Post-traumatic carpal instability

Arthroscopic Debridement for Treatment of Chronic Dynamic Scaphoid Instability

Background  There is a paucity of information on minimal surgical intervention for the treatment of chronic dynamic scaphoid instability (CDSI) that will achieve an acceptable mid-term result. Purpose  We hypothesize that by following a debride-first-then-wait protocol, some patients with CDSI can be treated with arthroscopic debridement alone and avoid a reconstructive procedure. Patients and Methods  We performed a retrospective, longitudinal study from January 2008 to December 2018 of all patients diagnosed with CDSI and treated with arthroscopic debridement of the scapholunate interosseous ligament. In all cases, a debride-first-then-wait protocol was followed that included a predetermined wait period after arthroscopic debridement, giving the patient a chance to experience possible symptom improvement. This approach integrated the patient's perceived wellness into the decision-making process. All wrists that remained symptomatic or experienced recurrence of symptoms were treated with a reconstructive procedure. The wrists were divided into two groups: arthroscopic debridement only (ADO) and reconstructive procedure (RP). Results  Seventy-nine wrists (72 patients) of 191 consecutive wrist arthroscopies met the inclusion criteria. The ADO group consisted of 43 wrists (54%). An average of 6.3 years later (range: 2-11 years), these patients remained satisfied with the results of the arthroscopic debridement and did not want further treatment. The RP group included 36 wrists (46%) with 91.7% of reconstructive surgeries occurring within 6 months of the arthroscopy. With a mid-term follow-up, 75% of Geissler grade II ligament tears, 48% of grade III tears, and 39% of grade IV tears were successfully treated with arthroscopic debridement alone and avoided a reconstructive surgery. Conclusion  By adopting a debride-first-then-wait protocol, some patients with CDSI can be treated with a more limited intervention, arthroscopic debridement. In this series, 54% of wrists with CDSI avoided a reconstructive surgery for an average of 6.3 years. Type of Study / Level of Evidence  Case Series, Level IV.

Physiotherapeutic Management for Acromioclavicular Joint Sprain With Volar Intercalated Segment Instability at the Wrist: A Case Report

Among sports enthusiasts and young individuals, acromioclavicular (AC) joint injuries are highly prevalent. In this, we discussed the comprehensive assessment and management of a 22-year-old male patient who is a student by occupation and a recreational badminton player who presented with left shoulder and wrist pain following a road traffic accident. The study highlights the clinical findings, diagnostic assessment, and therapeutic interventions for the patient with volar intercalated segment instability and a grade 1 AC joint sprain. The methodology involves a case report of the patient's clinical evaluation, including range of motion, manual muscle testing, and diagnostic imaging. The patient was managed conservatively with physiotherapy interventions, including Mulligan's movement with mobilization, cryotherapy, light amplification by stimulated emission of radiation, and progressive exercises. The results of the study demonstrate the successful implementation of a multidisciplinary conservative management approach for alleviating pain, restoring function, and promoting optimal recovery for the patient. The implications of the study underscore the significance of tailored physical therapy rehabilitation in the management of AC joint sprains and wrist instabilities.

Radiographic and Clinical Outcomes of Radioscapholunate Arthrodesis in Patients With Inflammatory and Posttraumatic Arthritis

BACKGROUND

Radioscapholunate (RSL) fusion is performed for painful radiocarpal arthritis that is typically posttraumatic or inflammatory in nature. The purpose of this study was to determine whether patients with inflammatory conditions undergoing RSL fusion had comparable outcomes as those with posttraumatic arthritis and to determine factors impacting union.

METHODS

This was a retrospective review of all RSL fusions over a 25-year period. Demographic information, wrist range of motion, postoperative complications, and surgical technique, including presence or absence of resection of distal scaphoid pole, data were collected. Radiographs were examined for evidence of healing of the RSL fusion site as well as development of midcarpal arthritis.

RESULTS

Fifty-six patients underwent RSL fusion. Eight patients required revision of radiocarpal arthrodesis for painful nonunion. The fusion rate was 85.7%, and median 25th to 75th percentile (time to healing was 4.0 3.2-5.2) months. There were no differences in time to or rate of union by inflammatory arthropathy status. Grip strength increased significantly and pain decreased significantly with surgery. Union rate was 90% with the use of K-wires, screws, or staples, which was significantly greater than plates, fusion cups, or multiple implant types. The use of autologous bone graft significantly decreased the rate of nonunion and significantly decreased time to union by 3 months compared to allograft alone. Extension was significantly improved with scaphoid distal pole resection versus without distal scaphoid pole resection.

CONCLUSIONS

Radioscapholunate (RSL) fusion is an effective treatment for radiocarpal arthritis but has high nonunion rates. Fixation with K-wires, screws, or staples and use of autograft confers improved union rate.

Radiocarpal fracture-dislocation: Review of the literature, new classification and decision algorithm

BACKGROUND

Radiocarpal fractures and dislocations are rarely described in the literature. However, the consequences at the functional level are severe, with the loss of almost half of the articular amplitude. The most widespread classification is that of Dumontier, which divides the injury into two categories according to the presence or absence of a fracture. Currently, no classification considers fracture-dislocations in a global and multi-tissue manner; therefore, no therapeutic strategy has been reported.

METHODS

We conducted an exhaustive bibliographic search for cohort or case report articles concerning radiocarpal fracture-dislocations published between 1990 and the present. Only descriptions of the injury were identified (noting the type of fracture, direction of displacement and carpal injuries).

RESULTS

In all, data were collected from 14 retrospective series and 16 case reports involving 218 patients. Thirty-five and 183 cases involved anterior and posterior displacement, respectively. A fracture of the distal radius was found in 183 cases and 35 cases had a dislocation only, with no significant fracture. Among the posterior displacements, 44 isolated styloid fractures, 62 styloid and posterior marginal fractures, 29 bimarginal fractures (large anterior fragment and small posterior fragment) and 31 fractures of all the fragments described by Medoff with impaction of the central pavement were found. Anterior displacement fractures were found in 17 cases (styloid and/or anterior marginal fracture). We were able to group the different traumatic clinical forms according to a six-category classification.

DISCUSSION

A review of the literature highlighted three major components in the management of radiocarpal fracture-dislocations: the bone component, the ligament component and the associated intracarpal lesions. These three components were included in our classification and allowed us to accurately describe all types of radiocarpal fracture-dislocations published in the literature. Authors currently agree on management of the bone component but disagree on that of the ligament component. Particular attention should be paid to intracarpal lesions, which lead to poor outcomes if ignored. Based on our biographical research, we propose a management plan for these complex injuries.

LEVEL OF EVIDENCE

VI.

Chronic post-traumatic pain: rheumatological and orthopedic aspects

Trauma causes a complex local and systemic reaction of the macroorganism, the consequences of which can be various functional, neurological and psychoemotional disorders. One of the most painful complications of injuries of the musculoskeletal system is chronic post-traumatic pain (CPTP), which occurs, depending on the severity of the damage, in 10–50% of cases. The pathogenesis of this syndrome is multifactorial and includes the development of chronic inflammation, degenerative changes (fibrosis, angiogenesis, heterotopic ossification), pathology of the muscular and nervous systems, neuroplastic changes leading to the development of central sensitization, as well as depression, anxiety and catastrophization. Risk factors for CPTP should be considered the severity of injury, comorbid diseases and conditions (in particular, obesity), stress and serious trauma-related experiences (within the framework of post-traumatic stress disorder), the development of post-traumatic osteoarthritis and chronic tendopathy, genetic predisposition, deficiencies in treatment and rehabilitation in the early period after injury. To date, there is no clear system of prevention and treatment of CPTP. Considering the pathogenesis of this suffering, adequate anesthesia after injury, active anti–inflammatory therapy (including local injections of glucocorticoids), the use of hyaluronic acid, slow-acting symptomatic agents and autologous cellular preparations – platelet-riched plasma, mesenchymal stem cells, etc. are of fundamental importance. However, therapeutic and surgical methods of CPTP control require further study

Perilunate fracture-dislocations: Clinical and functional outcomes at a mean follow-up of 3.3 years

INTRODUCTION

Perilunate lesions in the carpus are severe injuries whose functional consequences can limit patients' ability to regain their pre-injury activity levels. The aim of this study was to evaluate the outcomes of a series of patients who suffered a perilunate fracture-dislocation and to assess their ability to resume their social and professional activities.

HYPOTHESIS

After surgical management of this injury, the medium-term functional outcomes will allow patients to return to their pre-injury social and professional activities.

MATERIALS AND METHODS

This was a single center, retrospective study. Included patients were adults who had suffered a perilunate fracture-dislocation that was treated emergently. The clinical and functional assessment consisted of comparing the mobility and grip strength between the injured and contralateral wrists, determining the functional outcome scores and the resumption of social and professional activities. A radiological assessment was done to look for instability of the proximal row of the carpus, nonunion or necrosis of the carpal bones, loss of carpal height, and presence of carpal osteoarthritis.

RESULTS

Ten patients were included with a mean follow-up of 39.4 months. The mean flexion/extension arc decreased significantly to 88° (20°-150) which was 55% of the healthy contralateral side (p=0.0026) while the grip strength decreased but not significantly (40.6 Kg vs. healthy side 62.4 Kg, p=0.063). The mean MWS was 58.75 (40-100), the mean PRWE was 32.9 (4-67.5) and the mean QuickDASH was 30.2 (0-77). Six of the ten patients (60%) were able to return to work, although three required occupational reclassifications. Four patients had signs of proximal row instability. There were seven instances of radiocarpal osteoarthritis, two of which were combined with mid-carpal osteoarthritis.

DISCUSSION

This study found shorter range of motion and worse patient-reported outcomes than other published studies, which may be due to the severity of the perilunate fracture-dislocation injuries and the inclusion of polytrauma patients. Nevertheless, the subjective scores were comparable. These injuries have serious consequences on social and professional activities of manual workers.

LEVEL OF EVIDENCE

IV; retrospective study.

Volar Tilt of the Lunate After Open Reduction Internal Fixation of a Distal Radius Fracture

The pathophysiology of carpal adaptations after fracture of the distal radius is incompletely understood. We report 5 patients who had normal carpal alignment on injury radiographs that developed marked volar angulation of the lunate during recovery from volar plate fixation of a fracture of the distal radius. There were no signs of alteration of the carpal ligaments. Two patients had similar volar tilt on the contralateral side. The cause and optimal treatment of carpal malalignment after restoration distal radial alignment are unclear.

The role of concomitant ligament injury in the development of post-traumatic osteoarthritis after distal radius fractures: a protocol for a systematic review

INTRODUCTION

Treatment of distal radius fractures (DRFs) aims to restore anatomic position of the fracture fragments and congruity of the articular surface to optimise functional outcomes and prevent osteoarthritis in the long term. While ligament injury of the wrist is often associated with DRFs and sole ligament injuries of the wrist lead to osteoarthritis, it is plausible that concomitant ligament injury in DRFs may aggravate degenerative changes of the wrist. The relationship between concomitant ligament injury and post-traumatic osteoarthritis in patients with DRFs is unclear. This study aims to identify the types of associated ligament injury in patients with a DRF and to elucidate the association of ligament injury on the development of post-traumatic osteoarthritis.

METHODS AND ANALYSIS

This protocol is written in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. An electronic search in MEDLINE, Embase, Web of Science, Cochrane Central Register of Trials and Google Scholar has been created and performed by a Health Sciences librarian with expertise in systematic review searching. Original research articles in English literature, which report on concomitant ligament injury of the wrist in relation to post-traumatic osteoarthritis, patient-reported outcome measures or clinician-reported outcome measures in patients (aged ≥18 years) with DRFs will be included. Two reviewers will independently screen and appraise articles and perform data extraction. In case of any disagreements, a third reviewer will be consulted. A systematic qualitative synthesis will be performed using text and tables.

ETHICS AND DISSEMINATION

No ethical approval is required, since this is a protocol for a systematic review. The systematic review will be submitted for publication in a peer-reviewed scientific journal and for presentation at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42020165007.

Real-time three-dimensional MRI for the assessment of dynamic carpal instability

Background

Carpal instability is defined as a condition where wrist motion and/or loading creates mechanical dysfunction, resulting in weakness, pain and decreased function. When conventional methods do not identify the instability patterns, yet clinical signs of instability exist, the diagnosis of dynamic instability is often suggested to describe carpal derangement manifested only during the wrist’s active motion or stress. We addressed the question: can advanced MRI techniques provide quantitative means to evaluate dynamic carpal instability and supplement standard static MRI acquisition? Our objectives were to (i) develop a real-time, three-dimensional MRI method to image the carpal joints during their active, uninterrupted motion; and (ii) demonstrate feasibility of the method for assessing metrics relevant to dynamic carpal instability, thus overcoming limitations of standard MRI.

Methods

Twenty wrists (bilateral wrists of ten healthy participants) were scanned during radial-ulnar deviation and clenched-fist maneuvers. Images resulting from two real-time MRI pulse sequences, four sparse data-acquisition schemes, and three constrained image reconstruction techniques were compared. Image quality was assessed via blinded scoring by three radiologists and quantitative imaging metrics.

Results

Real-time MRI data-acquisition employing sparse radial sampling with a gradient-recalled-echo acquisition and constrained iterative reconstruction appeared to provide a practical tradeoff between imaging speed (temporal resolution up to 135 ms per slice) and image quality. The method effectively reduced streaking artifacts arising from data undersampling and enabled the derivation of quantitative measures pertinent to evaluating dynamic carpal instability.

Conclusion

This study demonstrates that real-time, three-dimensional MRI of the moving wrist is feasible and may be useful for the evaluation of dynamic carpal instability.

Perilunate carpal dislocation. Clinical evaluation of patients operated with reduction and percutaneous fixation without capsular-ligament repair

Objective

To qualitatively assess surgeries performed in patients with perilunate dislocations without associated fractures, who were operated using the closed reduction and percutaneous fixation method. The follow-up time ranged from one to seven years.

Methods

628 patient records with traumatic wrist injuries, operated by the same group of Hand Surgeons between 2008 and 2014 due to acute trauma were collected, with a mean follow-up of 3.2 years. Of these, 51 were cases of perilunate fracture-dislocations, and 38 were pure perilunate dislocations without associated fractures; of these, only 32 underwent percutaneous fixation without ligamentous repair, thus meeting the inclusion criteria. Of the nine patients with perilunate dislocations who were treated using the closed reduction and percutaneous fixation method, whose mean age was 38 years (range 26–49 years), the dominant side was the left in two-thirds of the cases, and the predominant trauma mechanism was direct trauma.

Results

This study is in agreement with the literature, showing that cases treated early present good results.

Conclusion

88% of patients who were treated by closed reduction and percutaneous fixation method maintained their daily activities and were assessed as excellent or good by the Clinical Scoring Chart.

Posttraumatic Static Volar Intercalated Segment Instability - Iatrogenic or Missed Injury

Introduction:

Carpal instability is broad category consisting of various patterns of injury, with dissociative type more common.

Case Report:

A 13 -year -old boy presented at 6 months following a fall with restriction of wrist movements. Patient had sustained a closed distal one -third both bones fracture forearm fixed with K -wire, and volar lunate instability was found during sequential follow -up.

Conclusion:

Posttraumatic carpal instability should be identified at the earliest to avoid poor hand function and morbidity associated with it.

High-energy injuries of the wrist

High-energy injuries to the wrist gather complex fractures of the distal radius, radiocarpal dislocations, perilunate dislocations, and other intracarpal dislocations. Depending on the energy of the injury and the position of the wrist at the time of impact, the patient, often a young male with a high functional demand, presents one of these injuries associating fracture(s) and ligament injury. The trauma is often bilateral, with proximal lesions (elbow) very often associated with contusion or compression of the median nerve. Diagnosis is confirmed by wrist X-rays, which are sufficient to determine treatment for radiocarpal and perilunate dislocations. In cases of distal radius fractures or other intracarpal dislocations, a preoperative CT is necessary. Reduction of the dislocation and relief of neurovascular compression are performed immediately. The final treatment of each lesion (bone fixation, ligament repair) can be undertaken simultaneously or delayed, depending on the patient and the lesions. Cartilage lesions, resulting from the high-energy injury, can be estimated using arthroscopy but cannot be repaired and determine the prognosis. The surgeon's objective is to restore joint congruence, which does not prevent stiffness, the main complication of these rare injuries, which the surgeon must know how to recognize and treat.