[Amputations of fingers and the hand]. / Amputationen an den Fingern und der Hand.

Revision amputation, ray amputation and narrowing of the hand can be indicated for pathological alterations of fingers and thumbs due to traumatic, inflammatory or vascular causes but also for functional deficits regarding mobility, sensibility, perfusion, and/or pain. Surgical amputation is considered if reconstructive options are no longer possible, not desired and are no longer meaningful with respect to effort and risks. Patients need to be informed about the expected deficits in function and esthetic appearance due to the amputation in advance. On the other hand, surgical amputations represent a good treatment option, for which the duration of treatment and scope are well estimated. Therefore, they are good options for patients with comorbidities, with concerns about extensive reconstructive surgery and with limited compliance. It is essential to respect anatomical and functional aspects to guarantee favorable surgical results and avoid complications, which might compromise the function of the hand beyond that which is unavoidable. The most frequent complications after creating a stump or ray resection are persistent pain, unstable skin and soft tissue conditions, mobility disorders, disturbing stumps without function, uncontrolled growth of nail remnants and recurrent inflammation.

Carpal Instability: I. Pathoanatomy.

The pathoanatomy of carpal instability is multifactorial and usually complex. A thorough medical history and clinical examination are essential, as well as profound knowledge of the specific instability patterns. The stability of the wrist is ensured by the carpal joint surfaces, by intact intra-articular (particularly the scapholunate interosseous ligament) and intracapsular ligaments, and by crossing extensor and flexor tendons, the latter making the proximal carpal row an "intercalated segment." An important classification feature is the distinction between dissociative and nondissociative forms of carpal instability. Among others, scapholunate dissociation, lunotriquetral dissociation, midcarpal instability, and ulnar translocation are the most common entities. Early forms of instability are considered dynamic. In the natural course, static instability of the wrist and osteoarthritis will develop. This review focuses on the pathoanatomical fundamentals of the various forms of carpal instability.

Outcome of proximal interphalangeal joint replacement with pyrocarbon implants: a long-term longitudinal follow-up study.

INTRODUCTION: The aim of this study was to compare the short-, mid-, and long-term results of pyrocarbon PIPJ arthroplasty. MATERIALS AND METHODS: Twenty-seven consecutive patients (9 males, 18 females) had arthroplasty for 32 pyrocarbon PIPJ prostheses. Two patients (two joints) were lost for follow-up. Four implants were removed during follow-up. Fifteen patients (18 implants) were available for a long-term follow-up assessment on average 9.7 (9-10.8) years postoperatively and seven patients with eight implants had telephone interviews to calculate the implant survival and complications. Of the 15 patients who came to the latest follow-up, 12 (14 implants) passed each of the three follow-up visits for short-term (ø 19 months), mid-term (ø 54 months), and long-term follow-up (ø 9.8 years) to compare functional and radiological parameters longitudinally. RESULTS: In total, seven of the 30 joints (23%) required a revision surgery, all within the first 2 years postoperatively, including three arthrodesis due to early infection or dislocation, and one distal component removal due to primary loosening. Three patients required soft tissue revisions. The implant survival after 9 years was 87%. There was minimal pain at rest throughout the 9-year follow-up analysis; pain with activity was rated 1.9 at the short-term assessment, 1.5 at mid-term, and 1.6 at long-term. The average active range of motion was at short-, mid-, and long-term examination 49°, 50°, and 48° and grip strength averaged 24, 24, and 21 kg, respectively. The DASH score was stable with 35, 36, and 33 points. At the long-term follow-up, all evaluated implants showed radiological signs of implant loosening or migration. According to the PIP joint outcome score, 57% resulted finally in a "good" outcome. CONCLUSIONS: Pyrocarbon PIPJ arthroplasty has a risk of early complications necessitating revision surgeries. In spite of radiological implant migration, good pain relief, grip strength, and high quality-of-life ratings are stable for a long time.

Parameters influencing hand grip strength measured with the manugraphy system.

BACKGROUND: This study aimed to determine whether sex, hand length and the individual training status affect hand strength and whether these measurements differ if they are recorded using the Jamar dynamometer or a new cylindrical measuring system. METHODS: For this purpose, 152 healthy adults were examined using a new manugraphy measuring system (novel, Munich, Germany) comprising two measuring cylinders of different sizes and a Jamar electronic dynamometer with two grip positions corresponding approximately to the sizes of the cylinders. A descriptive analysis was performed as well as a correlation analysis using the Pearson correlation coefficient. To prepare predictive models, multiple linear regression analyses were carried out to determine factors that influence the force and p ≤ 0.05 was considered statistically significant. RESULTS: A significant difference in the maximum and mean strength was observed that is dependent on sex, with men stronger than women, in line with expectations, and hand length, with small hands able to exert less force than large hands. No consistent increase in strength could be attributed to repetitive manual loads applied either at work or in leisure activities. CONCLUSIONS: Both measurement techniques yielded similar results, suggesting that manugraphy is well suited for clinical research purposes because it not only takes measurements that are just as reproducible and valid as the conventional measurement technique but in doing so measures not just the total strength of a hand but also enables more precise comparisons of isolated hand regions applying dynamic measurements.

Influence of Maximal or Submaximal Effort on the Load Distribution of the Hand Analyzed by Manugraphy.

PURPOSE: This study aims to investigate if the hands' load-distribution pattern differs during maximal and submaximal grip. METHODS: Fifty-four healthy subjects used the 200-mm Manugraphy cylinder to assess the load-distribution pattern of both hands. On 2 testing days, the subjects performed grip-force testing: 1 hand with maximal effort and the other with submaximal effort. Sides changed for the second testing day. The whole contact area of the hand was sectioned into 7 anatomical areas, and the percent contribution of each area, in relation to the total load applied, was calculated. Maximal and submaximal efforts were compared across the 7 areas in terms of load contributions. RESULTS: Comparing maximum effort of the left and right hand, the load distribution was very similar without statistically significant differences between the corresponding areas. Comparing the maximal and the submaximal effort for each hand, 4 (left) and 5 (right) of the 7 corresponding areas showed statistically significant differences. Comparing the right hand, performing with maximal effort, with the left hand, performing with submaximal effort, 5 areas varied significantly. With the right hand performing submaximal effort, all 7 anatomical areas were significantly different. CONCLUSIONS: The load distribution of a healthy hand is different when performing with submaximal effort compared with maximal effort. To analyze a hand's load-distribution pattern, the opposite hand can be used as a reference. CLINICAL RELEVANCE: The hand's load-distribution pattern may be a useful indication of submaximal effort during grip-force testing.

Load distribution of the hand during cylinder grip analyzed by Manugraphy.

STUDY DESIGN: Clinical measurement and basic research. INTRODUCTION: Manugraphy allows assessing dynamically all forces applied perpendicular to a cylinder surface by the whole contact area of the hand with a high spatial resolution. PURPOSE OF THE STUDY: To identify the physiological load distribution of the whole contact area of the hand during cylinder grip. METHODS: A sample of 152 healthy volunteers performed grip force tests with 3 cylinder sizes of the Manugraphy system (novel, Munich, Germany) on 3 different days. The whole contact area of the hand was sectioned into 7 anatomic areas, and the percent contribution of each area in relation to the total load applied was calculated. The load distribution of the dominant and nondominant hands and with different cylinder sizes was compared. Furthermore, the load distribution between the finger phalanges of each finger was analyzed. RESULTS: The results for the dominant and nondominant hands were in all 7 areas of the hand similar with the percent contribution differing within a range of 1%-4% (P > .138). Load distribution changed significantly with different cylinder sizes: all 7 areas differed between 1% and 7% with P < .001, most pronounced for the thumb. The load distribution of the phalanges showed that the contribution of the distal phalanges increased with ascending cylinder size, whereas the contribution of the proximal phalanges decreased. The interindividual variability of the load distribution pattern was noticeable. DISCUSSION: For the clinical practice, Manugraphy might be a useful supplement to traditional grip force measurement for identifying the individual characteristics of a patient's dysfunction and monitoring the progress of hand rehabilitation. CONCLUSIONS: There is no universal or typical load distribution pattern of the hand but only an individual pattern. To evaluate a compromised hand, it is permissible to compare it with the healthy opposite hand as a reference. Several cylinder sizes should be used for load distribution testing. Using smaller handles in the daily life can help to compensate impairment of the thumb and fingertips. LEVEL OF EVIDENCE: 2.

The Effect of Midcarpal Versus Total Wrist Fusion on the Hand's Load Distribution During Gripping.

PURPOSE: To analyze the total grip force and load distribution of the hand with midcarpal fusion (MCF) and total wrist fusion (TWF). METHODS: Twelve patients with unilateral TWF and 12 patients with unilateral MCF were assessed at an average 64 months (range, 19-100 months) postoperatively. The total grip force and load distribution of both hands were measured by the Manugraphy system using 3 cylinder sizes. The load applied to 7 anatomical areas of the hand during cylinder grip was analyzed, comparing the operated and the nonsurgical hands. RESULTS: For the 100 mm and 150 mm cylinders, a significantly lower total grip force was found in hands operated with either TWF or MCF. For the 200 mm cylinder, there was a significant difference between nonsurgical hands and those with MCF but not between nonsurgical hands and those with TWF. For the 100 mm cylinder, the difference between nonsurgical and operated hands was greater in hands with TWF than those with MCF. For the load distribution of the hand, no differences between the operated and the nonsurgical hand were found for either MCF or TWF. CONCLUSIONS: MFC and TWF resulted in a reduced cylinder grip force. With respect to the load distribution, neither procedure influenced the relative contribution that each area of the hand produced during cylinder grip. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Midcarpal fusion is also indicated in patients with advanced carpal collapse and already highly restricted range of motion preoperatively.

Although midcarpal fusion is a well-accepted treatment of advanced carpal collapse, 1 question remains unanswered: is this technically demanding procedure worthwhile in wrists with an already highly restricted flexion-extension arc (FEA) of less than 60 degrees preoperatively? Therefore, a retrospective analysis of the records of 142 consecutive patients who had had a midcarpal fusion of the wrist was performed. There were 50 patients in group 1 (FEA < 60 degrees) and 92 patients in group 2 (FEA ≥ 60 degrees) with a mean follow-up of 23 months. Flexion-extension arc preoperatively and postoperatively, pain evaluated by a visual analog scale from 0 to 10 as well as the patients' upper extremity functioning captured with the Disabilities of the Arm, Shoulder and Hand questionnaire were statistically analyzed. Functional range of motion was defined as 5-degree wrist flexion and 30-degree wrist extension. Median wrist flexion before versus after midcarpal fusion was 18 versus 22 degrees and 23 versus 25 degrees for wrist extension in group 1. In group 2, the data were 42 versus 27 degrees and 43 versus 30 degrees, respectively. Midcarpal fusion led to an improvement of FEA in 52% of patients in group 1 but only in 5.4% of patients in group 2. In group 1, the median FEA improved by 122%, whereas the median FEA declined to 69% in group 2. Preoperatively 20% of patients in group 1 and 95% of patients in group 2 reached a functional range of motion for flexion/extension, which changed to 36% in group 1 versus 62% in group 2 postoperatively. The visual analog scale score improved for group 1 from 5.7 to 2.4 and for group 2 from 5.7 to 3.2, respectively. The postoperative DASH score was for both groups 33 points. Our data demonstrate that even in patients with a highly restricted range of motion in advanced carpal collapse, it is still reasonable to perform a midcarpal fusion instead of total wrist fusion.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance.

INTRODUCTION: The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius' angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance. MATERIALS AND METHODS: For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6-8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one. RESULTS: Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly. CONCLUSIONS: Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

Force loss and distribution of load in the hands of patients with cubital tunnel syndrome.

Manugraphy with three different cylinder sizes was used to quantify the contribution of fingers, thumb and palm to grip force in patients with unilateral cubital tunnel syndrome. Forces in the affected and contralateral hands differed by up to 29%. Although grip force is usually maximal when gripping small handles, ulnar nerve palsy resulted in similar absolute grip forces using the 100-mm and 200-mm cylinders. The contact area between the affected hand and the cylinders was reduced by 5%-9%. We noted a high correlation between the contact area and grip force, visible atrophy and permanently impaired sensibility. The load distribution differed significantly between both hands for all cylinder sizes. When gripping large objects, the main functional impairment in cubital tunnel syndrome is weakness in positioning and stabilizing the thumb. Weak intrinsic finger muscles are responsible for loss of force when gripping small objects. Level of evidence: III.

Prospective study on harvesting autologous bone grafts from the anterior iliac crest using a new specialized reamer.

The iliac crest remains the most frequent donor site for bone harvesting. Despite the surgical access to the iliac crest being relatively simple and the operation being carried out regularly, there are frequent complications. Therefore, a new, manual iliac crest reamer (R group) was compared to the classical harvesting of a corticocancellous bone graft by means of an oscillating saw (Con group) in a prospective study on 80 consecutive patients having hand surgery. Follow-up time was 3 months. Operation time and incidence of hematomas, seromas, and paresthesias in the R group were significantly shorter and less, respectively, than in the Con group. Pain at harvest site measured with the visual analogue scale (VAS) at 5 days, 6 weeks, and 12 weeks postoperatively was significantly less in group R as well. The utilization of the iliac crest reamer allows bone graft harvest in a relatively quick and simple operation with relatively few complications but with the limitation in that the maximum diameter of a bone cylinder that it can harvest is 20 mm.

Radiographic diagnosis of scapholunate dissociation among intra-articular fractures of the distal radius: interobserver reliability.

PURPOSE: To evaluate the reliability and accuracy of diagnosis of scapholunate dissociation (SLD) among AO type C (compression articular) fractures of the distal radius. METHODS: A total of 217 surgeons evaluated 21 sets of radiographs with type C fractures of the distal radius for which the status of the scapholunate interosseous ligament was established by preoperative 3-compartment computed tomographic arthrography with direct operative visualization of diagnosed SLD (reference standard). Observers were asked whether SLD was present, and if yes, whether they would recommend operative treatment. Diagnostic performance characteristics were calculated with respect to the reference standard. We assessed interobserver reliability using the Fleiss generalized kappa. RESULTS: The interobserver agreement for radiographic diagnosis of SLD was moderate (κ = 0.44). Correct diagnosis for a given set of radiographs ranged from 8% to 98% (average, 79%) of observers. Diagnostic performance characteristics were: 69% sensitivity, 84% specificity, 84% accuracy, 68% positive predictive value, and 84% negative predictive value. Based on a prevalence of 5%, Bayes adjusted positive and negative predictive values were 18% and 98%, respectively. Raters recommended operative treatment in 74% to 100% of patients diagnosed with SLD. CONCLUSIONS: Radiographs are moderately reliable and are better at ruling out than ruling in SLD associated with type C fracture of the distal radius.

Improvement of research quality in the fields of orthopaedics and trauma: a global perspective.

The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon's knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today's "Cross Check Era", too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.

The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability.

INTRODUCTION: The reproducibility of diagnoses based on photo documents in wrist arthroscopies is limited and is expected to improve through the addition of video documents. AIM: The purpose of this study was to determine the effect of additional video documentation to photo documentation on intra- and interobserver reliability in wrist arthroscopies. MATERIALS AND METHODS: Sixty consecutive arthroscopies were documented by photographs of at least eight standard views and videos of the radiocarpal and midcarpal joints. After 3 months, the photographs and then the photographs together with the videos were reevaluated by the surgeon and by two hand surgeons to determine intra- and interobserver reliability. Percentage agreement and kappa coefficients were calculated. RESULTS: Using videos along with the photographs did not improve reproducibility in general. The assessments of the cartilage status were even worse. Some of the videos were criticized as being too short to allow adequate assessment of the cartilage. Lesions of the TFCC as well as its tension were assessed notably better by the videos, whereas assessment of SL and LT ligaments was not improved by the videos. Intraobserver reliability was better than interobserver reliability. CONCLUSION: As long as videos do not meet further quality criteria, they are not able to improve reliability in general. Nevertheless, videos should be used for documentation of the TFCC.

Corrective osteotomy of the distal radius following failed internal fixation.

INTRODUCTION: The purpose of this study was to quantify the clinical and radiographic outcomes after corrective osteotomy for malunions of the distal radius following failed internal fixation. MATERIALS AND METHODS: Results of 18 patients (8 women, 10 men; mean age 41 years) are presented an average of 7 years after osteotomy of a malunited distal radius fracture. We assessed active range of motion, grip strength, radiographic alignment, pain and disability. Subjective and objective data were summarized using the modified Mayo Wrist Score and the point-score system of Fernandez. RESULTS: Wrist motion, pain and deformity improved with the operation in all cases. The modified Mayo Wrist Score averaged 79 points. The scale of Fernandez indicated ten good, two fair and six poor results. CONCLUSIONS: The results of this study suggest that the operative correction of a distal radius malunion following an unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment.

Median neuropathy in malunited fractures of the distal radius.

PURPOSE: Irritation of the median nerve is a well-characterized complication after acute fractures of the distal radius, but there is limited literature on median neuropathy in malunited fractures. The aims of our prospective study were to estimate the prevalence of the median neuropathy, explore the relationship between radiographic findings and the condition, and investigate whether corrective osteotomy without carpal tunnel release was a sufficient treatment. METHODS: Thirty consecutive patients, who were referred to us for treatment of symptomatic distal radial malunion, underwent nerve conduction studies of both wrists by one board-certified neurologist under standardized conditions. Test results were correlated with conventional radiographic parameters (radial tilt, radial inclination, palmar shift, ulnar variance, radiolunate and capitolunate angle) and computer tomography (CT) based measurements of the cross-sectional area of the carpal tunnel. After corrective osteotomy without carpal tunnel release, 10 of 13 patients with unilateral preoperative median neuropathy agreed to an electrodiagnostic re-examination by the same neurologist. RESULTS: Nineteen patients demonstrated abnormal test results, but only seven patients complained about paresthesias of median-innervated fingers. There was no correlation between median neuropathy and conventional radiographic parameters. Surprisingly, the cross-sectional area of the carpal canal was significantly greater for patients with median neuropathy. Symptoms resolved in all patients after corrective osteotomy. Postoperatively, six of ten patients demonstrated improved nerve conduction studies, although only four patients demonstrated normal test results. DISCUSSION: There is a high rate of subclinical median neuropathy in malunited distal radial fractures that cannot be predicted by conventional radiographic parameters. Corrective osteotomy without carpal tunnel release is a sufficient treatment for neuropathy in malunited distal radius fractures.

The functional outcome of acute scapholunate ligament repair in patients with intraarticular distal radius fractures treated by internal fixation.

BACKGROUND: Intra-articular fractures of the distal radius (DRF) are associated with a twofold increase in the risk of scapholunate ligament injury (SLI). The aim of this study was to compare functional outcome, pain, and disability between patients with operatively treated DRF and either an acute, repaired scapholunate ligament injury or no ligament injury. METHODS: We retrospectively analyzed 18 patients with an intraarticular DRF and SLI that was diagnosed and treated (Group I) and compared them with 20 patients with DRF without associated ligament injury (Group II) (20 women, 18 men; average age 55 years, range 19-72). The two cohorts were analyzed for differences in motion, grip strength, pain, Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score an average of 43 months (range 12-73) after surgery. Radiographic assessment included fracture union, palmar tilt, radial inclination, ulnar variance, intercarpal angles, and arthrosis (according to Knirk and Jupiter). We used T-tests to compare range of motion, grip strength, pain (visual analog scale), DASH scores, and radiographic alignment between cohorts. A Chi-squared analysis was used to determine radiographic differences of arthritis. RESULTS: There were no significant differences in mean range of motion, grip strength, Quick DASH score, Mayo wrist score, pain level, or radiographic arthrosis between cohorts. There was no correlation between radiographic signs of osteoarthritis and the QuickDASH score, and pain level. CONCLUSION: The outcomes of intraarticular fractures of the distal radius with operatively treated associated SLI are comparable with the outcomes of intraarticular fractures of the distal radius without associated SLI.

[Our preferred Approaches to the distal Radius]. / Unsere bevorzugten Zugänge zum distalen Radius.

This article describes our preferred approaches to the distal radius treating acute fractures and malunion by plating.

Load analysis of hands and feet while using different types of crutches with various leg's weight bearing.

The study aimed to define the load on hands using various commonly used types of crutches while walking with a full load on both legs (FL), with 20 kg partial load (PL), or with the left leg wholly unloaded (UL). Twenty-six healthy subjects used crutches with ergonomic handles, with anatomic handles (wider and softer bearing surface), and arthritis crutches (horizontal supporting area for the forearm). Sensor mats between hand and handles continuously measured the load transmitted, while sensor soles in the shoes recorded the ground reaction forces simultaneously. The load on the palm and separately the radial and ulnar halves of the palm were analyzed. With arthritis crutches, significantly lower load was transferred to the hands compared to forearm crutches (FL 3% vs. 25% of body weight, PL 8% vs. 87%, UL 12% vs. 103%). The load on hands increased significantly from FL to PL and UL for both types of crutches. The ipsilateral left hand had to bear significantly more load than the right hand. However, the feet's time-ground reaction curves showed more irregularities, and PL on the left leg was significantly higher with arthritis crutches. Anatomic handles reduced the load on the ulnar half of the palm (FL 3% vs. 5%, PL 13% vs. 18%, UL 17% vs. 23%); the radial half of the palm had a similar load to bear with both types of handles (11/11%, 31/32%, 34/35%). Arthritis crutches allow unburdening hands at the expense of gait stability. Anatomic handles reduce the load on the Guyon's canal.

[Carpal Malalignment in Malunited Fractures of the Distal Radius]. / Konstellationen des karpalen Gefüges bei fehlverheilten extraartikulären distalen Radiusfrakturen.

PURPOSE: To evaluate and classify carpal alignment in malunited fractures of the distal radius. MATERIALS AND METHODS: On standardized lateral radiographs of the involved wrist of 72 patients with a symptomatic extra-articular malunion of the distal radius, 43 with a dorsal and 29 with a palmar angulation, radius tilt (RT), radiolunate (RL) and lunocapitate angle were measured. Malposition of the radius was defined as RT plus 11° in dorsal malunion and RT minus 11° in palmar malunion. A palmar tilt of the radius was marked with a minus sign. At the time of corrective osteotomy 9 dorsal malunions underwent for different reasons evaluation of the scapholunate ligament with 4 having a complete scapholunate ligament disruption. RESULTS: With respect to the RL-angle, carpal malalignment was categorized as follows: type P with a RL-angle less than -12°, type K with a RL-angle between -12 and 10°, type A with a RL-angle more than 10°, but less than the malposition of the radius, type D with a RL-angle greater than the malposition of the radius. All types of carpal malalignment were found in both, dorsally and palmarly tilted malunion. Type A carpal alignment was identified as the leading type in dorsal malunion (25 out of 43 patients), whilst in palmar malunion colinear subluxation of the carpus (type C) was the dominant type (12 out of 29 patients). To return the hand to a neutral position the rotation of the lunate was compensated by a contrarotation of the capitate in the dorsal malunion. In the palmar malunion a dorsal extension of the capitate returned the hand to a neutral position. In 4 of the 5 patients with type D carpal alignment, who had scapholunate ligament evaluation, a complete ligament tear was found. CONCLUSION: In this study four different types of carpal alignment in malunited extra-articular fractures of the distal radius were identified. Based on this data we suspect that type D carpal alignment in dorsal malunion may be associated with a scapholunate ligament tear. Therefore, we recommend wrist arthroscopy for this group of patients.