A systematic review of the psychometric properties of pressure pain detection threshold in evaluating mechanical pain threshold in people with hand or wrist injuries.

PURPOSE: The aim of this study was to conduct a systematic review of the psychometric properties of Pressure Pain Detection Threshold (PPDT) measures in people with hand or wrist injuries. STUDY DESIGN AND METHODS: MEDLINE, Embase, and CINAHL databases were searched to identify eligible studies evaluating psychometric properties of PPDT in samples composed of at least 50% of people with hand or wrist injury. The Consensus-based Standards for the Measurement of Health Instruments' risk of bias checklist was used to critically appraise the included studies, and qualitative synthesis was performed by pooling the results of all studies that presented the same measurement property using Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS: From 415 studies, 11 relevant studies were identified. Of the 11 studies, four hand or wrist injuries were represented; carpal tunnel syndrome, distal radius fractures, osteoarthritis, and complex regional pain syndrome. Intra-rater reliability was considered sufficient (intraclass correlation coefficient 0.64-0.94), with small reported standard error of the mean values (5.3-39.2 kPa). Results of validity and responsiveness could not be synthesized due to heterogeneity. Risk of bias for reliability and measurement error was assessed as very good or adequate, whereas validity and responsiveness were doubtful or inadequate. Overall quality of evidence was low or very low for all measurement properties. CONCLUSIONS: Inconsistent results and low quality evidence provide little confidence in the overall measurement properties of PPDT in a hand or wrist injury population. No criterion standard for pain further highlights complexities around pain measurement such that the results obtained from PPDT measures in clinical practice cannot be compared to a gold standard measure.

Outcomes of radiocarpal pinning to facilitate nerve repair in wrist-level ulnar nerve injuries with defect.

BACKGROUND: The ideal scenario for ulnar nerve repair is primary end-to-end neurorrhaphy in a tension-free environment. However, this could be complicated by soft tissue loss, scarring, and neuroma formation in a delayed injury, creating a nerve defect. With a wrist-level nerve defect, a flexion position can help shorten the nerve gap; however, maintaining the position can be challenging intraoperatively and postoperatively. METHODS: Previously, we proposed our method of using a 1.6-mm K wire for radius-lunate-capitate pinning of the wrist in flexion to minimize the nerve gap, thereby facilitating neuroma excision and end-to-end neurorrhaphy in delayed ulnar nerve injury. In this study, we elaborate our method and present our case series. RESULTS: From October 2018 to July 2020, five patients (mean age: 48.2 years; mean delay from injury to surgery: 84.6 days; mean follow-up: 17.5 months) were retrospectively reviewed. The mean flexion fixation angle was 52°, and the K wire was removed at an average of 5.1 weeks postoperatively. All patients were followed up for a minimum of 12 months. All patients achieved M4 and S3 or S3+ neurologically (according to the criteria of the Nerve Injuries Committee of the British Medical Research Council). The mean disabilities arm, shoulder, and hand score was 14.1. The mean grasp and pinch strengths were, respectively, 76.8% and 63.6% of the contralateral hand. All wrist range of motion returned to normal within 12 weeks. No complications were noted intraoperatively or postoperatively. CONCLUSION: Our study showed that radiocarpal pinning of the wrist in flexion was safe and convenient to minimize the nerve gap and to facilitate end-to-end neurorrhaphy in limited-sized wrist-level ulnar nerve defects.

[Scaphoid fractures : Current diagnostic and treatment concepts]. / Skaphoidfrakturen : Aktuelle diagnostische und therapeutische Konzepte.

Scaphoid fractures are by far the most frequent fractures of the carpal bones of the hand and often lead to problematic healing processes if the diagnostics and treatment are inadequate. The main complication of a scaphoid fracture is pseudarthrosis, which leads to carpal collapse and degenerative arthritis of the wrist if left untreated. Early diagnosis and individualized differentiated treatment aim to achieve bony healing with restoration of the scaphoid shape and preservation of the function of the wrist. The anatomical and biomechanical characteristics of the scaphoid can impede bony healing after a fracture and, in contrast to the diagnostics and treatment, cannot be influenced. A history of trauma and typical clinical signs of a scaphoid fracture should lead to systematic imaging diagnostics with obligatory computed tomography. Only by determining the exact fracture morphology can an appropriate treatment concept be established. Conservative treatment should be restricted to stable fractures without relevant displacement. Fractures of the proximal scaphoid pole are considered unstable even if they are not displaced. Operative treatment is indicated for all unstable fractures. The favored surgical procedure is osteosynthesis with a cannulated double-threaded screw, which can be used in a retrograde or antegrade manner and in a minimally invasive or open technique, depending on the fracture type. Surgical treatment results in earlier bony healing and quicker restoration of function but can be associated with a higher complication rate. Posttraumatic osteoarthritis after healing in malalignment is usually asymptomatic.

[Distal radius fracture-tactic and approach]. / Distale Radiusfrakturen ­ Taktik und Zugangswahl.

OBJECTIVE: The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare. INDICATIONS: Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement. CONTRAINDICATIONS: The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation. SURGICAL TECHNIQUE: The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen. POSTOPERATIVE MANAGEMENT: In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k­wires) require a longer period of immobilization. RESULTS: Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.

Comminuted lunate fracture combined with distal radius fracture and scaphoid fracture: A case report.

RATIONALE: Incidence of lunate fractures is very low, less than 1% of all fractures. Lunate fractures generally come from high-energy injuries, often combined with other wrist fractures. Simple lunate fractures can be fixed with screws or Kirschner wires. However, Comminuted lunate fractures are difficult to reduce and fixe by conventional methods. PATIENT CONCERNS: Here we report a 42-year-old male construction worker who was crushed by an excavator bucket and presented with comminuted lunate fracture combined with distal radius fracture and scaphoid fracture. DIAGNOSES: Comminuted lunate fracture, distal radius fracture, and scaphoid fracture. INTERVENTIONS: The posterior approach was used to reconstruct the radial lunate bone with polymethylmethacrylate cement, and cannulated screws were used to fix the scaphoid and distal radius fractures. OUTCOMES: At the 3rd month after surgery, the movement of the right wrist joint improved. At the sixth month after surgery, the patient returned to the building site and began working at the same intensity as before the injury. LESSONS: Although the incidence of comminuted lunate fractures is very low, they occur sometimes. For comminuted lunate fractures, early identification and intervention can preserve most of the function of the wrist joint.

Fracture Line Distributions of Undisplaced Distal Radius Fractures in Relation to Rupture of the Extensor Pollicis Longus Tendon.

Rupture of the extensor pollicis longus (EPL) tendon is a known complication after undisplaced distal radius fracture (DRF). However, no report has revealed the relationship between EPL tendon rupture and the fracture pattern. Thus, this study aimed to investigate the characteristics of fractures at risk of EPL tendon rupture using fracture line mapping of undisplaced DRFs. This study used computed tomography imaging data of undisplaced DRFs with (n=18) and without EPL tendon rupture (n=52). Fracture lines obtained from 3D reconstruction data were drawn manually after matching with a 2D template wrist model. Fracture maps represented the fracture line distribution by superimposing the fracture lines of all 70 patients. Heat maps showed the relative frequency of the fracture lines as a gradual color change. Fracture lines of cases with EPL tendon rupture were concentrated in the proximal border of Lister's tubercle. By contrast, fracture lines of cases without EPL tendon rupture were relatively dispersed.

Trapezial Fractures and Associated Fractures of the Ulnar Carpus: A Ring-Bone Model.

BACKGROUND: Fractures of the trapezium are rare; however, the incidence may be under-reported in the literature. The incidence of ulnar-sided carpal body fractures as a concomitant injury has not been reported. Our study aimed to evaluate the incidence of trapezium fractures in conjunction with ulnar-sided carpal body fractures. METHODS: Over a five-year period, our electronic records were queried and charts reporting carpal bone fractures were reviewed. All cases of trapezium fracture were evaluated further and presented. RESULTS: Eight trapezial fractures were identified, representing 8% of all carpal fractures and 26% of all nonscaphoid carpal fractures. Of the eight trapezium fractures identified, five (62.5%) were associated with Bennett fracture and four (50%) were associated with ulnar-sided carpal fractures. CONCLUSION: Our study demonstrates a higher incidence of trapezial fractures than previously reported. Previously unreported concomitant ulnar-sided carpal body fractures are reported at a frequency nearly equal to that of concomitant Bennett fractures in our series. We propose a mechanism of injury where the carpal canal and overlying transverse carpal ligament function as a ring-bone construct similar to the pelvis. When a trapezium fracture is identified, we recommend additional evaluation for ulnar-sided injuries of the carpus.

Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case-control study.

OBJECTIVES: To evaluate extensor carpi ulnaris (ECU) tendon pathology and ulnar styloid process bone marrow edema (BME) as diagnostic MRI markers for peripheral triangular fibrocartilage complex (TFCC) tears. METHODS: One hundred thirty-three patients (age range 21-75, 68 females) with wrist 1.5-T MRI and arthroscopy were included in this retrospective case-control study. The presence of TFCC tears (no tear, central perforation, or peripheral tear), ECU pathology (tenosynovitis, tendinosis, tear or subluxation), and BME at the ulnar styloid process were determined on MRI and correlated with arthroscopy. Cross-tabulation with chi-square tests, binary logistic regression with odds ratios (OR), and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to describe diagnostic efficacy. RESULTS: On arthroscopy, 46 cases with no TFCC tear, 34 cases with central perforations, and 53 cases with peripheral TFCC tears were identified. ECU pathology was seen in 19.6% (9/46) of patients with no TFCC tears, in 11.8% (4/34) with central perforations and in 84.9% (45/53) with peripheral TFCC tears (p < 0.001); the respective numbers for BME were 21.7% (10/46), 23.5% (8/34), and 88.7% (47/53) (p < 0.001). Binary regression analysis showed additional value from ECU pathology and BME in predicting peripheral TFCC tears. The combined approach with direct MRI evaluation and both ECU pathology and BME yielded a 100% positive predictive value for peripheral TFCC tear as compared to 89% with direct evaluation alone. CONCLUSIONS: ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to diagnose tears. KEY POINTS: • ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to confirm the presence of TFCC tears. • If there is a peripheral TFCC tear on direct MRI evaluation and in addition both ECU pathology and BME on MRI, the positive predictive value is 100% that there will be a tear on arthroscopy compared to 89% with direct evaluation alone. • If there is no peripheral TFCC tear on direct evaluation and neither ECU pathology nor BME on MRI, the negative predictive value is 98% that there will be no tear on arthroscopy compared to 94% with direct evaluation alone.

The onset, progress and factors influencing degenerative arthritis of the wrist following scaphoid fracture non-union.

BACKGROUND/AIMS: Scaphoid non-union causes osteoarthritis but factors associated are poorly understood. We investigated the rate of osteoarthritis after scaphoid fracture non-union, and if duration and fracture location influenced arthritis and its severity. METHODS: This retrospective cross-sectional observational study of 278 consecutive cases with scaphoid fracture non-union retrieved data on demographics, non-union duration, fracture location, dorsal intercalated segment instability (DISI), severity and distribution of wrist arthritis. Patient Evaluation Measure (PEM) and Quality of Life assessed impact on patients. Regression models investigated prediction of osteoarthritis by different variables. Time-to-event analysis investigated osteoarthritis evolution. Missing (MAR) data for the PEM and QoL was imputed and analysed. RESULTS: 278 patients, 246 males, aged 27.9 years (range 11 to 78 years), with a scaphoid fracture non-union confirmed on computed tomography (CT) scans (243) and plain radiographs (35) were reviewed. The interval between injury and imaging was 3.3 years (SD 5.9 years; range 0.1-45). The fracture was proximal to the ridge in 162, distal to the ridge in 83 and in the proximal 20% in 33. DISI (RLA ≥ 10°) occurred in 93.5% (260/278). Osteoarthritis was identified in 62.2% (173/278), and we classified a SNAC pattern in 93.6% (162/173). Of these, 100 (61.7%) had SNAC 1, 22 (13.6%) SNAC 2, 17 (10.5%) SNAC 3, and 23 (14.2%) SNAC 4. The mean duration in years for SNAC 1, 2, 3 and 4 were 2.5, 6.0, 8.2, and 11.3 years respectively. In fractures proximal to the ridge, 50% had arthritis in 2.2 years. Whereas in proximal pole, and distal to the ridge, 50% developed in 3.8 and 6.6 years, respectively. The PEM score was 42.8% (SD 18.9%) in those without arthritis and 48.8% (SD 21.5%) in those with arthritis. The mean QoL was 0.838 in patients without SNAC and 0.792 with SNAC. CONCLUSION: Scaphoid fracture non-union caused early carpal collapse, majority had osteoarthritis usually observed within a year following injury and occurred earliest in proximal waist fractures. Distribution of osteoarthritis (SNAC stage) may not always follow a distinctive pattern, as previously described.

Editorial Commentary: In Cases of Concurrent Triangular Fibrocartilage Complex Tears and Ulnar Styloid Process Fracture Nonunions, We May Neither Need to Excise nor Repair the Ulnar Styloid Fracture Nonunion Fragment.

The ulnar-sided wrist contains multiple potential pain generators that may present in isolation. Occasionally, however, wrist trauma results in multiple concurrent and overlapping injuries that make diagnosis and treatment of these conditions challenging. Deep/foveal tears of the triangular fibrocartilage complex (TFCC) may occur in the setting of nonunited ulnar styloid process fractures. Treatment of these injuries has historically included open TFCC repair with fixation or excision of the ulnar styloid fracture nonunion fragment; however, recent literature suggests that addressing the ulnar styloid nonunion fragment may not be as important as we think. Recent research shows that we may not need to excise or repair the ulnar styloid fracture nonunion fragment, which in turn may help preserve the complex ligamentous architecture that stabilizes the ulnar-sided wrist. One thing we know for sure is that foveal tears of the deep fibers of the TFCC, with or without ulnar styloid fracture (Palmer 1B, Atzei class 2 or 3), can produce distal radioulnar joint (DRUJ) instability and wrist dysfunction and should be addressed sooner rather than later to prevent long-term consequences, including DRUJ osteoarthritis. Whether you choose to approach the problem arthroscopically or open, the foveal TFCC tear should be repaired to prevent long-term sequalae.

Epidemiology of Hand and Wrist Injuries in Collegiate-Level Athletes in the United States.

PURPOSE: Hand and wrist injuries are common among competitive athletes and can have a substantial impact on playing time and future participation. The purpose of this study was to provide epidemiological data from the National Collegiate Athletic Association Injury Surveillance Program to correlate injury diagnosis with the need for surgery and time loss. METHODS: Using the National Collegiate Athletic Association Injury Surveillance Program, this retrospective study extracted data of hand and wrist injuries for all 25 National Collegiate Athletic Association sports from the academic years 2004-2005 to 2013-2014. The "severe" category was defined as injuries resulting in the following: (1) surgery, (2) season-ending status, or (3) more than 30 days of playing time loss. The epidemiologic data included injury rate per 100,000 athlete exposures (defined as 1 athlete participating in 1 practice or competition) based on diagnoses and demographic information such as sports and sex. We used a Poisson regression model to estimate the incidence rate and 95% confidence interval. RESULTS: Overall, 4,851 hand injuries were identified, with an injury rate of 41.2 per 100,000 athlete exposures. The most common diagnoses were metacarpal or phalangeal fractures (19.9%), lacerations or contusions (15.4%), and wrist sprains (14.7%). The surgical rate was 9.6%, and the season-ending rate was 5.8%. Severe injuries occurred in 17.5% of the hand and wrist injuries; within this subset, the most common diagnoses included metacarpal or phalangeal fractures (43.8%), scaphoid fractures (12.8%), and thumb ulnar collateral ligament tears (8.7%). Scaphoid fractures and metacarpal or phalangeal fractures had the highest surgical rate and season-ending rate among all the injuries. CONCLUSIONS: The injury rate of hand and wrist injuries is comparable with those of other common sports injuries. Approximately one fifth of the injuries were considered severe, which led to a high surgical rate, and these had a considerable impact on the athletes' ability to finish the season. TYPE OF STUDY/LEVEL OF EVIDENCE: Outcome research level II.

The association of three anatomical factors with ulnar-sided wrist pain: a radiological study.

BACKGROUND: Ulnar-sided wrist pain is associated with the development of multiple wrist pathologies. But the anatomical etiologies have not been fully understood. PURPOSE: To determine the association of three anatomical factors with ulnar-sided wrist pain, including ulnar variance (UV), distal ulnar volar angle (DUVA), and pisiform-ulnar distance (PUD). MATERIAL AND METHODS: A total of 64 patients who had ulnar-sided wrist pain associated with training injuries were retrospectively studied. A control group included 64 healthy athletes from the same unit. The UV, DUVA, and PUD of each individual was measured on radiographs. RESULTS: The average UV and DUVA of those in the ulnar-sided pain group were 0.84 mm and 174.65°, respectively; the control group values were 0.39 mm and 175.11°. The differences between the two groups had no statistical significance (P > 0.05). The average PUD of the ulnar-sided wrist pain group was shorter than that of the control group (2.37 cm vs. 2.65 cm); the difference had statistical significance (P < 0.05). PUD had a negative correlation with ulnar-sided pain; it was an anatomical protective factor (odds ratio = 0.01; P < 0.00; 95% confidence interval=0.00-0.05). Both UV and DUVA had no significant correlations with ulnar-sided wrist pain (P > 0.05). CONCLUSION: PUD has a significant correlation with ulnar-sided wrist pain. It is the anatomical protective factor. Both the UV and DUVA have no statistical association with ulnar-sided wrist pain, but we cannot ignore their potential pathogenic effects on wrists, and further studies are needed to confirm the results.

Does the surgical treatment of concomitant upper limb fractures affect the outcomes of hip fractures in the elderly population?

INTRODUCTION: Elderly patients with concomitant upper limb and hip fractures present a management dilemma because upper limb fractures potentially affect rehabilitation outcomes for the hip fracture. This study aims to evaluate whether the site of upper limb fractures and the decision to surgically treat such fractures affect the functional outcome of surgically treated hip fracture patients. METHODOLOGY: We retrospectively reviewed 1828 hip fracture patients treated at a single trauma centre over 3 years, of whom 42 with surgically treated hip fractures had concomitant upper limb fractures. Outcome measures, such as length of hospital stay, complications, mortality and readmission rates, were assessed, whilst the functional outcomes were evaluated using the Modified Barthel Index (MBI) on admission, post-operatively and at 6 and 12 months of follow-up. RESULTS: Amongst the 42 patients with surgically treated hip fractures, 31.0% had proximal humerus fractures, 50.0% had wrist fractures, 16.7% had elbow fractures and 2.4% had forearm fractures. 50.0% of these upper limb fractures were treated surgically. There was no difference in complications, inpatient morbidity, readmission rates or the length of hospital stay for patients whose upper limb fractures were surgically treated as compared to those non-surgically treated. There was no difference in absolute MBI scores at 6 and 12 months based on the management of upper limb fractures. However, patients with surgically treated wrist fractures had statistically significant higher MBI scores at 6 months as compared to those treated non-surgically. CONCLUSION: Surgical treatment of concomitant upper limb fractures does not appear to change the outcomes of the hip fractures. Hip fracture patients with surgically treated wrist fractures had better functional outcomes at 6 months compared to those treated non-surgically; however, there was no difference at 12 months. Hip fracture patients with concomitant wrist fractures had better functional outcomes compared to hip fracture patients with proximal humerus fractures.

Flexor Pollicis Longus Tendon Rupture and Carpal Tunnel Syndrome due to Scaphoid Nonunion Advanced Collapse: A Case Report.

CASE: We report a case of flexor pollicis longus (FPL) tendon rupture and carpal tunnel syndrome due to scaphoid nonunion advanced collapse deformity. Intraoperative findings showed disruption of the palmar joint capsule and a sharp proximal bone fragment protruding into the carpal tunnel. Removal of this proximal fragment and tendon grafting were performed. At the postoperative 2-year follow-up, the patient had no wrist pain, finger numbness, or restriction of thumb motion. CONCLUSION: Our results suggest that minimally invasive surgical procedures, such as proximal pole or osteophyte resection, might be optimal choices for early rehabilitation after tendon repair in cases of FPL tendon rupture due to asymptomatic scaphoid nonunion.

'Hook' Shape Lister Tubercle Is Associated with a Greater Incidence of Extensor Pollicis Longus Tendon Rupture after Distal Radius Fracture.

Background: A rupture of the extensor pollicis longus (EPL) tendon located close to the Lister tubercle is an uncommon complication of distal radius fractures. This study aimed to determine whether the size and shape of Lister tubercle in patients with EPL rupture differs from a matched group of patients with distal radius fractures without EPL rupture. Methods: We identified 15 patients with EPL rupture (3.5%) out of 426 with distal radius fractures treated conservatively at our hospital over 4 years. Out of the remaining 411 patients with distal radius fractures without EPL rupture, we selected patients using simple random sampling and pseudo-randomised them such that their age, sex and fracture type were matched with patients exhibiting EPL rupture. The size and shape of the Lister tubercle and the size of the EPL groove were measured in both groups using computed tomographic scans and compared. Results: There was no difference in the size of the Lister tubercle or the EPL groove between both groups. A 'hook'-shaped Lister tubercle was noted in 8 out of 15 patients with EPL rupture but in only 1 out of 15 matched patients without EPL rupture. Conclusions: A 'hook'-shaped Lister tubercle was seen more often in patients with EPL rupture following distal radius fracture. Level of Evidence: Level III (Therapeutic).

Perilunate dislocation and fracture dislocation of the wrist: Outcomes and long-term prognostic factors.

INTRODUCTION: Perilunate dislocations and fracture-dislocations are severe injuries that often have serious functional sequelae. Our goal was to evaluate the long-term clinical and radiological results of these perilunate injuries, and to look for prognostic factors of a poor clinical outcome. HYPOTHESIS: All patients who suffered perilunate injuries in their wrist have functional sequelae and long-term radiographic changes despite optimal treatment with anatomical surgical reduction. MATERIALS AND METHODS: We did a single-center, retrospective study of 32 patients who had either an isolated perilunate dislocation (n=7) or fracture-dislocation (n=25) in their wrist. Pain, range of motion, strength and functional scores (MWS, PRWE, QuickDASH) were evaluated. Radiographs were analyzed to look for signs of osteoarthritis or carpal instability. RESULTS: The mean follow-up time was 9.9years (3.5-24). The wrist joint had a mean flexion-extension of 86° (0-140), radioulnar deviation of 38° (0-65) and pronosupination of 153° (120-180). The mean grip strength was 35kg (5-56). The mean MWS, PRWE and QuickDASH scores were 65/100, 32/100 and 29/100, respectively. At the final assessment, 23 patients (79%) had radiographic signs of osteoarthritis while 5 patients (16%) had residual carpal instability. Three patients subsequently underwent palliative treatment. Opening the carpal tunnel and the magnitude of the lunate's displacement are significant predictors of a poor long-term functional outcome (p<0.05). Older age at the time of injury was a predictor for the development of osteoarthritis. DISCUSSION: Despite optimal treatment, perilunate dislocations and fracture-dislocations at the wrist cause functional sequelae such as pain, stiffness, strength deficit and posttraumatic arthritis in nearly 80% of patients. The functional outcomes are determined by the amount of lunate displacement (stage) and the patient's age. We do not recommend opening the carpal tunnel, even when signs of median nerve compression are present; reducing the dislocation helps to relieve the neurological symptoms. LEVEL OF EVIDENCE: IV; retrospective observational study.

Ulnar Wrist Pain in a Tennis Player: Case Review and Discussion: A Team-Based Approach.

¼: Ulnar-sided wrist pain is a common cause of debilitating wrist pain in stick-handling athletes. Due to the complexity of surrounding anatomy, the evaluation and diagnosis can be challenging. ¼: Injury of the triangular fibrocartilage complex (TFCC) is the most common cause of ulnar-sided wrist pain. Repetitive, unrestricted pronosupination, wrist deviation, and axial-loading activity, such as in tennis, place substantial stress on the TFCC. ¼: The ulnotriquetral (UT) ligament is a palmar thickening of the ulnar capsule arising from the palmar radioulnar (PRU) ligament of the TFCC. When injured, the UT ligament can be a source of acute or chronic ulnar-sided wrist pain. The ligament can avulse off bone, can rupture completely, or can split longitudinally. ¼: Arthroscopic-assisted repair is a safe, reliable, and effective treatment for UT ligament split tears and peripheral TFCC tears. ¼: Although the benefit of a team-based approach may be realized by most patients, high-performing, stick-handling athletes are part of a unique population who execute repetitive, extraordinary wrist movements. The high demand and functional requirement expected of the wrists require a uniquely tailored approach to return them to the same level of competitive play.

Open Foveal Repair of the Triangular Fibrocartilage Complex Tears Associated with Symptomatic Ulnar Styloid Non-union.

Background: Symptomatic ulnar styloid non-union can be treated by excision of the ulnar styloid fragment. For combined triangular fibrocartilage complex (TFCC) tears, several repair techniques such as arthroscopic repair, open repair to the fracture site or reconstruction using a tendon graft have been introduced. This study reports the technique and outcomes of open foveal repair of the TFCC with excision of the ulnar styloid fragment in patients with symptomatic ulnar styloid non-union and distal radioulnar joint (DRUJ) instability. Methods: Consecutive patients with symptomatic ulnar styloid non-union with TFCC tears and DRUJ instability who underwent excision of the ulnar styloid fragment and open foveal repair of the TFCC were retrospectively reviewed. After excising the ulnar styloid fragment, a capsular window was created between the triquetrum and TFCC, followed by attaching the TFCC to the fovea using three sutures through a bone tunnel from the ulnar cortex to the fovea. Additional ulnar shortening osteotomies were performed in patients with positive ulnar variance and ulnar impaction test. The outcomes were evaluated in terms of DRUJ stability and the Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: In total, 21 patients with a mean age of 40 were enrolled in the study. All patients demonstrated DRUJ stability at a mean follow-up duration of 14 months. The mean Quick DASH score significantly improved from 18.9 ± 11.7 to 2.5 ± 4.1 (p < 0.05). Eleven patients underwent combined ulnar shortening osteotomies, and no difference in the Quick DASH score was found between patients who underwent ulnar shortening osteotomy and those who did not. Conclusions: This study demonstrates that open foveal repair of the TFCC with ulnar styloid fragment excision is an effective strategy to surgically treat patients with symptomatic ulnar styloid non-union with TFCC tear and DRUJ instability. Level of Evidence: Level III (Therapeutic).

Galeazzi Fracture-Dislocation.

A Galeazzi fracture-dislocation is defined as a distal radius fracture with disruption of the distal radioulnar joint (DRUJ). The typical mechanism of injury is a forceful axial load with forearm torsion, which is often seen in a fall on the out stretched hand (FOOSH). The diagnosis is made with radiographs of the distal forearm and the wrist. The diagnosis can often be missed because ligament disruption of the distal radioulnar joint (DRUJ) can be overlooked. Treatment in children is usually nonsurgical with closed reduction and long arm cast. Adult treatment is usually open reduction and internal fixation. Complications can result in disability and include malunion, limited range of motion of the forearm, chronic pain, DRUJ instability, and osteoarthritis.

Outcomes after Bone-Ligament-Bone Intercarpal Ligament Reconstruction.

BACKGROUND: Numerous surgical reconstructive techniques have been described for chronic scapholunate and lunotriquetral interosseous ligament instability. METHODS: The authors retrospectively reviewed 16 consecutive patients who underwent bone-ligament-bone reconstruction for scapholunate or lunotriquetral intraosseous ligament predynamic and dynamic instability at a single tertiary care institution from 2013 to 2019. Clinical and radiographic outcomes, and complications, were recorded. RESULTS: Eleven patients had bone-ligament-bone reconstruction for scapholunate ligament injuries and five for lunotriquetral instability. Fourteen patients (87.5 percent) underwent diagnostic arthroscopy before bone-ligament-bone reconstruction, with nine of 14 having grade 3 and four of 14 having grade 4 injury. Capitohamate bone-ligament-bone grafts were used in nine patients (56 percent) and the graft was taken from Lister tubercle in seven (44 percent). The average age at surgery was 37 years. The average follow-up was 60.6 weeks. There were no significant differences between preoperative and postoperative radiographic parameters. Median postoperative wrist flexion was 45 degrees, and mean postoperative wrist extension was 53 degrees, which were significantly less than contralateral flexion (85 degrees; p < 0.0001) and extension (78 degrees; p < 0.0001). Thirty-eight percent of patients complained of persistent pain at final follow-up, and two patients (13 percent) underwent salvage procedures, both at approximately 6.5 months after the index reconstruction. CONCLUSION: Short-term outcomes of bone-ligament-bone reconstruction for early-stage scapholunate and lunotriquetral ligament injuries reveal many patients with residual postoperative wrist pain and disability, and almost uniform limitations in flexion-extension motion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.