Wrist

Arthroscopy

Indications

 

TFCC tears

SL instability

Dorsal wrist ganglion

Scaphoid fracture with percutaneous pinning

Distal radius fracture

 

Setup

 

Tourniquet

 

Finger Traps Index & middle

 

Overhead traction device

 

Wrist Scope set up

 

2.7 mm scope / small joint instrumentation

- insufflate with saline first at 3-4

 

Wrist Scope Insufflation

 

Radiocarpal Joint

 

RCJ is U shaped

 

Portals are between extensor compartments

- longitudinal incisions to protect extensor tendons

- blunt dissection to preserve SRN branches

- angle 30o volar due to shape distal radius

 

Wrist scope portalsWrist scope radiocarpal portal

 

3-4 Portal

- feel Lister's tubercle

- 1 cm distal is soft spot between 3 and 4

- between distal radius and scapholunate

- primary viewing portal

 

4-5 Portal

- roll finger over mobile 4th compartment

- feel soft spot

- slightly proximal to 3-4 because of slope of radius

- between distal radius and lunatetriquetral

- instrumentation

 

6-R and 6-U

- Named after their position about ECU

- 6-R working

- 6-U inflow

 

Midcarpal Joint

 

Anatomy

 

MCJ is S shaped

- midcarpal & radiocarpal have separate synovial cavities unless the SLL is torn

 

Midcarpal radial / MCR Portal

- 1 cm distal to 3/4 portal

- radial side of the third metacarpal axis 

- in line with Lister's tubercle

- soft depression between the capitate and scaphoid

- working portal

 

Midcarpal ulna / MCU Portal

- 1 cm distal to 4/5 portal

- in line with 4th metacarpal

- distal to lunate-triquetral joint

- proximal to capitate and hamate

 

Wrist scope portalsWrist Scope Midcarpal Scope

 

Radiocarpal Joint

 

Start at radial styloid and scaphoid

- work radial to ulnar

 

Distal radius

 

RSC Ligament

- immediately beside is Long RLL

- is extremely wide usually x3 RSCL

- next is short RLL

- often see blood vessels along this ligament

 

Scapholunate ligament

- examine from membranous prox portion to thicker dorsal ligamentous portion

 

Wrist scope SL Ligament Radiocarpal joint

 

TFCC

 

Follow ulnarly along lunate and its fossa 

- should be taut like a trampoline 

- actual ballottement with probe should give same feeling 

- trampoline test

 

Wrist Scope TFCC

 

Examine for tears 

- central or peripheral

- ulnar styloid recess is normal finding at base of styloid not a tear

 

Lunate chondromalacia

 

Midcarpal joint

 

Curved of head of capitate

 

Wrist scope midcarpal joint

 

SL joint

 

Wrist scope midcarpal joint SL jointWrist scope Midcarpal Joint Normal SL ligament

 

Lunate-triquetral joint

 

Wrist Scope Midcarpal Normal Lunate Triquetrum

 

Specific Conditions

 

Carpal Instability

 

SL and LT Ligaments

- must look from radiocarpal and midcarpal joints

- both joint ligaments should be tight and concave

- if inflow in RCJ with midcarpal outflow have tear in ligament

 

Arthroscopic classification

 

1.  Attenuation or haemorrhage within ligament

- no step

- can debride partial tears with good results

- Rx cast immobilisation

 

II. Incongruency or step-off in midcarpal space

- Use k-wire as joy stick to reduce

- treat with arthroscopic pinning

- 80% reported good results

 

III. Step-off on both sides

- pprobe may be passed between bones

- treat with arthroscopic or open repair

 

IV. Gross instability

- open repair

 

TFCC Injuries

 

Use 4-5 portal as visual portal and 6-R as working portal

 

Issues

- degenerative or traumatic

- central or peripheral

- with or without DRUJ instability

- without or without chondromalacia

- radial or ulnar avulsions

- +/- Styloid fracture

 

Techniques

 

Debride central tears acute or degenerative

 

Attempt repair of peripheral tears

 

Unstable DRUJ

- reinforce DRUL or PRUL with strip of ECU

 

Degenerative tear and ulnar plus 

- add ulnar shortening to debridement

- can perform arthroscopic wafer procedure

Base of Thumb OA

Definition

 

Degenerative arthritis at trapeziometacarpal joint (CMC)

- trapezoid - metacarpal

 

Epidemiology

 

Commonest hand joint involved in OA 

 

Most common in older women                                      

- 90% are females > 50 years                                                

- asymptomatic degenerative changes common

 

Associated with arthritis in scapho-trapezial joint in 50%

 

Anatomy

 

1.  Trapeziometacarpal Joint (TMJ)

2.  Scaphotrapezial Joint (STJ)

3.  Trapeziotrapezoidal Joint

4.  Trapezium - Index Metacarpal Joint

 

The last two joints are rarely involved with OA

 

Saddle shaped

- allows movement in 3 planes

- flexion / extension

- adduction / abduction

- opposition

 

Volar, palmar oblique "beak" ligament

- provides stability of TMT

- origin is volar tubercle trapezium

- insertion ulna base of MC

- resists dorsal subluxation

 

Palmar 1/2 loaded > dorsal

- 13 x pressure with pinch

 

Aetiology

 

Primary

 

Combination of                                                                

- high compressive loads                                          

- relatively unstable joint                                              

- complex range of movement

 

May be related to ligamentous laxity

 

Secondary

 

Gout                                                                

Rheumatoid arthritis                                              

Infection                                                                  

Trauma

 

Eaton Classification

 

Stage 1 

 

Joint normal with synovitis 

 

Stage 2 

 

Joint space narrowed                                                    

- may be mild subluxation (< 1/3) 

 

CMC OA Stage 2

 

Stage 3 

 

Joint space obliterated                                                

 

Subluxation base of thumb

- adducted position

- proximally is anchored by adductor pollicis

- base subluxes radially / beak ligament ruptured

 

CMC OA Stage 3

 

Stage 4 

 

Involvement of multiple joint surfaces especially STT joint

 

CMC OA Stage 4CMC OA Stage 4

 

Symptoms

 

Pain at base of thumb especially with pinch grip 

 

Becomes constant / difficulties with ADL 

 

Stiff thumb 

 

Weak pinch grip

 

Examination

 

Base of Thumb OA

 

Tenderness around CMC joint

 

Swelling from 

- synovitis 

- osteophytes 

 

Positive grind test 

- passive thumb circumduction and axial loading 

- causes pain 

 

Web space contracture

- fixed flexion-adduction contracture of 1st MC 

- compensatory MCPJ extension

 

DDx

 

De Quervain's

Radiocarpal OA

SNAC / SLAC

Scaphoid nonunion

Carpal tunnel syndrome 

FCR synovitis 

Volar ganglion

SRN neuroma

 

Management

 

Nonoperative Management

 

Majority of patients do not require surgery

 

Options

 

Rest / static splinting / thumb spica

 

Oral analgesics and NSAIDS

 

Intra-articular steroids / US guided

 

Operative Management

 

1.  Reconstruction of the volar ligament

 

Indication

- stage 1 disease

- non responsive to non operative management

 

Advantages

- minimises progression of degenerative changes

 

Technique

- reconstruction of the volar ligament with slip FCR

- tendon passed through MC base and trapezium 

- create stabilising ligament (tenodesis) 

 

2.  CMC Arthrodesis

 

Indication

- stage II and III disease 

- young manual workers 

- ligamentous laxity and neurological conditions

 

Contraindications

- pantrapezial OA

- i.e. involvement of STJ

 

Advantages

- pain-free 

- strong pinch 

- allows heavy use

 

Disadvantages

 

1.  Limits mobility of thumb MC 

- loss of abduction / adduction

- unable to put palm flat on table

 

2.  Increases stress on adjacent joints 

 

Position

- thumb position when fist made 

- 30-40o palmar abduction 

- 10-15o radial abduction

 

Technique

- dorsal incision at base of thumb over CMCJ

- dorsal to APL, between EPL and EPB

- protect SRN

- protect radial artery as it passes dorsally over STJ

- transverse incision capsule

- cut articular surfaces with saw

- ensure can pinch grip with IF / MF

- ensure can place across palm

- headless compression screws / plate

- POP for 6 weeks

 

3.  Hemitrapeziectomy

 

Removal of distal half of trapezium only

 

4.  Excisional arthroplasty / trapeziectomy

 

Thumb Trapeziectomy

 

Indications

- stage II & III disease

- no significant MC subluxation

 

Technique

- simple excision of trapezium

 

Advantages

- simple procedure 

- minimal immobilisation

 

Disadvantages

- shortening of thumb ray 

- weakness of pinch 

- thumb adduction

 

Results

- trapeziectomy without interposition / ligament reconstruction

- no evidence has worse results than any other more complicated procedure

 

5.  Trapeziectomy and LRTI

 

Indications

- stage III and IV disease 

 

Concept

- trapeziectomy +

- ligament reconstruction of beak ligament with FCR / PL

- tendon interposition (FCR / PL / Capsule)

 

Supposed Advantages

- maintains strength / pinch grip

- prevents shortening

 

Disadvantages

- tendon harvest

- longer / more involved procedure

- no evidence of improvement of pinch grip / prevention of shortening

 

Approach

 

Incision

- dorsoradial

- junction of volar and dorsal skin

 

Dissection

- protect SRN

- between APL and opponens

- radial artery over ST Joint 

- open capsule over trapezium 

- elevate thenar muscles from trapezium and 1st MC 

 

Excise trapezium 

- remove bone piecemeal / or in one piece 

- take care not to damage underlying FCR 

 

LRTI Technique 1

 

Make hole in base of MC 

- perpendicular to plane of thumbnail 

- from radial cortex to base 

 

Harvest lateral half FCR

- 10 - 12 cm strip

- 2 - 3 transverse incisions in forearm over FRC

- split all the way to base of second MT

- pass through base second MT then radial cortex

- pass around base to resurface

- suture to itself whilst pushing MC base medially

 

Make spacer 

- anchovy tendon on itself 

- insert it into trapezium fossa 

 

Stabilise with K wire

- MC reduced and out to length

 

Close wound & apply thumb spica 

 

Postoperative 

- ROS and K wire at 10 days 

- splint for another 3 weeks 

- progressive exercises

 

LRTI Technique 2

 

Harvest PL

- leave attached distally

- pass into base of thumb under FCR to where trapezium used to be

- ligament suspension by passing through radial capsule and FCR multiple times

- tightens the capsule and FCR into the gap

 

Capsular interposition technique

 

Open capsule as a distally base flap

- after trapeziectomy suture into base of wound as interposition

 

Results

- > 90% satisfactory results long-term 

- > 95% pain relief

- > 90% increased grip strength

- average loss of height is 13% at 9 years

 

6.  Silicone replacement arthroplasty

 

Indications

- stage III and IV disease 

- low-demand patient

- rheumatoid

 

Concept

- trapeziectomy

- insert silicone trapezium

 

Advantages

- retains movement at CMC joint

 

Disadvantages

- subluxation or dislocation 

- prosthesis breakage (50% at 4 years) 

- silicone synovitis 

 

Issue

- address subluxation by soft tissue reconstruction 

- strip of APL can be passed through hole in prosthesis 

 

7.  Joint replacement

 

High revision rate

- pain

- lysis

- loosening

 

Carpal Instability

Background

Definition

 

Loss of normal ligamentous and / or bony constraints of wrist

 

Anatomy

 

Overall alignment maintained by extrinsic and intrinsic  ligaments

 

1.  Intrinsic ligaments

 

Carpal bone to carpal bone

- support the lunate in a balanced position

 

A.  Scapho-lunate ligaments

 

SL ligament can be divided into three different zones

- dorsal ligamentous zone (structurally the most important)

- palmar ligamentous zone 

- proximal membranous fibrocartilaginous zone

 

B.  Luno-triquetral ligaments 

- also 3 components

- volar most strong

 

2.  Extrinsic Ligaments

 

Radius to carpus 

- obliquely oriented

- resist the tendency of the carpus to migrate ulnarly and palmarly

 

A.  Palmar extrinsic ligaments

 

A. Radioscaphocapitate ligament

B. Radiolunate ligament

C. Radioscapholunate ligament

- probably just a vascular fold

D. Ulnocarpal ligaments

E. Lunotriquetral ligament

 

Space of Poirier

- weak area of the palmar ligaments

 

B.  Dorsal Extrinsics

 

A. Dorsal radiotriquetral ligament / Dorsal radiocarpal ligament (DRC)

B. Dorsal radioulnar ligament

C. Triquetroscaphoid ligament / Dorsal intercarpal ligament (DIC)

 

No tendons attach to proximal row

 

Note: 

- acess to dorsal carpus

- raise a radially based flap

- between radiotriquetral and triquetroscaphoid

- between DRC and DIC

 

Biomechanics

 

Motion

 

Capitate is centre of rotation

 

Flexion / Extension

- 120o

- 50% midcarpal

- 50% radiocarpal

 

Radial / ulna deviation

- 60% midcarpal

- 40% radiocarpal

 

Radial deviation

- 20o

- proximal row and scaphoid flexes

 

Ulnar deviation

- 30o

- proximal row and scaphoid extends

 

Load transfer

 

Radius 80%

Ulna 20% (all via TFCC)

 

Pathology

 

Division of the scapholunate ligament 

- allows the lunate to follow the triquetrum's unrestrained position of extension

- dorsal intercalated segmental instability pattern (DISI)

- scaphoid flexes, lunate extends

 

Lunotriquetral ligament disruption 

- allows the lunate to follow the scaphoid into its position of unrestrained flexion

- lunate flexes

- volar intercalated segmental instability pattern (VlSI)

 

Classification of Carpal Instabilities (Amadio)

 

I. Carpal instability dissociative (CID)

 

Transverse injury

 

Injury inter-osseous ligaments

- within the carpal rows

- disassociative rather than associative motion between the bones of each row

 

A.Dorsiflexion (DISI)

- scapholunate ligament injury

 

B. Palmar flexion (VISI)

- triquetrolunate injury

 

II. Carpal instability non-dissociative (CIND)

 

Transverse injury

 

Normal associative motion between the bones of each carpal row 

- the dissociation is between rows

 

A. Radiocarpal Dislocation

 

CIND Dislocated Radiocarpal Joint APDislocated Radiocarpal Joint lateral

 

Radiocarpal Dislocation CT 1Radiocarpal Dislocation CT 2Radiocarpal Dislocation CT 3

 

B. Midcarpal

 

C. Ulnar Translocation

 

CIND DISI

 

Secondary to radial malunion

- treat with radial osteotomy if symptomatic

 

DISI CIND Secondary Radial Fracture

 

CIND VISI

 

Secondary to ligamentous laxity

- non operative treatment

- no progression to OA

 

Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation

 

III. Carpal instability complex (CIC)

 

Hyperextension injury

 

As the hand is forced into hyperextension

- ulnar deviation and intercarpal supination

- the ligamentous disruption

 

Mayfield Cadaver study 

- extend, ulna deviate, supinate

 

Stage 1 

- SL dissociation 

 

Stage 2

- CL dissociation 

- capitate dislocates

 

Stage 3

-  LT dissociation

 

Stage 4

-  Lunate dislocates

 

Types

 

A. Perilunate Dislocation

1. Dorsal (10%)

2. Volar (90%)

 

B. Trans-scaphoid Perilunate

 

IV. Carpal instability longitudinal (axial)

 

Longitudinal injury

 

The carpus may also be disrupted in a longitudinal fashion, as opposed to the perilunate transverse pattern

 

Classification

 

A.  Axial Ulnar (AU)

B.  Axial Radial (AR)

C. Axial Ulnar-Radial (AUR) / Combined

 

These are severe injuries

- crush, blast or compression

- may be open injuries

- not a diagnostic dilemma

 

Usually wrist is split into two columns

- metacarpals follow their corresponding carpus

 

Management

 

Deal with wounds and nerve / tendon injuries

CTD

K wire fixation

 

Greater and Lesser Arc Injuries

 

Greater arc injury

- fracture-dislocation of the scaphoid, capitate, hamate, triquetrum

- may include radial styloid

 

Lesser arc injury 

- a pure ligamentous injury

- around the lunate

 

 

 

 

 

Radiocarpal & Midcarpal Dislocation

A. Radiocarpal Dislocation

 

Dislocated Radiocarpal Joint Dislocated Radiocarpal Joint AP

 

Dislocated Radiocarpal Joint CT 1Dislocated Radiocarpal Joint CT 2Dislocated Radiocarpal Joint CT 3

 

Dorsal Radiocarpal Dislocation ORIF 1Dorsal Radiocarpal Dislocation ORIF 2

 

B. Midcarpal Dislocation

 

 

SLAC Wrist

Definition

SLAC Wrist

 

Scapho-lunate advanced collapse

- caused by malalignment of scaphoid on radius

- due to scapholunate disruption

 

Most common cause of wrist OA

 

Pathology

 

1.  Radio-scaphoid degenerative changes

- from abnormal flexion of scaphoid

- scaphoid fossa is elliptical causing incongruence with flexion of proximal scaphoid

- loads scaphoid fossa of radius peripherally

 

2.  Radiolunate joint preserved

- lunate fossa and proximal lunate spherical and congruent

 

3.  Capitate under increasing load descends into gap

- increasing loads on capitolunate joint

- separation of scaphoid and lunate

- capitate shears off radial edge of lunate

- get destruction on both lunate and proximal capitate 

 

X-ray

 

OA radio-scaphoid joint

Preservation of radiolunate joint

 

Staging

 

1.  Styloid OA

 

Stage 1 SLAC Radial Styloid OA

 

2.  Scaphoid Fossa OA

 

SLAC CT

 

3.  Lunato-capitate OA

- capitate descends in SL gap

 

SLAC Lunate Capitate OA

 

4.  Pancarpal OA

 

DDx

 

SNAC

- preservation of scaphoid fossa and proximal scaphoid congruence

- arthritis at scapho-capitate joint

 

Management

 

Stage 1

 

Definition

- styloid OA

- degeneration between the radial styloid and distal pole scaphoid

 

Options

 

1.  Styloidectomy

- early disease can respond well to styloidectomy

- remove at level A / no removal of scaphoid fossa

 

2.  Scapholunate Reconstruction 

 

A.  Excise fibrous tissue and insert SL screw

- fibrous ankylosis

- remove screw at 12/12

 

B.  Bone blocks with ligament

 

Stage 2 

 

Definition

- scaphoid fossa OA

- OA extends to involve scaphoid fossa and proximal pole scaphoid

 

Options

 

A.  Scaphoidectomy & four corner fusion

B.  Proximal Row Carpectomy

 

Scaphoidectomy & Four Corner Fusion

 

Scaphoidectomy and 4 corner fusion

 

Theory

- fusion of lunate to capitate

- loading is through normal lunate fossa

- fusion of lunate-capitate can be difficult

- add hamate and triquetrum in so called 4 corner fusion

- greatly increases fusion rates

- seemingly no deleterious effects

- if leave out scaphoid replacement tends to drift into radial deviation

- can use scaphoid for bone graft (but may not be high quality)

 

Advantage

- increased stability comared with PRC

- increased ROM compared with total wrist arthrodesis

 

Approach

- universal posterior approach

- base of EPL (3/4 interval)

- can use Lister's tubercle for BG

- make window on radial side so as not to get late rupture of EPL

- denervate wrist / remove terminal branch PIN

- ligament sparing exposure / open capsule between dorsal intercarpal and radiocarpal

- closure ER under EPL at end of case

 

Technique

- resect scaphoid

- denude surfaces of lunate / capitate / hamate / triquetrum

- use good quality BG from distal radius

- must reduce the lunate out of extension or will impinge dorsally

 

Scaphoidectomy 4 corner Fusion APScaphoidectomy 4 corner Fusion Lateral

 

Fixation

- headless compression screws

- dorsal circular plate

- K wires

 

Results

- strength 75-80% normal

- ROM 40 - 60% of normal

 

B.  Proximal row carpectomy

 

Proximal Row Carpectomy

 

Aim

- for capitate to articulate with distal radius

 

Disadvantages

- proximal capitate often devoid of good cartilage

- discard good lunate cartilage

- weakness ensues due to lengthening of tendons

- reported pain / instability / degeneration

 

Indications

- probably best in low demand patients

- not in stage 3 SLAC

 

Technique

- perform through standard dorsal approach

 

Results

- RCT of 4 corner fusion v PRC are comparable

 

Stage 3 

 

Definition

 

Capito-lunate OA 

- capitate migrates proximally between the scaphoid and the lunate

 

Options

 

A. Scaphoid excision & 4 corner fusion

B. Proximal Row Carpectomy

C. Wrist Arthrodesis

 

Note

- PRC may be bad options in stage 3

- they depend on the capitate and by definition the capitate is arthritic

 

Stage 4

 

Definition

 

Collapse / pancarpal OA

 

Options

 

Wrist arthrodesis

 

 

Scapholunate Ligament Injury / DISI

Scapholunate Disassocation

 

Definition

 

Dorsal Intercalated Segmental Instability / CID

 

Anatomy

 

Scapholunate joint

- C shaped

- 2-3 mm thick dorsally with transverse fibres

- thin palmar

 

Dorsal extrinsic ligaments

- V shaped, onto trapezium

 

1.  Dorsal RC ligament / DRC

- radius to triquetrum

 

2.  Dorsal Intercarpal Ligament / DIC

- trapezius to scaphoid

 

Between these two ligaments is access to SL joint

 

Volar extrinsic ligaments

 

Radioscapholunate

- ligament of Testut

 

Epidemiology

 

Most common form of carpal instability

 

Classification

 

CID

 

Static

- SL diastasis

 

Dynamic

- positive Kirk Watson test

- nil SL diastasis without dynamic / stress imaging

 

CIND DISI

- secondary to radial malunion

- adaptive posture of proximal row

- lunate extends

- capitate translates dorsally and get OA

- treat with radial osteotomy if symptomatic

 

Aetiology

 

FOOSH

 

Scapholunate dissociation

- Mayfield Stage 1

 

Wrist extended / ulna deviated / supinated

- capitate driven into interval between scaphoid and lunate

 

Pathomechanics

 

CID (Complex Instability Dissociative)

- disassociation between scaphoid and lunate

- Palmarflexion of scaphoid

- dorsiflexion of lunate

 

The scaphoid will move into flexion

- due to its ligamentous attachments to the distal carpal row

 

Lunate extends

- due to ligamentous attachment to triquetrum

 

History

 

History of injury 

Pain on radial side of wrist 

Weakness of wrist 

 

Certain movements may cause clicking or snapping

 

DDx

 

DR / scaphoid fracture

Dequervain's

Neuroma

Ganglion

STT, wrist, RC OA

 

Examination

 

Swelling and tenderness over SLJ

- most specific 

 

Pain with dorsiflexion and radial deviation

 

Kirk-Watson test 

 

Kirk Watson Test 1Kirk Watson Test 2

 

1.  Passive wrist ulnar deviation

- thumb on dorsum wrist / index finger on scaphoid tuberosity 

- in wrists with instability, the scaphoid is displaced dorsally over the lip of the radius

 

2.  Passive wrist radial deviation 

- the scaphoid's proximal pole returns to its position in the scaphoid fossa of the radius 

- as the scaphoid reduces, a clunking sensation and wrist pain are noted

 

1000 randomly examined wrists 

- 11% had unilateral, asymptomatic increased scaphoid mobility on KW test

 

Patients with dynamic instability are distinguished by

- symptoms of instability and pain with KW test

 

X-ray

 

Look for signs of SLAC wrist

- degenerative changes of scaphoid fossa with relative sparing lunate fossa

- indicates long standing

 

AP 

 

Terry Thomas sign 

- increased scapholunate interval 

- > 3 mm compared with other side

 

Scapholunate diasstasis

 

Stress views

- bilateral wrists clenched 

- in ulnar deviation 

- in radial deviation 

- may show Terry Thomas sign

 

Cortical Ring sign 

- end-on view of cortex of distal pole of scaphoid

 

Scapholunate Disassocation Cortical Ring Sign

 

Scaphoid shortened

- due to palmar flexion

 

SL injury shortened scaphoid

 

Lateral

 

Palmarflexion of scaphoid 

 

Dorsiflexion of lunate 

 

Increased scapholunate angle 

- > 70o

- usually 30 - 60o

 

Scapholunate Angle IncreasedScapholunate Angle IncreasedIncreased Scapholunate Angle

 

Increased luno-capitate angle

- normally < 10o

 

Scapholunate Injury Increased Lunate Capitate AngleIncreased Scapholunate Angle

 

Increased radio-lunate angle

- normally < 10o

- lunate extended > 10o

 

MRI

 

Can demonstrate tear

- need experienced radiologist

- need MRI in correct plane

- sensitivity may be as low as 40%

 

Arthroscopy

 

Best method of diagnosis

Gold Standard

 

Acute Management

 

Definition

 

Within 3-6 weeks

 

Options

 

Partial

- immobilise 6 / 52

 

Complete

- SL diastasis

- usually torn off scaphoid

- repair

 

Technique

 

Approach

- dorsal midline approach

- 3 / 4 interval (3rd and 4th extensor compartments)

- open capsule between DRC and DIC ligaments

- radially based flap

 

Reduction

- K wires into scaphoid and lunate

- use as joystick to reduce

- extend scaphoid, some flexion of lunate

- K wire fixation to hold in place (SL and SC x 2)

- neutralises rotational forces during healing

 

Repair

- micro anchors ain scaphoid

- or can place drill holes in scaphoid to pass sutures

- 2.0 ethibond

 

+ / - Augmentation

- Blatt capsulodesis

- SL screw / pseudoarthrosis

 

Post op

- 8 weeks POP

- remove K wires

- patient will lose some ROM

 

Chronic

 

Definition

 

> 12 weeks 

 

Indications

 

Failed reconstruction / missed injury

 

Failed Scapholunate Reconstruction

 

Surgery only for significant disability 

- no reconstructive technique excellent

- inconsistent results, loss of reduction, loss of pain relief over time

 

Options 

 

Ligament repair

Ligament reconstruction

Blatt capsulodesis

Reverse Blatt capsulodesis

Brunelli Tendodesis

Limited wrist fusion

 

1.  Ligament repair and capsulodesis

 

Sufficient tissue available for repair

Reinforce with Blatt capsulodesis

 

2.  Ligament reconstruction

 

Scapholunate Ligament Reconstruction APScapholunate Ligament Reconstruction Lateral

 

3.  Blatt Capsulodesis

 

Indications

- chronic DISI with insufficient tissue for repair

- to augment ligament repair

- dynamic instability

 

Technique

- dorsal, proximally based capsular flap 1 cm wide

- reduce scaphoid out of flexion and K wire (SL / SC)

- suture anchor distal pole scaphoid and attach capsular flap

- prevents flexion of scaphoid

- may combine with SLL reconstruction with PL

 

Post op

- plaster for 2/12

- removal K wires

 

The patients end up with a stiff wrist

 

4.  Reverse Blatt

 

Difference

- leave capsule attached distally

- advance proximally

- limits wrist flexion

 

5.  Brunelli Wrist Tenodesis

 

Harvest half FCR

- pass volar to dorsal through hole distal scaphoid

- insert dorsally into distal radius

- serves to derotate scaphoid

 

6.  Limited fusion 

 

Radial styloidectomy and STT fusion

 

Concept

- stabilise scaphoid in extended position

 

Kleinman J Hand Surg Am 1998

- no progression of arthritis seen in 16 wrists

 

 

VISI

Definition

 

Volar Intercalated Segmental Instability

- secondary to injury to the lunate-triquetral ligament

 

Epidemiology

 

Less common

 

Aetiology

 

Caused by fall on outstretched extended wrist

- hypothenar eminence strikes ground first 

- isolated LT ligament injury

 

Can be part of perilunate dislocation

- SL heals

- residual LT laxity

 

Anatomy

 

LT ligament

- also C shaped

- strongest palmar

 

Pathomechanics

 

Normally

- scaphoid imparts a flexion moment on proximal row

- triquetrum imparts an extension moment

- balanced by ligamentous attachments to lunate

 

Palmarflexion of lunate with dorsiflexion of triquetrum

 

Probably need injury to dorsal extrinsics to impart static collapse

- DRC ligament (radio-triquetral)

- ulnocarpal ligament

 

Classification

 

CID

 

Static

 

Dynamic

 

CIND VISI

 

Secondary to ligamentous laxity

- seen in teenage girls

- clunk on radial and ulna deviation with axial compression

 

Whole proximal row is flexed

- lunate triangular

- scaphoid cortical ring sign

- no SL disassociation

 

Non operative treatment

- no progression to OA

 

Symptoms

 

History of injury 

 

Pain on ulnar side of wrist 

 

Weakness of wrist

 

Signs

 

Swelling and tenderness over triquetro-lunate joint 

 

Ulna deviation / pronation / axial compression

- pain and clicks

 

Reagan Ballotment 

- Triquetro-lunate ballottement

- pisiform-triquetral with thumb and index finger

- lunate with other hand

 

Lunate Triquetral Ballotment

 

DDx

 

DRUJ instability

TFCC tear

Ulna head OA

Pisiform triquetral OA

Hamate fracture

ECU subluxation

 

AP Xray

 

Palmarflexion of scaphoid 

- Scaphoid shortened 

- Ring sign 

 

Palmarflexion of lunate 

- Appears triangular 

- Triquetrum distally displaced 

 

Broken Shenton's line (of proximal carpal row)

 

Lateral Xray

 

Decreased scapholunate angle 

- < 30o

 

Palmarflexion of lunate 

- capitate - lunate angle > 10o

- radio - lunate angle > 10o

 

Arthroscopy

 

Diagnostic and therapeutic

 

Management

 

Early

 

Options

 

A.  Repair

- dorsal approach

- restore LT orientation with K wires

- repair ligament with intra-osseous sutures

 

B Reconstruct with ECU

- if insufficient ligament for repair

- radial half of ECU

- pass through drill holes

 

Late

 

> 6 weeks 

 

Lunate-triquetral fusion

- very difficult

- high failure with k wires

- need compression screws

- insert bone graft

 

 

DDx Radial wrist pain

DOG WRIST RIFT

 

De Quervain tenosynovitis

OA CMC / STT

G   Ganglion - volar 

 

W  Wartenberg's Syndrome (Compression Superficial Branch Radial nerve)

R   Radial artery thrombosis

I    Intersection syndrome (ECRL/B crossed by APL & EPB)

S   Scaphoid fracture / non-union / SL instability / SLAC wrist

T   Tumour

 

R   RA - more common ulna 

I    Infection

F   FCR synovitis 

T   CTS

 

 

DRUJ / TFCC

Anatomy

Anatomy

 

1.  TFCC 

- central articular disc

- TFCC is major stabiliser of DRUJ

- arises ulnar aspect of lunate fossa of radius

- inserts fovea at base of ulna styloid

 

2.  Dorsal and Palmar Radio-Ulna ligaments 

 

Thick fibrous structures

- from ulna styloid

- important stabilises of DRUJ

 

In normal wrist

- Dorsal RU ligament tight in pronation

- Palmar RU ligament tight in supination

 

Unstable wrist is opposite

- in pronation wants to dislocate dorsally 

- PRUL which tightens

- in supination wants to dislocate volar

- DRUL tightens

 

3.  ECU Sheath

 

4.  Ulna Collateral ligament

- arises base of ECU sheath

 

5.  Ulnotriquetral / Ulnolunate ligaments

- ulno-carpal ligaments

- play important role 

- not part of TFCC

 

Conditions

 

TFCC tears

DRUJ instability (acute or chronic)

DRUJ arthritis

 

 

 

DRUJ Arthritis

 

DRUJ ArthritisDRUJ Arthritis

 

Options

 

Darrach's

- distal ulna excision

- best for elderly RA patient

 

Bower's interpositional hemiarthoplasty

 

Technique

- best for young OA

- excision of arthritic portion through 5/6 compartment / hemiresection

- intact TFCC for interposition

 

Indications

- young OA

- not suitable in RA as TFCC damaged

 

DRUJ Hemiresection

 

Suav-Kapanji

 

Technique

- distal radio-ulna arthrodesis with distal ulna pseuodoarthrosis

- distal ulna fused to distal radius with 2 screws

- distal ulna stabilised with half FCU

- interposition with pronator quadratus

 

DRUJ Replacement

 

DRUJ ReplacementDRUJ Replacement

 

 

DRUJ Instability

Types

 

Dorsal

- most common

Volar

 

Causes

 

1.  Acute traumatic peripheral tear TFCC with DRUJ dislocation

- usually major trauma

- dorsal or volar

 

2A.  Distal radial fracture

- Galleazzi fracture

- sigmoid notch fracture

 

2B.  Radial Malunion

 

3.  Ulna styloid fracture

 

4.  Essex Lopresti 

- fracture radial head with dislocation DRUJ

 

Diagnosis

 

Xray

- need true lateral

- ensure radial styloid overlies proximal scaphoid / lunate / triquetram

 

CT

- Axial view shows DRUJ incongruency

 

1A.  Dorsal Dislocation DRUJ

 

Mechanism

- hyperpronation

- tear of dorsal distal RUJ ligament

- with partial or complete TFCC tear

 

Clinically

- dorsal prominence

- forearm locked in pronation

- attempted supination painful

 

CT scan

 

Management

 

1.  Closed reduction

- maintain in supination 4/52

 

2.  Open reduction

- rarely needed

- failure closed reduction (ECU incarceration)

- chronically dislocated

- may require acute repair TFCC +/- K wires

 

TFCC Repair + K wire

 

1B.  Volar Dislocation DRUJ

 

Mechanism

- forced supination

- usually complete tear TFCC

 

Clinically

- arm locked in supination

 

CT scan

 

Management

- closed reduction

- maintain in pronation 4 weeks

- rarely need open reduction or in chronic cases

 

2A.  Acute Distal radial fracture / Galleazzi

 

Incidence

- up to 60%

 

Treatment

- Anatomical reduction of radius

- usually makes DRUJ stable

- rarely need to repair TFCC / K wire for stability

 

2B. Radial malunion / Non anatomical ORIF

 

A. Short radial fracture

- lengthening radius difficult

- ulna shortening

 

B.  Angulation / rotation

- radial osteotomy

- TFCC repair

- +/- TFCC reconstruction with strip ECU

 

3.  Displaced ulna styloid

 

Classification

 

Type 1

- tip fracture

- stable DRUJ

 

Ulna Styloid Tip FractureUlna Styloid Tip Fracture

 

Type 2

- base fracture

- unstable DRUJ

 

Wrist Ulna Styloid Fracture

 

Management

 

POP immobilisation in neutral rotation and UD for 6/52 

- ensure DRUJ remains located

 

Rarely need ulnar styloid ORIF if displaced and DRUJ unstable

 

4. Essex-Lopresti injury

 

Definition

- fracture radial head with dislocation DRUJ

- Essex-Lopresti variant - radial neck fracture with dislocation DRUJ

 

Type 1

- acute radial head fracture

 

Management

- reconstruct or replace radial head

- assess stability in supination

- occasionally need TFCC repair +/- K wire

 

Type 2

- late

- following excision of radial head with injury to interosseous membrane

- usually occurs within first two years following injury

 

Management

 

Nil degenerative changes

- ulna shortening with plate to reduce DRUJ

- radial head replacement to prevent recurrence

 

Degenerative changes

- Hemiresection / Darrach's / Kapandji

TFCC Tears

Definition

 

Present with pain but not instability

 

Types

 

Traumatic

Degenerative

 

Different treatment algorithms for each

 

History

 

Ulna side wrist pain

- may be worse with rotation

- opening doors and jars

 

History of trauma

 

Examination

 

Local tenderness DRUJ

 

Supinate / pronate

- pain

- click

 

Forcibly ulna deviate and pronate wrist

- grinds carpus against TFCC
- generates pain

 

Check for DRUJ instability / Piano Key

 

Ulna variance

 

Position

 

Xray in neutral supination / pronation

 

Variance is not static

- Pronation increases ulnar variance

- Supination decreases variance

- May be up to 3 mm

 

Measurement

 

Transverse line of lunate fossa

Transverse line of ulna head

 

Variation

 

Population is on average 1 mm ulna plus

- wide variation

- 1/4 wrists are ulna negative

 

Importance

 

Neutral variance

- Takes < 20% of load

 

Ulna Variance Neutral

 

2.5mm Ulnar negative

- 4.3% of load

 

Ulna NegativeUlna Variance Negative

 

2.5mm Ulnar positive

- 42% of load

 

Ulna Variance PositiveUlna Positive with abutmentUlna Variance Positive

 

Xray

 

Ulna Variance

 

Evidence ulnocarpal abutment / arthritis

 

MRI

 

Look for discontinuity of TFCC

- radial / ulna / central / carpal

 

TFCC Tear Ulna Side

 

Palmer Classification TFCC Lesions

 

Class 1 Traumatic

 

A. Central perforation

B. Ulnar avulsion 

- With distal ulnar fracture

- Without distal ulnar fracture

C. Carpal / Distal avulsion

- ulno-carpal ligament injury

D. Radial avulsion (+/- sigmoid notch fracture) 

 

Class 2 Degenerative 

 

Central

 

A. TFCC wear

B. TFCC wear

+ lunate and/or ulnar chondromalacia

C. TFCC perforation

+ lunate and/or ulnar chondromalacia 

D. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

E. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

+ ulnocarpal arthritis

 

TFCC Degenerative Tear with Chondromalacia

 

Arthroscopy

 

Diagnose central tears

 

Trampoline test

- TFCC should bounce on probe

- if very soft, likely has a peripheral tear

 

Management

 

Concepts

- acute repair if DRUJ unstable

- delayed repair if continued symptoms and ulna / radial tear

- debridement of central tears + ulna shortening if ulna positive

- ulna shortening if ulnocarpal abutment / arthritis

 

Class 1 Traumatic

 

A.  Ulna

 

Acute Injury

 

1.  Stable DRUJ

- immobilise in neutral rotation

- need long arm cast

- surgical repair if continued symptoms / non healing

 

2.  Unstable DRUJ

 

A.  Obtain closed reduction / supination

- immobilise

 

B.  Failure closed reduction

- open / arthroscopic TFCC repair to stabilise DRUJ

 

Operative repair

 

Indications

- acute instability

- continues pain / late presentation

 

Open

- good success as very vascular

- 5/6 approach / bed of EDM

- interval between EDM and ECU

- open capsule

- sutures in TFCC, pass  through drill holes in base ulna styloid

- immobilise in cast

 

Arthroscopic

 

B.  Radial

 

Commonest

- difficult to access / repair / very avascular

 

Open repair

- 5/6 approach

- drill holes through dorsal radius into ulna fossa

- use suture retriever

- stabilise with RU K wires if continued instability

 

C.  Central 

 

Site

- usually occur along avascular origin from radius 

- usually 1-2mm from origin

- may be traumatic or degenerative

 

Neutral ulna variance

- Arthroscopic debridement

- 73% success complete pain relief

- Can take central 2/3 of disk without problems

 

Positive ulna variance

- do worse if debride disc alone

- consider combining with ulnar shortening as well

 

Class 2 Degenerative 

 

Class 2A - C

 

Definition

- TFCC wear or perforation

- lunate and / or ulna chondromalacia

- lunate triquetral ligament intact

 

1.  Positive ulna variance

 

Shorten ulna +/- arthroscopic debridement TFCC

 

Options

 

A.  Ulnar shortening and plate fixation

- specific plates (Trimed)

- have advantage of rotational control throughout procedure

- midportion ulna, apply plate dorsal

- fix distally, sliding screw proximally

- oblique osteotomy through jig

- 5 or 8 mm

- shorten, lag screw through plate

- apply proximal screw

 

Ulna PositiveUlna Shortening

 

B.  Wafer / Bower's hemiresection procedure

- open or arthroscopic

- remove 2-3 mm ulna head

- aim to make ulna negative

- not indicated if > 4mm ulna positive

- leave ulna styloid / TFCC intact

 

2.  Ulna neutral

- arthroscopic debridement

- +/- ulna shortening

 

Class 2D

 

Definition

- Lunotriquetral ligament perforation

 

Options

- Arthroscopic debridement / ulna shortening 

- LT fusion if unstable

 

Type 2E / Ulnocarpal Impaction Syndrome

 

Definition

- LT ligament perforated

- ulnocarpal abutment / arthritis

 

Associated with positive ulnar variance

- from repetitive loading

 

Ulnocarpal Abutment

 

Options

 

1.  Bower's ulna head hemiresection

- resect 2mm ulna head leaving ulna styloid

- +/- interposition of dorsal capsule

2.  Darrach's

- excision of distal ulan

- +/- stabilisation with tendon transfer

3.  Suave-Kapandji

- distal radioulna fusion

 

 

De Quervain Syndrome

Definition

 

Stenosing tenosynovitis of the first dorsal compartment of wrist

 

Epidemiology

 

Most are middle aged women

 

Aetiology

 

Repetitive thumb movements

- abduction & extension

- combined with RD & UD movements

 

Any mechanical irritation

- foreign body

- prominent bony surface

- restricted fascial compartment

- abnormal muscle to epitenon

 

Anatomy

 

1st dorsal compartment

- over styloid process

- in osseoligamentous tunnel 

- shallow groove in styloid 

- roofed by dorsal ligament 

- attached by fibrous septa to bone

- tunnel ~1cm long

- 20% have 2 compartments

 

EPB

- phylogenetically young muscle

- found only in humans & gorillas as separate from APL

- EPB absent 5-7% 

- inserts base of P1

 

APL

- larger

- 75% of population has 2 or 3 or more tendinous slips

- varous insertions

- base of 1st MC / trapezium / volar carpal ligament /  opponens pollicis / APB

 

Associations

 

RA

Pseudogout / Gout

Hypothyroidism

TB

DM

Vascular Disease

OA

Post Trauma

Gout

Pregnancy

 

Clinical Features

 

Pain & swelling over styloid

 

Positive Finkelstein's test

- grasp the patient's thumb  / ulna deviation of wrist

 

Finkelstein Test

 

Eichoff maneuver

- patient grasps own thumb in fist, ulna deviation of wrist

 

Eichoff Test

 

Crepitus

 

X-ray

 

Exclude base of thumb OA

Look for bony spur that may need resection

 

DDx

 

Wartenberg's Syndrome 

- compression superficial branch radial nerve

 

CMC OA

 

Ganglion

 

Intersection syndrome

- ECRL/B crossed by APL & EPB 

 

Management

 

Non-operative

 

Rest

 

Thumb spica splint

 

HCLA

 

Prolonged conservative treatment

- pregnancy, DM etc

 

Operative

 

Technique

 

Transverse / Longitudinal incision

- longitudinal protects nerve

- transverse gives better scar

 

Identify and protect SRN

 

Divide Annular Ligament 

- ensure all compartments are decompressed

- may be more than one

- make incision ulna side to prevent radial instability

 

Assess floor of compartment for pathology

 

Asses for instability

- Z lengthen and repair fascial roof if present

 

Complications

 

Very common

- radial nerve neuroma / division

- hypertrophic scar from longitudinal incision

- volar subluxation of tendon if remove too much sheath

- insufficient release

 

Distal Radial Malunion

Definition

 

Unacceptable position of radius post fracture

 

1.   Radial Shortening > 4mm at DRUJ

 

Radial Malunion Shortening

 

2.   Radial Inclination < 15°

 

Distal Radial Malunion APRadial Maluion Loss Radial Inclination

 

3.   Radial Tilt 

- > 15° Dorsal 

- > 20° Volar

 

Distal Radial Malunion Dorsal Tilt

 

4.   Articular incongruity > 2mm

 

Distal Radial Step OADistal Radial Step OA 2

 

5.  Positive ulna variance > 4mm

 

Radial Malunion

 

Biomechanics

 

Dorsal Tilting 

 

1.  Increases dorsal load

- maintain midcarpal alignment

 

2.  DISI / CIND

- midcarpal instability

- get DISI pattern without interosseous ligament disruption

- may be increased in patients with ligamentous laxity

 

Radial shortening

 

1.  Alter kinematics of DRUJ

 

2.  Ulnocarpal abutment

 

Clinical Presentation

 

DDx Pain 

- synovitis

- RC OA 

- ulnocarpal abutment

- DISI

- TFCC tear

- RSD

 

Functional Loss of ROM

- DF loss > PF

- supination loss > pronation

- weak grip

 

Investigation

 

PA film in neutral 

- wrist neutral

- elbow & shoulder at 90°

 

5 Measurements

 

1.  Radial inclination

2.  Radial length 

3.  Ulnar Variance 

4.  Radial Tilt  

5.  Radial Shift 

- radial Styloid from longitudinal axis

- compare to contralateral side

 

NHx Painless malunion

 

No evidence for development OA

 

Operative Management

 

Indications

 

Pain

Disability

 

Contraindications

 

OA in RCJ / carpus 

Osteoporosis

CRPS

 

Timing

 

Early > late results

- Jupiter 1996

- < 2/12 since fracture best

 

However, period of non operative treatment is often desirable

 

Surgical Options

 

1.  Ulna shortening

2.  Radial osteotomy

3.  Radial osteotomy + ulna shortening

4.  Radial osteotomy + ulna ablation

5.  Intra-articular ostetomy

6.  Soft tissue releases

 

Ulnar Shortening

 

Indications

- short radius, positive ulna variance

- acceptable alignment distal radius

- acceptable DRUJ articular surface

 

Distal Radial Osteotomy

 

Indications

- positive ulna variance / shortening

- dorsal tilt

- DRUJ reducible by radial osteotomy

- acceptable DRUJ articular surface

 

Options

- dorsal opening wedge

- volar opening wedge

- volar closing wege

 

Dorsal Opening wedge osteotomy

 

Distal Radial Malunion Dorsal OsteotomyDistal Radial Malunion Dorsal Osteotomy

 

Advantage

- lengthens the distal radius

- may be easier to correct in coronal and sagittal plane

- this makes it the most popular

 

Disadvantage

- dorsal approach / dorsal plate (extensor tendon issues)

- usually requires bone graft

- increased instability

- increased risk of non union

 

Template

- xray normal wrist

- calculate correction / size of bone graft

 

Dorsal opening wedge

- 3rd dorsal compartment

- expose distal radius

- can use half pins to control distal fragment

- check osteotomy site with II (metaphyseal, site of deformity)

- protect structures with homan retractors

- osteotomy with microsagittal saw

- correct radial articular surface in sagittal & coronal planes

- trapezoidal bi-cortical iliac crest autograft / synthetic graft

- dorsal locking plate

 

Volar opening wedge

 

Radial Malunion Volar Opening Wedge OsteotomyRadial Malunion Volar Opening Wedge Osteotomy Lateral

 

Advantage

- volar approach

- apply volar plate to gain correction

 

Disadvantage

- require dorsal approach to bone graft

 

Technique

- bed of FCR approach

- protect radial with homans, osteotomy

- apply volar plate

- then either leave gap dorsally or

- second dorsal approach to insert bone graft

 

Closing wedge osteotomy

 

Advantages

- volar approach  / plate better tolerated

- nil bone graft, direct bone to bone contact

 

Disadvantage

- can shorten radius / may need to perform ulna shortening as well

 

Distal Radial Osteotomy & Ulnar Shortening

 

Indications

- unacceptable radial alignment

- DRUJ not reduced by radius osteotomy

- acceptable DRUJ articular surface

 

Distal Radial Osteotomy & Ulnar Ablation

 

Indications

- unacceptable radial alignment

- DRUJ irreducible by radial osteotomy

- unacceptable DRUJ articular surface

 

Options

- Bower's hemiresection

- Darrach's

- Suave-Kapandji

 

Intra-articular Osteotomy

 

Issues

 

A.  Scaphoid facet malunion

- intra-articular osteotomy

- radial styloidectomy

- proximal row carpectomy

 

B.  Lunate facet malunion

- osteotomy 

- radio-lunate fusion

 

C.  Global wrist involvement

- early intra-articular osteotomy

- total wrist fusion

 

D.  Anterior / Posterior rim malunion

- simple bone resection

 

Soft Tissues Releases

 

Options

 

DRUJ volar capsulotomy 

- restores supination

 

DRUJ dorsal capsulotomy 

- restores pronation

 

+/-  Pronator Quadratus release

 

 

Distal Radius Fracture

Epidemiology

 

2 groups

 

1.  Elderly

- low velocity injury

- osteoporotic

- need to start bisphosphonates

 

2.  Young patients

- high velocity injury

 

Anatomy

 

Distal Radius Angles

- radial volar tilt 11°

- radial inclination  22°

- radius is 11 mm longer than ulna 

- ulna variance 2mm positive on average

 

Distal Radius NormalNormal Radial InclinationNormal Radial Length

 

3 independent articular surfaces

1.  Scaphoid facet

2.  Lunate facet

3.  Sigmoid notch

 

Base of ulna styloid

- insertion point TFCC

- insertion point ulno-carpal ligaments

- crucial for stability DRUJ

 

3 Columns

 

1.   Lateral radial

2.   Medial radial

- dorsal medial radial

- volar medial radial

3.  Ulna column

- ulna styloid and TFCC

 

Volar radius

- subject to compressive forces

- thicker and stronger

 

Dorsal radius

- subject to tensile forces 

- thinner and cancellous

 

Associated  Injuries

- TFCC tears

- SL ligament

- LT ligament

 

Fracture Patterns

 

Radial Styloid and Lunate Fragments

 

Distal Radius Fracture Undisplaced Intraarticular

 

Dorsal ulna / volar ulna

 

Distal Radius Volar and Dorsal Ulna FragmentsDistal Radial Fracture CTDistal radius volar ulnar fracture

 

Distal Radius Dorsal Ulna FragmentDRUJ FractureDistal Radius Radioulna Fragments

 

Eponyms

 

Colle's Fracture

- distal radial fracture with dorsal displacement

 

Wrist Colle's Fracture

 

Smith's Fracture

- distal radial fracture with volar displacement

- need long arm cast in supination

 

Distal Radius Smiths Fracture

 

Volar Barton's

- volar intra-articular fragment

- inherently unstable

- usually need volar buttress plate

 

Wrist Volar BartonsVolar Bartons CTVolar Bartons Buttress Plate

 

Dorsal / Reverse Barton's

- dorsal intra-articular fragment

 

Wrist Dorsal BartonsWrist Dorsal Bartons CT

 

Chauffeur's Fracture

- radial styloid fracture

- ORIF displaced > 2mm (K wires / partially threaded screws / radial styloid plate)

- ensure not missing perilunate dislocations

 

 Radial styloid fractureRadial Styloid K wires.jpgRadial Styloid ORIF APRadial Styloid ORIF Lateral

 

Management

 

Initial

 

All fractures should be reduced initially and reassessed

- conscious sedation

- 2 minutes of traction / reduction of deformity

- backslab / elevation in gallows

- re-xray

 

Distal Radius Fracture Severely Displaced.jpgDistal Radius Post Reduction.jpg

 

CT for further evaluation of articular congruency

 

Indications for surgery

 

Absolute

- open fracture

- acute severe CTS

 

Relative

- failure to obtain and maintain adequate reduction

- instability

- articular incongruency

- likely unstable / dorsal comminution

 

Distal Radius Fracture Dorsal Comminution

 

Unacceptable reduction

 

1.  Distal radial Step > 2mm

- leads to RC OA radiographically

- not proven to lead to dysfunction

 

Distal Radius Fracture Articular Step Coronal CTDistal Radius Fracture Articular Step Sagittal CT

 

2.  Articular incongruency sigmoid notch / DRUJ > 2 mm

 

Distal Radius Fracture DRUJ incongruent

 

DRUJ FractureDRUJ Fracture CT

 

3.   Radial shortening > 5 mm

- leads to ulnocarpal abutment

 

4.  Radial inclination < 15o

 

5.  Sagittal tilt

- > 15o dorsal

- > 20o volar

- +/- marked dorsal comminution

 

7.   Risk carpal subluxation

- Barton's fracture / dorsal Barton's

 

8.  Ulna styloid

- no indication to treat unless unstable DRUJ

 

Options

 

K wires

Volar / Dorsal plates

External Fixation

 

Results

 

Operative v Nonoperative

 

Arora et al JBJS Am 2011

- RCT

- MUA & cast v plate fixation in > 65 year olds with displaced fractures

- no significant difference in functional outcome at one year

- improved grip strength in operative group, and better xray measurements but increased complications

 

K wire v Plates

 

Marcheix et al J Hand Surg Eur Vol 2010

- RCT of pins v fixed angle plate in dorsally displaced unstable fractures in patients > 50

- extra and intra-articular

- fewer loss of reduction and better functional scores at 6 months with fixed angle plates

 

Rozental et al JBJS Am 2009

- RCT of ORIF v K wire in 45 patients

- ORIF better functional scores early

- similar outcomes at one year

 

Plates v External Fixation

 

Abramo et al Acta Orthop 2009

- RCT of 50 patients unstable comminuted distal radial fractures

- at one year better ROM and fewer malunions in group treated with trimed plate

- no difference in subjective outcome

 

Leung JBJS Am 2008

- RCT of pins / external fixator v locking plates for intra-articular fractures

- significantly better outcome in locking plate group

 

Grewal et al J Hand Surg 2011

- RCT ORIF v external fixation

- ORIF better function early

- similar outcomes at one year

 

Surgical Techniques

 

1.  Percutaneous K Wire

 

Distal Radius Fracture K wiresDistal Radius Fracture K wires APDistal Radius Fracture K wires LateralDistal Radius K Wires

 

Indications

- extra-articular unstable fractures

- young people without osteoporosis 

- minimal comminution

 

Technique of Colles / Extra-articular fracture / Dorsal displacement

 

GA

- reduction of fracture

- check under II

 

Radial K wire

- distal to proximal

- insert percutaneously to bone

- can make small incision / blunt dissect to protect branches SRN

- Kapandji technique or simply cross fracture site

- engage other cortex

- 1.6 or 2 mm K wire

 

Dorsal K wire Kapandji technique

- percutaneous

- insert by hand into fracture site

- tilt to reduce dorsal displacement of distal fragment

- drive into proximal radius and engage volar cortex

 

2.  ORIF with locking plates

 

Distal Radius Plate APDistal Radius Plate Lateral

 

Advantages

- accurate restoration of intra-articular anatomy

- stable fixation

- early mobilisation

 

Equipment

 

Locking plates

- volar / radial styloid / dorsal plates

- screws act as fixed angle devices

- screws variable angle

 

Radial Styoid Plate

 

Fragment specific sets

- pin fixators / paper clips

- good for dorso-ulna fragments

- variable angle screws

 

Technique

 

Volar / Henry approach

- can extend into CTD if required

- floor of FCR

- divide fascia

- radial artery laterally

- palmar cutaneous branch median nerve medial side FCR

- elevate pronator quadratus from radial to ulna

- release BR if required

- do not incise volar capsule (cut RSC / RL and other important ligaments)

- doing so can lead to volar RC instability

 

Reduce fragments

- pull out to length / correct angulation

- temporarily stabilise with K wires

- check alignment

- apply volar plate

- check orientation of distal screws with K wire to ensure not in joint

- on lateral, raise hand 30o to view joint

- screw fixation in scaphoid and lunate fragments

- long screws to engage dorsal cortex (24 - 26mm)

- radial styloid plate if required

 

Volar ulna approach indications

- perform CTD

- use interval between long flexors and FCU to access DRUJ and volar-ulna radius

 

Dorsal approach

- if unstable dorso-ulna fragment

- midline incision

- open 3rd compartment

- open 4th and sharply dissect radially

- may wish to close ER under tendons to protect from plate

 

Post op

- POP backslab for 10 days

- early ROM if stable

 

3.  External Fixation + / - Supplemental K wires

 

Distal Radius External Fixation

 

Indications

- compound fractures

- severe unreconstructable injuries

- very osteoporotic bone

 

Technique

- 2 x half pins dorsal radius (4mm)

- 2 x half pins IF / MF metacarpal (3 mm)

 

Complications

 

1.  Tendon problems

- most common problem

 

A.  FPL ruptures

B.  FCR tenosynovites

C.  Dorsal extensor tendon involvement from protruding screw or from dorsal plates

 

2.  Stiffness

 

Can continue for up to 18 months

- difficulty regaining full supination / pronation

 

3.  Median nerve dysfunction

 

4.  CRPS 2

- excessive traction on median nerve / long surgery

 

4.  Radial artery pseuodoaneurysm

EPL Rupture

Aetiology

 

Undisplaced wrist fracture

- interrupts blood supply at a watershed area

- between 3 weeks and 3 months post injry

 

Spontaneous

- RA / SLE

 

Site

 

Just distal to extensor retinaculum at Lister's tubercle

 

Examination

 

Place hand flat on table

- lift only thumb

 

Management

 

Options

 

Direct repair

 

Often not possible

- poor tendon

- retracted

 

Palmaris longus graft

 

Extensor Indicis tendon transfer

 

IPJ fusion - RA

 

EI Transfer

 

Indications

- independently able to extend finger

- keep other fingers flexed, ask to extend IF
- indicates IE intact

 

Technique

 

Harvest

- incision at MCPJ

- EI is medial to EDC tendon

 

Reroute

- incision distal to extensor retinaculum

- incision at MCPJ thumb

- tunnel in straight line subcutaneously

 

Suture to EPL

- tension

- need to be able to obtain full flexion with wrist extended

Kienbock's Disease

Definition 

 

Avascular necrosis & subsequent disintegration of lunate

 

Aetiology

 

50-75% history of trauma

 

Occasionally seen in sickle cell / steroid use

 

Pathogenesis

 

Vascular Theory

 

Trauma disrupting vascularity

- single incident with disruption of blood supply

- multiple compression fracture with loss of blood supply to fragments

 

Linschield 

- high incidence of coronal fractures seen on CT

- not apparent on AP film

- disrupts intra-osseous anastomoses

 

Lunate Vascularity (Gelberman)

 

Group 1

- 10% 

- single incomplete palmar blood vessel

- higher risk AVN

- severe hyperextension may disrupt it

 

Group 2

- 90% 

- dorsal & palmar blood vessel

- well vascularized 

- need intra & extraosseous disruption

- low risk AVN

 

AVN not seen in lunate dislocation

- flap of volar capsule usually remains attached

 

Mechanical Theory

 

Normal ulna plus

- +2 to -6 mm

- +2 SD mean

 

Ulna minus variance

- subjects lunate to greater compression & shear forces

- increased radioulnar forces

- seen in 75% Kienbock's

- only 25% normal population

 

Ulna Minus

 

Lichtmann Classification

 

Stage 1 

- no radiological change 

- diagnosed on bone scan / MRI

 

Stage 2 

- sclerosis

 

Kienbocks Disease Stage 2

 

Stage 3 

- collapse / fragmentation

 

A: Normal carpal height

B: Loss of carpal height / scaphoid flexed / capitate migrates proximally

 

Stage 4 

- degeneration

- pan carpal arthritis (radiocarpal / midcarpal)

 

Epidemiology

 

Occurs in young active adults 

- age 20-40 

- usually dominant hand 

- rarely bilateral

- men > women

 

History

 

Gradual onset of stiffness & pain 

50% history of trauma

 

Examination

 

Decreased ROM

Poor grip strength

Tender over lunate

Passive dorsiflexion middle finger gives pain

 

X-ray

 

Kienbock's

- progressive changes of AVN

- mottling / collapse / OA

- look for scaphoid flexion / capitate descent

 

Ulna Variance

 

Supination and pronation alter values

- need zero rotation view

 

90 / 90 view

- PA film with wrist in neutral

- elbow 90° / shoulder Abducted 90°

 

Line from lunate fossa and ulna head

- mean ulna variance is 1 mm (range 2 - 4)

 

Ulna Negative

 

Bone Scan / MRI

 

Demonstrate AVN

 

CT

 

Often show coronal fracture with palmar fragment extruded

- ? Cause of decreased palmar flexion

 

NHx

 

Usually one of progressive collapse

- cccasionally can arrest and even reverse

- these patients may not be seen

- the usual patient presents late 

- makes interpreting treatment options difficult

 

Non-operative Management

 

Splint 

 

Rarely effective

- Stage 1

- trial of immobilisation for 3/12 to aid revascularisation

 

1.  Stage II / IIIA Negative Ulna Variance

 

Radial Shortening ~ 2mm 

 

Theory

 

With negative variance often have thick healthy TFCC 

- can tolerate loading well

 

Radius normally takes 80% of load

- with ulnar minus is increased to 96%

 

Redistribute stresses 

- 2mm: 20% decrease radiolunate load

- 4mm: 40% decrease in radiolunate load

- less stress on lunate / revascularisation 

- relative lengthening of tendons may decrease compressive forces

 

Aim

- aimed for neutral or +1 mm ulnar variance

- if >1mm positive then risked ulnar abutment

 

Technique

- volar approach

- resection of desired amount

- can use cutting guides which give 2 parallel oblique osteotomies of set distance

- ensure not violating DRUJ

- application volar plate

- can be done dorsally but plate can become problem

 

Results

 

Quenzer J Hand Surg 1997

- 68 patients

- diminished pain 90%

- increased grip strength 75%

- increased ROM 50%

- 1/3 had signs lunate revascularisation

 

2.  Stage II / IIIA with Neutral or Positive Ulna Variance

 

Capitate Shortening + Capitohamate fusion

 

Aim

- unload the lunate

 

Result

 

Almquist Hand Lin 1993

- 83% revascularisation and healing

 

Vascularised Bone graft 

 

Indications

- best success in stage II / precollapse

- can combine with capitate shortening

 

Options

- 2nd dorsal intermetacarpal A & V

- distal radius pronator quadratus pedicle

- dorsal distal radius on pedicle

 

3.  Stage IIIB

 

Limited fusion

 

A.  STT 

 

Theory

- lunate collapsing 

- scaphoid takes more of load and goes into flexed position much like DISI

- STT fusion gives stable radial column for load bearing

- prevents radiocarpal degeneration

 

Technique

- dorsal approach 3/4

- take scaphoid out of flexion / extend

- K wire into position

- fuse to trapezium and trapezoid using bone graft from distal radius

 

B.  4 corner fusion 

 

Theory

- provides ulnar load bearing column

 

Problem

- lunate is poor quality / necrotic

 

Proximal Row Carpectomy

 

Always consider adding denervation

 

4.  Stage IV

 

PRC

- contraindicated with severe capitate degeneration

 

Arthrodesis

- manual worker

 

Perilunate Fractures and Dislocations

Epidemiology

 

Young men in 20's and 30's

 

Aetiology

 

High energy injuries

- fall from heights

- MVA

 

Mayfield Classification

 

Injury progresses from radial to ulna

- usually disruption proximal row either side of lunate

 

1.  Capitate usually displaces dorsally initially

- volar lunate dislocation is end stage

 

2.  Volar capitate dislocations do occur

- dorsal lunate dislocation as end stage

 

Spontaneous reduction can also occur

 

Cadaver study 

 

Stage 1 - SL dissociation 

 

Stage 2 - CL dissociation / capitate dislocates

 

Stage 3 - LT dissociation

 

Stage 4 - Lunate dislocates

 

Presentation

 

Swollen and painful wrist

- +++ clinical suspicion

 

Volar lunate dislocations

- fingers semiflexed

 

1/3 have median nerve symptoms

 

Unusual to have compound wound

- usually palmar

 

X-ray

 

Disruption of Gilula's 3 smooth carpal arcs

 

Progressive Injury

 

1.  Capitate dorsal

- lunate remains with radius

- lunate looks triangular on AP

 

Scapholunate Dislocation Capitate Dorsal

 

Perilunate Dislocation 1Perilunate Dislocation 2

 

2.  Lunate dislocates

- usually volar

 

2 main groups of injury

 

1.  Dorsal trans-scaphoid dislocation

- 2/3 of cases

 

Transscaphoid Perilunate DislocationTransscaphoid Perilunate Dislocation Lateral

 

2.  Dorsal perilunate dislocation

- 1/3 of cases

 

Associated Injuries

 

Scaphoid fracture

Radial styloid fracture

Capitate fracture

 

Chronic presentations

 

Missed in 20%

- reasonable ROM

- little pain

 

May present with CTS

 

May present with flexor tendon ruptures

 

Management

 

A.  Acute perilunate dislocation

 

Initial Reduction

 

Traction under anaesthesia / conscious sedation

- dorsiflex wrist

- counterpressure on palmar lunate

- gradual wrist flexion with pressure on dorsal capitate

 

Perilunate Reduced 1Perilunate Reduced 2

 

Definitive

 

Poor results with non operative management

- require anatomical repair of proximal row

- wait 3-5 days for swelling to settle

 

1.  No scaphoid fracture

 

Reduce lunate

- closed reduction

- open reduction

 

Dorsal approach

- longitudinal incision

- 3/4 extensor compartment

- mobilise EPL laterally

- open dorsal between DRC and DIC ligaments

- joysticks in scaphoid and lunate

- reduce DISI deformity

- K wires SC / SL / LT (areas of ligament rupture)

- repair SL ligament back onto scaphoid with anchors / transosseous sutures

- ORIF any capitate fractures

- repair LT ligament + augment with capsule

 

+/- Volar approach

- difficulties reducing lunate

- perform CTD

- repair rent in volar capsule / Space of Poirier

 

Perilunate Dislocation ORIF APPerilunate Dislocation ORIF Lateral

 

Perilunate Dislocation APPerilunate Dislocation Lateral ORIF

 

Perilunate ORIF 1Perilunate ORIF 2

 

Recent trends

- add SL screw

- add Blatt capsulodesis

- repair rent in volar capsule

- make wrist as stiff as possible to prevent late OA

 

2.  Trans Scaphoid Perilunate

 

Perilunate Dislocation Closed ReductionTrans scaphoid Perilunate Pre ORIF

 

Trans scaphoid Perilunate ORIF

 

Dorsal approach

- ORIF scaphoid fracture

- repair LT ligament

- K wires LT and TC (SL ligament is intact)

- ORIF capitate

 

+/- Volar approach

- CTD

- repair rent in capsule

 

Post op

 

Aim is for a stable but stiff wrist

- 8 weeks in cast, then removal of K wires

- begin ROM

 

Results

 

80% strength

 

Reduced ROM

- usually 100o F/E

 

Chronic unreduced perilunate dislocations

 

< 6 months

 

Attempt open reduction

 

Salvage

 

Options

- scaphoidectomy + 4 corner fusion

- PRC

- wrist arthrodesis

Rheumatoid Wrist

EpidemiologyRheumatoid Wrist

 

Extremely common

- 90% by 10 years have wrist problems

 

Principles

 

Landsmeer 1961

- treat wrist at same time as treat fingers or will recur

 

Frequently combine procedures

- synovectomy

- tendon transfer

- ulna procedure

 

Treatment Priorities

 

1. Pain Control

2. Slow progression

3. Restore /  Function

4. Cosmetic Improvement

 

Pathology

 

1. Synovitis

 

Starts

- ulna styloid

- ulna head

- scaphoid midportion

 

Radial side 

- synovitis scaphoid midportion

- RCL & RSCL become attenuated 

- subluxation of scaphoid & scapholunate dissociation

- radiocarpal shortening

 

Ulnar side 

- synovitis begins ulna styloid

- TFCC, ULL & UTL attenuated 

- DRUJ stretches

- volar subluxation of ulnar carpus & supination

- develop caput ulna

- ulnar becomes prominent because carpus is falling away from it

- carpus volar translated & supinated

 

Wrist RA

 

2.  Loss of ECU mechanical advantage 

- secondary to supinated carpus & carpal collapse 

- ECU subluxes volar to flexion / extension axis

- increases mechanical advantage of radial wrist extensors 

- radial deviation of carpus 

 

3.  Carpal Collapse

- decreases mechanical advantage of long finger flexors / extensors

- leads to intrinsic plus deformity

 

Rheumatoid WristRheumatoid Wrist Carpal Collapse

 

Failure to address wrist deformity will lead to failure of MP or IP reconstruction

 

Operative Management

 

Indications

 

Failure of optimal rheumatology supervised medical management for 6 months

 

Options

 

Preventative

- synovectomy

- tendon transfers

- CTD

- tendon repairs

 

Salvage

- DRUJ excision

- arthrodesis

- arthroplasty

 

1.  Synovectomy

 

Indications

 

Persistent painful wrist synovitis not settling with medical management

-  > 6/12 

- minimal X-ray changes

 

Advantages

 

1.  Relieves pain

- no evidence synovectomy alone will halt progression of wrist deformity

 

2.  Prevents subsequent tendon rupture

- recurrent tenosynovitis rare

- once one tendon ruptures often followed by multiple ruptures 

- tendon rupture can occur by direct invasion

- seen in up to 50% at time of tenosynovectomy

 

Operations

 

A.  Flexor tenosynovectomy 

 

Often difficult to diagnose

- not as easily seen as dorsally

- patients present with limited active finger flexion / CTS

 

Technique

- through incision of CTD

 

B.  Dorsal Tenosynovectomy + Carpal Synovectomy

 

Clinically

- dumbbell shape under extensor retinaculum dorsally

 

Midline dorsal incision

- divide extensor retinaculum between 5th and 6th extensor compartments (EDM & ECU)

- elevate radially based flap to 1st compartment

- perform partial wrist denervation (PIN in floor of 4th)

 

RCJ & Intercarpal joints exposed 

- use ligament sparing arthrotomy (between DRC and DIC ligaments)

- synovectomy

 

DRUJ exposed through longitudinal incision

- debride

- stabilise if unstable

 

Repair extensor retinaculum underneath tendons to protect bed

 

2.  Tendon Transfer

 

ECRL to ECU insertion 

 

Timing

- at time of synovectomy 

 

Advantages

A.  Corrects a correctable radial deviation deformity

B.  Holds ECU over ulna head

- prevents ulna subluxation

 

3.  CTD

 

Cause

 

Secondary to synovitis

 

Management

- good results with decompression

- usually perform flexor tenosynovectomy at same time

- may wish to examine floor to ensure no bone protruding which may rupture tendons

 

4.  Tendon rupture

 

A.  Extensor tendon rupture

 

Dropped FingersDropped Fingers 1Dropped Fingers 2

 

Sequence

- EDQ > LF > RF > MF > IF > EI

- goes ulna to radial 

- opposite to flexor tendons

 

Cause of rupture

- tenosynovitis

- caput ulna (EDQ)

- EPL over Lister's tubercle

 

Extensor Digiti Quinti / Vaughan-Jackson Syndrome

 

5th dorsal compartment

- can be clinically silent

- EDC and juncturae tendinae compensate

 

Diagnosis

- attempt to hold LF extended whilst other fingers flexed

- indicates that progressive tendon rupture likely and intervention required

 

DDx dropped finger

- extensor tendon subluxation

- MCPJ dislocation

- dislocated extensor tendons

- PIN palsy (can't extend wrist or thumb)

- locked trigger

 

Extensor Tendon transfers

 

LF rupture

- side to side RF

 

LF / RF

- side to side MF

 

LF / RF / MF

- LF / RF to EI

- MF to IF

- or RF FDS to LF / RF

 

LF / RF / MF / EI / IF

- RF & MF FDS

 

B.  Flexor tendon rupture

 

Mannerfelt lesion

- distal pole of scaphoid and trapezium erode through volar capsule

- FPL most common

- FPL / FDP IF / FDS IF / MF

- opposite direction to extensors

 

Management

 

In severe deformity, may wish to fuse wrist to prevent further ruptures

 

Approach

- bed of FCR

- carpal tunnel incision

 

Debride bony prominences

- rotated capsule to cover floor

 

FPL rupture

- fuse IPJ

- young patient transfer FDS IF / RF +/- PL graft

 

IF FDP

- fuse DIPJ

 

IF FDP / FDS

- fuse DIPJ

- MF FDS transfer

 

5.  DRUJ

 

RA Wrist Caput UlnaRA Wrist Caput Ulna 2

 

Clinically

 

Frequently subluxes dorsally

- ECU may also be ruptured

 

Patient presents with pain with rotation

- may have extensor tendon rupture

 

Piano Key sign

- reduce the ulna, it simply redislocates

 

Options

 

A.  Darrach's 

 

Darrach's

 

Principle

- excision arthroplasty

 

Indications

- older patient

 

Technique

- same dorsal approach as for synovectomy

- radial based ER flap

- excise distal ulna

- proximal limit is articulation with sigmoid notch

- usually 1.5 cm

- round off radial side

- stabilise with volar capsule + ECU tenodesis

- can stabilise with Pronator Quadratus

 

Complications

- can be unstable

- even with ECU tenodesis

- revise by ECU / FCU tenodesis + pronator quadratus interposition

- or by further shortening!!!

 

B.  Suave - Kapandji

 

Principle

- fusion DRUJ & ulna pseudoarthrosis

 

Indication

- younger patient

 

Technique

- resection of 10 - 15 mm long segment of ulna proximal to DRUJ

- resect proximal periosteum +/- interposition of pronator quadratus to prevent regrowth

- DRUJ denuded of cartilage

- distal fragment brought slightly proximally to prevent ulno-carpal abutment  

- fuse to distal radius with screws or K wires

- 4 weeks in LA POP in neutral

 

Results

- may have better result than Darrach's in RA

- less instability

 

C.  Hemi-resection arthroplasty 

 

Not usually done in RA

- TFCC and DRUJ soft tissues very poor

- indicated for DRUJ arthritis with good soft tissue stability

 

D.  Arthroplasty

 

6.  Wrist Fusion

 

A.  Partial Wrist Fusion

 

Options

- Radiolunate / Radioscapholunate fusion 

 

Indications

- isolated arthritis

- midcarpal joint spared

 

Results

- usually have to do wrist fusion later

- may maintain some movement for 5 years or so 

 

B.  Total Wrist Fusion

 

Wrist Fusion APWrist Fusion Lateral

 

Advantage

- predictable

- stable and pain free wrist

 

Indications for Arthrodesis

- poor bone stock

- stiff wrist

- loss of wrist extensors

- painful erosive RA

- high demand

 

Techniques

 

A.  Steinmann pin in third MC / Mannerfelt Fusion

 

B.  Plate fixation 

 

RA Wrist Fusion Darrachs APRA Wrist Fusion and Darrachs Lateral

 

Gold standard

- Synthes low profile contoured plate

- 10o degrees extension

- fused to MF metacarpal

- avoid radial deviation

- ulna deviation OK 

 

Bilateral one up one down

 

Complications

- functional difficulties

- i.e. opening jar

 

7.  Arthroplasty

 

Indications

- low demand patient that requires ROM

- intact wrist extensors

- good bone stock

 

Results

 

Millander 1986

- 25% revision rate at 5 years

 

 

STT OA

Definition

 

OA of the scapho-trapezium-trapezoidal joints

 

Epidemiology

 

50% patients with CMC OA have STT OA

F > M

 

Xray

 

STT OASTT Arthritis 2

 

Management

 

Non operative

 

NSAIDS

Rest

Splint

HCLA injection

 

Operative

 

STT OA

 

Options

 

Excisional Arthroplasty

STT fusion

 

STT fusion

 

Dorsal approach

- base of thumb

- between EPB and EPL

- protect branches SRN

- excise distal scaphoid / proximal trapezium and trapezoid

- fix with K wire

- insert cancellous bone graft

 

Results

 

Srinivasan et al J Hand Surg Br 1996

- STT fusion in isolated OA in 8 patients

- good results in 7 patients

- 1 non union

 

 

 

 

Scaphoid

Avascular Necrosis

Diagnosis

 

Xray

- sclerosis

 

Scaphoid Fracture Proximal Pole AVNScaphoid Proximal Pole ORIF AVN

 

CT

 

Scaphoid AVN CT

 

MRI

- probably the most sensitive and specific

 

Bone Graft v Vascularised bone graft

 

Merrell J Hand Surg Am 2002

- meta-analysis

 

1.  Bone graft with proximal pole AVN

- union 50%

 

2.  Vascularised bone graft with proximal pole AVN

- union 88%

 

Vascularised bone grafting / VBG

 

1.  Pronator quadratus pedicle graft

- much less common now

 

2.  Vascularised distal radius graft / Zaidemberg

- most common

 

3.  2nd metacarpal graft

- very common

 

Technique Zaidemberg

 

Dorso-radial approach

- 1/2 intercompartmental supraretinacular branch of the radial artery

- travels distal to proximal

- between tendons of the first and second extensor compartments

- can use 2/3 if 1/2 small or missing

- follow to distal radius

- osteotome 3 sides preserving pedicle

 

Dorsal approach to scaphoid

- open non union site

- insert VBG

- fixation with screw

 

 

 

 

Fracture

Epidemiology

 

Young men

 

Aetiology

 

FOOSH

- axial load, dorsiflexion and radial deviation

 

DISI occurs in ulna deviation

 

Herbert Classification

 

Type A    Stable acute fracture

 

A1 Tubercle

Scaphoid Tuberosity FractureScaphoid Tuberosity Fracture

 

A2 Incomplete waist fracture

Incomplete Scaphoid FractureScaphoid Fracture Incomplete

 

Type B    Unstable acute fracture

 

B1 Distal oblique fracture

Scaphoid Fracture 3D Isolated

 

B2 Complete waist fracture

Scaphoid Fracture Complete

 

B3 Proximal pole fracture

Scaphoid Proximal Pole Fracture

 

B4 Trans-scaphoid perilunate fracture

 

Type C    Delayed Union

 

Type D    Established Non-union

 

D1 Fibrous Union (stable)

D2 Pseudarthrosis (unstable / early deformity)

D3 Sclerotic Pseudoarthrosis (Late deformity)

D4 Avascular Necrosis (fragmented proximal pole)

 

Anatomy

 

Scaphoid is Greek for boat

- shaped more like a twisted peanut

 

Scaphoid 3D VolarScaphoid 3D Dorsal

 

Majority is articular

- except for dorsal ridge

- this is the site of entry of majority of blood supply

 

Vascularity

 

Gelberman & Menon J Hand Surg 1980

- latex injection

 

2 major vascular leashes

 

1.  Dorsal ridge artery

- branch of radial artery

- major blood supply

- 70- 80% scaphoid including proximal pole

- enters through the non articular dorsal ridge

 

2.  Distal tubercle

- palmar & superficial palmar branches of radial artery

- perfuse distal 20% to 30% of scaphoid

 

Fracture Location

 

Waist 65%

Proximal third 25%

Distal third 10%

 

Complications

 

1.  Non union

 

Undisplaced

- union > 95%

- rare with immediate immobilisation

 

Displaced

- non union 50%

 

2.  AVN

- increases the more distal the fracture (50% proximal pole)

- increases with displacement (AVN 50%)

 

3.  Malunion and DISI

- associated with increased intra-scaphoid angle

 

Clinical Features

 

Tender anatomical snuffbox

Swelling

Reduced ROM

 

X-ray

 

5 images will pick up 99% of fractures

- PA 

- Lateral

- PA in 45° oblique pronation

- PA 45o oblique supination

- PA in ulna deviation

 

Scaphoid PAScaphoid Fracture LateralScaphoid Fracture ObliqueScaphoid Fracture Long Axis

 

Increased intra-scaphoid angle / humpback deformity

- > 35o abnormal

- > 45o associated with poor outcome i.e. DISI

- also demonstrated to lead to loss of extension

 

2 week delay

 

Issue

- tender in ASB

- no sign of fracture on initial x-ray

- usual treatment is to place in cast and xray in 2 weeks

- can be delayed appearance of scaphoid fracture

 

Leslie and Dixon JBJS 1981 

- 222 fractures

- 98% seen at time of presentation

- 2% became evident over ensuing weeks

- these were only incomplete and located on concave side of scaphoid

 

Excluding scaphoid fracture

- CT - easy to obtain, inexpensive

- MRI - highly sensitive, but expensive and difficult to obtain

 

Instability 

 

1.  Displacement > 1mm on any film

2.  Intra-scaphoid > 35o

3.  Proximal pole fracture

4.  Comminution

5.  SL > 60o

6.  Radio-lunate angle > 15o

7.  Perilunate trans-scaphoid dislocation

 

Can be very difficult to assess displacement on plain films

- suggest use of CT

 

CT

 

1mm slices in sagittal plane of scaphoid

- plane of metacarpal

 

Position

- patient prone 

- hand over head

- fully pronated 

 

Scaphoid Fracture 3D CTScaphoid Fracture 3D CT

 

Bone Scan

 

Highly sensitive

- 5% to 15% incidence of false positives

 

MRI

 

Very sensitive for occult fracture

Identifies AVN

Identifies carpal instability

 

Management

 

Non operative Management

 

1.  Anatomical Snuff Box Tenderness / Normal Xray

 

Options

 

1.  POP 2/52, rexray out of plaster

2.  MRI / CT

 

2.  Acute undisplaced stable

 

Types

- displaced < 1mm

- incomplete fracture

- tuberosity fracture

 

Scaphoid cast

- short arm thumb spica cast

- long arm cast not necessary

- some evidence that thumb spica not necessary

 

Time in cast

- distal / tuberosity  6/52

- middle 1/3 8/52

- proximal 1/3 10/52

 

Management

- x-ray at 2/52 to ensure no displacement

- x-ray out of cast for union

- see at 6/12 for final xray check union

 

Non-union

- union rate 90 - 95%

 

Operative Management

 

Indications for Surgery

 

A.  Instability

- displaced > 1mm

- intra-scaphoid > 35o

- complex instability / perilunate instability

 

B.  Proximal pole

- high risk of AVN

- 30% rate non union if non displaced

- all theoretically unstable

- could suggest that all need ORIF

- require dorsal approach

 

C.  Athlete / Manual worker with undisplaced

- percutaneous fixation

- early mobilisation and return to work

 

D.  Delayed diagnosis

- may have increased non union rates

 

2.  ORIF

 

Indications

- displaced fractures

- proximal pole

 

Approach

 

1.  Volar approach

- workhorse for waist fractures

- preserves dorsal blood supply

 

2.  Dorsal approach 

- for proximal 1/3 fractures

 

Scaphoid Proximal Pole Fracture

 

Volar approach technique

 

Scaphoid ORIF Volar ApproachScaphoid ORIF Volar Approach 2Scaphoid ORIF Volar Approach 3

 

Position

- supine on arm table

- lead hand

- tourniquet

 

Approach

- volar along FCR

- deviate along thenar edge to STT joint

- elevate thenar muscles

- FCR ulna, deep branch radial artery radially with APL

- divide superficial branch radial artery

- open capsule in line with FCR

- transverse opening at STT

- will divide RSC ligament

 

Clean and reduce fracture

- K wires as joysticks

 

Cannulated headless compression screw 

- central third

- more bone contact, longer screws

- increased stability and therefore union rates

- can remove volar beak of trapezium

- pass cannulated screw wire, measure length

- drive wire into distal radius for stability

- pass screw, bury head

 

Bone graft as required

- very comminuted fracture / unstable

- humpback deformity

- distal radius if small

- iliac crest if large

 

Closure

- close capsule and repair RSC

 

Post op

- 8/52 in thumb spica

- assess union

 

Dorsal approach technique

 

Scaphoid ORIF Proximal Pole Lateral

 

3/4 Approach

- midline incision on RC joint

- open EPL, reflect radially

- sharply elevate EDC, reflect ulnarly

- open capsule over SL joint

 

Flex wrist

 

Insert K wire

- proximal fragment into distal fragment

- entry point is just radial to SL ligament

- drive into trapezium

- check position on multiple views

 

Insert screw

 

Results

 

Herbert ORIF all type B fractures

- B1 90% union (oblique)

- B2 88% union (waist)

- B3 85% union (proximal pole)

 

Percutaneous fixation

 

Advantages

- faster union rates than cast

- union approaching 100%

- less time in cast

- earlier return to work

 

Indications

- minimally displaced fracture in acceptable position

- manual workers / athletes

- anyone who wants to limit time in POP

 

Technique

 

Set up

- supine, tourniquet / arm table / II

 

Traction on thumb

- ulna deviation

- flex wrist over roll of drapes

- II shows long axis of scaphoid

 

Volar stab incision

- over scaphoid tuberosity

- slightly distal

- insert K wire in long axis / central third scaphoid

 

Check wire position

- AP / lateral / 45o obliques

- drill

- can put K wire into distal radius for stability / second K wire

 

Insert cannulated screw

- slightly shorter screw to obtain compression

- usually 24 mm

 

Post op

- POP 2 weeks

- then allow to range out of plaster

- no manual labour / heavy lifting

- check for union at 6/52

 

 

 

Malunion

Definition

 

Flexed "humpback" deformity

- intrascaphoid angles >35o

- alters kinematics of wrist

 

Aetiology

 

Unstable displaced fracture

- non operative treatment

- distal segment flexes

- unites in poor position

 

NHx

 

DISI deformity

- carpal collapse

- pain and posttraumatic arthritis

 

Symptoms

 

Initially 

- pain

- reduced motion

- reduced grip strength

 

Eventually

- arthritis

 

Management

 

Osteotomy

- volar approach

- osteotomy with osteotome

- cortico-cancellous bone graft

- cannulated screw

 

 

 

 

Non union

Scaphoid Non union xrayScaphoid Nonunion Xray 2

 

NHx

 

Convincing association with development of osteoarthritis

- arthritic changes beginning at radial styloid

- progress to scaphocapitate & capitolunate 

 

End point representing scaphoid nonunion advanced collapse wrist (SNAC)

 

Issues

 

AVN

Humpback deformity (must correct to improve kinematics)

SNAC (contraindication to surgery to achieve union)

 

Xray

 

Sclerotic margins / no sign of healing

 

Scaphoid Nonunion Sclerotic Margin

 

Humpback deformity

 

Scaphoid Humpback Deformity

 

Look for signs of AVN

 

Scaphoid Non union

 

MRI

 

Advantage

- exclude AVN

- AVN has low signal on T1 and T2

- if AVN use vascularised bone graft

 

CT

 

Identify humpback deformity / plan size and shape of bone graft

 

Scaphoid Humpback CT 1Scaphoid Humpback CT 2Scaphoid Nonunion Humpback Deformity CT

 

Options

 

1.  Russe-type inlay corticocancellous bone graft 

- volar approach

- 2 corticocancellous struts 

- cancellous surfaces facing each other 

- placed longitudinally inside scaphoid

- 85% to 95% union

 

2.  Fisk wedge graft

- trapezoidal / triangular iliac crest graft

- designed to restore the scaphoid alignment 

- correct humpback deformity

- union rates of 95 - 100% with fixation

 

Scaphoid NonunionScaphoid Nonunion LateralScaphoid Nonunion Iliac Crest Bone GraftScaphoid Nonunion Iliac crest Bone Graft

 

Waist Non union

 

Technique

 

Volar approach

- clean fracture site of fibrous tissue

- osteotomes to reduce deformity

- do not disrupt dorsal cortex

- burrs if needed to remove fibrotic tissue

 

Scaphoid Approach

 

Assess for AVN

- look for evidence of punctate bleeding from distal fragment

 

Place bone graft

- reduce deformity if necessary

- fix with K wire

- place cannulated screw

 

Scaphoid Bone GraftScaphoid BG ORIF 1Scaphoid BG ORIF 2

 

Results

 

90% union

- some loss of ROM and strength 

 

Proximal pole non union

 

Scaphoid Proximal Pole Non UnionScaphoid Proximal Pole Nonunion Bone GraftScaphoid Proximal Pole Nonunion Bone Graft 2

 

Dorsal approach

 

Lower union rates

- 67%

- ? role for vacularised bone graft

SNAC

Definition

 

Scaphoid non union advanced collapse

 

Diagnosis

 

Xray / CT

- non union of scaphoid

- radio-scaphoid OA

 

SNAC Wrist APSNAC Wrist CT

 

Operative Options

 

1.  Radial Styloidectomy 

- technically straightforward 

- should be considered when arthrosis is localized to this region

- may preserve existing motion in the wrist

 

2.  Excision of fragment / Soft tissue interposition

- no intercarpal collapse is present

- a small proximal pole non-union 

 

3.  Scaphoid excision / Silicone replacement 

- shown to be effective when combined with fusion of the capitate to the lunate

 

4.  Proximal row carpectomy

- may also preserve motion

- grip strength unpredictable

- probably only for low demand elderly

 

Proximal Row CarpectomyProximal Row Carpectomy LateralProximal Row Carpectomy Lateral

 

5.  Scaphoidectomy & 4 corner fusion

 

SNAC AdvancedScaphoidectomy and 4 corner fusion

 

6.  Wrist arthrodesis

- provides a stable pain free wrist

 

 

 

Ulna Wrist Pain

DDx Wrist Pain Ulna

DRUJ

- dislocation / subluxation

- arthritis 

 

TFCC

- degeneration

- tears

 

Kienbock's

 

Fracture

- Ulna styloid Fracture

- Carpal fracture / hook of hamate

 

Ulnocarpal abutment

 

Ulnocarpal Abutment

 

Pisiform

- OA

- subluxation

 

LT instability

 

ECU

- subluxation and rupture

- tendonitis (+/- calcific)

 

Infection

Tumour

Ganglion

 

 

 

ECU Calcific Tendonitis

Symptoms

 

Sudden onset of pain without history of trauma

- ulnar aspect of the wrist

- particularly associated with repetitive ulnar deviation

 

Signs

 

Swelling over the ECU or FCU tendon sheaths 

- occasional crepitation on range of motion

 

X-ray 

 

May show calcific deposits within the tendon sheath

 

ECU Calcific Tendonitis

 

Management

 

Generally responds to non operative management

- oral NSAIDS 

- steroid injection with splinting

Pisiform

Subluxation & dislocation

 

Diagnosis

 

Pisotriquetral view

- forearm positioned 30° supinated off the neutral position

- loss of symmetry between the pisiform and triquetrum is required for the diagnosis

- carpal tunnel view may be helpful in further assessment of the joint

 

Osteoarthritis

 

Clinical

 

More common problem

 

Associated with localized tenderness over the pisotriquetral joint

- usually manipulation of the pisiform over the triquetrum causes intense pain

- local anaesthetic injection into the pisotriquetral joint confirms the diagnosis

 

X-ray

 

Often show loss of joint space and osteophyte formation

 

Management

 

Rest / NSAID's / HCLA pisotriquetral joint

 

Pisiform excision from the FCU tendon sheath

 

 

 

 

 

 

Subluxation ECU

Anatomy

 

6th compartment

- fibro-osseous tunnel overlying 1.5 cm to 2.0 cm of distal ulna

- held tight by the extensor carpi ulnaris tendon sheath

- the extensor retinaculum passes around the ulna to insert on the palmar aspect of the carpus

- extensor retinaculum is a separate structure from the ECU tendon sheath

 

Mechanism

 

Forced supination, palmar flexion, and ulnar deviation

- ECU tendon can rupture or attenuate the extensor carpi ulnaris tendon sheath

- dislocate in a palmar and ulnar direction

- the tendon relocates on forearm pronation

 

Most common in tennis players

 

Symptoms

 

Clicking or snapping of ECU with rotation

- may cause pain

 

Tends to dislocated dorsally with supination

 

Management

 

Acute cases

 

Immobilization in a long-arm plaster splint in pronation 

 

Chronic cases

 

Operative reconstruction of the extensor carpi ulnaris tendon sheath

- using extensor retinaculum