Hand and Wrist (Complete) Flashcards
What are the extensor compartments of the wrist and associated pathology?
- EPB + APL = De Quervain’s tenosynovitis
- ECRB + ECRL = intersection syndrome
- EPL = drummer’s wrist, traumatic rupture with DR #
- EDC + extensor indicis = extensor tenosynovitis
- EDM = Vaughn-Jackson syndrome
- ECU = snapping ECU
What are the extrinsic ligaments of the wrist?
[Rockwood and Green 8th ed. 2015]
- Volar ligaments (radial to ulnar)
- Radial collateral ligament
- Radioscaphocapitate
- Radioscapholunate
- AKA Ligament of Testut
- Actually a n.v. bundle
- No contribution to carpal stability
- Long radiolunate ligament
- Short radiolunate ligament
- Ulnolunate ligament
- Ulnotriquetral ligament
- Ulnocapitate ligament
2. Dorsal ligaments - Dorsal radiocarpal ligament (DRC)
- Dorsal intercarpal ligament (DIC)
What is normal wrist ROM?
[JBJS REVIEWS 2015;3(1):e1]
- Flexion = 80o
- Extension = 70o
- Pronation = 90o
- Supination = 90o
What is the differential diagnosis for radial sided wrist pain?
- Soft tissue
- De Quervains tenosynovitis
- FCR tendonitis/rupture
- Bone
- Radial styloid fracture
- Scaphoid fracture
- Joint
- CMC joint arthritis
- Radio-scaphoid arthritis
- Scapholunate instability
What is the differential diagnosis for ulnar sided wrist pain?
[JAAOS 2017;25:e150-e156]
- Soft tissue
- Snapping ECU/ECU tendonitis
- EDM tendinitis
- FCU tendinitis
- Bone
- Pisiform fracture
- Triquetral fracture
- Hamate fracture
- Ulnar styloid fracture
- Base of 5th metacarpal fracture
- Kienbock disease
3. Joint - Ulnar impaction syndrome
- Ulnar styloid triquetral impaction (USTI)
- TFCC tear
- Triquetrolunate instability
- Pisotriquetral arthritis
- DRUJ arthritis
- DRUJ instability
- LT ligament tear
- Ulnotriquetral ligament tear
4. Vascular - Ulnar artery thrombosis
5. Neurologic - Ulnar tunnel syndrome
Describe the SL ligament?
[JAAOS 2015;23:691-703]
Intra-articular C-shaped ligament with 3 components
- Dorsal – thickest, primary stabilizer
- Volar
- Proximal - thin, membranous
What is the motion of the scaphoid from ulnar to radial deviation ?
[JAAOS 2015;23:691-703]
Position of flexion and radial deviation to extension and ulnar deviation
What wrist motion minimizes motion between the scaphoid and lunate and minimizes tension on the SL ligament?
Dart throwers motion
- Radial-extension to ulnar-flexion
What percentage of patients with a DISI progress to SLAC wrist?
[JAAOS 2015;23:691-703]
<5-10%
Describe the Watson Scaphoid Shift test?
[JAAOS 2015;23:691-703]
Examiner provides dorsally directed pressure on the scaphoid tubercle while ranging the wrist from a position of ulnar deviation with slight extension to radial deviation with slight flexion
- If SLIL is injured:
- Dorsal pressure subluxates the scaphoid onto the dorsal rim of the radius
- When pressure is released, a palpable clunk and reproduction of dorsal wrist pain occur as the scaphoid relocates into the radioscaphoid fossa.
What are the radiographic classifications of SL ligament injury?
[JAAOS 2015;23:691-703]
- Static instability
* SL instability evident on plain film - Dynamic instability
- SL instability evident on stress views
- Stress view = AP clenched fist with 30° ulnar deviation
- Predynamic instability
* SL injury evident on advanced imaging or arthroscopy
What are the radiographic features of a SL ligament injury?
[JAAOS 2015;23:691-703]
- Widened SL distance
- Cortical ring sign
- Shortening of the scaphoid
- Scapholunate angle >70° (normal = 30-60)
- Lunate extension
- DISI defined by radiolunate angle >15°
What arthroscopic portal is the SL ligament best visualized from?
[JAAOS 2015;23:691-703]
Visualized from the radiocarpal space through the 3-4 portal
- Probe in the 4-5 or 6R portal
What is the arthroscopic classification of SL ligament injury?
[JAAOS 2015;23:691-703]
Geissler Classification
- Stage I
- 1mm probe cannot enter SL space from midcarpal joint
- Stage II
- 1mm probe can enter SL space from midcarpal joint but not rotate 90°
- Stage III
- 1mm probe can enter SL space from midcarpal joint and rotate 90°
- Stage IV
- 2.7mm scope can drive through the SL space from the midcarpal and radiocarpal joint
What are the surgical options for managing SL ligament injury?
[JAAOS 2015;23:691-703]
- Primary repair
- Repaired with two horizontal mattress sutures through bone tunnel or suture anchor
- Protected with K-wire or screw augmentation
- +/- capsulodesis augmentation
- Indicated for acute tears
2. Arthroscopic debridement - Indicated for symptomatic partial tears
3. Reconstructive procedures - Indicated for high grade tears with no arthritis
- Blatt capsulodesis
- Capsular flap is attached to the distal scaphoid to prevent flexion
- Recommend using the DIC ligament
- ***Note – does not address the SL gap or lunate extension
- Capsular flap is attached to the distal scaphoid to prevent flexion
- Modified Brunelli procedure
- Portion of the FCR from the base of the 2nd metacarpal is passed through the distal scaphoid and attached to the dorsal lunate
- Ligament reconstruction
- Most common donor site is retinaculum of the third dorsal compartment of the wrist with bone blocks from the distal radius
- RASL
- ‘Reduction and association of the scaphoid and lunate’
- Herbert screw fixes the scaphoid and lunate to create a fibrous union (‘neoligament’)
- Salvage Procedures
- Indicated for high grade tears with arthritis
- Arthroscopic debridement
- Radial styloidectomy
- Wrist denervation
- PRC
- 4-corner fusion
- Limited carpal fusion
- Arthroplasty
- Total wrist fusion
What is the technique for a Blatt capsulodesis?
- Original technique
- Utilized a strip of dorsal wrist capsule attached to the distal radius and inserted onto the distal pole of the scaphoid preventing scaphoid flexion
- Disadvantage
- Wrist flexion limited by ~20° due to crossing of the radiocarpal joint
- Modified DIC capsulodesis
* Detaches the proximal portion of the DIC from the triquetrum and after reduction of the scaphoid flexion it is attached to the lunate
What is the technique for the Brunelli procedure?
- Dual volar and dorsal incisions
- A portion of the FCR is passed through the scaphoid tuberosity and sutured to the remnants of the SLIL on the dorsal aspect of the scaphoid.
* The remaining portion of the FCR slip is anchored to the dorsal ulnar corner of the distal radius
What is the technique for the modified Brunelli procedure?
Triligament tenodesis described by Garcia-Elias
- A strip of FCR tendon is passed from the volar scaphoid tuberosity to the dorsal ridge to reconstruct the scaphotrapezial ligament
- The tendon is fixed dorsally to the lunate, passed through a slit in the dorsal radiotriquetral ligament, and sutured back on itself to recreate the SL ligament.
What is the most common pattern of wrist arthritis?
SLAC (55%)
What is the pathomechanics of SLAC and SNAC wrist development?
- In the normal wrist:
- Scaphoid links the proximal and distal carpal rows
- Proximal row moves with the scaphoid
- Scaphoid has a tendency to assume a flexed posture
- Capitate longitudinal load on the lunate is eccentric causing the lunate and triquetrum to extend
- These forces are balanced as long as the link between the scaphoid and lunate are intact
2. With SL ligament disruption: - The scaphoid flexes and lunate/triquetrum extend independently
- Radiolunate joint remains congruent with lunate extension
- Radiolunate joint preserved
- Radioscaphoid joint becomes incongruent with scaphoid flexion
- Radioscaphoid degeneration progresses
- With scaphoid nonunion
- The distal scaphoid flexes
- The proximal scaphoid extends with the lunate and triquetrum
What are the radiographic stages of SLAC wrist?
Stage I - radial styloid
Stage II - radioscaphoid joint
Stage III - capitolunate joint
[Stage IV - pancarpal involvment (controversial)]
***Radiolunate typically spared
Initially, degeneration occurs between the radial styloid and radial side of scaphoid near the waist
- Degeneration progresses to the proximal pole involving the entire radioscaphoid joint
- With scaphoid flexion and loss of the link between the distal and proximal rows increase load occurs in the midcarpal joints (loss of buttress)
- Capitolunate degeneration develops with eventual migration of the capitate proximally between the scaphoid and lunate
What are the radiographic stages of SNAC wrist?
Stage I - radial styloid
Stage II - proximal scaphocapitate joint
Stage III - capitolunate joint
Initially, degeneration occurs between the radial styloid and radial side of the distal scaphoid fragment
- Degeneration does not progress proximally in the radioscaphoid joint because the proximal scaphoid relationship with the lunate is maintained
- Degeneration progresses to the midcarpal joint starting with the proximal scaphocapitate joint then the capitolunate joint
What are the treatment options for SLAC and SNAC wrist?
Stage I
- Radial styloidectomy
- Distal pole excision (SNAC)
- Wrist denervation (AIN and PIN)
Stage II
- Proximal row carpectomy (PRC)
- Four corner fusion
Stage III
- Four corner fusion
- [PRC with capsular flap interposition]
(Stage IV – pancarpal)
- Total wrist fusion
- Total wrist arthroplasty
What is the most common complication following PRC?
[JHS (Eur Vol) 2015,40E(5) 450–457]
Synovitis and significant edema
What is the most common complication following 4-corner fusion?
[JHS (Eur Vol) 2015,40E(5) 450–457]
Nonunion
What are the advantages and disadvantages of a PRC and Four corner fusion?
[JHS (Eur Vol) 2015,40E(5) 450–457]
- PRC
- Advantages
- Greater postoperative ROM
- Flexion, extension, total flexion/extension arc
- Lower complication rate
- Others
- Earlier ROM
- No hardware
2. 4-corner fusion
- Greater postoperative ROM
- Advantages
- Greater radial deviation ROM
- Greater grip strength
What are the technical steps in performing a PRC?
- Longitudinal incision centred over Lister’s tubercle
- Flaps are elevated off the extensor retinaculum
- Extensor retinaculum is opened over the 3rd compartment and EPL is retracted radial
- 2nd and 4th compartments are elevated off the dorsal capsule
- PIN is identified and transected
- Ligament-sparing capsulotomy is performed
- Longitudinal split of the DRC and DIC
- Described by Berger, Bishop and Bettinger 1995
- Scaphoid, lunate and triquetrum are excised
- Preserve the volar radioscaphocapitate
- Capitate is seated in the lunate fossa
- Radial styloidectomy is performed if there is impingement noted with radial deviation
- Capsule is closed
- Extensor retinaculum is closed leaving the EPL subcutaneous
What are the technical steps in performing a 4-corner fusion?
- Longitudinal incision centred over Lister’s tubercle
- Flaps are elevated off the extensor retinaculum
- Extensor retinaculum is opened over the 3rd compartment and EPL is retracted radial
- 2nd and 4th compartments are elevated off the dorsal capsule
- PIN is identified and transected
- Ligament-sparing capsulotomy is performed
- Scaphoid is excised
- Lunate, capitate, hamate, triquetrum are prepared for fusion
* Articular cartilage and subchondral bone are removed along the dorsal 75% - Lunate extension is corrected and provisional fixation with K-wires between the carpal bones
- Bone graft options include excised scaphoid, local distal radius and ICBG
- Definitive fixation options include K-wire, staples, headless compression screws, circular plates
What is the DRUJ articulation?
[JAAOS 2012;20:623-632] [The Journal of Hand Surgery (European) 2014, 39E(7) 727–738]
- Ulnar head and sigmoid notch of distal radius
- Asymmetric
- Sigmoid notch has a 4- to 7-mm greater radius of curvature than the ulnar head
- Bony contribution to DRUJ stability is 20%
- TFCC primary soft tissue stabilizer
What motions does the DRUJ allow?
[JAAOS 2012;20:623-632]
- Rotation
- Translation (dorsal and volar)
- Dynamic translation
- Pronation = 2.8mm of dorsal translation
- Supination = 5.4mm of volar translation
- Longitudinal
- Dynamic ulnar variance
- Pronation = relative positive
- Supination = relative negative
What are the stabilizing structures of the DRUJ?
[JAAOS 2012;20:623-632]
- TFCC
- Pronator quadratus
- Interosseous membrane
- Joint capsule
From anatomy notes:
1) Triangular fibrocartilage complex (TFCC)
2) Joint capsule
3) IO membrane
4) Pronator quadratus
5) ECU tendon & sheath
What is the effect of forearm rotation on the volar and dorsal radioulnar ligaments?
- Pronation = dorsal superficial and volar deep ligaments tighten
- Supination = volar superficial and dorsal deep ligaments tighten
What is the effect of neutral, positive and negative ulnar variance on load transmission?
[JAAOS 2012;20:623-632]
- Neutral – 20% load through the distal ulna
- Positive – lengthening 1mm increases ulnocarpal loading by 50%
* 2.5mm lengthening increases load to 42% - Negative – decrease ulnocarpal load transmission
- 2.5mm shortening decreases load to 4%
- Also increases pressure in DRUJ and stabilizes DRUJ by increasing tension on TFCC
What is radioulnar convergence?
[JAAOS 2012;20:623-632]
- Ulnar head functions to maintain radioulnar distance during forearm rotation
- Loss of ulnar head leads to convergence of the radius and ulna
What are the causes of DRUJ arthritis?
[JAAOS 2012;20:623-632]
- Post-traumatic
- Distal radius malunion
- Distal radius fracture with extension into sigmoid notch
- Inflammatory arthritis (RA)
- Madelung deformity
- Tumor
* Osteochondroma
What are the surgical management options for DRUJ arthritis?
[JAAOS 2012;20:623-632]
- Darrach procedure
- Indications
- Low demand and non-reconstructable joint
- Technique
- Subperiosteal distal ulna exposure
- Distal ulna resection just proximal to sigmoid notch
- Preserve soft tissue
- TFCC
- ECU sheath
- Periosteum
2. Hemiresection
- Indications
- Requires intact TFCC
- Technique
- Classic
- Resection of articular distal ulna with remainder left insitu including TFCC attachment
- Hemiresection interposition technique (HIT)
- Resection as classic
- Soft tissue interposition into void to prevent radioulnar convergence
- Capsular flap or free tendon
3. Sauve-Kapandji procedure
- Capsular flap or free tendon
- Classic
- Indications
- Young, active patient with nonreconstructable joint
- Technique
- Dorsal or ulnar approach preserving soft tissue
- Identify and protect the dorsal cutaneous branch of the ulnar nerve
- Ulnar neck resection just proximal to sigmoid (~10-15mm)
- Sigmoid notch and ulnar head prepared for fusion (cancellous bone)
- DRUJ fusion with 2 k-wires or 3.5mm screw
- Neutral ulnar variance
- Pronator quadratus interposed in osteotomy site (prevents re-ossification)
- FCU slip can be tenodesed through drill hole in ulnar stump to prevent instability
- Partial ulnar head arthroplasty
- Indications
- Isolated DRUJ arthritis without instability
- Failed HIT
- Total ulnar head arthroplasty
- Indications
- Painful instability after failed resection
- Isolated instability
- Requires stability from native soft tissues
- Total DRUJ arthroplasty
- Indications
- Incompetent native soft tissues
- Salvage option after failed distal ulnar resection
What are complications of resection arthroplasty (Darrach, HIT, S-K procedure)?
[JAAOS 2012;20:623-632]
- Pain
- Ulnar stump instability
- Ulnar translation of carpus
- Radioulnar convergence
- Re-ossification of resection (S-K procedure)
What are surgical options to manage a residual ulnar stump instability?
[JAAOS 2012;20:623-632]
- ECU and FCU tenodesis
- Tendon allografts
- Achilles allograft in interosseous space between radius and ulna
- 2 slips of BR through distal radius and then around ulna stump
What are the types of DRUJ instability?
[The Journal of Hand Surgery (European) 2014, 39E(7) 727–738]
- Pathology
- Primary
- Relatively rare
- Usually due to inflammatory/connective tissue disease (eg. RA, Ehlers-Danlos)
- Posttraumatic
- Most common (11% of distal radius fractures)
- Worse DRUJ instability with increasing dorsal angulation of distal radius (signif beyond 20o)
- Post-surgical
- I.E. Darrach, Sauve-Kapandji
- Presents with pain/clicking with rotation
- Direction
- Dorsal
- Volar
- Bidirectional
- Severity
* Asymptomatic
* Symptomatic - Static vs dynamic
- Acute vs. chronic
What are the associated injuries with DRUJ instability?
- Distal radius fracture
- Ulnar styloid fracture
- Galeazzi fracture
- Essex-Lopresti lesion
- Both bone forearm fracture
- TFFC tear
- Capsule/ligament tear
What is included in the physical exam when assessing DRUJ instability?
- Inspection
* Prominent distal ulna - Palpation
* Ulnar styloid tenderness - ROM
- Observe for loss of supination/pronation compared to contralateral side
- Dorsal ulnar dislocation = preferential loss of supination (locked pronation)
- Volar ulnar dislocation = preferential loss of pronation (locked supination)
- Pain or subluxation
4. ‘Shuck test’ (Ulnar Ballotment) - Attempt volar and dorsal subluxation of distal ulna with forearm in pronation, neutral and supination
- Compare to contralateral side
- ‘Press test’
- Ask patient to arise from a chair using the wrists
- Focal pain at the distal ulna can indicate a TFCC injury
What imaging is indicated when evaluating DRUJ instability?
- Radiographs with forearm in neutral rotation
- CT
***Consider MRI if instability associated with intermittent ulnar neuropathy
- DRUJ subluxation can mechanically irritate the ulnar nerve at the wrist
- “Subluxation-related ulnar neuropathy”
What are 3 imaging findings with radioulnar impingement syndrome following distal ulnar resection?
- Shortened distal ulna ending proximal to the sigmoid notch
- Scalloping of the distal radius along its ulnar border
- Radioulnar convergence
* Narrowing between radius and ulna
What is the management of DRUJ instability?
[The Journal of Hand Surgery (European) 2014, 39E(7) 727–738][ASSH Manual of Hand Surgery]
- Nonoperative
- Acute dislocation
- Closed reduction and splinting in stable position for 6 weeks
- Dorsal radioulnar ligament injury
- Splint midsupination
- Volar radioulnar ligament injury
- Splint midpronation
2. Operative
- Splint midpronation
- Dorsal radioulnar ligament injury
- Closed reduction and splinting in stable position for 6 weeks
- Acute DRUJ instability indications
- Irreducible
- Open reduction
- +/- DRUJ pinning
- +/- TFCC repair
- +/- ulnar styloid fracture fixation
- Associated fractures
- ORIF of associated fractures often resolves the instability
- If remains unstable pin in reduced position
- TFCC tear
- Open or arthroscopic repair
- Open
- Dorsal interval between 5+6 compartment
- TFCC repaired to distal ulna with anchor or suture tunnels
- Open
- Reconstruction if repair fails
- Open or arthroscopic repair
- Irreducible
- Chronic DRUJ instability
- In Absence of arthritis
- Distal radius malunion
- Correction indicated if >20° of dorsal angulation (controversial)
- Correct distal radius malunion then assess DRUJ stability
- If still unstable reconstruct the DRUJ
- Reconstruction
- Indications
- TFCC or radioulnar ligament repair failure
- Unrepairable
- Adams procedure +/- notchplasty (if flat lesser sigmoid) [HAND (2007) 2:123–126]
- Dorsal approach between 5-6 compartments
- L-shaped capsulotomy
- Elevate 4th compartment off distal radius
- Drill 3.5mm from dorsal to volar just radial to lesser sigmoid notch (distal radius)
- 3.5mm drill hole from ulnar neck to fovea
- Harvest palmaris longus (alternative plantaris or slip of FCU)
- Small volar approach between ulnar nerve and flexor tendons
- Suture passer from dorsal to volar retrieves graft from volar side
- Limbs are then passed through ulnar tunnel, wrapped around ulnar neck then sutured to each other
- Indications
- Distal radius malunion
- In Presence of arthritis
- Darrach with ulnar stump stabilization
- Sauve-Kapandji
- In Absence of arthritis
What is the management of radioulnar impingement syndrome (failed Darrach or Sauve-Kapandji)?
- ECU and FCU tenodesis
- Tendon allografts
- Achilles allograft in interosseous space between radius and ulna
- 2 slips of BR through distal radius and then around ulna stump
- Ulnar head replacement
* Require some degree of native soft tissue - Total DRUJ replacement
* Does not require native soft tissue - Salvage
- One-bone forearm (radioulnar synostosis)
- Wide excision (25-50% of distal ulna)
What are the patterns of wrist arthritis and causes of each?
[Bone Joint 2015;97-B:1303–8]
- Pancarpal arthritis
* Advanced inflammatory or post-traumatic arthritis - Radioscapholunate arthritis
- Intra-articular distal radius fractures
- Kienbock’s
- Inflammatory arthritis
- Radioscaphoid arthritis
* SLAC, SNAC - Radiolunate arthritis
* Intra-articular lunate facet fracture
What are the treatment options for each pattern of wrist arthritis?
[Bone Joint 2015;97-B:1303–8]
- Pancarpal arthritis
- Low demand = wrist arthroplasty
- High demand = total wrist fusion
- Radiolunate arthritis
* Midcarpal joint preserved = radiolunate fusion - Radioscaphoid arthritis
- Capitate-lunate preserved = PRC or 4-corner fusion
- Capitate-lunate involved = 4-corner fusion
- Radioscapholunate arthritis
* Midcarpal joint preserved = radioscapholunate fusion
What are the important considerations when performing a radioscapholunate fusion?
[Bone Joint 2015;97-B:1303–8]
- Midcarpal is free of arthritis
- Distal scaphoid pole excision
* Increases ROM
* Decreases pain
* Rncreases rate of union due to unlocking the midcarpal joint
What is the resulting wrist function following total wrist arthrodesis?
[JAAOS 2017;25:3-11]
- Loss of flexion, extension, ulnar and radial deviation
- Supination and pronation are retained
What are the indications for total wrist fusion?
[JAAOS 2017;25:3-11]
- Rheumatoid arthritis
- Post-traumatic arthritis
- Spastic wrist contracture
- End stage osteonecrosis
- Kienbock disease
- Preiser disease
- Complete brachial plexus paralysis
- Failed wrist arthroplasty
- Postinfection degeneration
- Failed wrist surgery
- PRC
- SL reconstruction
- Arthrodesis
- Silicone synovitis
What are the contraindications for total wrist fusion?
[JAAOS 2017;25:3-11]
- Active infection
- Lack of an adequate soft tissue coverage
What are the complications associated with total wrist arthrodesis?
[JAAOS 2017;25:3-11]
- Major
- Nonunion
- Ulnocarpal impaction
- Carpal tunnel syndrome
- Extensor tenosynovitis
- Deep infection
- Implant-related problems
- Minor
- Superficial infection
- Carpal tunnel symptoms
- Intraoperative fractures
- Postoperative fractures
- Asymptomatic radiographic loosening
What are advantages of wrist arthrodesis vs. wrist arthroplasty?
[JAAOS 2017;25:3-11]
- Reliable pain relief
- Lower complication rate
- Less revision
What is the recommended position of wrist fusion?
[JAAOS 2017;25:3-11]
- Unilateral wrist arthrodesis
- 10-15° extension
- Slight ulnar deviation
- Bilateral wrist arthrodesis
- Dominant wrist = slight extension
- Nondominant wrist = neutral to slight flexion
What are the general principles of total wrist arthrodesis?
[JAAOS 2017;25:3-11]
- Adequately prepare the joints
- Remove cartilage and expose subchondral bone
- Without PRC:
- Radiolunate
- Radioscaphoid
- Scapholunate
- Scaphocapitate
- Lunocapitate
- Triquetrohamate
- 3rd CMC joint
- With PRC
- Radiocapitate
- Radiohamate
- 3rd CMC joint
- Prepare the distal radius to accept plate
- Remove dorsal cortical rim
3. +/- triquetrum excision - Prevents ulnocarpal abutment and provides bone graft
4. Bone graft - Triquetrum
- PRC
- Olecranon
- Precontoured stainless steel locking wrist fusion plate
- Fix to 3rd metacarpal shaft
- Compression across arthrodesis sites
- Manual compression and compression by design through plate
- +/- ECRL and ECRB tendon transfer over plate if finger extensor directly overlying plate
- +/- distal ulna resection if DRUJ arthritis present
- Manual compression and compression by design through plate
What are the radiographic parameters to assess for distal radius malunion and how do they affect the biomechanics of the wrist?
[JAAOS 2007;15:27-40]
- Radial tilt
* Dorsal angulation leads to:- Loads being shifted dorsal
- DRUJ incongruency
- Tightening of the interosseous membrane
- Resulting loss in supination-pronation
- Preferential loss of wrist flexion and forearm supination
* Dorsal angulation causes two forms of wrist instability: - Dorsal radiocarpal subluxation with maintenance of midcarpal alignment
- Adaptive DISI
* Volar angulation preferentially decreases extension and pronation
- Radial length
- Ulnar variance
* Ulnar positive variance leads to ulnocarpal impaction - Radial inclination
* Decrease in inclination shifts loads from the scaphoid fossa to the lunate fossa - Joint congruity
What are contraindications to distal radius osteotomy for malunion?
[JAAOS 2007;15:27-40]
- Advanced degeneration
- Fixed intercarpal malalignment
- Severe osteoporosis
- CRPS
- Inability to comply with postoperative therapy
- Serious medical comorbidiities
- Very low demand
What are the 4 components of surgical management for distal radius malunion?
[JAAOS 2007;15:27-40]
In order:
- Osteotomy
- Bone grafting
- Fixation
- Ulnar-side procedure
What are the advantages and disadvantages of closing vs. opening wedge osteotomy for correction of distal radius malunion?
[JAAOS 2007;15:27-40]
- Closing wedge osteotomy
- Advantage
- More stable construct (bone-to-bone contact)
- Disadvantage
- Shortening of radius relative to ulna
- Requires ulnar sided procedure
- Shortening of radius relative to ulna
- Opening wedge osteotomy
- Advantage
- Restores radial length
- Corrects ulnar variance
- Corrects inclination and tilt
- Disadvantage
- Less stable construct
- Increased risk for nonunion or hardware failure
What are the bone graft options typically used in osteotomies correcting distal radius malunion?
[JAAOS 2007;15:27-40]
- ICBG – corticocancellous
- Local distal radius graft
- Cancellous autograft or allograft
- Bone graft substitute
What are the advantages and disadvantages of volar vs. dorsal plating in osteotomy correction of distal radius malunion?
[JAAOS 2007;15:27-40]
- Dorsal plating
- Advantage
- Easy access for bone graft in dorsal opening wedge osteotomy
- Disadvantage
- Hardware irritation and tendon rupture
- Volar plating
- Advantage
- Less hardware irritation and tendon rupture
- Disadvantage
- Difficult access for bone graft
- May require additional releases
- Difficult access for bone graft
What are the ulnar-sided procedures that can be considered in context of distal radius malunion?
[JAAOS 2007;15:27-40]
- Hemiresection-interposition
- Ulnar shortening osteotomy
- ‘Wafer’ resection
- Sauve-Kapandji
* DRUJ fusion with proximal pseudoarthrosis) - Darrach
* Complete distal ulna resection - Arthroplasty
What is the best timing for distal radius corrective osteotomy for malunion?
As soon as possible
- Avoids soft tissue contracture
What are the general types of distal radius malunions and what are the surgical considerations for each?
[Operative Techniques in Hand, Wrist, and Elbow Surgery]
- Dorsally angulated, extra-articular
- Approach – volar or dorsal
- Volar approach requires:
- Volar locking plate fixation
- BR Z-lengthening or release
- Dorsal and radial soft tissue and periosteal release
- Use of the locking plate as a reduction/correction tool
- First fix to distal fragment anatomically
- Can often be done prior to osteotomy
- Then bring the plate to the shaft correcting inclination, tilt and length
2. Volarly angulated, extra-articular
- First fix to distal fragment anatomically
- Volar approach requires:
- Approach – volar
- Less radial and dorsal release required
- Intra-articular
- Approach – volar or dorsal depending on location of fragment
- Dorsal approach
- Transverse capsulotomy for direct visualization
- Volar approach
- Do not perform capsulotomy
- Reduction may be visualized through osteotomy
- Dorsal approach
- Intra-articular and extra-articular deformity
- Approach – volar, dorsal or combined
- Typically, the intra-articular malunion is corrected first followed by the extra-articular malunion
- Often a dorsal approach is needed for dorsal capsulotomy and visualization of articular reduction
- Fixation can be volar, dorsal or fragment specific
What are the risk factors for scaphoid nonunion?
[JAAOS 2009;17:744-755]
- Displacement >1mm
- Proximal fracture
- Delayed treatment
- Inadequate immobilization
- Associated carpal instability
- Osteonecrosis
What are signs of scaphoid proximal pole osteonecrosis?
[JAAOS 2009;17:744-755]
- Radiographic sclerosis
- MRI changes
- Absence of punctate bleeding intraoperative
What are the indications for vascularized bone grafting in scaphoid non-union?
[JAAOS 2009;17:744-755]
Scaphoid nonunion with proximal pole osteonecrosis and/or failure of previous grafting
What are the graft options for scaphoid nonunion based on location of fracture and presence of deformity?
[JAAOS 2009;17:744-755]
- Proximal 1/3 nonunion without significant humpback deformity
- Recommended
- 1,2 ICSRA (intercompartmental supraretinacular artery) - AKA Zaidenberg
- Origin
- Radial artery 5cm proximal to radiocarpal joint
- Advantages – single approach
- Disadvantages
- Unable to correct humpback deformity
- Vulnerable to kinking and impingement
- Origin
- Capsule-based (4th extensor compartmental artery)
- Advantages
- Simple harvesting technique
- Short arc of rotation and low risk of kinking
- Disadvantage
- Cannot correct humpback deformity
- Violates dorsal radiocarpal and intercarpal ligaments
- Advantages
- 1,2 ICSRA (intercompartmental supraretinacular artery) - AKA Zaidenberg
- Alternatives
- 2,3 ICSRA
- Free vascularized bone graft
- Medial femoral condyle or iliac crest
2. Waist nonunion and humpback deformity
- Medial femoral condyle or iliac crest
- Recommended
- Volar radius VBG (AKA Mathoulin)
- Origin
- Radial carpal artery
- Advantages
- Single incision
- Preserves dorsal blood supply
- Simultaneous correction of humpback deformity
- May preserve wrist flexion (compared to dorsal grafting)
- Single incision
- Origin
- Volar radius VBG (AKA Mathoulin)
- Alternatives
- Free VBG
- Medial femoral condyle or iliac crest
- Free VBG
What imaging should be obtained to assess for nonunion following prior surgical management of scaphoid fracture?
[JAAOS 2013;21:548-557]
- Radiographs
- Wrist PA, lateral, scaphoid, 45° pronated and supinated oblique view
- Assess for:
- Sclerosis
- Cysts
- Bone resorption at fracture site
- Hardware loosening
- CT scan
- Assess for:
- Bony union
- Arthritis
- Screw placement
- Fracture reduction
- Proximal pole sclerosis
What are the indications for reoperation following prior surgical fixation of scaphoid fracture?
[JAAOS 2013;21:548-557]
At 3 months if there is inadequate union and evidence of one of the following:
- Improper screw placement (at least 3-4 screw threads in each fragment)
- Insufficient compression across fracture site (presence of gapping)
- Inadequate fixation
- Lack of appropriate bone grafting
- Based on OR report or report from surgeon
What are the graft options for reoperation for scaphoid nonunion following prior surgical fixation?
[JAAOS 2013;21:548-557]
- Nonvascularized Bone Graft
- Useful when technical error is the primary cause
- IE. Screw malposition, fracture malreduction
- Options:
- Distal radius
- Tricortical iliac crest (deformity correction)
- Advantages – less technically challenging
- Disadvantages
- Heals by creeping substitution and resorption
- Prolongs time to union and reduces mechanical stability during healing
- Heals by creeping substitution and resorption
- Union rate = 70%
2. Vascularized bone graft - Union rate = 86%
- Options
- Zaidenberg (1,2 ICSRA)
- Mathoulin (Volar branch radial carpal artery)
- Free VBG (Femoral condyle of Iliac crest)
- Arterialization
* Direct implantation of the second dorsal intermetacarpal artery into the scaphoid
What is the approach to surgical management of scaphoid nonunion following prior surgical fixation?
[JAAOS 2013;21:548-557]
- If scaphoid alignment and initial screw position is acceptable and scaphoid is viable:
* Revise with a larger diameter variable pitch screw following the same tract with distal radius bone graft - If screw placement not acceptable:
* Redirect the screw
What is the treatment algorithm for scaphoid nonunion based on specific fracture characteristics?
[Operative Techniques: Hand and Wrist Surgery, 3rd Ed. Chung]
- Delayed union (<6 months)
* ORIF with headless compression screw - Established nonunion without humpback
* ORIF with headless compression screw + bone graft (cancellous ICBG or distal radius) - Nonunion with humpback deformity; no AVN
* ORIF via volar approach + corticocancellous bone graft - AVN without humpback deformity
* Vascularized bone graft via volar or dorsal approach - AVN with humpback deformity
* Vascularized medial femoral condyle bone graft via volar approach
What is the blood supply to the lunate?
[Kienbock’s Disease, 2016]
- Volar and dorsal branches from the radial artery
* Volar is dominant and 20% of the time it is sole supply - Gelberman described 3 patterns:
* ‘Y’ = 59%
* ‘I’= 31%
* ‘X’ = 10% - Gelberman hypothesized that a lunate at risk has only one arterial supply or dorsal and volar supply but no anastomoses
What is the classification system for Kienbock’s disease?
[J Hand Surg 2016:41(5);630][JAAOS 2001;9:128-136]
Lichtman Classification
- Stage I
- Normal xray
- MRI decreased signal T1
- Bone scan positive
- Stage II
- Lunate sclerosis
- Stage IIIa
- Lunate collapse (no scaphoid rotation)
- Carpal height maintained
- Stage IIIb
- Lunate collapse
- Carpal collapse
- Scaphoid rotation (hyperflexed, RS angle >60o)
- Cortical ring sign
- Capitate migrates proximal
- Decreased carpal height
- Stage IV
- Pancarpal arthritis (Kienbock’s disease advanced collapse)
What are the treatment options for Kienbock’s disease based on stage of disease?
[J Hand Surg 2016:41(5);630]
Stage I
- Nonoperative (3 months immobilization)
Stage II
- Radial shortening osteotomy
- If ulnar negative or neutral
- Capitate shortening
- If ulnar positive
- (vascularized bone graft)
Stage IIIa
- Same as Stage II
- Vascularized bone graft (dorsal pedicle)
- 4,5 ECA graft
- Vascularized pisiform
- Free vascularized medial femoral condyle
Stage IIIb
- Scaphocapitate fusion
- STT fusion
- PRC
Stage IV
- PRC
- Total wrist arthrodesis
What are the components of the TFCC?
[JBJS REVIEWS 2015;3(1):e1]
- Articular disc
* Extends between the volar and dorsal radioulnar ligaments (hammock) - Meniscus homologue
- Volar and dorsal radioulnar ligaments
* Superficial and deep (ligamentum subcruentum)
* Major stabilizers of the DRUJ - Sheath of ECU
- Ulnar capsule (ulnar collateral ligament)
* Arises from the ulnar styloid and extends between the ulnotriquetral ligament and the ECU sheath - Ulnolunate and ulnotriquetral ligaments (volar)
What is the function of the TFCC?
[JBJS REVIEWS 2015;3(1):e1]
- Stabilize ulnocarpal joint
- Stabilize DRUJ
- Transmits load from carpus to ulna
- Assists with wrist mechanics
What is the blood supply of the TFCC?
[JBJS REVIEWS 2015;3(1):e1]
- Peripheral 20% vascularized
- Central avascular
- Ulnar artery and anterior interosseous artery
* Palmar and dorsal branches
What is the innervation of the TFCC?
[JBJS REVIEWS 2015;3(1):e1]
- Ulnar nerve
- PIN
What is the classification of TFCC tears?
[JAAOS 2012;20:725-734] [JBJS REVIEWS 2015;3(1):e1]
Palmer classification
- Type 1 = traumatic
- 1A – central
- 1B – peripheral avulsion from ulnar styloid
- 1C – volar ulnocarpal ligaments
- 1D – radial attachment
- Type 2 = atraumatic
- 2A – TFCC wear (no tear)
- 2B – TFCC wear with lunate or ulnar head chondromalacia
- 2C – 2B + TFCC perforation
- 2D – 2C + LT ligament perforation
- 2E – 2D + ulnocarpal arthrosis
What are the physical examination findings/tests in a TFCC tear?
[JBJS REVIEWS 2015;3(1):e1]
- Prominent ulna
- Fovea sign
- Palpation of the depression volar between ulnar styloid, FCU and pisiform
- Tenderness suggests:
- Tear of ulnotriquetral ligament
- Foveal disruption of TFCC
- Chondromalacia of ulnar aspect lunate
- Suggestive of ulnocarpal impaction
- Ulnocarpal stress test
* Ulnar deviation with axial loading in alternating supination and pronation - Positive grind test
* Clicking, crepitus or pain with passive supination and pronation - Lunotriquetral shuck test
* Pain and laxity when examiner grasps the pisiform/triquetrum and lunate with opposite hands and translates volar and dorsal
What imaging is indicated for TFCC tears?
[JBJS REVIEWS 2015;3(1):e1]
- Radiographs
- Neutral rotation PA and lateral
- PA in ulnar and radial deviation
- Pronated PA clenched-fist views
- MRI/MRA
What are the findings during wrist arthroscopy?
[JBJS REVIEWS 2015;3(1):e1]
- Trampoline test
- Probe is used to test central disc tautness and rebound ability
- Laxity suggests detachment from one or more insertion points
- Hook test
- Traction applied to ulnar-most aspect of TFCC
- Ability to pull the TFCC radial and upward suggests foveal attachment disruption
What is the treatment of TFCC tears?
[JBJS REVIEWS 2015;3(1):e1]
- Nonoperative
* Most tears are initially treated nonoperative - Operative
- Contraindications:
- Severe OA
- Previous infection
- Severe osteoporosis of ulnar head
- Open
- Indicated when fixing distal radius fracture or surgeon not familiar with arthroscopy
- Arthroscopic
- Palmar 1A – debridement
- Palmer 1B, C, D – repair
- Transosseous or suture anchor fixation
- Ulnar positive wrists
- Perform ulnar shortening osteotomy or wafer procedure at time of TFCC repair
- Better outcomes
- Perform ulnar shortening osteotomy or wafer procedure at time of TFCC repair
What is ulnocarpal impaction?
[Hand Clin 26 (2010) 549–557]
- Mechanical abutment of the distal ulna with the carpus
- Usually associated with positive ulnar variance
What are the causes of positive ulnar variance?
[Hand Clin 26 (2010) 549–557]
- Congenital
- Physiologic
- Madelung
- Acquired
- Distal radius malunion
- Radial head excision
- Premature physeal closure of radius
- Post-wrist fusion
What is the resulting pathology from ulnocarpal abutment?
[Hand Clin 26 (2010) 549–557]
- Degenerative TFCC tears (Palmer 2A-E)
- Chondromalacia of ulnar head
- Chondromalacia of ulnar lunate
- Chondromalacia of triquetrum
- LT ligament perforation
What results in dynamic ulnar positive variance?
[Hand Clin 26 (2010) 549–557]
- Pronation
- Grip
[Do pronated grip view to elicit positive ulnar variance]