Carpal Ligament Injuries with Acute Scaphoid Fractures – A Combined Wrist Injury

Arthroscopic surgery for scaphoid nonunion: a 10-year systematic literature review

The purpose of the study was to investigate whether arthroscopic treatment of carpal scaphoid nonunions by osteosynthesis with bone grafting represents a successful surgical technique. This systematic literature review, conducted following the PRISMA guidelines, explores the past 10 years of clinical studies concerning the arthroscopic treatment of scaphoid nonunions. The most relevant keywords were used to search the databases, and the Downs and Black 27-item checklist has been used as quality assessment tool. Twelve papers that meet the premised eligibility criteria have been identified. These studies demonstrate the efficacy of this surgical solution, achieving a postoperative union rate of 96% in the average time of 13.5 weeks. Regardless of the method of synthesis and the origin of the graft used, excellent results were obtained. Patients who underwent this procedure reported a pain reduction of almost 80% compared to the preoperative level, improvement in grip strength close to 40%, and recovery in wrist function during daily activities. Arthroscopy has numerous advantages compared to the open approach. These are technically recognized by the surgeon and by the patient. Some disadvantages include a longer intraoperative time and considerable significant technical difficulty. Arthroscopic treatment of scaphoid nonunion by osteosynthesis with bone graft achieves a 96% union rate of the treated scaphoid with satisfying clinical results.

Artificial intelligence for automated detection and measurements of carpal instability signs on conventional radiographs

OBJECTIVES

To develop and validate an artificial intelligence (AI) system for measuring and detecting signs of carpal instability on conventional radiographs.

MATERIALS AND METHODS

Two case-control datasets of hand and wrist radiographs were retrospectively acquired at three hospitals (hospitals A, B, and C). Dataset 1 (2178 radiographs from 1993 patients, hospitals A and B, 2018-2019) was used for developing an AI system for measuring scapholunate (SL) joint distances, SL and capitolunate (CL) angles, and carpal arc interruptions. Dataset 2 (481 radiographs from 217 patients, hospital C, 2017-2021) was used for testing, and with a subsample (174 radiographs from 87 patients), an observer study was conducted to compare its performance to five clinicians. Evaluation metrics included mean absolute error (MAE), sensitivity, and specificity.

RESULTS

Dataset 2 included 258 SL distances, 189 SL angles, 191 CL angles, and 217 carpal arc labels obtained from 217 patients (mean age, 51 years ± 23 [standard deviation]; 133 women). The MAE in measuring SL distances, SL angles, and CL angles was respectively 0.65 mm (95%CI: 0.59, 0.72), 7.9 degrees (95%CI: 7.0, 8.9), and 5.9 degrees (95%CI: 5.2, 6.6). The sensitivity and specificity for detecting arc interruptions were 83% (95%CI: 74, 91) and 64% (95%CI: 56, 71). The measurements were largely comparable to those of the clinicians, while arc interruption detections were more accurate than those of most clinicians.

CONCLUSION

This study demonstrates that a newly developed automated AI system accurately measures and detects signs of carpal instability on conventional radiographs.

CLINICAL RELEVANCE STATEMENT

This system has the potential to improve detections of carpal arc interruptions and could be a promising tool for supporting clinicians in detecting carpal instability.

The role of arthroscopy in the diagnosis of concomitant soft tissue injuries in scaphoid fractures and the effect of concomitant soft tissue injuries and fracture comminution on outcomes: A case-control study

Objectives

This study aims to evaluate the role of arthroscopy in the diagnosis of concomitant injuries, to investigate the relationship between comminution and concomitant injuries, and to analyze the effect of concomitant injuries on functional outcomes in acute and subacute scaphoid fracture.

Patients and methods

Between January 2011 and September 2018. A total of 32 acute scaphoid fracture patients (29 males, 3 females; mean age: 30±12 years; range, 18 to 65 years) were retrospectively analyzed. None of them had an obvious ligament injury in the radiological assessment. Functional outcomes were compared between concomitant and non-concomitant injuries and between comminuted and non-comminuted injuries. The percentage of range of motion (ROM), grip, and pinch strength were recorded according to the contralateral extremity to detect the restriction rate. The Mayo Wrist Score (MWS), the Turkish version of the Quick Disability of the Arm, Shoulder, and Hand (Q-DASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to evaluate the functional results. Subjective pain was assessed using the Visual Analog Scale (VAS). The relationship between concomitant injuries and comminution was investigated.

Results

There were 13 patients with comminuted fractures. Concomitant injuries were diagnosed in 17 patients. The presence of concomitant injuries was higher in comminuted fractures than in non-comminuted fractures. There was no significant difference between the groups in ROMs. The final follow-up Q-DASH, PRWE, MWS, and VAS scores and the pinch strength of non-comminuted fractures were found to be statistically better than those of comminuted fractures. There were statistically worse Q-DASH, PRWE, MWS, and VAS scores in patients with concomitant injuries.

Conclusion

Arthroscopic scaphoid fracture surgery allows the diagnosis and treatment of concomitant lesions. The functional outcomes of concomitant lesions and comminuted fractures seem to be worse than those of others, while the ROM is comparable.

Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders

The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.

Carpal kinematic changes after scaphoid nonunion: an in vivo study with four-dimensional CT imaging

The aim was to evaluate if motion between the scaphoid bone fragments is related to the position of the fracture line and if a scaphoid nonunion results in the uncoupling of the proximal and distal carpal row during wrist motion. The influence of dorsal intercalated segment instability on interfragmentary motion was also analysed. In this study, 12 patients were included with unilateral scaphoid nonunion. Four-dimensional computerized tomography was used to analyse flexion-extension and radioulnar deviation motion of both wrists. We found that an increased instability of the scaphoid fragments is associated with the presence of dorsal intercalated segment instability and is not dependent on the position of the fracture line relative to the scaphoid apex. Additionally, a scaphoid nonunion results in an uncoupling of the carpal rows.

Role of Wrist Arthroscopy in the Management of Established Scaphoid Nonunion

Introduction Patients with scaphoid nonunion and wrist pain may have a wide spectrum of potential concomitant pathologies that may be diagnosed and potentially managed arthroscopically. The aim of this study is to assess the usefulness of wrist arthroscopy in the assessment and treatment of scaphoid nonunion and any associated injuries. Materials and Methods We retrospectively reviewed 34 consecutive patients with established scaphoid nonunion between January 2006 and December 2012 who had undergone arthroscopic assessment. The average age of the patients was 40 years (range: 25-64), and all the patients had arthroscopic assessment of the wrist joint before definitive surgery. The patients with associated intra-articular problems, which could be addressed along with the scaphoid open reduction internal fixation (ORIF) and bone grafting (BG), had definite procedure in the same sitting. However, if the patients had major intra-articular pathology that needed change in the management plan, they had staged definitive treatment after discussing with them about the arthroscopic findings. Results Arthroscopic assessment of the 34 joints showed varying degrees of arthritis affecting radioscaphoid joint (41%) followed by injuries to the triangular fibrocartilage complex (TFCC) (35%), lunotriquetral ligament (LTL) tears (32%), and scapholunate ligament (SLL) injuries (26%). Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (62%), TFCC debridement (32%), loose body removal (17%), and DRUJ stabilization and TFCC repair (3%). Twenty-nine patients had arthroscopy and definitive procedure in the same sitting, and the remaining had staged or delayed definitive treatment. Conclusion Our study highlights the usefulness of wrist arthroscopy in assessment and management of the scaphoid nonunion and associated pathologies. Besides in 18% of our patients, the initial management plan changed after arthroscopy. Level of Evidence This is a Level IV study.

Scaphoid fractures with scapholunate ligament involvement: Instability or ligamentous laxity? Role of arthroscopy and pinning

PURPOSE

Percutaneous fixation of scaphoid fractures often does not allow the evaluation of potential ligamentous lesions. Arthroscopy is an useful tool in the management of scaphoid fractures to visualize potentially associated lesions. With arthroscopic assistance, we often found scapholunate ligament lesions. Our study's aim was to evaluate the role of arthroscopy in the treatment of scaphoid fracture and in particular if the alteration found was a real lesion causing instability or just a paraphysiologic laxity. Furthermore, we evaluated whether the scapholunate joint pinning alters the outcome.

METHODS

We performed a retrospective study on 39 patients (33 males and 6 females), with an average age at trauma of 31.2 years (range 15-67), who underwent surgery for scaphoid fractures between 2010 and 2016 in our Center of Hand Surgery. Patients were divided into four groups based on surgical technique and finding of scapholunate lesions.

RESULTS

Differences between the four groups analyzed, both in terms of clinical scores and ROM, were not statistically significant. This corroborates the hypothesis that all four treatments are equivalent.

CONCLUSIONS

Based on our experience and the literature available, we believe the systematic use of arthroscopy to be useful in patients needing surgical treatment for scaphoid fractures. This is because arthroscopy allows the control of the fracture reduction, screw protrusion evaluation and ligamentous lesions assessment. In cases of partial scapholunate ligament alteration in which no sign of acute lesion is present (hemorrhage and clear rupture), pinning is not necessary since it might just be a paraphysiologic laxity.

LEVEL OF EVIDENCE

IV.

Análisis artroscópico de las lesiones asociadas a las fracturas de escafoides carpiano

Objetivo: La artroscopia de muñeca ha permitido el diagnóstico y el tratamiento de las fracturas a nivel de la muñeca, así como de las lesiones asociadas a estas.

Existen lesiones asociadas a las fracturas de escafoides que pueden condicionar el éxito del tratamiento y llevarnos a resultados poco satisfactorios y a un retraso en la recuperación funcional.

Material y método: Se estudiaron y cuantificaron las lesiones asociadas encontradas en 17 casos con fractura aguda de cintura de escafoides que fueron tratadas mediante reducción y colocación artroscópica de un tornillo canulado de escafoides. Se analizaron los resultados del tratamiento con la escala de muñeca de la Clínica Mayo (Mayo Wrist Score) y la consolidación con radiografías simples.

Resultados: Se diagnosticaron lesiones asociadas de tejidos blandos y/o condrales/osteocondrales en 14 casos, lo que supone un 82% de los casos. Las lesiones más frecuentemente encontradas fueron las lesiones del ligamento escafolunar (53%) en diferentes grados, las lesiones del fibrocartílago triangular (35,3%) y las lesiones osteocondrales (35,3%). Los resultados funcionales (Mayo Wrist Score) fueron excelentes o buenos en 13 de los pacientes (76,5%), en 3 casos (17,5%) los resultados fueron regulares y solo un caso (5,9%) tuvo un pobre resultado.

Conclusiones: La artroscopia ofrece una valoración completa de la muñneca y consigue diagnosticar lesiones asociadas a las fracturas de cuello de escafoides que pueden condicionar el resultado final del tratamiento.

The Role of Dynamic (4D) CT in the Detection of Scapholunate Ligament Injury

Background Scapholunate (SL) interosseus ligament injuries detected at an early stage could allow the surgeon to prevent progression through the spectrum of injury that leads to instability, and eventually osteoarthritis. We contend that early instability following injury can be detected by visualizing the relative motions and distances between the involved carpal bones (scaphoid and lunate) during wrist movement in vivo. The purpose of this study is to demonstrate the utility of dynamic CT (i.e., 4DCT) in diagnosing SL interosseus ligament injuries in two patients with clinical suspicion of SL interosseus ligament injury during flexion-extension (FE), radial-ulnar (RU) deviation, and dart thrower's (DT) motions. Case Description 4DCT images obtained from two individual cases were analyzed to assess the proximity between the scaphoid and lunate during wrist motion using standard image processing techniques. Proximity maps representing the distances between the scaphoid and lunate bones during each phase of wrist motion were determined. These maps provide insight into the severity of diastasis (large separation) and location of diastasis at the SL joint. The patients' proximity maps indicated dorsal diastasis and subtle uniform diastasis. Literature Review Complex musculoskeletal abnormalities, such as wrist joint instabilities, elude diagnosis during 2D fluoroscopy due to the 3D geometry of the anatomy and the inherent 3D nature of the bony kinematics. Even the most recent advances with MR arthrography lack good correlation with wrist arthroscopy. Wrist arthroscopy remains the gold standard for diagnosis to assess for intercarpal laxity. However, arthroscopy is an invasive procedure subjecting patients to the risk of infection, nerve injury, pain, and stiffness. Clinical Relevance 4DCT allows noninvasive characterization of where ligament injuries likely occur; this may allow for a more selective surgical treatment directed at the specific location of the tear.

The Effect of Debridement of Coexisting Partial Ligament Injuries on Outcomes Following Arthroscopic Osteosynthesis for Minimally Displaced Scaphoid Nonunions

PURPOSE

Partial intercarpal ligament injuries can coexist with scaphoid nonunions. However, whether these injuries should be debrided simultaneously when scaphoid nonunions are treated is unclear. The purpose of this study was to compare union rates and clinical outcomes after arthroscopic management of scaphoid nonunions, in which coexisting partial ligament injuries were, or were not, simultaneously debrided.

METHODS

This retrospective study included 46 patients with scaphoid nonunions and coexisting partial intercarpal ligament injuries who underwent arthroscopy-guided bone grafting and fixation (K-wires or headless screws) between March 2008 and May 2014 with a minimum follow-up of 1 year. None of the cases had necrosis of the proximal fragment (determined by contrast-enhanced magnetic resonance imaging), severe deformities, or advanced arthritis. The partial intercarpal ligament injuries were either simultaneously debrided (25 patients; group D) or not debrided (21 patients; group ND). Visual analog scale pain scores, grip strength, flexion-extension arc of the wrist, Mayo Wrist Scores, and Disabilities of Arm, Shoulder, and Hand scores were used to compare clinical outcomes between the 2 groups.

RESULTS

The nonunions united in 93% (43 of 46) of the patients. There were no differences between the 2 groups with regard to patient demographics, preoperative outcome measures, location of scaphoid nonunion, and degree of ligament injury. The overall union rate was similar between group D (92%; 23 of 25) and group ND (95%; 20 of 21). At a median follow-up of 24 months for group D and group ND, the visual analog scale pain score, grip strength, Mayo Wrist Scores, and Disabilities of the Arm, Shoulder, and Hand scores were significantly improved in both groups, compared with preoperative scores. Flexion-extension arc showed no change in both groups compared with preoperative angles. All of the follow-up measurements were similar in the 2 groups.

CONCLUSIONS

In patients who underwent arthroscopic bone grafting and fixation of scaphoid nonunions, simultaneous debridement of incidentally found partial intercarpal ligament injuries did not result in a better union rate or clinical outcomes than not debriding the partial ligament injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Is Arthroscopic Bone Graft and Fixation for Scaphoid Nonunions Effective?

BACKGROUND

Arthroscopic management of scaphoid nonunions has been advanced as a less invasive technique that allows evaluation of associated intrinsic and extrinsic ligamentous injuries; however, few studies have documented the effectiveness of arthroscopic treatment of scaphoid nonunions and which intraarticular pathologies coexist with scaphoid nonunions.

QUESTIONS/PURPOSES

(1) What are the outcomes of arthroscopic management of scaphoid nonunions as assessed by the proportion of patients achieving osseous union, visual analog scale (VAS) pain score, grip strength, range of motion, Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder and Hand (DASH) score? (2) What complications are associated with arthroscopic scaphoid nonunion management? (3) What forms of intraarticular pathology are associated with scaphoid nonunions?

METHODS

Between 2008 and 2012, we treated 80 patients surgically for scaphoid nonunions. Of those, 45 (56%) had arthroscopic management. During that time, our general indications for using an arthroscopic approach over an open approach were symptomatic scaphoid nonunions without necrosis of the proximal fragment, severe deformities, or arthritis. Of the patients treated arthroscopically, 33 (73%) were available for followup at least 2 years later. There were five distal third, 19 middle third, and nine proximal third fractures. The mean followup was 33 months (range, 24-60 months). Union was determined by CT taken at 8 to 10 weeks after operation with bridging trabecula at nonunion site. VAS pain scores, grip strength, active flexion-extension angle, MWS, and DASH scores were obtained preoperatively and at each followup visit. The coexisting intraarticular pathologies and complications were also recorded.

RESULTS

Thirty-two (97%) scaphoid nonunions healed successfully. At the last followup, the mean VAS pain score decreased (preoperative: mean 4.5 [SD 1.8], postoperative: mean 0.6 [SD 0.8], mean difference: 3.9 [95% confidence interval {CI}, 3.2-4.6], p < 0.001) and the mean active flexion-extension angle increased (preoperative: mean 100° [SD 26], postoperative: mean 109° [SD 16], mean difference: 9° [95% CI, 2-16], p = 0.017). The mean grip strength increased (preoperative: mean 35 kg of force [SD 8], postoperative: mean 50 kg of force [SD 10], mean difference: 15 kg of force [95% CI, 11-19], p < 0.001). The mean MWS increased (preoperative: mean 56 [SD 23], postoperative: mean 89 [SD 8], mean difference: 33 [95% CI, 26-41], p < 0.001) and the mean DASH score decreased (preoperative: mean 25 [SD 18], postoperative: mean 4 [SD 3], mean difference: 21 [95% CI, 15-28], p < 0.001). There were no operation-related complications and no progression of arthritis at the last followup. Seventeen patients had coexisting intraarticular pathology, including nine triangular fibrocartilage complex tears (seven traumatic and two degenerative), 17 intrinsic ligament tears (nine scapholunate interosseous ligament tears and eight lunotriquetral interosseous ligament tears), and five mild radioscaphoid degenerative changes.

CONCLUSIONS

Arthroscopic management of scaphoid nonunions without severe deformities or arthritis was effective in this small series. Although intraarticular pathologies such as triangular fibrocartilage complex tears and intrinsic ligament injuries commonly coexisted with scaphoid nonunions, patients generally achieved good results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Arthroscopic Management of Scaphoid Nonunions

The difficulty in healing scaphoid nonunions is challenged further by the dynamic, unstable nature of the fracture-fragment interface. Recently, several investigators have introduced a minimally invasive technique for scaphoid nonunion repair, which has the advantages of minimal morbidity and accurate articular reduction, resulting in less postoperative stiffness and increased functional outcomes. However, failure to recognize the critical steps during minimally invasive surgery can result in incorrect treatment or limit any chances for successful bone repair. We reviewed the selected literature pertinent to arthroscopic techniques in the treatment of scaphoid nonunions. Furthermore, we presented a new arthroscopic approach that can be used in place of traditional formal open exposures in challenging cases of nonunion.

Use of arthroscopy for the treatment of scaphoid fractures

Arthroscopy allows the surgeon to use smaller incisions and still have predictable outcomes in the treatment of scaphoid fractures. Similar to large joint arthroscopy, the ability to visualize the fracture site allows one to not only fine tune the reduction and to assess the vascularity of the fracture fragments but to evaluate and treat any associated soft tissue injuries that may affect the end result. Specialized equipment and a basic knowledge of wrist arthroscopy however are required.

Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography

PURPOSE

This study compares the diagnostic performance of multidetector CT arthrography (CTA), conventional 3-T MR and MR arthrography (MRA) in detecting intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist.

MATERIALS AND METHODS

Ten cadaveric wrists of five male subjects with an average age 49.6years (range 26-59years) were evaluated using CTA, conventional 3-T MR and MRA. We assessed the presence of scapholunate ligament (SLL), lunotriquetral ligament (LTL), and TFCC tears using a combination of conventional arthrography and arthroscopy as a gold standard. All images were evaluated in consensus by two musculoskeletal radiologists with sensitivity, specificity, and accuracy being calculated.

RESULTS

Sensitivities/specificity/accuracy of CTA, conventional MRI, and MRA were 100%/100%/100%, 66%/86%/80%, 100%/86%/90% for the detection of SLL tear, 100%/80%/90%, 60%/80%/70%, 100%/80%/90% for the detection of LTL tear, and 100%/100%/100%, 100%/86%/90%, 100%/100%/100% for the detection of TFCC tear. Overall CTA had the highest sensitivity, specificity, and accuracy among the three investigations while MRA performed better than conventional MR. CTA also had the highest sensitivity, specificity, and accuracy for identifying which component of the SLL and LTL was torn. Membranous tears of both SLL and LTL were better visualized than dorsal or volar tears on all three imaging modalities.

CONCLUSION

Both CT and MR arthrography have a very high degree of accuracy for diagnosing tears of the SLL, LTL, and TFCC with both being more accurate than conventional MR imaging.

Lesions of the scapholunate ligament associated with minimally displaced or non-displaced fractures of the scaphoid waist. Which incidence?

INTRODUCTION

It was commonly considered that a non-displaced or minimally displaced isolated scaphoid fracture was mechanically incompatible with a lesion of the scapholunate ligament (SL). However, some authors who described such an association have recently challenged this statement. The aim of this prospective study was to determine, after screw fixation and using arthroscopy, the existence and incidence of lesions of the SL as associated with acute non-displaced or minimally displaced isolated fractures of the scaphoid.

METHODS

Between December 2009 and January 2011, the study included all patients presenting with an acute non-displaced or minimally displaced isolated fracture of the scaphoid waist, eligible for percutaneous screw fixation and accepting the procedure after informed consent. The surgical protocol included a first retrograde arthroscopically controlled percutaneous screwing of the scaphoid, followed by a second arthroscopy seeking only lesions of the SL. Geissler's classification was used for the classification of SL lesions.

RESULTS

Eighteen patients were included in the study. The mean was 29 years. In 17 cases, the scaphoid fracture was due to a low-energy fall, and in 1 case, to a road accident. No SL lesion was evidenced by the diagnostic arthroscopy.

CONCLUSION

Unlike some published reports, we did not observe any SL lesion associated with non-displaced or minimally displaced isolated fractures of the scaphoid. Nevertheless, despite such results and based on the literature, we recommend arthroscopy with percutaneous scaphoid screw fixation, with the triple advantage of providing reduction control, adequate screw fixation verification, and diagnosis of potential associated ligament lesions.

Current innovations in wrist arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.

Immunohistochemical composition of the human lunotriquetral interosseous ligament

PURPOSE

The human lunotriquetral ligament (LTL) is a functionally important intrinsic hand ligament, which is assumedly subjected to insertion angle changes at the entheses during movement. To clarify whether the current model of the ligament's mechanical environment is reflected in its structural composition, we determined the regional distribution of extracellular matrix-related antigens.

METHODS

The extracellular matrix was immunohistochemically investigated in 12 LTLs from both wrists of 6 human donors (Mean age: 60 y).

RESULTS

The dorsal, proximal, and volar portions of the ligament immunolabeled for type I, III collagen and versican. Both entheses labeled strongly for type II collagen, aggrecan, and link protein and were distinctly cartilaginous. The ligament midsubstance was positive for collagen II in 30%, for aggrecan in 40%, and for keratocan and lumican in 100% of specimens. In contrast, keratocan and lumican were absent from the fibrocartilaginous entheses and the articular cartilage. Ligament insertion at a carpal bone occurs either directly through fibrocartilage or indirectly through a bilayered configuration of fibrocartilage and hyaline-like cartilage. The hyaline-like cartilage is continuous with the neighboring articular cartilage.

CONCLUSIONS

The LTL has an extracellular matrix comparable with that of ligaments experiencing a combination of tensile and shear/compressive load at the attachment sites. All regions of the LTL exhibit fibrocartilaginous entheses; purely fibrous attachment sites are rare. The ligament midsubstance shows a more fibrous phenotype than the entheses and expresses keratocan and lumican, which previously have not been recorded in any human hand ligament.

Percutaneous screw and axial Kirschner wire fixation for acute transscaphoid perilunate fracture dislocation

PURPOSE

In this retrospective, nonrandomized study, we evaluated the clinical outcomes of percutaneous screw and K-wire fixation in the treatment of acute transscaphoid perilunate fracture dislocation.

METHODS

Between 2004 and 2009, we studied 24 patients treated by fixation with a 2.0-mm (0.078-in) axial K-wire across the capitolunate joint and a percutaneous screw (3.0-mm AO cannulated screws were used in 13 patients, and Herbert-Whipple screws were used in 11 patients) within 7 days of the injury. We performed a comparative radiographic assessment of the scapholunate angle, radiolunate angle, capitolunate angle, revised carpal height ratio, and gap between the scapholunate joint between the injured wrist and the contralateral, healthy wrist. Clinical outcomes were evaluated on the basis of range of motion, pain, functional status, and Mayo scores.

RESULTS

Twenty-three patients (96%) achieved scaphoid union at a mean union time of 18 weeks (range, 14-28 wk). Radiographic assessments revealed no statistically significant difference between the injured wrist and the contralateral, healthy wrist. However, significant differences were noted in the mean range of motion during flexion and forearm supination between the injured wrist and contralateral healthy wrist. The mean wrist function results were encouraging, and the average Mayo score was 83.

CONCLUSIONS

A percutaneous procedure involving screw fixation for the scaphoid fracture and an axial K-wire fixation for intercarpal dislocation is a successful treatment for acute transscaphoid perilunate fracture dislocation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Isolated scaphoid fracture with anterosuperior dislocation of the proximal fragment

Isolated fracture of the scaphoid with an associated anterosuperior dislocation of the proximal fragment is an extremely rare injury. We present two cases where open reduction and internal fixation through a palmar and dorsal approach was performed. No instances of non-union, necrosis of the proximal fragment of the scaphoid or scapholunate dissociation were noted during a mean follow-up period of 18 months. Clinical results (active motion, power grip, DASH) following such injury and intervention are presented. The aetiology of this rare injury is discussed.

Intercarpal ligamentous laxity in cadaveric wrists

The purposes of this study were to define the range of laxity of the interosseous ligaments in cadaveric wrists and to determine whether this correlated with age, the morphology of the lunate, the scapholunate (SL) gap or the SL angle. We evaluated 83 fresh-frozen cadaveric wrists and recorded the SL gap and SL angle. Standard arthroscopy of the wrist was then performed and the grades of laxity of the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) and the morphology of the lunate were recorded. Arthroscopic evaluation of the SLIL revealed four (5%) grade I specimens, 28 (34%) grade II, 40 (48%) grade III and 11 (13%) grade IV. Evaluation of the LTIL showed 17 (20%) grade I specimens, 40 (48%) grade II, 28 (30%) grade III and one (1%) grade IV. On both bivariate and multivariate analysis, the grade of both the SLIL and LTIL increased with age, but decreased with female gender. The grades of SLIL or LTIL did not correlate with the morphology of the lunate, the SL gap or the SL angle. The physiological range of laxity at the SL and lunotriquetral joints is wider than originally described. The intercarpal ligaments demonstrate an age-related progression of laxity of the SL and lunotriquetral joints. There is no correlation between the grades of laxity of the SLIL or LTIL and the morphology of the lunate, the SL gap or the SL grade. Based on our results, we believe that the Geissler classification has a role in describing intercarpal laxity, but if used alone it cannot adequately diagnose pathological instability. We suggest a modified classification with a mechanism that may distinguish physiological laxity from pathological instability.

The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures

PURPOSE

To determine the incidence of associated intrinsic and extrinsic ligament injuries in patients with a nondisplaced or displaced scaphoid waist fracture.

METHODS

During a 3-year period, a study of all scaphoid fractures was performed at our institution. Diagnosis was confirmed by plain radiographs, computed tomography, and magnetic resonance imaging. A 3-part anatomic classification was used to categorize the scaphoid fractures. The study population comprised 40 patients with 41 scaphoid waist fractures who had wrist arthroscopy for treatment and evaluation of the scaphoid fracture and associated carpal injuries.

RESULTS

We observed fresh intrinsic ligament injuries in 34 of 41 wrists. In 29 cases, the scapholunate ligament was injured, with complete rupture occurring in 10 wrists. The lunotriquetral ligament was injured in 8 wrists, and the triangular fibrocartilage complex was injured in 11 wrists. Statistically, the number of intrinsic ligament injuries did not differ between nondisplaced and displaced scaphoid fractures (p> .30).

CONCLUSIONS

In this study of acute scaphoid waist fractures, the overall incidence of associated ligament injuries was surprisingly high, at 34 of 41 wrists. Complete scapholunate ligament rupture was found in 10 of 41 wrists. This incidence is higher than previously reported and emphasizes the need for careful assessment of the intrinsic and extrinsic ligaments, particularly the scapholunate ligament, before deciding on treatment.

Minimally invasive management of trans-scaphoid perilunate fracture-dislocations

This retrospective study evaluates the functional and radiological results of a series of acute trans-scaphoid dorsal perilunate fracture-dislocations treated operatively by minimally invasive technique. Twenty-one patients had surgery performed by one of three surgeons between 1994 and 2006, and all cases involved: (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; and (3) closed reduction and multiple Kirschner wire stabilisation of the carpal dissociation. Seventeen males and four females with an average age of 29 years were evaluated. Ninety five per cent of internally fixed scaphoid healed at a mean time of 16 weeks. Radiographic alignment of the carpus was satisfactory in 17 cases. The average Mayo wrist score was 80 with three excellent and two poor results. There was one patient with asymptomatic DISI deformity. Two patients had radiographic evidence of mid-carpal arthritis. One patient with a scaphoid nonunion required surgical repair with bone grafting. The results of this study suggest that a minimally invasive technique for treating acute trans-scaphoid perilunate fracture-dislocations can be considered as an alternative to open approaches.

Percutaneous screw fixation for scaphoid fracture: a comparison between the dorsal and the volar approaches

PURPOSE

To evaluate the position of the screws and find the difference of clinical and radiologic outcome between the volar approach and the dorsal approach groups in percutaneous screw fixation for acute scaphoid fractures.

METHODS

Forty-one consecutive patients with an acute scaphoid fracture, who had percutaneous fixation via either the volar approach or the dorsal approach, were evaluated at an average of 30 months after the surgery. The volar approach was used in 19 patients and the dorsal approach in 22 patients. By using a computerized digital image program, angles between the Herbert screw with respect to the long axis of the scaphoid and the fracture line were measured with plain radiographs in the posteroanterior, lateral, and the 45 degrees semipronated oblique views.

RESULTS

The screws showed no significant difference between the 2 groups in posteroanterior and lateral views; however, screws in the dorsal approach group were observed to be placed more parallel to the long axis of the scaphoid in the semipronated oblique view. The screws in the dorsal approach group were positioned more perpendicular to the fracture lines of the scaphoid compared with those of the volar approach group for all 3 different radiographic views. There was no statistically significant difference between the 2 treatment groups regarding fracture healing. According to the Mayo wrist score system, excellent results were recorded in 18 patients in the dorsal approach group and 15 patients in the volar approach group.

CONCLUSIONS

This study suggests that screws are placed more parallel to the long axis of the scaphoid and perpendicular to the fracture line via the dorsal approach; however, there was no significant difference with regard to functional outcome and bone union.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Wrist arthroscopy: current concepts

Wrist arthroscopy has steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The number of conditions that are amenable to arthroscopic treatment continues to grow. A detailed knowledge of the topographical and intracarpal anatomy, however, is essential to minimize complications and maximize the benefits. Although wrist arthroscopy can identify an anatomic abnormality, it cannot be used to differentiate between an asymptomatic degenerative condition versus a pathologic lesion that is the cause of wrist pain. A thorough wrist examination is still integral to any arthroscopic assessment. This article focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.

Incidence of ligamentous and other injuries associated with scaphoid fractures during arthroscopically assisted reduction and percutaneous fixation

PURPOSE

The purpose of this study was to describe chondral/osteochondral and ligamentous injuries associated with scaphoid fractures treated with arthroscopically assisted reduction and percutaneous fixation.

METHODS

The study consisted of 8 patients with stable scaphoid fractures and 16 with unstable scaphoid fractures. The mean age was 32 +/- 14 years (range, 17 to 75 years). The arthroscopic findings were recorded, including intrinsic and extrinsic ligamentous injuries as well as osteochondral injuries. Percutaneous screw fixation through a dorsal approach was performed. In all patients with associated soft-tissue injuries, a short-arm thumb spica cast was used for a 3- to 6-week period. Follow-up included clinical evaluation with the Mayo Modified Wrist Score and plain radiographs. The mean follow-up time was 27 +/- 16 months, with a minimum of 1 year. The mean healing time was 7 +/- 4 weeks (range, 6 to 24 weeks).

RESULTS

Associated soft-tissue and/or chondral/osteochondral injuries were diagnosed arthroscopically in 15 of 24 cases in this series. The result was scored as good or excellent in 23 patients and poor in 1. Complications included 1 case with partial necrosis of the proximal scaphoid pole and 2 patients with loss of wrist flexion and grip strength that improved after hardware removal.

CONCLUSIONS

In this series, 15 of 24 patients with acute scaphoid fractures presented with associated ligamentous and/or chondral/osteochondral injuries.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Wrist arthroscopy

Arthroscopic surgery, a minimally invasive, outpatient procedure, is a valuable tool in the diagnosis and treatment of most disorders of the wrist. It offers direct visualization of the structures of the joint anatomy and existing disease processes while causing minimal damage to surrounding soft tissue. Other benefits of arthroscopic treatment compared to traditional open procedures include less postoperative pain, shorter recovery times, and fewer surgical complications.

Complications in dorsal percutaneous cannulated screw fixation of nondisplaced scaphoid waist fractures

PURPOSE

With advances in tools and techniques, percutaneous screw fixation of nondisplaced fractures of the scaphoid waist has gained increasing popularity in recent years as an alternative to prolonged cast immobilization or open reduction and internal fixation. Many reports cite low complication rates, including no complications in some series. The purpose of this study was to evaluate the complications encountered with dorsal percutaneous cannulated screw fixation of nondisplaced scaphoid waist fractures.

METHODS

A retrospective chart review was performed for 24 patients who had surgery performed by a single surgeon over a 5-year period. All cases involved dorsal percutaneous cannulated screw fixation of nondisplaced (<1 mm) fractures of the scaphoid waist. Complications were rated a priori as major or minor based on modifications of established criteria.

RESULTS

The overall complication rate was 29%; there were 21% (5/24) major complications and 8% (2/24) minor complications. Major complications consisted of 1 case of nonunion, 3 cases involving hardware problems, and 1 case of postoperative fracture of the proximal pole of the scaphoid. Minor complications included intraoperative equipment breakage-1 case involving a screw and 1 case involving a guide wire.

CONCLUSIONS

Complications in dorsal percutaneous cannulated screw fixation of scaphoid fractures may be more common than previously reported.