A "Congenitally Adapted" TFCC Tear in Radial Longitudinal Deficiency: Case Report and Review of Literature.

We present a case of chronic wrist pain in a 14-year-old child with mild radial longitudinal deficiency and radiographic carpal collapse due to the absence of the scaphoid. Wrist arthroscopy demonstrated synovitis and a tear to the TFCC, which would be called "degenerative," according to the Palmer classification. This was debrided, and the patient is still asymptomatic at long-term follow-up. Review of the literature found one paper with a similar observation in a 17-year-old adolescent. We propose that paediatric "degenerative" tears ought to be called "congenitally adapted" tears.

Wrist Arthroscopy in Juvenile Idiopathic Arthritis: A Review of Current Literature and Future Implications.

Introduction Juvenile Idiopathic Arthritis (JIA) is the most common rheumatological condition in children and frequently affects the wrist. The roles for wrist arthroscopy and arthroscopic synovectomy (AS) in JIA are unclear. Our aim was to find the current evidence supporting its use. Methods Systematic literature review of relevant publications from 1990 to present in the Cochrane Library, Clinical Knowledge Summaries, DynaMed, PEMSoft, NICE Guidance, MEDLINE, EMBASE, and PubMed. Results We found no publications detailing the use of arthroscopy or AS specifically in patients with JIA involving the wrist. There is evidence that AS reduces pain, improves function, and induces remission in patients with rheumatoid arthritis resistant to medical management. Discussion and Conclusion Although there is paucity in evidence for the use of AS in the wrists of patients with JIA, studies suggest it to be safe and effective, and could be applied to patients with refractive JIA. It is possible that early identification of patients suffering from JIA with extensive joint destruction and little symptoms could benefit from AS, delaying joint destruction and preserving function.

The role of arthroscopy in carpal instability.

Carpal instability is predominantly caused by trauma and presents as a painful wrist with signs and symptoms of weakness, clicking, clunking and a sense of giving way. Wrist arthroscopy is widely regarded as the 'gold standard' in diagnosing and understanding carpal instability. This article is based on an extensive literature search to evaluate the evidence behind the use of wrist arthroscopy in the assessment and management of these patients. There is convincing evidence supporting the role of arthroscopy in diagnosis and assessment of factors involved in the development of carpal instability, but weak evidence for the effectiveness of arthroscopic techniques in the actual treatment of this condition. The article reviews mechanisms behind, and the role for arthroscopy in the management of scapholunate, lunotriquetral, midcarpal and radiocarpal instability. It also presents how the author incorporates the 'evidence-base' into an 'experience-based' clinical practice.

Distal radio-ulnar joint instability in children and adolescents after wrist trauma.

UNLABELLED: This study retrospectively evaluated the medical records and radiographs of patients younger than aged 25 that were referred for a second opinion due to ulnar-sided wrist pain and persistent distal radio-ulnar (DRU) joint instability. We identified 85 patients with a major wrist trauma before the age of 18. Median age at trauma was 14 years. Median time between trauma and diagnosis of DRUJ instability was 3 years. Sixty-seven patients (79%) had sustained a fracture at the initial trauma. The two most common skeletal injuries related to the DRUJ instability were Salter-Harris type II fractures (24%) and distal radius fractures (19%). In 19 patients (22%), the secondary DRUJ instability was caused by malunion or growth arrest. Eighteen patients (21%) had no fracture; in spite of this, they presented with subsequent symptomatic DRUJ instability. Fourteen of these 18 patients had a triangular fibrocartilage complex (TFCC) tear, confirmed by arthroscopy, open surgery, or magnetic resonance imaging. In conclusion, late DRUJ instability due to wrist fractures or isolated TFCC tears was found to be common in children and adolescents. LEVEL OF EVIDENCE: IV.

Assessment of scapholunate instability and review of evidence for management in the absence of arthritis.

Scapholunate ligament tear is a common wrist injury and may lead to degenerative arthritis of the wrist in the long term. We review the assessment and classification of scapholunate instability and discuss the findings from our search for evidence for the management of scapholunate instability in the absence of arthritis. Strong evidence (level 1 or 2) for management is lacking and published recommendations are largely experience-based. The choice of procedure in the absence of arthritis depends on the extent of the tear, quality of the ligament remnants, and reducibility of the joint. Prospective, randomized studies with validated outcome measures are needed to establish the efficacy of intervention on symptoms and function and its effect on the risk of future arthritis.

A new definition of wrist sprain necessary after findings in a prospective MRI study.

INTRODUCTION: Wrist injuries with negative X-rays are diagnosed as acute wrist sprains. The prognosis is usually good, but some patients suffer from long-lasting pain and reduced wrist function, probably due to missed diagnosis followed by inappropriate treatment. The aim of this study was to investigate acute wrist sprains with MRI to detect the pathoanatomy of the injury. PATIENTS AND METHODS: This prospective magnetic resonance imaging (MRI) study included patients between 18 and 49 years, who attended the Accident and Emergency Department (A&E) Bergen, Norway, after sustaining an acute wrist trauma within the previous week. Initial X-rays of the wrist were normal. MRI was done within a median of 1 day (range 0-31 days) after the trauma, 80% within 4 days. The study period lasted from 5 November 2009 to 4 November 2010. RESULTS: A total of 155 acute MRIs were done, out of which 30 were completely normal. Patients with positive MRI had a median of two (range 0-8) pathological findings. We found 54 fractures and 56 bone bruises, mostly located to the radius followed by the scaphoid, the triquetrum, the capitate and the lunate. There were 73 soft-tissue injuries, which included 15 injuries to the triangular fibrocartilage complex (TFCC) and five scapho-lunate (SL) ligament lesions. CONCLUSIONS: Wrist sprain is an inaccurate diagnosis. In four out of five patients with normal X-rays, MRI identified pathological findings and a large variety of injuries in different structures. We suggest that wrist sprain should be defined as "occult partial or complete soft tissue (ligament, tendon, muscle) or bony injury in relation to a trauma with negative X-ray". The MRI findings led to a more differentiated treatment in more than a third of the patients. We recommend that MRI should be considered as a part of an early investigation, especially when the wrist pain does not settle within the first couple of weeks.

Wrist denervation in isolation: a prospective outcome study with patient selection by wrist blockade.

Surgical wrist denervation involves division of the anterior and posterior interosseous nerves and articular branches of the superficial radial nerve. In this outcome study, 37 patients were individually assessed and deemed suitable for denervation surgery due to appreciable symptom resolution following a local anesthetic wrist block. At a mean of 18 months following denervation surgery, median activity pain scores had decreased by 60% (p < 0.001) from initial assessment levels, and more than three quarters (30/37) of patients reported continued improvement in their activity pain (p < 0.001). More than two thirds of patients had a satisfaction VAS of greater than 50, with less postoperative resting pain and a greater reduction in postoperative activity pain as the important predictors of patient satisfaction. Thirty-one out of the 37 patients had not represented to our department for revision wrist surgery by a mean of 10.3 years follow-up. We have found this procedure useful in ameliorating symptoms for some patients who would conventionally have required partial or total wrist fusions with greater residual functional limitation.

The benefit of radiologically-guided steroid injections for trapeziometacarpal osteoarthritis.

INTRODUCTION: Osteoarthritis of the trapeziometacarpal joint (TMJ) is a common condition causing significant disability. Conservative treatments include intra-articular steroid injections. PATIENTS AND METHODS: This clinical, observational study prospectively reviewed the longevity of benefit of steroid injections into the TMJ. Eighty-three patients were recruited with a median age of 62 years and injected with steroid and local anaesthetic under radioscopic guidance. They were followed up until the analgesic effects ceased with a questionnaire including visual analogue scores. RESULTS: Two-thirds of patients were improved at 2 months, with nearly half having a 3-month improvement. One in six patients had a 6-month benefit, with some patients still improved 2 years after injection. Previously injected patients had a reduced duration of benefit compared to their previous injection. Severity of osteoarthritis did not affect the injection efficacy. CONCLUSIONS: Based on this study, we recommend steroid injections in all degrees of TMJ osteoarthritis.

The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment.

The distal ulna represents the fixed point around which the radius and the hand acts in daily living. The significance of distal ulnar fractures is often not appreciated and often results in inadequate treatment in comparison to its larger counterpart; the radius. There is little guidance in the current literature as how to manage these fractures and their associated injuries. This paper aims to critically review the current literature and combine it with treatment suggestions based on the experience of the authors to help guide investigation and management of these often complex injuries.

[Arthroscopic treatment of distal radius fracture.] / Traitement des fractures du radius avec assistance arthroscopique.

The orthopaedic surgeons cannot predict the functional results after a distal intra articular radius fracture. The intra-articular incongruity of more than 1 mm is associated with the development of secondary osteoarthrosis. The wrist arthroscopy became an essential help for the reduction of these fractures. The hand is normally in an upright position with a traction of approximately 4-5 kg which facilitates the reduction of the extra-articular fracture component. It is possible to use a technique of horizontal traction. The arthroscopy allows the reduction and control of the fixing of the various fragments, but also the treatment associated lesions associated. One randomized study, which compared 34 arthroscopically treated fractures with 48 openly treated, concluded that the arthroscopy-treated group had better outcome, better reduction, better grip strength and better range of motion than the openly treated group. The treatment of intra articular distal radius fractures with arthroscopic assistance is thus the guaranteeing of the most anatomical reduction of articular surface. It allows the diagnosis and the treatment of the associated lesions, decreases the peripheral fibrous scars of soft tissues by avoiding initially extensive approaches and finally gives better functional results.

[Arthroscopic treatment of distal radius fracture]. / Traitement des fractures du radius avec assistance arthroscopique.

The orthopaedic surgeons cannot predict the functional results after a distal intra articular radius fracture. The intra-articular incongruity of more than 1 mm is associated with the development of secondary osteoarthrosis. The wrist arthroscopy became an essential help for the reduction of these fractures. The hand is normally in an upright position with a traction of approximately 4-5 kg which facilitates the reduction of the extra-articular fracture component. It is possible to use a technique of horizontal traction. The arthroscopy allows the reduction and control of the fixing of the various fragments, but also the treatment associated lesions associated. One randomized study, which compared 34 arthroscopically treated fractures with 48 openly treated, concluded that the arthroscopy-treated group had better outcome, better reduction, better grip strength and better range of motion than the openly treated group. The treatment of intra articular distal radius fractures with arthroscopic assistance is thus the guaranteeing of the most anatomical reduction of articular surface. It allows the diagnosis and the treatment of the associated lesions, decreases the peripheral fibrous scars of soft tissues by avoiding initially extensive approaches and finally gives better functional results.

Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures.

Fifty-three patients with less than 14 day-old, undisplaced fractures of the waist of the scaphoid were randomized to two groups. Twenty-eight patients were treated by immobilisation in a below elbow plaster cast for 10 weeks while 25 were treated by percutaneous insertion of an Acutrak standard screw. There were no statistically significant differences between the two treatment groups with regard to either the rate of union or the time to union. Patients who underwent surgery had a significantly better range of motion at 16 weeks but there were no significant differences for grip strength. Acute percutaneous internal fixation of undisplaced scaphoid waist fractures using the Acutrak screw allows early mobilisation without adverse effects on fracture healing.

Wrist arthroscopy in distal radial fractures using a modified horizontal technique.

Wrist arthroscopy has today become an important adjunct in the management of displaced intra-articular distal radial fractures, with reduction of joint incongruencies as well as detection and treatment of associated soft-tissue injuries. However, standard upright arthroscopy makes it difficult to combine arthroscopic-assisted reduction with additional treatment of the often comminuted, extra-articular fracture component. This article describes a modified arthroscopic technique in which the arm is blocked in pronation with the traction horizontally over a handle on a normal hand table, without any other changes in the arthroscopy itself. The author has operated on 17 patients using this horizontal technique in combination with arthroscopic-assisted reductions, closed and open osteosynthesis, and soft-tissue procedures. The horizontal technique allows complete treatment of comminuted, unstable distal radial fractures, intra-articular and extra-articular reduction, and bone grafting, as well as assessment and treatment of associated soft-tissue injuries.

Distal radioulnar instability is an independent worsening factor in distal radial fractures.

Distal radial fractures in patients who are younger than the age when osteoporosis usually develops are different from fractures in the elderly. Arthroscopy has revealed these fractures often have a complex pattern of fracture related chondral and ligament injuries in the wrist. In Lund, Sweden, of the 92 distal radial fractures that occurred during 1 year in patients younger than the age when osteoporosis usually develops, 76 patients were assessed after more than 1 year (range, 14-38 months). The examination included questions, a visual analogue scale for pain, a physical examination, bilateral radiographic assessment, and wrist score determination according to Gartland and Werley. Instability at clinical examination of the distal radioulnar joint was associated with a worse wrist score and doubled the visual analogue measures for pain at rest and pain at load. This instability was not correlated to any radiographic variable at the time of fracture or at followup. The distal radioulnar joint was painful in 17 of the 27 patients with instability. Radiographic scapholunate dissociation did not affect the outcome. However, radiographic osteoarthrosis Grade 1 was associated with a worse wrist score. The outcome was dependent on the stability of the distal radioulnar joint, which in turn was not correlated to any radiographic parameter. Thus, destabilizing ligamentous injuries are thought to be an important cause of residual problems.

Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures.

The aim of this prospective study was to determine whether peripheral tears of the triangular fibrocartilage complex (TFCC) in patients younger than the osteoporotic age (males,<60 years; females, <50 years) were related to chronic distal radioulnar joint (DRUJ) instability. Fifty-one patients (27 women) with displaced distal radial fractures were included in the study. The median age was 41 years (range, 20-57 years). Arthroscopy at the time of fracture showed complete or partial TFCC tears in 43 patients (24 had only peripheral tears, 10 had only central perforations, and 9 had combined tears). The 1-year (range, 11-27 months) follow-up period included an interview, physical examination, and radiographic evaluation. Ten of the 11 patients with complete peripheral TFCC tears had DRUJ instability at the follow-up examination compared with 7 of the 32 patients with only partial or no peripheral tears. Patients with instability of the DRUJ had a worse Gartland and Werley wrist score. Instability was not associated with any radiographic finding either at the time of fracture or at the follow-up examination. Initial fracture or nonunion of the styloid was even slightly more common in stable patients.

Fractures of the distal forearm in young adults. An epidemiologic description of 341 patients.

We describe the epidemiology of all distal radial fractures in young adults (men 20-59 years, women 20-49 years) in Lund (1992-95) and Malmö (1994-95), Sweden. During the study period, there were 341 patients with 346 fractures in the two cities, found through the Hospital Register of Diagnoses in Lund and the register of the Radiology Department in Malmö. More than half of the fractures were dislocated and 2/3 of the cases involved the radiocarpal or radioulnar joints, in contrast to the predominantly extra-articular fractures in the elderly. There was an even distribution between sexes and the fractures were mainly caused by a severe trauma, i.e., more than a simple fall, most often sports injuries in January, February and May. Our findings suggest that distal radial fractures in nonosteoporotic young adults should be regarded as a special entity, at least in epidemiological studies. Possibly they also require treatment differing from that for osteoporotic fractures.

Complications and outcome in open carpal tunnel release. A 6-year follow-up in 92 patients.

In this retrospective study, 92 patients (83% attendance rate) were examined 6 years after open carpal tunnel release. A questionnaire was answered by the patient and a physical examination was made by an independent observer. Five complications were found, of which 4 were early postoperative problems and one was a major complication with long-term disability. In one third of the patients numerous complaints were noted even after six years. Recurrences were found in 9 cases. No lacerations of nerves, tendons or vessels were seen and no patient developed reflex sympathetic dystrophy. The overall subjective outcome showed that 91% of the patients were free of symptoms or improved. The grip strength at follow-up was reduced, if the symptoms had been present for more than 12 months, as compared to less than 12 months, (p = 0.009) and when associated, unspecific brachialgia had been present (p = 0.02). No differences were found in conjunction with the operating surgeon being either an orthopaedic resident or a specialist in hand surgery. In conclusion, open carpal tunnel release had a subjectively favourable outcome, but due to complications and postoperative complaints, further investigations into alternative techniques seem necessary.

Ligament lengthening compared with simple division of the transverse carpal ligament in the open treatment of carpal tunnel syndrome.

It has been suggested that the new (and controversial) endoscopic techniques are more successful than standard operation for the preservation of the ligamentous pulley function across the carpal tunnel and for the separation of the gliding structures from the subcutaneous tissues after release of the carpal ligament in carpal tunnel syndrome. We therefore decided to study the possible importance of preserving the continuity of the carpal ligament by doing an open lengthening of the ligament. This retrospective, unrandomised study included 99 patients with carpal tunnel syndrome who underwent open release of the carpal tunnel with or without a simultaneous lengthening of the transverse carpal ligament. The duration of follow up ranged from 4-8 years. The group who had the ligament lengthened had significantly longer sick leave (p < 0.01) than the group who had transverse ligament section alone. There were no advantages to reconstruction of the transverse ligament.

Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients.

We examined the frequency of associated chondral and ligament lesions in distal fractures of the radius in young adults (men 20-60 years, women 20-50 years). Fifty initially displaced fractures were examined arthroscopically. Chondral lesions were found in 16 patients (32%). All patients but one were found to have a ligamentous injury in the wrist. No major instability was found. The most frequent ligament tear was the triangular fibrocartilage complex in 39 cases (78%), with a statistical correlation to ulnar styloid fractures. The scapholunate ligament was partially or totally torn in 27 cases (54%). No correlation was found between specific fracture type and pattern of ligament injury. Chondral and ligamentous lesions were frequent and may explain poor outcomes after seemingly well-healed distal fractures of the radius. The ligament lesions should also be kept in mind when early mobilization of the distal fracture of the radius is considered.