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PubMed2005

Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures.

Sixty-one wrists in 61 patients with osteoarthritis of the distal radioulnar joint treated by three consecutive procedures (20 Darrach, 25 Sauvé-Kapandji and 16 hemiresection-interposition arthroplastic procedures) were retrospectively evaluated. We preferred to perform Darrach's procedure in even the early stages of osteoarthritis of the distal radioulnar joint prior to introduction of Sauvé-Kapandji and hemirestion-interposition arthroplastic procedures. Subsequently the hemirestion-interposition arthroplasty was indicated when the triangular fibrocartilage cartilage was intact or could be reconstructed and the Sauvé-Kapandji when the triangular fibrocartilage complex could not be reconstructed or there was positive ulnar variance of more than 5 mm even though the triangular fibrocartilage complex was functional. Patient's age at operation averaged 59.8 years. There were 36 men and 25 women. There were 38 primary and 23 secondary osteoarthritis cases. Post-operative pain, range of motion, grip strength, return to work status; and radiographic results were evaluated. At the five- to 14-year (average, ten years) follow-up evaluation, relief of pain from Darrach procedure was inferior to the Sauvé-Kapandji procedure and hemiresection-interposition arthroplasty although this was not statistically significant. After both the Sauvé-Kapandji procedure and hemiresection-inteposition arthroplasty, post-operative improvements in flexion and extension of the wrist had statistical significance. Post-operative improvements in pronation and supination of the forearm showed statistical significances after all procedures. Improvements of post-operative grip strength and return to an original job in the Sauvé-Kapandji procedure and hemiresection-interposition arthroplasty were statistically superior to those with a Darrach's procedure. There were many post-operative complications following the Darrach's procedure. Darrach's procedure is better indicated for severe osteoarthritic changes of the distal radioulnar joint in elderly patients. We believe the operative indications between the Sauvé-Kapandji procedure and hemiresection-interposition arthroplasty are best determined prior to surgery by the existence and status of the triangular fibrocartilage complex and the amount of the positive ulnar variance.

Aged↗

PubMed1994

[Arthroscopy of the wrist].

Wrist arthroscopy may add specific datas to that provided by standard or motion view radiographs, arthrography, bone scan, TDM or RMN. Eight portals allow direct visualization of articular surfaces of radio-carpal and medio-carpal joints, triangular fibrocartilage, spaces between the carpal bones, interosseous and extrinsic ligaments. Wrist arthroscopy may be useful to evaluate lesions involving ligaments or cartilages, in degenerative or post-traumatic conditions. Arthroscopy may help to the decision in treatment of carpal instabilities, scaphoid pseudarthrosis, or Kienbock disease. Operative arthroscopy may allow shaving of damaged cartilage or fibrocartilage, bone resection or triangular fibrocartilage reinsertion.

Arthroscopy↗

PubMed2002

Radius pull test: predictor of longitudinal forearm instability.

BACKGROUND: Longitudinal instability of the forearm (the Essex-Lopresti lesion) following radial head excision may be difficult to detect. This cadaveric study examines a stress test that can be performed in the operating room to identify injury to the ligamentous structures of the forearm. METHODS: Twelve cadaveric upper extremities were randomized into two groups and underwent radial head resection. Group 1 underwent sequential transection of the triangular fibrocartilage complex and the interosseous membrane. Group 2 underwent sequential transection of the interosseous membrane and the triangular fibrocartilage complex. Ulnar variance and radial migration were examined with use of fluoroscopy of the wrist before, during, and after the application of a 9.1-kg load via longitudinal traction on the proximal part of the radius. RESULTS: Group 1 demonstrated no significant changes in proximal radial migration with load (compared with the findings after radial head resection alone) after transection of the triangular fibrocartilage complex. However, Group 2 demonstrated significant changes in proximal radial migration with load after transection of the interosseous membrane (p = 0.03; median, 3.5 mm). In both groups, transection of both the triangular fibrocartilage complex and the interosseous membrane resulted in significant changes in proximal radial migration with load (p = 0.001; median, 9.5 mm). When the load was removed, specimens were ulnar positive (median, 3.0 mm), with no specimen returning to the preload position of ulnar variance (p = 0.001). CONCLUSION: After radial head resection, 3 mm of proximal radial migration with longitudinal traction indicated disruption of the interosseous membrane. In all specimens, proximal radial migration of > or =6 mm with load indicated gross longitudinal instability with disruption of all ligamentous structures of the forearm.

Biomechanical Phenomena↗

PubMed1999

Is a subset of wrist ganglia the sequela of internal derangements of the wrist joint? MR imaging findings.

PURPOSE: To determine if there is an association between wrist ganglia and internal derangements of the wrist joint by reviewing magnetic resonance (MR) images. MATERIALS AND METHODS: Two observers retrospectively reviewed MR images of the wrist obtained in 625 patients at 1.5 T for the presence of ganglia and associated triangular fibrocartilage complex, scapholunate ligamentous, or lunotriquetral ligamentous tears that were within 3 mm of the ganglion. When available, surgery and/or pathology records were reviewed. RESULTS: There were 122 ganglia and 37 internal derangements. Of the 22 ulnar-sided ganglia, 10 (45%) demonstrated associated triangular fibrocartilage complex tears. Of the 97 radial-sided ganglia, 27 (28%) demonstrated ligamentous tears related to the site of the ganglion. The radial-sided tears involved the radial aspect of the triangular fibrocartilage complex in 12 ganglia; the scapholunate ligament, in isolation, in eight ganglia; and both the triangular fibrocartilage complex and the scapholunate ligament in six ganglia. Only one of the ganglia demonstrated an associated lunotriquetral ligamentous tear. Surgical findings confirmed the ligamentous tears in 25 patients. CONCLUSION: Wrist ganglia are associated, not infrequently, with internal derangements of the wrist.

Humans↗

PubMed1991

The distal radioulnar ligaments: a biomechanical study.

The mechanical roles of the triangular fibrocartilage have been examined in three experiments. Kinematic analysis by a stereophotogrammetric method revealed that the palmar radioulnar ligament was taut in supination and that the dorsal radioulnar ligament was taut in pronation. In full pronation, the palmar radioulnar ligament decreased to an average of 71% of its length in tension. In full supination, the dorsal radioulnar ligament decreased to an average of 90% of its length. Mechanical testing of the triangular fibrocartilage under axial load disclosed a significant laxity (mean: 10.4 mm), which was decreased in pronation. Transverse loading tests demonstrated that the triangular fibrocartilage is less stiff in neutral forearm rotation. Study of the material properties of the palmar and dorsal parts of the triangular fibrocartilage showed these structures to be strong ligaments with material properties similar to those of the radiocarpal ligaments.

Biomechanical Phenomena↗

PubMed1996

Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy.

Fifty consecutive patients who had a history and clinical findings consistent with internal derangement of the wrist were prospectively entered into a study to compare the findings of triple-injection arthrography with those of arthroscopy of the wrist with use of three portals. Twenty-six patients were men, and twenty-four were women. They had an average age of thirty-six years (range, eighteen to seventy years). The average duration of symptoms in the wrist was eight months (range, one to twenty-four months). The arthrograms of the wrist, which included cineradiographs, were all made and evaluated by the same radiologist. The arthroscopic evaluation of the wrists was performed by two hand surgeons who had previous knowledge of the arthrographic findings. The abnormal findings included in this study were limited to those that should be detectable with both arthrography and arthroscopy. These were full-thickness tears of the scapholunate ligament, the lunotriquetral ligament and the triangular fibrocartilage. The findings of arthrography were normal in eighteen wrists, demonstrated a single lesion in twenty-one, and demonstrated multiple lesions in eleven. Twelve wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and eighteen, a tear of the triangular fibrocartilage. The arthroscopic findings were normal in six wrists, demonstrated a single lesion in twenty-five, and demonstrated multiple lesions in nineteen. Twenty-two wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and thirty, a tear of the triangular fibrocartilage. When compared with arthroscopy of the wrist, the sensitivity, specificity, and accuracy of triple-injection cinearthrography in detecting tears of the scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage, as a group, were 56, 83,and 60 per cent. Although arthrography of the wrist is a well accepted diagnostic modality in the evaluation of pain in the wrist, this study suggests that normal arthrographic findings do not necessarily rule out the possibility of internal derangement of the wrist.

Adolescent↗

PubMed1995

[Magnetic resonance imaging of lesions of the triangular carpal ligament].

The wrist is a complex anatomical joint which is frequently involved in daily activities and exposed to trauma and overuse. That is why chronic wrist pain syndrome can be somewhat difficult to assess and requires the use of several imaging modalities. Three-compartment arthrography is an invasive but well-known technique that can evaluate interosseous ligaments as well as the triangular fibrocartilage complex; however in recent years MRI has become an important diagnostic tool in imaging wrist injuries, particularly triangular fibrocartilage complex. Its overall accuracy in detecting triangular fibrocartilage complex tears varies from 80 to 95% according to several authors, and even if there is still some controversy about the imaging of the small interosseous ligaments, MRI can also depict some other associated lesions.

Humans↗

PubMed1994

Incidence of ligament lesions and associated degenerative changes in the elderly wrist.

The scapholunate, lunotriquetral, and triangular fibrocartilage of 62 cadaveric wrists were examined to determine the incidence of pathologic changes in asymptomatic elderly wrists. A scapholunate ligament lesion was noted in 18 wrists; the majority of defects were incomplete and involved the central portion of the ligament only. Lunotriquetral ligament defects were noted in 20 wrists; eight were partial defects, most of them were central ligament lesions. Triangular fibrocartilage defects were present in 33 wrists and consisted of two distinct patterns: a central oval pattern with actual tissue loss and a linear defect running in the dorsal anterior direction 2-3 mm ulnar to the radial attachment of the triangular fibrocartilage. X-ray film evaluation showed few significant degenerative changes with no pronounced collapse deformities. Defects involving the scapholunate, lunotriquetral, or triangular fibrocartilage were very common, with the presence of at least one of these ligament defects in wrists. These ligament defects occur as a process of aging and behave in a manner quite different from traumatic lesions of these same structures in the younger population.

Aged↗

PubMed1990

Is MR better than arthrography for evaluating the ligaments of the wrist? In vitro study.

The purpose of this study was to determine the relative merits of MR imaging and three-compartment digital arthrography in the assessment of carpal ligaments in vitro. We performed MR imaging and arthrography in 10 normal wrists of fresh cadavers ranging in age from 48 to 71 years, and compared the appearance of the interosseous ligaments and triangular fibrocartilage complex with findings on anatomic sections of the joints. In six of the specimens, relatively T1-weighted MR images, 800/20 (TR/TE), preceded three-compartment digital arthrography performed with standard contrast material. In the other four specimens, arthrography, using an MR solution of iodinated contrast material mixed with cupric sulfate and gelatin, was performed before MR imaging. This was done to mimic the intraarticular fluid that might be seen in an injured wrist. MR allowed accurate assessment of the triangular fibrocartilage complex and scapholunate ligament in eight of 10 cases. Consistent MR visualization of the lunotriquetral ligament was difficult. Three-compartment digital arthrography allowed accurate assessment of the triangular fibrocartilage complex and scapholunate and lunotriquetral ligaments in all 10 cases. We concluded that MR is useful but inferior to arthrography in the evaluation of interosseous ligaments and the triangular fibrocartilage complex.

Aged↗

PubMedDate not supplied

[Magnetic resonance arthrography in chronic wrist pain].

PURPOSE: To investigate the clinical role of Magnetic Resonance Arthrography (MRA) of the wrist in subjects with chronic pain. MATERIAL AND METHODS: Thirty-five patients complaining of wrist pain for more 6 months were submitted to MRI and MRA. All patients received an intra-articular (monocompartment radiocarpal joint) injection of 2-10 mL of a 10 mmol saline solution of Gd-DPTA. Two radiologists independently evaluated the conspicuity of the intrinsic intercarpal ligaments and of the triangular fibrocartilage complex and expressed it on a 3-grade semiquantitative scale. On MRI images, complete visualization of the two structures was graded as 0, partial visualization as 1 and no visualization as 2. On MRA images, no contrast agent passage through the ligament or the complex was graded as 0, minimal passage as 1 and complete passage as 2. Sixteen patients had surgical confirmation (arthroscopy in 10 and open surgery in 6 patients). RESULTS: On MRI images the scapholunate ligament was completely visualized in 7 patients (21%) and partially or not visualized in 28 patients (89%). MRA images showed an intact ligament in 15 cases (44%) and a partial or total tear in 20 cases (48% and 8% respectively, 56% in all). On MRI images the luno-pyramidal ligament was completely visualized in 6 patients (18%) and partially or not visualized in 29 cases (82%). On MRA images the luno-pyramidal ligament was intact in 21 cases (58%) and had a partial or total tear in 14 cases (27% and 15% respectively, 42% in all). On MRI images the triangular fibrocartilage complex was normal in 27 cases (76%) and it was only partially visualized in 8 cases (24%). On MRA images the triangular fibrocartilage complex was normal in 13 cases (37%) and had a partial injury in 22 cases (63%). There were no severe side-effects to contrast agent injection, nor severe complications. The overall diagnostic accuracy rates of MRI and MRA were 40% and 81% respectively, with sensitivity and specificity of 63% and 39% (MRI) and of 82% and 79% (MRA). CONCLUSIONS: Compared with MRI, MRA can be considered a useful tool for the visualization of interosseous carpal ligaments and of the triangular fibrocartilage complex. MRA also helps detect injuries in these structures.

Adult↗

PubMed2000

Pressure mapping of the radioulnar carpal joint: effects of ulnar lengthening and wrist position.

The purpose of this study was to investigate the effects of ulnar lengthening and wrist position on force transmission through the radioulnar carpal joint in a forced dorsiflexed wrist position. Eight cadaveric arms were subjected to a 30 kg compressive load directed down the forearm towards the wrist. A pressure sensor recorded forces across the wrist joint with the triangular fibrocartilage complex intact and excised. The biomechanics of the distal radioulnar joint were altered by changes in ulnar length and wrist position. Pressures at the ulnolunate articulation increased as the ulna was lengthened and were significantly lower when the triangular fibrocartilage complex was excised. An inverse relationship between triangular fibrocartilage complex thickness and ulnar variance was shown. Greater increases in ulnolunate pressure were observed in more positive ulnar variant wrists.

Biomechanical Phenomena↗

PubMed1998

The interosseous membrane and its influence on the distal radioulnar joint. An anatomical investigation of the distal tract.

From the interosseous membrane of the forearm a tract extends to the dorsal capsule of the distal radioulnar joint. The structure and function of this tract have been investigated. The tract originates from the radius 22 mm proximal to the distal dorsal corner of the sigmoid notch. Central fibres are attached there with fibrous cartilage and superficial bundles mix with the periosteum. The tract is 8 mm wide, 31 mm long and 1 mm thick. Distally it inserts at the capsule of the distal radioulnar joint between the tendon sheaths of extensor digiti minimi and extensor carpi ulnaris. Deep fibres insert directly at the triangular fibrocartilage. The tract of the interosseous membrane is taut in pronation and loose in supination. It strengthens the dorsal capsule of the distal radioulnar joint. During pronation the tract protects the ulnar head in a sling. Its attachment at the triangular fibrocartilage influences the distal radioulnar joint. Its insertion at the triangular fibrocartilage and the support of the weakest part of the dorsal capsule are of interest.

Aged↗

PubMed1990

Ulnar styloid fixation in the treatment of posttraumatic instability of the radioulnar joint: a biomechanical study with clinical correlation.

Biomechanical displacement testing was done on nine fresh human upper extremities to define the stabilizing influence of the triangular fibrocartilage on the radioulnar joint and the efficacy of triangular fibrocartilage-ulnar styloid avulsion fracture repair in restoring lost stability. Test data confirmed that the triangular fibrocartilage is a major stabilizer of the radioulnar joint and internal fixation of triangular fibrocartilage-ulnar styloid avulsion fractures can restore preavulsion stability in all positions of forearm rotation. On the basis of this data and a successful clinical experience, primary repair of displaced ulnar styloid avulsion fractures is advised as a means of stabilizing the radioulnar joint and preventing the disability associated with chronic radioulnar joint instability.

Biomechanical Phenomena↗

PubMed2002

Kinematic analysis of the distal radioulnar joint after a simulated progressive ulnar-sided wrist injury.

A kinematic analysis of a progressive, ulnar-sided wrist injury was performed using a cadaver model to study the static and dynamic stabilizers of the distal radioulnar joint with a 3-dimensional motion tracking system. Anatomically based loads were applied to achieve pronation and supination and then the specimens were evaluated after serial transection of the triangular fibrocartilage, the extensor carpi ulnaris sheath, and the ulnocarpal ligaments. Statistically significant increases in translation of the radius relative to the ulna occurred with sectioning of both the triangular fibrocartilage proper and the extensor carpi ulnaris tendon sheath. No significant change in position of the forearm could be appreciated with subsequent sectioning of the ulnocarpal ligaments. Our observations support the idea that the ulnocarpal ligaments do not need to be surgically reconstructed when there are serious injuries to the triangular fibrocartilage complex.

Biomechanical Phenomena↗

PubMed1998

MRI of fractures of the distal radius: comparison with conventional radiographs.

OBJECTIVE: To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury. DESIGN AND PATIENTS: Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation. RESULTS: Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears. CONCLUSION: MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intraarticular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.

Adult↗

PubMed1989

Chronic wrist pain: evaluation with high-resolution MR imaging.

The diagnostic performance of magnetic resonance (MR) imaging in the evaluation of the triangular fibrocartilage complex and the intrinsic and extrinsic ligaments of the wrist was assessed in 43 patients with chronic wrist pain. Forty-one patients underwent correlative arthrography. Twenty-three patients underwent arthroscopy or arthrotomy or both. The normal anatomy of the triangular fibrocartilage and the intrinsic and extrinsic ligaments could be demonstrated effectively with MR imaging. MR imaging was effective in the evaluation of triangular fibrocartilage tears with a sensitivity of 1.0, a specificity of 0.93, and an accuracy of 0.95 when compared with arthrography; 0.89, 0.92, and 0.90, respectively, when compared with arthroscopy and arthrotomy. MR imaging could also be used effectively to evaluate tears of the intercarpal ligaments, particularly the scapholunate ligament. Disruptions of the extrinsic ligaments, articular cartilage defects, and subluxations of the distal radioulnar joint were also well demonstrated. MR imaging is an effective procedure in assessing patients with chronic wrist pain.

Cartilage, Articular↗

PubMed2001

Magnetic resonance imaging of the wrist: diagnostic performance statistics.

AIM: To review the published diagnostic performance statistics for magnetic resonance imaging (MRI) of the wrist for tears of the triangular fibrocartilage complex, the intrinsic carpal ligaments, and for osteonecrosis of the carpal bones. MATERIALS AND METHODS: We used Medline and Embase to search the English language literature. Studies evaluating the diagnostic performance of MRI of the wrist in living patients with surgical confirmation of MR findings were identified. RESULTS: We identified 11 studies reporting the diagnostic performance of MRI for tears of the triangular fibrocartilage complex for a total of 410 patients, six studies for the scapho-lunate ligament (159 patients), six studies for the luno-triquetral ligament (142 patients) and four studies (56 patients) for osteonecrosis of the carpal bones. CONCLUSIONS: Magnetic resonance imaging is an accurate means of diagnosing tears of the triangular fibrocartilage and carpal osteonecrosis. Although MRI is highly specific for tears of the intrinsic carpal ligaments, its sensitivity is low. The diagnostic performance of MRI in the wrist is improved by using high-resolution T2* weighted 3D gradient echo sequences. Using current imaging techniques without intra-articular contrast medium, magnetic resonance imaging cannot reliably exclude tears of the intrinsic carpal ligaments. Hobby, J. L. (2001). Clinical Radiology, 56, 50-57.

Carpal Bones↗

PubMed1986

Force transmission through the distal radioulnar carpal joint: effect of ulnar lengthening and shortening.

Although numerous surgical procedures are performed on the wrist joint, little has been written regarding the effect of these procedures on the biomechanics of the wrist. This study has been undertaken to examine the in vitro consequences of ulnar lengthening and shortening. We have measured the axial forces transmitted through the distal radius and ulna and the pressure distribution on the articulating surface of the radius and triangular fibrocartilage complex for the intact wrist, with ulnar lengthening and with ulnar shortening. Lengthening of the ulna by 2.5 mm in the intact wrist increased the force borne by the ulna from 18.4% to 41.9% of the total axial load. Shortening of the ulna by 2.5 mm decreased axial load borne by the ulna to 4.3%. Removal of the articular disc portion of the triangular fibrocartilage complex decreased the load on the intact ulna from 18.4% to 6.2%. The peak pressure at the ulnolunate articulation increased from 1.4 N/mm2 for the unaltered wrist to 3.3 N/mm2 when the ulna was lengthened by 2.5 mm. These results suggest that the biomechanics of the wrist joint can be dramatically altered with relatively small (2.5 mm) changes in ulnar length and by removal of the articular disc portion of the triangular fibrocartilage complex.

Biomechanical Phenomena↗