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Cartilaginous and ligamentous degeneration of the wrist Anatomic study
383
© Soci~t~d'Edition de l'Associationd'EnseignementM#dical des HOpitauxde Paris 1994
Cartilaginous and ligamentous degeneration of the wrist Anatomic study Y. FORTEMS, L. de SMET, G. FABRY SUMMARY : The growing precision of diagnostic techniques (MRI, arthrography, arthroscopy) and the consequent increase of the diagnosis of cartilaginous and ligamentous lesions of the wrist led us to undertake a detailed anatomical study of the carpus and to extend this study to the search for correlations between these lesions and the radio-ulnar index. Fifty one cadaveric wrists were dissected from an elderly population (mean age of 76 years). Cartilaginous lesions were found in two-thirds of radioulnar joints of the wrist with a marked predominance for the lunate bone (43 %). The triangular cartilage of the fibrocartilaginous complex (TFCC) was perforated in 23 wrists (46 %). We established a correlation between the radio-ulnar index and perforations of the TFCC (p < 0.05), as well as the thickness of this structure (p < 0.05). The relationship between age and rupture of intrinsic ligaments (p < 0,05), and the radio-ulnar index (p < 0.05) and age was also established. We present our figures, discuss the clinical implications, and draw the following conclusions from this study. 1) The carpus is a complex joint which is subject to age-related degeneration. 2) The large number of cartilaginous lesions observed in this study must be taken into account in the interpretation of MRI and the <>precise results of arthroscopy. Ann Chir Main (Ann Hand Surg), 1994, 13, n ° KEY-WORDS
5,383-386.
: Cartilaginous lesions. - - R a d i o - u l n a r index. - - M R I . - - A r t h r o s c o p y .
Anatomy remains one of the cornerstones of surgery and this certainly applies for hand surgery. It is therefore a pleasure for me to present a work on cartilaginous and ligamentous degeneration of the human wrist. Due to the increased precision of diagnostic t e c h n i q u e s i n c l u d i n g arthrography, CT-scan, N M R ' s and of course wrist arthroscopies, hand surgeons face a problem since a large amount of observed lesions do not correlate with clinical findings. So, what is the significance of the observed lesions and what is the normal evolution of the wrist with age ? To answer these questions we decided to undertake an anatomical and radiological study in an elderly population. 51 wrists from 30 cadavers were studied. Before amputation the radius and ulna were transfixed with a screw, in the neutral position as described by Palmer thus allowing correct standardized measurements with the ring technique on the retrieved limbs. The wrist was incised through a
standard dorsal approach allowing good observation of the radiocarpal joint. The incidence of cartilage wear on scaphoid, lunate and triquetrum was noted and the integrity of the scapholunate and triquetrolunate ligament tested. Only if frank displacement of the corresponding bones could be elicited the ligament was recorded as ruptured. Before excision of the TFCC the integrity of the triangular ligament was recorded. This could be either intact or perforated centrally or at its periphery. The excised triangular ligament was measured at its thinnest point with a special biconvex micrometer. Finally the cartilage wear of the ulnar head and radial articular surface was recorded.
Dpt of Orthopaedic Surgery, University Hospital Pellenberg WeIigerveld 1, B-3212 PELLENBERG (Belgium). Manuscrit re~u ~ la R~daction le 16 f~vrier 1994. Accept(~ le 12 juillel 1994.
384
ANN CHIR MAIN/ANNHAND SURG 1994, 13, N ° 5
CARTILAGINOUS AND LIGAMENTOUS DEGENERATION
Centered X-rays were later taken to allow ulna variance measurements. You can appreciate the old age of the population. The mean age was 76,6 y (ranging from 58 to 94 y). Let's now have a look at the results. The scapholunate ligament was ruptured in 20 % of the wrists, the triquetrolunate in 30 %. Cartilaginous lesions in the radiocarpal joint were seen in 66 % of the wrists. The lunate showed the highest rate with 43,1%, followed by the triquetrum, radial articular surface, ulnar head and finally the scaphoid. A TFCC perforation was present in 46 % of the wrists. All but one were central perforations. The mean thickness of the triangular ligament was 0,51 mm (ranging from zero for the perforated ones to 1,82 mm). The mean ulnar variance was -0,37 mm ranging from - 3 to + 2. (20 wrists were ulnar negative, 18 neutral and 12 ulnar positive). This correlates with the average ulnar variance in a caucasian population. All these collected data were statistically analyzed in a search for correlations and I will only illustrate the most striking ones. W h e n we compared the ulnar variance with TFCC thickness and TFCC perforations we found significant correlations (p < 0,05). You see the graphical representation of the relation between TFCC thickness and UV (fig. 1). On the right you see an example of a central perforation of a triangular ligament. We also noted a very good correlation between age and UV as previously described by other authors including K. D'Hoore, Nakamura & Murata. As you can see on these slides the mean ulnar variance tends to become less negative with age. A significant relation between age and intrinsic ligament ruptures was also highlighted. When male and female wrists were compared the female tend to have significantly less perforations of the TFCC and they have as a whole, thicker TFCC's, Men on their side have a bigger scatter of the ulnar variance compared to women. To our surprise and contrarily with the litterature we could not establish a significant relation between cartilage lesions on the lunate and positive ulnar variance, we obtained borderline non-significant figures. However, in a extention of the study to 89 wrists for this specific item a statistically significant relation was established. I am grateful to Steve Viegas to have recently published his data on a large anatomical study in
MM 2 1.5 1 0.5
-2
- 1
0
1
+2
UV Fig. 1. - - Ulnar variance against triangular ligament thickness, Fig. 1. - - Variance cubitale en fonction de 1'4paisseur du ligament triangulaire. Fig. 1. - - Variacidn cubital en funci6n del espesor del cartflago triangular.
the american edition of the Journal of Hand Surgery. It allows me to compare our results since some figures are overlapping in both studies. While he centered his study on the midcarpal and radiocarpal joint, you will have noticed we only looked at the radiocarpal joint. The amount of ligament ruptures is fairly the same as well as the overall amount a cartilage wear except at the radial surface of the lunate where we found a much higher incidence of wear with 43 % compared to 2 1 % . Both studies also have in common the relation between age and intrinsic ligament ruptures. In order to be complete, I'd like to add he found a high incidence of cartilage attenuation on the proximal pole of the hamate, something previously not reported. So, in conclusion, let's summarize our results. The cartilage of the articular surface of the wrist is prone to degeneration. In our population the lunate had a high incidence of cartilage wear with 43 % of the wrists involved. Perforation of the TFCC was present in 46 % of the wrists and seems to be part of a process of degeneration. A clear relation was established between the ulnar variance and TFCC thickness and TFCC perforation and between ulnar variance and cartilage
ANN CHIR MAIN/ANN HAND SURG 1994, 13, N ° 5
CARTILAGINOUS AND LIGAMENTOUS DEGENERATION
wear on the radial surface of the lunate in an extension of the study. The relation between ulnar variance and age was confirmed as was the relation between age and incidence of intrinsic ligament ruptures. I can understand these dry and boring figures do not really appeal to you, but they have to be kept in mind when it comes to the interpretation of these
385
~>precise diagnostic data >>since we k n o w out of e x p e r i e n c e that most elderly people are asymptomatic and that lesions found in one wrist often are present on the controlateral side as nicely described by Herbert and by S. Viegas. So I think a clear correlation between clinical findings and anatomical lesions is mandatory before undertaking any further surgical steps.
REFERENCES 1. D ' H O O R E K., SMET L. (de), VRAL J., FABRY G. - - Ulnar variance and Kienbrck's disease. J Hand Surg (Am) (In press). 2. HERBERT T.J., FAITHFULL R.G., Mc CANN D.J., IRELAND J. - - Bilateral arthrography of the wrist. J Hand Surg, 1990, 15B, 233-235. 3. MIKIC Z. - - Age changes in the triangular fibrocartilage of the wrist joint. JAnat, 1987, I26, 367-378. 4. NAKAMURA R., TANAKA Y., IMAEDA T., MIURA T. - - The influence of age and sex on ulrlar variance. J Hand Surg, 1991, 16B, 84-88.
5. PALMER A., GLISSON R., WERNER F. - - Ulnar variance determination. J Hand Surg, 1982, 7A, 376-379. 6. PALMER A., GLISSON R., WERNER F. - - Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg, 1984, 9A, 681. 7. PALMER A., WERNER F. - - Biomechanies of the distal radioulnar joint. Clin Orthop, 1984, 187, 26-35. 8. VIEGAS S.F. - - Wrist anatomy : incidence distribution and correlation of anatomic variations, tears and arthrosis. J Hand Surg, 1993, 18A, 463-475.
F O R T E M S Y., S M E T L. (de), F A B R Y G. - - D r g r n r r e s c e n c e l i g a m e n t e u s e et cartilagineuse. Etude anatomique. (En Anglais). Ann Chir Main (Ann Hand S u r g ) , 1994, 13, n ° 5 , 3 8 3 - 3 8 6 .
F O R T E M S Y., S M E T L. (de), F A B R Y G. - - D e g e n e r a c i r n l i g a m e n t a r i a y cartilaginosa. Estudio a n a t r m i c o . Ann Chir Main (Ann Hand S u r g ) , 1994, 13, n ° 5 , 3 8 3 - 3 8 6 .
RI~SUMI~ • La prrcision croissante des techniques diagnostiques (IRM, arthrographie, arthroscopie) et l ' a u g m e n t a t i o n consdquente du diagnostic des 16sions cartilagineuses et ligamentaires du carpe nous a suggrr6 d'entreprendre une 6tude anatomique approfondie du carpe, et d'rtendre l'rtude ~t la r e c h e r c h e des relations entre ces 16sions et l'index radio-cubital. A cet effet 51 poignets cadavdriques ont 6t6 dissrqurs dans une population ~gre (~tge moyen 76 ans). Dans deux tiers des articulations radio-carpiennes du poignet nous avons trouv6 des 16sions cartilagineuses avec une nette prrdominence pour l'os semi-lunaire (43 %). Le cartilage triangulaire du complexe fibrocartilagin e u x ( T F C C ) 6tait p e r f o r 6 dans 23 p o i g n e t s (46 %). Nous avons pu 6tablir une corrrlation entre l'index radio-cubital et les perforations du TFCC (p < 0,05), ainsi que l'rpaisseur de cette structure (p < 0,05). La relation entre l'Sge et les ruptures des ligaments intrinsbques (p < 0,05), et l'index radio-cubital (p < 0,05) et l'fige a anssi ~t6 6tabli. Nous prdsentons nos chiffres, discutons les implications cliniques, et tirons les conclusions suivantes de cette 6tude. 1) Le carpe est une articulation complexe qui est sujette ~t une drgrn~rescence avec l'age. 2) Le grand nombre des 16sions cartilagineuses remarqu6 dans cette 6tude doit atre retenu dans le cadre de l'interprrtation des IRM et des rdsultats arthroscopiques ~>prrcis.
RESUMEN : La creciente precisi6n de las tdcnicas diagn6sticas (IRM, artrograffa, artroscopia) y el aumento consecuente del diagn6stico de lesiones cartilaginosas y ligamentarias del carpo nos sugiri6 la idea de efectuar un estudio anatdmico profundo del carpo, y de extender el estudio a la bfisqueda de las relaciones entre estas lesiones y el fndice radiocubital. Por esta raz6n 51 mufiecas de cadfiver fueron disecadas en una poblaci6n afiosa (promedio de edad 76 afios). En dos tercios de las articulaciones radiocarpianas de la mufieca hallamos lesiones cartilaginosas con una predominancia neta por el semilunar (43 %). El cartflago triangular del complejo fibrocartilaginoso (TFCC) se hallaba perforado en 23 mufiecas (46 %). Pudimos establecer una correlacirn entre el/ndice radio cubital y las perforaciones del TFCC (p < 0.05), a s / c o m o con el espesor de esta estructura (p < 0.05). La relacirn entre la edad y las rupturas de los ligamentos intrfnsecos (p < 0.05), y entre el fndice radio cubital (p < 0.05) y la edad tambirn fueron establecidas. Presentamos nuestras cifras, discutimos las implicaciones clinicas y obtenemos las conclusiones siguientes de este estudio. 1) E1 carpo es una articulacirn compleja sujeta a la degeneraci6n con el tiempo. 2) La gran cantidad de lesiones cartilaginosas observadas en este estudio debe tenerse en cuenta en el contexto de la interpretaci6n de un IRM y de los resultados artrosc6picos.
M O T S - C L t ~ S : L r s i o n s cartilagineuses. - - I n d e x radio-cubital. - - IRM. - - Arthroscopie.
PALABRAS CLAVE : Lesiones cartilaginosas. -- Indice radio-cubital. - - IRM. - - Artroscopia.
© Soci~t~d'Edition de l'Associationd'EnseignementM#dical des HOpitauxde Paris 1994
Cartilaginous and ligamentous degeneration of the wrist Anatomic study Y. FORTEMS, L. de SMET, G. FABRY SUMMARY : The growing precision of diagnostic techniques (MRI, arthrography, arthroscopy) and the consequent increase of the diagnosis of cartilaginous and ligamentous lesions of the wrist led us to undertake a detailed anatomical study of the carpus and to extend this study to the search for correlations between these lesions and the radio-ulnar index. Fifty one cadaveric wrists were dissected from an elderly population (mean age of 76 years). Cartilaginous lesions were found in two-thirds of radioulnar joints of the wrist with a marked predominance for the lunate bone (43 %). The triangular cartilage of the fibrocartilaginous complex (TFCC) was perforated in 23 wrists (46 %). We established a correlation between the radio-ulnar index and perforations of the TFCC (p < 0.05), as well as the thickness of this structure (p < 0.05). The relationship between age and rupture of intrinsic ligaments (p < 0,05), and the radio-ulnar index (p < 0.05) and age was also established. We present our figures, discuss the clinical implications, and draw the following conclusions from this study. 1) The carpus is a complex joint which is subject to age-related degeneration. 2) The large number of cartilaginous lesions observed in this study must be taken into account in the interpretation of MRI and the <
5,383-386.
: Cartilaginous lesions. - - R a d i o - u l n a r index. - - M R I . - - A r t h r o s c o p y .
Anatomy remains one of the cornerstones of surgery and this certainly applies for hand surgery. It is therefore a pleasure for me to present a work on cartilaginous and ligamentous degeneration of the human wrist. Due to the increased precision of diagnostic t e c h n i q u e s i n c l u d i n g arthrography, CT-scan, N M R ' s and of course wrist arthroscopies, hand surgeons face a problem since a large amount of observed lesions do not correlate with clinical findings. So, what is the significance of the observed lesions and what is the normal evolution of the wrist with age ? To answer these questions we decided to undertake an anatomical and radiological study in an elderly population. 51 wrists from 30 cadavers were studied. Before amputation the radius and ulna were transfixed with a screw, in the neutral position as described by Palmer thus allowing correct standardized measurements with the ring technique on the retrieved limbs. The wrist was incised through a
standard dorsal approach allowing good observation of the radiocarpal joint. The incidence of cartilage wear on scaphoid, lunate and triquetrum was noted and the integrity of the scapholunate and triquetrolunate ligament tested. Only if frank displacement of the corresponding bones could be elicited the ligament was recorded as ruptured. Before excision of the TFCC the integrity of the triangular ligament was recorded. This could be either intact or perforated centrally or at its periphery. The excised triangular ligament was measured at its thinnest point with a special biconvex micrometer. Finally the cartilage wear of the ulnar head and radial articular surface was recorded.
Dpt of Orthopaedic Surgery, University Hospital Pellenberg WeIigerveld 1, B-3212 PELLENBERG (Belgium). Manuscrit re~u ~ la R~daction le 16 f~vrier 1994. Accept(~ le 12 juillel 1994.
384
ANN CHIR MAIN/ANNHAND SURG 1994, 13, N ° 5
CARTILAGINOUS AND LIGAMENTOUS DEGENERATION
Centered X-rays were later taken to allow ulna variance measurements. You can appreciate the old age of the population. The mean age was 76,6 y (ranging from 58 to 94 y). Let's now have a look at the results. The scapholunate ligament was ruptured in 20 % of the wrists, the triquetrolunate in 30 %. Cartilaginous lesions in the radiocarpal joint were seen in 66 % of the wrists. The lunate showed the highest rate with 43,1%, followed by the triquetrum, radial articular surface, ulnar head and finally the scaphoid. A TFCC perforation was present in 46 % of the wrists. All but one were central perforations. The mean thickness of the triangular ligament was 0,51 mm (ranging from zero for the perforated ones to 1,82 mm). The mean ulnar variance was -0,37 mm ranging from - 3 to + 2. (20 wrists were ulnar negative, 18 neutral and 12 ulnar positive). This correlates with the average ulnar variance in a caucasian population. All these collected data were statistically analyzed in a search for correlations and I will only illustrate the most striking ones. W h e n we compared the ulnar variance with TFCC thickness and TFCC perforations we found significant correlations (p < 0,05). You see the graphical representation of the relation between TFCC thickness and UV (fig. 1). On the right you see an example of a central perforation of a triangular ligament. We also noted a very good correlation between age and UV as previously described by other authors including K. D'Hoore, Nakamura & Murata. As you can see on these slides the mean ulnar variance tends to become less negative with age. A significant relation between age and intrinsic ligament ruptures was also highlighted. When male and female wrists were compared the female tend to have significantly less perforations of the TFCC and they have as a whole, thicker TFCC's, Men on their side have a bigger scatter of the ulnar variance compared to women. To our surprise and contrarily with the litterature we could not establish a significant relation between cartilage lesions on the lunate and positive ulnar variance, we obtained borderline non-significant figures. However, in a extention of the study to 89 wrists for this specific item a statistically significant relation was established. I am grateful to Steve Viegas to have recently published his data on a large anatomical study in
MM 2 1.5 1 0.5
-2
- 1
0
1
+2
UV Fig. 1. - - Ulnar variance against triangular ligament thickness, Fig. 1. - - Variance cubitale en fonction de 1'4paisseur du ligament triangulaire. Fig. 1. - - Variacidn cubital en funci6n del espesor del cartflago triangular.
the american edition of the Journal of Hand Surgery. It allows me to compare our results since some figures are overlapping in both studies. While he centered his study on the midcarpal and radiocarpal joint, you will have noticed we only looked at the radiocarpal joint. The amount of ligament ruptures is fairly the same as well as the overall amount a cartilage wear except at the radial surface of the lunate where we found a much higher incidence of wear with 43 % compared to 2 1 % . Both studies also have in common the relation between age and intrinsic ligament ruptures. In order to be complete, I'd like to add he found a high incidence of cartilage attenuation on the proximal pole of the hamate, something previously not reported. So, in conclusion, let's summarize our results. The cartilage of the articular surface of the wrist is prone to degeneration. In our population the lunate had a high incidence of cartilage wear with 43 % of the wrists involved. Perforation of the TFCC was present in 46 % of the wrists and seems to be part of a process of degeneration. A clear relation was established between the ulnar variance and TFCC thickness and TFCC perforation and between ulnar variance and cartilage
ANN CHIR MAIN/ANN HAND SURG 1994, 13, N ° 5
CARTILAGINOUS AND LIGAMENTOUS DEGENERATION
wear on the radial surface of the lunate in an extension of the study. The relation between ulnar variance and age was confirmed as was the relation between age and incidence of intrinsic ligament ruptures. I can understand these dry and boring figures do not really appeal to you, but they have to be kept in mind when it comes to the interpretation of these
385
~
REFERENCES 1. D ' H O O R E K., SMET L. (de), VRAL J., FABRY G. - - Ulnar variance and Kienbrck's disease. J Hand Surg (Am) (In press). 2. HERBERT T.J., FAITHFULL R.G., Mc CANN D.J., IRELAND J. - - Bilateral arthrography of the wrist. J Hand Surg, 1990, 15B, 233-235. 3. MIKIC Z. - - Age changes in the triangular fibrocartilage of the wrist joint. JAnat, 1987, I26, 367-378. 4. NAKAMURA R., TANAKA Y., IMAEDA T., MIURA T. - - The influence of age and sex on ulrlar variance. J Hand Surg, 1991, 16B, 84-88.
5. PALMER A., GLISSON R., WERNER F. - - Ulnar variance determination. J Hand Surg, 1982, 7A, 376-379. 6. PALMER A., GLISSON R., WERNER F. - - Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg, 1984, 9A, 681. 7. PALMER A., WERNER F. - - Biomechanies of the distal radioulnar joint. Clin Orthop, 1984, 187, 26-35. 8. VIEGAS S.F. - - Wrist anatomy : incidence distribution and correlation of anatomic variations, tears and arthrosis. J Hand Surg, 1993, 18A, 463-475.
F O R T E M S Y., S M E T L. (de), F A B R Y G. - - D r g r n r r e s c e n c e l i g a m e n t e u s e et cartilagineuse. Etude anatomique. (En Anglais). Ann Chir Main (Ann Hand S u r g ) , 1994, 13, n ° 5 , 3 8 3 - 3 8 6 .
F O R T E M S Y., S M E T L. (de), F A B R Y G. - - D e g e n e r a c i r n l i g a m e n t a r i a y cartilaginosa. Estudio a n a t r m i c o . Ann Chir Main (Ann Hand S u r g ) , 1994, 13, n ° 5 , 3 8 3 - 3 8 6 .
RI~SUMI~ • La prrcision croissante des techniques diagnostiques (IRM, arthrographie, arthroscopie) et l ' a u g m e n t a t i o n consdquente du diagnostic des 16sions cartilagineuses et ligamentaires du carpe nous a suggrr6 d'entreprendre une 6tude anatomique approfondie du carpe, et d'rtendre l'rtude ~t la r e c h e r c h e des relations entre ces 16sions et l'index radio-cubital. A cet effet 51 poignets cadavdriques ont 6t6 dissrqurs dans une population ~gre (~tge moyen 76 ans). Dans deux tiers des articulations radio-carpiennes du poignet nous avons trouv6 des 16sions cartilagineuses avec une nette prrdominence pour l'os semi-lunaire (43 %). Le cartilage triangulaire du complexe fibrocartilagin e u x ( T F C C ) 6tait p e r f o r 6 dans 23 p o i g n e t s (46 %). Nous avons pu 6tablir une corrrlation entre l'index radio-cubital et les perforations du TFCC (p < 0,05), ainsi que l'rpaisseur de cette structure (p < 0,05). La relation entre l'Sge et les ruptures des ligaments intrinsbques (p < 0,05), et l'index radio-cubital (p < 0,05) et l'fige a anssi ~t6 6tabli. Nous prdsentons nos chiffres, discutons les implications cliniques, et tirons les conclusions suivantes de cette 6tude. 1) Le carpe est une articulation complexe qui est sujette ~t une drgrn~rescence avec l'age. 2) Le grand nombre des 16sions cartilagineuses remarqu6 dans cette 6tude doit atre retenu dans le cadre de l'interprrtation des IRM et des rdsultats arthroscopiques ~
RESUMEN : La creciente precisi6n de las tdcnicas diagn6sticas (IRM, artrograffa, artroscopia) y el aumento consecuente del diagn6stico de lesiones cartilaginosas y ligamentarias del carpo nos sugiri6 la idea de efectuar un estudio anatdmico profundo del carpo, y de extender el estudio a la bfisqueda de las relaciones entre estas lesiones y el fndice radiocubital. Por esta raz6n 51 mufiecas de cadfiver fueron disecadas en una poblaci6n afiosa (promedio de edad 76 afios). En dos tercios de las articulaciones radiocarpianas de la mufieca hallamos lesiones cartilaginosas con una predominancia neta por el semilunar (43 %). El cartflago triangular del complejo fibrocartilaginoso (TFCC) se hallaba perforado en 23 mufiecas (46 %). Pudimos establecer una correlacirn entre el/ndice radio cubital y las perforaciones del TFCC (p < 0.05), a s / c o m o con el espesor de esta estructura (p < 0.05). La relacirn entre la edad y las rupturas de los ligamentos intrfnsecos (p < 0.05), y entre el fndice radio cubital (p < 0.05) y la edad tambirn fueron establecidas. Presentamos nuestras cifras, discutimos las implicaciones clinicas y obtenemos las conclusiones siguientes de este estudio. 1) E1 carpo es una articulacirn compleja sujeta a la degeneraci6n con el tiempo. 2) La gran cantidad de lesiones cartilaginosas observadas en este estudio debe tenerse en cuenta en el contexto de la interpretaci6n de un IRM y de los resultados artrosc6picos.
M O T S - C L t ~ S : L r s i o n s cartilagineuses. - - I n d e x radio-cubital. - - IRM. - - Arthroscopie.
PALABRAS CLAVE : Lesiones cartilaginosas. -- Indice radio-cubital. - - IRM. - - Artroscopia.