Addressing the Central Band in Acute and Chronic Essex-Lopresti Injury: A Case Report and Technique Description.

CASE: A 34-year-old man was acutely treated with radial head arthroplasty and central band repair following Essex-Lopresti injury. A 38-year-old man presented with chronic longitudinal instability following failed radial head arthroplasty, which was performed for failed fixation. Treatment with revision radial head arthroplasty and central band reconstruction restored longitudinal stability. CONCLUSION: We have a low threshold to repair the central band in acute Essex-Lopresti injury with sufficient evidence of disruption. Nearly all chronic cases require central band reconstruction to restore longitudinal stability. We do not temporarily pin the DRUJ, and distal ulnar shortening is rarely indicated.

Radiocarpal and midcarpal kinematics in scapholunate instability: a four-dimensional CT study in vivo.

The distribution of motion between the radiocarpal and midcarpal joints in scapholunate instability is poorly understood. This has potential implications in predicting degenerative changes and in selecting salvage procedures. We studied 19 healthy wrists and 19 wrists with scapholunate instability using dynamic computed tomography during wrist extension to flexion and ulnar to radial deviation. Radiocarpal and midcarpal kinematics of the scaphoid and the lunate were computed. In scapholunate instability, in the radial column, there was increased motion in the radiocarpal joint when the wrist was radially deviating beyond 10° or moving from 70° to 40° extension. In both groups, the capitolunate joint was the dominant articulation in the central column. In scapholunate instability, there was significantly more capitolunate motion during 70° to 30° extension. These changes may predict the development of radioscaphoid arthritis and enable identifying a kinematically abnormal wrist. The motion distribution in scapholunate instability was abnormal beyond 10° of radial deviation and between 70° and 40° of wrist extension.Level of evidence: III.

Classification of elbow stiffness.

Stiffness is a clinical disorder that affects the patient's function of the entire upper limb. Many classifications systems have been developed for elbow stiffness based on the plane of motion, severity, aetiology, prognosis or anatomical location. A new classification, the Stiffness types and Influencing Factors Classification System, is proposed as a treatment algorithm to guide the surgical treatment and the preferred operative approach (open or arthroscopic).

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Scaphoid kinematics in scapholunate instability: a dynamic CT study.

OBJECTIVE: The scaphoid is proposed to be driven by the distal carpal row in scapholunate instability (SLI) as it is dissociated from the proximal row. The aim of this study was to describe the 6 degrees of freedom kinematics of the scaphoid using dynamic CT in the normal and SLI wrists. We hypothesised that the SLI scaphoid would demonstrate kinematic evidence conforming to distal row motion. MATERIALS AND METHODS: We studied dynamic CT scans of 17 SLI and 17 normal wrists during ulnar to radial deviation and extension to flexion. The radio-scaphoid angles in three anatomic planes were calculated in the wrist neutral position and during wrist motion. The centroid position was also calculated in the wrist neutral position and during wrist motion. The scapho-capitate motion index (SCI) was calculated as a ratio between the scaphoid and the capitate motion. RESULTS: In the neutral position of the wrist, the SLI scaphoid was flexed, internally rotated, and radially translated compared to the normal scaphoid. During wrist motion, the SLI scaphoid had more 'in-plane' motion and less 'out-of-plane' motion with a higher SCI during wrist neutral to radial deviation and extension to neutral. CONCLUSION: We have described the malalignment of the SLI scaphoid in the neutral position of the wrist and 6 degrees of freedom kinematics during wrist motion of the SLI scaphoid compared to the normal. The SLI scaphoid conformed more to the distal row motion than the normal scaphoid. This information may help define the surgical reconstruction techniques for SLI.

Lunate Fracture Morphology in Kienbock's Disease-A Computed Tomography Study.

Background The pathogenesis of Kienbock's disease is poorly understood. The coronal fracture line is acknowledged as a poor prognostic marker in the disease. Other fracture types in the Kienbock's wrist have subsequently been identified. Questions/Purposes The aim is to study the fracture morphology of the lunate in a cohort of patients using computed tomography. Methods Patient images were acquired using a set protocol with four-dimensional computed tomography scanning. Images were reviewed by two orthopaedic surgeons and a consultant radiologist. Static and dynamic images were assessed and a fracture map created. The relationship of fracture type to other parameters was then analyzed. Results Twenty-three patients were included in the study, including 11 males and 12 females, with a mean age of 43 years. Total frequency of fracture lines in the cohort was coronal - 26, proximal subchondral bone plate type - 24, avulsion - 19, sagittal - 16, and distal subchondral bone plate type - 11. There were statistically significantly more proximal than distal subchondral bone plate fractures ( p = 0.03), and more coronal fractures than distal subchondral bone plate fractures ( p = 0.01). There were statistically significantly more radiolunate ligament-avulsion types ( p <0.001) than other types. The sagittal fracture line through the lunate approximated closely to the ulnar edge of the capitate and the ulnar edge of the radius. Conclusion Study on the fracture morphology in the Kienbock's wrist has improved our understanding of the disease pathogenesis. Fracture lines may correspond to loading points, intrinsic and extrinsic ligament avulsions. These fracture types may play a role in disease progression and are important to identify when considering lunate salvage surgery.

Scapholunate instability: why are the surgical outcomes still so far from ideal?

The wrist is a universal joint with intrinsic and extrinsic ligaments that function and fail as ligamentous complexes. Those related to scapholunate instability (SLI) include the dorsal scapholunate complex (DSLC), volar radiolunate complex and scaphotrapeziotrapezoid complex. Together the DSLC, scaphoid and lunate create an 'acetabulum' for the capitate, with the dorsal intercarpal ligament being a labrum to contain the capitate. SLI results from failure of the DSLC, typically from its scaphoid attachments. Failure of the lunate and or triquetral attachments increases the instability. DSLC failure leads to radioscaphoid instability, which is the symptomatic clinical problem. SLI reconstruction with open surgery and trans-osseous tendon graft techniques have been challenging. We discuss a biological arthroscopic approach to identify, mobilize and debride the disrupted DSLC. This ligament/capsular/periosteum sheet is then advanced and secured to the debrided footprint. Thereby reconstituting the acetabulum, labrum and scaphoid stability.

Risk factors for intra-articular involvement in proximal humeral fractures.

INTRODUCTION: Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures. MATERIALS AND METHODS: One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks. RESULTS: Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface. CONCLUSION: Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making. LEVEL OF EVIDENCE: Basic science; anatomy study.

Three-dimensional cortical and trabecular bone microstructure of the proximal ulna.

INTRODUCTION: The three-dimensional (3D) microstructure of the cortical and trabecular bone of the proximal ulna has not yet been described by means of high-resolution 3D imaging. An improved characterization can provide a better understanding of their relative contribution to resist impact load. The aim of this study is to describe the proximal ulna bone microstructure using micro-computed tomography (micro-CT) and relate it to gross morphology and function. MATERIALS AND METHODS: Five dry cadaveric human ulnae were scanned by micro-CT (17 µm/voxel, isotropic). Both qualitative and quantitative assessments were performed on sagittal image stacks. The cortical thickness of the trochlear notch and the trabecular bone microstructure were measured in the olecranon, bare area and coronoid. RESULTS: Groups of trabecular struts starting in the bare area, spanning towards the anterior and posterior side of the proximal ulna, were observed; within the coronoid, the trabeculae were orthogonal to the joint surface. Consistently among the ulnae, the coronoid showed the highest cortical thickness (1.66 ± 0.59 mm, p = 0.04) and the olecranon the lowest (0.33 ± 0.06 mm, p = 0.04). The bare area exhibited the highest bone volume fraction (BV/TV = 43.7 ± 22.4%), trabecular thickness (Tb.Th = 0.40 ± 0.09 mm) and lowest structure model index (SMI = - 0.28 ± 2.20, indicating plate-like structure), compared to the other regions (p = 0.04). CONCLUSIONS: Our microstructural results suggest that the bare area is the region where most of the loading of the proximal ulna is concentrated, whereas the coronoid, together with its anteromedial facet, is the most important bony stabilizer of the elbow joint. Studying the proximal ulna bone microstructure helps understanding its possible everyday mechanical loading conditions and potential fractures. LEVEL OF EVIDENCE: N.A.

Volar Lunate Facet Fractures of the Distal Radius: Fracture Mapping Using 3D CT Scans.

Background Fractures of the distal radius involving the lunate facet at the volar articular surface are unstable injuries and are usually managed operatively. Management of these fractures is challenging as our understanding of the exact fracture characteristics and associated injuries to the carpus is poor. Purpose This study aims to define the anatomy and associated injuries of lunate facet fractures using three-dimensional computed tomography (CT) scans and fracture mapping techniques. Methods A consecutive series of CT wrists was analyzed to identify intra-articular fractures involving the lunate facet at the volar distal radius. Fractures were mapped onto standardized templates of the distal radius using previously described fracture mapping techniques. We also identified instabilities of the carpus including volar carpal translation, ulnar translocation, scapholunate diastasis, and distal radioulnar joint (DRUJ) instability. Results We present 23 lunate facet fractures of the distal radius. The lunate facet fragment displaces in a volar and proximal direction and the lunate always articulates with the displaced fragment. The smaller fragments displace a greater amount, in a volar direction, with pronation. The fracture tends to occur between the origin of the short and long radiolunate ligaments. Conclusion Lunate facet fractures are frequently comprised of osteoligamentous units of the distal radius involving the short and long radiolunate ligaments and the radioscaphocapitate ligament. Assessment and management of volar carpal subluxation, scapholunate instability, ulnar translocation, and DRUJ instability should be considered. Clinical relevance Our mapping of these fractures contributes to our understanding of the anatomy and associated instabilities and will aid in surgical planning and decision making.

Suprascapular nerve block for the treatment of adhesive capsulitis: a randomised double-blind placebo-controlled trial.

OBJECTIVE: Adhesive capsulitis is a common painful shoulder condition. Treatment for the condition remains unsatisfactory. Suprascapular nerve block (SSNB) shows promise as a treatment option for adhesive capsulitis but there are no randomised controlled trials that examine its effect on pain or duration of the condition. The objective of this study was to examine the efficacy of SSNB for the management of adhesive capsulitis. METHODS: A randomised double-blind placebo-controlled trial of SSNB and standard therapy versus placebo and standard therapy was performed. In total, 54 patients were enrolled in the study. 27 patients received a glenohumeral joint (GHJ) injection and physiotherapy plus a 3-month SSNB, and 27 patients received a GHJ injection and physiotherapy plus a 3-month placebo injection. Patients were followed to resolution of their symptoms as measured by a combination of range of movement, pain scores, Shoulder Pain and Disability Index (SPADI) scores and perceived recovery scores. The primary outcome measure was time to resolution of symptoms. RESULTS: Participants who received the SSNB reduced the duration of their symptoms of adhesive capsulitis by an average of 6 months (mean time to resolution 5.4 (95% CI 4.4 to 6.3) months vs 11.2 (95% CI 9.3 to 13) months) in the placebo group. They also had reduced pain scores, improved range of movement and lower SPADI scores compared with the placebo group across all time points. CONCLUSION: SSNB reduced the duration of adhesive capsulitis and resulted in improved pain and disability experience for patients. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ANCTRN 12615001378516).

The Pathoanatomy and Biomechanics of Kienböck Disease.

Kienböck disease (KD) involves osseous, vascular, and chondral aspects of the lunate and wrist. We present our theories on the etiology and pathogenesis of the condition based on basic science models, seminal literature, personal case experience, and kinematic observations of the Kienböck wrist. Three phenotypes of Kienböck disease occur, and each tends to have different morphology, rates of progression, and disease pattern. The lunate fracture in KD is well-recognized but different fracture types can occur. Dynamic assessment of the Kienböck wrist allows assessment of the complex kinematics of KD. Disease onset and progression require a "perfect storm" of risk factors.

Preiser's Disease-Current Concepts of Etiology and Management.

The term Preiser's disease typically is used to describe idiopathic avascular necrosis of the scaphoid, but there have been a number of putative etiologies considered. It is rare and the natural history is not fully understood. Management of the condition should be based on patient factors as well as the stage of disease with regard to the scaphoid and the surrounding wrist. This chapter appraises the available evidence and aims to provide the reader with a framework to manage this rare condition.

Management of osteochondritis dissecans (OCD) of the elbow trochlea in the adolescent population: A systematic review.

Background: Elbow trochlea osteochondritis dissecans (OCD) is rare with limited information on it. The aim of this systematic review is to assess the published evidence on trochlea OCD in terms of presenting symptoms, location of OCD and outcome of management in adolescent patients. Patient & Methods: A review of the online databases MEDLINE and Embase was conducted according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting on any aspect of trochlea OCD management were eligible for inclusion and appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results: 16 studies were eligible for inclusion with a total of 75 elbow. Mean age was 14 years (8-19) of which 46 were males. The main presenting symptoms were pain (95%). Non-operative care was reported in 86% of elbows with resolution of symptoms in 76%. Surgical management was described in 14%. There were equal number of arthroscopic and open procedures. 94% had successfully resolution of symptoms post-operatively. Conclusion: Elbow trochlea OCD is a rare pathology and one that can be managed non-operatively in the majority of cases with good resolution of symptoms. However, if this fails, operative options are available with excellent results reported. Level of evidence: Level IV, Systematic review.

Volar Marginal Rim Fractures of the Distal Radius Have a Higher Rate of Associated Carpal Injuries-A Comparative Cohort Study.

Background Volar marginal rim distal radius fractures can be challenging due to volar instability of the carpus. The associated carpal injuries, however, have not previously been reported. Purpose The aim of this study was to compare volar marginal rim fractures to other distal radius fractures to determine if there is any association with other carpal injuries. If so, do these injuries lead to further instability and fixation failure? Materials and Methods A retrospective radiological review of 25 volar marginal rim fractures was conducted. This was compared with a comparison cohort of 25 consecutive intra-articular distal radius fractures not involving the volar marginal rim. All radiographs were reviewed for associated carpal injuries, including carpal and ulnar styloid fractures, scapholunate instability, and carpal translocation. Results Volar marginal rim fractures had a significantly higher incidence of associated carpal injuries per patient (2.52 vs. 1.64), scapholunate diastasis (36 vs. 12%), and carpal dislocation (80 vs. 48%). The fixation chosen was more likely to involve a volar rim-specific plate (44 vs. 0%). Following surgical fixation, the volar marginal rim fractures had a significantly higher incidence of carpal instability (56 vs. 24%), failure of fixation (24 vs. 0%), and revision surgery (12 vs. 0%). Conclusions Volar marginal rim fractures have significantly more carpal injuries, scapholunate instability, and volar carpal instability, compared with other distal radius fractures. Despite the use of volar rim-specific plating, volar marginal rim fractures have a significantly higher incidence of persistent carpal instability, including scapholunate instability, ulnar translocation, volar subluxation, failure of fixation, and revision surgery. Level of Evidence This is a level III, retrospective review.

Anatomical and Clinical Concepts in Distal Radius Volar Ulnar Corner fractures.

Background Volar ulnar corner fractures are a subset of distal radius fractures that can have disastrous complications if not appreciated, recognized, and appropriately managed. The volar ulnar corner of the distal radius is the "critical corner" between the radial calcar, distal ulna, and carpus and is responsible for maintaining stability while transferring force from the carpus. Description Force transmitted from the carpus to the radial diaphysis is via the radial calcar. A breach in this area of thickened cortex may result in the collapse of the critical corner. The watershed ridge (line) is clinically important in these injuries and must be appreciated during planning and fixation. Fractures distal to the watershed ridge create an added level of complexity and associated injuries must be managed. An osteoligamentous unit comprises bone-ligament-bone construct. Volar ulnar corner fractures represent a spectrum of osteoligamentous injuries each with their own associated injuries and management techniques. The force from the initial volar ulnar corner fracture can propagate along the volar rim resulting in an occult volar ligament injury, which is a larger zone of injury than appreciated on radiographs and computerized tomography scan. These lesions are often underestimated at the time of fixation, and for this reason, we refer to them as sleeper lesions. Unfortunately, they may become unmasked once the wrist is mobilized or loaded. Conclusions Management requires careful planning due to a relatively high rate of complications after fixation. A systematic approach to plate positioning, utilizing several fixation techniques beyond the standard volar rim plate, and utilizing fluoroscopy and/or arthroscopy is the key strategy to assist with management. In this article, we take a different view of the volar ulnar corner anatomy, applied anatomy of the region, associated injuries, and management options.

Precision Medicine for Kienböck Disease in the 21st Century.

One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.

Arthroscopic Resection of Lunotriquetral Coalition.

Carpal coalition is a rare condition caused by a failure in the process of apoptosis. It is often incidentally diagnosed and seldomly symptomatic. The lunotriquetral joint is the most commonly affected joint, accounting for 90% of carpal coalitions. Minnaar classified the lunotriquetral coalitions into 4 types based on their type, extent, and associated abnormalities. Accurately classifying the coalition requires advanced imaging, and we show an example that includes 2-dimensional and 4-dimensional computed tomography and magnetic resonance imaging. Management of carpal coalitions include nonoperative and operative management. Splinting, anti-inflammatory drugs, hand therapy, activity modification, and steroid injections are all examples of nonoperative management. Operative management of coalitions in the carpus has historically been an arthrodesis whereas in the tarsal bones the gold standard is resection. Arthrodesis has a high complication rate and reduces wrist range of motion, whereas resection retains range of motion and allows the patient to return to activity sooner. We present 2 techniques of treating symptomatic carpal lunotriquetral coalition with arthroscopic resection.

History of Wrist Arthroscopy.

Wrist arthroscopy has a rich history, drawing on contributions from around the world. Its foundation was laid in Japan with Kenji Takagi and Masaki Watanabe, who developed the arthroscope and the techniques for arthroscopy. Across several decades they advanced the optic and lighting technology, allowing the miniaturization which made wrist arthroscopy technologically feasible. A safe and standardized technique for wrist arthroscopy was evolved by Terry Whipple, Gary Poehling, and James Roth in the 1980s, and they shared this with their fellow surgeons through courses and publications. The techniques then spread across the world, leading to widespread uptake and exploration of new therapeutic possibilities. The worldwide spread of wrist arthroscopy was accelerated by the European Wrist Arthroscopy Society (EWAS), founded in 2005 by Christophe Mathoulin. The Asia Pacific Wrist Association (APWA), founded by PC Ho in 2015, also extended the progression of wrist arthroscopy. This article brings together this history and tells the global story of its development through the recollections of those involved. The manuscript includes some amazing videos of the early historical arthroscopy. There are also videos of Gary and Terry describing some of their special memories of the early politics, developments, and evolution of wrist arthroscopy.