Diagnosis and Treatment of Acute Lunotriquetral Ligament Injuries

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.

Occult Lunotriquetral Ligament Injuries in Adolescent Golfers

Publications on lunotriquetral interosseous ligament (LTIL) injuries among adolescent professional golfers are scarce. Inconclusive clinical and radiographic imaging in rendering a definitive treatment may inform the lack of documentation in literature. In this case study, we present three case series of highly competitive adolescent golfers who presented with persistent and intractable ulnar-sided wrist pain. While the physical examination was clinically suspicious for lunotriquetral (LT) ligament injury, plain radiographs and MRI imaging did not elucidate the cause. The diagnosis was confirmed solely via wrist arthroscopy. Although most ulna-sided wrist pain can be treated conservatively, without a proper diagnosis, a missed LTIL injury can be disastrous to an adolescent golfers' future. This case series aims to create awareness of the diagnosis and stress the advantages of utilising wrist arthroscopy. Level of Evidence: Level V (Therapeutic).

Revisiting Lunotriquetral Arthrodesis in Chronic Lunotriquetral Ligamentous Injuries

Background  Chronic lunotriquetral (LT) ligament tears are a source of ulnar-sided wrist pain. Left untreated, complete tears of the LT ligament may progress to a volar intercalated segment instability deformity and eventual carpal arthritis. Various treatments have been proposed, one of which is LT arthrodesis. LT arthrodesis has been criticized for high rates of nonunion frequently requiring reoperation, and therefore has largely fallen out of favor. However, our experience has been quite different from the literature. This study examines a single surgeon's experience with LT arthrodesis over a 15-year period. Methods  A retrospective review of the senior author's practice over a 15-year period was performed. All adult cases of LT arthrodesis for chronic LT injuries were included. Headless compression screw and cancellous bone graft from the distal radius were used for primary arthrodesis in all cases. The primary outcome was rate of union, and secondary outcomes were time to union, secondary or salvage procedures, and range of motion. Nonparametric statistical analysis was used to calculate differences in outcomes. Results  Twenty-eight patients met inclusion criteria. The median age was 45.5 (interquartile range [IQR] 35-50) years and 75% were male. The dominant hand was most commonly affected. Eighty-six percent of patients achieved union, one patient required redo arthrodesis, and one patient went on to wrist salvage. Three patients developed a pain-free pseudoarthrosis. Median time to radiographic union was 8.8 (IQR 5.9-11.9) weeks. Conclusion  Despite multiple previous reports, this study demonstrates that LT arthrodesis for chronic LT injuries is a safe technique with high rates of successful union. Further comparative studies are warranted to determine the optimal treatment for chronic LT injuries.

Wrist and Hand Trauma Imaging

Injuries to the wrist and hands occur frequently in athletes from the high forces applied during sporting events. The examples presented illustrate the important role imaging has in the diagnosis of wrist and hand injuries. In addition, different imaging modalities are complementary and various examinations may be needed to help guide the management of wrist and hand traumatic pathology.

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.

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.

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.

Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC!

BACKGROUND

Ulnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine.

PURPOSE

Because of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual's choice to do a systematic assessment and follow in their routine clinical practice. We propose the 'storey concept' for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint.

CONCLUSION

Also, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.

Imaging evaluation of traumatic carpal instability

PURPOSE

To review the epidemiology, pertinent wrist anatomy, classification system, and emergent imaging evaluation of carpal instability with a focus on radiographic assessment of instability.

METHODS

A review of current literature on carpal instability was performed with summary presentation of carpal instability epidemiology, carpal anatomy, imaging evaluation, and classification with imaging evaluation focused on diagnosis in the emergency setting.

RESULTS

Carpal instability is a common pathology in falls on outstretched hand and is likely underdiagnosed due to instability being occult or demonstrating subtle malalignment on static imaging of the wrist. While there is a complex network of intrinsic and extrinsic ligaments contributing to carpal instability, a detailed knowledge of these ligaments is not necessary for radiologists to make an accurate diagnosis in the emergency setting, as identification and classification of carpal instability is based on identification of carpal malalignment patterns on radiography as opposed to identification of specific ligament injuries on advanced imaging. The Mayo classification is the most widely used classification system, which divides carpal instability into four categories: dissociative, non-dissociative, complex, and adaptive. Understanding this classification system allows radiologists to successfully classify almost all carpal instability injuries they will encounter, even in the setting of unusual or rare instability patterns.

CONCLUSION

In working with the treating clinician, it is essential that the emergency radiologist is comfortable with identifying and classifying carpal instability. This will ensure prompt treatment of seemingly benign injuries and those that require intervention, surgical or otherwise, improving the likelihood of a good outcome.

Association of lunate morphology, sex, and lunotriquetral interosseous ligament injury with radiologic measurement of the capitate-triquetrum joint

OBJECTIVE

Radiologic presentation of carpal instability at the radial side of the carpus, e.g. scapholunate diastasis following scapholunate interosseous ligament injury, has been studied extensively. By comparison, presentation at the ulnar-sided carpus has not. The purpose of this study was to assess the effects of lunate morphology, sex, and lunotriquetral interosseous ligament (LTIL) status on the radiologic measurement of the capitate-triquetrum joint (C-T distance). Further, we sought to evaluate the diagnostic accuracy of C-T distance for assessing LTIL injuries.

MATERIALS AND METHODS

We retrospectively identified 223 wrists with wrist radiographs and MR arthrograms with contrast injection. Data collected included sex, lunate morphology and LTIL status from MR arthrography, and C-T distance from radiography. The effects of lunate morphology, sex, and LTIL injury status on C-T distance were evaluated using generalized linear models. Diagnostic performance of C-T distance was assessed by the area under receiver-operator characteristic curve (AUROC).

RESULTS AND CONCLUSION

Lunate morphology, sex, and LTIL injury status all had significant effects on C-T distance; wrists with type II lunates, men, and wrists with LTIL injuries had greater C-T distances than wrists with type I lunates, women, and wrists without LTIL injuries, respectively (p < 0.01). The diagnostic value of the C-T distance for identifying patients with full-thickness LTIL tears was sufficient for women with type I (AUROC = 0.67) and type II lunates (0.60) and good for men with type I (0.72) and type II lunates (0.77). The demonstrated influence of LTIL status on C-T distance supports the use of C-T distance as a tool in assessing for full-thickness LTIL tears.

Lunotriquetral Ligament Reconstruction Utilizing a Palmaris Longus Autograft

Injury to the lunotriquetral ligament can result in midcarpal instability, with resultant alterations in normal wrist kinematics and subsequent arthrosis. We performed a previously undescribed technique of lunotriquetral ligament reconstruction in two patients utilizing a palmaris longus tendon autograft. Average age at presentation was 24 years old with a mean follow up of 10 months. Average range of motion was 62.5° of flexion and 57.5° of extension. Total arc of motion was 83% of the contralateral uninvolved extremity. Average grip strength was 31 kg which was 91% of the contralateral extremity. Average Quick Disability of Arm, Shoulder and Hand score was 12.5 and Modern Activity Subjective Survey of 2007 was 1.5. No complications were noted.

Inestabilidad lunopiramidal

Históricamente, la inestabilidad en el lado radial de la muñeca ha recibido mucha más atención que la inestabilidad en el lado ulnar, a pesar de ser una patología relativamente frecuente. Como consecuencia de ello, suele darse un retraso en el diagnóstico correcto y el tratamiento apropiado. Las lesiones del ligamento lunopiramidal pueden ser parciales o completas, y estas últimas pueden estar asociadas a lesión de los estabilizadores secundarios. Cuando se lesionan estos estabilizadores es cuando se produce una inestabilidad estática del carpo conocida como Volar Intercalated Segmentary Instability (VISI). Entre los test clínicos más utilizados para detectar una inestabilidad del ligamento lunopiramidal están el Ballottement test, descrito por Reagan, y el Shear test, descrito por Kleinman, aunque ambos poseen una sensibilidad y una especificidad bajas. Para el diagnóstico de estas lesiones se emplean técnicas como la radiografía simple (que suele ser normal si no hay una inestabilidad estática del carpo), la artrografía y la RMN, entre otras, aunque el gold standard lo constituye la artroscopia de muñeca. No existe un consenso en cuanto al tipo de tratamiento óptimo, ya que la mayoría de los estudios publicados son retrospectivos de nivel iv sin medidas objetivas estandarizadas mediante instrumentos validados. Además, en su mayoría describen los resultados del tratamiento tardío, ya que no se suelen diagnosticar en la fase aguda. Dentro de los tratamientos descritos se encuentran el tratamiento artroscópico (desbridamiento/termocoagulación asociados o no a estabilización con agujas de Kirscher), la reparación abierta, la reconstrucción del ligamento y la artrodesis del ligamento lunopiramidal.

Performing Hand Surgery Under Local Anesthesia Without a Tourniquet in China

In China, wide-awake surgeries are increasingly used by surgeons in a growing number of hospitals for hand and upper extremity surgeries. Experience suggests that wide-awake surgery is safe, economical, and patient-friendly, optimizing hospital resource allocation and increasing efficiency. This article discusses which procedures are most suitable, variations in procedures, departmental impacts, and future direction.