A Changing Landscape in the Surgical Management of Wrist Arthritis: An Analysis of National Trends From 2009 to 2019.

PURPOSE: The purpose of this study was to analyze the trends in the annual volume and incidence of proximal row carpectomy (PRC), four-corner fusion (4CF), total wrist arthrodesis (TWF), and total wrist arthroplasty (TWA) from 2009 to 2019 in the United States. METHODS: The IBM Watson Health MarketScan databases were queried to identify annual case volumes for PRC, 4CF, TWF, and TWA from 2009 to 2019. The annual incidence of these procedures was then calculated based on the population estimates from the US Census Bureau. Trends in annual volume and incidence over the study period were evaluated using regression line analysis. Further subgroup analysis was conducted based on age and region. RESULTS: From 2009 to 2019, the total case volumes for the four procedures increased by 3.4%, but the incidence decreased by 2.8%. However, PRC case volume and incidence trends significantly increased (38.2% and 29.7%, respectively), whereas 4CF remained constant. Conversely, the case volume and incidence of TWA significantly decreased (-52.2% and -54.5%, respectively), whereas TWF remained constant. When stratified by age, all four procedures decreased in the <45-year-old cohort (combined -35.1%) significantly for 4CF, TWF, and TWA. TWA decreased significantly in the <45-year-old and 45- to 65-year-old cohorts (53.6% and 63.2%, respectively). For age >65 years, the total case incidence increased by 98.9%, including a significant positive trend in TWF (175%). CONCLUSIONS: Surgical management of wrist arthritis remains a controversial issue. However, PRC has gained recent support in the literature, and our results reflect this shift, even for the <45-year-old cohort. Furthermore, TWA declined, despite reports of positive early outcomes for fourth-generation implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

[Technique Optimization of Interposition Arthroplasty During Proximal Row Carpectomy with Regard to the Vascularity of the Capsule in Carpal Joint: Cadaverous Study]. / Optimalizace techniky interpozicní artroplastiky pri proximální karpektomii s ohledem na vaskularizaci dorzální kapsuly karpu: kadaverózní studie.

PURPOSE OF THE STUDY The study aimed to propose an optimal based fl ap creation with the view to ensure long-term survival of the interposition arthroplasty. MATERIAL AND METHODS A total of 28 dorsal wrist capsules were collected from 16 cadavers (with age range at death 18 to 80 years, with no visible wrist pathology). Altogether 112 histological specimens were obtained from these 28 samples. Post-hoc Dunn's tests were used to analyse the percentage of vascularisation of individual sides of the dorsal capsule (circumference and area) at the 0.05 level of signifi cance. Spearmann's correlation analysis was used to assess the effect of age on vascularization of the dorsal wrist capsule. In cadavers in whom both capsules were collected, the limbs were compared. For the sake of comparison, the Wilcoxon matched pairs test was used. RESULTS Regarding statistical signifi cance, the largest share of the total circumference and area of the measured vessels of the dorsal capsule is constituted by the distal side (35.2% of the circumference and 30.9% of the area). The blood supply of the dorsal capsule received on the ulnar side is the lowest (12.9% of the circumference and 17.6% of the area). There was no signifi cant effect of age on vascularization of the dorsal wrist capsule confi rmed. Also, the comparison of vascularization of both limbs from a single cadaver did not yield any statistically signifi cant results. DISCUSSION Proximal row carpectomy is a long-established surgical technique used to manage the degenerative changes in the wrist. Our results showed the best vascularization on the distal and radial sides of the dorsal wrist capsule. In this light, the distally-based fl ap or the fl ap described by Berger, which respects the clinically important ligaments, appear to be the least invasive and help maintain the future stability of the wrist. CONCLUSIONS In clinical practice, we advise that a radially-based fl ap according to Berger is created and the distal side of the dorsal capsule, the most vascularized portion based on our results, is preserved as much as possible. The fl ap created in this manner also preserves the important carpal ligaments and appears to the authors of this study to be the most benefi cial, also with respect to the presence of the largest arteries, contrary to the distal side. Another option is to use a distally-based fl ap for interposition arthroplasty. Key words: interposition arthroplasty, proximal row carpectomy, vascularization, degenerative changes, wrist.

Immediate Proximal Row Carpectomy for Severe Perilunate Dislocation Injuries: A Minimum 5-Year Follow-Up.

Background: In patients with perilunate injuries (PLI) with multiple ligamentous and bony injuries involving the proximal carpal row, open reduction and internal fixation (ORIF) can be difficult and lead to poor functional outcomes. Proximal row carpectomy (PRC) is an alternative procedure that has been used for severely comminuted fractures. The aim of our study is to evaluate the long-term functional outcome (minimum 5 years) of patients that underwent an emergency PRC for PLI. Methods: We conducted a retrospective study of patients who underwent PRC at our centre between 2001 and 2016. Only patients with follow-up data of more than 5 years were included in the study. We evaluated range of motion, grip strength, Mayo Modified Wrist Score (MMWS) and Quick Disabilities of Arm, Shoulder and Hand (Quick-DASH). Radiographic analyses were performed to assess the presence of radiocarpal osteoarthritis and the space between the radius and capitate. Results: Thirteen patients were included, with an average follow-up of 78.07 months (6.5 years). The MMWS was 65 points (four excellent and good, four fair and five poor results) and the Quick-DASH score was 30 points. X-ray analysis reported only 15.3% of patients with radiocarpal arthrosis and an average radio-capitate joint space of 1.92 mm. Conclusions: The outcomes of PRC in the management of PLI are comparable to the results reported in literature for conventional ORIF. PRC is a simpler procedure that minimises the need for re-intervention. Level of Evidence: Level IV (Therapeutic).

Wrist and Distal Radioulnar Joint Arthroplasty: Maximizing Results in Difficult Conditions.

Traditional management of wrist arthritis consists of proximal row carpectomy, partial carpal fusions, or, in the event of pancarpal arthritis, total wrist fusion. Although proximal row carpectomy and partial wrist fusions preserve some motion at the wrist while relieving pain symptoms, the quality of results obtained from these procedures is not predictable or optimal in many instances. Management of hip, knee, ankle, and shoulder joints has evolved from arthrodesis to arthroplasty. The wrist joint is following the same pattern of evolution with the advent of reliable designs.

Coexisting Kienböck's and Preiser's Disease of the Wrist: Experience with Proximal Row Carpectomy with Dorsal Capsular Interposition Technique.

BACKGROUND: Idiopathic avascular necrosis of the lunate is known as Kienböck's disease and that of the scaphoid is known as Preiser's disease. Because the prevalence of coexisting Kienböck's and Preiser's diseases is very low, standardized stages of disease and treatments are not established. CASE PRESENTATION: We report coexisting avascular necrosis of the scaphoid and lunate in a 68-year-old woman with no history of steroids or other risk factors. We treated her with proximal row carpectomy with capsular interposition technique. A distal-based dorsal capsular flap was prepared and repaired the palmar capsule. At the last follow-up, she had no pain and had gained improved range of wrist motion. There was no arthritic change at the newly formed radiocapitate joint. CONCLUSIONS: In the case of collapsed lunate and scaphoid with avascular necrosis, the proximal row carpectomy procedure has an advantage. Proximal row carpectomy with dorsal capsular interposition can be performed when the lunate or scaphoid cannot be saved. Arthritic changes of the capitate head and distal radius lunate facet can be covered with the dorsal capsule.

Artificial Lunate Arthroplasty for Kienböck Disease With Multiple Extensor Tendon Ruptures: A Case Report.

CASE: A 73-year-old woman presented with wrist pain and loss of extension in the middle and ring fingers. Radiography revealed a dorsally displaced lunate fragment, resulting in a diagnosis of Kienböck disease with extensor tendon rupture. Artificial lunate replacement and tendon transfer were performed as treatment. Two years postoperatively, the pain was relieved, and the extension lag was 0°. The wrist motion and carpal height had also improved. CONCLUSION: Lunate excision, partial wrist arthrodesis, or proximal row carpectomy are known treatments for Kienböck disease with extensor tendon rupture. Lunate arthroplasty is a novel, useful treatment option for this condition.

Lunotriquetral Coalition.

Lunotriquetral (LT) coalition is the most common carpal coalition. Four morphological types of LT coalition have been described. LT coalition is usually asymptomatic, but rarely a fibrocartilaginous type may cause ulnar wrist pain. We report a case of bilateral asymptomatic LT coalition that was seen incidentally on conventional radiography taken after a wrist injury. Conventional radiography is the first imaging technique to detect and classify this type of LT coalition. Magnetic resonance imaging is a useful tool to investigate possible associated pathology of the carpal joints, particularly if surgical treatment of a symptomatic patient is anticipated.

Proximal row carpectomy versus four-corner arthrodesis in the treatment of SLAC and SNAC wrist: meta-analysis and literature review.

A systematic literature review was performed on 84 articles from 2000 to 2020 on proximal row carpectomy (PRC) or four-corner arthrodesis (FCA) in patients with posttraumatic wrist osteoarthritis. Qualitative assessment was conducted on 14 articles. Pain, range of motion (ROM), grip strength and complications were analyzed using weighted average means. Meta-analysis with a random effects model was performed for the flexion-extension arc and grip strength. A total of 1,066 PRCs and 2,771 FCAs were analyzed, with a mean follow-up of 9 and 7 years respectively. Mean flexion after PRC and FCA respectively was 36.2 ° and 31.1 °, mean extension 41.4 ° and 32.4 °, and mean grip strength 26.4 kg and 27.5 kg. PRC had a larger flexion-extension arc than FCA, with a standard mean difference (SMD) of 0.41 (range, 0.02-0.81). No significant difference was found for grip strength. Osteoarthritis occurred in 42.2% of PRC cases, independently of capitate shape. Conversion to wrist arthrodesis was performed in 10.1% of failed PRCs. Revision was chosen in 4.7% of FCAs and conversion to wrist arthrodesis in 4.6%. We conclude that the functional results of both techniques are similar, but prefer PRC to FCA because of the lower complications rate.

Arthroscopic lunate fossa resection arthroplasty for Kienböck's disease.

The aim of this study was to assess the outcome of arthroscopic lunate fossa resection arthroplasty for patients with Kienböck's disease, previously managed without operation, and a non-functional lunate fossa. For adult patients with relapse or exacerbation of pain from Kienböck's disease 2 years after the onset of symptoms, arthroscopic removal of lunate fossa cartilage was performed to reach bleeding bone, if the cartilage in the lunate fossa was non-functional and the scaphoid fossa was intact. Sixteen patients (mean age 35 years; range 27-56) were included. At a mean follow-up of 39 months (range 24-64), the preoperative mean visual analogue pain scale and QuickDASH score decreased from 7 (SD 2.2) and 50 (SD 16) to 1.4 (SD 1.6) and 13 (SD 9.6), respectively. A minor deterioration in mean radioscaphoid angle and carpal height ratio occurred. Arthroscopic lunate fossa resection arthroplasty is a viable option for selected patients with Kienböck's disease.Level of evidence: IV.

Long-term results of first row carpectomy with proximal capitate resurfacing using a pyrocarbon implant.

The functional results of proximal row carpectomy with a proximal capitate resurfacing using a pyrocarbon implant were evaluated in a retrospective, multicentric, multi-operator study. The outcomes of patients operated on at five surgical centres between January 2005 and December 2018 were reviewed. The data were collected by an independent observer during standardized consultations. Based on 30 patients with a mean follow-up of 7 years, the median range of flexion and extension was 65° and the median radioulnar tilt was 45°. The median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 14 and the improvements in strength and pain were good. Compared with the preoperative values, significant improvements were seen in the flexion and extension range of motion, radioulnar tilt and pain score. No postoperative complications were recorded.Level of evidence: IV.

Intercarpal arthrodesis: A systematic review.

Intercarpal arthrodesis is a well-established option to treat various disorders of the carpus, such as localized osteoarthritis, carpal instability, and Kienböck's disease. This is a non-conservative procedure aimed at obtaining a stable and congruent interface between the radius and the proximal carpal row, which restores wrist function by minimizing pain and restoring grip strength. These procedures generally yield good predictable results that are maintained over time. However, all intracarpal arthrodesis procedures cause a loss of wrist range of motion. To optimize outcomes and minimize complications, especially nonunion, this surgery may require a learning curve. A precise surgical technique for preparing the bone surfaces, bringing enough bone graft, and using reliable fixation is essential. Since the late 1960s, several intracarpal arthrodesis procedures have been described. Commonly used fusions target the scaphotrapeziotrapezoid, scaphocapitate, four corners, capitolunate or capitohamatolunate regions. Lesser used fusions focus on specific lesions such as the scapholunate, scapholunocapitate, lunotriquetral and triquetrohamate. Here, we propose a systematic review of the various types of intercarpal arthrodesis procedures described in the literature. After having described each arthrodesis, we specify their indications, the variations of the surgical techniques, and then present an overview of the results and complications. Finally, we discuss how these surgeries affect wrist biomechanics. LEVEL OF EVIDENCE: III.

Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients.

PURPOSE: Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC. METHODS: The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation. RESULTS: There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA. CONCLUSIONS: Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Comparison of Clinical Outcomes in Open and Arthroscopically-Assisted Mini Open Proximal Row Carpectomy for Lichtman Stage IIIB and IIIC Kienböck Disease.

PURPOSE: Proximal row carpectomy (PRC) can be performed in the late stages of Kienböck disease using the traditional open technique or arthroscopically. In this study, we describe the arthroscopically-assisted mini-open PRC technique. The aim of the study was to compare the functional results with the open PRC technique in advanced-stage Kienböck disease. METHODS: The medical records of patients with Kienböck disease who underwent open PRC between 2006-2010 (Cohort A) and arthroscopically-assisted PRC (AAPRC) between 2010-2018 (Cohort B) were analyzed. The Quick Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale, and Modified Mayo Wrist Scores were compared, which were obtained at the early postoperative (third month) and final follow-up. RESULTS: Cohort A had 14 and Cohort B 21 patients. The preoperative, early, and final mean visual analog scale scores were 7, 3, and 0.3, respectively, for Cohort A, and 7, 0.3, and 0.1, respectively, for Cohort B. The preoperative mean Quick Disabilities of the Arm, Shoulder, and Hand scores decreased from 69 to 34 at the third-month and 6.1 on the final follow-up visit for Cohort A and from 77 to 18, and 5 for Cohort B. The final Mayo wrist scores were excellent in 4, good in 4, and moderate in 6 of the Cohort A patients, and excellent in 11, good in 8, and moderate in 2 of the Cohort B patients. Mean flexion increased to 52° from 43° for Cohort A and to 62° from 41° for Cohort B. CONCLUSIONS: AAPRC, compared to the open PRC, resulted in increased wrist motion and increased Mayo wrist scores in the long-term. Also, the third-month patient-related outcomes revealed favorable results in the AAPRC group. We attribute these findings to the earlier initiation of postoperative wrist motion and the less invasive character of the AAPRC procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pre-operative imaging for surgical decision-making and the frequency of wrist arthrodesis and carpectomy procedures: a scoping review.

OBJECTIVES: Our objectives were to (1) analyze the imaging modalities utilized pre-operatively that influence surgical decision-making for wrist arthrodesis and carpectomy procedures and (2) determine the type and frequency of these procedures for the treatment of wrist arthritis. MATERIALS AND METHODS: This review was performed according to the guidelines of PRISMA Extension for Scoping Reviews. Using PubMed, Embase, and Scopus, peer-reviewed literature from 2011 to 2022 was searched for use of imaging in pre-operative decision-making for wrist arthrodesis and carpectomy surgical procedures. Data were compiled to determine the type(s) of imaging modalities used pre-operatively and types of surgical techniques reported in the literature. RESULTS: Of 307 articles identified, 35 articles satisfied eligibility criteria, with a total of 1377 patients (68% men; age mean, 50.9 years [range, 10-81]) and 1428 wrist surgical interventions. Radiography was reported for pre-operative planning in all articles for all patients. Pre-operative cross-sectional imaging was reported in 2 articles (5.7%), but no articles reported detailed data on how CT or MRI influenced pre-operative wrist arthrodesis and carpectomy procedure decision-making. A dozen different types of surgical techniques were reported. The four most common procedures were four-corner arthrodesis with scaphoid excision (846, 59%), proximal row carpectomy (239, 17%), total wrist arthrodesis (130, 9%), and scaphocapitate arthrodesis (53, 4%). CONCLUSION: Radiography is always used in pre-operative decision-making, but the literature lacks data on the influence of CT and MRI for selecting among a dozen different types of wrist arthrodesis and carpectomy procedures.

Pyrocarbon interposition implant after lunate resection in Kienböck's disease: A case series.

In advanced stages of Kienböck's disease, the lunate is no longer conservable. One of the surgical options is to resect the lunate and replace it with a prosthesis. The procedure consisted in lunate resection and interposition of a free APSI® or Pi2® pyrocarbon implant through a dorsal approach. Follow-up was clinical and radiological on QuickDASH and PRWE scores. At a median follow-up of 3 years, 12 patients were reviewed, with a median age of 56 years. Flexion significantly decreased from 42° to 28° (p < 0.01). Extension and pronation-supination were conserved. Strength was 94% compared to the opposite side, with no significant difference from the preoperative measurement. Median QuickDASH and PRWE scores were 15.9 and 23.5 respectively and had significantly improved. One patient underwent scaphocapitate fusion because she was still in pain; the other patients were pain-free. No patients had to change jobs because of their wrist. Radiographically, there was no carpal collapse and carpal height was conserved. Radioscaphoid angle and ulnar translation were stable. There was 1 case of asymptomatic implant dislocation. Interposition of a pyrocarbon implant after lunate resection in advanced Kienböck's disease is a motion-conserving procedure that provides pain relief and functional recovery in the short and medium term. LEVEL OF EVIDENCE: IV.

InternalBrace for Intercarpal Ligament Reconstruction.

SUMMARY: Intercarpal ligament injuries such as scapholunate and lunotriquetral tears are common causes of wrist pain. There is no shortage of surgical techniques to address these injuries, nor is there a lack of literature exploring this topic. However, research progress has not led to a consensus regarding the optimal management of subacute and chronic injuries without articular wear. The senior author (K.C.C.) has performed the spectrum of reconstructive techniques, including dorsal and volar approaches, tendon weaves, ligament tenodesis procedures, reduction and association procedures, and bone-ligament-bone techniques. In the absence of convincing, consistent outcomes, the authors began investigating a novel all-dorsal reconstructive technique using the Arthrex InternalBrace system. The complexity and unpredictable outcomes associated with traditional ligament tenodesis procedures led them to adopt the all-dorsal InternalBrace technique as their primary reconstructive approach. The authors have performed more than 20 procedures with this technique since 2019. In an average tourniquet time of under 60 minutes, they are able to achieve predictable carpal stabilization, pain relief, and restoration of motion. This is the preferred reconstructive approach of the senior author.

A Case for Acute Proximal Row Carpectomy for Perilunate Injuries.

Background: Perilunate injuries are complex injuries typically arising from high-energy injuries to the wrist. Standard treatment involves open reduction and internal fixation with ligamentous reconstruction; however, outcomes are fraught with complications including pain, stiffness, and arthrosis. Several case reports have demonstrated the role of proximal row carpectomy as a salvage procedure for complex carpal trauma in the setting of significant cartilage injury or bone loss. The authors believe that proximal row carpectomy may be an appropriate acute treatment in certain patient populations, with functional results similar to those obtained with ligamentous reconstruction. Methods: A retrospective review of two cases with perilunate dislocations managed with primary proximal row carpectomy are presented. Results: At greater than 1-year follow-up, both patients had stable radiocarpal alignment. Quick-DASH scores were 22.7 and 27.3. Conclusion: Primary proximal row carpectomy is a treatment option in the acute setting for perilunate injuries in elderly, lower-demand patients. Functional results are similar to those obtained with ligamentous reconstruction, with a shorter recovery period. Level of Evidence: IV.

[Dislocation due to injury with trajectory in the scaphoid-trapezoid-trapezoid periscaphoid-perisemilunar bones. Case report and literature review]. / Luxación por lesión con trayecto en los huesos escafoide-trapecio-trapezoidea periescafo-perisemilunar. Reporte de caso y revisión de la literatura.

INTRODUCTION: dislocations of carpal bones without associated fractures are considered a rare injury, the most common mechanism of injury being axial loading with wrist in extension plus ulnar deviation. The literature reports a wide variety of complex carpal injuries, even so, it is possible to identify previously undescribed injuries. OBJECTIVE: to present an atypical case of a patient with an injury to the midcarpal stabilizing mechanism and the stabilizing mechanism of the proximal row of the wrist following trauma to the hand that required carpectomy as definitive surgical treatment. PRESENTATION OF CASE: a 48 year old male patient is presented who is admitted to our hospital unit after presenting injury to the left hand after being run over by a motor vehicle, with axial load mechanism, presenting deformity in the left thoracic extremity, fracture of the proximal metaphysis of the second phalanx of the third finger as well as dislocation of the proximal interphalangeal joint, with traumatic amputation of the second phalanx of the fourth finger plus extensor injury in zone V of the fifth finger with loss of skin coverage of the fourth and fifth finger, attending our hospital unit 24 hours after the injury. CONCLUSIONS: carpal bone dislocations are an orthopedic emergency, with 20% going unnoticed in trauma centers. Early closed reduction is the initial treatment to avoid severe complications, however, surgical treatment is the gold standard for fixation. Carpectomy is considered a mostly adequate sequelae management treatment, however it is well accepted for complex injuries to the wrist stabilization mechanisms, as it can be performed in a short surgical time and early rehabilitation can be initiated and functional ranges of motion can be achieved with low sequelae.

INTRODUCCIÓN: las luxaciones de los huesos del carpo sin presentar fracturas asociadas se considera una lesión infrecuente; el mecanismo de lesión más común es la carga axial con muñeca en extensión más desviación cubital. La literatura reporta una gran variedad de lesiones complejas del carpo; aun así, es posible identificar lesiones no descritas previamente. OBJETIVO: presentar caso atípico de paciente con lesión a nivel del mecanismo estabilizador medio-carpiana y estabilizador de la fila proximal de la muñeca posterior a traumatismo en mano que requirió carpectomía como tratamiento quirúrgico definitivo. PRESENTACIÓN DEL CASO: paciente masculino de 48 años de edad, quien ingresa a nuestra unidad hospitalaria tras sufrir lesión en mano izquierda posterior a ser arrollado por vehículo automotor, con mecanismo de carga axial, presentando en extremidad torácica izquierda deformidad hacia volar, fractura de metáfisis proximal de segunda falange del tercer dedo así como luxación de articulación interfalángica proximal, con amputación traumática de segunda falange del cuarto dedo más lesión extensora en zona V del quinto dedo con pérdida de cobertura cutánea del cuarto y quinto dedos. Acude a nuestra unidad hospitalaria 24 horas después de la lesión. CONCLUSIONES: las luxaciones en huesos del carpo es una urgencia ortopédica, pasando desapercibidas en 20% en centros de traumatología. La reducción cerrada temprana es el tratamiento inicial para evitar complicaciones severas; sin embargo, el tratamiento quirúrgico es el estándar de oro para la fijación de las mismas. La carpectomía se considera un tratamiento mayoritariamente para el manejo adecuado de secuelas; sin embargo, es bien aceptado para las lesiones complejas que se presentan en los mecanismos estabilizadores de la muñeca, dado a que se puede realizar en un tiempo quirúrgico y se puede iniciar una rehabilitación temprana, con lo que se pueden alcanzar rangos de movimientos funcionales y con bajo grado de secuelas.

Pathophysiology of Avascular Necrosis.

Avascular necrosis is a complicated, multifactorial disease with potentially devastating consequences. Although the underlying root cause is a lack of appropriate vascular perfusion to affected bone, there are often varying patient-specific, anatomic-specific, and injury-specific predispositions. These factors generally fall into 3 categories: direct vascular disruption, intravascular obliteration, or extravascular compression. The initial stages of disease can be insidiously symptomatic because edematous bone marrow progresses to subchondral collapse and subsequent degenerative arthritis. Although much of the current literature focuses on the femoral head, other common areas of occurrence include the proximal humerus, knee, and the carpus. The low-incidence rate of carpal avascular necrosis poses a challenge in establishing adequately powered, control-based validated treatment options, and therefore, optimal surgical management remains a continued debate among hand surgeons. Appreciation for expectant fracture healing physiology may help guide future investigation into carpal-specific causes of avascular necrosis.

Vascular Supply of the Wrist.

The vascular anatomy of the wrist is vital in the development of multiple disorders at the carpus. Understanding this vascular network may prevent iatrogenic injury to the blood supply and can be used by surgeons through vascularized bone grafts. Multiple surgical techniques take advantage of the vascular network. This article reviews the blood supply of the distal radius, ulna, and carpal bones and its clinical implications.