Imaging findings in ulnar-sided wrist impaction syndromes

Is ulnar shortening osteotomy effective for the treatment of ulnar styloid impaction syndrome compared to ulnar impaction syndrome?

PURPOSE

This study aimed at evaluating the outcomes of ulnar shortening osteotomy (USO) for the treatment of ulnar styloid impaction syndrome (USIS) and to compare them with those of USO for the treatment of ulnar impaction syndrome (UIS).

METHODS

We enrolled 144 patients who underwent USO between March 2015 and October 2021. The patients were divided into a UIS group (group I, n = 93) and a USIS group (group II, n = 51). Clinical and radiological parameters, including Disabilities of the Arm, Shoulder, and Hand (DASH) score, ulnar variance, ulnar styloid length, and ulnar styloid process index (USPI), were collected pre-operatively and one year post-operatively, and a comparative analysis was performed.

RESULTS

The DASH score showed significant improvement in both groups (p < .001 and p < .001), and there was no significant difference between the two groups one year after surgery (p = .143). The USPI was significantly different between the two groups (p < .001). The ulno-lunate and ulno-triquetrum distances showed significant increases in both groups, with significant differences between the two groups (p = .020, and p < .001, respectively). The incidence of post-operative arthritic changes in the distal radioulnar joint was significantly greater in the UIS group than that in the USIS group (21 vs 3, respectively; p = .017). No remarkable differences were observed in the post-operative evidence of chondromalacia at the last follow-up between the two groups.

CONCLUSION

The USO, which was performed as a treatment for USIS showed reliable outcomes compared to the USO for the treatment of UIS. Therefore, USO is a viable option for the treatment of USIS.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries

OBJECTIVES

The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique.

METHODS

Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists.

RESULTS

Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds.

CONCLUSIONS

Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC.

CLINICAL RELEVANCE STATEMENT

MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries.

KEY POINTS

• Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Pronated Grip View With Wrist Deviation: A Pilot Study on the Effect on Ulnocarpal Relationships

BACKGROUND

We hypothesize that different positions of the wrist in the coronal plane makes the carpus susceptible to ulnar impaction.

METHODS

We prospectively enrolled 10 adult volunteers and obtained fluoroscopic images of each wrist in 12 different positions using a standardized protocol. Distances from the ulna to the lunate (UL) and ulna to the triquetrum (UT) were digitally measured as was the portion of the lunate surface area that was uncovered (LUR) with wrist deviation.

RESULTS

A wrist position of Pronation, Neutral Deviation, and Grip (P-ND-G) significantly shortened the ulnocarpal distance when compared to a position of Neutral Rotation, Neutral Deviation, and No Grip (NR-ND-NG). Radial deviation during pronation and gripping (Pronated, Radial Deviation, Gripping [P-RD-G]) resulted in the lowest mean UL distance (1.2 mm). UT distance was minimized by a position of ulnar deviation during a pronated grip (Pronated, Ulnar Deviation, Gripping [P-UD-G]) (3.1 mm). The lunate becomes more uncovered with radial deviation.

CONCLUSION

Radial deviation minimizes the UL distance while ulnar deviation minimizes the UT distance during a wrist position of pronation and gripping. Further, there is more proximal lunate surface area uncoverage during all positions of radial deviation compared to ulnar deviation.

The effect of ulnar variance on the pisotriquetral joint

BACKGROUND

Pisotriquetral joint (PTJ) disorders are an important cause of ulnar-sided wrist pain but are often underrecognized. Ulnar variance (UV) has been associated with several wrist pathologies.

PURPOSE

To determine the effect of UV on PTJ in patients with trauma.

MATERIAL AND METHODS

A total of 143 patients (77 men, 66 women; mean age=41.64 ± 18.07 years) were included. Patients with fractures, severe and high-energy trauma, arthritic conditions, avascular necrosis, congenital deformity, bone and soft-tissue tumors, suboptimal image quality, and incorrect joint position were excluded. UV and the amount of PTJ subluxation were evaluated using coronal and sagittal computed tomography images.

RESULTS

PTJ subluxation was divided into five grades. A statistically significant difference was found between the presence of PTJ subluxation and sex (P = 0.045). PTJ subluxation was more common in men (46.8%) than in women (30.3%). There was no significant difference between the presence of PTJ subluxation and age (P = 0.758). The patients were also divided into three groups as positive, neutral, and negative UV. A statistically significant relationship was found between the UV and presence of PTJ subluxation (P = 0.01). PTJ subluxation was significantly less in the neutral (none=51.1%, present=48.9%; P < 0.05) and negative (none=77.8%, present=22.2%; P < 0.05) groups.

CONCLUSION

PTJ subluxation was found to be less among the groups with neutral and negative UV in our study population. PTJ subluxation is more common in men while there is no relationship with age. UV and gender may be risk factors for PTJ subluxation by affecting force dynamics at the wrist joint.

Clinical and Radiographic Evaluation of Ulnar-Sided Wrist Pain

PURPOSE OF REVIEW

Ulnar-sided wrist pain is a challenging diagnostic workup. A thorough and complete physical examination followed by appropriate radiographic studies can help the clinician diagnose and treat these conditions.

RECENT FINDINGS

Recent research has been focused on diagnostic modalities such as arthroscopy and high-resolution MRI. Ulnar-sided wrist pain is a challenging clinical workup that must be approached systematically with the aid of adjunctive diagnostic modalities.

Return to Usual Work Following an Ulnar Shortening Osteotomy: A Sample of 111 Patients

PURPOSE

The primary aim of this study was to analyze the median time until patients performed their usual work following an ulnar shortening osteotomy (USO). The secondary aim was to identify factors influencing the median time until return to their usual work.

METHODS

We used a retrospective cohort of patients with ongoing data collection from our institution in the Netherlands. Patients with paid employment who underwent USO were invited to complete a return-to-work questionnaire at 6 weeks, 3 months, 6 months, and 12 months after surgery. The probability of and median time until return to usual work were assessed using an inverted Kaplan-Meier analysis. Factors influencing the return to usual work were evaluated using multivariable Cox proportional hazard regression.

RESULTS

In total, 111 patients who underwent USO were included, with a mean age of 46 years. The probability of returning to usual work in the first year was 92%, and the median time was 12 weeks. The type of work was independently associated with a return to work, with median times of 8, 12, and 14 weeks for light, moderate, and heavy physical work, respectively. We did not find differences in return to usual work based on age, sex, duration of complaints until surgery, treatment side, smoking status, the preoperative Patient-Rated Wrist Evaluation score, or whether the osteotomy was performed freehand or with an external cutting device.

CONCLUSIONS

Half of the patients that underwent USO fully performed their usual work by 12 weeks following surgery. We found that 92% of the patients performed their usual work within 1 year after surgery. We found a large variation in the time until a return to work based on the type of work. Surgeons can use this data to inform patients on the rehabilitation phase after USO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Long-term outcomes after ulna shortening osteotomy: a mean follow-up of six years

Aims

The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome.

Methods

Overall, 89 patients treated between July 2011 and November 2017 who had previously taken part in a routine outcome evaluation up to 12 months postoperatively were sent an additional questionnaire in February 2021. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) total score. Secondary outcomes included patient satisfaction with treatment results, complications, and subsequent treatment for ulnar-sided wrist pain. Linear mixed models were used to compare preoperative, 12 months, and late follow-up (ranging from four to nine years) PRWHE scores.

Results

Long-term outcomes were available in 66 patients (74%) after a mean follow-up of six years (SD 1). The mean PRWHE total score improved from 63 before surgery to 19 at late follow-up (difference in means (Δ) 44; 95% confidence interval (CI) 39 to 50; p = <0.001). Between 12 months and late follow-up, the PRWHE total score also improved (Δ 12; 95% CI 6 to 18; p = < 0.001). At late follow-up, 14/66 of patients (21%) reported a PRWHE total score of zero, whereas this was 3/51 patients (6%) at 12 months (p = 0.039). In all, 58/66 patients (88%) would undergo the same treatment again under similar circumstances. Subsequent treatment (total n = 66; surgical n = 57) for complications or recurrent symptoms were performed in 50/66 patients (76%). The most prevalent type of reoperation was hardware removal in 42/66 (64%), and nonunion occurred in 8/66 (12%).

Conclusion

Ulna shortening osteotomy improves patient-reported pain and function that seems to sustain at late follow-up. While satisfaction levels are generally high, reoperations such as hardware removal are common.

Cite this article: Bone Jt Open 2022;3(5):375–382.

Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist

Background

In wrist arthrograms, aberrant contrast material is frequently seen extending into the soft tissue adjacent to the ulnar styloid process. Since the prestyloid recess can mimic contrast leakage in CT arthrography, this study aims to provide a detailed analysis of its morphologic variability, while investigating whether actual ulnar-sided leakage is associated with injuries of the triangular fibrocartilage complex (TFCC).

Methods

Eighty-six patients with positive wrist trauma history underwent multi-compartment CT arthrography (40 women, median age 44.5 years). Studies were reviewed by two board-certified radiologists, who documented the morphology of the prestyloid recess regarding size, opening type, shape and position, as well as the presence or absence of ulnar-sided contrast leakage. Correlations between leakage and the presence of TFCC injuries were assessed using the mean square contingency coefficient (r_ɸ).

Results

The most common configuration of the prestyloid recess included a narrow opening (73.26%; width 2.26 ± 1.43 mm), saccular shape (66.28%), and palmar position compared to the styloid process (55.81%). Its mean length and anterior–posterior diameter were 6.89 ± 2.36 and 5.05 ± 1.97 mm, respectively. Ulnar-sided contrast leakage was reported in 29 patients (33.72%) with a mean extent of 12.30 ± 5.31 mm. Leakage occurred more often in patients with ulnar-sided TFCC injuries (r_ɸ = 0.480; p < 0.001), whereas no association was found for lesions of the central articular disc (r_ɸ = 0.172; p = 0.111).

Conclusions

Since ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist.

Outcomes of ulna shortening osteotomy: a cohort analysis of 106 patients

Background

Ulna shortening osteotomy (USO) for ulnar impaction syndrome (UIS) aims to improve pain and function by unloading the ulnar carpus. Previous studies often lack validated patient-reported outcomes or have small sample sizes. The primary objective of this study was to investigate patient-reported pain and hand function at 12 months after USO for UIS. Secondary objectives were to investigate the active range of motion, grip strength, complications, and whether outcomes differed based on etiology.

Materials and methods

We report on 106 patients with UIS who received USO between 2012 and 2019. In 44 of these patients, USO was performed secondary to distal radius fracture. Pain and function were measured with the Patient Rated Wrist/Hand Evaluation (PRWHE) before surgery and at 3 and 12 months after surgery. Active range of motion and grip strength were measured before surgery and at 3 and 12 months after surgery. Complications were scored using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions (ICHAW) tool.

Results

The PRWHE total score improved from a mean of 64 (SD = 18) before surgery to 40 (22) at 3 months and 32 (23) at 12 months after surgery (P  < 0.001; effect size Cohen’s d = −1.4). There was no difference in the improvement in PRWHE total score (P = 0.99) based on etiology. Also, no clinically relevant changes in the active range of motion were measured. Independent of etiology, mean grip strength improved from 24 (11) before surgery to 30 (12) at 12 months (P  = 0.001). Sixty-four percent of patients experienced at least one complication, ranging from minor to severe. Of the 80 complications in total, 50 patients (47%) had complaints of hardware irritation, of which 34 (32%) had their hardware removed. Six patients (6%) needed refixation because of nonunion.

Conclusion

We found beneficial outcomes in patients with UIS that underwent USO, although there was a large variance in the outcome and a relatively high number of complications (which includes plate removals). Results of this study may be used in preoperative counseling and shared decision-making when considering USO.

Level of evidence

Therapeutic III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-021-00621-8.

Ulna shortening osteotomy for ulnar impaction syndrome: Impact of distal radioulnar joint morphology on clinical outcome

INTRODUCTION

Treatment of ulnar impaction syndrome (UIS) is based on ulnocarpal decompression, which may be achieved by ulna shortening osteotomy. The aim is to restore zero or negative ulnar variance. Tolat et al. described 3 distal radioulnar joint (DRUJ) morphologic types: vertical, oblique and reverse. Joint type has been thought to influence the clinical result of shortening, especially in the reverse type.

HYPOTHESIS

DRUJ type does not influence clinical results in ulna shortening osteotomy.

MATERIAL AND METHODS

Twenty-nine wrists were operated on in 27 patients: 13 female, 14 male; mean age at surgery, 43 years (range, 18-72 years). In 20 cases, UIS was idiopathic and in 7 post-traumatic. Mean preoperative ulnar variance was 3.6mm (range, 2-18mm). The osteotomy was fixed by screwed plate.

RESULTS

Twenty-five patients (27 wrists) were assessed at a mean 64 months (range, 18 months to 13 years). There were no cases of infection or hematoma. DRUJ was type 1 (vertical) in 6 cases (22%), type 2 (oblique) in 14 (52%) and type 3 (reverse) in 7 (26%). Mean postoperative pain score on VAS was 0.7/10 (range, 0-4); 9 wrists remained painful. Mean Quick-DASH was 16.9 (range, 0-48) and mean PRWE 21.9 (range, 16.9-59). Thirteen patients were very satisfied, 11 satisfied, 1 moderately satisfied, and 2 dissatisfied. Mean postoperative ulnar variance was -0.1mm (range, -4 to +8mm). Three wrists developed osteoarthritis, all following traumatic UIS. There were no significant correlations between DRUJ type and other clinical or radiological parameters.

DISCUSSION

Ulna shortening osteotomy has proven efficacy in UIS. The literature reports excellent or good results in 75% of cases. In the present study, 96% of patients considered themselves cured or improved by surgery, and none reported worsening. Ulna shortening osteotomy can be used in all 3 DRUJ types; DRUJ coronal morphology does not impact clinical result.

LEVEL OF EVIDENCE

IV-retrospective study.

Postoperative Imaging of Ulnar Wrist Pain

Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.

[Osseous variations in radiological diagnostics of the wrist]

CLINICAL/METHODICAL ISSUE

The carpal joint is one of the most complex joints in the body comprising multiple bones that allow flexibility while simultaneously providing stability. Variations in osseous structures that may be either cause or result of pathological changes may make radiological reporting challenging. Only the knowledge of important osseous variations allows a reliable assessment of carpal imaging studies.

STANDARD RADIOLOGICAL METHODS

The standard imaging technique for evaluation of osseous carpal structures is conventional radiography, which is followed by computed tomography (CT) and-under special circumstances-magnetic resonance imaging (MRI). Other imaging methods such as sonography or nuclear medicine studies do not play a significant role in clinical routine.

METHODICAL INNOVATIONS

Apart from continuous reduction in effective radiation dose, there have been no significant methodical improvements in the past decade regarding imaging of osseous carpal structures in clinical routine.

PRACTICAL RECOMMENDATIONS

As the initial diagnostic procedure, conventional radiography usually allows a safe and reliable diagnosis of osseous structures. Unclear or discrepant imaging findings between clinical and imaging assessment should initiate further imaging, preferably with CT. Only for certain questions or to reduce effective radiation dose in children MRI studies should be performed in clinical routine.

Osseous Pathology on Wrist Magnetic Resonance Imaging

Advanced imaging of the osseous structures of the wrist by magnetic resonance imaging (MRI) yields powerful information regarding marrow composition and overall bone structure. Various forms of pathology, both benign and malignant, have unique marrow signal abnormalities that can be easily detected by MRI given its high sensitivity to radiographically occult processes. In particular, osseous pathology can be seen in the setting of traumatic, degenerative, congenital, infectious, and neoplastic conditions. The acuity or chronicity of these conditions can often be determined by imaging to aid in appropriate therapy. A thorough understanding of the breadth of pathology and corresponding MRI appearances can allow the interpreting radiologist to formulate a concise and accurate assessment of an examination.

Importance of measurement methods and demographic characteristics in evaluating ulnar variance: A retrospective comparative study

OBJECTIVE

This study aimed to compare 2 methods of ulnar variance (UV) measurement (the perpendicular method and the circular method) and to determine whether UV changed based on the demographic characteristics (sex and age).

METHODS

UV was measured on bilateral wrist radiographs of 124 patients (62 men, 62 women; mean age=48.5 years; range=18-79 years) who had no history of trauma, congenital wrist anomaly, previous wrist surgery, and wrist osteoarthritis by a single radiologist with 4 years of experience. All measurements were made on standardized radiographic images using 2 methods: the perpendicular method and the circular method. All the patients were then divided into groups based on sex and age, and the study population was determined by selecting a similar number of patients for each sex and age group.

RESULTS

The mean UV of the right and left wrists was measured as 0.33 (range=-4.3 to 5.7) mm by the perpendicular method and as 0.034 (range=-5 to 5.7) mm by the circular method. A significant difference was determined between the 2 measurement methods (p<0.001). There was a statistically significant difference between sex and UV values in the left wrist measurements by both methods (p<0.05). A significant correlation was found between the UV and age in both right and left side measurements, indicating a statistically significant difference between the methods (p<0.001).

CONCLUSION

The results of our study demonstrated significant differences in the UV measurement between the 2 methods. Furthermore, UV measurement may change based on age and sex. These differences should be considered in the treatment planning of patients with wrist disorders.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome

Post-traumatic or constitutional ulnar impaction syndrome can be treated by shortening the ulna. This can be achieved by diaphyseal or metaphyseal osteotomy, or by arthroscopic epiphyseal resection. The objective of this study was to compare the results of the diaphyseal shortening osteotomy (USO) and arthroscopic wafer procedure (AWP) of the ulna in this indication. This was a retrospective case series of 33 patients operated for ulnar impaction syndrome by the same surgeon between 1997 and 2017. The diagnosis was made based on pain on the ulnar edge of the wrist with positive provocative tests. Radiographs were made and CT arthrography or MRI were used to confirm the diagnosis. Per-and post-operative assessments were functional (DASH and PRWE scores), clinical (pain, range of motion and grip strength) and radiographic. Diaphyseal ulnar shortening osteotomy (USO) was performed in 9 patients using a volar plate and a cutting guide. Twenty-four patients underwent an arthroscopic wafer procedure. Mean follow-up was 103 ± 8 months in the USO group versus 55 ± 4 months in the AWP group. There was no significant difference between groups in pain levels (1.2/10 in the USO group versus 0.9/10 in the AWP group, p = 0.88), grip strength (39 Kg in the USO group versus 34 Kg in the AWP group, p = 0.27) and PRWE score (5,8/100 in the USO group versus 11,2 in the AWP group, p = 0.34), and DASH score (25/100 in the USO group versus 28 in the AWP group, p = 0.63). The time away from work was long in the USO group than in the AWP group (7.86 months versus 3.75 months) (p = 0.002). Seven patients were reoperated in the USO group (5 plate removal, 1 nonunion and 1 delayed union) versus 3 in the AWP group (1 ECU stabilization, 1 ablation for painful ulnar styloid due to nonunion and 1 wrist denervation) (p = 0.0004). The study found no clinical differences between these two techniques except the return to work time. In our series, diaphyseal USO was associated with a greater number of reoperations than the AWP.

Surgical Repair of Acute TFCC Injury

Triangular fibrocartilage complex tears are a common source of ulnar-sided wrist pain and distal radioulnar joint instability. Symptoms recalcitrant to conservative management or injuries in high-demand athletes may indicate surgical management. Both open and arthroscopic techniques offer improvements in objective measures, patient-centered outcome scores, and return to work, but may be complicated by nerve irritation, persistent wrist instability, and pain. Recently developed knotless arthroscopic techniques are not well studied but may limit morbidity.

Magnetic resonance imaging of the wrist and hand

The anatomy of the wrist and hand is complex and contains numerous small structures. Magnetic resonance imaging (MRI) is often an ideal imaging modality in the assessment of various traumatic and pathologic conditions of this region, and it is frequently performed after initial radiographs. In this manuscript we describe the normal anatomy, imaging techniques, and MRI findings of various traumatic and pathologic conditions of the wrist and hand including occult fractures, osteonecrosis, ligamentous and tendon injuries, and entrapment neuropathies.

Evaluation of ulnar variance on wrist MR imaging: is it a reliable measure?

OBJECTIVE

To determine if ulnar variance can be evaluated by magnetic resonance (MR) imaging and if this measure can be used as a reliable indicator when correlated to the gold standard technique, conventional radiography (CR).

MATERIALS AND METHODS

From January to July 2018, the MR images of 64 participants, comprising 66 wrists (mean age 34.9 years; 33 females; 31 males), were obtained. Among those, 29 were referred for evaluation of the wrist for different medical reasons and 35 were asymptomatic volunteers from our radiology group. All subjects had a plain radiography of the wrist in a posteroanterior view with a mean interval between images of 1 day. Local ethics committee approved the study and written informed consent was obtained from all patients. Two musculoskeletal radiologists evaluated the images. Correlation coefficients and a linear regression model were used for statistical analyses.

RESULTS

Intra- and inter-observer analyses were performed for both diagnostic methods with results showing concordance (intra-observer: kappa score: MR 0.915/CR 0.931; p < 0.05; inter-observer: kappa score: MR 0.857/CR 0.931; p < 0.05). The intraclass correlations of MR and CR to evaluate agreement between the radiologists was slightly higher for radiologist #1 (0.771) than for radiologist #2 (0.659). A linear regression model showed good model fit indicating that MR does correlate with the ulnar variance as measured by CR (CR = 0.554 + 0.897 × MR, R² = 0.665).

CONCLUSION

Although CR is the gold standard method for the evaluation of ulnar variance, our study demonstrated that MR can be used as a reliable qualitative option.

Ulnar Shortening Osteotomy: Our Experience

Objective  The objective of the present study was to evaluate the clinical and radiographic results of our series regarding ulnar shortening osteotomy, as well as to briefly review the pathology, indications and surgical options of ulnocarpal conflict. Methods  We performed a retrospective analysis of consecutive patients who were treated with ulnar shortening osteotomy between January 2012 and June 2017 at our hospital. We clinically evaluated pain, articular range of motion, grip strength and functional outcomes using the quick-DASH questionnaire. We radiographically measured the pre- and postoperative ulnar variance and the shortening performed. Results  We identified eight operated patients, and it was possible to evaluate seven of them. Pain decreased in this population (visual analogue scale [VAS] score changed from 7 to 2.6, p  < 0.05), there was a decrease in quick-DASH (64 to 28, p  < 0.05) and we found a decrease in the articular amplitude ∼ 7° for flexion ( p  = 0.2), and of 5.5° for supination ( p  = 0.3), as well as decreasing grip strength to about 86% on the contralateral side ( p  = 0.07). The ulnar variance changed from a mean of + 5.5 mm to - 1.1 mm ( p  < 0.05). Two out of 8 patients (25%) presented plaque-related symptoms and one of them underwent a new intervention to extract the material. Conclusions  Ulnar shortening osteotomy is an effective surgical procedure both in the treatment of ulnocarpal conflict and in the discharge of the ulna. The results presented agreement with other results published in the literature, with good clinical and radiographic results.

Ulnar Abutment Syndrome in the Athlete

Ulnar abutment (ulnocarpal impaction) syndrome may be a source of ulnar-sided wrist pain in the athlete. This condition results from excessive load transfer across the triangular fibrocartilage complex and ulnocarpal joints with characteristic degenerative changes. It frequently occurs in patients with either static or dynamic ulnar positive variance. Treatment is tailored to the athlete and their sporting demands. Surgical treatment focuses on addressing ulnar variance to unload the ulnocarpal joint, with multiple surgical options, including the metaphyseal closing wedge osteotomy achieving this goal. This review focuses on the presentation, biomechanics, and treatment options for ulnar abutment syndrome in the athlete.

Imaging of ulnar-sided wrist pain

Ulnar-sided wrist pain is a complex entity to diagnose clinically and frequently requires imaging to help confirm or determine the diagnosis. This article reviews the imaging and the logical imaging pathway of the common causes of ulnar-sided wrist pain, and illustrates various pathologies. It also discusses appropriate imaging modalities for various conditions. The causes of ulnar-sided wrist pain are stratified according to the affected anatomical structures, such as bony, soft tissue or neurovascular aetiologies. This review provides a handy imaging framework for non-radiologist clinicians of the common conditions producing ulnar-sided wrist pain. A linked article (10.12968/hmed.2019.80.8.456) detailing the diagnosis of ulnar-sided wrist pain is included in this issue.

Diagnosis of ulnar-sided wrist pain: a pragmatic approach for the non-specialist

Ulnar-sided wrist pain is often unfairly labelled as the 'back pain' of the wrist. This reputation comes from the complexity of diagnosing problems related to this area of the wrist. This article summarizes the anatomy and biomechanics of the wrist and presents a logical approach to diagnosing the aetiology of the pain. The problems are categorised based on the anatomical structure from which the pain arises: either bony, soft tissue-related or arising from nerves or vascular structures. The article also outlines the relevant examination findings and the most appropriate investigation that would yield a diagnosis with any given presentation. A linked article detailing the imaging of ulnar-sided wrist pain is included in this issue (10.12968/hmed.2019.80.8.461).

Radiographic/MR Imaging Correlation of the Wrist

In this review article, the authors discuss the imaging features of the most common pathologic conditions of the wrist by putting the emphasis on radiographic and MR imaging correlations. A topographic approach based on the 3 functional columns of the wrist (radial, central, and ulnar) serves as a framework. The pathologic conditions are classified, based on the structures involved, as fractures, ligament injuries, arthropathies, bone abnormalities, and tendinopathies. The authors describe and evaluate classic radiographic signs and explain how they correlate with MR imaging. The advantages and limitations of each technique are thoroughly discussed as well as other imaging modalities.

Review article: the differential diagnosis of bone marrow edema on wrist MRI

There is a large variety of conditions that can result in 'bone marrow edema' or 'bone marrow lesions' (BML) in the wrist on magnetic resonance imaging (MRI). The combination of clinical history and the distribution of the BML can serve as a valuable clue to a specific diagnosis. This article illustrates the different patterns of BML in the wrist to serve as a useful guide when reviewing wrist MRI studies. Imaging artefacts will also be briefly covered.

Analysis of Radiographic Relationship between Distal Radius, Ulna, and Lunate

Background  Wrist anatomy variability is associated with differing susceptibility to pathology. For example, a flat radial inclination is associated with Kienbock's disease. Lunate facet inclination (LFI) also exhibits variability. Its relationship with other wrist features is poorly documented. Purposes  We tested the hypothesis that high LFI is associated with increased uncovering of the lunate, negative ulnar variance (UV), and type 2 lunates to balance forces across wrists. Methods  In total, 50 bilateral and 100 unilateral wrist posteroanterior radiographs were reviewed. Lunate type, lunate uncovering index (LUI), lunate tilting angle (LTA), UV, and sigmoid notch angle (SNA) were measured, and correlation with LFI was assessed on 150 right wrist radiographs followed by an assessment of differences based on lunate morphology. Symmetry of 50 bilateral wrists was assessed. Results  There was no correlation of LFI with lunate morphology, LUI, and LTA. There was a low correlation of LFI with SNA and UV. There was an inverse relationship between UV and SNA. Wrists with type 2 lunates had more oblique sigmoid notches and higher LTA in comparison to wrists with type 1 lunates. Side-to-side comparison revealed strong correlation except for LUI, which exhibited moderate correlation. Conclusions There is no correlation between LFI, LUI, and lunate morphology. Type 2 lunates are associated with higher LTA and more oblique SNA. Wrists were symmetrical. Clinical Relevance  Factors other than lunate morphology are essential in balancing forces across wrists. A better understanding of soft tissue and other factors will improve the understanding of wrist biomechanics and pathology. Contralateral wrist radiographs can guide reconstructive surgery.

Functional and Surgical Anatomy of the Upper Limb: What the Radiologist Needs to Know

The anatomy of the upper limb is complex and allows for exceptional functionality. The movements of the joints of the shoulder, elbow, and wrist represent a complex dynamic interaction of muscles, ligaments, and bony articulations. A solid understanding and of the characteristics and reciprocal actions of the anatomic elements of the joints of the upper limb helps explain the mechanisms and patterns of injury. This article focuses on the anatomy and functionality of the shoulder, elbow, and wrist, with emphasis on the stabilizing mechanisms, to set the foundation for understanding the occurrence of pathologic conditions.

Lunate subchondral cysts: Are there specific radiologic findings for patients with symptomatic ulnocarpal impaction?

BACKGROUND

There are few clinical studies evaluating the relationship between lunate cysts and symptomatic ulnar impaction syndrome (UIS). The purpose of this study was to investigate the prevalence and relationship between lunate cysts and UIS by comparing data from patients with UIS against those without.

MATERIALS AND METHODS

From March 2012 to January 2015, 375 patients who had undergone MRI or CT for reasons other than ulnar-sided wrist pain were classified into the 'asymptomatic group' (Group I). Thirty three patients who had been diagnosed with UIS were classified in the 'UIS group' (Group II). We determined whether any differences were present between the two groups and evaluated prognostic factors for lunate cysts.

RESULTS

The prevalence of lunate cysts was significantly higher in Group II but only reached just above 50% (10.4% vs. 57.6%, p < 0.001]. Dorsal-side lunate cysts were more frequent than palmar side in Group I, while Group II had more cysts on the palmar side (74.4% vs. 52.6%, p = 0.001). Logistic regression analysis revealed that UIS and patient age was a significant factor for the presence of lunate cysts (odds ratio: 11.692, p < 0.001; odds ratio: 1.063, p < 0.001, respectively). However, positive ulnar variance or duration of symptom in Group II was not a predisposing factor for lunate cysts (odds ratio: 1.035, p = 0.598; odds ratio: 1.007, p = 0.877, respectively).

CONCLUSION

Since positive ulnar variance or duration of symptom did not affect the formation of the lunate cyst and only slightly more than 50% (57.6%) of patients with UIS had a lunate cyst, it seems unlikely that these cysts are a pathognomonic finding. Surgeons can obtain some evidence from lunate cysts on radiographic exams, but care must be taken that this diagnosis is not made hastily or without due consideration.

Lunotriquetral coalition and ulnar impaction syndrome: a pictorial essay

Lunotriquetral coalition and ulnar impaction syndrome are among the spectrum of pathology encountered at the medial wrist. The co-existence of these entities in the same wrist is rare. The purpose of this pictorial essay is to present the etiology, clinical course, imaging findings, and treatment of lunotriquetral coalition and ulnar impaction syndrome, and co-existing disease.

Correlation of the Lateral Wrist Radiograph to Ulnar Variance: A Cadaveric Study

PURPOSE

Both positive and negative ulnar variance have been implicated in a variety of wrist disorders. Surgery aims to correct the variance in these pathologic conditions. This necessitates accurate and reproducible measuring tools; however, the most accurate radiographic measurement technique remains unclear. The purposes of this study were to evaluate 3 methods for determining ulnar variance and to compare each with direct anatomic measurement in a cadaver model.

METHODS

We fixed 10 fresh above-elbow cadaver specimens in neutral rotation and obtained standardized fluoroscopic posteroanterior and lateral wrist images. A dorsal approach was performed and two independent investigators directly measured ulnar variance using digital calipers with the cartilage both intact and denuded. Ulnar variance was measured radiographically using the lateral, perpendicular, and central reference point methods. The reliability of each set of measurements (within a 1-mm cutoff) was assessed by the intraclass coefficient; agreement between radiographic and direct measurements was evaluated by the Bland-Altman method.

RESULTS

Each method of determining ulnar variance demonstrated near perfect agreement by the intraclass coefficient. The lateral radiograph method correlated highly with the directly measured ulnar variance with the cartilage denuded with an average measurement difference of 0.06 mm. No radiographic measurement technique demonstrated consistent agreement within 1 mm of the measured ulnar variance with the cartilage intact.

CONCLUSIONS

Ulnar variance measured by the lateral wrist radiograph technique correlates highly with the directly measured osseous ulnar variance. The remaining measurement techniques did not correlate reliably to within 1 mm of the directly measured ulnar variance with 95% confidence. No method was able to account accurately for the articular cartilage thicknesses at the lunate facet of the radius or the distal ulnar head, which we found to vary in an unpredictable manner. Whereas the lateral radiograph has been shown to allow for more reliable standardization of wrist position compared with the posteroanterior view, this study also highlights the inherent limitations of using static radiographic images in evaluating ulnar variance.

CLINICAL RELEVANCE

The results of the current study demonstrate the utility of the lateral wrist radiograph for assessing bony ulnar variance.

Outcomes of the Ulnar Shortening Osteotomy Using a Dynamic Compression Plate on the Ulnar Surface of the Ulna

Background  The purpose of this study is to evaluate the results of patients with ulnar impaction syndrome treated with diaphyseal osteotomy using freehand technique and fixation with ulnar osteotomy compression plate placed on the ulnar surface of the ulna. Materials and Methods  A retrospective chart review of patients with ulnar impaction syndrome between 2010 and 2014 identified 38 patients. The following clinical data were observed: patient age, sex, range of motion, grip strength, visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiological assessment, and complications. The mean follow-up period is 30 months. Eleven patients were excluded from the study. Results  Compared with the contralateral side, the 27 patients included in this study attained 93 to 96% of wrist and forearm motion and 81% of the grip strength. The average DASH score was 18 in a mean follow-up period of 30 months. Three patients required plate removal and one case showed nonunion and a further operation was needed. Two patients reported persistent ulnar-sided wrist pain. Conclusion  We concluded that placing the ulnar osteotomy plate on the ulnar surface of the ulna is a quicker procedure, with less soft tissue dissection and irritation, and very high union rate. Level of Evidence  Level IV.

Prognostic value of clinical and radiological findings for conservative treatment of idiopathic ulnar impaction syndrome

Ulnar impaction syndrome (UIS) is a common source of ulnar-sided wrist pain, yet not all cases of radiographic ulnar impaction are symptomatic. We retrospectively analyze clinical or radiologic factors that affect prognoses of conservative treatment for idiopathic UIS. A total of 114 patients who had been diagnosed with UIS were treated with 6 weeks of short arm orthosis followed by formal physiotherapy for 6 weeks, with lifestyle modification to limit aggravating movements. The response to treatment, including pain numeric rating scale on an ulnar provocation test, grip strength, Disability of the Arm, Shoulder, and Hand score (DASH), was assessed at 24-week follow-up. For the 24-week follow-up, 29 patients (25%) underwent ulnar shortening osteotomy due to persistent symptoms after conservative treatment, and 18 (16%) patients had pain scores of greater than 5, but they had not undergone surgery. After controlling for confounding variables, female gender (odds ratio (OR) 1.39), duration of symptom (OR 1.27), high pain NRS score on provocation test (OR 1.45), and enhanced carpal or distal ulna bone on MRI (OR 1.82) were associated with a higher likelihood of treatment failure. Knowledge of the factors offers physicians insight into predicting prognoses and helps patients set realistic expectations.

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

High-resolution 3-T MRI of the triangular fibrocartilage complex in the wrist: injury pattern and MR features

OBJECTIVES

To investigate if using high-resolution 3-T MRI can identify additional injuries of the triangular fibrocartilage complex (TFCC) beyond the Palmer classification.

MATERIALS AND METHODS

Eighty-six patients with surgically proven TFCC injury were included in this study. All patients underwent high-resolution 3-T MRI of the injured wrist. The MR imaging features of TFCC were analyzed according to the Palmer classification.

RESULTS

According to the Palmer classification, 69 patients could be classified as having Palmer injuries (52 had traumatic tears and 17 had degenerative tears). There were 17 patients whose injuries could not be classified according to the Palmer classification: 13 had volar or dorsal capsular TFC detachment and 4 had a horizontal tear of the articular disk.

CONCLUSION

Using high-resolution 3-T MRI, we have not only found all the TFCC injuries described in the Palmer classification, additional injury types were found in this study, including horizontal tear of the TFC and capsular TFC detachment. We propose the modified Palmer classification and add the injury types that were not included in the original Palmer classification.

Lunate morphology as a risk factor of idiopathic ulnar impaction syndrome

AIMS

Positive ulnar variance is an established risk factor for idiopathic ulnar impaction syndrome (UIS). However, not all patients with positive ulnar variance develop symptomatic UIS and other factors, including the morphology of the lunate, may be involved. The aim of this study was to clarify the relationship between lunate morphology and idiopathic UIS.

PATIENTS AND METHODS

A cohort of 95 patients with idiopathic UIS (UIS group) was compared with 95 asymptomatic controls with positive ulnar variance. The shape of the lunate was measured using the capitate-triquetrum distance (CTD), ulnar coverage ratio (UCR), radiolunate distance and radiolunate angle. The association of radiographic parameters and lunate types with the development of UIS was investigated in univariable and multivariable analyses. Receiver operating characteristic curves were used to estimate a cutoff for any statistically significant variables.

RESULTS

The proportion of type II lunates, which have a medial hamate facet, were significantly higher in the UIS group than in the control group in the univariable analysis (p = 0.001). CTD (odds ratio (OR) 1.52; 95% confidence interval (CI) 1.11 to 2.06; p = 0.008) and UCR (OR 44.78; 95% CI 5.35 to 374.90; p = 0.002) showed a positive association with UIS in the multivariable analysis. Estimated cutoff values were 2.5 mm for the CTD (area under the curve (AUC) = 0.65) and 0.4 for the UCR (AUC = 0.64).

CONCLUSION

The proportion of type II lunates was greater in the UIS group than in the control group. A large UCR, which represents the broad base of the lunate, was positively associated with the development of idiopathic UIS. Cite this article: Bone Joint J 2017;99-B:1508-14.

MRI and Arthroscopic Correlation of the Wrist

Since its introduction in 1979, the practice of and indications for wrist arthroscopy in the diagnosis and treatment of pathologic conditions in the wrist continues to grow. Magnetic resonance imaging (MRI) is another commonly used tool to noninvasively examine the anatomy and pathology of the wrist joint. Here, we review the normal wrist anatomy as seen arthroscopically and through MRI. We then examine the various common pathologic entities and define both the arthroscopic findings and correlated MRI findings in each of these states.

The effect of ulnar variance on scapholunate and capitolunate angles

Background Ulnar variance (UV), which is measured using anteroposterior (AP) X-rays, is associated with the development of multiple wrist pathologies. The scapholunate angle (SLA) and capitolunate angle (CLA) are measured using lateral X-rays, and these can be used in the diagnosis of intercalated segmental instability. Purpose To determine the effect of UV on SLA and CLA. Material and Methods A total of 140 patients (73 women, 67 men; mean age, 37.8 ± 14.6 years; 95% confidence interval [CI], 35.4-40.3) were included in the study. Participants were excluded if they presented with fractures or malunions, any arthritic conditions, avascular necrosis, congenital deformities, or bone and soft tissue tumors. UV, SLA, and CLA were measured using AP and lateral wrist X-rays. Results Patients were grouped as positive, neutral, and negative UV. There was no statistically significant difference in mean ages, sex, and sides (left or right) between the UV groups ( P > 0.05). In addition, there was no statistically significant difference in the mean values of SLA and CLA between the UV groups ( P > 0.05). UV showed no statistically significant association with SLA and CLA (r = -0.064; P = 0.455, and r = 0.059; P = 0.485, respectively). However, there was a statistically significant association between SLA and CLA (r = -0.482; P < 0.001). Conclusion There is higher prevalence of neutral UV and no correlation between UV with respect to age and sex of patients in the local Turkish population. SLA and CLA are not affected by UV. There is a negative correlation between SLA and CLA.

MR imaging of the traumatic triangular fibrocartilaginous complex tear

Triangular fibrocartilage complex is a major stabilizer of the distal radioulnar joint (DRUJ). However, triangular fibrocartilage complex (TFCC) tear is difficult to be diagnosed on MRI for its intrinsic small and thin structure with complex anatomy. The purpose of this article is to review the anatomy of TFCC, state of art MRI imaging technique, normal appearance and features of tear on MRI according to the Palmar's classification. Atypical tear and limitations of MRI in diagnosis of TFCC tear are also discussed.

The Oblique Metaphyseal Shortening Osteotomy of the Distal Ulna: Surgical Technique and Results of Ten Patients

Background Ulnocarpal abutment is a common condition following distal radius fractures. There are different surgical methods of treatment for this pathology: open and arthroscopic wafer procedure or an ulnar shortening osteotomy. We describe an oblique metaphyseal shortening osteotomy of the distal ulna using two cannulated headless compression screws. We report the results of 10 patients treated with this method. Materials and Methods Out of 17 patients, 10 could be reviewed retrospectively for this study. Patient-rated outcomes were measured using the VAS (visual analogue scale) for pain, PRWHE (patient-rated wrist and hand evaluation) survey, and Quick-DASH (disability of arm, shoulder and hand) survey for functional outcomes. At the review we measured the range of motion (ROM) of the wrist (extension and flexion, ulnar and radial deviation, pronation and supination). Grip strength, pronation, and supination strength of the forearm was measured using a calibrated hydraulic dynamometer. ROM and strength of the affected wrist was compared with ROM and strength of the unaffected wrist. Surgical Procedure Oblique long metaphyseal osteotomy of the distal ulna (from proximal-ulnar to distal-radial), fixed with two cannulated headless compression screws. Results The average postoperative VAS score for pain was 23.71 (standard deviation [SD] of 30.41). The average postoperative PRWHE score was 32.55 (SD of 26.28). The average postoperative Quick-DASH score was 28.65 (SD of 27.21). The majority of patients had a comparable ROM and strength between the operated side and the non-operated side. Conclusion This surgical technique has the advantage of reducing the amount of hardware and to decrease the potential hinder caused by it on medium term. Moreover, the incision remains smaller, and the anatomic metaphyseal localization of the osteotomy potentially allows a better and rapid healing.

Imaging of Sports-related Hand and Wrist Injuries: Sports Imaging Series

Hand and wrist injuries are common occurrences in amateur and professional sports and many of them are sport-specific. These can be divided into two categories: traumatic injuries and overuse injuries. The aim of this article is to review the most common hand and wrist sports-related lesions. Acute wrist injuries are predominantly bone fractures, such as those of the scaphoid, hamate hook, and ulnar styloid. Ligament lesions are more challenging for radiologists and may lead to carpal instability if undiagnosed. Overuse wrist injuries are mainly represented by tendinous disorders, with De Quervain syndrome and extensor carpi ulnaris tendon disorders being the most common among them; however, there are other possible disorders such as impaction syndromes, stress fractures, and neurovascular lesions. Finally, finger lesions, including closed-tendon injuries (mallet and boutonniere injuries, jersey finger, and boxer's knuckle), flexor pulley injuries, and skier's thumb, should also be detected. (©) RSNA, 2016 Online supplemental material is available for this article.

Ulnar-Sided Wrist Pain due to Long Ulnar Styloid: A Case Report

Ulnar styloid impaction syndrome involves repetitive friction between an excessively long ulnar styloid and the carpus, resulting in chondromalacia, synovitis, and pain. The arthroscopic diagnosis, evaluation, and management of this syndrome are not well characterized. We present a patient with chronic wrist pain of unknown origin, culminating with arthroscopic findings demonstrating substantial loss of articular cartilage on both the lunate and triquetrum. The patient successfully underwent operative ulnar styloid excision, ultimately resolving chronic wrist pain symptomology.

The Outcomes of Arthroscopic Repair Versus Debridement for Chronic Unstable Triangular Fibrocartilage Complex Tears in Patients Undergoing Ulnar-Shortening Osteotomy

PURPOSE

The aim of this study was to compare the results of arthroscopic peripheral repair (AR) and arthroscopic debridement (AD) for the treatment of chronic unstable triangular fibrocartilage complex (TFCC) tears in ulnar-positive patients undergoing ulnar-shortening osteotomy (USO).

METHODS

A total of 31 patients who underwent arthroscopic treatments combined with USO for unstable TFCC tears and were followed-up at a minimum of 24 months were included in this retrospective cohort study. Fifteen patients were treated with AR, and 16 patients were treated with AD while at the same time undergoing a USO. Outcome measures included wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, and overall outcomes according to the modified Mayo wrist scoring system. In addition, a stress test to assess distal radioulnar joint (DRUJ) stability was performed before and after surgery to compare the 2 cohorts.

RESULTS

Both respective cohorts showed significant improvements in grip strength and subjective scores at the final follow-up. Grip strength, DASH, and PRWE scores were better in the AR group than in the AD group. The recovery rate from DRUJ instability observed during the preoperative examination was superior in the AR group.

CONCLUSIONS

Both AD and AR of the TFCC combined with USO are reliable procedures with satisfactory clinical outcomes for unstable TFCC tears in ulnar-positive patients. However, AR of the TFCC is suggested if DRUJ stability is concomitantly compromised.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatments for Kienböck disease: what the radiologist needs to know

The etiology of Kienböck disease, or avascular necrosis of the lunate, is controversial, and there are a myriad of treatments aimed at correcting the various hypothesized pathologies. Interventions to reduce mechanical stress on the lunate have been used for decades, including radial osteotomy with or without radial shortening, ulnar lengthening and metaphyseal core decompression procedures. However, these procedures require preservation of lunate architecture. Newer procedures to revascularize the lunate bone have emerged in the last 10 years, such as pedicled corticoperiosteal vascularized bone grafting. Once there is collapse of the radiocarpal joint or midcarpal arthrosis, the conventional treatments have included proximal row carpectomy and complete or partial wrist joint arthrodesis. Newer salvage procedures such as lunate excision with autologous or synthetic interposition grafts are now being used when possible. As this disease is relatively rare, radiologists may not be familiar with the expected post-operative radiologic findings and complications, especially of the newer treatments. The goals of this paper are to review the available treatment options and their expected appearance on postoperative imaging, with discussion of possible complications when appropriate.

Clinical DRUJ instability does not influence the long-term functional outcome of conservatively treated distal radius fractures

OBJECTIVE

The presence of distal radioulnar joint (DRUJ) instability remains often unnoticed initially, but may worsen functional outcome of distal radius fractures (DRF). The aim of this study was to evaluate the influence of concurring clinical DRUJ instability on the outcome of conservatively treated DRF.

METHODS

In a retrospective cohort study, all unilateral, conservatively treated DRF patients were invited for physical examination, CT scan of both wrists and filling out questionnaires. Static and dynamic DRUJ instability were clinically tested.

RESULTS

Forty-nine DRF patients with a mean follow-up of 4.2 years (SD 0.5) were assessed. Seventeen patients tested positive for DRUJ instability. No differences were found in baseline characteristics between the DRUJ stable and unstable group. Apart from wrist flexion, no statistical significant differences in outcome was found between patients with and without DRUJ instability.

CONCLUSION

The presence of clinical DRUJ instability does not seem to affect functional outcome of conservatively treated distal radius fractures at long-term follow-up.