Diagnostik und Therapie von radiokarpalen Luxationsfrakturen

In contrast to the common intra- or extra-articular fractures of the distal radius, radiocarpal fracture dislocations are rare injuries. Concerning this issue, only a small number of publications can be found. Nevertheless, it is important to be informed about this injury since prompt operative treatment is often required and immobilization alone will not be sufficient. Sometimes, radiocarpal fracture dislocations are combined with carpal injuries. In such cases, both the radiocarpal dislocation and carpal injury have to be treated. Diagnostic difficulties can lead to misinterpretation or underdiagnosis. Insufficient reduction and fixation may result in joint incongruity and subsequent osteoarthritis. Reconstruction of the radiocarpal ligaments is a substantial part of operative treatment.     

20-Year outcome of TFCC repairs

The aims of this study were to investigate the functional result and rate of osteoarthritis 15–25?years after a TFCC-repair. Forty-seven patients completed the questionnaire Patient Rated Wrist Evaluation (PRWE), and 43 had new X-rays. Fifty-seven percent had a simultaneous arthroscopy. Sixteen patients had later additional surgery to the wrist, of these eight had a reoperation of the TFCC-injury due to recurrent instability. Radiographs showed that 17.5% had developed radiocarpal osteoarthritis and 34% osteoarthritis in the distal radioulnar joint. The median PRWE result was 22.5. Patients with radiocarpal osteoarthritis and patients who had additional surgery had significantly worse scores. Patients who had undergone arthroscopy significantly less often had developed radiocarpal osteoarthritis. The result is acceptable but not impressive and efforts should be made to diagnose these injuries early and also diagnose associated injuries, advisably by arthroscopy.     

Radiocarpal fracture-dislocations

Radiocarpal fracture-dislocations most often are caused by high-energy trauma. These difficult, uncommon injuries involve significant soft-tissue and osseous trauma, requiring meticulous reduction and fixation. The mechanism of injury is generally a severe shear or rotational insult. Anatomically, the dislocation results in disruption of the radiocarpal ligaments and, usually, both the radial and the ulnar styloid. Understanding the anatomy of the radiocarpal joint is central to understanding the osseous and soft-tissue constraints that are disrupted with a radiocarpal dislocation. Diagnosis can be reliably made on physical examination and radiographic evaluation. Radiocarpal fracture-dislocation injuries must be differentiated from Barton fractures. Associated injuries such as open fractures, neurovascular involvement, and distal radioulnar dislocations also must be taken into account. Closed reduction can be obtained relatively easily, but open reduction and internal fixation is typically necessary to ensure accurate anatomic restoration of injured bone and ligaments.     

Radial styloid fractures

Radial styloid fractures can occur in isolation or in association with other injuries, including complex intra-articular distal radius fractures, carpal fractures, carpal dislocations, and radiocarpal dislocations. The anatomy surrounding the radial styloid is complex, and complications related to surgical approach, treatments, and symptomatic hardware can occur. Operative treatments vary according to the injury pattern present, and pattern recognition is the key to optimizing treatment of these injuries. Outcomes are related to the precision of the reconstruction as well as the magnitude of the injury; better results are associated with lower-energy patterns.     

Bridge plating of the wrist for temporary stabilization of concomitant radiocarpal, intercarpal, and carpometacarpal injuries: a report of two cases

Concomitant injuries of the radiocarpal, intercarpal, and carpometacarpal joints are rare and usually result from very high-energy trauma. The skeletal injury is often accompanied by severe soft tissue trauma. Repair of the radiocarpal and intercarpal ligaments needs to be augmented with immobilization. Traditional methods of immobilization, such as casts and external fixators have limitations. We describe our experience in 2 patients using a technique in which a wrist arthrodesis plate is temporarily placed from the radius to metacarpal to span the carpus and protect the radiocarpal and intercarpal repairs. The plate is removed after 3 months.     

Carpal dislocations

Carpal dislocations are rare but devastating injuries. They most often occur from high-energy trauma such a motor vehicle accidents, falls from a height, or industrial-related accidents. Encompassing a spectrum of pathology, these injuries include perilunate dislocations, transcarpal fracture-dislocations, radiocarpal dislocations, axial or longitudinal dislocations, and the rare isolated carpal bone dislocations. A thorough understanding of the carpal anatomy, injury patterns, and treatment options is critical for proper management of these serious injuries. In this article, the authors address the five main categories of carpal dislocations, the associated anatomy, and their diagnosis, treatment, and prognosis.     

Perilunate dislocation and perilunate fracture-dislocation

Perilunate dislocations and perilunate fracture-dislocations usually result from high-energy traumatic injuries to the wrist and are associated with a characteristic spectrum of bony and ligamentous damage. Radiographic evaluation of the wrist reveals loss of normal radiocarpal and intercarpal colinearity and bony insult, which may be overlooked at the initial presentation. Prompt recognition is important to optimize outcomes. Closed reduction is performed acutely, followed by open reduction and ligamentous and bony repair with internal fixation. Complications include posttraumatic arthrosis, median nerve dysfunction, complex regional pain syndrome, tendon problems, and carpal instability. Despite appropriate treatment, loss of wrist motion and grip strength, as well as persistent pain, is common. Medium- and long-term studies demonstrate radiographic evidence of midcarpal and radiocarpal arthrosis, although this does not correlate with functional outcomes.     

Volar radiocarpal dislocation with ulnar translocation

The first known reported case of volar radiocarpal dislocation with ulnar translocation is described with a review of previous literature on the isolated components of these injuries. Radiographic criteria for their diagnosis are presented with recommendations for early operative intervention to minimize the risk of subsequent carpal instability and provide an optimum functional result. An awareness of the possible coexistence of these injuries leading to early diagnosis and expedient treatment is essential to a good functional result.     

Lunotriquetral injuries in the athlete

The athlete with an LT injury typically presents with ulnar-sided wrist pain after a high-energy impaction of the wrist. Reagan's LT ballottement test and Kleinman's shear test help the examiner identify these injuries. A thorough radiographic examination includes standard PA and lateral radiographs. Magnetic resonance imaging or arthrography can be performed, but the sensitivity of these imaging studies varies. The palmar portion of the LT interosseous ligament, dorsal radiocarpal ligament, and dorsal intercarpal ligament play the most significant roles in LT stability. Lunotriquetral injuries without instability respond well to immobilization. Arthroscopy is valuable in staging and determining treatment but requires a thorough radiocarpal and midcarpal examination. Acute LT injuries with instability are treated with arthroscopic-assisted reduction and pinning. If desired, this procedure can be incorporated with an open ligament repair through a volar approach. Chronic LT tears without instability can also be treated arthroscopically. Treatment of the chronic LT tear with instability depends on the degree of collapse. Treatment in the athlete includes ligament reconstruction with capsulodesis or, rarely, intercarpal LT arthrodesis.     

Diagnostic and operative arthroscopy of the wrist

The evaluation and diagnosis of wrist disorders has traditionally been difficult and problematic. Ligamentous wrist sprains and their associated carpal instabilities, triangular fibrocartilage complex disruptions, and cartilage injuries have been virtually impossible to fully assess because of the inadequacy of current diagnostic techniques. Arthroscopy of the wrist allows a thorough evaluation of the soft-tissue structures and cartilaginous surfaces within the radiocarpal and midcarpal joints. In selected cases, wrist arthroscopy can be employed to surgically modify the intraarticular lesions and to assist in the planning of reconstructive operations.     

Palmar radiocarpal dislocation resulting in ulnar radiocarpal translocation and multidirectional instability

Posttraumatic ulnar radiocarpal translation is a rare, often subtle, highly unstable, and potentially devastating manifestation of severe "proximal radiocarpal ligamentous instability. Radiocarpal dislocation should alert the treating physician to the risks of the spectrum of radiocarpal instabilities. Radiocarpal instability may initially be masked or unappreciated owing to presentation without radiocarpal dislocation, local pain and swelling, initially normal standard wrist radiographs, lack of recognition, or delay in the appearance of a static lesion. The specificity, sequence, and extent of extrinsic radiocarpal and ulnocarpal ligament traumatic disruptions are not fully understood, vary with injury severity, and may differ in instances of dorsal as opposed to palmar subluxation or dislocation. Multidirectional (global) wrist instability typically accompanies this ulnar radiocarpal instability in its most severe form and consequences may be dire. The carpus may be difficult to reduce or maintain owing to marked instability, compressive forces across the wrist, and soft tissue or bony fragment interposition. Additional local distal radioulnar joint or intercarpal injuries may further confound stability and require their own specific and simultaneous treatment. Radiocarpal reduction and repair of the radioscaphocapitate ligament and radiolunate ligaments may be sufficient treatment for acute isolated palmar radiocarpal instability. Temporary K-wire fixation may be added as a precaution to prevent palmar carpal subluxation during the time of ligament healing. Radiocarpal reduction, palmar and dorsal soft-tissue repair, and temporary K-wire fixation comprise one method of treatment for early recognized cases of post-traumatic ligamentous ulnar radiocarpal transposition. Halikis et al have recommended radiolunate arthrodesis. Rayhack et al have suggested that limited or complete wrist arthrodesis may be indicated for patients with delayed presentation or in acute cases with extreme instability. Wrist arthrodesis is one means of management for patients with severe radiocarpal instability confounded by distal radioulnar joint or intercarpal instability, as seen in our patient. Damaged ligaments may have a poor blood supply and often may not hold sutures or heal well. Bone anchor sutures or some type of ligament augmentation may help to restore joint stability in some patients. Loss of stability may occur later owing to ligamentous laxity or inadequate soft-tissue healing. Radiolunate, radiocarpal, or complete wrist arthrodesis may be necessary to relieve pain, restore wrist alignment and stability, and reestablish extremity function for patients with chronic radiocarpal instability. Wrist symptoms, age, general health, hand dominance, and occupation may be among the factors that influence the necessity for and timing of reconstruction. Rayhack et al have also postulated that negative ulnar variance may accommodate the occurrence of ulnar radiocarpal translocation and confound repair owing to lack of buttress at the ulnocarpal joint. They further speculated that a joint leveling procedure might improve the support for ligamentous repair or reconstruction in these cases. Permanent functional impairment must be anticipated in patients with ulnar radiocarpal instability. Impairment has typically been commensurate with the extent of the initial lesion, additional confounding local lesions, and length of follow-up.     

Articular ganglia of the volar aspect of the wrist: Arthroscopic resection compared with open excision. A prospective randomised study

Our aim was to compare two methods of treatment of ganglia on the volar aspect of the wrist (the open excision done through a longitudinal volar skin incision and the arthroscopic resection through two or three dorsal ports), to see if arthroscopy could reduce the risks of operating in this area and the time to healing. Twenty radiocarpal and five midcarpal volar ganglia were operated on by open approach and an equivalent group was treated by arthroscopy. Fifteen radiocarpal and five midcarpal ganglia were treated with good results in the open group and 18 radiocarpal and one midcarpal ganglia in the arthroscopic group (no visible or palpable ganglion, a full range of active wrist movement, grip strength equal to preoperatively, no pain, and a cosmetically acceptable scar). In the open group there were four injuries to a branch of the radial artery, two cases of partial stiffness of the wrist associated with a painful scar, one case of neuropraxia, and one recurrence (all of which were among the 20 radiocarpal ganglia). In the arthroscopic group there was one case of neuropraxia, one injury to a branch of the radial artery, and three recurrences (three of the complications were among the five midcarpal ganglia). The mean functional recovery time was equal to 15 (6) days in the open group and 6 (2) days in the arthroscopic group. The mean time lost from work was equal to 23 (11) days in the open group and 10 (5) days in the arthroscopic group. Our results suggest that arthroscopic resection is a reasonable alternative to open excision in treating radiocarpal volar ganglia because it has less postoperative morbidity and a better cosmetic result. Midcarpal volar ganglia, however, should still be treated by open operation.     

Anterior and posterior marginal fracture-dislocations of the distal radius. An analysis of the results of treatment

Anterior and posterior marginal fractures of the distal end of the radius associated with dislocation of the carpus are rare injuries. The results of 20 patients with 12 anterior and eight posterior marginal fracture-dislocations of the distal radius were reviewed. Eleven patients had closed reduction and plaster cast immobilization, including three with external fixation, while nine patients required surgery and internal fixation. At a mean of 3.2 years, 40% were rated as excellent, 45% as good, 5% as fair, and 10% as poor. There was roentgenographic evidence of posttraumatic arthritis in 13 patients (65%). Major factors affecting the clinical results were accurate articular realignment and the presence of ipsilateral carpal injuries. There were no significant differences in results between anterior and posterior marginal fractures or between closed or operative methods of treatment when the radiocarpal articular surface was restored to less than 1 mm residual displacement. Restoration of articular congruency is the primary goal of management of these fractures.     

Complications of Colles' fractures

Patients with Colles' fractures have serious complications more frequently than is generally appreciated. A study of 565 fractures revealed 177 (31 per cent) with such complications as persistent neuropathies of the median, ulnar, or radial nerves (forty-five cases), radiocarpal or radio-ulnar arthrosis (thirty-seven cases), and malposition-malunion (thirty cases). Other complications included tendon ruptures (seven), unrecognized associated injuries (twelve), Volkmann's ischemia (four cases), finger stiffness (nine cases), and shoulder-hand syndrome (twenty cases). In many patients, incomplete restoration of radial length or secondary loss of the reduction position caused the complications.     

Distale Radiusfrakturen -Frakturformen und Verletzungsmuster

Fractures at the distal end of the radius are the most frequent fractures. There are still many therapeutical problems. The success of conservative or operative treatment depends mainly on the different types of fractures. In order of compare endresults and to recommend therapy, it is necessary to define different fracture types, based on practical classification. A classification of fractures at the distal end of the radius is presented, with localization and reference to the extent of injury with consideration of lesions of the radiocarpal joint and indirectly to the distal radio ulnar joint. In the period of growth five types of injuries are differentiated. In adults three main groups, depending on the involvement of the radiocarpal joint are described. These are subdivided according to dislocation. The fractures types were classified by using X-rays of cases over a period of several years. With this classification the pattern of injury of 593 fractures of the distal end to the radius, treated in 1980 in our clinic, was analysed.     

Classification and management of intra-articular fractures of the distal radius

A classification of distal radial articular fractures is described, based on observations of consistent patterns of fracture fragmentation and displacement. The classification categorizes articular fractures into four types, with the medial complex assuming a pivotal position as the cornerstone of both the radiocarpal and distal radioulnar joints. The purpose of this classification is four-fold: (1) to afford identification and an understanding of the displacement characteristics of the major fracture components, (2) to provide practical and rational guidelines for the management of these injuries based on specific fracture patterns, (3) to emphasize the frequency of concurrent soft tissue and other skeletal injuries associated with the more severe types of articular disruption, and (4) to serve as a prognostic gauge for the varied spectrum of distal radius articular injury. Optimal management of distal radius fractures necessitates the differentiation of articular from extra-articular fractures as well as prompt detection of unstable injuries. While the majority of unstable fractures can be successfully managed by closed methods, a substantial and increasing number require open treatment for restoration of articular congruity as well as repair of concomitant soft tissue and skeletal injuries. In all cases, precise reduction of the key medial fragments is essential to maximum recovery.     

The role of radiocarpal injection arthrography and magnetic resonance imaging in the diagnosis of triangular fibrocartilage complex injuries

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The role of radiocarpal injection arthrography and magnetic resonance imaging in the diagnosis of triangular fibrocartilage complex injuries.

OBJECTIVE: To investigate the radiocarpal joint injection arthrography and magnetic resonance imaging for diagnosis of the triangular fibrocartilage complex (TFCC) injuries. METHODS: Thirteen cases whose main complaints were ulnar wrist pain were given radiocarpal joint arthrography and eight of them were also given magnetic resonance imaging for evaluating the integrity of the triangular fibrocartilage complex. RESULTS: Ten of thirteen cases presented the leakage of contrast medium to distal radioulnar joint from the radiocarpal joint, in whom, 8 were demonstrated triangular fibrocartilage tear on magnetic resonance imaging, and 3 located at radial side, 2 at central, 3 at ulnar side. One of three cases which were demonstrated without the leakage of contrast medium in arthrography were displayed with marked TFCC tear on magnetic resonance imaging. CONCLUSIONS: The wrist arthrography can provide a definite diagnosis for triangular fibrocartilage disruption with higher sensitivity. magnetic resonance imaging not only demonstrates the site of triangular fibrocartilage disruption as the same value as wrist arthrography, but also displays the other related bony and soft tissues changes.