腕关节韧带解剖及组织学特性研究

目的了解腕关节韧带解剖及组织学特性。方法成人腕关节标本34侧,其中32侧为福尔马林固定标本,2侧为新鲜标本。解剖并观察腕关节韧带的起止、走行、与关节囊的关系及韧带的比邻;测量其长度,取每条韧带的中段测量其宽度和厚度。8侧福尔马林固定标本,解剖出部分腕关节韧带石蜡包埋、切片、HE染色,光镜观察。结果腕关节韧带掌侧较强韧,同时数量也多。相邻韧带形成多个“V”形结构。桡舟韧带、桡舟头韧带和桡月韧带的组织结构相似,由肌腱样的胶原纤维束组成,胶原纤维束之间有少量的疏松组织,其间有血管分布,胶原纤维束呈小的波浪状。桡舟月韧带主要由疏松结缔组织组成,没有粗大的肌腱样胶原纤维束,胶原纤维束很少,而血管束丰富。舟月骨间韧带和月三角骨间韧带的掌侧、背侧和近侧的3个部分不同,特别是近侧部与掌侧、背侧部分。背侧部分主要由粗大成束的横行胶原纤维束组成;掌侧部分也由胶原纤维束组成,其排列方向是斜行,在桡舟月韧带与舟月骨间韧带结合处,可见桡舟月韧带的血管束进入舟月骨间韧带掌侧部分;近侧部分主要由纤维软骨成份构成,其间无血管神经分布。结论大部分腕关节韧带由密集粗大的胶原纤维束为主构成。而桡舟月韧带,则主要由疏松结缔组织组成,其间血管丰富,其功能主要是供血。舟月骨间韧带和月三角骨间韧带的近侧部分,主要由纤维软骨成份组成,其间没有血管。     

Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III

PURPOSE: This study continued our previous investigations of the ligaments stabilizing the scaphoid and lunate in which we examined the scapholunate interosseous ligament, the radioscaphocapitate, and the scaphotrapezial ligament. In this current study, we examined the effects of sectioning the dorsal radiocarpal ligament, dorsal intercarpal ligament, scapholunate interosseous ligament, radioscaphocapitate, and scaphotrapezial ligaments. In the current study, the scapholunate interosseous ligament, radioscaphocapitate, and scaphotrapezial ligaments were sectioned in a different order than performed previously. METHODS: Three sets of 8 cadaver wrists were tested in a wrist joint motion simulator. In each set of wrists, only 3 of the 5 ligaments were cut in specific sequences. Each wrist was moved in continuous cycles of flexion-extension and radial-ulnar deviation. Kinematic data for the scaphoid and lunate were recorded for each wrist in the intact state, after the 3 ligaments were sectioned in various sequences and after the wrist was moved through 1,000 cycles of motion. RESULTS: Dividing the dorsal intercarpal or scaphotrapezial ligaments did not alter the motion of the scaphoid or lunate. Dividing the dorsal radiocarpal ligament alone caused a slight statistical increase in lunate radial deviation. Dividing the scapholunate interosseous ligament after first dividing the dorsal intercarpal, dorsal radiocarpal, or scaphotrapezial ligaments caused large increases in scaphoid flexion and lunate extension. CONCLUSIONS: Based on these findings, we concluded that the scapholunate interosseous ligament is the primary stabilizer and that the other ligaments are secondary stabilizers of the scapholunate articulation. Dividing the dorsal radiocarpal, dorsal intercarpal, or scaphotrapezial ligaments after cutting the scapholunate interosseous ligament produces further changes in scapholunate instability or results in changes in the kinematics for a larger portion of the wrist motion cycle.     

Radiocarpal articular contact characteristics with scaphoid instability

The relative importance of the three major periscaphoid ligament complexes in maintaining the normal radiocarpal articulation was assessed. Pressure-sensitive film recorded the changes in radioscaphoid and radiolunate articular contact that occurred with sequential ligament sectioning in 12 cadaver wrists. Alterations in the radiocarpal articular contact as a result of ligament disruption are evident in the absence of the recognizable static x-ray changes of carpal instability. The scapholunate interosseous ligament is essential in preventing scapholunate diastasis and dorsoradial subluxation of the proximal scaphoid. Rotatory subluxation of the scaphoid occurs when disruption of the scapholunate interosseous ligament is coupled with disruption of either the palmar intracapsular radiocarpal ligaments or the scaphotrapezial ligament complex. These data help explain the development of degenerative arthritis caused by carpal ligamentous instability.     

Dorsal wrist ligament insertions stabilize the scapholunate interval: cadaver study

This study examined sequential arthroscopic sectioning of volar, interosseous, and dorsal ligaments about the scapholunate complex in cadaver wrists. We attempted to clarify the contributions of the dorsal ligamentous complex to scapholunate instability and carpal collapse. We found that after sequential sectioning of volar ligaments and the scapholunate interosseous ligament, no scapholunate diastasis or excessive scaphoid flexion occurred. After dividing the dorsal intercarpal ligament, scapholunate instability occurred without carpal collapse. With sectioning of the dorsal radiocarpal ligament from the lunate, a dorsal intercalated scapholunate instability deformity ensued. This information may be of value in comprehending the pathogenesis of scapholunate instability and carpal collapse and in devising the rationales for conservative measures and surgical intervention.     

Severity of scapholunate instability is related to joint anatomy and congruency

PURPOSE: To determine whether the bony architecture of the distal radius and proximal scaphoid have a role in stabilizing the scaphoid, and to determine whether a relationship between the bony geometry measurements and the amount of wrist constraint could be determined. METHODS: Eight cadaver wrists were tested in a wrist joint motion simulator. The level of scapholunate instability after sectioning the scapholunate interosseous, radioscaphocapitate, and the scaphotrapezium ligaments was determined and related to radiographic measurements of volar tilt, lateral tilt (ulnar tilt of the radioscaphoid fossa), the depth of the radioscaphoid fossa, and 6 radii of curvature measurements of the proximal scaphoid and distal radius. The force to dorsally dislocate the scaphoid out of the radioscaphoid fossa was computed. RESULTS: The radioscaphoid fossa and scaphoid curvatures were larger in those wrists that did not show gross instability after ligamentous sectioning in the wrist simulator. Similarly, those wrists with a deeper radioscaphoid fossa and greater volar tilt were also more stable. The force required to dislocate these wrists was greater than in those wrists that showed gross carpal instability. CONCLUSIONS: This study suggests that the bony anatomy of the radius and scaphoid have a role in stabilizing the carpus after ligament injury. The effect of ligament sectioning on producing carpal instability may be moderated by the bone geometry of the radiocarpal joint. This may explain why some people may have a tear of the scapholunate interosseous ligament but not present with clinical symptoms.     

Static scapholunate dissociation: a new reconstruction technique using a volar and dorsal approach in a cadaver model

We used 4 fresh-frozen cadaver arms to assess a method of reconstruction we designed for static scapholunate dissociation. The dorsal scapholunate ligament, scapholunate interosseous ligament, radioscapholunate, and radioscaphocapitate ligaments were sectioned. Radiographs were taken before sectioning, after sectioning, and after reconstruction. Passive motion was also measured before sectioning and after the repair. The dorsal scapholunate ligament was repaired directly; the palmar radioscapholunate and radioscaphocapitate ligaments were reconstructed using a free flexor carpi radialis tendon autograft and Mitek mini suture anchors (1.8-mm diameter and 5.4-mm length; Mitek Products, Norwood, MA) for anatomic fixation. An independent board-certified hand surgeon analyzed the radiographs of the wrists taken before and after sectioning and after reconstruction. Assessment of the unsectioned wrists revealed an average scapholunate angle of 45 degrees. After scapholunate dissociation was created the average scapholunate angle was 71 degrees. Repair of the dorsal scapholunate ligament alone did not improve the scapholunate angle. Average scapholunate angle after repair of the dorsal scapholunate ligament and reconstruction of the palmar ligaments was 43 degrees. Average range of motion on flexion, extension, and radial and ulnar deviation before ligament sectioning and after reconstruction was unchanged at 54 degrees, 59 degrees, 19 degrees, and 40 degrees respectively. This technique shows an improvement in scapholunate angle on lateral radiographs, and passive motion remained relatively unchanged.     

Microvascular anatomy of the radioscapholunate ligament of the wrist

The microvascular circulation and basic structural features of the radioscapholunate ligament of the wrist were studied in six fresh cadaver specimens by injection and clearing techniques. A rich vascular supply was found to originate from vessels that perforate the palmar capsule and enter the synovium that surrounds the ligament. By way of branches from the synovium, the radioscapholunate ligament and most of the scapholunate interosseous ligament receive an abundant blood supply. No contributions are derived from the bony attachments. Observation under light microscopy revealed a delicate, well-vascularized ligament consisting of regular collagen bundles. No elastic fibers were observed. This study indicates that the radioscapholunate ligament has a vascular supply that may be sufficient for healing by known methods.     

Development of a arthroscopic severity score for scapholunate instability

INTRODUCTION: We report the development of an arthroscopic severity score for scapholunate instability based on dynamic testing of the scapholunate joint. METHOD: Seventy patients who had a scapholunate instability diagnosed by arthroscopy were reviewed. There were 21 static instabilities, 19 dynamic instabilities and 30 preradiographic instabilities. The arthroscopic finding was systematized. In the radiocarpal space the scapholunate interosseous ligament was seen and palpated. In the midcarpal space, the dynamic manoeuvre of dissociation was done using the examining hook. RESULTS: An arthroscopic classification was developed: in stage 0, it is impossible to put the tip of the hook between the scaphoid and the lunate; in stage 1, it is possible to put the tip of the hook between the scaphoid and the lunate; in stage 2, it is possible to create a scapholunate diastasis with the use of a twisting motion applied to the hook; in the stage 3, the 2.7-mm arthroscope passes between the scaphoid and lunate from the midcarpal to the radiocarpal space. We found 4 stage 1, 43 stage 2 and 23 stage 3. DISCUSSION: Even if other diagnostic tools such as the arthroscanner or MRI are able to diagnose scapholunate interosseous ligament tears, wrist arthroscopy is for us the Gold Standard to quantify and directly explore the scapholunate joint. The goal of the score of severity presented here is to guide the different therapeutic indications.     

Arthoscopic diagnosis of partial scapholunate ligament tears as a cause of radial sided wrist pain in patients with inconclusive x-ray and MRI findings

To clarify the pathology of radial-sided wrist pain with inconclusive X-ray and MRI findings, we performed arthroscopic examinations of 11 wrists in 10 patients. Physical examination and various image investigations could not identify the cause of the pain. Arthroscopy revealed partial to complete tears of the scapho-lunate interosseous ligament and synovitis and/or chondral bone defects at the scaphotrapezio-trapezoidal joint in all 11 wrists. Surgical procedures consisted of eight simple synovectomies, two ligament reconstructions and one percutaneous pinning. Pain relief was achieved in 10 wrists. One wrist which had a simple synovectomy did not recover, so underwent secondary scaphotrapezio-trapezoidal fusion. In conclusion, we found that various degrees of scapholunate interosseous ligament tear and scaphotrapezio-trapezoidal joint osteoarthritis were the main causes of radial-sided wrist pain with inconclusive X-ray and simple MRI findings.     

An anatomic guide for arthroscopic visualization of the wrist capsular ligaments

Wrist arthroscopy allows examination of the palmar capsular wrist ligaments without extensive exposure. Arthroscopic examination of the wrist requires an accurate knowledge of the ligamentous anatomy as seen from inside the joint. In this study 13 fresh cadaver wrists were examined from the inside out to provide a visual guide for ligament identification during arthroscopy. The major palmar capsular ligaments seen from the inside of the wrist at the radiocarpal joint include the radioscaphoid, radioscaphocapitate, radiolunate, radioscapholunate, ulnolunate, ulnotriquetral ligaments, and the ulnar capsule. At the midcarpal joint, the scaphocapitate, radioscaphocapitate, triquetrocapitate, and triquetrohamate ligaments are identified palmarly. Dorsally, constant capsular structures at the radiocarpal joint are the radiolunate and radioulnotriquetral ligaments along with a prominent synovial fold.     

Micro-CT扫描下舟月骨间韧带的显微解剖学研究

目的研究舟月骨间韧带(SLIL)的形态和血供分布,并从解剖学角度探讨临床上SLIL损伤对其血供的影响及重建的方法。方法2018年10月至2018年12月,选取12例新鲜成人前臂标本,从尺动脉或桡动脉灌注明胶-氧化铅溶液,于Micro-CT下扫描,通过Mimics软件三维重建图像,观察SLIL在中立位的形态和韧带内滋养血管分布,测量韧带掌侧、背侧和近端的宽度、长度、厚度,测量SLIL内滋养血管入口处的解剖参数,并分析其与舟、月骨的血供关系。结果①数字化技术三维重建SLIL的大体形态并测量其解剖参数,近端长度均值最大,掌侧、背侧长度相近;韧带掌侧最宽,厚度最小,而背侧与近端在厚度与宽度上相近。②SLIL的近端无滋养血管分布,掌侧与背侧均有丰富的滋养血管分布,其血供分布差异无统计学意义(P>0.05)。③SLIL的掌侧与背侧内滋养血管从SLIL附着处进入舟、月骨内形成吻合。结论SLIL掌侧较宽且厚度小,从解剖学角度分析其较其它亚区更易损伤;其掌侧与背侧亚区均有丰富的血供且与舟、月骨内相吻合,而近端无血管分布,因此,掌、背侧韧带早期轻度损伤有一定的自我修复能力,而近端损伤则较难修复,韧带掌侧与背侧损伤对舟、月骨血供会产生一定影响。     

A comparison of scaphoid-trapezium-trapezoid fusion and four-bone tendon weave for scapholunate dissociation.

The contact characteristics of the radiocarpal joint (area, pressure, and ratios of scapholunate area, pressure and force transmitted) were determined with the use of pressure-sensitive film in seven normal wrists after ligament sectioning to create scapholunate instability, with reconstruction involving a scaphoid-trapezium-trapezoid fusion, and with reconstruction involving a four-bone tendon weave procedure. The results demonstrated that the scaphoid-trapezium-trapezoid fusion significantly altered the contact characteristics of the wrist, transferring load, pressure, and area to the radioscaphoid joint, thereby unloading the lunate. In contrast, the tendon weave reconstruction produced characteristics similar to those of the normal joint.     

The anatomy of the ligaments of the wrist and distal radioulnar joints

The ligaments of the wrist are responsible for guiding and constraining the complex motion of the carpal bones relative to the forearm bones, the metacarpals, and contiguous carpal bones. The majority of wrist ligaments are found within the joint capsule as organized thickenings composed of parallel collagen fascicles, small caliber nerves and blood vessels, and lined on their deep surfaces by synoviocytes. The palmar radiocarpal ligament complex is composed of the radioscaphocapitate, long radiolunate, radioscapholunate and short radiolunate ligaments. The ulnocarpal ligaments include the ulnolunate, ulnotriquetral and ulnocapitate ligaments. Dorsally, the radiocarpal joint is spanned by the dorsal radiocarpal ligament. Palmar ligaments connecting the proximal and distal carpal rows include the scaphotrapeziotrapezoid, scaphocapitate, triquetrocapitate and triquetrohamate ligaments. Within each row are interosseous ligaments connecting adjacent carpal bones, each divisible into dorsal and palmar components. There are unique regions within some of the ligaments, such as a zone of fibrocartilage in the proximal regions of the scapholunate and lunotriquetral interosseous ligaments, and strong deep regions connecting the trapezoid, capitate, and hamate. The distal radioulnar joint is connected by the triangular fibrocartilage complex, composed of a fibrocartilaginous disc and the palmar and dorsal radioulnar ligaments. The ulnocarpal ligaments attach to the palmar radioulnar ligament rather than directly to the ulna, allowing increased independence between wrist and forearm motion.     

Traction radiography for the diagnosis of scapholunate ligament tears

The diagnosis of scapholunate ligament injury by traction radiography was investigated within a consecutive study. The right wrists of 25 healthy volunteers and 22 wrists with arthroscopically proven complete scapholunate ligament tears were examined. Traction radiography was performed under fluoroscopy with a force of 5 kg applied to the thumb. In the normal wrists, this led to selective widening of the scapholunate joint space whereas the lunotriquetral distance remained unchanged. In 25 healthy right wrists, the median scapholunate distance measured 2.1 (range 1.3-2.6) mm on resting radiographs and 2.2 (range 1.7-3.5) mm on the stress radiographs. For the 22 wrists with complete scapholunate ligament tears, the median scapholunate distance was increased from 2.0 (range 1.0-3.0) mm to 3.8 (range 3.0-5.5) mm by traction (median difference of 1.8 (range 1.0-3.0) mm). In conclusion, a scapholunate distance of 3.0 mm or more in unloaded wrists or widening of the scapholunate interval by 1.0 mm or more under thumb traction should both be considered as pathological findings. We recommend traction radiography as a simple and valuable diagnostic procedure for suspected scapholunate ligament injury.     

Nerve endings of the wrist joint: a preliminary report of the dorsal radiocarpal ligament.

As part of an investigation of the articular nerve ending populations in the wrist joint capsule associated with the anterior and posterior interosseous nerves, this study addresses the nerve ending population in the dorsal radiocarpal ligament. The ligaments were harvested from four wrists of two fresh cadavers within 12 h of death. Tissues were fixed, cryostat sectioned, and processed for fluorescence immunohistochemistry using antibody to protein gene product 9.5 (PGP 9.5), a general or pan neuronal marker, and a secondary antibody conjugated to a fluorescent tag (Alexa Fluor 488). The sections were evaluated with a confocal laser microscope and an image analyzer. Labeled nerve endings were mapped, measured, and categorized. Type I (Ruffini-like ending), Type III (Golgi-like tendon organ) and Type IV (noncorpuscular) nerve endings could be identified in all four DRC ligaments, with Types I and IV dominating. These receptors were distributed primarily over the superficial two thirds of the ligament (>80%), and near the bony attachments (>70%). The dorsal radiocarpal ligament has a rich sensory innervation from the posterior interosseous nerve terminating in nerve endings located in the superficial two-thirds of the ligaments, primarily near bony attachment sites.     

Current innovations in wrist arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.     

The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability

PURPOSE: Scapholunate instability (SLI) is the most common carpal instability. Recent studies have suggested that the dorsal intercarpal (DIC) and the dorsal radiocarpal ligaments play an important role in stabilization of the scaphoid and lunate. Differences between dynamic SLI and static SLI with a dorsal intercalated segment instability (DISI) are clearly described in the clinical literature; however, there has never been a clear explanation of the anatomic differences. This study describes the role of the DIC in the development of dynamic and static SLI with DISI in a cadaver model. METHODS: Five fresh cadavers were studied radiographically and by 3-dimensional digitization. Six increasing stages of instability were developed by sectioning progressively the following structures: the dorsal capsule, the palmar and proximal (membranous) portion of the scapholunate interosseous ligament, the DIC from its insertion on the scaphoid and trapezium, the dorsal scapholunate interosseous ligament from the scaphoid, the DIC ligament from its attachment on the lunate, and the lunotriquetral interosseous ligament. RESULTS: The scaphoid position and the scapholunate gap changed significantly after sectioning the entire scapholunate interosseous ligament and DIC from the scaphoid when a 5-kg load was applied. The lunate position was unchanged in both the loaded and the unloaded conditions. After detaching the DIC from the lunate, both the scaphoid and lunate moved and the scapholunate gap increased significantly in both loaded and unloaded conditions and showed a DISI deformity. CONCLUSIONS: This study describes an anatomic difference between dynamic and static scapholunate instability. Complete disruption of the scapholunate ligament did not result in the development of a static collapse of the lunate. The DIC had an important role in stabilizing the scaphoid and lunate and preventing DISI deformity. This study suggests that in the clinical setting the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction of the DIC ligament attachments to both the scaphoid and the lunate.     

Traction radiography for the diagnosis of scapholunate ligament tears: an experimental cadaver study

The aim of this experimental cadaver study was to verify that thumb traction radiography can be used to diagnose scapholunate interosseous ligament (SLIL) injury. Eight cadaver forearms were positioned vertically so that the thumb could be held in a Chinese finger trap and traction force applied using a 5 kg weight. Fluoroscopy was performed with the thumb unloaded and under traction, and then unloaded and under traction after division of the SLIL. The scapholunate joint gaps were measured electronically. The difference between the unloaded and loaded wrists with sectioned SLIL was not statistically significant. These results suggest that thumb traction radiography might not reliably detect acute, complete SLIL tears.     

The two parts of the dorsal radiocarpal (radiolunotriquetral) ligament

An anatomical study was performed to identify the configuration of the dorsal radiocarpal ligament. Fourteen fresh frozen wrists from seven cadavers (mean age 65 years) were dissected under loupe magnification. The study demonstrates that the dorsal radiocarpal ligament had, in every case examined, an additional superficial component which has not been previously described. It arises from the distal part of the interosseous border of the radius. It runs obliquely, distally and ulnarward, over the distal ulna to attach to the lunate and triquetrum. The dorsal radiocarpal ligament blends with the underlying dorsal radioulnar ligament which runs transversely, at a deeper plane, between the radius and ulna. The paper discusses the clinical implications of this finding.     

腕关节镜辅助下修复舟月韧带治疗腕关节不稳定

目的分析腕关节镜辅助下利用骨锚修复腕舟月韧带的疗效。方法自2008年10月一2011年4月,对6例腕关节损伤患者通过腕关节镜探查舟月韧带,确定损伤部位后,应用Mitek骨锚重建舟月韧带,术后石膏托固定腕关节于功能位4周后开始患腕被动活动,6周后开始主动运动。术后随访6个月,测定患腕术前及术后的握力、应用改良Mayor评分法对腕关节功能进行客观评分、患者源性调查表（disabilityofarm-shoulder-hand,DASH）问卷法进行主观评分,以及术前与术后的x片检查对比。并与健侧腕关节x片进行对比。结果术后6例患者腕关节疼痛均有缓解．握力明显改善。按照改良Mayor评分：优2例,良3例,可1例,优良率为83．3％,与术前评分的差异有统计学意义（P〈O．01）。术后DASH分值平均为（14．6±7．0）,与术前评分差异有统计学意义（P〈O．01）。结论舟月韧带损伤是导致腕关节不稳定的重要原因之一,在腕关节镜辅助下利用骨锚修复舟月韧带是一种微创、实用的方法。