Acute blockage of forearm supination due to flap tear of the triangular fibrocartilage disc: A case report

RATIONALE

Acute blockage of forearm supination has been reported in several studies. It is caused by loose bodies in the wrist joint, extensor carpi ulnaris tendon interposition, and distal radioulnar joint (DRUJ) injuries, including forearm bone fractures. Some studies have reported cases of DRUJ injuries caused by triangular fibrocartilage complex (TFCC) tears.We report a case of acute blockage of forearm supination after minor trauma and suggest a possible TFCC tear when a patient complains of forearm supination blocking. In addition, we present a comparison between our case and other reports on etiology, magnetic resonance imaging (MRI) findings, and arthroscopic findings, and show the specific characteristics of our case.

PATIENTS CONCERNS

A 22-year-old male presented with left wrist pain as the chief complaint. He was injured 2 months prior to pushing his left hand on the floor during exercise. Physical examination showed a relative limitation of range of motion (ROM) in the left wrist of about 10° in flexion and about 15° in extension compared with the right side. The patient also complained of supination limitation and volar side wrist pain during supination. The patient showed tenderness in the axial compression test.

DIAGNOSES

Plain radiographs showing no abnormalities. MRI showed a TFCC tear in the central portion. A torn flap of the TFCC was interposed on the volar side of the DRUJ.

INTERVENTIONS

Arthroscopic surgery of the left wrist joint was performed. Arthroscopic examination revealed a tear in the TFCC on the radial side. A torn flap was interposed on the volar side of the DRUJ. We removed the flap from the DRUJ using an arthroscopic grasper and partially resected it.

OUTCOMES

Intraoperative tests showed no locking and the forearm was well supinated. Two months after the surgery, the patient had no pain and showed full forearm supination.

LESSONS

DRUJ blocking due to a TFCC tear should be suspected when acute blockage of forearm supination occurs after minor trauma. MRI is helpful for diagnosis; however, we suggest that the diagnosis should be confirmed through arthroscopy. Symptoms can be resolved by surgical treatment using arthroscopy.

Complications after arthroscopic triangular fibrocartilage complex (TFCC) surgery

Wrist arthroscopy is a valuable and widely utilized tool in the treatment of triangular fibrocartilage complex (TFCC) injuries. These procedures include synovectomy alone, peri-capsular or transosseous repair, and arthroscopic-assisted reconstruction, and each are associated with specific complications. This review describes the types of complications and their rates in different types of arthroscopic TFCC surgery reported in the literature and in our centre. Across the spectrum of arthroscopic TFCC surgery, complication rates and the learning curve increase with surgical complexity. Relevant anatomy, prevention and management of complications including nerve injury and irritation, extensor tendon injury and tendinitis, fracture, stiffness, and persistence of symptoms or instability are discussed. Vigilance to anatomical details and careful dissection can help to reduce complications that may result in disturbing pain and functional loss.

Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint

BACKGROUND

Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget).

PURPOSE

In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury.

STUDY DESIGN

This was a prospective cohort study.

METHODS

Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five.

RESULTS

Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Scapholunate ligament injuries: an instructional review for the FRCS examination

An instructional review of the anatomy, investigation, and management of scapholunate ligament injuries. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Paediatric fractures of carpal bones other than the scaphoid

OBJECTIVES

Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome.

MATERIAL AND METHODS

Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study.

RESULTS

In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good.

CONCLUSION

Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation.

A systematic review of the psychometric properties of pressure pain detection threshold in evaluating mechanical pain threshold in people with hand or wrist injuries

PURPOSE

The aim of this study was to conduct a systematic review of the psychometric properties of Pressure Pain Detection Threshold (PPDT) measures in people with hand or wrist injuries.

STUDY DESIGN AND METHODS

MEDLINE, Embase, and CINAHL databases were searched to identify eligible studies evaluating psychometric properties of PPDT in samples composed of at least 50% of people with hand or wrist injury. The Consensus-based Standards for the Measurement of Health Instruments' risk of bias checklist was used to critically appraise the included studies, and qualitative synthesis was performed by pooling the results of all studies that presented the same measurement property using Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

From 415 studies, 11 relevant studies were identified. Of the 11 studies, four hand or wrist injuries were represented; carpal tunnel syndrome, distal radius fractures, osteoarthritis, and complex regional pain syndrome. Intra-rater reliability was considered sufficient (intraclass correlation coefficient 0.64-0.94), with small reported standard error of the mean values (5.3-39.2 kPa). Results of validity and responsiveness could not be synthesized due to heterogeneity. Risk of bias for reliability and measurement error was assessed as very good or adequate, whereas validity and responsiveness were doubtful or inadequate. Overall quality of evidence was low or very low for all measurement properties.

CONCLUSIONS

Inconsistent results and low quality evidence provide little confidence in the overall measurement properties of PPDT in a hand or wrist injury population. No criterion standard for pain further highlights complexities around pain measurement such that the results obtained from PPDT measures in clinical practice cannot be compared to a gold standard measure.

Can a Deep Learning Algorithm Improve Detection of Occult Scaphoid Fractures in Plain Radiographs? A Clinical Validation Study

BACKGROUND

Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting.

QUESTIONS/PURPOSES

(1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level?

METHODS

This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured.

RESULTS

Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures.

CONCLUSION

CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Management of Complex Hand and Wrist Ligament Injuries

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

Diagnostic Performance and Advanced Imaging Reduction With Digital Tomosynthesis in Scaphoid Fracture Management

BACKGROUND

Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS.

METHODS

From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question.

RESULTS

A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information.

CONCLUSIONS

Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.

Severe spaghetti wrist injury: Should we expand the terminology from wrist to proximal forearm?

Objectives

This study aims to point out the key principles for the management of multicomponent soft tissue injuries of the wrist and forearm to discuss whether we should expand the term “spaghetti” from the wrist to forearm in such terrifying cases.

Patients and methods

Data from a total of 50 patients (44 males, 6 females; mean age: 48.5±25.7 years; range, 10 to 70 years) who were treated for multicomponent soft tissue injuries of the wrist and forearm, including at least one major artery and one major nerve, between February 2020 and December 2021 were retrospectively analyzed. The patients were divided into the wrist injury group (n=30) and forearm injury group (n=20) according to the location of laceration. Demographic characteristics, including age, sex ratio and mechanism and side of injury, total lacerated structures, and outcomes, including tendon function, opposition, intrinsic muscle function, deformities, sensation and grip strength were evaluated.

Results

In the wrist injury group, a mean of 12.27±3.53 structures at the volar side were injured. It took a mean time of 1.8±0.4 h for emergency surgical repair and, after a mean of 16.6±5.3 month follow-up, most patients received excellent/good outcomes in the six aspects. In the forearm injury group, a mean of 12.95±2.96 structures at the volar side were injured. It took an average time of 2.1±0.4 h for emergency surgical repair and, after a mean of 15.4±6.4 month follow-up, most patients received excellent/good outcomes and were satisfied with the functional recovery. Only surgical time (p=0.018) and final grip strength (p=0.023) between the two groups showed a statistically significant difference.

Conclusion

We propose to merge the severe wrist and proximal forearm laceration of multiple tendons/muscles with at least one major artery and one major nerve as a whole, namely the spaghettiketchup injury, since the laceration of wrist and that of proximal forearm in this study share similar mechanisms and outcomes after primary repair or reconstruction.

Management and Outcomes of Clinical Scaphoid Fractures in Children

Background: Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves immobilization and repeat radiographs in 10 to 14 days. When repeat radiographs are normal but a scaphoid fracture is still clinically suspected, the optimal management in children is unknown. This study retrospectively assessed the management and outcomes of pediatric patients diagnosed with clinical scaphoid fractures. Methods: A retrospective study was performed of all patients over a 2-year period treated for a clinical scaphoid fracture at a tertiary pediatric center. Patients were included if they had clinical signs of a scaphoid fracture and 2 negative x-rays 7 to 14 days apart postinjury. Results: Ninety-one patients with a mean age of 13.2 years (range: 7.8-17.7) were included. Sixteen patients (17.6%) underwent computed tomography (CT) or magnetic resonance imaging (MRI) at a mean time of 10.2 weeks postinjury. Five patients (5.5%) were diagnosed with a scaphoid fracture by x-ray or CT at an average of 4.5 weeks postinjury (range: 3-6). Six patients were diagnosed with other wrist fractures at a mean time postinjury of 3.1 (range: 3-6.5) weeks. Out of 195 total radiographs, the surgeon and radiologist disagreed on 59 (30.2%) images. No patients underwent surgery. Conclusions: Management of clinical scaphoid fractures at our institution was relatively uniform: nearly all patients were immobilized and less than 20% received advanced imaging. Our findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and lack of advanced imaging, providing an avenue for future prospective studies.

Diagnosis of Suspected Scaphoid Fractures

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Suspected scaphoid fractures are a diagnostic and therapeutic challenge despite the advances in knowledge regarding these injuries and imaging techniques. The risks and restrictions of routine immobilization as well as the restriction of activities in a young and active population must be weighed against the risks of nonunion that are associated with a missed fracture.

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The prevalence of true fractures among suspected fractures is low. This greatly reduces the statistical probability that a positive diagnostic test will correspond with a true fracture, reducing the positive predictive value of an investigation.

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There is no consensus reference standard for a true fracture; therefore, alternative statistical methods for calculating sensitivity, specificity, and positive and negative predictive values are required.

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Clinical prediction rules that incorporate a set of demographic and clinical factors may allow stratification of secondary imaging, which, in turn, could increase the pretest probability of a scaphoid fracture and improve the diagnostic performance of the sophisticated radiographic investigations that are available.

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Machine-learning-derived probability calculators may augment risk stratification and can improve through retraining, although these theoretical benefits need further prospective evaluation.

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Convolutional neural networks (CNNs) are a form of artificial intelligence that have demonstrated great promise in the recognition of scaphoid fractures on radiographs. However, in the more challenging diagnostic scenario of a suspected or so-called "clinical" scaphoid fracture, CNNs have not yet proven superior to a diagnosis that has been made by an experienced surgeon.

LT Ligament Tears

Lunotriquetral (LT) ligament injuries are uncommon, however, should be considered in patients with ulnar-sided wrist pain. LT injuries are often associated with other injuries but can occur in isolation. Understanding the anatomy and pathomechanics will aid in making the diagnosis. Similar to other injuries, a thorough history and focused physical examination is critical. Radiographs may show normal findings; however, advanced imaging can support the diagnosis. Arthroscopy remains the gold standard for diagnosis. Most patients do well with conservative management; however, injury acuity and severity will direct surgical management. Anatomy, pathophysiology, and treatment options are discussed.

[Sport wrist ligament injuries]

The wrist is a joint structure particularly exposed during sports practice to trauma or overuse. Ligament trauma is particularly common as well as tendinopathies. A rigorous clinical examination is the key to the management of the sports patient. The additional examinations will confirm the diagnosis and help guide the management. The purpose of the treatment in the athlete will depend on his sports activity, his age, the sport, the time between the accident and the sports season.

The Hook Test Is More Accurate Than the Trampoline Test to Detect Foveal Tears of the Triangular Fibrocartilage Complex of the Wrist

PURPOSE

To evaluate the accuracy of the trampoline and hook tests, used in the arthroscopic assessment of triangular fibrocartilage complex (TFCC) tears compared with arthroscopic direct visualization of the radiocarpal joint (RCJ) and of the distal radial ulnar joint (DRUJ).

METHODS

In total, 135 patients (97 male, 38 female, mean age 43.5 years) were divided into 2 groups: (1) 80 patients with chronic ulnar-sided wrist pain and positive fovea sign and (2) 55 patients with other complaints. TFCC was assessed by RCJ and DRUJ arthroscopy and by the trampoline and hook tests to detect rupture of distal and proximal components of the TFCC. Accuracy, specificity, sensitivity, and likelihood ratio of the 2 diagnostic methods were measured and compared, using RCJ and DRUJ arthroscopy as reference.

RESULTS

The trampoline and the hook tests showed an overall accuracy of 70.37% and 86.67%, respectively. The accuracy of the trampoline test was similar for distal (69%), proximal (66%), and complete (73%) TFCC tears. The hook test was more accurate when evaluating proximal (97%) and complete (98%) tears, rather than distal lesions (75%). Sensitivity for the trampoline and hook tests was 75.00% and 0.00% (P < .001) for distal tears and 78.85% and 100.00% (P < .001) and 58.33% and 100.00% (P < .001) for complete or isolated proximal tears, respectively. Specificity for the trampoline and hook tests was 67.27% and 96.36% (P < .001) respectively.

CONCLUSIONS

The trampoline and hook tests can assure accurate diagnosis of peripheral TFCC tear. The hook test shows greater specificity and sensitivity to recognize foveal TFCC tears. Values of positive likelihood ratio suggest a greater probability to detect foveal laceration of peripheral TFCC for the hook test than for the trampoline test. These findings suggest that DRUJ arthroscopy is not necessary to confirm foveal incompetence of the TFCC, if the hook test is positive.

LEVEL OF EVIDENCE

Level II, retrospective diagnostic trial.

Arthroscopic treatment of chronic wrist pain after distal radius fractures

We report the arthroscopic and clinical findings of patients with chronic wrist pain following distal radius fracture (DRF) who underwent diagnostic arthroscopy and arthroscopically-assisted tailored treatment.We retrospectively analyzed the records of 15 patients with chronic wrist pain following DRF, who underwent diagnostic arthroscopy and arthroscopically-assisted tailored treatment from 2010 to 2017. The average patient age was 44 years (range, 20-68 years), average time from injury to treatment 21 ± 23.46 months (range, 3-96 months) and average follow up period 20.13 ± 8.71 months (range, 12-39 months). The functional outcome was evaluated by comparing the preoperative and final follow up values of the range of motion, grip strength, pinch strength, visual analogue scale for pain and quick disabilities of the arm, shoulder and hand score.Based on the arthroscopic findings, synovitis was found in all cases and the pathologic intra-articular lesions were classified into 4 patterns. Triangular fibrocartilage complex rupture was seen in 14 cases, intercarpal and radiocarpal ligament ruptures in 9 cases, ulnar impaction syndrome in 5 cases, and cartilage lesion in 9 cases. In terms of surgical treatment, 15 patients underwent arthroscopic synovectomy, 7 foveal or capsular repair of TFCC, 7 intercarpal Kirschner wires fixation or intercarpal thermal shrinkage, 1 intercarpal ligament reconstruction, 2 Sauve-Kapandji procedure, and 2 unlar shortening osteotomy. Postoperatively, the average range of motion, grip strength, and pinch strength increased significantly. From preoperative to final follow up values, the average visual analogue scale and quick disabilities of the arm score decreased from 5.93 ± 1.58 (range, 3-8) to 1.33 ± 1.29 (range, 0-3) (P = .001) and from 49.38 ± 19.09 to 12.63 ± 7.63 (P = .001), respectively.Diagnostic arthroscopy and arthroscopically-assisted tailored treatment of chronic wrist pain following DRF can provide an accurate diagnosis, significant pain relief, and functional improvement.

Treatment of distal radius fractures with palmar plates and locking screws. Comparisson of two different types of plate

Various plating systems are available to fix distal radius fractures, each with a specific design. The purpose of this study was to compare radiological outcome and complications of the Variable Angle LCP Plate 2.4-mm (DePuy Synthes) with the VariAx volar locking plate (Stryker). One hundred patients (103 wrists) operated on for a distal radius fracture were retrospectively reviewed with a mean follow-up of 3.5 years. Seventy-three wrists were treated with a DePuy Synthes plate and 30 with a VariAx plate. The overall complication rate was 32%. Nineteen cases underwent revision surgery, 18 had malunion and 3 complex regional pain syndrome. Complicaton rate was 43% with DePuy Synthes plates and 27% with Variax plates, but the difference was not significant.

Palmar-divergent dislocation of the scaphoid and lunate treated using percutaneous pinning and pin-in-plaster: A case report

Acute lunate and perilunate dislocations are not commonly observed injuries. In particular, palmar-divergent dislocation is a very rare injury with only a few cases reported in the literature. In this report, we describe the case of a 37-year-old patient with palmar-divergent dislocation of the scaphoid and lunate and discuss the mechanism of this type of injury. We also report a potential treatment for this pattern of palmar-divergent dislocation. The scapholunate and scaphocapitate joints were stabilized with K-wires and a modified pin-in-plaster fixation for 5 weeks after successful closed reduction. At the 1-year follow-up, magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate. However, radiographs showed mild dorsal intercalated segment instability deformity. The patient experienced no intermittent wrist pain or limitation in motion, with only 15% loss in grip strength. The Mayo wrist score was 90/100, and the patient resumed work as a craftsman. The carpal height ratio at the 4-year follow-up was 1.51 and 1.52 for the left and right wrists, respectively. In conclusion, we recommend this treatment method due to its benefits of being relatively simple, easy to perform, and having a relatively short operation time. Essentially, a good outcome was achieved using this method, including full range of motion and freedom from pain.

[Retrospective study of Galeazzi fractures in adults hospitalized in the Department of Orthopaedics at the Habib Bourguiba University Hospital, Sfax, Tunisia: about 45 cases]

Galeazzi fracture is defined as the association of radius fracture and inferior radioulnar joint dislocation. Its diagnosis is often unrecognized initially. The purpose of our study is to determine the epidemioclinical features of Galeazzi fracture-dislocations in adults and to assess the functional and radiological outcomes of our case series. We conducted a retrospective descriptive study of 45 patients with Galeazzi fractures treated surgically whose data were collected in the Department of Orthopaedics at the Habib Bourguiba University Hospital, Sfax, Tunisia, over a period ranging from 2009 to 2018. We used Mestdagh score for the clinical evaluation of the results. The mean time between fracture and treatment initiation was 5.35 days. Fixation of the radius was performed using screwed plate in 39 cases and fixation of the radio-ulnar joint using a plug in 13 cases. The average time for union was 10.5 weeks. Outcomes were excellent in 35 patients, good in 3 patients, medium in 6 patients and adverse in a patient. We had 3 cases of sepsis at the level of the plug and two cases of malunions. Galeazzi fracture-dislocation is an under diagnosed disorder in some cases. Dynamic intraoperative examination after solid fixation of the radius can allow for good functional results.

Arthroscopic assisted treatment of distal radius fractures and concomitant injuries

Wrist arthroscopy is mainly used to assist fracture reduction and fixation and to diagnose and treat concomitant injuries mainly to the scapholunate (SL), lunotriquetral (LT) ligament and the triangular fibrocartilage complex (TFCC). Arthroscopy is beneficial in improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures (DRFs). Yet, the literature that the functional outcome correlates with the use of arthroscopy, is limited. Non-surgical treatment and immobilization is recommended for Geissler grade I-III Sl-ligament injuries, while open reduction, ligament suture and/or K-wire pinning is mandatory for complete ligament tears according to Geissler grade IV. This manuscript describes the current literature and gives insight into the authors' opinions and practice.

Wrist Arthroscopy Scope for the Best and Plan for the Worst

Wrist arthroscopy is a useful surgical technique that has been steadily gaining popularity since the 1980s. In addition to being a valuable diagnostic tool, wrist arthroscopy can be used for an expanding array of therapeutic interventions and is an attractive, minimally invasive treatment modality for patients. However, wrist arthroscopy is not without its complications, and a detailed understanding of the relevant anatomy, instrumentation, and methodology is critical for success.

Wrist pain: a systematic review of prevalence and risk factors- what is the role of occupation and activity?

OBJECTIVE

To evaluate the prevalence and risk factors of wrist pain.

METHODS

Systematic review.

DATA SOURCES

The MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO databases were searched from database inception to 9th March 2018. Specific criteria were used to define inclusion and exclusion. Data was extracted independently by a pair of reviewers.

RESULTS

In total 32 cross sectional studies were identified for inclusion (1 with a longitudinal component). The median prevalence of wrist pain in the general population and non-manual workers within the short term (within last week) was 6 and 4.2% within the medium term (> 1 week and within a year). The median prevalence of wrist pain in physically demanding occupations and sports people was 10% within the short term and 24% within the medium term. Non-modifiable factors associated with wrist pain included increased age (1 study in adults and 3 studies in children/adolescents) and female sex (2 studies). Modifiable risk factors included high job physical strain (2 studies), high job psychological strain (1 study), abnormal physeal morphology in children/adolescents (2 studies), high frequency impact tool use (1 study) and effort reward imbalance (1 study).

CONCLUSIONS

Wrist pain is highly prevalent in groups who partake in physically demanding activities from day to day such as manual labourers and sportspeople. It is less prevalent in the general population and non-manual workers, although there is a relative lack of research in the general population.

TRIAL REGISTRATION

The review protocol was registered with PROSPERO under the registration number CRD42018090834.

LEVEL OF EVIDENCE

1 (Prognostic study).

Entrapment of the extensor pollicis longus tendon in a pediatric Smith fracture: A case report

RATIONALE

Most pediatric distal radius fractures are effectively treated nonoperatively; however, operative intervention is indicated in patients with open and highly unstable fractures, in those with concomitant neurovascular injuries and in patients whom soft tissue interposition between fracture fragments precludes anatomical reduction. Notably, soft tissue interposition between fracture fragments is diagnostically challenging. Surgeons must be mindful of this rare complication for early detection and prompt treatment.

PATIENT CONCERNS

A 14-year-old boy presented to the emergency department with left wrist pain after falling from a bicycle. Plain radiography and computed tomography revealed a displaced Smith fracture, which was irreducible by closed reduction, necessitating open reduction and volar plate fixation. The patient reported inability to extend his thumb at his 6-week postoperative follow-up visit.

DIAGNOSIS

Ultrasonography showed extensor pollicis longus (EPL) tendon entrapment near the fracture site.

INTERVENTIONS

A second operation was performed 10 weeks after the first surgery, and intraoperative exploration revealed EPL tendon entrapment. The EPL tendon was torn to shreds; therefore, extensor indicis proprius tendon transfer was performed for EPL tendon reconstruction.

OUTCOMES

The patient's thumb motion was completely restored after the second operation.

LESSENS

EPL tendon entrapment in a pediatric Smith fracture is rare. Signs of EPL tendon entrapment include inability to perform active thumb extension, dorsal wrist pain radiating along the course of the EPL tendon, which is exacerbated by thumb flexion, a tenodesis effect elicited on thumb examination, and difficulty in anatomical fracture reduction. Surgical exploration of the EPL tendon is warranted in patients presenting with any of these signs following attempted reduction of a Smith fracture.

First-stage scapholunate fusion for the treatment of a chronic lunate dislocation: A case report

RATIONALE

Lunate dislocation is a rare injury to the wrist caused by high-energy trauma, and poor prognosis is often associated with missed initial diagnosis. To date, there is no consensus regarding an effective treatment plan for such cases.

PATIENT CONCERNS

Here, we describe the case of a 36-year-old man who presented with lunate dislocation following a delay in diagnosis of over 7 weeks, and further illuminate its diagnosis and treatment.

DIAGNOSIS

The diagnosis of chronic lunate dislocation was rendered.

INTERVENTIONS

The patient was treated using reduction via the dorsal approach brachial plexus anesthesia. After the reduction, a headless compression screw fixation was performed for first-stage scapholunate fusion, and Kirschner wire fixation of the lunate-triquetrum-hamate was used to stabilize the distal and proximal carpal rows.

OUTCOMES

The patient was followed up for 1 year and showed wrist function recovered well; radiographic examination showed no lunate dislocation and successful scapholunate bony fusion. A satisfactory outcome was achieved.

LESSONS

The case study presented here provide evidence that performing an effective first-stage scapholunate fusion is recommended to achieve better therapeutic outcomes for a chronic lunate dislocation. Furthermore, this approach led to a good long-term clinical outcome in our case.

[Intersection syndrome in a tetraplegic hand cyclist]

Wrist tendinopathies are common overuse injuries in athletes and often associated with activities such as rowing, riding or racket sports. Correctly diagnosing the various tendinopathies is essential for management of cases refractory to initial treatment. Easily mistaken for de Quervain's tenosynovitis, the intersection syndrome may be effectively managed by simple taping negating the need for corticosteroid injection and tendon release surgery. We present an unusual case report of intersection syndrome in a tetraplegic hand cyclist following a 24-hour endurance race.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

BACKGROUND

Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking.

QUESTIONS/PURPOSES

(1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures?

METHODS

Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made.

RESULTS

Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138).

CONCLUSIONS

Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Arthroscopic Management of Triangular Fibrocartilage Complex Peripheral Injury

Patients suffering from ulnar-sided wrist pain after trauma may develop tenderness, clicking, a positive fovea sign, or instability of the distal radioulnar joint. If the pain is persistent, conservative treatment does not help, and the patient agrees to surgery, arthroscopy may reveal a triangular fibrocartilage complex (TFCC) injury with capsular detachment, foveal avulsion, or a combination thereof. Capsular reattachment is possible using an arthroscopic assisted technique. The reattachment can be performed with an inside-out, outside-in, or all-inside technique, providing good to excellent results, which tend to persist over time, in 60% to 90% of cases.

A rare case of an acute lunate dislocation in a child

Acute lunate dislocations are unusual and devastating injuries to the wrist. They are very rare in adult wrist injuries but extremely rare in children. Only six cases of perilunate dislocations in children have been reported in the literature, and in addition to this, only a single case of a lunate dislocation in a child has been reported.Here, we report a case of a 10-year-old boy who presented with an acute lunate dislocation of the wrist, following trauma, a second of its kind.

[Fixed angle carbon fiber reinforced polymer composite plate for treatment of distal radius fractures : Pilot study on clinical applications]

BACKGROUND

The clinical implementation of a new carbon-fiber-reinforced polyetheretherketon (PEEK) plate for distal radius fractures might offer advantageous properties over the conventional metallic devices. This includes similar elastic modulus to cortical bone, radiolucency, low artifacts on MRI scans and the lack of metal allergies.

OBJECTIVE

The aim of this study was to evaluate the clinical results at 6-week and 12-month follow-up using either a new fixed angle (monoaxial) PEEK plate system or a fixed angle (polyaxial) titanium plate.

METHODES

We included 26 patients (mean age 59.3) with displaced fractures of the distal radius (all AO types). Radiological and functional outcomes were measured prospectively at a 6-week and 12 month follow-up.

RESULTS

We documented no cases of hardware breakage or significant loss of the surgically achieved fracture reduction with the usage oft the new PEEK device. Operating time was 101.0 min using PEEK versus 109.3 min in titanium plates, recorded times were including preparation, draping, and postoperative processing (ns, p 0.156). At the 6-week follow up the PEEK plate showed a trend for better range of motion and functional results (DASH-score, Mayo-wrist score, VAS) with no statistical significance. Results of 12 month follow up with PEEK showed comparable results with corresponding studies examining titanium plate after this period.

CONCLUSION

First experience with PEEK plate osteosynthesis demonstrate quick clinical implementation with good clinical outcome and the advantage of excellent postoperative radiological assessment. At early follow-up PEEK even showed a trend for improved functional results.

The ulnar side of the wrist: Clinically relevant anatomy and biomechanics

BACKGROUND

In the hectic environment of a hand therapy clinic, the opportunity to carefully consider the relationships among pathology, pathomechanics, surgical repair techniques, tissue healing, postoperative management, and rehabilitation program development and progression is limited. Clinicians often default to seeking a protocol, a recipe to follow.

OBJECTIVES

Using the ulnar side of the wrist as an example, relevant anatomy and biomechanics are directly related to several commonly seen pathologies, including fractures, ligament injuries, and instability.

CONCLUSION

Armed with knowledge of anatomy, biomechanics, and surgical procedures, the need for a protocol disappears. Each patient can be individually managed according to his or her unique set of variables and responses to injury, repair, healing, and recovery of function.

Preferences for the emergency department or alternatives for older people in aged care: a discrete choice experiment

Background

To estimate the effect of factors that influence decisions to transfer residents of aged care facilities to an emergency department (ED) for acute medical emergencies.

Design and Participants

A discrete choice experiment with residents (N = 149), the relatives of residents (N = 137) and staff members (N = 128) of aged care facilities.

Setting

Aged care facilities in three Australian states.

Outcome Measures

Using random parameter logit models, parameter estimates and odds ratios were estimated, and resultant utility functions for ED and alternate care were constructed.

Results

All attributes (including waiting time, complication rates, symptom relief and time spent alone) significantly influence choice for accessing acute care. There is a strong overall preference for ED care (odds ratio 1.73, 95% confidence interval 1.57–1.92), but this varies by clinical scenario, being the strongest for pneumonia and weakest for wrist fracture. Relatives of residents were less tolerant of reductions in care quality than staff members or residents themselves.

Conclusion

Underlying preference for ED transfer of aged care facility residents in acute medical emergencies is strong and independent of commonly used quality of care measures.

Assessment of pisotriquetral misalignment with magnetic resonance imaging: Is it associated with trauma?

OBJECTIVE

Our objective was to determine whether there is an association between pisotriquetral (PT) malalignment and acute distal radius fracture by using magnetic resonance imaging (MRI).

METHODS

We evaluated 138 patients who underwent 3-T MRI of the wrists. Group A comprised 85 patients with acute distal radius fracture, and group B comprised 53 patients without trauma. PT interval and angle and pisiform excursion were measured on oblique axial and sagittal multiplanar reformats. The presence of abnormalities in the flexor carpi ulnaris tendon (FCU), pisometacarpal ligament (PML), and pisohamate ligament (PHL) were evaluated.

RESULTS

PT interval was wider in group A on both the axial and sagittal planes (P < 0.001). Axial PT angle opened more radially in group A (P < 0.001), and the absolute value of the sagittal PT angle in group A was wider than that in group B (P = 0.006). Abnormalities in FCU, PML, and PHL were more frequently observed in group A (P < 0.001). On multiple linear regression, distal radius fracture remained significant after adjusting for the patient's age and PT osteoarthritis.

CONCLUSIONS

Acute distal radius fracture can affect normal alignment of the PT joint, resulting in associated injuries to the primary PT joint stabilizers.

KEY POINTS

• Acute distal radius fracture is associated with malalignment of PT joints. • Acute distal radius fracture is associated with abnormalities of PT stabilizers. • PT joint alignment can be evaluated with MRI with 3D sequences. • Wrist MRI is useful for evaluating primary PT stabilizer injuries.

[Examination of the wrist and hand]

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

Traction Radiography for the Diagnosis of Scapholunate Ligament Tears

The diagnosis of scapholunate ligament injury by traction radiography was investigated within a consecutive study. The right wrists of 25 healthy volunteers and 22 wrists with arthroscopically proven complete scapholunate ligament tears were examined. Traction radiography was performed under fluoroscopy with a force of 5 kg applied to the thumb. In the normal wrists, this led to selective widening of the scapholunate joint space whereas the lunotriquetral distance remained unchanged. In 25 healthy right wrists, the median scapholunate distance measured 2.1 (range 1.3–2.6) mm on resting radiographs and 2.2 (range 1.7–3.5) mm on the stress radiographs. For the 22 wrists with complete scapholunate ligament tears, the median scapholunate distance was increased from 2.0 (range 1.0–3.0) mm to 3.8 (range 3.0–5.5) mm by traction (median difference of 1.8 (range 1.0–3.0) mm). In conclusion, a scapholunate distance of 3.0 mm or more in unloaded wrists or widening of the scapholunate interval by 1.0 mm or more under thumb traction should both be considered as pathological findings. We recommend traction radiography as a simple and valuable diagnostic procedure for suspected scapholunate ligament injury.

Combined Palmer Type 1A and 1B Traumatic Lesions of the Triangular Fibrocartilage Complex A New Category

We present a series of eight patients who underwent wrist arthroscopy for presumed solitary tears of the triangular fibrocartilage (TFC) and were, instead, found to have combined 1A (central tear) and 1B (ulnar avulsion) tears. The Palmer Classification does not currently categorize this combined pattern. All but one patient had a traumatic injury. Each subject had preoperative radiographs and MRI scans. TFC tears were evident on all MRI scans, though only one was suggestive of a combined tear pat - tern. Surgical management included arthroscopic central tear debridement and ulnar peripheral repair. Average follow-up was 22 months. Grip strength in the affected hand improved from 16% deficit as compared to the unaffected side, to 3.5% deficit postoperatively (p = 0.003), and visual analog scores (VAS) decreased from an average of 7.1/10 preoperatively to 2.3/10 postoperatively (p < 0.001). There was no statistically significant change in wrist range of motion (ROM), however. Arthroscopic debridement of the central perforation (1A lesion) with concomitant repair of the ulnar detachment (1B lesion) resulted in functional and symptomatic improvement. This combined 1A/1B TFC injury is not reliably diagnosed preoperatively and should be considered a new subset in the Palmer classification, as this will raise awareness of its presence and assist in preoperative planning of such lesions.

1-Year outcome of concomitant intracarpal lesions in patients with dislocated distal radial fractures: a systematic assessment of 78 distal radial fractures

INTRODUCTION

Ligamentous lesions are concomitant to dislocated distal radius fractures in a high percentage. The purpose of this study was to evaluate the relevance of intracarpal lesions.

METHODS

Seventy eight of an original cohort of 104 distal radius fractures (74%) were studied over a follow-up period of one year after surgery with complete data (X-rays, CT, MRI, follow-up X-rays and questionnaire).

RESULTS

Most of our radius fractures (AO 23 type: A 39, B 9, C 30) present additional lesions: 97%. One-year evaluation showed an average Castaing score of 4.5 ± 2.5 points, means a "good" result of a scale of 0-27. Fifty five of seventy eight had an "excellent" or "good" result (<6 points). No patient had more than 12 points ("fair").

CONCLUSIONS

The dislocated distal radial fracture implies severe and complex injury to the whole wrist, mostly concerning intracarpal concomitant lesions (MRI). Surgical therapy of dislocated radius fractures followed by 6 weeks relief through thermoplastic splint seems to be sufficient to achieve good 1-year results. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance.

Diagnosis of occult scaphoid fractures: a randomized, controlled trial comparing bone scans to radiographs for diagnosis

BACKGROUND

Many patients with suspected scaphoid fractures but negative radiographs are immobilized for ≥ 2 weeks and are eventually found to have no fracture. Bone scans are reportedly 99% sensitive for these injuries if done ≥ 72 hours postinjury.

OBJECTIVE

The purpose of this study was to determine if early bone scans would allow for shorter cast immobilization periods in patients with suspected scaphoid fractures.

METHODS

Twenty-seven patients with clinically suspected scaphoid fractures and negative radiographs were randomized to early diagnosis (bone scan within 3-5 days; n  =  12) or traditional diagnosis (radiographs 10-14 days postinjury; n  =  15). The primary outcome was number of days immobilized in a cast.

RESULTS

The mean number of days immobilized was 26 in the traditional group and 29 in the bone scan group. Overall, 6 patients had scaphoid fractures (2 in the traditional diagnosis group and 4 in the bone scan group; p > 0.05), and 8 had other types of fractures. These other types of fractures included four distal radius fractures, two triquetral fractures, one trapezoid fracture, and one hamate fracture. There was no significant difference in the number of other types of fractures between groups. The Kaplan-Meier survival analysis using the log-rank test revealed that there was no statistically significant difference between days immobilized between the radiograph and bone scan groups (p  =  0.38).

CONCLUSIONS

The current study suggests that the use of bone scans to help diagnose occult scaphoid fractures does not reduce the number of days immobilized and that the differential diagnosis of occult scaphoid fractures should remain broad because other injuries are common.

[High-Resolution MR Examination of the Scapholunate Ligament using a Microscopic Coil: Comparison with Direct MR Arthrography and Arthroscopy Findings]

PURPOSE OF THE STUDY Scapholunate dissociation is a clinically most frequently diagnosed form of carpal instability. The aim of this study was to compare high resolution MRI using a microscopic coil with direct MRI arthrography in patients with suspected scapholunate ligament lesions and compare the results with arthroscopy findings and Geissler's arthroscopy classification. MATERIAL AND METHODS A prospective study was carried out in 47 patients (average age, 30.7 years) with clinical symptoms of wrist instability from 2013 to 2014. The patients were examined with the MR device Philips Achieva 1.5T using a microscopic coil and subsequently by direct MR arthrography. The results of examination were evaluated independently by two groups of physicians using a modified arthroscopic classification. The results were verified arthroscopically. For evaluation, an adjusted Geissler's classification was used. The study was approved by the Multicentre Ethics Committee of the Faculty of Medicine in Brno and informed consent was obtained from each patient. RESULTS A total of The MRI examination was evaluated and included in the study in 44 patients (three were excluded for the presence of motion artefacts). Only 20 patients underwent arthroscopy. Examination with a microscopic coil correctly classified 14 of them; an accuracy of 70 % (95 % CI: 45.7 % - 88.1 %) and p = 0.021. Direct MR arthrography correctly classified 16 of 20 injured ligaments, i.e., an accuracy of 80 % (95 % CI: 56.3 % - 94.3 %) and p = 0.002. DISCUSSION Currently, the diagnosis of pathological changes in the wrist is made by routine MRI especially when there is the possibility of using sequences with high spatial resolution. Even though we achieved poorer results by native examination using these techniques, when they were compared with the results of direct MR arthrography, they were still better than those reported in the recent literature. CONCLUSION The optimal method for an examination algorithm of scapholunate ligament lesions is direct MR arthrography. In our study correct findings of direct MR arthrography using Geissler's classification were shown in 80 % of the patients. Key words: scapholunate ligament, scapholunate ligament lesion, direct MR arthrography, microscopic coil, Geissler's classification.

Perilunate Dislocations and Fracture Dislocations

Perilunate dislocations and fracture dislocations are the result of an axial load with hyperextension and ulnar deviation of the wrist, combined with intercarpal supination. Prompt treatment injuries is essential. There is a high rate of missed or incorrect diagnosis. In the past, closed management was recommended. These methods proved to be ineffective. Current research and data show better results with anatomic restoration of carpal alignment and direct ligament repair. A combined dorsal and volar approach is preferred. This article reviews the current literature and discusses the surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament.