Incidence and Functional Outcomes of Scapholunate Diastases Associated Distal Radius Fractures: A 2-year Follow-Up Scapholunate Dissociation

Is the Repair of Acute Scapholunate Injuries Associated With Distal Radius Fractures Necessary at the Time of Osteosynthesis? A Systematic Review and Meta-Analysis

BACKGROUND

Acute scapholunate ligament injuries (SLIs) can occur in distal radial fractures (DRFs). This systematic review compares patient-reported outcomes and range of motion (ROM) between operative and nonoperative treatment of acute SLIs in association with surgical fixation of DRFs. We hypothesize that there is no clinical difference.

METHODS

A meta-analysis was used to evaluate the effectiveness of SLI repair versus no repair occurring with DRF with Disabilities of the Arm, Shoulder, and Hand (DASH) scores. We identified 154 articles of which 14 were eligible for review. Only 7 studies reported sufficient radiographic or clinical outcomes data and were included: 3 for meta-analysis and 4 underwent narrative analysis due to lack of homogeneity. We analyzed the patients in 2 groups: operative SLI (O-SLI) versus nonoperative SLI (NO-SLI). The primary outcomes were ROM and DASH scores with 1-year follow-up, where a pooled effect size was generated to determine a difference between groups.

RESULTS

A total of 128 patients were included (71 O-SLI and 57 NO-SLI), with a mean follow-up of 70.2 months (SD: 23.5). The overall effect size for ROM for flexion was 1.74 (95% confidence interval [CI], -3.48 to 6.95; P = .51) and for extension was 0.79 (95% CI, -3.41 to 4.99; P = .71), while the overall effect size for DASH scores was -0.28 (95% CI, -0.66 to 0.10; P = .14). Although NO-SLI led to better ROM and O-SLI led to lower DASH scores, these were not significantly different.

CONCLUSION

The acute surgical intervention of a scapholunate interosseous ligament injury is no different from conservative management in the setting of acute DRFs undergoing osteosynthesis. But the sample size for pooed analyses was small, hence the evidence to date is low to recommend either way.

[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

Concomitant ligament injuries can be left untreated during surgery of distal radial fractures

Instability of the distal radioulnar joint and scapholunate dissociation may cause pain, functional impairment and subsequent arthrosis. There is no consensus about whether these injuries should be treated acutely in patients undergoing surgery for distal radial fractures. We conducted a prospective cohort study to determine whether concomitant distal radioulnar joint instability or scapholunate dissociation negatively influence patient-related outcomes in these patients. The primary outcome was the patient-reported wrist/hand evaluation at 6 and 12 months after surgery. Out of 62 patients, 58% and 27% had intraoperative distal radioulnar joint instability and scapholunate dissociation, respectively. No significant differences were found in patient-reported scores at follow-up between patients with stable and unstable distal radioulnar joints, nor between patients with and without scapholunate dissociation. Sixty-three per cent of patients with an unstable distal radioulnar joint during surgery were stable on retesting after 6 months. Our study suggests that a wait-and-see policy in these patients therefore seems reasonable.Level of evidence: III.

The Current Role of Arthroscopy in Traumatic Wrist Injuries: An Expert Survey

Background  Wrist arthroscopy has become increasingly popular for diagnosing and treating traumatic wrist injuries. How wrist arthroscopy has influenced the daily practice of wrist surgeons remains unclear. The objective of this study was to evaluate the role of wrist arthroscopy for the diagnosis and treatment of traumatic wrist injuries among members of the International Wrist Arthroscopy Society (IWAS). Methods  An online survey was conducted among IWAS members between August and November 2021 with questions regarding the diagnostic and therapeutic importance of wrist arthroscopy. Questions focused on traumatic injuries of the triangular fibrocartilage complex (TFCC) and scapholunate ligament (SLL). Multiple-choice questions were presented in the form of a Likert scale. The primary outcome was respondent agreement, defined as 80% answering similarly. Results  The survey was completed by 211 respondents (39% response rate). The majority (81%) were certified or fellowship-trained wrist surgeons. Most respondents (74%) had performed over 100 wrist arthroscopies. Agreement was reached on 4 of the 22 questions. It was agreed that the outcomes of wrist arthroscopy strongly depend on surgeons' experience, that there is sufficient evidence for the diagnostic purposes of wrist arthroscopy, and that wrist arthroscopy is better than magnetic resonance imaging (MRI) for diagnosing TFCC and SLL injuries. No agreement was reached on the preferred treatment of any type of TFCC or SLL injury. Conclusion  There is agreement that wrist arthroscopy is superior to MRI for diagnosing traumatic TFCC and SLL injuries, yet experts remain divided on the optimal management. Guidelines need to be developed for the standardization of indications and procedures. Level of Evidence  This is a Level III study.

An experienced surgeon's take on scapho-lunate diastasis with distal radius fracture: What does this mean? Does this influence functional outcome?

Radiographic evidence of scapho-lunate diastasis associated with a displaced distal radius fracture has been well recognized yet the clinical significance remains in question. If left untreated, will this progress to both radiographic and clinical changes consistent with intercarpal arthritis? Using the accumulated data of over 400 surgically treated distal radius fractures in the ICUC database, 16 cases of untreated scapho-lunate diastasis were followed on an average of 8 years without evidence of progressive functional or radiographic deterioration. In 50% of these cases, incidental findings of similar scapho-lunate diastasis was noted in the opposite uninjured wrist.

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

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

Outcomes Associated With Scapholunate Ligament Injury Following Intra-Articular Distal Radius Fractures

PURPOSE

The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF.

METHODS

A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain.

RESULTS

One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°-68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°-87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°-87°) to 78.5° (range, 71°-107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups.

CONCLUSIONS

Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

[Research progress in the treatment of distal radius fractures assisted by wrist arthroscopy]

OBJECTIVE

To review the research progress of wrist arthroscopy assisted treatment of distal radius fractures.

METHODS

To summarize and describe the anatomical characteristics and fracture classification of the distal radius, indications and contraindications of wrist arthroscopy-assisted treatment, surgical methods, and associated soft tissue injuries, and summarize the advantages and disadvantages of the operation through a large number of literature at home and abroad on the treatment of distal radius fractures assisted by wrist arthroscopy.

RESULTS

Wrist arthroscopy as a minimally invasive technique for the treatment of distal radius fractures, compared with traditional surgery, can accurately observe intra-articular damage and perform operations under the microscope to avoid secondary damage to blood vessels, nerve, and tendon, etc., and can achieve one-stage repair and reconstruction by repairing the ligament, trigonal fibrocartilage complex, and carpal dislocation. It has the advantages of less trauma, fast postoperative recovery, extensive indications, fewer complications, and satisfactory effectiveness.

CONCLUSION

Wrist arthroscopy has advantages that traditional X-ray film, CT, MRI, and arthrography examinations do not have. Moreover, wrist arthroscopy has achieved satisfactory effectiveness in the adjuvant treatment of intra-articular distal radius fractures.

Bilateral scapholunate widening may have a nontraumatic aetiology and progress to carpal instability and osteoarthritis with advancing age

It was hypothesized that bilateral widening of the scapholunate gap is relatively common in the absence of trauma and that it progresses to radiological carpal instability and scapholunate advanced collapse. Electronic files of 1000 patients with bilateral X-rays were studied in retrospect. Wide scapholunate gaps were bilaterally present in 67 and unilaterally in 51 patients. Scapholunate advanced collapse was observed in 26 patients; in nine it was in both wrists. A trauma was recorded in less than half of the patients with a bilateral wide scapholunate gap. Patients with bilateral wide gaps were younger if signs of carpal instability or osteoarthritis were absent. Bilateral scapholunate widening may not be caused by an acute trauma, but may lead to carpal instability and degenerative changes with advancing age.