n = 27, 68%) followed by UT split tears (n = 11, 28%). MRI overall demonstrated high specificity (82% to 94%), but low sensitivity (14% to 71%) for ulnar-sided wrist conditions. Accuracy varied between 70% and 83% depending on the specific injury. CONCLUSION While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. Surgeons should have a high degree of suspicion for TFCC-related pathology in the setting of positive provocative clinical examination despite negative MRI findings in young patients. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IIb.
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Affiliation(s)
- Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Andrew F Emanuels
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Sanjeev Kakar
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Mayo Clinic, Rochester, MN
| | - Steven L Moran
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
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Farr S, Zlotolow DA, Bachy M, Peymani A, Hülsemann W, Winge MI. State of the art review: The pathogenesis and management of Madelung deformity. J Hand Surg Eur Vol 2023; 48:1116-1125. [PMID: 37572317 DOI: 10.1177/17531934231191208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Madelung deformity remains a fascinating yet unresolved challenge. There is an increasing awareness for early diagnosis by healthcare providers with improvement in diagnostic modalities, however, the exact mechanisms for the development of the deformity have still to be clarified. While some corrective procedures have been described to effectively address an established deformity, the existing literature lacks clear and evidence-based treatment guidelines on how to proceed in daily practice. This review article aims to summarize the current best evidence on this topic, including particular areas of controversy and areas with need for future research.
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Affiliation(s)
- Sebastian Farr
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria
| | - Dan A Zlotolow
- Shriners Hospitals for Children, Philadelphia and Greenville; The Hospital for Special Surgery, New York, USA
| | - Manon Bachy
- Sorbonne University, AP-HP, Hôpital Trousseau, Service de Chirurgie Orthopédique et réparatrice de l'enfant, Paris, France
| | - Abbas Peymani
- Amsterdam UMC, Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam, The Netherlands
| | - Wiebke Hülsemann
- Handsurgery Department, Children's Hospital Wilhelmstift, Hamburg, Germany
| | - Mona I Winge
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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Fischer R, Tschudi SB, Schaefer DJ, Kaempfen A. Wrist Arthroscopy Is Effective for the Diagnosis and Treatment of Chronic Wrist Pain in Pediatric Patients. Arthrosc Sports Med Rehabil 2022; 4:e1403-e1408. [PMID: 36033170 PMCID: PMC9402464 DOI: 10.1016/j.asmr.2022.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/26/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To determine the outcomes of diagnostic and therapeutic arthroscopy in patients with chronic wrist pain who are younger than 16 years of age. Methods We retrospectively analyzed collected data from medical records of patients who had undergone wrist arthroscopy by the senior author between 2015 and 2017 for longstanding wrist pain and were 16 years old or younger. Findings from preoperative magnetic resonance imaging (MRI) were compared with the intraoperative diagnosis, and midterm results were gathered by a telephone interview. Results Ten patients were included. Eight of 10 patients had undergone conservative therapy before surgery, and 60% had a history of single trauma. In 6 of 10 patients, the arthroscopic diagnosis correlated with the MRI findings. Eight of 10 wrists (80%) showed a tear of the triangular fibrocartilage complex (TFCC). Only 4 of the 8 TFCC tears were correctly identified by 3-Tesla MRI. Conclusions In our study, wrist arthroscopy was an effective tool not only to diagnose but also to treat relevant TFCC lesions both in adolescents and children suffering from persistent wrist pain. A 3-Tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists. Level of Evidence IV, Therapeutic case series.
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Affiliation(s)
| | - Samuel B. Tschudi
- Address correspondence to Dr. Med. Samuel Tschudi, M.D., Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Spitalstr. 21, 4031 Basel, Switzerland.
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Pediatric Ulnar-sided Wrist Pain: A Review of the Current Literature. J Am Acad Orthop Surg 2022; 30:711-720. [PMID: 35862211 DOI: 10.5435/jaaos-d-21-01029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/25/2022] [Indexed: 02/01/2023] Open
Abstract
Patients presenting with ulnar-sided wrist pain can pose a diagnostic and therapeutic challenge to physicians because there are several pathologies with similar signs and symptoms. In comparison with adult patients, other etiologies must be considered in the pediatric patient, given the skeletal immaturity and potential for known or unrecognized syndromes. In addition, these patients may not be able to articulate their symptoms as clearly as an adult patient, further stressing the importance of obtaining a pertinent history and performing a focused physical examination. Having a thorough understanding of the anatomy, the varying pathologies, and the indications for surgical and nonsurgical management will assist in improved patient outcomes.
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Aly AM, El-Sadek RE. Physeal sparing distal radio-ulnar joint ligament reconstruction in children. J Pediatr Orthop B 2022; 31:55-59. [PMID: 33528228 DOI: 10.1097/bpb.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Distal radio-ulnar joint (DRUJ) injuries are under-reported in the paediatric population. No single study has discussed methods of DRUJ reconstruction in immature patients with chronic instability. We present a physeal sparing ligamentoplasty for chronic DRUJ instability and describe the outcomes in two patients. Two consecutive children with chronic DRUJ instability were treated using physeal sparing ligamentoplasy. After the failure of triangular fibrocartilage complex repair, reconstruction was done using palmaris longus tendon graft that was tunnelled through the distal radius epiphysis and wrapped subperiosteally around the ulnar neck. Graft was tied in a neutral forearm position. DRUJ stability was achieved in both patients. Grip strength averaged 90% of the healthy side. Prono-supination range of motion (ROM) averaged 88 and 86%, respectively, of the healthy side, without intraoperative nor postoperative complications. Our novel technique was effective in the regain of DRUJ stability with minor effect on the prono-supination ROM. Further studies are planned to experiment the biomechanical effectiveness of our technique. Level of evidence: Therapeutic IV.
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Affiliation(s)
- Amr M Aly
- Department of Orthopaedic Surgery, Université libre de Bruxelles, Brussels, Belgium
- Hand and Microsurgery Unit, Division of Orthopaedic Surgery, Ain Shams University Hospital
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Dorich JM, Cornwall R. Evaluation of a Grip-Strengthening Algorithm for the Initial Treatment of Chronic, Nonspecific Wrist Pain in Adolescents. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:8-13. [PMID: 35415596 PMCID: PMC8991628 DOI: 10.1016/j.jhsg.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/22/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Chronic, nonspecific wrist pain in adolescents can be challenging to assess and treat. We hypothesized that an algorithmic approach beginning with grip strengthening can alleviate pain, improve function, and identify patients in need of further intervention. Methods We retrospectively reviewed the results of a grip-strengthening protocol for adolescents with chronic, nonspecific wrist pain. Before and after treatment, grip strength was measured using handheld dynamometry, and patient-reported pain and function were measured using the adolescent self-reported Pediatric Outcomes Data Collection Instrument’s (PODCI’s) Pain/Comfort and Upper Extremity Function domains (PODCI/pain and PODCI/UE, respectively). Results Thirty-two patients (28 female, 4 male) were included, with a mean age of 14 years (range, 10–18 years) and the dominant hand affected in 19, nondominant hand in 9, and bilateral impacts in 4. The mean symptom duration prior to presentation was 9 months (range, 1–63 months); 17 patients had undergone prior immobilization and 5 prior occupational/physical therapy. Grip-strengthening treatment, lasting a mean of 40 days (range, 21–82 days) with a median of 4 therapy visits (range, 2–6), was associated with significantly improved grip strength (mean, 32–48 lbs), PODCI/pain scores (mean, 49.0–78.2 points), and PODCI/UE scores (mean, 78.2–91.2 points). Improvements in grip strength correlated with improvements in PODCI/pain and PODCI/UE scores (r = 0.64 and 0.70, respectively). Eight patients (25%) had either no or incomplete pain relief: 5 underwent successful further intervention (2 ganglion cyst excisions, 1 triangular fibrocartilage complex repair, 1 arthroscopic debridement, 1 steroid injection), 2 received ongoing pain management for generalized pain syndromes, and 1 was lost to further follow-up. No pretreatment variables were identified that predicted failure. Conclusions Grip strengthening relieves pain and improves function in the majority of adolescents with chronic, nonspecific wrist pain. Systematic use of this protocol helps to identify patients who require further intervention. Type of study/level of evidence Therapeutic IV.
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Affiliation(s)
- Jenny M. Dorich
- Division of Occupational and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Roger Cornwall
- Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
- Corresponding author: Roger Cornwall, MD, Division of Orthopaedic Surgery, Cincinnati Children’s Hospital, 3333 Burnet Avenue, Cincinnati, OH 45229.
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Abstract
Triangular fibrocartilage complex (TFCC) tears can cause ulnar-sided wrist pain in children and adolescents following acute rotational injury or prior distal radius fracture. Surgical treatment, guided by the Palmer classification, is considered after activity modification and occupational therapy. All concomitant wrist pathologies, such as distal radioulnar joint instability, ulnocarpal impaction, and distal radius malunion, must be recognized and addressed at the time of TFCC debridement or repair. This article reviews recent literature guiding clinical evaluation and surgical treatment of children and adolescents with TFCC injuries. The authors' techniques for arthroscopic-assisted outside-in repair of Palmer 1B and 1D tears are described.
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Affiliation(s)
- Stella J Lee
- Department of Surgery, Anna Jaques Hospital, 25 Highland Avenue, Newburyport, MA 01950, USA.
| | - Donald S Bae
- Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Fegan 2nd Floor, Boston, MA 02115, USA
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Folchert M, Breuner C, Steinman S. Impact of Biofeedback in the Treatment of Nonspecific Persistent Wrist and Forearm Pain in Adolescents. J Hand Surg Am 2021; 46:152.e1-152.e6. [PMID: 33223344 DOI: 10.1016/j.jhsa.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 07/10/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Biofeedback is a self-regulation technique in which patients learn to control what were once thought to be involuntary bodily processes. The goal of this study was to examine a sample of adolescents with persistent, nonspecific wrist and forearm pain to assess whether biofeedback can improve symptoms. A secondary goal was to identify any shared characteristics. METHODS This is a retrospective case series of patients seen by an upper-extremity surgeon and a biofeedback expert at a pediatric hospital from 2011 through 2017. Data collected included Multidimensional Anxiety Scale for Children (MASC) and Children's Depression Inventory (CDI) scores, pain intensity, frequency, and duration; as well as self-report of depression, anxiety, self-harm, and/or suicidal ideation. Additional data included biological sex, brace or orthosis wear, history of injury, prior medical or surgical treatments, and the presence of paresthesias. Biofeedback sessions were held every 1 to 2 weeks, for typically 5 sessions. RESULTS Sixteen patients met inclusion criteria; 9 completed biofeedback. Eight patients were female (88%) and 1 was male (11%). The dominant extremity was affected in 8 patients (89%). Seven of the 9 patients who completed biofeedback had improvement or resolution of symptoms (78%). Both patients who completed biofeedback but did not have improvement in pain underwent surgery before biofeedback referral. Three patients reported paresthesias; each had an elevated CDI and MASC score (33%). Six patients did not report paresthesias, and one patient had similar elevated CDI and MASC scores CONCLUSIONS: More females than males were seen and referred to biofeedback in this study group. There appears to be an association between underlying anxiety or depression and the report of paresthesias. Biofeedback is an available nonsurgical treatment modality for persistent wrist and forearm pain that should be considered in appropriate patients. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
| | - Cora Breuner
- Department of Orthopedics and Sports Medicine, Seattle, WA; Department of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
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van der Post AS, Jens S, Smithuis FF, Obdeijn MC, Oostra RJ, Maas M. The triangular fibrocartilage complex on high-resolution 3 T MRI in healthy adolescents: the thin line between asymptomatic findings and pathology. Skeletal Radiol 2021; 50:2195-2204. [PMID: 33864484 PMCID: PMC8449761 DOI: 10.1007/s00256-021-03779-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the study is to provide a reference for morphology, homogeneity, and signal intensity of triangular fibrocartilage complex (TFCC) and TFCC-related MRI features in adolescents. MATERIALS AND METHODS Prospectively collected data on asymptomatic participants aged 12-18 years, between June 2015 and November 2017, were retrospectively analyzed. A radiograph was performed in all participants to determine skeletal age and ulnar variance. A 3-T MRI followed to assess TFCC components and TFCC-related features. A standardized scoring form, based on MRI definitions used in literature on adults, was used for individual assessment of all participants by four observers. Results per item were expressed as frequencies (percentages) of observations by all observers for all participants combined (n = 92). Inter-observer agreement was determined by the unweighted Fleiss' kappa with 95% confidence intervals (95% CI). RESULTS The cohort consisted of 23 asymptomatic adolescents (12 girls and 11 boys). Median age was 13.5 years (range 12.0-17.0). Median ulnar variance was -0.7 mm (range - 2.7-1.4). Median triangular fibrocartilage (TFC) thickness was 1.4 mm (range 0.1-2.9). Diffuse increased TFC signal intensity not reaching the articular surface was observed in 30 (33%) observations and a vertical linear increased signal intensity with TFC discontinuation in 19 (20%) observations. Discontinuation between the volar radioulnar ligament and the TFC in the sagittal plane was seen in 23 (25%) observations. The extensor carpi ulnaris was completely dislocated in 10 (11%) observations, more frequent in supinated wrists (p = 0.031). Inter-observer agreement ranged from poor to fair for scoring items on the individual TFCC components. CONCLUSION MRI findings, whether normal variation or asymptomatic abnormality, can be observed in TFCC and TFCC-related features of asymptomatic adolescents. The rather low inter-observer agreement underscores the challenges in interpreting these small structures on MRI. This should be taken into consideration when interpreting clinical MRIs and deciding upon arthroscopy.
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Affiliation(s)
- Anne-Sophie van der Post
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, The Netherlands
| | - Sjoerd Jens
- grid.415930.aDepartment of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Frank F. Smithuis
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Miryam C. Obdeijn
- grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,grid.7177.60000000084992262Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- grid.7177.60000000084992262Department of Medical Biology, Section Clinical Anatomy and Embryology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, The Netherlands
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Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents. J Hand Surg Am 2020; 45:449.e1-449.e9. [PMID: 31519316 DOI: 10.1016/j.jhsa.2019.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 03/24/2019] [Accepted: 06/28/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the clinical results and patient-reported outcomes following surgical treatment for triangular fibrocartilage complex (TFCC) tears in the pediatric and adolescent population. METHODS We reviewed 149 patients with 153 arthroscopy-confirmed TFCC tears. Mean age at surgery was 15.5 years (range, 7-19 years). There were 86 females. Plain radiographs and magnetic resonance imaging were used to characterize bony and soft tissue pathology. Mayo Modified Wrist Score (MMWS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Short Form assessed functional outcomes. Median patient follow-up was 21.8 months (IQR:5.9-55.4). RESULTS Pre-operatively, all patients had wrist pain or instability with activities. The median pre-operative MMWS was 80 (interquartile range [IQR], 65-90). Fifty-six (35%) presented with positive ulnar variance. Concomitant pathology included distal radioulnar joint (DRUJ) instability (14%), ulnocarpal impaction (20%), ulnar styloid nonunion (33%), and distal radius growth arrest (30%). On arthroscopy, there were 15 (10%) isolated 1A, 79 (52%) 1B, 1 (1%) 1C, 30 (20%) 1D tears, and 25 (16%) cases of multiple tears. Twenty-six percent of wrists underwent TFCC debridement, 68% arthroscopy-assisted repair, 6% both for combined tears. Fifty-one percent of wrists underwent bony procedures-most commonly ulnar-shortening osteotomy to achieve neutral ulnar variance (40%) and symptomatic ulnar styloid nonunion excision with concomitant TFCC repair (39%). At final follow-up, pain, wrist range of motion, DRUJ stability, ulnar variance, and MMWS (median, 95 [IQR, 86.5-100]) improved significantly. The median PROMIS T-score at final follow-up was 57 (IQR, 45-57). The MMWS was better in those with concomitant bony procedures at index surgery than those with only repair or debridement of TFCC tears. CONCLUSIONS Most pediatric TFCC tears are posttraumatic and peripheral. Surgical treatment of TFCC tears and concomitant pathology in the pediatric and adolescent population results in decreased pain, improved motion and stability, and excellent functional outcomes in the majority of patients. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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11
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Schachinger F, Wiener S, Carvalho MF, Weber M, Ganger R, Farr S. Evaluation of radiological instability signs in the distal radioulnar joint in children and adolescents with arthroscopically-verified TFCC tears. Arch Orthop Trauma Surg 2020; 140:993-999. [PMID: 32382940 PMCID: PMC7295725 DOI: 10.1007/s00402-020-03470-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Recent reports in the adult literature reported the use of standardized radiographic measurement techniques to determine distal radioulnar joint (DRUJ) instability. The aim of this study was to evaluate the efficacy and accuracy of (1) the MRI-based modified radioulnar ratio technique and (2) the pisoscaphoid (PiSca) and radioulnar (RaUl) distances in true lateral radiographs in children and adolescents with arthroscopically-verified TFCC tears. MATERIALS AND METHODS We retrospectively assessed lateral wrist radiographs and axial MRI sequences of 18 adolescent patients (22 wrists) who had arthroscopically-confirmed TFCC tears and compared them to similar imaging of a control group of 28 healthy patients (28 wrists). Three raters assessed the images twice in a 2-week interval. Intraclass correlation coefficients (ICCs), unifactorial ANOVA, and ROC analysis were performed with regards to the different radiographic variables. RESULTS The interrater ICCs were almost perfect for all measurements except RaUl1, which showed a substantial agreement (0.751) among the three observers. The intrarater ICCs were almost perfect when measuring PiSca and MRI, and substantial to almost perfect for RaUl. Pearson's correlation showed a moderate, positive correlation between PiSca and RaUl distances (r = 0.608; p < 0.001), and a moderate, negative correlation between RaUl distance and MRI shift (r = - 0.486; p = 0.010). When the three core groups (peripheral, central tear, controls) were compared to each other regarding the radiographic instability parameters, only the MRI shift revealed a statistically significant difference (p = 0.003). Comparisons revealed significant differences between patients and controls (p = 0.004) and peripheral tears vs. controls (p = 0.001 and p = 0.010). The ROC analysis revealed a significant AUC only for the MRI (AuC 0.787 and p = 0.002). CONCLUSIONS Children and adolescents with peripheral TFCC tears showed significantly increased instability parameters in MRI compared to controls. These measurement techniques are no replacement for a thorough clinical examination but may be helpful for indicating diagnostic wrist arthroscopy in ambiguous cases. LEVEL OF EVIDENCE Level III; Diagnostic.
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Affiliation(s)
- Florian Schachinger
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising, Medical University Vienna, Speisingerstrasse 109, 1130 Vienna, Austria
| | - Sascha Wiener
- II. Orthopedic Department, Herz-Jesu Hospital, Vienna, Austria
| | - Marcos F. Carvalho
- EPE, Department of Pediatric Orthopaedics, Pediatric Hospital of Coimbra, CHUC, Coimbra, Portugal
| | - Michael Weber
- Departement of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising, Medical University Vienna, Speisingerstrasse 109, 1130 Vienna, Austria
| | - Sebastian Farr
- Department of Pediatric Orthopaedics and Foot and Ankle Surgery, Orthopedic Hospital Speising, Medical University Vienna, Speisingerstrasse 109, 1130 Vienna, Austria
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12
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Trehan SK, Schimizzi G, Shen TS, Wall LB, Goldfarb CA. Arthroscopic treatment of triangular fibrocartilage complex injuries in paediatric and adolescent patients. J Hand Surg Eur Vol 2019; 44:582-586. [PMID: 30704330 DOI: 10.1177/1753193418825070] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We assessed outcomes of 43 paediatric and adolescent patients (44 wrists) undergoing arthroscopic triangular fibrocartilage complex surgery by a single surgeon between 2003 and 2016. Medical records were reviewed for clinical, imaging, and operative data. Preoperatively, 49% of patients had additional diagnoses and mean QuickDASH was 47. Patients were telephoned to assess current wrist pain, subsequent treatment(s), satisfaction, and to complete QuickDASH and Patient-Rated Wrist Evaluation questionnaires. Twenty-five patients responded with mean follow-up of 70 months (minimum 13 months). In those patients not reached by telephone, mean clinical follow-up was 21 months. Seven patients had subsequent surgery (most commonly ulnar shortening osteotomy); this was associated with lower satisfaction scores. At final follow-up, mean QuickDASH was 4, Patient-Rated Wrist Evaluation 8 and patient and parent satisfaction scores were 9 and 9 out of 10, respectively. In conclusion, arthroscopic triangular fibrocartilage complex treatment in paediatric patients yielded favourable outcomes and patient/parent satisfaction. Level of evidence: IV.
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Affiliation(s)
- Samir K Trehan
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Gregory Schimizzi
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Tony S Shen
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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Pfanner S, Diaz L, Ghargozloo D, Denaro V, Ceruso M. TFCC Lesions in Children and Adolescents: Open Treatment. J Hand Surg Asian Pac Vol 2019; 23:506-514. [PMID: 30428785 DOI: 10.1142/s2424835518500509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND There has been little discussion regarding the lesion of the TFCC in pediatric and adolescent patients. This study examines 11 cases treated with open technique. METHODS Range of motion (ROM), strength and functional scores (QUICK DASH, PWRE, VAS pain, and NAKAMURA score) were evaluated. RESULTS The mean postoperative flexion-extension arc was 95% of the contralateral side, the radio-ulnar deviation 91% of the contralateral side and the pronation-supination arc 94% of the unaffected side. Grip strength was 85.6% of the uninjured wrist, pinch was 88%. The mean PRWE decreased from 84.4 to 9.85 postoperatively. The mean Q-DASH scored 10.4. The VAS pain under stress decreased from a mean of 6.8 to a mean of 2.27, while at rest it decreased from a mean of 5 to a mean of 0.5. The final clinical results obtained by Nakamura score were 2 excellent, 6 good and 3 fair. CONCLUSIONS This study emphasizes that open surgical TFCC repair is a safe and reliable therapeutic procedure in children and adolescent populations.
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Affiliation(s)
- Sandra Pfanner
- * Surgery and Reconstructive Microsurgery of the Hand, AUO Careggi, Florence, Italy
| | - Lorenzo Diaz
- † Orthopedics and Traumatology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Dariush Ghargozloo
- ‡ Orthopedics and Traumatology Department, ASST Valcamonica, Esine Hospital, Esine (BS), Italy
| | - Vincenzo Denaro
- † Orthopedics and Traumatology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Massimo Ceruso
- * Surgery and Reconstructive Microsurgery of the Hand, AUO Careggi, Florence, Italy
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Farr S. Comments on "The Diagnostic Utility and Clinical Implications of Wrist MRI in the Pediatric Population". Hand (N Y) 2018; 13:606. [PMID: 28858534 PMCID: PMC6109894 DOI: 10.1177/1558944717726140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sebastian Farr
- Orthopedic Hospital Speising, Vienna, Austria,Sebastian Farr, Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Speisingerstrasse 109, Vienna 1130, Austria.
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15
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Maloney E, Zbojniewicz AM, Nguyen J, Luo Y, Thapa MM. Anatomy and injuries of the pediatric wrist: beyond the basics. Pediatr Radiol 2018; 48:764-782. [PMID: 29557490 DOI: 10.1007/s00247-018-4111-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/12/2018] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Ezekiel Maloney
- Department of Radiology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Andrew M Zbojniewicz
- Division of Pediatric Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, College of Human Medicine, Helen DeVos Children's Hospital, Advanced Radiology Services, Michigan State University, Grand Rapids, MI, USA
| | - Jie Nguyen
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yu Luo
- Department of Radiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, TN, USA
| | - Mahesh M Thapa
- Department of Radiology, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
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Gornitzky AL, Lin IC, Carrigan RB. The Diagnostic Utility and Clinical Implications of Wrist MRI in the Pediatric Population. Hand (N Y) 2018; 13:143-149. [PMID: 28719991 PMCID: PMC5950963 DOI: 10.1177/1558944717695752] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Unexplained wrist pain is a common presentation in children. To our knowledge, no studies have explored the clinical utility of magnetic resonance imaging (MRI) in the diagnostic workup of pediatric patients. METHODS We retrospectively reviewed 307 consecutive wrist MRIs ordered at a tertiary-care pediatric hospital. Demographic data and the indication for imaging were recorded and grouped into admitting categories. The final impression of each MRI was scored with regard to potential impact on future treatment (0 = normal, 1 = minimal, 2 = moderate, 3 = high). Patients who went on to wrist surgery within 1 year were noted. RESULTS In our cohort, 27% of all studies were normal, including 34% of those with pain. Although pain was the most common category, MRI was most useful in the delineation of a mass/cyst, evaluating for infection and evaluating arthropathy. Compared with all other categories, patients with pain were 3.6 times more likely to have a normal study and 4.6 times more likely to have a clinical score less than or equal to 1. Given an admitting diagnosis of pain, females were 1.7 times more likely to present for an MRI and 2.4 times more likely to have a normal MRI. The Spearman correlation revealed no linear relationship between age and MRI outcome. In all, 13% of patients went on to have surgery within 1 year of MRI. CONCLUSIONS At our pediatric institution, the majority of wrist MRIs were ordered for wrist pain. Given our data, wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis.
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Affiliation(s)
| | - Ines C. Lin
- University of Pennsylvania, Philadelphia, USA
| | - Robert B. Carrigan
- Children’s Hospital of Philadelphia, PA, USA,Robert B. Carrigan, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Division of Orthopaedics, Philadelphia, PA 19104, USA.
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Farr S, Schüller M, Ganger R, Girsch W. Outcomes after Arthroscopic Debridement of the Triangular Fibrocartilage Complex in Adolescents. J Wrist Surg 2018; 7:43-50. [PMID: 29383275 PMCID: PMC5788757 DOI: 10.1055/s-0037-1604394] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/26/2017] [Indexed: 10/19/2022]
Abstract
Background To the best of our knowledge, we are not aware of any reports focusing on results of arthroscopic debridement of triangular fibrocartilage complex (TFCC) tears in immature patients. Purpose The purpose of this study was to evaluate our results after arthroscopic debridement of TFCC tears in adolescents. Materials and Methods We retrospectively identified all patients of 18 years or less, who received an arthroscopic TFCC debridement due to a traumatic or degenerative tear according to Palmer. These cases were clinically re-evaluated after a mean period of 6.7 years (SD ± 3.9 years). All patients completed the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) inventory, and Patient-Rated Wrist Evaluation (PRWE). Results Thirteen adolescent patients (mean age: 15.6 ± 2.2 years at surgery) were included. The mean MMWS increased significantly from 70 ± 13.6 to 90 ± 6.5 after the TFCC debridement; mean postoperative DASH and PRWE scores of 17 ± 15.2 and 21 ± 18.5, respectively, indicated good and excellent outcomes for the majority of the cohort. The mean pain level decreased significantly from a mean of 5.7 ± 2.0 to 1.8 ± 2.0 at follow-up. Six patients needed a reoperation to achieve a successful outcome. Conclusion Arthroscopic debridement of TFCC tears, performed as a concomitant wrist surgery in adolescents, efficiently reduced wrist pain and yielded good to excellent results in the long term. However, under certain circumstances, its results are unpredictable and further surgery may be necessary to eventually achieve the satisfying outcomes. Further studies are needed to confirm these findings. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Sebastian Farr
- Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria
| | - Marion Schüller
- Department of Physical Medicine and Rehabilitation, Orthopedic Hospital Speising, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria
| | - Werner Girsch
- Department of Pediatric Orthopedics and Adult Foot and Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria
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Wrist Arthroscopy in Children and Adolescent With Chronic Wrist Pain: Arthroscopic Findings Compared With MRI. J Pediatr Orthop 2017; 37:e321-e325. [PMID: 28594695 DOI: 10.1097/bpo.0000000000000887] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Wrist arthroscopy is a dynamic diagnostic procedure and its indications are growing as a treatment modality in the adult population. The aim of the study was to retrospectively report our series of pediatric and adolescence with chronic wrist pain, with or without wrist instability who underwent wrist arthroscopy after failing at least 4 months of conservative management. Our secondary aim was to report the sensitivity and specificity of clinical examination and magnetic resonance imaging evaluation for various injury subgroups against the gold standard of the arthroscopic findings. Technical challenges, complications, and outcomes are also discussed. METHODS A retrospective review of the medical records of 32 pediatric and adolescent patients who underwent wrist arthroscopy was conducted. Preoperative clinical diagnosis, radiographic, and intraoperative findings including classifications of triangular fibrocartilage complex (TFCC) and interosseous ligaments were obtained. Patients were followed up to 1 year postoperatively and were discharged if symptom free. RESULTS Thirty-three wrist arthroscopies in 32 patients were performed from 1996 to 2004. There were 2 male and 30 female patients. At arthroscopy 16 wrists were found to have TFCC injuries, 11 wrists had scapholunate injuries, and 8 had lunotriquetral (LT) injuries. Clinical examination for diagnosis of TFCC injury was too sensitive and nonspecific; however, clinical diagnosis of scapholunate injury was sensitive and specific. LT injury was under diagnosed clinically. Magnetic resonance imaging was found to have a low sensitivity for diagnosis of LT injury but diagnosis of TFCC was sensitive and specific. CONCLUSIONS The sex ratio of 2 males:30 females was startling. Nevertheless, this therapeutic level 3 study supports a thorough search for pathology in any patient with persistent wrist symptoms because pathology was identified in 32 of the 33 wrists at arthroscopy. LEVEL OF EVIDENCE Level III-Therapeutic.
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Hinds RM, Gottschalk MB, Strauss EJ, Capo JT. Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data. Arthroscopy 2016; 32:645-50. [PMID: 26821961 DOI: 10.1016/j.arthro.2015.11.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 11/03/2015] [Accepted: 11/03/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze orthopaedic resident case log data to report temporal trends in performing arthroscopic procedures and to assess variability in arthroscopic case volume among residents. METHODS Accreditation Council for Graduate Medical Education orthopaedic surgery resident case logs were reviewed from 2007 to 2013. The mean number of wrist, elbow, shoulder, knee, and ankle arthroscopic procedures performed by graduating residents was analyzed. The median number of arthroscopic procedures reported by the 70th and 30th percentiles of graduating residents (by arthroscopic case volume) was also recorded. Temporal trends were assessed using a linear regression model. RESULTS From 2007 to 2013, there were significant increases in the mean number of wrist (5.8 to 6.3; P = .038), elbow (2.5 to 3.2; P < .001), shoulder (93.5 to 133.8; P < .001), knee (170.6 to 185.1; P = .011), and ankle (5.8 to 7.4; P < .001) arthroscopies performed per resident. Residents in the 70th percentile of caseload performed significantly more wrist (7 v 2; P < .001), elbow (3.3 v 1; P < .001), shoulder (134.1 v 70.6; P < .001), knee (205 v 128.7; P < .001), and ankle (7.9 v 2.9; P < .001) arthroscopies than residents in the 30th percentile. CONCLUSIONS Our findings indicate that arthroscopic caseload is increasing among orthopaedic residents. However, resident experience performing arthroscopic procedures is substantially disparate. Although the educational implications of this disparity are not well understood, our findings may aid in efforts to optimize arthroscopic training during orthopaedic residency.
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Affiliation(s)
- Richard M Hinds
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York, U.S.A..
| | - Michael B Gottschalk
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York, U.S.A
| | - Eric J Strauss
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York, U.S.A
| | - John T Capo
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York, U.S.A
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Reply to comments on Farr et al.: “Clinical experience with arthroscopically-assisted repair of peripheral triangular fibrocartilage complex tears in adolescents—technique and results”. INTERNATIONAL ORTHOPAEDICS 2015; 39:2089-90. [DOI: 10.1007/s00264-015-2820-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
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Clinical experience with arthroscopically-assisted repair of peripheral triangular fibrocartilage complex tears in adolescents—technique and results. INTERNATIONAL ORTHOPAEDICS 2015; 39:1571-7. [DOI: 10.1007/s00264-015-2795-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
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Andersson JK, Lindau T, Karlsson J, Fridén J. Distal radio-ulnar joint instability in children and adolescents after wrist trauma. J Hand Surg Eur Vol 2014; 39:653-61. [PMID: 24401745 DOI: 10.1177/1753193413518707] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study retrospectively evaluated the medical records and radiographs of patients younger than aged 25 that were referred for a second opinion due to ulnar-sided wrist pain and persistent distal radio-ulnar (DRU) joint instability. We identified 85 patients with a major wrist trauma before the age of 18. Median age at trauma was 14 years. Median time between trauma and diagnosis of DRUJ instability was 3 years. Sixty-seven patients (79%) had sustained a fracture at the initial trauma. The two most common skeletal injuries related to the DRUJ instability were Salter-Harris type II fractures (24%) and distal radius fractures (19%). In 19 patients (22%), the secondary DRUJ instability was caused by malunion or growth arrest. Eighteen patients (21%) had no fracture; in spite of this, they presented with subsequent symptomatic DRUJ instability. Fourteen of these 18 patients had a triangular fibrocartilage complex (TFCC) tear, confirmed by arthroscopy, open surgery, or magnetic resonance imaging. In conclusion, late DRUJ instability due to wrist fractures or isolated TFCC tears was found to be common in children and adolescents. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J K Andersson
- Department of Hand Surgery, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Sweden
| | - T Lindau
- Pulvertaft Hand Centre, Kings Treatment Centre, Royal Derby Hospital, Derby, UK
| | - J Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Sweden
| | - J Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Sweden
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