Treatment of Hand and Wrist Cartilage Defects in Athletes.

Cartilage injuries of the hand and wrist can be debilitating in the athlete. Diagnosis is difficult given the broad spectrum of presenting symptomatology. History and physical examination is crucial to achieve the correct diagnosis, and advanced imaging can offer helpful assistance to the clinician as well. TFCC injuries and ulnar impaction syndrome are among the most common conditions in athletes with hand and wrist pain. Treatment of these injuries is initially nonoperative, but elite athletes may elect to bypass nonoperative treatment in favor of earlier return to sport. Surgical treatment varies but can include open and arthroscopic methods. The clinician should tailor treatment plans to each athlete based on level of competition, type of sport, and individual preferences and goals.

Etiology and Diagnostic Challenges of Ulnar Wrist Pain in Pediatric and Adolescent Patients.

PURPOSE: Diagnosing the cause of ulnar-sided wrist pain can be difficult in the pediatric and adolescent age group. While frequently used, the diagnostic accuracy of magnetic resonance image (MRI), as compared with intraoperative arthroscopic findings, is not well-described in this population. This study aimed to determine concordance rates between magnetic resonance and arthroscopic findings depending on the specific ulnar wrist pathology. METHODS: A retrospective review was performed to identify pediatric and adolescent patients who underwent operative treatment of ulnar wrist pain between 2004 and 2021. Patients were included in the analysis if they were <18 years of age, complained of ulnar-sided wrist pain, underwent MRI of the affected wrist with an available report interpreted by a consultant radiologist, and had a diagnostic arthroscopy procedure within one year of imaging. Ulnar pathologies analyzed included triangular fibrocartilage (TFCC) tears, ulnotriquetral (UT) ligament tears, lunotriquetral ligament abnormalities, and ulnocarpal impaction. RESULTS: A total of 40 patients with a mean age of 15-years-old (range 11 to 17) were included in the analysis. Twenty-four were female, and approximately half had their dominant extremity affected. Most had a history of antecedent trauma (n = 34, 85%), but only 15/40 (38%) had a history of fracture. The mean duration of symptoms prior to presentation was six months (standard deviation, 7). The most common etiologies were Palmer 1B TFCC tears (n = 27, 68%) followed by UT split tears (n = 11, 28%). MRI overall demonstrated high specificity (82% to 94%), but low sensitivity (14% to 71%) for ulnar-sided wrist conditions. Accuracy varied between 70% and 83% depending on the specific injury. CONCLUSION: While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. Surgeons should have a high degree of suspicion for TFCC-related pathology in the setting of positive provocative clinical examination despite negative MRI findings in young patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IIb.

Acute blockage of forearm supination due to flap tear of the triangular fibrocartilage disc: A case report.

RATIONALE: Acute blockage of forearm supination has been reported in several studies. It is caused by loose bodies in the wrist joint, extensor carpi ulnaris tendon interposition, and distal radioulnar joint (DRUJ) injuries, including forearm bone fractures. Some studies have reported cases of DRUJ injuries caused by triangular fibrocartilage complex (TFCC) tears.We report a case of acute blockage of forearm supination after minor trauma and suggest a possible TFCC tear when a patient complains of forearm supination blocking. In addition, we present a comparison between our case and other reports on etiology, magnetic resonance imaging (MRI) findings, and arthroscopic findings, and show the specific characteristics of our case. PATIENTS CONCERNS: A 22-year-old male presented with left wrist pain as the chief complaint. He was injured 2 months prior to pushing his left hand on the floor during exercise. Physical examination showed a relative limitation of range of motion (ROM) in the left wrist of about 10° in flexion and about 15° in extension compared with the right side. The patient also complained of supination limitation and volar side wrist pain during supination. The patient showed tenderness in the axial compression test. DIAGNOSES: Plain radiographs showing no abnormalities. MRI showed a TFCC tear in the central portion. A torn flap of the TFCC was interposed on the volar side of the DRUJ. INTERVENTIONS: Arthroscopic surgery of the left wrist joint was performed. Arthroscopic examination revealed a tear in the TFCC on the radial side. A torn flap was interposed on the volar side of the DRUJ. We removed the flap from the DRUJ using an arthroscopic grasper and partially resected it. OUTCOMES: Intraoperative tests showed no locking and the forearm was well supinated. Two months after the surgery, the patient had no pain and showed full forearm supination. LESSONS: DRUJ blocking due to a TFCC tear should be suspected when acute blockage of forearm supination occurs after minor trauma. MRI is helpful for diagnosis; however, we suggest that the diagnosis should be confirmed through arthroscopy. Symptoms can be resolved by surgical treatment using arthroscopy.

Complications after arthroscopic triangular fibrocartilage complex (TFCC) surgery.

Wrist arthroscopy is a valuable and widely utilized tool in the treatment of triangular fibrocartilage complex (TFCC) injuries. These procedures include synovectomy alone, peri-capsular or transosseous repair, and arthroscopic-assisted reconstruction, and each are associated with specific complications. This review describes the types of complications and their rates in different types of arthroscopic TFCC surgery reported in the literature and in our centre. Across the spectrum of arthroscopic TFCC surgery, complication rates and the learning curve increase with surgical complexity. Relevant anatomy, prevention and management of complications including nerve injury and irritation, extensor tendon injury and tendinitis, fracture, stiffness, and persistence of symptoms or instability are discussed. Vigilance to anatomical details and careful dissection can help to reduce complications that may result in disturbing pain and functional loss.

Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint.

BACKGROUND: Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget). PURPOSE: In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury. STUDY DESIGN: This was a prospective cohort study. METHODS: Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five. RESULTS: Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Foveal triangular fibrocartilage complex pathology: a potentially under-recognized injury.

The primary aim of the present study was to present a case series of 24 patients with foveal triangular fibrocartilage complex (TFCC) injuries that were treated with arthroscopically assisted TFCC foveal repair. In total, 19 patients had a stable distal radioulnar joint (DRUJ) and five had an unstable DRUJ. Despite this, all patients were found to have a foveal tear upon DRUJ arthroscopy. Magnetic resonance imaging (MRI) scans detected only eight out of 23 patients with foveal injuries. In addition to their foveal injury, 19 of the 24 patients had additional pathology that required treatment. At a mean follow-up of 18 months, there was a statistically significant improvement in pain, range of motion, grip strength and functional scores. In this study, we demonstrate that having a stable DRUJ upon clinical examination and normal MRI findings does not rule out foveal TFCC injury and a high index of clinical suspicion is needed when managing patients with ulnar sided wrist pain.Level of evidence: IV.

Paediatric fractures of carpal bones other than the scaphoid.

OBJECTIVES: Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome. MATERIAL AND METHODS: Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study. RESULTS: In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good. CONCLUSION: Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation.

Scapholunate ligament injuries: an instructional review for the FRCS examination.

An instructional review of the anatomy, investigation, and management of scapholunate ligament injuries. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Percutaneous Suspensory Stabilization of Chronic Distal Radioulnar Joint (DRUJ) Dislocation Using an Adjustable Loop Endobutton Construct: Case Report / Fixação suspensiva percutânea de luxação crônica da articulação radioulnar distal (ARUD) usando um dispositivo de endobutton de laço ajustável: Relato de caso

Abstract Chronic distal radioulnar joint (DRUJ) dislocation has been treated historically with complex osteotomies and reconstructive procedures, often resulting in intractable stiffness and loss of function. It is desirable to use a technique of fixation that will not only restore the wrist biomechanics but also be cosmetically appealing to the individual. We present a novel technique of reduction and fixation of a chronically dislocated DRUJ in a 26-year-old male using a minimally invasive approach, with successful restoration of DRUJ function and no postoperative complications.

Resumo Luxação crônica da articulação radioulnar distal (ARUD) foi tratada historicamente com osteotomias complexas e procedimentos reconstrutivos, geralmente resultando em rigidez intratável e perda de função. É desejável usar uma técnica de fixação que não apenas restaure a biomecânica do punho, mas também seja esteticamente atraente para o indivíduo. Apresentamos uma nova técnica de redução e fixação de uma ARUD deslocada cronicamente em um homem de 26 anos, usando uma abordagem minimamente invasiva, com restauração bem-sucedida da função da ARUD e sem complicações pós-operatórias.

Can a Deep Learning Algorithm Improve Detection of Occult Scaphoid Fractures in Plain Radiographs? A Clinical Validation Study.

BACKGROUND: Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting. QUESTIONS/PURPOSES: (1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level? METHODS: This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured. RESULTS: Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures. CONCLUSION: CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective. LEVEL OF EVIDENCE: Level II, diagnostic study.

Multidisciplinary treatment and functional outcome evaluation of combined injuries of nerves, vessels, and flexor tendons: spaghetti wrist.

OBJECTIVE: In this study, we aimed to evaluate the effectiveness of the modified Kessler technique in managing spaghetti wrist lacerations by multidisciplinary treatment. PATIENTS AND METHODS: Patients who were operated and followed up with the diagnosis of spaghetti wrist tears in our clinic between January 2012 and December 2020 were included in the study. In the postoperative follow-ups, the parameters evaluating the functionality of the patients were examined. RESULTS: Patients were 105 male (86.7%) and 16 women (13.2%), with a mean age of 36.83 ± 16.38 years. At the final follow-up, functional outcomes were assessed. The most common injury mechanism was glass-related injuries (35.5%). The mean starting surgery time of the patients was 4.64±2.98 hours. The most frequently involved structures were the palmaris longus with a rate of 51% and the flexor digitorum superficialis with a rate of 45%. There were significant differences regarding intrinsic function and grip strength between male and female patients (p = 0.04, p = 0.21, respectively). There were significant differences regarding sensation and grip strength between smoker and nonsmoker patients (p = 0.03, p = 0.01, respectively). The number of the damaged structures was negatively correlated with postsurgical functional outcomes of four tests, including tendon function, opposition, intrinsic function, and grip strength. The physical therapy period was correlated to hand function tests (r = 0.756, p < 0.05). Nerve damage was negatively correlated with sensation (p = 0.011, r = -0.932). CONCLUSIONS: The modified Kessler technique is reliable with functional outcomes for spaghetti wrist injuries involving tendons, nerves, and arteries. Meticulous and early surgical treatment within the first 8 hours of spaghetti wrist injury and early initiation and long-term physical therapy are vital in patients' functional outcomes.

Our Disagreement on "Iceberg View" on the Ulnar Wrist and Clinical Implications.

The diagnosis of ulnar-sided wrist symptoms concentrates on distal radioulnar joint and triquetral-hamate joint pathology. I consider this is only looking at the "tip of the iceberg" and ignoring other possible pathologies. In particular, this ignores the role of triquetrohamate and pisotriquetral pathologies. I outline our approaches to these pathologies noting the important ligamentous structures, the clinical presentations, the relevant investigations, and the surgical treatments and outcomes that I have found to be reliable. I would encourage hand surgeons to think more widely about ulnar-sided wrist symptoms, in particular triquetrohamate and pisotriquetral joint instabilities.

Severe spaghetti wrist injury: Should we expand the terminology from wrist to proximal forearm?

OBJECTIVES: This study aims to point out the key principles for the management of multicomponent soft tissue injuries of the wrist and forearm to discuss whether we should expand the term "spaghetti" from the wrist to forearm in such terrifying cases. PATIENTS AND METHODS: Data from a total of 50 patients (44 males, 6 females; mean age: 48.5±25.7 years; range, 10 to 70 years) who were treated for multicomponent soft tissue injuries of the wrist and forearm, including at least one major artery and one major nerve, between February 2020 and December 2021 were retrospectively analyzed. The patients were divided into the wrist injury group (n=30) and forearm injury group (n=20) according to the location of laceration. Demographic characteristics, including age, sex ratio and mechanism and side of injury, total lacerated structures, and outcomes, including tendon function, opposition, intrinsic muscle function, deformities, sensation and grip strength were evaluated. RESULTS: In the wrist injury group, a mean of 12.27±3.53 structures at the volar side were injured. It took a mean time of 1.8±0.4 h for emergency surgical repair and, after a mean of 16.6±5.3 month follow-up, most patients received excellent/good outcomes in the six aspects. In the forearm injury group, a mean of 12.95±2.96 structures at the volar side were injured. It took an average time of 2.1±0.4 h for emergency surgical repair and, after a mean of 15.4±6.4 month follow-up, most patients received excellent/good outcomes and were satisfied with the functional recovery. Only surgical time (p=0.018) and final grip strength (p=0.023) between the two groups showed a statistically significant difference. CONCLUSION: We propose to merge the severe wrist and proximal forearm laceration of multiple tendons/muscles with at least one major artery and one major nerve as a whole, namely the spaghetti-ketchup injury, since the laceration of wrist and that of proximal forearm in this study share similar mechanisms and outcomes after primary repair or reconstruction.

Management and Outcomes of Clinical Scaphoid Fractures in Children.

Background: Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves immobilization and repeat radiographs in 10 to 14 days. When repeat radiographs are normal but a scaphoid fracture is still clinically suspected, the optimal management in children is unknown. This study retrospectively assessed the management and outcomes of pediatric patients diagnosed with clinical scaphoid fractures. Methods: A retrospective study was performed of all patients over a 2-year period treated for a clinical scaphoid fracture at a tertiary pediatric center. Patients were included if they had clinical signs of a scaphoid fracture and 2 negative x-rays 7 to 14 days apart postinjury. Results: Ninety-one patients with a mean age of 13.2 years (range: 7.8-17.7) were included. Sixteen patients (17.6%) underwent computed tomography (CT) or magnetic resonance imaging (MRI) at a mean time of 10.2 weeks postinjury. Five patients (5.5%) were diagnosed with a scaphoid fracture by x-ray or CT at an average of 4.5 weeks postinjury (range: 3-6). Six patients were diagnosed with other wrist fractures at a mean time postinjury of 3.1 (range: 3-6.5) weeks. Out of 195 total radiographs, the surgeon and radiologist disagreed on 59 (30.2%) images. No patients underwent surgery. Conclusions: Management of clinical scaphoid fractures at our institution was relatively uniform: nearly all patients were immobilized and less than 20% received advanced imaging. Our findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and lack of advanced imaging, providing an avenue for future prospective studies.

Incidence and treatment of hand and wrist injuries in Dutch emergency departments.

PURPOSE: The purpose of this study was to describe the epidemiology, treatment and costs of hand and wrist injuries presenting to the Dutch ED. With increasing medical costs and crowding of emergency departments (ED), a more detailed description of emergency department attendance of hand and wrist injuries and their treatment may help to facilitate more adequate allocation of health care services. METHODS: The Dutch Injury Surveillance System obtained a total of 160,250 hand and wrist injuries. Patient characteristics, incidence rates, type of injury, treatment, and costs were described. RESULTS: The incidence of hand and wrist injuries in the Netherlands in 2016 was 11 per 1000 in males and 8 per 1000 in females. This is about 25% of all injuries presented at the ED. Of all hand injuries, only 3% was directly admitted to the hospital or received emergency surgery. Thirty percent did not need further treatment in the hospital. CONCLUSION: The current data suggest that a substantial proportion of the hand and wrist injuries needed no subsequent specialized treatment. Although the severity of the injury could not be deduced from our data, the data suggest a ground for a more extensive role of primary health care (general) practitioners in the primary triage and treatment of hand and wrist injuries. This may reduce health care cost and help decongest the ED departments. Prospective studies are needed to confirm these preliminary conclusions. LEVEL OF EVIDENCE: III.

Identification of Prognostic Factors in Spaghetti Wrist Injuries.

Background: Spaghetti wrist injuries involve a complete transection of three or more structures at the wrist level (including tendons, nerves, or arteries). Few studies on spaghetti wrist trauma have been reported in the literature, and most of them have focused on functional recovery rather than the prognostic factors which affect the outcome. We attempted to address some of the lacunae in current knowledge. Methods: Patients who were operated between January 2017 to January 2019 for spaghetti wrist injuries at a level 1 trauma center were included in the study. Several variables such as age, gender, smoking, education level, mechanism of injury, time gap between the injury to surgery, number of damaged structures and pattern of neurovascular structure were selected as potential prognostic factors to be included in the analysis. Motor recovery, sensory recovery & QuickDash score were used for the outcome assessment. A Multivariate analysis was done to identify the prognostic factor(s). Results: Thirty patients were included in the study. The mean age was 30.5 years (range: 7-57 years). Male population was predominantly affected (93.33%). The dominant limb was injured in 73.33%. The most common mechanism of injury was accidental glass cut (n = 19,63.33%), the most frequently affected structure was flexor digitorum superficialis of the middle finger (n = 23, 76.6%). Combined nerve injury was present in 23.33%. Intrinsic muscle recovery was affected significantly by presence of crush injury (e = 7.189, std error = 2.425, p = 0.003), education significantly affected power grip recovery (p < 0.0001), age was associated with pinch grip recovery (e = 0.083, std error = 0.039, p = 0.034). Conclusions: Increasing age, low education level, and presence of crush injury were identified as negative prognostic factors in the study. These findings may be used for counselling of patients affected by spaghetti wrist injuries.

Artificial intelligence to diagnosis distal radius fracture using biplane plain X-rays.

BACKGROUND: Although the automatic diagnosis of fractures using artificial intelligence (AI) has recently been reported to be more accurate than those by orthopedics specialists, big data with at least 1000 images or more are required for deep learning of the convolutional neural network (CNN) to improve diagnostic accuracy. The aim of this study was to develop an AI system capable of diagnosing distal radius fractures with high accuracy even when learning with relatively small data by learning to use bi-planar X-rays images. METHODS: VGG16, a learned image recognition model, was used as the CNN. It was modified into a network with two output layers to identify the fractures in plain X-ray images. We augmented 369 plain X-ray anteroposterior images and 360 lateral images of distal radius fractures, as well as 129 anteroposterior images and 125 lateral images of normal wrists to conduct training and diagnostic tests. Similarly, diagnostic tests for fractures of the styloid process of the ulna were conducted using 189 plain X-ray anteroposterior images of fractures and 302 images of the normal styloid process. The distal radius fracture is determined by entering an anteroposterior image of the wrist for testing into the trained AI. If it identifies a fracture, it is diagnosed as the same. However, if the anteroposterior image is determined as normal, the lateral image of the same patient is entered. If a fracture is identified, the final diagnosis is fracture; if the lateral image is identified as normal, the final diagnosis is normal. RESULTS: The diagnostic accuracy of distal radius fractures and fractures of the styloid process of the ulna were 98.0 ± 1.6% and 91.1 ± 2.5%, respectively. The areas under the receiver operating characteristic curve were 0.991 {n = 540; 95% confidence interval (CI), 0.984-0.999} and 0.956 (n = 450; 95% CI 0.938-0.973). CONCLUSIONS: Our method resulted in a good diagnostic rate, even when using a relatively small amount of data.

Triangular Fibrocartilage Complex Injuries in Children and Adolescents.

Triangular fibrocartilage complex (TFCC) tears can cause ulnar-sided wrist pain in children and adolescents following acute rotational injury or prior distal radius fracture. Surgical treatment, guided by the Palmer classification, is considered after activity modification and occupational therapy. All concomitant wrist pathologies, such as distal radioulnar joint instability, ulnocarpal impaction, and distal radius malunion, must be recognized and addressed at the time of TFCC debridement or repair. This article reviews recent literature guiding clinical evaluation and surgical treatment of children and adolescents with TFCC injuries. The authors' techniques for arthroscopic-assisted outside-in repair of Palmer 1B and 1D tears are described.

LT Ligament Tears.

Lunotriquetral (LT) ligament injuries are uncommon, however, should be considered in patients with ulnar-sided wrist pain. LT injuries are often associated with other injuries but can occur in isolation. Understanding the anatomy and pathomechanics will aid in making the diagnosis. Similar to other injuries, a thorough history and focused physical examination is critical. Radiographs may show normal findings; however, advanced imaging can support the diagnosis. Arthroscopy remains the gold standard for diagnosis. Most patients do well with conservative management; however, injury acuity and severity will direct surgical management. Anatomy, pathophysiology, and treatment options are discussed.