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PubMed1999

[The importance of the distal radioulnar joint for reconstructive procedures in malunited distal radius fracture].

Clinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignment of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.

Fractures, Malunited↗
PubMed1999

[Diagnostic and therapeutic significance of arthroscopy in distal radius fracture].

Non-operative and minimal-invasive treatment of distal radius fractures have still a poor outcome. Although bony structures often heal acceptable, additional lesions of intraarticular ligamentous structures cause persistent pain and disability. Aim of the study was to present the diagnostic and therapeutic possibilities of arthroscopically assisted treatment of distal radius fractures. Diagnostic wrist arthroscopy found in 6 of 30 patients with distal radius fractures (23 AO type C fractures) a scapho-lunate ligament tear (20%) of which 3 had to be stabilized operatively. 18 patients (60%) presented with tears of the triangular fibrocartilage complex [Palmer classification: 1A (1); 1B (5); 1D (2); 1A, 1B (2); 1A, 1D (6); 1B, 1D (2)], which were repaired by arthroscopic shaving (n = 12), Kirschner wire stabilization of ulna head (n = 2) or arthroscopic suture (n = 3). Fractures were stabilized in most cases by combinations of canulated titan screws (3.0 mm) and Kirschner wires (n = 12). In 27 patients, the radial joint surface and the distal radio-ulnar joint could be reconstructed without any specific complications. Arthroscopic reduction of distal radius fractures allows minimal-invasive reconstruction of the joint surface, diagnoses relevant ligamentous tears and should applied with incongruencies of the joint surface greater than 2 mm and in widely dislocated fractures.

Adult↗
PubMed1999

Ulnar variance and its relationship to ligament injuries of the wrist.

An anatomic study on cadavers and a clinico-radiological study on patients were undertaken to verify if ligament injuries of the wrist could be associated with ulnar variance. Neither scapholunate nor triquetrolunate ligament injuries could be related to shorter or longer ulnae. Longer ulnae were associated with significantly more perforations of the triangular fibrocartilage complex (TFCC).

Adolescent↗
PubMed2000

Use of magnetic resonance imaging to diagnose common wrist disorders.

Magnetic resonance imaging is being used more frequently to diagnose and plan treatment of wrist disorders. This article reviews the common pathologic lesions of the wrist: avascular necrosis, triangular fibrocartilage complex tears, ligamentous tears, ganglion cysts, carpal tunnel syndrome, and osteoarthritis. The typical magnetic resonance imaging characteristics of these lesions is discussed.

Carpal Tunnel Syndrome↗
PubMed2001

[Magnetic resonance (MR) imaging of the shoulder, elbow, and wrist].

Thorough knowledge of small structures in the joints is becoming important as the resolution of magnetic resonance (MR) imaging has improved during the past decade. The author discusses the MR anatomy and pathology of three representative structures in the joints of the upper extremities: the labral-ligamentous complex of the shoulder, ulnar collateral ligament(UCL) of the elbow, and triangular fibrocartilage complex(TFCC) of the wrist. The labral-ligamentous complex is composed of the anterior labrum and three glenohumeral ligaments. Because of their similar MR appearance, the labral sulcus is difficult to differentiate from traumatic detachment of the labrum, even with the aid of MR arthrography. Insertion of the UCL to the medial condyle in the growing elbow presents different MR appearances according to age. Acute and chronic UCL tears are commonly seen in elbows with medial tension overload and are well depicted with three-dimensional Fourier transform(3DFT) gradient-echo images. 3DFT images are the most suitable for observation of the TFCC as well. Since abnormally high signals of the articular disc suggestive of tear are often seen in asymptomatic subjects, MR imaging may not reliably be used to differentiate clinically significant tears from asymptomatic defects. In this review article, the author emphasizes developmental anatomy and normal variations in the interpretation of MR images.

Collateral Ligaments↗
PubMed2001

Diagnosis of ulnar wrist pain.

In the diagnosis of ulnar wrist pain, physical examinations including provacative tests are primary elements in identifying the site and nature of ulnar wrist pain. Imagings techniques are helpful for diagnosing occult fractures and distal radioulnar subluxation, but unsatisfactory for diagnosing ulnocarpal impaction syndrome, tears of the triangular fibrocartilage complex and lunotriquetral ligament, and joint mouse, imagings. Therefore, prior to surgical intervention arthroscopy is recommended for patients with persistent ulnar wrist pain that interferes with their daily activity.

Arthroscopy↗
PubMed2002

[Arthroscopic examination of the wrist joint].

Arthroscopy is a standard procedure for the diagnosis of wrist disorders. Provided it is preceded by a thorough clinical investigation it is highly effective in detecting cartilagineous, osseous and ligamenteous lesions. Sometimes even intraarticular occult ganglia are visible. Especially triangular-fibrocartilage-lesions can be classified and give hints at instabilities of the distal radioulnar joint. Arthroscopy of the radiocarpal joint alone is not sufficient. The midcarpal joint must be visualized, too. Although disorders of the distal radioulnar joint are frequent, it is usually too narrow to permit an arthroscopic investigation.

Arthroscopy↗
PubMed1992

[MRI of the wrist joint].

Due to the development of new surface coils and the use of thin slices, MRI has become an essential diagnostic tool in wrist pathology. After several technical considerations, the authors describe the normal MRI appearance of the various anatomical structures of the wrist, particularly the triangular fibrocartilaginous complex of the wrist and the elements of the carpal tunnel. They review the principal indications for MRI: chronic diseases such as carpal tunnel syndrome and traumatic ligamentous and cartilaginous lesions. The bone marrow lesions detected in the presence of occult fractures and osteonecrosis of the lunate or scaphoid are then briefly considered. The diagnostic criteria of median nerve compression (carpal tunnel syndrome) include morphological and signal changes in the nerve, abnormal palmar convexity of the flexor retinaculum and signs of tenosynovitis of the intracarpal flexor tendons. However, in practice, MRI is only useful when there is disagreement between the clinical and EMG findings and in postoperative recurrences, in which case it may reveal insufficient section of the retinaculum or the presence of exuberant postoperative fibrosis responsible for persistent nerve compression. Traumatic tears of the triangular fibrocartilage are characterised by a linear high signal intensity image (on T1 and T2 weighted sequences), usually situated in the periphery of the articular disk. Degenerative lesions tend to be central, within the disk and are frequently observed after the age of 40 years.

Carpal Bones↗
PubMed1992

[Arthroscopy of the wrist and elbow joint].

Arthroscopy of the wrist and elbow is a helpful diagnostic procedure in patients with chronic disability not demonstrated by clinical and radiological examinations. At the wrist, especially triangular fibrocartilage, chondral or ligamentous defects can often not be demonstrated by other tests. Arthroscopy of the wrist allows examination of more than a dozen separate articular surfaces and the function of eight discrete joints. The geometry of the elbow joint limits intra-articular inspection and the use of instruments. The risk of neurovascular injuries is great and depends on exact puncture sites and portals. Its efficiacy is not yet proven.

Adult↗
PubMed1992

The role of arthroscopy in the treatment of wrist injuries in the athlete.

As a minimally invasive procedure, wrist arthroscopy provides the advantages of accurate, direct visual inspection of intra-articular structures for diagnostic purposes and dramatically reduced morbidity for surgical treatment of certain disorders. For an athlete who has a limited window of opportunity to compete, arthroscopy can offer an earlier, more accurate, more complete diagnosis than other imaging techniques for soft-tissue disorders of the wrist. Arthroscopic surgery can frequently offer an abbreviated recuperation period and earlier return to competition. Arthroscopy offers advantageous treatment options for extrinsic and intrinsic ligament injuries, removal of loose bodies, reduction of articular fractures of the distal radius and scaphoid and definitive treatment of injuries to the triangular fibrocartilage complex. It is a modality well worth including in the treatment armamentarium for wrist disorders in athletes.

Arthroscopy↗
PubMed1992

Current status of magnetic resonance imaging of the wrist.

Conventional imaging of the wrist has relied heavily on plain radiography, tomography, fluoroscopy and arthrography. More recently, computed tomography and magnetic resonance imaging (MRI) have been added to this armamentarium. In this article the authors review the normal anatomy of the wrist and demonstrate a variety of pathologic conditions that can be assessed with MRI, including avascular necrosis and tears of the intrinsic and the extrinsic ligaments and the triangular fibrocartilage. MRI of the wrist is still evolving rapidly, and its place in the work-up of wrist disorders is only now being defined.

Bone Diseases↗
PubMed1992

Biomechanics of the distal radioulnar joint.

The distal radioulnar joint (DRUJ) is a complex joint involved in pronosupination and ulnocarpal motion and support. The ulnar head, in a rolling, sliding motion, moves from the dorsal to the volar rim of the sigmoid notch as the joint moves from pronation to supination. The triangular fibrocartilage (TFC) is taut first dorsally and then volarly in the same sequence. The ulnar carpus is supported variably, as a function of ulnar length relative to the radial articular surface, by the pole of the distal ulna through the TFC. The TFC does not resist the pistonlike movement of the DRUJ, which occurs under dynamic loading. The coronal alignment of the DRUJ minimizes shear stress on the articular surfaces because of its alignment with the rotational axis of the forearm. Ulnar variance is a factor in the development of several clinical conditions.

Biomechanical Phenomena↗
PubMed1992

The distal joint of the radius and ulna. Diagnostic studies and treatment rationale.

Three areas of functional anatomy are present in the distal ulna. Each of these has a specific function in load bearing of the wrist, rotation of the forearm, and maintenance of the relationship between the radius and ulna. The distal portion of the ulna serves as a suspensory post for ligaments that stabilize the ulnar border of the wrist. The midportion of the distal ulna contains the load-bearing triangular fibrocartilage complex. The proximal portion of the distal ulna articulates with the radius at the sigmoid notch and participates in forearm rotation. Each of these areas is assessed in problems related to ligament instability, load bearing, and range of motion. Mechanical problems that affect the distal joint of the radius and ulna include the affects of trauma, degenerative change, and inflammatory disease. Each of these requires evaluation in the treatment of joint derangement. Diagnostic studies that relate to problems in the distal radioulnar joint area include standard roentgenographs, arthrograms, magnetic resonance (MR) scanning, and arthroscopy. Each of these studies has particular advantages and disadvantages in providing data for analysis of joint malfunction. A medical history, physical examination, and use of proper diagnostic studies will assist in an appropriate diagnosis of problems in the distal joint of the radius and ulna.

Adult↗
PubMed1991

Dorsal dislocation of the distal end of the ulna in a judo player.

A 32-year-old policeman injured his left wrist while engaged in judo training. A distal radio-ulnar dislocation, ulna dorsal, was reduced under general anesthesia, but, as the distal radio-ulnar joint was unstable, a Liebolt's ligamentous reconstruction procedure and a partial excision of the triangular fibrocartilage complex were carried out. The patient could resume his job eight weeks after the operation, and light training after a further six months. The need for proper physical examination and accurate radiographic positioning is stressed.

Adult↗
PubMed1991

The ulnar impaction syndrome.

The ulnar impaction syndrome can be defined as the impaction of the ulnar head against the triangular fibrocartilage complex and ulnar carpus resulting in progressive degeneration of those structures. The differential diagnosis in patients who present with ulnar wrist pain and limitation of motion can also include ulnar impingement syndrome and arthrosis or incongruity of the distal radioulnar joint. Structural abnormalities involving the distal radioulnar joint, distal radius, and ulnar carpus must be carefully elucidated prior to developing a treatment plan. When such abnormalities are identified and appropriately addressed, surgical treatment can be expected to be effective in the majority of cases. It is important to remember that in the absence of obvious structural abnormalities, the ulnar impaction syndrome may result from daily activities that result in excessive intermittent loading of the ulnar carpus. In this group of patients, treatment is directed at decreasing ulnar load by shortening the distal ulna in any of several ways. If relative instability of the ulnar ligamentous complex is a factor, then ulnar shortening by recession is the treatment of choice. Malunion of the distal radius resulting in ulnar impaction syndrome is best treated by addressing the deformity; that is, corrective radial osteotomy. Patients who present with a combination of ulnar impaction syndrome along with distal radioulnar joint, abnormalities must have both of these abnormalities addressed at the time of surgery. The matched ulnar resection and the hemiresection interposition arthroplasty are both effective procedures; however, the Suave-Kapandji procedure also can be used to address relative ligamentous laxity at the ulnar aspect of the wrist. The Darrach procedure is presently not recommended as a first-line treatment in these cases; however, when used as a salvage procedure, satisfactory results can be obtained in properly selected patients. Careful preoperative evaluation and planning are therefore the key to successful treatment of the ulnar impaction syndrome.

Biomechanical Phenomena↗
PubMed1990

[Treatment of distal radius fracture--diagnosis and therapy of local concomitant injuries].

In a high percentage the accompanying local injuries in Colles' type fractures of the distal radius are related to lesions of the triangular fibrocartilage complex (TFCC) and the distal radioulnar joint (DRUG). Frequency and importance of these local injuries concerning the long-term result after distal radius fractures are described and diagnostic and therapeutical proceedings are presented.

Fracture Fixation, Internal↗
PubMed1991

Diagnostic and operative arthroscopy of the wrist.

The evaluation and diagnosis of wrist disorders has traditionally been difficult and problematic. Ligamentous wrist sprains and their associated carpal instabilities, triangular fibrocartilage complex disruptions, and cartilage injuries have been virtually impossible to fully assess because of the inadequacy of current diagnostic techniques. Arthroscopy of the wrist allows a thorough evaluation of the soft-tissue structures and cartilaginous surfaces within the radiocarpal and midcarpal joints. In selected cases, wrist arthroscopy can be employed to surgically modify the intraarticular lesions and to assist in the planning of reconstructive operations.

Adolescent↗
PubMed1991

Radiologic evaluation of hand and wrist motion.

Abnormal motion due to instability at the carpus and distal radioulnar joint can be difficult to diagnose clinically, and radiologic evaluation can be very helpful. The anatomy and kinematics are complex, and a directed approach is necessary to detect the findings that may be subtle and transient. Plain radiographic evaluation of the distal radioulnar joint is very sensitive to slight variations in patient position, and CT is more accurate when pain or cast immobilization make positioning difficult or when there is associated distal radial deformity. Static carpal instability patterns are present on routine radiographs where examination of the lateral view provides the key to diagnosis. The relations between the longitudinal axes of the radius, lunate, capitate, and scaphoid form the basis for classification of these instabilities. In dynamic carpal instability, routine radiographs are normal. The instability is demonstrated only with positional change or manipulation. Motion views can be very helpful, although direct observation of wrist motion on videotape fluoroscopy is the key to the diagnosis of dynamic instability. MR imaging motion studies provide better soft tissue definition and may show subtle changes in the triangular-fibrocartilage-associated distal radioulnar instability, as well as periarticular tendon subluxation about the wrist. The clinical role of MR imaging in the evaluation of wrist motion has yet to be clearly defined.

Carpal Bones↗