Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Scaphoid kinematics in scapholunate instability: a dynamic CT study.

OBJECTIVE: The scaphoid is proposed to be driven by the distal carpal row in scapholunate instability (SLI) as it is dissociated from the proximal row. The aim of this study was to describe the 6 degrees of freedom kinematics of the scaphoid using dynamic CT in the normal and SLI wrists. We hypothesised that the SLI scaphoid would demonstrate kinematic evidence conforming to distal row motion. MATERIALS AND METHODS: We studied dynamic CT scans of 17 SLI and 17 normal wrists during ulnar to radial deviation and extension to flexion. The radio-scaphoid angles in three anatomic planes were calculated in the wrist neutral position and during wrist motion. The centroid position was also calculated in the wrist neutral position and during wrist motion. The scapho-capitate motion index (SCI) was calculated as a ratio between the scaphoid and the capitate motion. RESULTS: In the neutral position of the wrist, the SLI scaphoid was flexed, internally rotated, and radially translated compared to the normal scaphoid. During wrist motion, the SLI scaphoid had more 'in-plane' motion and less 'out-of-plane' motion with a higher SCI during wrist neutral to radial deviation and extension to neutral. CONCLUSION: We have described the malalignment of the SLI scaphoid in the neutral position of the wrist and 6 degrees of freedom kinematics during wrist motion of the SLI scaphoid compared to the normal. The SLI scaphoid conformed more to the distal row motion than the normal scaphoid. This information may help define the surgical reconstruction techniques for SLI.

Volar Marginal Rim Fractures of the Distal Radius Have a Higher Rate of Associated Carpal Injuries-A Comparative Cohort Study.

Background Volar marginal rim distal radius fractures can be challenging due to volar instability of the carpus. The associated carpal injuries, however, have not previously been reported. Purpose The aim of this study was to compare volar marginal rim fractures to other distal radius fractures to determine if there is any association with other carpal injuries. If so, do these injuries lead to further instability and fixation failure? Materials and Methods A retrospective radiological review of 25 volar marginal rim fractures was conducted. This was compared with a comparison cohort of 25 consecutive intra-articular distal radius fractures not involving the volar marginal rim. All radiographs were reviewed for associated carpal injuries, including carpal and ulnar styloid fractures, scapholunate instability, and carpal translocation. Results Volar marginal rim fractures had a significantly higher incidence of associated carpal injuries per patient (2.52 vs. 1.64), scapholunate diastasis (36 vs. 12%), and carpal dislocation (80 vs. 48%). The fixation chosen was more likely to involve a volar rim-specific plate (44 vs. 0%). Following surgical fixation, the volar marginal rim fractures had a significantly higher incidence of carpal instability (56 vs. 24%), failure of fixation (24 vs. 0%), and revision surgery (12 vs. 0%). Conclusions Volar marginal rim fractures have significantly more carpal injuries, scapholunate instability, and volar carpal instability, compared with other distal radius fractures. Despite the use of volar rim-specific plating, volar marginal rim fractures have a significantly higher incidence of persistent carpal instability, including scapholunate instability, ulnar translocation, volar subluxation, failure of fixation, and revision surgery. Level of Evidence This is a level III, retrospective review.

Endoscopic cubital tunnel decompression: state of the art.

Cubital tunnel syndrome is a common compressive neuropathy of the upper limb. Surgical decompression is indicated for patients who failed conservative therapy. Decompression in situ has shown to achieve comparable outcomes as decompression with anterior transposition in idiopathic cubital tunnel syndrome. Endoscopic cubital tunnel decompression has gained popularity in recent years, as surgeons can attain decompression of the ulnar nerve along its course using a small incision. Results from randomised controlled studies and systematic reviews, comparing endoscopic with open decompression in situ, are promising. Cases in which anterior transposition of the ulnar nerve is needed, an endoscopic technique can still be used by creating an additional volar portal, for the mobilisation of ulnar nerve. Early short-term results are encouraging. Further adequately powered, prospective, preferably double-blinded, randomised study are needed.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Treatment of elbow instability: state of the art.

The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.

Complications After Distal Biceps Tendon Repair: A Systematic Review.

BACKGROUND: Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature. PURPOSE: To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications. STUDY DESIGN: Systematic review. METHODS: Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods. RESULTS: Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate. CONCLUSION: This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent. REGISTRATION: CRD42017074066 (PROSPERO).

The modified anterolateral approach to the humerus.

INTRODUCTION: The anterior and anterolateral approaches to the humerus describe splitting brachialis longitudinally, assuming its fibres run parallel to the shaft. Recent improvements in the understanding of brachialis anatomy however have demonstrated it has two distinct heads, with the bulk of its fibres running oblique relative to the humerus. Attempting to split brachialis longitudinally to the extent required for plate osteosynthesis invariably leads to transection of a significant number of muscle fibres. The authors present a less muscle destructive modification to the anterolateral approach (ALA) based on a bicipital brachialis muscle. METHOD: In order to preserve brachialis muscle fibres, the modified ALA elevates the superficial head from the underlying humerus and longitudinally splits the deep head to allow a fixation device to be tunnelled. Case notes of patients with a humeral shaft fracture fixed via the modified ALA were retrospectively reviewed. RESULTS: Ninteen humeral shaft fractures were fixed via the modified ALA. No post-operative nerve palsies were reported. Of the 19 patients, 14 (73.7%) received clinical and radiological follow-up. All reported being satisfied with their outcome. One developed a superficial wound infection and one (previous diagnosis of spondyloepiphyseal dysplasia tarda) developed a non-union requiring revision surgery. Of the five patients lost to follow-up, two died, and three reported no ongoing orthopaedic issues via telephone. CONCLUSIONS: Improved anatomical understanding of brachialis has resulted in the described modification to the ALA which is less muscle destructive and follows a truer inter-nervous plane. This small series demonstrates satisfactory outcomes using this approach.

Microstructure of the Distal Radius and Its Relevance to Distal Radius Fractures.

Background There is a paucity of information on the microstructure of the distal radius, and how this relates to its morphology and function. Purpose This study aims to assess the microanatomical structure of the distal radius, and relate this to its morphology, function, and modes of failure. Methods Six dry adult skeletal distal radii were examined with microcomputed tomography scan and analyzed with specialist computer software. From 3D and 2D images, the subchondral, cortical, and medullary trabecular were assessed and interpreted based on the overall morphology of the radius. Results The expanded distal radial metaphysis provides a wide articular surface for distributing the articular load. The extrinsic wrist ligaments are positioned around the articular perimeter, except on the dorsal radial corner. The subchondral bone plate is a 2 mm multilaminar lattice structure, which is thicker below the areas of the maximal articular load. There are spherical voids distally, which become ovoid proximally, which assist in absorbing articular impact. It does not have Haversian canals. From the volar aspect of the lunate facet, there are thick trabecular columns that insert into the volar cortex of the radius at the metaphyseal-diaphyseal junction. For the remainder of the subchondral bone plate, there is an intermediate trabecular network, which transmits the load to the intermediate trabeculae and then to the trabecular arches. The arches pass proximally and coalesce with the ridges of the diaphyseal cortex. Conclusion The distal radius morphology is similar to an arch bridge. The subchondral bone plate resembles the smooth deck of the bridge that interacts with the mobile load. The load is transmitted to the rim, intermediate struts, and arches. The metaphyseal arches allow the joint loading forces to be transmitted proximally and laterally, providing compression at all levels and avoiding tension. The arches have a natural ability to absorb the impact which protects the articular surface. The distal radius absorbs and transmits the articular impact to the medullary cortex and intermediate trabeculae. The medullary arches are positioned to transmit the load from the intermediate trabeculae to the diaphysis. Clinical Relevance The microstructure of the distal radius is likely to be important for physiological loading of the radius. The subchondral bone plate is a unique structure that is different to the cancellous and cortical bone. All three bone types have different functions. The unique morphology and microstructure of the distal radius allow it to transmit load and protect the articular cartilage.

Erratum: Microstructure of the Distal Radius and Its Relevance to Distal Radius Fractures.

[This corrects the article DOI: 10.1055/s-0037-1602849.].

Kienböck Disease: A New Algorithm for the 21st Century.

Background It has been over 100 years since the initial description of avascular necrosis of the lunate. Over the last two decades, there has been the introduction of advanced information regarding the etiology, natural history, classification, and treatment options for lunate osteonecrosis. There have been new classifications developed based on advanced imaging, perfusion studies of lunate viability, and arthroscopic assessment of the articular cartilage. Purpose This article brings together a new treatment algorithm, incorporating the traditional osseous classification system (Lichtman) with the perfusion/viability classification (Schmitt) and the articular cartilage classification (Bain). Methods We have developed a new algorithm to manage Kienböck avascular necrosis of the lunate. This new algorithm incorporates the current concepts of the diseased lunate and its effects on the remainder of the wrist. Conclusion For patients with a good prognosis and in the earliest stages, the "intact lunate" is initially protected utilizing nonoperative measures. If this fails, then appropriate lunate unloading procedures should be considered. If the lunate is "compromised" then it can be reconstructed with a medial femoral condyle graft or proximal row carpectomy (PRC). With the further collapse of the lunate, the wrist is then also compromised, with the development of secondary degeneration of the central column articulation. The "compromised wrist" will have functional articulations, which allows motion-preserving procedures to be utilized to maintain a functional wrist. With advanced disease (Kienböck disease advanced collapse), the wrist is not reconstructable, so only a salvage procedure can be performed. Other than these objective pathoanatomical factors, the final decision must accommodate the various patient factors (e.g., age, general health, lifestyle, financial constraints, and future demands on the wrist) and surgeon factors (skill set, equipment, and work environment).

Erratum: Addendum: Kienböck Disease: A New Algorithm for the 21st Century.

[This corrects the article DOI: 10.1055/s-0036-1593734.].

The Etiology and Pathogenesis of Kienböck Disease.

Kienböck disease is a condition that typically occurs in the "at-risk" patient, in the "at-risk" aspect of the proximal condyle of the "at-risk" lunate. In the active male, repetitive loading causes the stress fracture that commences in the single layer proximal subchondral bone plate. The lunate fracture commences at the point the lunate cantilevers over the edge of the distal radius, and then takes on the shape of the radius. We postulate that the stress fracture violates the parallel veins of the venous subarticular plexus-leading to localized venous hypertension and subsequent ischemia and edema of the fatty marrow. The increased osseous compartment pressure further potentiates the venous obstruction, producing avascular necrosis. If the fracture remains localized, it can heal or settle into a stable configuration, so that the wrist remains functional. Fractures of the subchondral bone plate produce irregularity of the lunate articular surfaces and secondary "kissing lesions" of the lunate facet and capitate, and subsequent degeneration. The lunate collapses when the fracture is comminuted, or there is disruption of the spanning trabeculae or a coronal fracture. The secondary effect of the lunate collapse is proximal migration of the capitate between the volar and dorsal fragments, producing collapse of the entire central column. The proximal carpal row is now unstable, and is similar to scapholunate instability, where the capitate migrates between the scaphoid and lunate. The scaphoid is forced into flexion by the trapezium, however, degeneration of the scaphoid and scaphoid facet only occurs in late disease or following failed surgery. In Kienböck disease, the secondary effects of the collapsing lunate are a "compromised" wrist, including: deformity and collapse of the central column, degeneration of the central column (perilunate) articulations, proximal row instability (i.e., between the central and radial columns), and degeneration of the radial column.

Development of a Protocol for SPECT/CT in the Assessment of Wrist Disorders.

Background Single-photon emission computed tomography and computed tomography (SPECT/CT) is a hybrid diagnostic imaging modality that allows clinicians to integrate their diagnostic evaluations and deliver a definitive diagnosis in musculoskeletal disorders. Specifically, in identification of osseous pathology, the conventional bone scan delivers greater specificity compared with magnetic resonance imaging (MRI). However, use of SPECT/CT enhances the sensitivity and specificity. Use of this modality denotes the possibility to specify the lesion more accurately and precisely while grading the activity according to osseous structural changes. Purpose This study aimed to evaluate the clinical utility of SPECT/CT in the diagnoses and management of osseous wrist disorders. The objectives were to examine the value of SPECT/CT in the diagnosis of osseous-related wrist pain and whether the findings altered management. Patients and Methods A retrospective cohort study of 20 patients with such wrist pain was conducted. SPECT/CT was used in the diagnostic process for these patients. Results Following SPECT/CT imaging, the common final diagnoses were osteoarthritis (10; 50%) and avascular necrosis (5; 25%). Less common diagnoses included ulnar carpal impact syndrome, infection, malunion, complex regional pain syndrome, and carpal boss. Some presented with multiple pathologies. SPECT/CT changed the final diagnosis in 11 cases, resulting in nonoperative treatment (7; 63%) or surgery (4; 37%). Conclusion Findings from this study and the literature demonstrate the clinical utility of SPECT/CT in the assessment of osseous-related wrist disorders. We present an algorithm for the assessment of wrist pain with osseous pathology. This commences with clinical assessment and plane radiographs (first-line investigation). Some cases will require a second-line investigation (ultrasound, CT, and/or MRI). If the diagnosis remains unclear, SPECT/CT is recommended as a third-line investigation.

Erratum: The Etiology and Pathogenesis of Kienböck Disease.

[This corrects the article DOI: 10.1055/s-0036-1583755.].

Salvage Procedures for Distal Radioulnar Joint Complications.

The distal radioulnar joint (DRUJ) allows forearm rotation and load transmission across the wrist. Post-traumatic and degenerative joint disease of DRUJ may cause pain and disability. Deficiency of the soft tissue or bony supports may result in DRUJ instability. Various techniques have been developed to address arthritis and / or instability of the DRUJ. A comprehensive review of the spectrum of surgical techniques and arthroplasty options is presented. The concepts of these procedures are discussed in detail, with a focus on special points of interest to optimise outcomes and to avoid complications. The salvage of the complications of arthroplasties is also presented in detail.

Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics.

BACKGROUND: In vitro, Propionibacterium acnes (P acnes) is highly susceptible to commonly used antibiotics and antiseptics, yet in vivo, it still causes postsurgical infections of the shoulder. We hypothesized that the local environment within the pilosebaceous glands protects P acnes and that incision of the skin transects these glands, exposing viable P acnes to the wound. METHODS: Fifty consecutive patients undergoing open shoulder surgery were prospectively studied. Prophylactic antibiotics were administered to all patients. Microbiologic swabs of the skin surface were taken before and after skin preparation with 70% alcoholic chlorhexidine. The skin was incised, and a further swab and dermal biopsy specimen were taken. RESULTS: P acnes was cultured in 21 of 50 prepreparation skin surface swabs (42%), 7 of 50 postpreparation skin surface swabs (14%), 26 of 50 dermal swabs (52%), and 20 of 50 dermal biopsy specimens (40%). There was a significantly higher incidence of P acnes growth from the skin surface (P = .009) and dermis (P = .01) of patients aged ≤50 years old and in the dermal biopsy specimens of patients undergoing revision surgery (P = .01) and a trend toward increased incidence of P acnes in men. P acnes growth from a prepreparation skin surface swab had a sensitivity of 69%, specificity of 88%, positive predictive value of 86%, and negative predictive value of 72% at predicting subsequent P acnes growth from the dermal swab or biopsy specimen. CONCLUSIONS: Viable P acnes persists within the skin dermis, despite standard antimicrobial precautions. These findings suggest that incising the skin is likely to lead to deep seeding of the surgical wound, which has implications for the pathogenesis and prevention of postsurgical shoulder infections.

Kienböck Disease: Recent Advances in the Basic Science, Assessment and Treatment.

Kienböck disease is a disorder of impaired lunate vascularity which ultimately has the potential to lead to marked degeneration of the wrist and impaired wrist function. The aetiology of the avascular necrosis is uncertain, but theories relate to ulnar variance, variability in lunate vascularity and intraosseous pressures. Clinical symptoms can be subtle and variable, requiring a high index of suspicion for the diagnosis. The Lichtmann classification has historically been used to guide management. We present a review of Kienböck disease, with a focus on the recent advances in assessment and treatment. Based on our understanding thus far of the pathoanatomy of Kienböck's disease, we are proposing a pathological staging system founded on the vascularity, osseous and chondral health of the lunate. We also propose an articular-based approach to treatment, with an arthroscopic grading system to guide management.

RSL Fusion with Excision of Distal Scaphoid and Triquetrum: A Cadaveric Study.

Radioscapholunate (RSL) fusion has been utilized for treatment of radiocarpal arthritis for patients with an intact midcarpal joint. This preserves midcarpal joint motion while alleviating pain. Dart thrower's motion (DTM), which has been emphasized recently, is mainly a midcarpal joint motion. Question A cadaveric study was designed to measure and compare the range of motion (ROM) of the human wrist before and after an RSL fusion, followed by distal scaphoid excision, and finally excision of the triquetrum. Methods Twelve embalmed adult cadaveric upper limbs were assessed. The wrist motion was measured with an electrogoniometer. Measurements of the flexion-extension plane and radial-ulnar deviation plane were obtained for baseline after capsulotomy, after simulated RSL fusion with memory staples, after distal scaphoidectomy, and after excision of the triquetrum. Results The effects of scaphoid and triquetrum excision were expressed as improvements in movement over that of the preceding step. RSL fusion alone resulted in a decrease of the flexion-extension (F-E) arc by 36% and the radioulnar deviation (R-U) arc by 30%. Excision of the distal scaphoid with RSL improved the F-E arc by 34% and the R-U arc by 34%. With excision of the triquetrum, the F-E arc improved further by 13% and the R-U arc by 21%. The ROM of the simulated RSL fusion with distal scaphoidectomy is improved with excising the triquetrum, mainly through an increase in ulnar deviation motion. RSL fusion with distal scaphoidectomy and triquetrectomy can be an alternative to total wrist arthrodesis for patients with an intact midcarpal joint.

Translunate perilunate injuries-a spectrum of this uncommon injury.

Purpose To review a series of translunate perilunate dislocations to analyze the, mechanism of injury, diagnosis, management, and outcome. Methods A literature review and a survey of the International Wrist Investigators Workshop were performed to locate cases. Results Translunate perilunate injuries are rare. There is a spectrum of severity. The mechanism of injury is usually high-energy, and multiple fractures are the norm. High-energy mechanism, perilunate dislocation, comminuted lunate fracture and delayed presentation greater than 7 days are associated with a higher likelihood of a salvage procedure being required. Discussion Translunate injuries are a complex variant of perilunate dislocations. Early diagnosis is critical in understanding the complexity of the injury. Lunate fixation should be performed prior to bony and ligamentous stabilization of the proximal row. In delayed or highly comminuted cases, salvage procedures are the preferred option. Including a translunate arc in addition to the greater and lesser carpal arc would lead to a more inclusive classification. Level of Evidence Level IV.