Radial-sided wrist pain differentials: presentation, pathoanatomy, diagnosis, and management / Dolor radial de muñeca: diferencias en la presentación, anatomía patológica, diagnóstico y tratamiento

Abstract Patients with radial-sided wrist pain can be challenging to diagnose and treat. Various physicians, including emergency physicians, primary care physicians, and orthopedic or plastic surgeons can be involved in the initial and subsequent evaluation. We delve into the differential diagnosis of radial-sided wrist pain including osteoarticular, ligament, tendon, nerve, and other pathologies. We review the physical exam findings, diagnostic studies, and treatment options for each pathology based on recent and updated literature.

Resumen Los casos de pacientes que presentan dolor radial de muñeca pueden ser de difícil diagnóstico y tratamiento. Varias especialidades médicas, incluidas emergentólogos, médicos de atención primaria, cirujanos ortopédicos o cirujanos plásticos, pueden estar involucrados desde el inicio de la patología y subsecuente evaluación. Pro fundizamos aquí en el diagnóstico diferencial del dolor radial de muñeca incluyendo las debidas a patologías osteoarticulares, ligamentosas, tendinopatías y neuropatías, entre otras. Esta revisión incluye examen físico, estudios diagnósticos, y opciones terapéuticas para cada condición con base en la literatura reciente y actualizada.

Analysis of the Postoperative Outcomes of the Chronic Scapholunate Ligament Instability Managed by Various Surgical Techniques

PURPOSE: To investigate mid-term clinical outcomes of various methods of scapholunate reconstruction for chronic scapholunate instability. METHODS: We retrospectively reviewed 11 patients diagnosed as chronic scapholunate instability, from 2005 to 2013 and followed up for more than one year after surgery. 7 patients were treated with Garcia technique of triple ligament reconstruction, 2, bone-ligamemt-bone repair, and 2, dorsal capsulodesis. Mean age was 42 years (range, 23-61 years). The right side was involved in 6 patients, and the left in 5. The follow-up period averaged 42 months (range, 13-125 months). The postoperative functional outcomes were assessed with Modified Mayo wrist score (MMWS), disability of the arm, shoulder and hand (DASH) score and range of motion. The postoperative radiologic results were analyzed with the change of scapholunate angle and distance. RESULTS: The mean MMWS score improved from 65 preoperatively to 77 postoperatively (p=0.072). The mean DASH score improved from 29.4 (range, 18.3-43.3) preoperatively to 12.7 (range, 0-38.3) postoperatively (p=0.003). The dorsiflexion increased from 67° to 78°, the volar flexion decreased from 51° to 45°, the supination increased from 69° to 88°, and the pronation increased from 62° to 66°. The SL angle changed from 55° preoperatively to 51° postoperatively, the mean SL distance changed from 3.4 mm preoperatively to 1.7 mm postoperatively. CONCLUSION: The chronic scapholunate instability is amenable to various techniques and postoperative functional outcomes improved satisfactory.

Length changes and their significance of scapholunate interosseous ligament at forearm rotation and wrist hyperextension / 中华创伤杂志

Objective To investigate the length changes of scapholunate interossous ligament (SLIL) at wrist full extension and forearm rotation and the related significance.Methods Eighteen healthy volunteers (12 males and 6 females) aged at 20-38 years (mean,28 years) were divided into forearm rotation group,wrist hyperextension group and wrist hyperextension-rotation group according to the random number table,with 6 cases per group.CT images of the wrist were analyzed and reconstructed in three-dimensions.Length of SLIL in dorsal,proximal and palmar segments was measured in different settings and compared.Results Conpared with the neutral position,lengths of palmar SLIL in distal,middle and proximal parts increased by (1.4 ±0.5)mm,(1.4 ±0.4)mm and (1.3 ±0.4)mm respectively in wrist hyperextension and increased by (0.3 ± 0.1) mm,(0.2 ± 0.1)mm and (0.3 ± 0.1)mm respectively in forearm maximal pronation.At the positions of wrist full extension,hyperextension with radial deviation or forearm maximal rotation,the palmar and part of proximal SLIL were elongated significantly (P ＜ 0.05).At forearm maximal pronation,palmar and part of proximal SLIL were elongated (P ＜ 0.05).Conclusions At wrist full extension,strain is greater in the palmar and proximal components of the SLIL.SLIL is inclined to injury at wrist hyperextension and forearm rotation.

Intercarpal Ligament Injuries Associated with Distal Radius Fractures: Relation with the Radiographic Findings and Arthroscopic Treatment / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to analyze the relationship between intercarpal ligament injuries associated with distal radius fracture and the fracture patterns and radiologic parameters, and to report on the clinical results of arthroscopic treatment for these injuries. MATERIALS AND METHODS: Fifty-two patients who underwent arthroscopic surgery for intercarpal ligaments injuries associated with distal radius fracture and who had a minimum 1 year follow-up were enrolled. There were 44 patients who sustained scapholunate interosseous ligament injury (SLIL) and 30 patients who sustained lunotriquetral interosseous ligament (LTIL) injury. Among them, 22 patients had both SLIL and LTIL injuries. The carpal ligament injuries were graded according to the Geissler classification and they treated with arthroscopic debridement only for a grade I and II injury and arthroscopic reduction and percutaneous pinning for a grade III and IV injury. The patients were divided into two groups and we assessed the functional and radiological outcomes: Group 1 consisted of the patients with a grade I and II injury and group 2 consisted of the patients with a grade III and IV injury. RESULTS: The preoperative mean radial inclination of group 2 with lunotriquetal interosseous ligament injury was 15.1+/-9.9degrees, which was significantly different from 20.4+/-5.1degrees of group 1, and the extra-articular type injury was more common in group 2 (p<0.05). On the follow-up radiographs, the mean scapholunate interval measured 2.1+/-0.5 mm in group 1 and 1.7+/-0.5 mm in group 2, which was significantly different (p<0.05). CONCLUSION: The grade of LTIL injury combined with distal radius fractures is associated with the loss of radial inclination and the extra-articular fracture type at the time of initial presentation. Complete tears of the SLIL can be stabilized with arthroscopic reduction and percutaneous pinning.

Arthroscopic assessment of soft tissue injuries in comminuted intra-articular fractures of the distal radius / 中华创伤骨科杂志

Objective To diagnose and evaluate soft tissue injuries in intra-articular fractures of the distal radius using arthroscopy. Methods Twenty young patients with displaced intra-articular fractures of distal radius were recruited in this prospective study. Three AO C2 and 17 C3 fractures were included. After arthroscopic examination fractures of distal radius were treated by external fixation with limited internal fixation or open plate fixation.Results Triangular fibrocartilage complex (TFCC) injury was found in 18 patients (90%) . Most were isolated Palmer type 1D injuries (67 %). Scapho-lunate ligament injury was found in two patients: one partial tear (grade Ⅱ) and one complete tear (grade Ⅲ). Follow-ups ranged from 6 to 18 months. At the last follow-up, wrist function was excellent in one patient (6%), good in eight(44%) and fair in 11 (50%). Conclusion TFCC injuries are common in intra-articular fractures of the distal radius while injuries to scapho-luuate ligament are uncommon.

Scapholunate Dissociation Associated with Distal Radius Fracture / 대한정형외과학회잡지

PURPOSE: To analyze the relationship of fracture patterns in cases diagnosed as scapholunate dissociation after treatment for distal radius fracture. MATERIALS AND METHODS: Forty-six cases were analyzed clinically and radiographically. Twenty-four cases were treated by closed reduction and percutaneous k-wire fixation, twelve cases by closed reduction, k-wire and external fixator application, and ten cases by open reduction and plate fixation. For radiological evaluation, scapholunate gap, scapholunate angle, and radiolunate angle were analyzed to detect scapholunate dissociation and dorsal intercalated segmental instability. RESULTS: In the 7 cases with a borderline scapholunate gap (>2 mm), 3 cases with an initial fracture line involving the interfacet prominence progressed to static scapholunate dissociation. CONCLUSION: Initial scapholunate gap and fracture line geometry of the distal radius were helpful for predicting progression to static scapholunate dissociation

Radiological Analysis of the Scaphoid Shift Test / 대한정형외과학회잡지

PURPOSE: To evaluate the carpal behaviors during the scaphoid shift test and to compare the results of clinical examination to findings of the radiological analysis. MATERIALS AND METHODS: Sixty patients who suffered from chronic wrist pain were evaluated clinically and radiologically when the scaphoid shift test was performed. Clinical findings were graded on the basis of the degree of palpable scaphoid shift and degree of pain on the dorsal aspect of the wrist. The scaphoid shift test was repeated under fluoroscopy. Radiological paramenters of displacement (scaphoid-lunate displacement index and scaphoid-radius displacement index) and rotation (change of scaphoid-radius angle and lunate-radius angle) were measured. Radiological parameters were evaluated according to the degree of clinical severity. RESULTS: Degree of clinical shift during the test was significantly associated with both scaphoid-lunate displacement and scaphoid-radius displacement, whereas degree of pain was significantly associated with scaphoid-lunate displacement,.not scaphoid-radius displacement. Patients who complaint pain during the test showed significantly higher radiological scaphoid-lunate displacement index when compared to those who did not have pain, but not significantly different scaphoid-radius displacement index. CONCLUSION: This study revealed that the presence of pain reflected the instability between the scaphoid and lunate rather than the degree of dorsal scaphoid shift. We conclude that radiological observation during the scaphoid shift test would be helpful in diagnosing the pathologic scapho-lunate instability.

Midcarpal Fusion with Excision of Scaphoid for Scapholunate Advanced Collapse ( SLAC ) / 대한정형외과학회잡지

Scapholunate advanced collapse (SLAC) deformity most often occurs with chronic rotary scaphoid instability from scaphoiunate ligament tear and scaphoid fracture. Prior to 1984 when Watson HK reported his concept on SLAC wrist deformity, the most popular procedure for this pathology was scaphoid implant arthroplasty with or without midcarpal fusion. We have reviewed 15 cases of SLAC deformity treated with scaphoid excision and midcarpal fusion from 1984 to 1993. Among them, scaphoid implants made of silicone were inserted in 4 cases. Scaphoid implant arthroplsty without carpal fusion has been excluded. The mean period of follow-up was 8.8 years and the mean age of patients was 47.5 years. Males and right wrists were predominant. Wrist motion was 56% and grip power was 71% of the normal opposite side. On the average overall, 8 patients had no pain and 7 patients had mild pain. The grade of pain was minimal, 0.5 in grade (Rating system: no pain-0, mild- 1, moderate-2, severe-3). However, all of the 4 cases of limited carpal fusion with a scaphoid implant developed silicone particulate induced synovitis and pain. The procedure appears to be effective in maintaining function of the hand with minimal pain up to 5.8 years. However, silicone scaphoid implant appears not to be necessary and is not recommended with a limited carpal fusion for this pathology.

Treatment of Post-traumatic Scapho-lunate Dissociation / 대한정형외과학회잡지

We have analyzed 27 cases(38.8%) of scapho-lunate(SL) dissociation which were the most com- mon type of total 72 cases of post-traumatic wrist instabilities since 1985. As a result, SL dissociations associated with wrist fracture were 23 cases, more common than simple dynamic SL dissociation(4 cases). Early diagnosis and treatment influenced on their prognosis, and both wrist PA roentgenograms were useful for the confirmative diagnosis of SL dissociation. In 16 cases with early diagnosis, closed reduction, 2 or 3 K-wires fixation under C-arm image and short arm cast for 8 weeks were effective. But in 11 cases with neglected diagnosis and with wrist fractures showed poor results. Excessive wrist ligamentous reconstruction in chronic cases should be avoided because of osteoporosis and wrist stiffness. Conclusively, clinical wrist symptoms are more important than radiological changes in wrist insta- bilites. So if the symptoms are not so severe, we must consider the patient's age, occupation and their social activities etc. to decide the proper way of treatment.

A Radiological Study of Normal Wrist in Korean People / 대한정형외과학회잡지

The carpal injury is difficult to diagnose due to anatomical complexity and the like. So, in order to get radiological knowledge of normal wrist, the authors measured the values which will be described on the wrist PA and lateral roengenogram obtained from 440 normal wrists(male : 188 cases, female : 252 cases) in randomly selected patients. The following results were obtained. l. Ulnar variance(mm±standard deviation): Total 1.1±1.2 : negative variance : 9.3%, positive variance : 56.1%, 2. Scapholunate Gap(mm±standard deviation): Total 0.4±0.7, 3. Ulnar Tilt(degrees±standard deviation): Total 23.6±5.3, 4. Volar Tilt, 5. Carpal height rstio : Total 0.52±0.05 male 0.53±0.04 female 0.51±0.05 : Total 13.1±5.9, 6. Carpal ulnsr distance ratio Total 0.05±0.05, 7. Scapholunate Angle : Total 49.9'±10.1', 8. Capitatolunate Angle Total 17.5'±10.0', 9. Radiolunate Angle Total 8.8'±6.7', 10. Carpal width ratio Total 0.72±0.08 11. Carpal thickness ratio Total 0.49±0.07.