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Wrist arthroscopy in diagnosing incomplete perilunar dislocations
SESSION 11
fracture or displacement grade did not affect the result. Anatomic reduction produced better results (P=0.015) and 14 patients out of 19 had normal X-rays at review: stable wrist without arthritis. Five films had some modifications: VISI (1), DISI (1), scaphoid delayed fusion (1), lunotriquetro-hamatocapitate arthrodesis (1). Late injuries - conservative treatment had anatomic reduction, good clinical results (score 95) and normal X-rays. Proximal carpectomies had fair results (average score 65) with a radio-capitate arthritis for one patient.
Discussion The injuries, treatments and results are analysed in literature. All authors now recommend surgical treatment to acheive a perfect reduction and prevent further displacement before healing. The precise surgical procedure is controversial, especially with regard to approach, fixation and ligament repair or plasty. Conclusion Reduction and control can be achieved by an exclusive posterior approach. Fixation of the scaphoid fracture is performed with small screw from proximal to distal. A second anterior approach may be necessary in case of difficulties, but carpal tunnel opening is not compulsory for acute median nerve injury. For late injuries, authors suggest conservative treatment before the third month and proximal carpectomy later on; but this must be adapted to each case according to injuries.
Wrist arthroscopy in diagnosing incomplete perilunar dislocations
35
Results Twenty-six of these 34 wrist arthroscopies showed lesions of carpal ligaments. Thirteen wrists had an isolated rupture of the scapho-lunate intercarpal ligament (stage 1 perilunar dislocation), 5 had an additional rupture of the radio-capitate ligament (stage 2), and 4 had ruptures of scapho-lunate, radiocapitate, and .luno-triquetral ligaments (stage 3). Four wrists had ligament'lesions other than perilunar type. Fourteen out of 22 patients with incomplete perilunar dislocations had additional cartilage or discus lesions; only 2 of these 14 wrists were suitable for direct scapho-lunate ligament repair. 10 limited intercarpal fusions were performed. Eight out of 22 patients had exclusively ligamentous lesions, and 6 of these had good stumps for ligamentous re-insertion. The scapho-lunate ligament was repaired through a dorsal approach in 5 patients, an additional repair of the radio-capitate ligament through a patmar approach was done in one patient. Conclusion Wrist arthroscopy gives reliable results for diagnosing incomplete perilunar dislocations and for planning adequate therapy. It establishes therapeutic concepts and comparable outcome evaluations.
Ligamentous tears associated with distal fractures of the radius. Fifty-four intraoperative arthroscopies M. Fischer, C. Denzler, G. Sennwald
Chirurgie St. Leonhard, Pestalozzistr 2, CH - 9000 St. Gallen, Switzerland
B. Bickert, J. Huber, G. G e r m a n n
Department of Burns, Hand and Plastic Surgery Berufsgenossenschaftlich Unfallklinik Ludwigshafen, Germany Problem Perilunar dislocations have been graded into 4 stages: 1. rupture of the scapho-lunate intercarpal ligament; 2. rupture of the radio-capitate ligament; 3. rupture of the luno-triquetral ligaments; and 4. palmar dislocation of the lunate. Stages 1 to 3 are incomplete perilunar dislocations, which can easily be missed in early post-traumatic clinical and X-ray examination, and, if untreated, often lead to carpal instability. Since late reconstructions have been unconvincing (tendon transfers) or lead to a significant reduction of wrist motion (limited carpal fusions), the best choice of treatment might be an early direct ligament repair. Can wrist arthroscopy provide reliable information needed for an eal'ly treatment of incomplete perilunar dislocations? Patients and methods From October 1993 to June 1995, all patients, who were referred to us following a recent wrist trauma, underwent a standardized clinical examination: palpation of the perilunar intercarpal joints for pain and instability, testing for a dorsal or palmar shift of the carpus, testing for a dorsal shift of the scaphoid by ulnar-to-radial deviation of the hand with pressure on the scaphoid tubercle (Watson's test), and provoking abnormal clunks. Thirty-four patients had signs of a carpal ligament lesion, and their wrists were arthroscopied. Wrist arthroscopies were routinely done through the ports 3/4 and midcarpal-radial, a palpation hook was inserted into port 4/5 or 6R.
Objective Intracarpal tigamentous tears and fracture of the distal radius may have a similar injury mechanism. We performed arthroscopy of the wrist in 54 patients with distal radius fracture to find out the frequency of associated ligamentous tears. Materials and methods" All patients had intraoperative arthroscopy including radiocarpal and midcarpal inspection of the wrist. The type of fracture was classified as extra-articular, intra-articular or complex intra-articular by a surgeon not involved in surgery. The ligaments were described as normal, superficially spread, partially or totally ruptured Results In only 3 patients were no ligamentous tears found. Forty-one patients with an extra-articular fracture of the distal radius had at least one severe ligamentous tear of a carpal ligament. In the group of patients with intra-articular fractures we detected ligamentous tears in 89°/'oof cases. Most frequent were tears of the luno-triquetral ligament. Multiple tears were detected in 70.4% of the patients as shown in the Table below. Classification
SL+LTmid+TFCC SL+LTmid SL+TFCC LTmid+TFCC
Extraarticular
Intraarticular
Multiple intra-articular
0 0 1 1
3 4 3 6
4 7 4 6
Total 7 10 8 13
fracture or displacement grade did not affect the result. Anatomic reduction produced better results (P=0.015) and 14 patients out of 19 had normal X-rays at review: stable wrist without arthritis. Five films had some modifications: VISI (1), DISI (1), scaphoid delayed fusion (1), lunotriquetro-hamatocapitate arthrodesis (1). Late injuries - conservative treatment had anatomic reduction, good clinical results (score 95) and normal X-rays. Proximal carpectomies had fair results (average score 65) with a radio-capitate arthritis for one patient.
Discussion The injuries, treatments and results are analysed in literature. All authors now recommend surgical treatment to acheive a perfect reduction and prevent further displacement before healing. The precise surgical procedure is controversial, especially with regard to approach, fixation and ligament repair or plasty. Conclusion Reduction and control can be achieved by an exclusive posterior approach. Fixation of the scaphoid fracture is performed with small screw from proximal to distal. A second anterior approach may be necessary in case of difficulties, but carpal tunnel opening is not compulsory for acute median nerve injury. For late injuries, authors suggest conservative treatment before the third month and proximal carpectomy later on; but this must be adapted to each case according to injuries.
Wrist arthroscopy in diagnosing incomplete perilunar dislocations
35
Results Twenty-six of these 34 wrist arthroscopies showed lesions of carpal ligaments. Thirteen wrists had an isolated rupture of the scapho-lunate intercarpal ligament (stage 1 perilunar dislocation), 5 had an additional rupture of the radio-capitate ligament (stage 2), and 4 had ruptures of scapho-lunate, radiocapitate, and .luno-triquetral ligaments (stage 3). Four wrists had ligament'lesions other than perilunar type. Fourteen out of 22 patients with incomplete perilunar dislocations had additional cartilage or discus lesions; only 2 of these 14 wrists were suitable for direct scapho-lunate ligament repair. 10 limited intercarpal fusions were performed. Eight out of 22 patients had exclusively ligamentous lesions, and 6 of these had good stumps for ligamentous re-insertion. The scapho-lunate ligament was repaired through a dorsal approach in 5 patients, an additional repair of the radio-capitate ligament through a patmar approach was done in one patient. Conclusion Wrist arthroscopy gives reliable results for diagnosing incomplete perilunar dislocations and for planning adequate therapy. It establishes therapeutic concepts and comparable outcome evaluations.
Ligamentous tears associated with distal fractures of the radius. Fifty-four intraoperative arthroscopies M. Fischer, C. Denzler, G. Sennwald
Chirurgie St. Leonhard, Pestalozzistr 2, CH - 9000 St. Gallen, Switzerland
B. Bickert, J. Huber, G. G e r m a n n
Department of Burns, Hand and Plastic Surgery Berufsgenossenschaftlich Unfallklinik Ludwigshafen, Germany Problem Perilunar dislocations have been graded into 4 stages: 1. rupture of the scapho-lunate intercarpal ligament; 2. rupture of the radio-capitate ligament; 3. rupture of the luno-triquetral ligaments; and 4. palmar dislocation of the lunate. Stages 1 to 3 are incomplete perilunar dislocations, which can easily be missed in early post-traumatic clinical and X-ray examination, and, if untreated, often lead to carpal instability. Since late reconstructions have been unconvincing (tendon transfers) or lead to a significant reduction of wrist motion (limited carpal fusions), the best choice of treatment might be an early direct ligament repair. Can wrist arthroscopy provide reliable information needed for an eal'ly treatment of incomplete perilunar dislocations? Patients and methods From October 1993 to June 1995, all patients, who were referred to us following a recent wrist trauma, underwent a standardized clinical examination: palpation of the perilunar intercarpal joints for pain and instability, testing for a dorsal or palmar shift of the carpus, testing for a dorsal shift of the scaphoid by ulnar-to-radial deviation of the hand with pressure on the scaphoid tubercle (Watson's test), and provoking abnormal clunks. Thirty-four patients had signs of a carpal ligament lesion, and their wrists were arthroscopied. Wrist arthroscopies were routinely done through the ports 3/4 and midcarpal-radial, a palpation hook was inserted into port 4/5 or 6R.
Objective Intracarpal tigamentous tears and fracture of the distal radius may have a similar injury mechanism. We performed arthroscopy of the wrist in 54 patients with distal radius fracture to find out the frequency of associated ligamentous tears. Materials and methods" All patients had intraoperative arthroscopy including radiocarpal and midcarpal inspection of the wrist. The type of fracture was classified as extra-articular, intra-articular or complex intra-articular by a surgeon not involved in surgery. The ligaments were described as normal, superficially spread, partially or totally ruptured Results In only 3 patients were no ligamentous tears found. Forty-one patients with an extra-articular fracture of the distal radius had at least one severe ligamentous tear of a carpal ligament. In the group of patients with intra-articular fractures we detected ligamentous tears in 89°/'oof cases. Most frequent were tears of the luno-triquetral ligament. Multiple tears were detected in 70.4% of the patients as shown in the Table below. Classification
SL+LTmid+TFCC SL+LTmid SL+TFCC LTmid+TFCC
Extraarticular
Intraarticular
Multiple intra-articular
0 0 1 1
3 4 3 6
4 7 4 6
Total 7 10 8 13