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.     

Transstyloid radiocarpal dislocation: A case report

Introduction and importanceTransstyloid radiocarpal dislocation is a rare injury. It is due to high-energy trauma. It usually associates a radiocarpal dislocation, a fracture of the radial and/or cubital styloid process, and a cortical volar/dorsal margin avulsion.Case presentationWe present a case of a 31-year-old male who sustained a fell from a 4 m height causing a transstyloid radiocarpal dislocation. He was treated with a radial styloid process pinning and wrist arthrorisis with and splint immobilization.Clinical discussionDifferent treatment options can be available for this type of injury with or without ligaments reconstruction.ConclusionAlthough it is rare, the transstyloid radiocarpal dislocation has a good outcome with different types of treatment.     

Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases

BACKGROUND: The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. METHODS: Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. RESULTS: From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. Grip strength averaged 38 kg. Seven patients had complications. CONCLUSIONS: On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.     

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.     

Post-traumatic hemarthrosis of the knee. Diagnostic steps and value of arthroscopy

The authors report their experience of the arthroscopic diagnosis of acute traumatic hemarthrosis of the knee. They point out the value of testing stability under anaesthesia. A very important laxity, according to severe damage of peripheric structures and cruciate ligaments, need surgical repair. Otherwise, in all cases with minor instability, arthroscopy is very useful: some arthrotomies are so avoided, some associated lesions were diagnosed. Any way arthroscopy is reported to allow adequate treatment of traumatic hemarthrosis of the knee.     

Luxation dorsale de l’articulation radiocarpienne chez une femme de 85 ans

The authors report the case of a dorsal, closed, radiocarpal dislocation with a small posterior marginal fracture of the radius, in an 85-year-old woman, without violent trauma (fall from her height). The dislocation was reduced by traction and the wrist immobilized in a plaster cast for 6 weeks. Six months after the accident, the patient had resumed her activities without pain with a diminished range of motion. This dislocation is exceptional at this age. In our case, the functional outcome was good after orthopaedic treatment.     

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.     

Therapeutic interest of wrist arthroscopy: about 1000 cases

Wrist arthroscopy is a relatively recent procedure because it was described in the 70's. During the first period of 80's it became an indisputable technique of diagnosis. Since the 90's many therapeutic procedure were described by several authors all over the world. This technique increase a lot the understanding of wrist pathologies and ameliorate significantly the results for patients. We report our experience about 1000 wrist arthroscopy between 1998 and 2005. The patients were always operated on outpatient basis under local regional anaesthesiology. The arm was laid on the table and the hand on in-line traction (5-7 kg). We used a 2.4 mm arthroscope, 30 degree angled. The both joints, radiocarpal and midcarpal, were systematically explored. The small portals were not closed. In our experience, only 42 arthroscopies (4%) were without surgical procedure. We separated the indications in 7 chapters: (1) arthoscopic assistance for fractures treatment (distal radius and scaphoid: 7%; (2) TFCC tears (17%); (3) treatment of intrinsic ligaments tears (scapholunate and lunotriquetral: 21%); (4) ectomy (radial styloidectomy, wafer, carpal boss 13%); (5) resection of wrist ganglia (21%); (6) partial prosthesis (2.5%); (7) others techniques (arthrolysis, synovectomy 14.5%).     

Dorsal radiocarpal dislocation in a patient with Goldenhar syndrome: case report

Background

Fracture–dislocations of the carpus are rare, generally occurring after high-energy trauma. Goldenhar syndrome is among a group of genetic abnormalities associated with radial limb defects. We present a case of a dorsal radiocarpal dislocation in a patient with Goldenhar syndrome after a low-energy fall. To our knowledge, there has been no previous report of radiocarpal dislocation in the setting of Goldenhar syndrome.

Methods

This patient with Goldenhar syndrome had a dorsal radiocarpal dislocation in the setting of an absent scaphoid and dysplastic distal radius. A computed tomography scan, recognized as a useful modality to evaluate the wrist and scaphoid, was used to rule out any other osseous trauma or avulsion fractures.

Results

Closed reduction and 6 weeks of immobilization resulted in a successful treatment.

Conclusions

The incidence of radiocarpal dislocations in patients with Goldenhar syndrome and the appropriate long-term treatment for patients with Goldenhar syndrome with radiocarpal dislocations require further investigation.     

Radiocarpal dislocation--classification and rationale for management

Radiocarpal dislocation is a rare injury. The authors reviewed seven cases with this injury and identified two groups of patients. Type I involves a dislocation of only the radiocarpal joint, while Type II involves intercarpal dislocation also. Four patients were included in Type I dislocation (3 dorsal and 1 volar). The other three patients had Type II dislocations, all of which were volar dislocations. Two patients had evidence of injury to the median and ulnar nerves at the time of the injury and both recovered completely. Closed reduction was possible with good results in three patients with Type I dislocation. All patients with Type II dislocation required open reduction and all had residual problems. The distinction between Type I and Type II is essential in order to evaluate the full extent of the injury. Closed reduction should always be attempted in Type I dislocation. Type II dislocation should be treated by open reduction and repair of all torn ligaments.     

Arthrotomography of the wrist. The palmar radiocarpal ligaments

Twenty-one fresh cadaver wrists were studied by arthrography and arthrotomography. Arthrography was unreliable in accurately delineating the palmar radiocarpal ligaments. However, lateral arthrotomograms predictively and precisely outlined the radiolucent radiocapitate and radiotriquetral ligaments. The radial and more distant radiolucent area was the radiocapitate ligament, and the ulnar and more proximal area was the radiotriquetral ligament. A constant radiopaque invagination between the outlines of contrast material demonstrated the sulcus anatomically separating these two ligaments. When the ligaments were transected contrast material entered the substance of the ligaments, rendering them radiopaque and, thus, visible on the radiographs. The authors believe that arthrotomography may be a useful clinical tool in the evaluation of post-traumatic injuries to the palmar radiocarpal ligaments of the wrist.     

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.     

Early arthroscopy in diagnosis and treatment of acute injury of the knee]

Twelve patients with swelling and functional embarrassment of the knee joint caused by a traffic accident were radiographically found to have tibial plateau fractures (7 patients), posterior dislocation (1), fracture of anterior tibial spine (1), single fracture of the posterior tibial spine (1), anterior dislocation (1), and negative findings (1). Arthroscopy was performed 2 to 10 days after trauma, revealed associated injuries not shown on X-ray films in every knee including rupture of cruciate ligaments (ACL 8, PCL 1), tear of menisci (lateral one 8; medial one 2), and disruption of collateral ligaments (medial one 3; lateral 1). These injuries were promptly treated accordingly either through the scope or by open operation. Beside, inadequately reduced bone fragments, viewed through the scope, were further corrected incidentally and conveniently. We believe that early arthroscopy for acute knee injury is a real necessity in perfecting diagnosis and improving 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.     

The role of midcarpal arthroscopy in the diagnosis of disorders of the wrist.

The findings of midcarpal versus radiocarpal arthroscopic examinations were compared in the diagnosis of a variety of wrist pathology in 89 patients. During 15 months 89 midcarpal arthroscopic examinations were performed in conjunction with radiocarpal arthroscopic examinations. Eighty-one wrists underwent arthroscopy for acute or chronic intracarpal instability. Eight wrists underwent arthroscopy for arthroscopy-assisted intra-articular distal radius fracture reduction. In the acute wrist instability group midcarpal arthroscopy added to the radiocarpal diagnosis in 21 of 26 (82%) of the wrists. In the chronic wrist instability group midcarpal arthroscopy added to the radiocarpal diagnosis in 46 of 55 (84%) of the wrists. In the distal radius group 5 of 8 wrists had additional pathology on the midcarpal arthroscopy examination, leading to additional surgical intervention. These results demonstrate that midcarpal arthroscopy added statistically significant information to the radiocarpal examination compared with wrist arthroscopy performed without a midcarpal examination.     

La luxation radiocarpienne (à propos de neuf cas)

Radiocarpal dislocation is an uncommon entity in traumatolgy. The purpose of this study was to detail the pathogenesis of radiocarpal dislocation and describe its complications and treatment. Nine radiocarpal dislocations were reviewed retrospectively. Dorsal displacement was observed for seven dislocations, anterior displacement for two dislocations. All were associated with fractures of the radial styloid. Treatment was always surgical. At last follow-up (mean 3 years), the overall functional outcome was satisfactory. The Green and O’Brien (modified by Cooney) score was excellent for three patients, fair for four, and mediocre for two. Two cases of radiocarpal degeneration were observed at last follow-up. Intracarpal and/or distal radio-ulnar lesions must be stabilized in order to limit the risk of future degeneration.     

膝关节脱位多韧带损伤Ⅰ期修复重建的临床观察

目的:探讨关节镜下Ⅰ期异体肌腱重建并结合关节外微创技术治疗膝关节脱位合并多发韧带损伤的临床疗效。方法:2008年1月至2012年1月共收治48例膝关节脱位患者,排除腘血管损伤,采用关节镜下Ⅰ期重建前后交叉韧带,并结合关节外微创技术修复膝关节韧带损伤。男38例,女10例;年龄20～59岁,平均35.6岁;左膝22例,右膝26例;伤后至手术时间2 d～2周。前交叉韧带(ACL)、后交叉韧带(PCL)、内侧副韧带(MCL)及后外侧复合体(PLC)损伤2例,ACL、PCL及MCL损伤36例,ACL、PCL及PLC损伤10例。合并腓总神经损伤4例。比较术前及末次随访时Lysholm 评分以评价膝关节功能。结果:所有患者获得随访,时间12～30个月,平均(18.2±6.3)个月,患者关节活动度和稳定性明显改善,Lysholm评分由术前40.3±4.1提高为随访时87. 0±6.4.结论:关节镜下应用同种异体肌腱Ⅰ期重建膝关节脱位并多韧带损伤,能较好地恢复关节稳定性,保留关节功能。术前训练指导及术后个体化康复是膝关节功能恢复的关键。     

Clinical applications of volar portals in wrist arthroscopy

Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular structures as well as the palmar aspects of the carpal ligaments. The volar radial portal is relatively easy to use and is an ideal portal for evaluation of the dorsal radiocarpal ligament and the palmar aspect of the scapholunate interosseous ligament. The volar midcarpal portal may be considered as an occasional accessory portal for visualizing the palmar aspects of the capitate and hamate in cases of avascular necrosis or osteochondral fractures. The volar ulnar portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament.     

Dorsal radiocarpal dislocation

Dorsal radiocarpal dislocation is rare. Large forces are necessary to produce such injuries and the majority of these patients have severe associated injuries and are unable to remember exactly how they occurred. A case is reported in which there was an isolated dorsal radiocarpal fracture-dislocation associated with contusion of the median nerve. The manner of injury is well demonstrated.     

Palmar-divergent dislocation of the scaphoid and the lunate

We describe a patient with palmar-divergent dislocation of the scaphoid and lunate. After successful closed reduction, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach, and the anterior capsule was sutured through the palmar approach. The scapholunate and lunotriquetral joints were fixed with Kirschner wires for 7 weeks. At the 1-year follow-up, magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate, and radiographs showed no evidence of the dorsal and volar intercalated segment instability patterns associated with carpal instability. However, flexion of the scaphoid and a break in Gilula’s line remained. To our knowledge, this is the first report showing treatment of palmar-divergent dislocation of the scaphoid and lunate by suturing the carpal interosseous ligaments.