Perilunate injuries: diagnosis and treatment

Traumatic Ulnar Carpal Translocation, Distal Radioulnar Joint Subluxation with Occult Perilunate Injury

Background  Perilunate injuries pose a significant treatment challenge, particularly when initially missed or underestimated. These injuries have a multitude of variations as propagation of the injury may be through ligaments and/or bone, with more recent appreciation given to nondislocated perilunate injuries. Case Description  We present a new variant of perilunate injuries, not dislocated (PLIND). This occult ligamentous perilunate injury was associated with ulnar carpal translocation, radiocarpal subluxation, and distal radioulnar subluxation. The extent of injury was fully appreciated intraoperatively, with only subtle clues present on preoperative exam and imaging, emphasizing the high index of suspicion required to identify these injuries. Clinical outcome at 1-year follow-up was very satisfactory. Literature Review  PLIND consist a distinct subset within the spectrum of perilunate injuries in which there is no observed disruption of the capitolunate relationship. Based on few cases reported in the literature (attributable to their rare occurrence and likely additional lack of awareness surrounding the injury pattern), current recommendations for surgical management include arthroscopic or open approach to appropriately address osseous and ligamentous injuries. Clinical Relevance  Recognition of PLIND injuries is challenging given the lack of frank dislocation of the capitate head on the lunate, as observed in classic perilunate injuries. Heightened clinical suspicion in patients with consistent mechanism and presentation, followed by timely surgical management, may limit sequelae of persistent instability and arthritis. Our case contributed to relevant literature by presenting a previously undescribed PLIND variant combined with radiocarpal instability, ulnar carpal translocation, and distal radioulnar subluxation.

Machine Learning-Aided Diagnosis Enhances Human Detection of Perilunate Dislocations

BACKGROUND

Perilunate/lunate injuries are frequently misdiagnosed. We hypothesize that utilization of a machine learning algorithm can improve human detection of perilunate/lunate dislocations.

METHODS

Participants from emergency medicine, hand surgery, and radiology were asked to evaluate 30 lateral wrist radiographs for the presence of a perilunate/lunate dislocation with and without the use of a machine learning algorithm, which was used to label the lunate. Human performance with and without the machine learning tool was evaluated using sensitivity, specificity, accuracy, and F1 score.

RESULTS

A total of 137 participants were recruited, with 55 respondents from emergency medicine, 33 from radiology, and 49 from hand surgery. Thirty-nine participants were attending physicians or fellows, and 98 were residents. Use of the machine learning tool improved specificity from 88% to 94%, accuracy from 89% to 93%, and F1 score from 0.89 to 0.92. When stratified by training level, attending physicians and fellows had an improvement in specificity from 93% to 97%. For residents, use of the machine learning tool resulted in improved accuracy from 86% to 91% and specificity from 86% to 93%. The performance of surgery and radiology residents improved when assisted by the tool to achieve similar accuracy to attendings, and their assisted diagnostic performance reaches levels similar to that of the fully automated artificial intelligence tool.

CONCLUSIONS

Use of a machine learning tool improves resident accuracy for radiographic detection of perilunate dislocations, and improves specificity for all training levels. This may help to decrease misdiagnosis of perilunate dislocations, particularly when subspecialist evaluation is delayed.

Adjunctive Dorsal Spanning Plate Fixation in the Stabilization of Perilunate Dislocations

PURPOSE

To compare the biomechanical properties of adjunctive dorsal spanning plate (DSP) fixation with traditional K-wire fixation of perilunate dislocations in a cadaveric model.

METHODS

Fourteen fresh-frozen cadaveric wrists underwent simulated perilunate injury. The specimens were randomly allocated to either K-wire fixation versus K-wire and DSP fixation. Scapholunate (SL) ligament repair was performed in all specimens. The constructs were tested using a robot cyclically and to failure. Fluoroscopic images were obtained of the specimens prior to simulated injury, after fixation, after 10 and 100 loading cycles, and at construct failure. Differences in carpal alignment parameters (SL interval, SL angle, lunotriquetral interval, and capitolunate angle) and load to failure were recorded.

RESULTS

There were no statistically significant differences between the two group's carpal alignment parameters after fixation. Specimens fixated with K-wires and DSP required significantly higher loads to achieve construct failure. The only significant difference between the two groups' carpal alignment parameters was SL interval change at failure.

CONCLUSIONS

Compared with K-wire fixation alone, adjunctive DSP fixation resulted in significantly increased loads to failure and decreased change in SL interval at the time of failure.

CLINICAL RELEVANCE

Adjunctive DSP may be a useful technique in the polytraumatized patient in whom providing back a weight-bearing extremity may be advantageous in the rehabilitation process.

[Trans-scapho-perilunar fracture-dislocation: a case report]

Trans-scaphoid perilunate fractures-dislocations are rare injuries caused by high-energy trauma of the wrist. Diagnosis is based on medical history, physical examination, and tools such as radiographs, computed tomography scan, and magnetic resonance imaging. Early treatment consists of closed reduction and casting to stabilize the limb. Definitive treatment is surgical and includes bone and soft tissue repair. A case of trans-scaphoid perilunate fracture-dislocation is presented, along with diagnosis, management and outcome.

The Impact of Wrist Fractures on Long-Term Basketball Performance

Background

Wrist joint fractures may present challenging obstacles for the rehabilitating athlete upon return to play. Although current literature has examined the effects of specific injuries to the upper extremity for basketball athletes, little is known about long-term performance outcomes following wrist joint fractures.

Methods

Review of all National Basketball Association players who sustained wrist joint fractures was conducted. Player characteristics, preinjury and postinjury performance, and overall efficiency were analyzed.

Results

A total of 31 players were deemed appropriate for inclusion, with an average age of 26.2 ± 4.3 years and a mean of 5.2 ± 3.6 years played before injury and 4.1 ± 3.1 years played upon return. Operative management was pursued in 48.4% of players. Players demonstrated a significant decrease in win shares before injury (mean: 24.3 ± 31.5) compared to after return from injury (mean: 9.6 ± 19.6) (p < 0.032). Multivariate regression demonstrated that increased points per game before injury (standardized β: 0.71; 95% confidence interval [CI]: 1.2-8.5, p < 0.011) and increased win shares before injury (β: 1.0; 95% CI: 1.4-9.5, p < 0.001) were both independently predictive with increased win shares after return to play. Player position, age, management type, and all other statistics were not significantly associated with any other findings upon return.

Conclusion

Overall efficiency following return to play in the setting of basketball-associated wrist joint fractures appears to be decreased in athletes. However, preinjury performance as captured through win share efficiency and points per game appears to be predictive of increased productivity after successful return.

Perilunate Injury Timing and Treatment Options: A Systematic Review

Introduction  Perilunate injuries are uncommon yet challenging and often missed injuries, representing 7% of all carpal traumas. Two types of injuries can be identified as follows: perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD). The purpose of this study was to conduct a systematic review and meta-analysis to establish which surgical treatment is superior for patients with perilunate injuries and the significance of delayed treatment. Methods  A total of 2056 articles were screened, and 16 articles were included. Risk of bias for case-control series and case series were assessed through the National Institute of Health study quality assessment tool. Qualitative outcomes of clinical scores for hand function were compared between different time points (acute, < 7 days; delayed 7-45 days; chronic > 45 days), open and closed reduction, and PLD and PLFD. Results  Overall, the clinical outcome scores of patients treated within 7 days are good. The results suggest that closed reduction and internal fixation (CRIF) offers slightly better outcomes than open reduction and internal fixation (ORIF) for PLFD. Patients treated 6 weeks or more after the initial injury seem to have the worst overall outcomes than patients in the acute or delayed setting. The results suggest that patients with chronic PLD have even worse outcomes than patients with chronic PLFD. Conclusions  Timing of surgery is essential for an optimal outcome. When there is a delay of treatment, the outcomes are inferior to those treated acutely. Early referral to centralized treatment units for perilunate injuries would allow for targeted treatment and facilitate research on this difficult wrist injury.

Dorsal Spanning Plate for Perilunate Dislocations

Purpose  The purpose of this study was to compare radiographic outcomes in patients treated with the traditional method of open reduction, internal fixation (ORIF) and casting as compared with those treated with ORIF and dorsal spanning plate (DSP) fixation. We hypothesized that the application of a DSP to augment the repair of perilunate dislocations would maintain carpal stability while also allowing early loadbearing through the carpus. Materials and Methods  This is a retrospective radiographic review of patients with a perilunate dislocation, who were treated with ORIF and casting or ORIF with a dorsal spanning plate between 2012-2018. Scapholunate (SL) and lunotriquetral (LT) intervals were measured immediately after the index surgery and after scheduled hardware removal. A total of 28 patients met inclusion criteria, including 13 cases with traditional treatment and 15 cases with dorsal spanning plate fixation. Results  Comparison of the change in SL interval and LT interval between the 13 patients in the traditional treatment group and the 15 patients in the DSP group did not yield any clinically relevant variation after statistical analysis. Both groups demonstrated minimal change in the radiographic markers of carpal stability from postoperative radiographs obtained immediately after the index repair and after the removal of hardware. Conclusion  DSP fixation placed at the index surgery with early loadbearing for the treatment of perilunate dislocation is not inferior to the current mainstay of treatment consisting of cast immobilization without loadbearing and does not confer any increased carpal instability in comparison to ORIF and casting.

Nuanced Trans-scaphoid, Perilunate Fracture Dislocations With Complete Scapholunate Dissociation: Two Cases With Proximal Row Preservation

We offer two reports of trans-scaphoid perilunate fracture dislocations, both involving complete dissociations and loss of vascular supply to the proximal scaphoid poles. Case 1 involves a 25-year-old man who fell on an outstretched hand and suffered a trans-styloid, trans-scaphoid, perilunate fracture dislocation. The patient underwent open reduction and screw fixation of the scaphoid using a dorsal approach. Kirchner wire fixation and suture anchor ligamentous repairs were used to reduce the scapholunate, lunar-triquetral, and radioscaphocapitate intervals. At 6 months, the patient was released to work without restrictions. Case 2 is a 66-year-old man who suffered a trans-scaphoid, perilunate fracture dislocation after a fall from a horse. A portion of the completely torn scapholunate ligament remained intact to the proximal pole, but no soft-tissue attachment to the rest of the carpus remained. The patient underwent open reduction of the scaphoid with compression screw and Kirschner wire fixation to repair the scapholunate and lunar-triquetral ligaments. At 1-year, the patient was released to full activity. Intraoperatively, the proximal scaphoid poles were completely devoid of any uninterrupted soft-tissue attachments, elevating concern for osteonecrosis. Although both patients showed radiographic signs of transient ischemia, neither patient displayed osteonecrosis or proximal pole collapse at their terminal visits.

Perilunate injuries: biomechanics, imaging, and classification

Perilunate injuries are uncommon injuries that are often misdiagnosed. Although conventional radiographs can underestimate the severity of the perilunate injuries, assessment with cross-sectional imaging can be complex, and terminology is inconsistent in the scientific literature. The aim of this paper is to describe the biomechanics, anatomy, and classification of perilunate trauma in order to provide a systematic approach to the description and diagnosis of these injuries.

Fragment-Specific Fixation in Distal Radius Fractures

PURPOSE OF REVIEW

Fragment-specific fixation can be a useful tool in treating distal radius fractures. In order to best utilize these techniques, surgeons require an understanding of the normal anatomy, fracture patterns, approaches, and fixation strategies.

RECENT FINDINGS

Fragment-specific fixation may be appropriate for certain fracture patterns particularly when monoblock plating techniques are not sufficient. Radial styloid, volar rim, dorsal wall, dorsal-ulnar corner, and impacted intraarticular fragments may be secured with implants designed specifically for each individual fragment. Although more technically demanding, advantages include accurate articular reconstruction, minimal hardware irritation, and reliable functional outcomes.

A Stepwise Approach to Management of Open Radiocarpal Fracture-Dislocations: A Case Report

Radiocarpal dislocations are uncommon and occur after significant trauma. We describe a unique case of open radiocarpal fracture-dislocation presenting with progressive neurovascular compromise. Staged management was necessary. As a first stage, emergent provisional bedside reduction in the emergency room with manual pressure through the open wounds was performed. The second stage then involved formal open reduction and internal fixation as soon as operating room staff and resources became available.

[Fenton's naviculo-capitate fracture syndrome (about a case)]

La fracture scapho-capitale ou syndrome naviculo-capital de Fenton, est une lésion très rare, souvent méconnue. Elle résulte d'un traumatisme du poignet de haute énergie. Son mécanisme est controversé. Les auteurs rapportent l'observation d'un patient,qui a présenté dans les suites d’un accident de la voie publique une fracture du scaphoïde associée à une fracture du capitatum, du triquetrum et de la styloïde cubitale. La voie d'abord dorsale, a permis une réduction et une contention par embrochage de la première rangée, indépendamment de la deuxième rangée. Les ligaments interosseux scapho-lunaire et lunaro-triquétral étaient intacts. Une immobilisation plâtrée antébrachio-palmaire a été mise en place pour 12 semaines. La rééducation a durée six mois. A deux ans de recul, le score fonctionnel de Cooney était bon et l'ensemble des fractures a consolidé sans aucune désaxation intracarpienne. La reprise du travail était au huitième mois après l’accident.

Scapho-capitate fracture or Fenton’s naviculo-capitate fracture syndrome is a very rare and often ignored lesion. It is caused by a high-energy traumatic injury to the wrist. Its mechanism is controversial. This study reports the case of a patient with scaphoid fracture associated with fracture of the capitatum, triquetrum and ulnar styloid due to public road accident. Dorsal approach allowed reduction and containment by internal fixation in the first row, regardless the second row. Scapholunate interosseous ligaments and luno-triquetral were intact. The patient underwent antebrachial-palmar plaster immobilization for 12 weeks. Rehabilitation program lasted for six months. Cooney’s wrist function score was good and all fractures consolidated without intracarpal malalignment at 2 years follow up. The patient resumed work in the eighth month after the road accident.

Functional outcome after surgical treatment of perilunate injuries: A series of 12 cases

PURPOSE

Perilunate injuries (PLIS) are complex injuries, which are frequently missed in the initial setting, and delayed presentation leads to poor functional outcomes. In this study, we are presenting our experience of treating these injuries by surgical treatment and the effect of neglect on their outcome.

MATERIALS AND METHODS

In this retrospective study, 11 patients with 12 PLIS, which presented to our center from January 1, 2000 to December 31, 2012 were included. They were managed surgically as open reduction and internal fixation. Function was documented by using Mayo score. To ascertain the effect of the delay/neglect on the outcome, the patients were divided into two groups according to time between day of injury and final surgery (group I - operated within 6 weeks of injury and group II - treated after 6 weeks of injury).

RESULTS

Average postoperative Mayo score was 76.4. Average Mayo score in group I was 93.7 (90-95). Average Mayo score in group II was 67.1 (60-75). Although functional result as Mayo score was significantly better in group I (p value <0.5) even chronic or delayed group patients also had good to fair results.

CONCLUSION

Early diagnosis and treatment of such injuries should be emphasized as delay in treatment leads to progressive poor results. Well-planned surgical management gives good functional results even in delayed cases.

Arthroscopic treatment of perilunate dislocations and fracture dislocations

Background The key to a successful result in the treatment of perilunate dislocations (PLDs) and fracture-dislocations (PLFDs) is the restoration of normal alignment of the carpal bones, followed by stable maintenance until healing. This article aimed to assess whether arthroscopic techniques are a reliable surgical option for the treatment of this challenging injury. Materials and Methods Twenty patients with an acute PLD or PLFD were treated by an arthroscopic technique. They were retrospectively reviewed at an average follow-up of 31.2 months (range 18-61 months). Functional outcomes were assessed with the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and Patient-Rated Wrist Evaluation (PRWE) score as well as radiographic evaluations. Description of Technique Arthroscopic reduction and percutaneous fixation was performed to the scapholunate and lunotriquetral intervals using Kirschner wires (K-wires) as joysticks as well as to the scaphoid using a cannulated headless screw for transscaphoid-type injuries. The K-wires were removed at 10 weeks postoperation. Results Overall functional outcomes according to the MMWS were rated as excellent in three patients, good in eight, fair in seven, and poor in two. The mean DASH score was 18, and the mean PRWE score was 30. On the basis of radiographic parameters, reduction obtained at the operation was maintained within normal ranges in 15 patients. No patient had developed arthritis by the last follow-up. Conclusions The medium-term results show that arthroscopic treatment can provide proper restoration and stable fixation of carpal alignment and results in satisfactory functional and radiologic outcomes for acute perilunate injuries. Level of Evidence Level IV.

Extremity trauma: field management of sports injuries

Traumatic injuries to the extremities are common in athletic competitions. The practitioner providing coverage of sporting events must be prepared to diagnose and provide initial treatment of these injuries. A thorough history and physical examination should result in a provisional diagnosis. Many injuries will require subsequent radiographs or orthopedic consultation. Limb threatening emergencies are rare but must be promptly recognized and referred to a hospital. Early treatment can protect athletes from further injury and may hasten their return to competition. Some athletes with extremity trauma can return to the contest, but this decision must be made on an individual basis.

Trans-scaphoid Trans-lunotriquetral Perilunate Dislocation in a Patient with a Carpal Coalition

SUMMARY

Congenital carpal coalitions are rare conditions that arise from a failure or an incomplete cavitation of a common cartilaginous precursor of the carpal bones between the fourth and eighth week of intrauterine life. The incidence of coalitions has been estimated to occur in about 0.1% of the population and up to 1.6% in people of African descent. This study reports a case of trans-scaphoid trans-lunotriquetral perilunate dislocation with a lunotriquetral coalition and successful management with closed reduction, percutaneous fixation, and a thumb spica cast.

Unusual proximal dislocation without fracture: a case report

Carpal instability includes a broad spectrum of osseous and ligamentous injuries which have been subclassified into greater and lesser arc injuries, in addition to combinations of both (Mayfield et al. J Hand Surg [Am] 5:226-241, 1980; Yaeger et al. Skeletal Radiol 13(2):120-30, 1985). The injuries typically occur from a fall on the outstretched hand with the wrist in ulnar deviation, hyperextension, and intercarpal supination (Yaeger et al. Skeletal Radiol 13(2):120-30, 1985). The force classically propagates from the radial to the ulnar side of the wrist resulting in a fracture (greater arc) or dislocation (lesser arc) pattern with the extent of the injury occurring in an orderly pattern depending upon the degree of hyperextension and the duration and magnitude of the force (Mayfield et al. J Hand Surg [Am] 5:226-241, 1980; Yaeger et al. Skeletal Radiol 13(2):120-30, 1985). Multiple variations occur, including transradial styloid fractures as well as fractures through carpal bones surrounding the lunate (Mayfield et al. J Hand Surg [Am] 5:226-241, 1980; Yaeger et al. Skeletal Radiol 13(2):120-30, 1985; Kozin SH. J Am Acad Orthop Surg 6 (2): 114-20, 1998. Although carpal dislocations have been noted for many years, the mechanisms and classification have only been recently clarified. We report a case of a complex dislocation involving the entire proximal carpal row without an associated fracture. While this type of complex carpal dislocation has been previously described, to our knowledge, it has never been reported without a fracture of the forearm, wrist, or hand.

Arthroscopic reduction and percutaneous fixation of perilunate dislocations and fracture-dislocations

PURPOSE

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with arthroscopic reduction and percutaneous fixation.

METHODS

Twenty patients who had an acute dorsal perilunate dislocation or fracture-dislocation were treated with an arthroscopic technique at a median interval of 3.9 days from the time of injury. They were retrospectively reviewed at a mean follow-up of 31.2 months (range, 18 to 61 months). Range of motion and grip strength were measured. Radiographic evaluations included time to scaphoid union, measurement of radiologic parameters, and any development of arthritis. Functional outcomes were determined by the modified Mayo wrist score; Disabilities of the Arm, Shoulder and Hand questionnaire; and Patient-Rated Wrist Evaluation score.

RESULTS

The flexion-extension motion arc and grip strength of the injured wrist averaged 79% and 78%, respectively, of the corresponding values for the contralateral wrists. The mean Disabilities of the Arm, Shoulder and Hand score was 18, and the mean Patient-Rated Wrist Evaluation score was 30. According to modified Mayo wrist scores, overall functional outcomes were rated as excellent in 3 patients, good in 8, fair in 7, and poor in 2. Nonunion developed in 2 patients with a trans-scaphoid perilunate injury; 1 of the 2 underwent scaphoid excision and midcarpal fusion. On the basis of radiographic parameters, reduction obtained during the operation was maintained within normal ranges in 15 patients. Arthritis had not developed in any patient by the last follow-up.

CONCLUSIONS

This study suggests that arthroscopic reduction with percutaneous fixation is a reliable minimally invasive surgical method for acute perilunate injuries in that it provides proper restoration and stable fixation of carpal alignment and results in satisfactory functional and radiologic outcomes on a midterm basis.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Surgical approaches to the distal radius

INTRODUCTION

Fractures of the distal radius are among the most common fractures seen. They encompass a myriad of presentations and fracture patterns that often benefit from various open reduction and internal fixation techniques-including volar plating, dorsal plating, radial plating, intramedullary nailing, and fragment-specific fixation. In order to obtain optimal reduction of these fractures, surgeons require a thorough understanding of the anatomy and various surgical exposures.

ANATOMY

The distal radius is surrounded by a soft tissue envelope rich in vascularity and cutaneous innervation. The osseous surface consists of two articular surfaces and three cortical sides covered almost entirely by soft tissue.

SURGICAL APPROACHES

Approaches to the distal radius can be broadly divided into volar, radial, and dorsal. Visualization of the articular surface can be accomplished best arthroscopically. Arthroscopy can be performed alone or in conjunction with other open approaches to the distal radius.

SUMMARY

This article will review the pertinent anatomy and various surgical approaches in order to facilitate the surgeon's ability to safely expose a distal radius fracture.

Arthroscopically assisted percutaneous fixation for trans-scaphoid perilunate fracture dislocation

Trans-scaphoid perilunate fracture dislocation is a complex carpal dislocation causing marked disruption of the carpal structures. Open treatment has been accepted as standard for this injury. We have used arthroscopically assisted percutaneous screw fixation and bone grafting to treat this injury in four patients. The functional outcome was good. All patients achieved solid union without nonunion or malunion. The complication and morbidity was relatively low; all patients had proper alignment and there was no evidence of instability or avascular necrosis or midcarpal arthritis.

Open reduction for perilunate injuries--clinical outcome and patient satisfaction

PURPOSE

Perilunate injuries cause severe carpal malalignment. Open reduction and internal fixation of these injuries has become the treatment of choice. This study evaluated clinical outcome and the patients' perception of disability in activities of daily living after open reduction, ligament reconstruction, and/or internal fixation of the scaphoid. In addition, potential prognostic factors for functional outcome and individual perceptions of disability were analyzed and compared with radiologic findings.

METHODS

This study consisted of a retrospective analysis of patients with perilunate dislocations or fracture dislocations (Mayfield stage 3/4) who were treated in a single institution from 1995 to 2004. Evaluation focused on postoperative radiologic results, range of motion, pain, sensitivity, grip strength, Mayo and Krimmer wrist scores, arthrosis, and the patients' disability in performing activities of daily living (according to the Disabilities of the Arm, Shoulder, and Hand score).

RESULTS

Of the 72 patients treated in the study period, 39 patients (all men) were available for complete follow-up (average, 65.5 mo). Thirty injuries were fracture dislocations; the dominant hand was injured in 14 cases. Normal scapholunate (SL) angles and Gilula arcs were achieved intraoperatively in 34 and 25 cases, respectively. At follow-up, 18 patients had larger than normal SL angles, and 6 patients had ulnar shifting of the carpus. Twenty patients were diagnosed with radiocarpal arthrosis. According to the Visual Analog Scale, pain was 1.8 at rest and 4.8 with activities. Average extension/flexion was 77°; radial/ulnar abduction was reduced to 42°. Average grip strength was reduced to an average of 36.6 kg (compared with 51.6 kg on the opposite side). Twenty-seven patients returned to their former occupations. Average Mayo and Krimmer wrist scores were both 70. The average Disabilities of the Arm, Shoulder, and Hand score was 23.

CONCLUSIONS

Satisfactory results can be achieved with open reduction for perilunate injuries. However, despite this treatment, loss of reduction and arthrosis are frequent findings. Radiologic results do not necessarily correlate with functional outcome; high patient satisfaction was observed in this study.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of carpal instability in athletes

Hand and wrist injuries are common in most athletic events and sports. Carpal fractures and ligamentous injuries are common in athletes and require physicians, trainers, and therapists who treat and diagnosis these injuries to have an understanding of the carpal bone anatomy and vascularity along with the potential for progression to instability. Research is still needed to further investigate the optimal treatments of all carpal injuries in athletes along with designing new means to prevent these injuries.

Linear and torsional mechanical characteristics of intact and reconstructed scapholunate ligaments

The mechanical behavior of human scapholunate ligaments is not well understood. Presently, intact scapholunate specimens were mechanically tested in linear distraction and torsion. Fresh bovine tendon grafts were used to reconstruct the scapholunate interval and the tests repeated. Tests yielded the following average values for intact specimens: linear stiffness (48.9 Nmm), linear load retained at 100 s (44%), torsional stiffness (19.5 N mmdeg), torque remaining at 100 seconds (66%), torque-to-failure (1253.9 N mm), and angle-to-failure (50.4 deg). Tests showed the following average values for reconstructed specimens: linear stiffness (5.4 Nmm), linear load retained at 100 s (49%), torsional stiffness (12.6 N mmdeg), torque remaining at 100 s (71%), torque-to-failure (936.8 N mm), and angle-to-failure (54.5 deg). There were no statistically significant differences between the intact and reconstructed specimens, with the exception of linear stiffness. Biomechanically, this is the first study in the literature to quantify torsional stress relaxation, failure torque, and failure angle for the intact and repaired human scapholunate ligament. Surgically, reconstruction with bovine tendon may warrant further investigation as a method to potentially retain function and strength after scapholunate injury.

A biomechanical assessment of the coupling of torsion and tension in the human scapholunate ligament

The mechanical behaviour of human scapholunate ligaments is not well described in the literature with regard to torsion. In this study, intact scapholunate specimens were mechanically tested in torsion to determine whether a simultaneous tensile load was generated. Human intact scapholunate specimens ( n = 19) were harvested. The scaphoid and lunate bones were potted in square chambers using epoxy cement, while the interposing ligament remained exposed. Each specimen was mounted rigidly in a specially designed test jig and remained at a fixed axial length during all tests. Specimens were subjected to a torsional load regime that included cyclic preconditioning, ramp-up, stress relaxation, ramp-down, rest, and torsion to failure. Torque and axial tension were monitored simultaneously. The relationship between torsion and tension was determined. Graphs of torque versus tension were generated, from which outcome measures were extracted. Tests demonstrated a clear relationship between applied torsion and the resulting generation of tension for the ligament during ramp-up (torsion-to-tension ratio, 38.86 ± 29.00 mm; linearity coefficient R2 = 0.89 ± 0.15; n = 19), stress relaxation (torsion-to-tension ratio, 23.43 ± 15.84 mm; R2 = 0.90 ± 0.09; n = 16), and failure tests (torsion-to-tension ratio, 38.81 ± 26.39 mm; R2 = 0.77 ± 0.20; n = 16). No statistically significant differences were detected between the torsion-to-tension ratios ( p = 0.13) or between the linearity ( R2) of the best-fit lines ( p > 0.085). A strongly coupled linear relationship between torsion and tension for the scapholunate ligament was exhibited in all test phases. This may suggest interplay between these two parameters in the stabilization of the ligament during normal motion and for injury cascades.

Open reduction and internal fixation in a case with transscaphoid perilunate dislocation 8 months after the injury: a patient with a 5-year follow-up

The management of perilunate dislocations diagnosed later than three months continue to elicit debate with literature being scarce. We report a 22-year-old male with transscaphoid perilunate dislocation who reported to our hospital 8 months after sustaining the injury. Open reduction was done along with bone grafting. Five years after the surgery the patient is symptom-free with an excellent range of motion.

Bilateral volar lunate dislocation

A 12 years follow-up of a case of bilateral volar lunate dislocation treated by open reduction and K-wire stabilisation of both wrists six days after injury is described. Despite aseptic necrosis of both lunates, the patient is pain free and has useful function, without the development of lunate ischaemia and collapse, carpal instability or posttraumatic osteoarthritis.

Arthroscopically assisted reduction and percutaneous fixation of dorsal perilunate dislocations and fracture-dislocations

Perilunate injuries are severe disruptions of the wrist joint that produce variable patterns of injury to the carpal anatomy. Most surgeons advocate an open reduction followed by ligament repair or internal fixation. We tried to reduce and fix the carpal bones under arthroscopic control to minimize surgical trauma and to preserve blood supply. While viewing the articular surface with the arthroscope, the disrupted proximal carpal row was anatomically reduced using Kirschner wires as joysticks, and fixed percutaneously without any repair of the capsuloligamentous tears. Three patients with dorsal perilunate dislocations or fracture-dislocations were treated by this technique. All the patients achieved accurate reduction and stable fixation, and showed successful healing of the carpal fractures with proper alignment after 10 to 12 weeks of immobilization. At 16 to 22 months follow-up, all patients showed normal radiographic findings with no evidence of instability or arthritis. The arthroscopic treatment of acute dorsal perilunate injuries is technically feasible in achieving anatomic reduction and stable fixation. Our preliminary clinical results were encouraging, but the long-term results need to be observed.

The Wrist: Common Injuries and Management

Primary care physicians not only have an important role in the diagnosis and initial treatment of wrist injuries, but also play a key role in the education of families about prevention. Children and adolescents are often competitive in sports throughout the year. Periods of rest can be important in prevention of overuse injuries in the very active, developing athlete. Protective gear such as wrist guards, used during activities such as inline skating and snowboarding, has been shown to prevent acute injuries that often require surgery or lead to prolonged disability [84,85].A primary care physician will often be the first health care provider to assess most wrist complaints. The intent of this article is to familiarize the primary care physician with the most common wrist injuries in active people, and to demonstrate that many injuries can have poor outcomes if unrecognized. It is important to have good clinical knowledge of the functional anatomy of the wrist in order to maximize the information gathered on examination and to narrow one's differential diagnosis. The athlete's sport and desires regarding return to play, and the impact of the timing of injury management on his or her further participation in sport are important to consider. A highly active person may be referred to a musculoskeletal specialist for advanced testing or surgical repair earlier in the evaluation of certain injuries than a less active one. Armed with good clinical knowledge of anatomy and an understanding of common wrist injuries,primary care physicians can successfully manage many wrist complaints.

Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire

PURPOSE

To determine the clinical outcome of patients with perilunate and lunate dislocations treated with a combined dorsal and volar approach and intraosseous cerclage wire.

METHODS

A combined dorsal and volar approach with an intraosseous wiring technique was used to treat 22 isolated perilunate and lunate dislocations. The mean interval between injury and surgery was 3 days. Outcome was assessed after an average of 49 months. Patients were assessed subjectively with a Disabilities of the Arm, Shoulder, and Hand questionnaire and were asked to rate their overall satisfaction, pain relief, problems with activities of daily living, and return to work and previous activity status. Results were assessed objectively by range of motion and grip-strength measurements and initial postsurgical radiographs were compared with final radiographs with regard to scapholunate angle and gap.

RESULTS

Patient satisfaction was high in 15 of 22 patients. Seven patients stated they had problems with activities of daily living after their injury. Only 10 patients returned to the same job they had before their injury; however, all 22 patients were able to return to some type of work. Sixteen of the patients stated they were able to return to their previous level of activity. The wrist flexion-extension arc and grip strength averaged 80% and 77%, respectively, compared with the opposite side. Follow-up radiographs showed no significant change in scapholunate angle or gap with time. As expected the scapholunate cerclage wire broke frequently. The cerclage wire was removed in 16 patients, 12 because of broken hardware and 4 because of pain.

CONCLUSIONS

Our results show that a combined dorsal and volar approach with an intraosseous wiring technique can restore effectively normal intercarpal relationships, providing acceptable pain relief, functional motion, and grip strength.

Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation

Twenty-two consecutive patients (23 wrists) underwent open reduction internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches. One of 5 experienced wrist surgeons performed these procedures within an average of 3 days of injury (range, 0-26 days) and intercarpal fixation was kept within the proximal carpal row. Motion was instituted an average of 10 weeks (range, 5-16 weeks) after injury. All patients were males. The average age at the time of injury was 32 years (range, 16-60 years). The average follow-up period was 37 months (range, 13-65 months). Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively, compared with the contralateral wrist. The scapholunate angle increased and the revised carpal height ratio decreased over time, which was statistically significant for both measurements. Three patients (3 wrists) required wrist arthrodesis and a fourth patient had an immediate scaphoid excision and 4-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched US population values; physical summary scores were significantly less. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Seventy-three percent of all patients had returned to full duties in their usual occupations and a total of 82% were employed.

Lunotriquetral instability: diagnosis and treatment

Isolated injury of the lunotriquetral interosseous ligament complex and associated structures is less common and is poorly understood compared with the other proximal-row ligament injury, scapholunate dissociation. The spectrum of injuries ranges from isolated partial tears to frank dislocation, and from dynamic to static carpal instability. The diagnosis may be difficult to establish because of the many possible causes of ulnar-sided wrist pain and the often normal radiographic appearance. The mechanism of injury is variable and includes attrition by age, positive ulnar variance, and perilunate or reverse perilunate injury. Appropriate treatment requires assessment of the degree of instability and the chronicity of the injury. Options include corticosteroid injection, immobilization, ligament repair, ligament reconstruction with tendon grafts, limited intercarpal arthrodesis, and ulnar shortening.

Complications of hand and wrist surgery in the athlete

The hand injuries reviewed in this article are those about which the treating physician should be suspicious, whether an athlete presents with them on the field or shortly thereafter in the emergency department or clinic. Education on the part of the physician and the patient are the primary safeguards to limiting complications.