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A patient with wrist pain and cystic changes of the ulnar head is presented. This x-ray finding has not previously been reported in patients without rheumatoid arthritis. At the time of operation a tear of the triangular fibrocartilage was present.
Seven wrists are presented with a septum connecting the lunotriquetral interosseous ligament and triangular fibrocartilage, resulting in bicompartmentalization of the radiocarpal joint. In all of the 7 wrists, having no history of trauma, the septums were suspected to be of congenital origin. The histopathology of the septum in 1 cadaver wrist showed a fibrocartilaginous structure. Two types of radiocarpal joint bicompartmentalization were identified by arthrography. Type 1 (2 wrists) had a septum with normal (intact) lunotriquetral interosseous ligament, and type 2 (5 wrists) had a septum with a communicating defect of the lunotriquetral interosseous ligament. The septum is most likely a congenital malformation caused by a disturbance of the vacuolization of the mesenchymal mass between the forearm and carpus.
To assess the efficacy, role, and limitations of diagnostic ultrasound in the hand and wrist, the results of 98 examinations performed for a variety of surgical conditions were retrospectively analyzed. Ultrasound was shown to be reliable in evaluating radiolucent foreign body, tendon rupture versus tendon adhesion, tendinitis, peritendinitis, and ganglion cyst (specificity, 1; positive predictive value, 1). A correct suggestion of soft tissue mass histology was offered in six of eight operated cases. Tumor size and extent was accurately assessed in all but one case. The observed limitation of ultrasound was a small false negative rate in each category, which related to a variety of factors, including operator dependence, resolution threshold in the submillimeter range, image degradation due to postoperative edema, a narrow field of view, and one instance of indiscrete tumor margination. More work is needed to determine the role (if any) of ultrasound in the evaluation of peripheral nerve, triangular fibrocartilage, dorsal carpal ligament, and bone pathology.
The biomechanical function of the interosseous membrane of the forearm was examined in 12 fresh cadaver forearms. The strain in the central band of the interosseous membrane was found to be greatest in full pronation and was significantly increased with excision of the radial head. The proximal/distal location of the lunate fossa of the radius with respect to the ulna was measured and was found to be most distal in supination and most proximal in pronation, in both the intact specimen and after excision of the radial head. Serial sectioning of the interosseous membrane and the triangular fibrocartilage complex (TFCC) demonstrated that both the central band and the TFCC are important to the axial stability of the forearm. Reconstruction of the central band, using a graft based upon the flexor carpi radialis, was performed in all 12 specimens after the interosseous membrane and the TFCC were sectioned. It was successful in preventing complete migration of the radius to the capitellum, but it was not capable of completely restoring the longitudinal stability of the forearm. Central band reconstruction as described here has not been performed in the clinical setting and is not advocated for clinical application at this time.
Arthroscopy was used to assess the soft tissue injuries associated with distal radial fractures in 118 acute intra- and extra-articular fractures. The triangular fibrocartilage complex (TFCC) was torn in 46 of 118 patients--in 35% of intra-articular fractures and in 53% of extra-articular fractures. No correlation between ulnar styloid fractures and TFCC injuries could be found. Scapholunate (SL) ligament injuries with instability were present in 21.5% of intra-articular fractures and in 6.7% of extra-articular fractures. Lunotriquetral (LT) ligament injuries with instability were present in 6.7% of intra-articular fractures. and in 13.3% of extra-articular fractures. Combined SL and LT injuries were present in 5.6% of intra-articular fracture. Preoperative radiographs correlated with TFCC injury. Patients with TFCC tears had greater shortening and dorsal angulation on the preoperative radiographs. Preoperative radiographs had no predictive value for interosseous ligament injury. Ligamentous injuries are commonly associated with both intra-articular and extra-articular distal radial fractures.
In wrist injury, plain radiographs form the basis of diagnostic imaging, and can provide definitive answers in most cases. MR imaging is the method of choice for several diagnostic problem cases. These problems can include radiographically occult fractures where MRI enables early diagnosis compared to follow-up radiographs. Early stage diagnosis of a post-traumatic avascular osteonecrosis with high sensitivity and specificity, is only possible with MRI. In these instances, radiographs are only sensitive in later stages and scintigraphy is quite nonspecific. Stress fractures, invisible with other modalities, are also demonstrable with MRI. In addition, MRI is helpful in special circumstances with regard to non-union or pseudarthrosis. In wrist instability, radiographs in combination with stress views and fluoroscopy are still the initial diagnostic step. MRI, with the advantage of direct visualization of the wrist ligaments and triangular fibrocartilage complex, offers very promising results in this area. Generally, for the evaluation of wrist injury, MRI can be considered the most important second-step procedure in patients where radiographs are nondiagnostic.
Different types of triangular fibrocartilage complex (TFCC) lesions have been described. We propose an arthroscopic repair of the peripheral tear, as it is a tear in the vascular portion of the TFCC. The technique is based on one used for meniscal repairs of the knee, and it is quite easy to perform.
The authors report a rare case of dorsal dislocation of the radiocarpal joint without any bony lesion associated. The traumatic cause was a high energy motorbike accident. Fractures of the other limbs were associated. The authors report the clinical, radiological, and arthroscopic features. Wrist arthroscopy showed a complete tear of all the extrinsic ligaments, a radial avulsion of the triangular fibrocartilage complex, and the integrity of the intracarpal ligaments, which guided the treatment. The dislocation was treated by closed reduction and radiocarpal pinning. The authors propose wrist arthroscopy in radiocarpal dislocation for diagnosis of soft tissue and cartilaginous lesions to guide the treatment (close or open).
Intracarpal ligamentous tears and fractures of the radius often have a similar mechanism. For instance, no prospective studies have defined the real incidence of such associations, which are not antagonistic. The authors performed a systematic operative wrist arthrogram during distal radius fractures in a group of 58 patients with a mean age less than 50 years. Such a population was at low risk of degenerative ligamentous tears. Triangular fibrocartilage complex was torn in two-thirds of all types fractures. Extra-articular radius fractures were associated with an intracarpal ligamentous tear in 25% and always a luno-triquetral lesion type. In contrast, intra-articular and radius styloid fractures were frequently associated with a scapho-lunate lesion.
In the past, the diagnostic imaging algorithm for evaluating the painful wrist included initial plain radiographic examination followed by arthrography, tomography, bone scintigraphy, or computed tomography. In recent years, magnetic resonance imaging (MRI) has been proven efficacious for diagnosing a number of maladies of the bones, ligaments, and soft tissues. MRI can be of aid in evaluation of carpal instability, disorders of the triangular fibrocartilage, ulnar impaction syndrome, distal radioulnar joint (DRUJ) instability, fracture, avascular necrosis (AVN), tendinopathy, nerve entrapment syndromes, synovial abnormalities, and soft tissue masses.
Sixteen fresh-frozen adult human cadaveric upper extremities were used in a biomechanical analysis of distal radioulnar joint (DRUJ) stability. The relative contribution to stability of the DRUJ by the surrounding anatomic structures presumed to stabilize the joint was analyzed with respect to forearm rotation and wrist flexion and extension using a purpose-built 4-axis materials testing machine. The dominant structures stabilizing the DRUJ were the ligamentous components of the triangular fibrocartilage complex proper. The major constraint to dorsal translation of the distal ulna relative to the radius is the palmar radioulnar ligament. Palmar translation of the distal ulna relative to the radius is constrained primarily by the dorsal radioulnar ligament, with secondary constraint provided by the palmar radioulnar ligament and interosseous membrane. The ulnocarpal ligaments and extensor carpi ulnaris subsheath did not contribute significantly to DRUJ stability; however, approximately 20% of DRUJ constraint is provided by the articular contact of the radius and ulna. These relationships were consistent regardless of wrist position or degree of forearm rotation.
Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.
Fourteen patients with posttraumatic distal radioulnar joint instability were treated with a reconstruction of the distal radioulnar ligaments. The technique is anatomically accurate, is reproducible, and requires less dissection than previously described techniques. Candidates for the procedure had joint instability and an irreparable triangular fibrocartilage complex. Ten patients had bidirectional instability. Two patients had a concurrent corrective osteotomy of the distal radius for a malunion. The procedure restored stability and relieved symptoms in 12 of 14 patients at 1 to 4 years' follow-up evaluation. One patient with a deficient sigmoid notch and one with ulnocarpal ligament injury did not achieve full stability. All patients attained near full pronation and supination. The procedure is an effective treatment for an unstable distal radioulnar joint when its articular surfaces are intact and the other wrist ligaments are functional, and it can be used in combination with a distal radius corrective osteotomy.
The most common method to treat the arthralgic distal radioulnar joint is resection of the entire ulnar head (Darrach procedure). Pain and weak grip strength usually manifest complications related to instability of the distal forearm. In an attempt to mechanically stabilize the distal forearm after ulnar head resection, an endoprosthesis was developed to replace the ulnar head after Darrach resection. The goals of this study were to evaluate the dynamic effects of the Darrach procedure on radioulnar convergence and the mechanical efficacy of implantation of an ulnar head endoprosthesis after Darrach resection. Cadaver forearms were rotated actively and passively and relevant muscles were loaded simultaneously with a dynamic PC-controlled forearm simulator. Resultant total forearm torque and 3-dimensional kinematics of the ulna, radius, and third metacarpal were recorded simultaneously in 7 fresh-frozen cadaver upper extremities. Comparisons were made between the intact state, after Darrach resection, and after implantation of ulnar head endoprosthesis. The Darrach resection created substantial forearm instability with movement of the radius ulnarly (0.92-0.38 cm vs intact state) and anteroposterior translation in each loading condition. Implantation of the ulnar head endoprosthesis effectively restored distal radioulnar joint stability by simulating the geometry of the ulnar head, further stabilized by attaching the triangular fibrocartilage complex. These laboratory data provide validity to implanting an ulnar head endoprosthesis to stabilize the distal forearm after Darrach resection.
Thirteen wrists with ulnar neutral or negative variance were treated by open distal ulna excision (the wafer procedure). The mean follow-up was 25 months (range, 12-38). At final follow-up grip strength had increased a mean of 14 kgf and 12 of the 13 patients were very satisfied with the functional outcome and pain relief. In treatment of the ulnar impaction syndrome, the wafer procedure provides excellent pain relief and functional restoration particularly in patients with ulnar neutral or negative wrists in whom triangular fibrocartilage tears have not yet developed.
A three-dimensional rigid body spring model (3D-RBSM) was used to analyse force distribution through the wrist joint. In the neutral position, 48% of the force was transmitted through the radioscaphoid fossa, 40% through the radiolunate fossa, and 12% through the triangular fibrocartilage complex. In the functional position, the wrist joint was slightly extended, resulting in significantly increased force through the lunate (53%). The lunate appears to bear more load than has been reported previously.
Carpal impaction with the ulnar styloid process (stylocarpal impaction) occurs less frequently than with the ulnar head (ulnocarpal impaction), and more commonly develops in wrists with negative ulnar variance. Physical examination, radiographic evaluation, and wrist arthroscopy are all helpful in excluding alternative causes of ulnar wrist pain. When an ulnocarpal stress test elicits pain, and radiographs suggest that this is due to carpal impaction with the ulnar styloid, partial resection of the styloid process provides successful treatment, so long as the insertion of the triangular fibrocartilage at the base of the styloid is not disrupted.
Between 1996 and 1999, 54 patients with wrist pain had magnetic resonance imaging performed using a 1.5 Tesla scanner without a wrist coil. Wrist arthroscopy was performed using a standard technique. The findings were then compared. Magnetic resonance imaging had a low sensitivity for the detection of triangular fibrocartilage complex injuries (0.44) and scapholunate ligament injuries (0.11) when wrist arthroscopy was used as the standard of reference. We conclude that when a magnetoresonance technique that does not employ a dedicated wrist coil is used, a negative magnetic resonance imaging scan does not exclude these two significant injuries.