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Management of chronic lunotriquetral ligament tears
Management of chronic lunotriquetral ligament tears Treatment of chronic disruptions of the lunotriquetral (LT) ligament is not well-defined. Eleven patients treated by LT fusion with use of a compression screw are reported. The hrjury frequently resulted from hyperextension of the wrist. Pain on the ulnar side of the wrist, limited motion, and tenderness over the LT joint exacerbated by ballottement were present. Standard radiographs were normal. Arthrography showed the ligamentous tear in all cases. After operation, bumobilixation was continued until fusion was apparent radiographically. Fusion was achieved in all cases between 2 and 5 months. Four patients were free of pain, four patients had pain only at the extremes of motion, and three patients had persistent pain. Mean wrist motion was as follows (preoperative/postoperative): flexion (53 degrees/45 degrees), extension (60 degrees/49 degrees), radial deviation (17 degrees/21 degrees), and ulnar deviation (25 degrees/l8 degrees). Maximum grip strength as a percentage of the uninjured side was 73% preoperatively and 59% postoperatively. LT tears can exist de novo or as part of the ulnar impaction syndrome; a method for differentiation is presented. (J HANDSURG1989;14A:77-83.)
Paul G. Pin, MD, V. Leroy Young, MD, Louis A. Gilula, MD, and Paul M. Weeks, MD, St. Louis, MO.
R
upture of the lunotriquetral interosseous ligament is one of many causes of ulnar-sided wrist pain. It may occur either as an isolated injury or as part of a complex injury. Treatment of isolated injuries has included immobilization, ligament repair,’ ligament reconstruction,** 3 cap&ate-hamate-lunate-triquetral fusion: and lunotriquetral fusion5 No single treatment has been uniformly successful. Reagan and colleagues’ reported a series of four patients with LT disruptions without static instability treated by lunotriquetral arthrodesis. One patient had a fair result and three had poor results. Nonunion was alluded to, but the incidence was not specified. The operative technique employed a peg bone graft from the iliac crest and Kirschner wire fixation. We report 11 patients with From the Division of Plastic and Reconstructive Surgery; and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO. Received for publication Feb. 3, 1988; accepted in revised form March 26, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Paul M. Weeks, MD, Division of Plastic and Reconstructive Surgery, Suite 17424, E. Pavilion, 4949 Barnes Hospital Plaza, St. Louis, MO 63110.
chronic complete lunotriquetral ligament rupture without static instability treated by LT arthrodesis by use of a compression screw. Materials
and methods
Seven men and four women, aged 24 to 6 1 years, were examined 3 to 12 months after a specific injury which resulted in persistent pain on the ulnar side of the wrist (Table I). Most frequently, the patient described sudden axial loading of the extended wrist, although two patients related twisting injuries, one while bowling and one while playing golf. All wrists had been continuously immobilized for at least 6 weeks without relief of symptoms. Examination of the wrist uniformly revealed no swelling but definite localized tenderness over the LT joint. The LT ballottement test consistently produced pain.’ Pronation and supination of the forearm without resistance did not produce pain. However, pronation and supination of the forearm against the stabilized hand produced a twisting motion of the wrist and resulted in pain over the lunotriquetral joint. Grip strength in the injured extremity was diminished when compared with the uninjured extremity, while wrist motion was maintained (Table II). Radiographic evaluation of each patient began with THE JOURNALOF
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77
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The Journal of HAND SURGERY
Pin et al.
Table I. Preoperative evaluation Patient
Age
Sex
1 2
51 19
F M
3 4 5
53 24 46
M F M
6 I 8 9
37 21 31 61
M M F M
10 11
34 71
F M
Mechanism
of injury
Lifting Fell on outstretched hand Struck on wrist Bowling Fell on outstretched hand Hyperextension Hyperextension Crush Fell on outstretched hand Hyperextension Golf
Arthrogram: LT LigamentlTFCC
Plain Jilm: Ulnar variance (mm)
Bone scan
0 +1.0
Tom I Tom* Tom/ Normal
Normal Increased over Triquetrum
0 0 - 1.0
Tom I Normal Tom/ Normal Tom I Normal
-2.0 +2.0 0 + 1.0
Tom/Normal Tom/Tom* Tom/ Normal Tom/Tom*
Increased over Lunate -
+1.0 -2.0
Tom/ Normal Tom I Normal
Normal -
-
*‘WCC tom at radial attachment.
Table II. Mean wrist motion and strength after lunotriquetral arthrodesis Preoperative Motion Flexion Flexion Radial deviation Ulnar deviation Strength Maximum grip strength (% of normal side)
53” 60” 17” 25” 73%
a routine four-view wrist survey that included posteroanterior, scaphoid, oblique, and lateral views.6*7Patient positioning was carefully controlled to allow a meaningful interpretation of ulnar variance.*-‘o Films were obtained with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and the wrist and hand flat. The films were normal in each case. Ulnar variance was + 2.0 mm in one patient, + 1.O mm in three patients, ulna neutral in four patients, - 1.O mm in one patient, and - 2.0 mm in two patients. The carpal instability series was normal in each patient. Specifically, there was no widening of the LT space, no overlapping of the lunate and the triquetrum, and the LT angles were normal. Volar intercalary segment instability (VISI) patterns were not demonstrable. Wrist arthrography of the radiocarpal and the distal radioulnar joints was done in each case and demonstrated tears of the LT ligament in all patients (Fig. 1). Three patients also had perforations on the radial side of the triangular librocartilage complex (TFCC) and these were associated with ulnar
Postoperative
45” 49” 21” 18” 59%
Net change
-8” - 11” f4” -1” - 14%
variances of 0, + 1.O, and + 2.0 mm. Bone scans were obtained in four patients; two were normal, one had slightly increased uptake over the lunate, and one had slightly increased uptake over the triquetrum. Because of persistent pain despite cast immobilization for at least 6 weeks, all patients had a compression screw arthrodesis of the LT joint. At operation, all patients had complete rupture of the LT ligament. The three patients with TFCC perforations also had debridement of the central portion of the TFCCs.” LT arthrodesis was recommended based on the observation that complete congenital coalitions are asymptomatic and allow normal wrist motion.“. I3 Operative technique With the patient under axillary block and tourniquet ischemia, a dorsal semicircular incision is made beginning just distal to the lateral prominence of the triquetrum and extended proximally and medially to the midline along the radiocarpal joint. The sensory branch of
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Chronic lunotriquetral ligament tears
79
Fii. 1. Radiocarpal joint arthrogram demonstrating the free flow of contrast through the lunotriquetral joint and into the midcarpal joint.
Fig. 2. Postoperative film after lunotriquetral arthrodesis with a compression screw. Bony fusion is evident.
the ulnar nerve is retracted and the sheath of the extensor carpi ulnaris is open over the triquetrum. The extensor digiti mimini tendon sheath is open distally and the tendon retracted. The ulnar collateral ligament is left intact. The radiocarpal and lunotriquetral joints are exposed through an inverted T-shaped incision. The extensor tendons in the fourth compartment are retracted. A stab wound is made in the extensor carpi ulnaris (ECU) tendon sheath where it attaches to the triquetrum. With the ECU tendon retracted, a Kirschner wire is driven through the triquetrum and into the lunate. Direct observation of tbe articular surfaces of the lunate and triquetrum in the radiocarpal and midcarpal joints and insertion of the Kirschner wire before removing any articular surfaces ensures proper bony alignment. Chisels are used to remove the opposing articular surfaces of the lunate and triquetrum. The drill hole length is determined with a depth gauge and tapped for a 4.0 mm cortical screw. The drill hole in the triquetrum is enlarged so that the screw threads will not
grasp the triquetrum, thus preventing compression. If deemed necessary to maintain external carpal dimensions, cancellous bone from the distal radius may be packed between the lunate and triquetrum before the cortical screw is inserted and tightened. The cortical screws used in our series varied from 24 to 30 mm in length. The ECU tendon sheath is closed over the head of the screw. The dorsal capsule is repaired and a splint applied to support the wrist. In 3 to 5 days the splint is discarded, and a short arm cast applied until there is radiographic evidence of bony union. Results
Follow-up was obtained in all patients, ranging from 8 to 26 months, with a mean of 12.7 months (Table III). Fusions were obtained in all patients between 2 and 5 months, with a mean of 3 months (Fig. 2). Four patients were completely free of pain, four had pain only at the extremes of motion, and three patients had significant, persistent pain when last seen. The
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The Journal of HAND SURGERY
Pin et al.
Table III. Postoperative Patient
evaluation
Follow-up 04
Time to fusion (mo)
Return to work (mol
Pain
W.C.*
1
26
3
No
Persistent pain
*
2 3
12 14
2 2
2 2
Pain free Pain free
*
4 5 6 I 8 9
8 14 8 15 11 7
2 3 3 4 3 3
2 3 No 6 6 4
Pain free Pain only Persistent Persistent Pain only Pain only
10 11
26 12
5 2
5 4
at extremes pain pain at extremes at extremes
* * * * *
Pain only at extremes Pain free
* Worhan’s Compensation.
eight patients with significant pain relief returned to their preoperative vocation in a mean of 4 months. Postoperative analysis of wrist motion revealed only minimal changes in most cases (Table II). Mean grip strength was decreased preoperatively and showed further loss postoperatively when compared with the uninjured extremity. Screw removal was performed with the patient under axillary block anesthesia in four patients because of local irritation.
Discussion The many causes of pain on the ulnar side of the wrist make evaluation and treatment difficult.‘4a ” The differential diagnosis includes soft tissue disorders, such as calcific tendonitis, and extensor carpi ulnaris subluxation, and bone-based diagnoses, such as carpal bone and radius fractures. Joint-based entities constitute the largest group and include: distal radioulnar joint subluxation/dislocation, distal radioulnar joint arthritis, TFCC tears, and ligament injuries. I6 Further diagnostic problems arise because each disorder may occur separately or may be coincident with another entity. TFCC tears may be degenerative or traumatic in origin, occur alone, with other ligamentous injuries, or as part of the ulnar impingement syndrome (UIS).” Similarly, LT ligament disruptions may occur alone, with other ligamentous injuries, or as part of the ulnar impingement syndrome. The mechanism of LT ligament injury is thought to be variable.” By use of Mayfield’s model of progressive perilunate instability, where a predictable sequence of ligamentous injuries occur when the wrist is loaded in extension, supination and ulnar deviation, Lichtman et al. “3 ‘O has suggested that these injuries represent a forme fruste of stage III perilunate instability where
the radial-sided injury is not apparent. Conversely, Reagan and associates’ suggested LT ligament injuries can result from “reverse” perilunate instability when the destructive forces cause wrist extension, radial deviation and intercarpal pronation, so that ulnar-sided injury precedes the radial-sided injury. Finally, LT ligament injury may occur in association with ulnar impingement, as delineated by Palmer et al.2’-23The radius bears the majority of any axial load placed on the wrist. With progressive lengthening of the ulnar relative to the radius (positive ulnar variance), an increased amount of axial loading is borne by the ulna.24 Such excessive loading can result in ulnar-sided pain and tears of the TFCC with failure of the LT ligament. Positive ulnar variance can be congenital or acquired, as after malunion of a Colles’ fracture. A dilemma arises when trying to decide if a tom LT ligament is an isolated injury or is part of the ulnar impingement syndrome. This distinction is essential as isolated ligament injuries can be treated by joint stabilization, and UIS requires reduction of ulnar loading (e.g., ulnar shortening), in addition to LT joint stabilization.25*28 The patients in our series with persistent pain underscore the importance of this distinction. Patients 1 and 7 had coexistent tears in their TFCC and an ulnar variance of 0.0 and + 2.0, respectively. These factors suggest that their LT injuries may have been associated with an UIS and their treatments might have been more successful had ulnar shortening been included. It is unclear why patient 6 (ulna variance of -2.0) had a poor result. Of interest, all patients with poor results had sustained work-related injuries. Ulnar impaction syndrome is caused by excessive ulnar axial loading. The ulna variance may be either neutral or positive. An acute increase in loading can
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Chronic lunotriquetral ligament tears
81
Fig. 4. Radiocarpaljoint arthrogram in a patient with UIS, showing disruption of the lunouiquetral ligament and perforation of the TFKX. Fig. 3. Film demonstrating5.Omm of positive ulnar variance after a malunion of a distal radius fracture.
occur after malunion of a distal radius fracture. Without fracture, chronic loading by job demands can cause the development of ulna-sided pain, eventual TFCC tear, and either osteochondral injury to the lunate and ulna or tear of the lunotriquetral ligament. Injury in those with an anatomic predisposition and subsequent chronic loading can also lead to the development of UIS. Thus a spectrum of UIS exists beginning with symptoms of ulnar-sided pain, with or without ligamentous tear, and progressing to the full-blown syndrome with ligamentous tear and/or osteochondral injury to the lunate and/ or triquetrum. Differentiation of UIS from isolated LT ligament tear is facilitated by the following observations. Ulnar variance. For comparison of patients and treatments, standard radiographic positioning of patients is required. However, the variance determined in this position may not be the variance the patient is subjected to when performing tasks that produce symptoms. Motions that require marked pronation (e.g., removing a bolt with a wrench) would functionally in-
crease ulnar variance, possibly producing UIS.9 Thus, pronation and supination views of the wrist with the elbow at the side and flexed 90 degrees should be obtained in addition to the standard views with the shoulder abducted 90 degrees. In UIS, ulna variance may be neutral or positive (Fig. 3). In isolated LT ligament disruption, ulna variance may be negative, neutral or positive. Onset of symptoms. UIS is a chronic condition usually associated with minor, repetitive trauma. It may follow a fracture of the radius producing increased loading of the ulna. In our cases, LT ligament disruption was always associated with a well-defined injury with pain persisting after the injury. Arthrographic abnormalities. In UIS, tear of the TFCC usually precedes LT ligament failure (Fig. 4). The palmar extrinsic ligaments are not injured in UIS and therefore, static carpal instability is rare. With LT ligament disruption, the TFCC may be tom, perforated, or intact. All TFCC abnormalities must be evaluated critically, in view of the high prevalence of asymptomatic TFCC perforations.” Static instability patterns did not occur in our series, but might be expected in patients with more extensive ligamentous damage.
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The Journal of HAND SURGERY
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than 3 months old, and usually respond to 6 weeks of cast immobilization. ‘*5 Conservative treatment of acute injuries is unwarranted if static instability is present radiographically and irreducible. In these cases, open reduction and direct ligamentous repair, if possible, is preferred.5 When repair is technically unfeasible, arthrodesis is indicated. Chronic LT ligament lesions respond to immobilization so infrequently that it is no longer considered a treatment option. ‘3’ Ligament repair is even more difficult than in the acute situation and is seldom an alternative. Ligament reconstruction has not proven to be a durable procedure and has been abandoned in our practice.2* 3 LT arthrodesis is now the treatment of choice for chronic complete LT ligament injuries. Although arthrodesis can be accomplished by many techniques, compression screw arthrodesis is straightforward and provides rigid internal fixation. Eight of 11 patients obtained satisfactory results after this procedure. There were no nonunions in our series. By use of the diagnostic criteria described above, future results seem likely to improve as patients with isolated LT injuries are distinguished from those with UIS. REFERENCES Fig. 5. Bone scintigraphy in a patient with UIS of the right wrist, demonstrating increased activity over the lunate, triquetrum, and distal ulna.
Bone scintigraphy. In UIS, chondromalacia of the distal ulna and proximal lunate occurs and is manifest by localized increased uptake of technetiumg9 (Fig. 5). A normal bone scan makes the diagnosis of UIS less tenable, but does not exclude the diagnosis. In LT ligament disruptions, recent tears are associated with focal uptake of technetium* over the lunate and triquetrum. Older tears may not demonstrate increased uptake at the site of tear. Even with these guidelines, the differentiation of UIS and isolated LT ligament tear can be difficult. LT ligament injuries or sprains are commonly divided into tears or dissociations based on whether or not static carpal instability is present radiographically. Static instability is associated with more severe ligamentous injuries. Although this is helpful, it does not address the primary issue, which is how symptomatic the patient is from the instability. Even so, all symptomatic instability needs to be treated regardless of the difficulty in demonstrating them radiographically. LT ligament injuries are classified as acute if less
1. Palmer AK, Dobyns JH, Linscheid RL. Management of post-traumatic instability of the wrist secondary to ligament rupture. J HANDSURG 1978;3:507-32. 2. Glickel SZ, Millender L. Ligamentous reconstruction for chronic intercarpal instability. J HAND SURG 1984;9A: 514-27. 3. Goldner JL. Treatment of carpal instability without joint fusion: current assessment. J HANDSURG 1982;7:325-6. 4. Watson HK, Goodman ML, Johnson TR. Limited wrist arthrodesis: II. intercarpal and radiocarpal combinations. J HANDSURG 1981;6:223-33. 5. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J HANDSURG 1984;9:502-14. 6. Gilula LA, Weeks PM. Post-traumatic ligamentous instability of the wrist. Radiology 1978;129:641-51. 7. Gilula LA, Destout JM, Weeks PM, et al. Roentgenographic diagnosis of the painful wrist. Clin Orthop 1984;187:52-64. 8. Palmer AK, Glisson RR, Werner PW. Ulnar variance determination. J HANDSURG 1982;7:376-9. 9. Epner RA, Bowers WH, Guilford WB. Ulnar variance: the effect of wrist positioning and roentgen filming technique. J HANDSURG 1982;7:298-305. 10. Hardy DC, Totty WG, Reinus WR, Gilula LA. Posteroanterior wrist radiography: importance of arm positioning. J HANDSURG 1987;12A:504-8. 11. Menon J, Wood VE, Schoene HR. et al. Isolated tears of triangular fibrocartilage of wrist: results of partial excision. J HANDSURG 1984;9A:527-30.
Vol. 14A, No. 1 January 1989
12. O’Rahilly R. A survey of carpal and tarsal anomalies. J Bone Joint Surg 1953;35A:626-42. 13. Simmons BP, McKenzie WD. Symptomatic carpal coalition. J HANDSURG 1985;10A:190-3. 14. Taleisnik J. Post-traumatic carpal instability. Clin Orthop 1980;149:73-85. 15. Bowers WH. Problems of the distal radioulnar joint. Adv Orthop Surg 1984;1:289-97. 16. Palmer AK, Werner PW. The triangular fibrocartilage complex of the wrist: anatomy and function. J HAND SURG 1981;6:153-62. 17. Milch H. Treatment of disabilities following fracture of the lower end of the radius. Clin Orthop 1963;29:15763. 18. Mayfield JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin North Am 1984;15:209-16. 19. Lichtman DM, Noble III WI-I, Alexander CE. Dynamic triquetrolunate instability: case report. J HAND SURG 1984;9A:185-8. 20. Lichtman DM, Schneider JR, Swafford AR, et al. Ulnar midcatpal instability-clinical and laboratory analysis. J HANDSURG 1981;6:515-23.
Chronic lunotriquetral ligament tears
21. Palmer AK. The distal radioulnar joint. Orthop Clin North Am 1984;15:321-35. 22. Palmer AK, Werner PW. Biomechanics of the distal radiouhuu joint. Clin Orthop 1984;187:26-35. 23. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J HANDSURG 1984;9A:681-3. 24. Werner FW, Palmer AK, Glisson RR. Forum load transmission: the effect of ulnar lengthening and shortening. Transactions of the twenty-eighth annual meeting of the Orthopedic Research Society. New Orleans: 1982:273. 25. Milch H. Cuff resection of the ulna for malunited Colles’ fracture. J Bone Joint Surg 1941;23:31 l-3. 26. Linscheid RL. Ulnar recession for disorders of the distal radioulnar joint. Orthop Tram 1982;6:475-80. 27. Darrow JC, Linscheid RL, Dobyns JH, et al. Recession of the distal ulna for ulnocarpal impingement syndrome. J HAND SURG 1984;91\:602. 28. Darrow JC, Linscheid RL, Dobyns JH, et al. Distal ulnar recession for disorders of the distal radioulnar joint. J HANDSURG 1985;10A:482-91. 29. Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint. J Anat 1978;126:367-83.
Replacement of the trapeziometacarpal joint with a cemented (Caffinike) prosthesis Between 1978 and 1985, 31 Cafiiniere prostheses were implanted in the iIrst carpometacarpai joints of 28 patients for treatment of degenerative osteoarthritis (26 patients) or rheumatoid arthritis (2 patients). At follow-up an average of 48 (13 to 77) months after operation, four hands had reoperation, with the replacement of six components, five cups and one metacarpal component. In addition, there were x-ray signs of component loosening in three other cases. Of the 29 thumbs that could be evaluated with regard to pain, 27 had no pain at ail or only slight pain, and two patients had moderate pain. No patient suffered from severely disabling pain. Mobility and strength were satisfactory. (J HAND SURC 1989;14A:83-9.)
Michel E. H. Boeckstyns, MD, A. Sinding, MD, Klaus T. Elholm, MD, and Kurt Rechnagel, MD, HilZer@d, Denmark
From the Department of Orthopaedic Surgery, the county of Frederiksborg Hospital in Hiller0d, Denmark. Received for publication Dec. 8, 1986; accepted in revised form kb. 9, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indiitly to the subject of this article. Reprint requests: Adam Sinding, Kohavevej 34 B, DK 2950 Hilled, Demnark.
I
n 1973 Caffini&re presented preliminary results after arthroplasty of the trapeziometacarpal joint using a cemented prosthesis of his design.’ Subsequently the same author reported intermediate and longterm result~.~~ 3 Other authors have published series treated by the Caffini&res method.4*5 Still others have reported results using similar devices.‘* ’ The time of observation in these studies was, however, rather short. THE JOURNAL OF HANDSURGERY
83
Paul G. Pin, MD, V. Leroy Young, MD, Louis A. Gilula, MD, and Paul M. Weeks, MD, St. Louis, MO.
R
upture of the lunotriquetral interosseous ligament is one of many causes of ulnar-sided wrist pain. It may occur either as an isolated injury or as part of a complex injury. Treatment of isolated injuries has included immobilization, ligament repair,’ ligament reconstruction,** 3 cap&ate-hamate-lunate-triquetral fusion: and lunotriquetral fusion5 No single treatment has been uniformly successful. Reagan and colleagues’ reported a series of four patients with LT disruptions without static instability treated by lunotriquetral arthrodesis. One patient had a fair result and three had poor results. Nonunion was alluded to, but the incidence was not specified. The operative technique employed a peg bone graft from the iliac crest and Kirschner wire fixation. We report 11 patients with From the Division of Plastic and Reconstructive Surgery; and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO. Received for publication Feb. 3, 1988; accepted in revised form March 26, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Paul M. Weeks, MD, Division of Plastic and Reconstructive Surgery, Suite 17424, E. Pavilion, 4949 Barnes Hospital Plaza, St. Louis, MO 63110.
chronic complete lunotriquetral ligament rupture without static instability treated by LT arthrodesis by use of a compression screw. Materials
and methods
Seven men and four women, aged 24 to 6 1 years, were examined 3 to 12 months after a specific injury which resulted in persistent pain on the ulnar side of the wrist (Table I). Most frequently, the patient described sudden axial loading of the extended wrist, although two patients related twisting injuries, one while bowling and one while playing golf. All wrists had been continuously immobilized for at least 6 weeks without relief of symptoms. Examination of the wrist uniformly revealed no swelling but definite localized tenderness over the LT joint. The LT ballottement test consistently produced pain.’ Pronation and supination of the forearm without resistance did not produce pain. However, pronation and supination of the forearm against the stabilized hand produced a twisting motion of the wrist and resulted in pain over the lunotriquetral joint. Grip strength in the injured extremity was diminished when compared with the uninjured extremity, while wrist motion was maintained (Table II). Radiographic evaluation of each patient began with THE JOURNALOF
HAND SURGERY
77
78
The Journal of HAND SURGERY
Pin et al.
Table I. Preoperative evaluation Patient
Age
Sex
1 2
51 19
F M
3 4 5
53 24 46
M F M
6 I 8 9
37 21 31 61
M M F M
10 11
34 71
F M
Mechanism
of injury
Lifting Fell on outstretched hand Struck on wrist Bowling Fell on outstretched hand Hyperextension Hyperextension Crush Fell on outstretched hand Hyperextension Golf
Arthrogram: LT LigamentlTFCC
Plain Jilm: Ulnar variance (mm)
Bone scan
0 +1.0
Tom I Tom* Tom/ Normal
Normal Increased over Triquetrum
0 0 - 1.0
Tom I Normal Tom/ Normal Tom I Normal
-2.0 +2.0 0 + 1.0
Tom/Normal Tom/Tom* Tom/ Normal Tom/Tom*
Increased over Lunate -
+1.0 -2.0
Tom/ Normal Tom I Normal
Normal -
-
*‘WCC tom at radial attachment.
Table II. Mean wrist motion and strength after lunotriquetral arthrodesis Preoperative Motion Flexion Flexion Radial deviation Ulnar deviation Strength Maximum grip strength (% of normal side)
53” 60” 17” 25” 73%
a routine four-view wrist survey that included posteroanterior, scaphoid, oblique, and lateral views.6*7Patient positioning was carefully controlled to allow a meaningful interpretation of ulnar variance.*-‘o Films were obtained with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and the wrist and hand flat. The films were normal in each case. Ulnar variance was + 2.0 mm in one patient, + 1.O mm in three patients, ulna neutral in four patients, - 1.O mm in one patient, and - 2.0 mm in two patients. The carpal instability series was normal in each patient. Specifically, there was no widening of the LT space, no overlapping of the lunate and the triquetrum, and the LT angles were normal. Volar intercalary segment instability (VISI) patterns were not demonstrable. Wrist arthrography of the radiocarpal and the distal radioulnar joints was done in each case and demonstrated tears of the LT ligament in all patients (Fig. 1). Three patients also had perforations on the radial side of the triangular librocartilage complex (TFCC) and these were associated with ulnar
Postoperative
45” 49” 21” 18” 59%
Net change
-8” - 11” f4” -1” - 14%
variances of 0, + 1.O, and + 2.0 mm. Bone scans were obtained in four patients; two were normal, one had slightly increased uptake over the lunate, and one had slightly increased uptake over the triquetrum. Because of persistent pain despite cast immobilization for at least 6 weeks, all patients had a compression screw arthrodesis of the LT joint. At operation, all patients had complete rupture of the LT ligament. The three patients with TFCC perforations also had debridement of the central portion of the TFCCs.” LT arthrodesis was recommended based on the observation that complete congenital coalitions are asymptomatic and allow normal wrist motion.“. I3 Operative technique With the patient under axillary block and tourniquet ischemia, a dorsal semicircular incision is made beginning just distal to the lateral prominence of the triquetrum and extended proximally and medially to the midline along the radiocarpal joint. The sensory branch of
Vol. WA, No. 1 January 1989
Chronic lunotriquetral ligament tears
79
Fii. 1. Radiocarpal joint arthrogram demonstrating the free flow of contrast through the lunotriquetral joint and into the midcarpal joint.
Fig. 2. Postoperative film after lunotriquetral arthrodesis with a compression screw. Bony fusion is evident.
the ulnar nerve is retracted and the sheath of the extensor carpi ulnaris is open over the triquetrum. The extensor digiti mimini tendon sheath is open distally and the tendon retracted. The ulnar collateral ligament is left intact. The radiocarpal and lunotriquetral joints are exposed through an inverted T-shaped incision. The extensor tendons in the fourth compartment are retracted. A stab wound is made in the extensor carpi ulnaris (ECU) tendon sheath where it attaches to the triquetrum. With the ECU tendon retracted, a Kirschner wire is driven through the triquetrum and into the lunate. Direct observation of tbe articular surfaces of the lunate and triquetrum in the radiocarpal and midcarpal joints and insertion of the Kirschner wire before removing any articular surfaces ensures proper bony alignment. Chisels are used to remove the opposing articular surfaces of the lunate and triquetrum. The drill hole length is determined with a depth gauge and tapped for a 4.0 mm cortical screw. The drill hole in the triquetrum is enlarged so that the screw threads will not
grasp the triquetrum, thus preventing compression. If deemed necessary to maintain external carpal dimensions, cancellous bone from the distal radius may be packed between the lunate and triquetrum before the cortical screw is inserted and tightened. The cortical screws used in our series varied from 24 to 30 mm in length. The ECU tendon sheath is closed over the head of the screw. The dorsal capsule is repaired and a splint applied to support the wrist. In 3 to 5 days the splint is discarded, and a short arm cast applied until there is radiographic evidence of bony union. Results
Follow-up was obtained in all patients, ranging from 8 to 26 months, with a mean of 12.7 months (Table III). Fusions were obtained in all patients between 2 and 5 months, with a mean of 3 months (Fig. 2). Four patients were completely free of pain, four had pain only at the extremes of motion, and three patients had significant, persistent pain when last seen. The
80
The Journal of HAND SURGERY
Pin et al.
Table III. Postoperative Patient
evaluation
Follow-up 04
Time to fusion (mo)
Return to work (mol
Pain
W.C.*
1
26
3
No
Persistent pain
*
2 3
12 14
2 2
2 2
Pain free Pain free
*
4 5 6 I 8 9
8 14 8 15 11 7
2 3 3 4 3 3
2 3 No 6 6 4
Pain free Pain only Persistent Persistent Pain only Pain only
10 11
26 12
5 2
5 4
at extremes pain pain at extremes at extremes
* * * * *
Pain only at extremes Pain free
* Worhan’s Compensation.
eight patients with significant pain relief returned to their preoperative vocation in a mean of 4 months. Postoperative analysis of wrist motion revealed only minimal changes in most cases (Table II). Mean grip strength was decreased preoperatively and showed further loss postoperatively when compared with the uninjured extremity. Screw removal was performed with the patient under axillary block anesthesia in four patients because of local irritation.
Discussion The many causes of pain on the ulnar side of the wrist make evaluation and treatment difficult.‘4a ” The differential diagnosis includes soft tissue disorders, such as calcific tendonitis, and extensor carpi ulnaris subluxation, and bone-based diagnoses, such as carpal bone and radius fractures. Joint-based entities constitute the largest group and include: distal radioulnar joint subluxation/dislocation, distal radioulnar joint arthritis, TFCC tears, and ligament injuries. I6 Further diagnostic problems arise because each disorder may occur separately or may be coincident with another entity. TFCC tears may be degenerative or traumatic in origin, occur alone, with other ligamentous injuries, or as part of the ulnar impingement syndrome (UIS).” Similarly, LT ligament disruptions may occur alone, with other ligamentous injuries, or as part of the ulnar impingement syndrome. The mechanism of LT ligament injury is thought to be variable.” By use of Mayfield’s model of progressive perilunate instability, where a predictable sequence of ligamentous injuries occur when the wrist is loaded in extension, supination and ulnar deviation, Lichtman et al. “3 ‘O has suggested that these injuries represent a forme fruste of stage III perilunate instability where
the radial-sided injury is not apparent. Conversely, Reagan and associates’ suggested LT ligament injuries can result from “reverse” perilunate instability when the destructive forces cause wrist extension, radial deviation and intercarpal pronation, so that ulnar-sided injury precedes the radial-sided injury. Finally, LT ligament injury may occur in association with ulnar impingement, as delineated by Palmer et al.2’-23The radius bears the majority of any axial load placed on the wrist. With progressive lengthening of the ulnar relative to the radius (positive ulnar variance), an increased amount of axial loading is borne by the ulna.24 Such excessive loading can result in ulnar-sided pain and tears of the TFCC with failure of the LT ligament. Positive ulnar variance can be congenital or acquired, as after malunion of a Colles’ fracture. A dilemma arises when trying to decide if a tom LT ligament is an isolated injury or is part of the ulnar impingement syndrome. This distinction is essential as isolated ligament injuries can be treated by joint stabilization, and UIS requires reduction of ulnar loading (e.g., ulnar shortening), in addition to LT joint stabilization.25*28 The patients in our series with persistent pain underscore the importance of this distinction. Patients 1 and 7 had coexistent tears in their TFCC and an ulnar variance of 0.0 and + 2.0, respectively. These factors suggest that their LT injuries may have been associated with an UIS and their treatments might have been more successful had ulnar shortening been included. It is unclear why patient 6 (ulna variance of -2.0) had a poor result. Of interest, all patients with poor results had sustained work-related injuries. Ulnar impaction syndrome is caused by excessive ulnar axial loading. The ulna variance may be either neutral or positive. An acute increase in loading can
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Fig. 4. Radiocarpaljoint arthrogram in a patient with UIS, showing disruption of the lunouiquetral ligament and perforation of the TFKX. Fig. 3. Film demonstrating5.Omm of positive ulnar variance after a malunion of a distal radius fracture.
occur after malunion of a distal radius fracture. Without fracture, chronic loading by job demands can cause the development of ulna-sided pain, eventual TFCC tear, and either osteochondral injury to the lunate and ulna or tear of the lunotriquetral ligament. Injury in those with an anatomic predisposition and subsequent chronic loading can also lead to the development of UIS. Thus a spectrum of UIS exists beginning with symptoms of ulnar-sided pain, with or without ligamentous tear, and progressing to the full-blown syndrome with ligamentous tear and/or osteochondral injury to the lunate and/ or triquetrum. Differentiation of UIS from isolated LT ligament tear is facilitated by the following observations. Ulnar variance. For comparison of patients and treatments, standard radiographic positioning of patients is required. However, the variance determined in this position may not be the variance the patient is subjected to when performing tasks that produce symptoms. Motions that require marked pronation (e.g., removing a bolt with a wrench) would functionally in-
crease ulnar variance, possibly producing UIS.9 Thus, pronation and supination views of the wrist with the elbow at the side and flexed 90 degrees should be obtained in addition to the standard views with the shoulder abducted 90 degrees. In UIS, ulna variance may be neutral or positive (Fig. 3). In isolated LT ligament disruption, ulna variance may be negative, neutral or positive. Onset of symptoms. UIS is a chronic condition usually associated with minor, repetitive trauma. It may follow a fracture of the radius producing increased loading of the ulna. In our cases, LT ligament disruption was always associated with a well-defined injury with pain persisting after the injury. Arthrographic abnormalities. In UIS, tear of the TFCC usually precedes LT ligament failure (Fig. 4). The palmar extrinsic ligaments are not injured in UIS and therefore, static carpal instability is rare. With LT ligament disruption, the TFCC may be tom, perforated, or intact. All TFCC abnormalities must be evaluated critically, in view of the high prevalence of asymptomatic TFCC perforations.” Static instability patterns did not occur in our series, but might be expected in patients with more extensive ligamentous damage.
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than 3 months old, and usually respond to 6 weeks of cast immobilization. ‘*5 Conservative treatment of acute injuries is unwarranted if static instability is present radiographically and irreducible. In these cases, open reduction and direct ligamentous repair, if possible, is preferred.5 When repair is technically unfeasible, arthrodesis is indicated. Chronic LT ligament lesions respond to immobilization so infrequently that it is no longer considered a treatment option. ‘3’ Ligament repair is even more difficult than in the acute situation and is seldom an alternative. Ligament reconstruction has not proven to be a durable procedure and has been abandoned in our practice.2* 3 LT arthrodesis is now the treatment of choice for chronic complete LT ligament injuries. Although arthrodesis can be accomplished by many techniques, compression screw arthrodesis is straightforward and provides rigid internal fixation. Eight of 11 patients obtained satisfactory results after this procedure. There were no nonunions in our series. By use of the diagnostic criteria described above, future results seem likely to improve as patients with isolated LT injuries are distinguished from those with UIS. REFERENCES Fig. 5. Bone scintigraphy in a patient with UIS of the right wrist, demonstrating increased activity over the lunate, triquetrum, and distal ulna.
Bone scintigraphy. In UIS, chondromalacia of the distal ulna and proximal lunate occurs and is manifest by localized increased uptake of technetiumg9 (Fig. 5). A normal bone scan makes the diagnosis of UIS less tenable, but does not exclude the diagnosis. In LT ligament disruptions, recent tears are associated with focal uptake of technetium* over the lunate and triquetrum. Older tears may not demonstrate increased uptake at the site of tear. Even with these guidelines, the differentiation of UIS and isolated LT ligament tear can be difficult. LT ligament injuries or sprains are commonly divided into tears or dissociations based on whether or not static carpal instability is present radiographically. Static instability is associated with more severe ligamentous injuries. Although this is helpful, it does not address the primary issue, which is how symptomatic the patient is from the instability. Even so, all symptomatic instability needs to be treated regardless of the difficulty in demonstrating them radiographically. LT ligament injuries are classified as acute if less
1. Palmer AK, Dobyns JH, Linscheid RL. Management of post-traumatic instability of the wrist secondary to ligament rupture. J HANDSURG 1978;3:507-32. 2. Glickel SZ, Millender L. Ligamentous reconstruction for chronic intercarpal instability. J HAND SURG 1984;9A: 514-27. 3. Goldner JL. Treatment of carpal instability without joint fusion: current assessment. J HANDSURG 1982;7:325-6. 4. Watson HK, Goodman ML, Johnson TR. Limited wrist arthrodesis: II. intercarpal and radiocarpal combinations. J HANDSURG 1981;6:223-33. 5. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J HANDSURG 1984;9:502-14. 6. Gilula LA, Weeks PM. Post-traumatic ligamentous instability of the wrist. Radiology 1978;129:641-51. 7. Gilula LA, Destout JM, Weeks PM, et al. Roentgenographic diagnosis of the painful wrist. Clin Orthop 1984;187:52-64. 8. Palmer AK, Glisson RR, Werner PW. Ulnar variance determination. J HANDSURG 1982;7:376-9. 9. Epner RA, Bowers WH, Guilford WB. Ulnar variance: the effect of wrist positioning and roentgen filming technique. J HANDSURG 1982;7:298-305. 10. Hardy DC, Totty WG, Reinus WR, Gilula LA. Posteroanterior wrist radiography: importance of arm positioning. J HANDSURG 1987;12A:504-8. 11. Menon J, Wood VE, Schoene HR. et al. Isolated tears of triangular fibrocartilage of wrist: results of partial excision. J HANDSURG 1984;9A:527-30.
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12. O’Rahilly R. A survey of carpal and tarsal anomalies. J Bone Joint Surg 1953;35A:626-42. 13. Simmons BP, McKenzie WD. Symptomatic carpal coalition. J HANDSURG 1985;10A:190-3. 14. Taleisnik J. Post-traumatic carpal instability. Clin Orthop 1980;149:73-85. 15. Bowers WH. Problems of the distal radioulnar joint. Adv Orthop Surg 1984;1:289-97. 16. Palmer AK, Werner PW. The triangular fibrocartilage complex of the wrist: anatomy and function. J HAND SURG 1981;6:153-62. 17. Milch H. Treatment of disabilities following fracture of the lower end of the radius. Clin Orthop 1963;29:15763. 18. Mayfield JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin North Am 1984;15:209-16. 19. Lichtman DM, Noble III WI-I, Alexander CE. Dynamic triquetrolunate instability: case report. J HAND SURG 1984;9A:185-8. 20. Lichtman DM, Schneider JR, Swafford AR, et al. Ulnar midcatpal instability-clinical and laboratory analysis. J HANDSURG 1981;6:515-23.
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21. Palmer AK. The distal radioulnar joint. Orthop Clin North Am 1984;15:321-35. 22. Palmer AK, Werner PW. Biomechanics of the distal radiouhuu joint. Clin Orthop 1984;187:26-35. 23. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J HANDSURG 1984;9A:681-3. 24. Werner FW, Palmer AK, Glisson RR. Forum load transmission: the effect of ulnar lengthening and shortening. Transactions of the twenty-eighth annual meeting of the Orthopedic Research Society. New Orleans: 1982:273. 25. Milch H. Cuff resection of the ulna for malunited Colles’ fracture. J Bone Joint Surg 1941;23:31 l-3. 26. Linscheid RL. Ulnar recession for disorders of the distal radioulnar joint. Orthop Tram 1982;6:475-80. 27. Darrow JC, Linscheid RL, Dobyns JH, et al. Recession of the distal ulna for ulnocarpal impingement syndrome. J HAND SURG 1984;91\:602. 28. Darrow JC, Linscheid RL, Dobyns JH, et al. Distal ulnar recession for disorders of the distal radioulnar joint. J HANDSURG 1985;10A:482-91. 29. Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint. J Anat 1978;126:367-83.
Replacement of the trapeziometacarpal joint with a cemented (Caffinike) prosthesis Between 1978 and 1985, 31 Cafiiniere prostheses were implanted in the iIrst carpometacarpai joints of 28 patients for treatment of degenerative osteoarthritis (26 patients) or rheumatoid arthritis (2 patients). At follow-up an average of 48 (13 to 77) months after operation, four hands had reoperation, with the replacement of six components, five cups and one metacarpal component. In addition, there were x-ray signs of component loosening in three other cases. Of the 29 thumbs that could be evaluated with regard to pain, 27 had no pain at ail or only slight pain, and two patients had moderate pain. No patient suffered from severely disabling pain. Mobility and strength were satisfactory. (J HAND SURC 1989;14A:83-9.)
Michel E. H. Boeckstyns, MD, A. Sinding, MD, Klaus T. Elholm, MD, and Kurt Rechnagel, MD, HilZer@d, Denmark
From the Department of Orthopaedic Surgery, the county of Frederiksborg Hospital in Hiller0d, Denmark. Received for publication Dec. 8, 1986; accepted in revised form kb. 9, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indiitly to the subject of this article. Reprint requests: Adam Sinding, Kohavevej 34 B, DK 2950 Hilled, Demnark.
I
n 1973 Caffini&re presented preliminary results after arthroplasty of the trapeziometacarpal joint using a cemented prosthesis of his design.’ Subsequently the same author reported intermediate and longterm result~.~~ 3 Other authors have published series treated by the Caffini&res method.4*5 Still others have reported results using similar devices.‘* ’ The time of observation in these studies was, however, rather short. THE JOURNAL OF HANDSURGERY
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