Carpal Instability: Evaluation and Treatment

Carpal instability is a common cause of wrist pain, motion loss, and disability. Diagnosis and treatment of carpal instability are dependent on a clear understanding of wrist anatomy and carpal kinematics, both normal and pathologic, as well as their relation to the current concepts regarding management. A brief review of anatomy and normal kinematics is presented, followed by a detailed discussion of specific instability patterns, including pathomechanics. A treatment algorithm is provided, detailing the authors' preferred treatment for the most common instability patterns.     

Arthroscopic excision of dorsal carpal ganglion cysts

Ganglion cysts are the most common tumor in the wrist. Dorsal carpal ganglion cysts represent 60 to 70% of all ganglion cysts in the hand and wrist. Standard treatment has been limited to observation, rest, immobilization, aspiration with or without injection, and surgical excision. Arthroscopic resection of dorsal carpal ganglion cyst have been done since the late 1980s. It has the advantages of less scarring and stiffness, the ability to inspect the wrist for other pathology and wrist instability. To date, the success of arthroscopic ganglion cyst resection is at least as good (1% recurrence) as current open techniques (0 to 10% recurrence). Risks of the procedure are similar to open techniques. Patient satisfaction with the procedure is high. In the largest reported series, there have been no major complications. This technique, for those who are comfortable with wrist arthroscopy, is effective and safe in treating this common wrist mass. The technique for this procedure is described as well as a brief history of treatment for dorsal carpal ganglion cysts.     

腕关节镜辅助治疗腕骨内腱鞘囊肿

目的：探讨腕关节镜治疗腕骨内腱鞘囊肿的方法及疗效。方法2013年5月—2014年5月,应用腕关节镜治疗腕骨内腱鞘囊肿5例,其中月骨3例,舟骨1例,三角骨1例。主要症状为腕部不适、疼痛,伴握力下降和活动度降低。 X线平片及CT显示腕骨内圆形或类圆形骨密度减低区,边界清楚,有硬化缘。 MRI显示病灶内为液体。采用腕关节镜下病灶刮除＋自体松质骨或注射型人工骨移植术治疗,术后腕关节功能位固定3周。结果5例均获得随访,平均6.8个月。所有病例无复发,植骨愈合满意。患者腕关节疼痛及不适症状明显缓解,术后均恢复正常的生活工作。结论腕关节骨内腱鞘囊肿是慢性腕关节疼痛原因之一,腕关节镜技术在腕骨内腱鞘囊肿的治疗中,手术方法安全,并发症少,功能恢复快,手术效果满意。     

Occult scapholunate ganglion: a cause of dorsal radial wrist pain

There are multiple causes for chronic dorsal wrist pain over the scapholunate ligament, including occult dorsal carpal ganglion cyst, scaphoid impaction syndrome, dorsal carpal capsulitis, distal posterior interosseous nerve syndrome, and dynamic scapholunate ligament instability. Patients with such pain often have normal x-rays. A retrospective study of 21 patients undergoing surgical exploration for chronic dorsal radial wrist pain who had no palpable cyst and normal x-rays revealed that 18 of the patients had occult scapholunate ganglion cysts or myxomatous degeneration within the scapholunate ligament. All had failed long-term conservative management. Surgery involved an approach through Langer's lines, resection of a large triangular portion of the capsule between the dorsal intercarpal and radiotriquetral ligaments, and tangential debridement of the area of myxoid degeneration proximal to the distal 2 to 3 mm of dorsal scapholunate interosseous ligament. None of the patients had scapholunate instability or scaphoid impacting syndrome. Of the 18 patients with histologically confirmed myxomatous changes in the scapholunate ligament, 16 had an excellent outcome as defined by rigorous criteria; 1 had a good outcome. There was 1 patient with a poor result. A compelling argument is made for surgical exploration of the scapholunate joint in patients with persistent dorsal radial wrist pain and scapholunate point tenderness.     

Management of chronic scapholunate ligament injury

Scapholunate ligament is the most commonly injured ligament in the wrist and requires accurate diagnosis and treatment. It presents with pain, stiffness and can lead to carpal instability as well as degenerative arthritis if left untreated, with subsequent loss of function and disability. There are several management options currently available but there is no consensus on how best to manage a wrist with chronic sequelae of scapholunate ligament injury. This review explores available evidence in the literature on optimal treatment options including non-operative and operative procedures, relevant surgical techniques and their associated outcomes. A summary of the current concepts in the management of Chronic Scapholunate ligament injury is presented.     

Fracture pathologique du scaphoïde carpien (kyste synovial intraosseux). Aspect clinique et thérapeutique. À propos d’un cas

The authors report a case of fracture of the carpal scaphoid through an intraosseous synovial cyst. Synovial cysts are not uncommon in the carpal region, and are usually discovered as an incidental radiological finding: they rarely present with wrist pain and only exceptionally as a fracture. In our knowledge, only one other case of intraosseous synovial cyst of the carpal scaphoid presenting as a fracture has been published. Surgical treatment of these benign tumors, in cases of fracture or painful symptoms, consists of curettage of the lesion followed by impaction grafting of cancellous bone combined with stabilization in the case of a fracture. The use of a vascularized bone graft pedicled on the volar carpal artery enables simultaneous treatment of both the cyst and the fracture. The prognosis is good and relapse is exceptional.     

Wrist arthrodesis with excision of the proximal carpal bones using the Ao/ASIF wrist fusion plate and local bone graft

We present our series of 17 patients who underwent wrist arthrodesis with excision of the proximal row carpal bones using the AO wrist fusion plate and local bone graft obtained from the excised proximal carpal row. All patients were evaluated using a questionnaire to assess pain, function, ability to perform an occupation and satisfaction with the procedure. The mean follow-up was 17 months, at which time all the fusions had united. Clinical outcome scores showed that 14 and 15 of the 17 patients achieved good or excellent results with regard to their current condition and clinical improvement, respectively. Four patients required secondary surgery, two for fractures and two for instability of the distal radio-ulnar joint unrelated to the wrist fusion.     

The occult dorsal carpal ganglion

Chronic wrist pain has many causes, the diagnosis of which is often difficult. Clinical and anatomical research in this area has replaced the diagnosis of "wrist sprain" with a differential diagnosis including carpal chondromalacia, dynamic carpal instability, positive and negative ulnar variance, triangular fibrocartilage complex injuries, and early carpal avascular necrosis. The ubiquitous dorsal ganglion can also cause chronic wrist discomfort and the diagnosis of "occult dorsal carpal ganglion" should be included in the differential diagnosis. Nine patients with chronic wrist pain were diagnosed clinically as having an occult dorsal carpal ganglion despite the absence of a palpable mass. Each was treated by limited dorsal capsulectomy with excision of a small portion of the dorsal scapho-lunate ligament, and small intracapsular ganglia and/or cystic mucinous degeneration of the capsule were found in all nine patients. Of the eight patients available for follow-up examination, the preoperative pain was relieved in seven of the eight and no recurrences were noted at follow-up averaging six months.     

Post-traumatic cyst of the scaphoid--a case report]

Carpal bone cysts are very uncommon and they are usually occasionally diagnosed during radiological examination of the wrist after trauma. Some carpal bone cysts are symptomatic and then they are revealed on routine X-ray investigation. We present a case of 14 years old boy, in whom a scaphoid bone cyst developed around the foreign body (a splinter), stacked into the wrist when he fell on the wooden board. Because of pain, swelling and reduction of active range of motion of the wrist occurred at the load of the hand and lasted 3 months, patient was given radiological examination which was negative, and eventually CT scanning revealed a scaphoid bone cyst. Patient underwent operation: curettage of the lesion followed by filling of the bone defect with prepared allogenic bone. Histopathological examination of the contents of the cyst showed presence of wood piece, surrounded with granulomatic tissue and necrotic trabecular bone. This suggested a splinter stacked in the wrist at the primary injury to be a cause of cyst formation. Surgery resulted in complete recovery in 6 months.     

Complete dorsal dislocation of the carpal scaphoid with perilunate dorsal dislocation

Complete dorsal dislocation of the carpal scaphoid combined with dorsal perilunate dislocation is an extremely rare carpal injury. We describe the case of a 23-year-old man who presented with a complete dorsal dislocation of the carpal scaphoid, combined with a perilunate dislocation. Surgical treatment was performed with open reduction and interosseus ligament repair. At 4 years follow up, the patient''s wrist pain had completely resolved without limitations of wrist joint motion and without evidence of avascular necrosis of the carpal scaphoid.     

Uncommon carpal fractures

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.     

Carpal arch alteration after carpal tunnel release

A retrospective clinical study quantitated postoperative widening of the transverse carpal arch after carpal tunnel release in a group of 50 patients. The relationship of this widening with postoperative pain, forearm circumference, grip strength, and wrist range of motion was evaluated. Mean widening of the transverse carpal arch after carpal tunnel release is 10.4% or 2.7 mm. A direct relationship exists between widening of the transverse carpal arch and loss of grip strength. Residual pain, forearm circumference, and wrist range of motion are not related to widening of the transverse carpal arch.     

Which Outcome Measure is the Best? Evaluating Responsiveness of the Disabilities of the Arm,Shoulder, and Hand Questionnaire,the Michigan Hand Questionnaire and the Patient-Specific Functional Scale Following Hand and Wrist Surgery

The purpose of this study was to determine and compare the responsiveness of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Michigan Hand Questionnaire (MHQ), and the Patient-Specific Functional Scale (PSFS) in patients with carpal tunnel syndrome, wrist pain, finger contracture, or tumor. Eighty-one subjects prospectively completed each questionnaire shortly before and 3 and 6 months after surgery. Data were analyzed using one-way analysis of variance and Newman–Keuls multiple comparison tests. Responsiveness to clinical change was calculated using standardized response means. The DASH was responsive for those with carpal tunnel syndrome (0.77), wrist pain (0.61), and tumor (0.55); the MHQ was responsive for those with carpal tunnel syndrome (1.04), wrist pain (0.87), and finger contracture (0.62); and the PSFS was responsive for those with carpal tunnel syndrome (0.65) and finger contracture (0.64). The interval during which the highest responsiveness occurred for the carpal tunnel, wrist pain, and finger contracture groups was the preoperative to 6-month period. The tumor group experienced the highest responsiveness during the preoperative to 3-month period. Our results indicate that one or more of the instruments evaluated are suitable for outcomes research related to surgery to treat carpal tunnel syndrome, wrist pain, finger contracture, and tumor.     

Scapholunate interosseous reconstruction and imbrication of palmar ligaments

Twenty-eight patients with scapholunate interosseous ligament disruption, carpal instability, and persistent wrist pain were treated by carpal reduction, stabilization, and palmar ligament reconstruction. In twenty-two of these patients pain was well controlled, carpal alignment was maintained, and they were able to resume their previous employment. Grip and pinch strengths averaged eighty-two percent and range of motion averaged seventy-six percent of the normal uninvolved side.     

Ganglion cysts and carpal tunnel syndrome

We review 12 cases of ganglion cyst with carpal tunnel syndrome in 11 patients seen at the Hand Rehabilitation Center. Mean age was 42 years (range, 28 to 60 years). One half of the cysts were associated with direct trauma, usually with wrist hyperextension. Symptoms usually developed after the appearance or sudden growth of the cyst. Motor conduction or distal sensory latency was abnormal in seven of eight studied cases. Tinel's sign on tapping the cyst may be pathognomonic for this syndrome. Cyst removal and incision of the flexor retinaculum relieved the symptoms in 11 cases. The other case had total resolution after spontaneous cyst rupture. This syndrome is successfully treated with cyst decompression with release of the carpal canal and has an excellent prognosis. To our knowledge this represents the largest operative series of carpal tunnel syndrome and ganglion cyst.     

Cystic radiolucencies of carpal bones, distal radius and ulna as a marker for dialysis-associated amyloid osteoarthropathy.

Patients on long-term hemodialysis (HD) are known to develop amyloid osteoarthropathy, evidenced as cystic radiolucencies on X-rays of the affected joints. To study the relationship between cystic radiolucencies and amyloid osteoarthropathy in 394 patients, we classified the severity of the cystic radiolucencies seen in the wrist joint on a 4-point scale and evaluated the association between lesion severity (grade) and several parameters. Biopsy was performed in 8 patients with 11 bone cysts of the wrist joint who had been operated for carpal tunnel syndrome. HD for 10 years or longer, age 50 or older and the presence of carpal tunnel syndrome were associated with severe cyst rating. There was no association between lesion grade and serum level of PTH-C, aluminum or beta 2-microglobulin (B2M). Ten of the 11 biopsied bone cysts in 8 patients with carpal tunnel syndrome demonstrated amyloid deposits which reacted with B2M. We conclude that a cystic radiolucency observed in the wrist joint of a patient undergoing HD indicates the deposition of amyloid. The cyst grade provides a useful marker for the severity of amyloid osteoarthropathy in HD patients.     

Ulnocarpal abutment after wrist arthrodesis

We report three patients aged from 22 to 34 years, in whom ulnocarpal abutment developed after wrist arthrodesis. Two were treated by excision of the triquetrum and one by excision of the pisiform. The three patients were seen after wrist fusion because of ulnar wrist pain on forearm rotation, which was relieved by excision of a carpal bone. Two patients had had wrist arthrodesis because of wrist pain resulting from degenerative arthritis and silicone synovitis resulting from silicone rubber replacement of the lunate as treatment for Kienb?ck's disease. One patient had had a wrist arthrodesis to treat degenerative arthritis after an intra-articular distal radius fracture. The arthrodeses were all done with an A. O. plate and iliac crest bone graft. One patient gained forearm rotation after the excision of the carpal bone and none of the patients lost rotation. The average follow-up was 16 months.     

部分腕骨融合术治疗腕部疾患进展

目的 综述近年来国内外有关部分腕骨融合治疗腕部疾患及其实验研究进展。方法 广泛查阅相关文献,对部分腕骨融合的临床应用效果和实验研究进展分析和综合。结果 部分腕骨融合既能解除腕关节疼痛,又能稳定和保留一定范围活动度。结论 采用部分腕骨融合术治疗腕部疾患,只要适应证和手术方法选择合适,应当首选。     

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.     

Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure.

Forty-three rheumatoid wrists in 43 patients with bilateral wrist involvement were treated with synovectomy of the extensor tendons and wrist joint combined with a Darrach procedure in the period from 1966 to 1986. Clinical and radiologic assessment of the wrists was carried out after an average follow-up period of 11 years, with comparison of the treated and the opposite untreated wrists. The authors confirmed what others have concluded regarding the operation: pain was generally decreased, forearm rotation increased, and wrist extension and palmar flexion changed little. Radiologically, carpal collapse and palmar carpal subluxation progressed nearly parallel to the opposite wrists, but ulnar carpal shift was much greater in the surgically treated wrists. Therefore it is suggested that some measure to prevent ulnar carpal shift, such as Clayton's tendon transfer or radiolunate arthrodesis, should be included in this operation.