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

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

Minimally Invasive Procedure for Correcting Extra-Articular Malunions of Metacarpals and Phalanges.

PURPOSE: Extra-articular malunions of metacarpals and phalanges may cause palmar pain, finger scissoring, and splaying, and interfere with function. Current treatment involves open osteotomy and fixation with plates and screws. We present a minimally invasive method using cannulated headless screws for correction of malunions and examine the outcomes in a series of patients. METHODS: Twenty malunions were operated on in 17 patients. In 16 cases, the malunion involved the metacarpal and in 4 it involved the proximal phalanx. All proximal phalanx and 3 metacarpal malunions were malrotation types, while the rest of the metacarpal malunions were dorsal angulations. The operation consisted of an opening wedge osteotomy in 8 patients; closing wedge osteotomy in 5; and a transverse osteotomy and derotation in the rest. Concomitant surgery to release tendon adhesions or contracted joints or to perform adipofascial flaps was performed in 8 cases. Fixation was achieved by means of a cannulated headless screw. Immediate range of motion was permitted in all cases. RESULTS: Correction of the malunion and osteotomy union was achieved in all cases. One patient required manipulation of a digit that was found rotated at the first follow-up visit. Eleven fingers achieved more than 280° of total active motion. In 9 digits, the total active motion was less than 280° after the operation, yet improved 76° (range, 140°-30°) from their preoperative total active motion. The mean single-assessment numeric evaluation score for the whole group was 9.1. CONCLUSIONS: The fixation provided by the cannulated headless screw is sufficient to permit immediate range of motion. Due to the minimal tissue disruption, this approach may be a reasonable alternative to the standard approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Collapse after Carpal Bone Tunneling. An Underreported Complication?

PURPOSE: To report the complication of carpal bone tunnel collapse in scapholunate reconstruction. METHODS: The authors present six cases of carpal collapse or bone necrosis after bone tunneling for ligamentous reconstruction, three in the scaphoid bone and three in the lunate. RESULTS: All six cases were secondary to ligament reconstruction for chronic scapholunate dissociations, none of which had preoperative structural scaphoid or lunate deformities. CONCLUSIONS: Although the incidence of this occurrence is unknown, the consequences could be substantial; therefore, patients should be warned of this possibility when discussing complications of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Outcomes of Arthroscopic-Assisted Distal Radius Fracture Volar Plating: A Meta-Analysis.

PURPOSE: The use of wrist arthroscopy to assist fixation of distal radius fractures with volar locking plates (VLPs) has been gaining popularity in recent years; however, there is no consensus on its benefits. This meta-analysis compares outcomes of arthroscopic-assisted VLP to fluoroscopic-assisted VLP in distal radius fractures through a systematic review of the published literature. METHODS: A systematic search of publications from databases (Medline, EMBASE, Scopus, and Cochrane) was obtained from inception to May 2020. A random-effects meta-analysis was used to calculate effect sizes. Outcomes included postoperative radiographic reduction (gap, stepoff, radial inclination, volar tilt, and ulnar variance), procedural outcomes (operative time, additional soft tissue injuries and complications), and functional outcomes (range of motion; visual analog scale score; Disabilities of the Arm, Shoulder, and Hand score; Patient-Rated Wrist Evaluation score; Mayo clinic score; and grip strength). RESULTS: Six studies, involving 280 patients, met the final inclusion criteria. The meta-analysis for postoperative stepoff was statistically significant, favoring arthroscopic-assisted VLP. In addition, there was greater identification of associated soft tissue injuries, increased wrist extension, and a longer operative duration when performing arthroscopic-assisted VLP fixation. There were no differences in other postoperative radiographic outcomes, complications, or functional outcomes. CONCLUSIONS: The current literature suggests that arthroscopic-assisted VLP is a useful adjunct to intra-articular reduction and treatment of associated soft tissue injuries in distal radius fractures. Considerations should include operative time, costs, and the additional training required. Further studies are needed to assess functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Free vascularized second metatarsophalangeal joint transfer for scaphotrapezial joint reconstruction after distal scaphoid excision and carpal collapse: A case report.

Treatment of the destroyed scaphotrapezial (ST) joint in young patients is challenging due to the limited available options as they might not tolerate the stiffness, loss of grip strength and long-term complications of partial fusions, bone resections, and interposition implants or arthroplasties. This report presents the results of a free osteocutaneous joint transfer used to reconstruct the ST joint in a young patient suffering from ST destruction and carpal collapse. This 34-year-old patient was previously treated for a right scaphoid nonunion with distal scaphoid excision and interposition implant that evolved to destruction of the ST space, symptomatic carpal collapse associated and a ST height loss of 7 mm. The DASH score was 34 and the grip strength of 32 kg. The patient was treated with an osteocutaneous vascularized free transfer from the second metatarsophalangeal joint vascularized by the first dorsal metatarsal artery and anastomosed to the palmar carpal branch of the radial artery and a palmar superficial vein. After 3.5 months, the patient returned to full duty work as a mechanic. At the last follow-up, 3 years after the surgery, the patients had complete range of motion without clinical nor radiological degenerative changes. There were no postoperative complications. The DASH score was 3 and the grip strength was 53 kg. This reconstructive procedure allows to recreate a functional ST joint and to correct a carpal collapse avoiding degenerative wrist changes. It may be proposed to young patients who aim to recover a near normal function of their wrist.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Dry Wrist Arthroscopy for Ulnar-Sided Wrist Disorders.

With the evolution of dry wrist arthroscopy, there is an ever-increasing role for its use in the treatment of disorders of the wrist including ligament repair or reconstruction, bony procedures such as distal radius corrective osteotomies or fracture fixation, and partial arthrodesis. We describe some of the tips and tricks that can be used to manage ulnar-sided wrist pain. We particularly emphasize the different technical points to perform dry wrist arthroscopy compared with previously described wet arthroscopic procedures.

Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders.

The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.

Effectiveness of an Arthroscopic Technique to Correct Supination Losses of 90° or More.

PURPOSE: To present a new arthroscopic method for treating supination losses. METHODS: Six patients (15-71 y) were eligible for this study. All had a history of trauma to the wrist more than 6 months previously. Five of them had sustained a distal radius fracture: 3 had been treated with a volar plate (1 of them for an extra-articular malunion), 1 with an external fixator and K-wires, and 1 had been treated in a cast. One of these patients underwent a further operation for correcting an intra-articular malunion. The last patient underwent an open reduction of a transscaphoid perilunate dislocation. During a standard radiocarpal arthroscopy, a curved periosteal elevator was inserted through the 6R portal into the volar-radial corner of the triangular fibrocartilage complex and advanced proximally gliding on the anterior ulnar head surface. The volar capsule was then distended with the periosteal elevator and by means of gentle sweeping motion adherences between them, the volar capsule and the ulnar head were freed. Finally, the arthroscopic release was combined with a gentle passive supination force applied by the surgeon. Full supination was maintained in an orthosis for 2 to 3 days. Afterward, regular physical therapy was instituted. Concomitant surgery, arthroscopic or open, was performed in all to treat associated conditions. RESULTS: Full supination (90°) was achieved in all intraoperatively. At a mean follow-up of 3.3 years, mean supination was 76° in the latest follow-up (range, 50° to 90°). Mean improvement in supination was 80° (range, 50° to 100°). No distal radioulnar instability or other complications were noted. CONCLUSIONS: The method presented proved effective in severe forms of supination deficits. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Arthroscopic Partial Capitate Resection for Type Ia Avascular Necrosis: A Short-Term Outcome Analysis.

PURPOSE: To examine short-term clinical results of arthroscopic partial resection for type Ia avascular necrosis of the capitate. METHODS: Patients who underwent arthroscopic treatment for type 1a avascular necrosis of the capitate with at least 1-year follow-up were identified through a retrospective chart review. The necrotic capitate head was arthroscopically resected with removal of the lunate facet and preservation of the scaphoid and hamate facets. Wrist range of motion, grip strength, and radiographic parameters--carpal height ratio, radioscaphoid angle, and radiolunate angle-were determined before surgery and at the latest follow-up. Patients completed a visual analog scale for pain; Disabilities of the Arm, Shoulder, and Hand measure; and the Patient-Rated Wrist Evaluation score before surgery and at the latest follow-up. RESULTS: Five patients (1 male, 4 females) with a mean age of 34 years (range, 16-49 years) and a mean follow-up duration of 20 months (range, 12-36 months) were identified during the chart review. All were type Ia (Milliez classification). Arthroscopy revealed fibrillation or softening with cartilage detachment at the lunate facet of the capitate head and an intact articular surface at the scaphoid and hamate facet. At the latest follow-up, the mean wrist flexion-extension was 123° (vs 81° before surgery) and grip strength was 74% (vs 37% before surgery). The visual analog scale score for pain; the Disabilities of the Arm, Shoulder, and Hand score; and the Patient-Rated Wrist Evaluation score before surgery showed a significant improvement following treatment. Radiographic parameters did not significantly change at the final follow-up, although the proximal carpal row trended toward flexion. CONCLUSIONS: Arthroscopic partial resection of the capitate head was an acceptable treatment for type Ia avascular necrosis of the capitate. It provided adequate pain relief and improved the range of wrist motion and grip strength during short-term follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Foot web free flaps for single-stage reconstruction of hand webs.

PURPOSE: To present a method for reconstructing the digital web in posttraumatic defects using a free tissue transfer of the web from the foot and to present the functional and aesthetic results. METHODS: Nine web free flaps were performed; 8 were used to reconstruct posttraumatic web losses and 1 was used to reconstruct a defect resulting from to infection. All cases involved the first (3) or second (6) webs of the hand. Web flaps were taken from the foot first web (2 patients), from the second (6 cases), and from the third (1 case) in a patient with congenital syndactyly of second foot web space. The donor site was managed by skin grafting from the instep (1 case), creation of a syndactyly (7 cases), or both (1 case). RESULTS: All flaps survived without complications. Finger abduction and flexion-extension were similar to the contralateral side. No functional limitations, pain, or contracture were reported. One donor site healed with hypertrophic scars; otherwise, no donor site complications occurred. On a visual analog scale (0-10), the patient assessed appearance of the hand and the donor foot as 9.0 and 9.0, respectively, on average. One web was not well-positioned in the first operation and required revision. CONCLUSIONS: The foot web free flap reconstructs the hand web by replacing it with a similar functional subunit rather than attempting to recreate the complex geometry, and allows for full function and excellent appearance of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws.

PURPOSE: To present the technique, indications, and outcomes of metacarpal and phalangeal fractures fixed with intramedullary cannulated headless screws (CHS). METHODS: We retrospectively reviewed all charts of patients whose metacarpal and phalangeal fractures had been treated with intramedullary CHS in our practice. A total of 69 fractures (48 metacarpal and 21 phalangeal) were identified in 59 patients. Seventeen were open fractures. Eleven patients had multiple fractures (29 in total); of those, 21 were managed with CHS. In 4 other fractures the method was abandoned intraoperatively. The defect created by the entrance of the screw in the proximal phalanx was identified by computed tomography in 20 patients. RESULTS: In 63 fractures a single screw was used; in 6 fractures 2 screws were used to provide stronger fixation. All patients returned to full duties or sport activities at an average of 76 days (range, 3 wk to 15 mo). At the latest follow-up (range, 5-54 mo; average, 19 mo) total active motion was on average 247° (range, 150° to 270°) for all fractures, 249° (range, 210° to 270°) for metacarpal, and 243° (range, 150° to 270°) for proximal phalangeal fractures. All fractures were healed and within acceptable radiological parameters. A comminuted basilar phalangeal fracture displaced secondarily yielding a poor functional result. Two patients required tenolysis and further procedures before the final result was achieved. The screw hole represents around 20% of the proximal phalanx distal articular surface. CONCLUSIONS: Unstable transverse fractures in the phalanx and metacarpal are amenable to single intramedullary CHS fixation. Comminuted fractures require more complex configurations. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes of free adipofascial flaps combined with tenolysis in scarred beds.

PURPOSE: To review our outcomes of transferring vascularized free adipofascial flaps used to change the local tissue conditions at the time of tenolysis in adhesion-prone beds. METHODS: Eleven free adipofascial flaps were transplanted in 10 patients after tenolysis on the forearm (3 cases), the dorsum of the hand (5 cases), or the dorsum of the proximal phalanx (3 cases). All recipient areas had badly scarred beds, 7 of which had previously failed tenolyses. In addition to tenolysis (10) or the insertion of bridging tendon grafts (1), arthrolysis of several involved joints and bone fixation for nonunion (3 cases) were carried out simultaneously. The adipofascial flap was then wrapped around the tendons or interposed between the scarred tissue and the freed tendons. In 8 cases, the flap was the lateral arm adipofascial flap, whereas adipose flaps from the toes were used for the fingers. RESULTS: All flaps survived without vascular crisis. In all cases, total active motion was similar to the passive motion obtained at surgery. Average Disabilities of the Arm, Shoulder, and Hand score improved from 69 to 10, and average Patient-Rated Wrist Hand Evaluation score improved from 65 to 9. Secondary surgery was needed to reduce the bulk of the flap in 3 patients. One patient required an additional procedure to obtain an optimum result. CONCLUSIONS: Free adipofascial flaps provided satisfying results in this group of patients. The flaps should be considered when the bed is scarred or after a failed tenolysis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic reduction of comminuted intra-articular distal radius fractures with diaphyseal-metaphyseal comminution.

PURPOSE: In the setting of severely comminuted diaphyseal-metaphyseal fractures of the distal radius, arthroscopic reduction of the joint surface is difficult and often results in shortening and collapse. Yet, several authors have shown the benefits of arthroscopy in articular distal radius fractures. We present a method that safely allows a combination of arthroscopic reduction and rigid fixation and describe the outcomes in a small group of patients. METHODS: Four consecutive patients with severely comminuted diaphyseal-metaphyseal articular fractures of the distal radius were treated using the stable reference fragment technique. For all cases, we used an extra-long volar locking plate applied to the diaphysis of the radius. Preoperative computed tomography scanning was used to identify the largest articular fragment. This reference fragment was reduced and stabilized with locking pegs or screws to the volar plate under fluoroscopic guidance. The articular reduction continued arthroscopically, using the reference fragment as a guide. Once the articular reduction was complete, the comminuted metaphysis was addressed and secured to the plate. RESULTS: All patients achieved excellent clinical and radiological results. Flexion-extension averaged 124° and pronation-supination averaged 174°. One patient showed minor signs of radiocarpal osteoarthritis on radiographs at 3 years. CONCLUSIONS: By securing the reference fragment before addressing the metaphyseal comminution, a stable platform was created. Thus, intra-articular reduction was achieved while maintaining extra-articular alignment. Although the results were excellent, the number of cases was small. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Onycho-osteo-cutaneous defects of the thumb reconstructed by partial hallux transfer.

PURPOSE: To present our experience in distal thumb amputations reconstructed by partial toe to hand transfers with special emphasis on manual workers. METHODS: Twenty-five patients who experienced amputation of the thumb distal to the interphalangeal joint, excluding pure soft tissue losses, were included in the study. All but 2 were manual workers. Twenty were reconstructed within 2 weeks after injury. The other 5 were referred late. In all patients, the ipsilateral hallux was used as donor, based on the proper digital artery (18 cases), the intermetatarsal artery (6 cases), and the dorsalis pedis artery (1 case). RESULTS: All transferred flaps survived. At a minimum follow-up of 1 year (range, 1-14 y), active range of motion at the interphalangeal joint was more than 55° in 23 patients. Two had an interphalangeal joint arthrodesis, 1 of them before referral. Pinch and grip were similar to the contralateral side. Two-point discrimination was normal in the dorsal oblique amputations and 7 to 11 mm in the rest. Patient satisfaction was high from a functional and aesthetic standpoint (9.5 out of 10 on a visual analog scale for both outcomes). All patients returned to work 2 to 4.5 months after the operation. Delayed donor site healing was noticed in 4 cases. CONCLUSIONS: In contrast to classic teaching that recommends stump closure for cases of distal thumb amputation, we attained excellent results with partial toe transfer in manual workers. In our experience, the thumb can be restored to nearly normal with an acceptable donor site sequela. The best indication is for cases of dorsal oblique amputations, because thumb sensibility is unaffected, and for amputations where the germinal matrix is preserved, because nail regrowth occurs. Early transfer is strongly recommended. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The stacking concept: cannulated screws for extra-articular metacarpal base fracture of the thumb.

An alternative technique to treat extra-articular fractures of the base of the first metacarpal with intramedullary canulated headless screws is presented. The principle is creating an internal fixator within the medullary canal by introducing multiple retrograde screws until they have jammed.

Salvage of failed proximal interphalangeal arthroplasty with vascularised toe joint transfer: Report of two cases.

Failed implants of the proximal interphalangeal joint may result in bone and soft tissue deficits and joint instability with limited reliable options for reconstruction besides an arthrodesis procedure. The purpose of this report is to illustrate the use of vascularized second toe joint for salvage of failed, multi-operated proximal interphalangeal joint in two active patients. Pre-existing scars are used to define the approach and choice of donor site. Flow through anastomosis was performed on the finger digital artery. At final follow-up, the transplanted joints achieved 80-90 degrees of motion and the patients were able to return to their desired level of activities. The procedure is a good alternative for the fit patient wanting to achieve a stable finger with preservation of motion in catastrophic failure of prosthetic proximal interphalangeal joint arthroplasty.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects.

PURPOSE: To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes. METHODS: Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred. RESULTS: All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100). CONCLUSIONS: Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Diagnosis and Outcomes of 225 Consecutive Cases of Complex Regional Pain Syndrome of the Hand.

BACKGROUND: The lack of specific tests and potential diagnostic inaccuracy may be behind the stunning figures of complex regional pain syndrome (CRPS) cases. The author tested the hypothesis that patients diagnosed with CRPS at referral could be assigned to recognized conditions and treated accordingly. METHODS: From January of 2018 to April of 2021, 225 consecutive patients attended the author's office having been diagnosed with and treated for CRPS for an average of 16 ± 26 months. There were 180 women and 45 men; no patient was excluded. RESULTS: All patients could be allocated in named conditions: 79 had a wrong diagnosis; seven had a true causalgia; 16 were dystonic-psychogenic hands; 20 presented a flare reaction; and 90 had an "irritative" carpal tunnel syndrome. The remaining 13 patients had a miscellany of symptoms within a substandard management setting. Surgery was offered to 175 with a correctable cause; 50 (20 of whom had a tangible cause responsible for their pain) declined, and their outcome is unknown. The remaining 125 were operated on and tracked for an average of 20 ± 9 months. In the operated group, pain dropped 7.5 ± 2.2 points ( P < 0.0001) on a numerical rating scale of 0 to 10. Disabilities of the Arm, Shoulder, and Hand questionnaire scores fell from 80 to 16 ( P < 0.0001). Patients who were operated on rated their satisfaction on a scale of 0 to 10 as 8.9 ± 1.9. CONCLUSIONS: Unlike with CRPS, all patients in this series had a true, diagnosable condition explaining their clinical picture. Most patients who agreed to be operated on had a favorable outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

MR and CT arthrography of the wrist.

The study of the wrist represents a major diagnostic challenge because of its complex anatomy and the small size of individual structures. Recent advances in imaging techniques have increased our diagnostic capabilities. However, 3T magnets, multichannel specific wrist coils, and new MRI sequences have not restricted the indications of arthrographic imaging techniques (CT arthrography and MR arthrography). Distension of the different wrist compartments at CT arthrography and MR arthrography significantly improves the diagnostic accuracy for triangular fibrocartilage (TFC) complex injuries and carpal instability. Dedicated multichannel wrist coils are essential for an adequate study of the wrist, but the placement of these coils and the positioning of the wrist are also important for proper diagnosis. The development of dynamic multislice CT studies allows a diagnostic approach that combines dynamic information and the accurate assessment of ligaments and the TFC complex. New advances in arthroscopy have changed the anatomical description of the TFC with a functional division in the proximal and distal TFC complex, and they have allowed a better characterization of lesions of the TFC complex with subclassification of Palmer 1B and 1D lesions and description of new lesions not included in the Palmer classification, such as capsular injuries.