Carpal Malalignment Research Articles

Carpal malalignment in malunion of the distal radius and the effect of corrective osteotomy.

Introduction Malunions of the distal radius often induce carpal malalignment. Two different types can be distinguished: an adaptive midcarpal malalignment (so-called CIA wrist: carpal instability, adaptive) and a radiocarpal malalignment (dorsal translation of the whole carpus). The effect of distal radial osteotomy on the carpal alignment has hardly been studied. Material and Methods 31 wrists in 31 patients (mean age 44 years) with malunion of the distal radius after a Colles fracture were treated with a corrective osteotomy. The patients were divided on basis of effective radio-lunate flexion (ERLF) in the two patterns of carpal malalignment. The radiographic changes were evaluated. Results There were 20 patients with midcarpal malalignment (ERLF ≤ 25°) and 11 with radiocarpal malalignment (ERLF > 25°). There was a correction of radial tilt and ulnar variance in both groups. There was a significant improvement of the carpal alignment in the midcarpal malalignment group, up to normal parameters. Neither age nor delay between fracture and osteotomy correlated. In the radiocarpal malalignment group a significant effect on the ERLF was observed. In the patients with dorsal plating 70% of the hardware had to be removed. Conclusion Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and carpal malalignment.

Ulnar shortening osteotomy for distal radius malunion.

Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. Level IV.

Cadaveric scapholunate reconstruction using the ligament augmentation and reconstruction system.

Background Untreated scapholunate ligament disruption may lead to progressive wrist arthritis. Current techniques used to treat the disruption may not prevent arthritis because of attenuation of a reconstructive ligament substitute or failure to re-establish normal wrist kinematics. Questions/Purposes This study evaluates a combined synthetic-autologous technique for the treatment of scapholunate dissociation. Methods Scapholunate dissociation was created in six cadaveric wrists. The dorsal and volar components of the scapholunate ligament were reconstructed using the Ligament Augmentation & Reconstruction System (LARS; LARS, Arc-sur-Tille, France) and a modified Blatt capsulodesis performed. Reconstructed wrists were subjected to cyclic passive motion. Outcomes were measured radiologically and compared using Student's t-test. Results Carpal alignment was re-established following scapholunate ligament reconstruction. Carpal alignment was maintained after cyclic loading. Conclusions The technique described corrected the carpal malalignment associated with scapholunate dissociation. Corrected positions were maintained after one thousand cycles of flexion and extension without fraying or loosening of the LARS. Clinical Relevance Current popular techniques for scapholunate reconstruction do not address the important dorsal and palmar components of the ligament that control their intercarpal motion. Reconstruction of the dorsal and palmar components of the scapholunate ligament can be achieved through a dorsal approach to the wrist.

Carpal Coalition

Carpal coalition is a relatively common, yet poorly recognized, anomaly that may present independently or in association with syndromic or metabolic disorders. While largely asymptomatic, symptoms may manifest secondary to biomechanical stress at the site of fusion. The purpose of this report is to describe 103 cases of carpal synostosis and provide a review of the etiology, classification, and clinical significance of intercarpal fusion. Retrospective review of medical and radiographic records was conducted on all patients with identified carpal coalitions, between 2008 and 2012, at our institution. Demographic and historical data regarding trauma, infection, documented joint disease, and prior wrist symptomatology were analyzed for each case, and radiographic evaluation of carpal alignment was performed. A total of 103 cases of carpal coalition, among 85 individuals, were reviewed. All cases presented asymptomatically with the highest proportion noted among individuals of African-Caribbean descent. The most frequent variant in our study population was lunate-triquetral coalition, which was present in 92 of the 103 identified cases. None of the cases evaluated in this study demonstrated clinical or radiographic evidence of carpal mal-alignment or instability. The results of our investigation demonstrate that carpal coalition presented most frequently among individuals of African-Caribbean descent. While the prevalence of this condition has yet to be studied specifically in Hispanic and African-Caribbean populations, our findings may reflect the genetic linkage between these and certain West African populations. To our knowledge, this represents the largest clinical series of carpal coalition in the English literature.

L’extenseur ulnaire du carpe et sa pathologie

The extensor carpi ulnaris tendon is the only extensor tendon of the wrist and produces axial wrist extension in synergy with the two extensors carpi radialis It is therefore much in demand in professional or sports use of the wrist. Repetitive stress of the tendon may induce tenosynovitis whereas traumatic lesions exposes to palmar dislocation of the tendon following rupture of its sheath. In rheumatic disease (mainly in rheumatoid arthritis), it is the most frequent site of inflammatory tenosynovitis at the back of the wrist. When neglected, tenosynovitis of the extensor carpi ulnaris is then a source of progressive destabilization and palmar dislocation of the tendon, which favors posterior instability of the ulnar head and carpal malalignment.

Résection arthroscopique du pôle distal du scaphoïde dans l’arthrose scapho-trapézo-trapézoidienne

We present the results of surgical treatment of eight patients operated in the service of osteoarthritis scapho-trapézo-trapézoidienne (STT) by resection of the distal pole of the scaphoid under arthroscopic. Studies have already shown the good results of this technique in open surgery. This is a retrospective study of eight patients of mean age 70 years. They had an isolated STT osteoarthritis, which is not relieved by medical treatment. They were operated between 2004 and 2007 by the same surgeon and were reviewed at a mean of 13 months by an independent examiner. The evaluation was focused on pain, range of motion and grip strength. A radiological assessment was conducted to examine a possible carpal mal-alignment. Two patients were excluded because they had received a trapeziectomy for rhizarthrosis associated. The pain had decreased in seven cases with complete disappearance in six cases. The force had been increased or stabilized in seven cases and the mobility is the same in six cases. We got six very good results, one good result and one bad result without aggravation. Furthermore, no patient had been taken, nor any complications noted. The good results obtained with this minimally invasive outpatient surgery, encourages us to offer first-line therapy in patients with isolated STT osteoarthritis is not relieved by medical treatment. The resection of the distal pole of the scaphoide under arthoscopy gives less burdensome and less complication that the arthrodesis, while providing very good results.

Scaphoid morphology and clinical outcomes in scaphoid reconstructions

Scaphoid malunion and carpal malalignment can result after scaphoid reconstruction, if the two fragments are not properly reduced before fixation. However, currently there is no information about which degree of deformity or malalignment can be tolerated without impairing clinical function.The purpose of this study was to investigate the influence of the scaphoid morphology and carpal alignment on clinical outcomes after scaphoid reconstruction.A total of 65 patients with an average age of 29 years were followed-up after a mean period of 45 months. In all patients, osseous union after a first-time scaphoid reconstruction in the middle third had been confirmed. Scapholunate (SL) and radiolunate (RL) angles were obtained on plain radiographs as were intrascaphoid (ISA) and dorsal cortical (DCA) angles and the height/length (H/L) ratio of the reconstructed scaphoid on computed tomography (CT) scans. These parameters were correlated with clinical outcome measures. RL angles correlated significantly with wrist range of motion, grip strength and pain levels, whilst SL angles, ISA, DCA and H/L ratio failed to show significant correlations.Our data suggest that clinical outcome is correlated with correct restoration of bone morphology and carpal alignment. After reconstruction, the RL angle should not exceed 10°.

Chronic Scapholunate Dissociation

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.

Analysis of Carpal Malalignment Caused by Scaphoid Nonunion and Evaluation of Corrective Bone Graft on Carpal Alignment

Analysis of Carpal Malalignment Caused by Scaphoid Nonunion and Evaluation of Corrective Bone Graft on Carpal Alignment

Analysis of Carpal Malalignment Caused by Scaphoid Nonunion and Evaluation of Corrective Bone Graft on Carpal Alignment

To clarify the correlation between a scaphoid deformity and carpal malalignment in patients with scaphoid waist nonunion and to investigate how accurately a corrective bone graft improves carpal malalignment according to the preoperative plan. A total of 38 patients were analyzed retrospectively. Surgery was performed according to the anterior wedge bone graft method described by Fernandez. The scaphoid deformity and carpal malalignment were evaluated by the changes in the intrascaphoid angle (ISA) and axial length (AL) and by the changes in the radiolunate angle (RLA) and scapholunate angle (SLA), respectively, compared with the uninjured side by using standardized x-rays. Each variable was measured at 1 year after surgery. By performing multiple regression analysis, the correlation between the scaphoid deformity and carpal malalignment and between the correction of the scaphoid deformity and the change in carpal alignment were analyzed. Compared with the uninjured side, the mean respective changes in the ISA, AL, RLA, and SLA were 11°, -1.3 mm, 14°, and 11°, preoperatively. The changes in the RLA and SLA correlated with the change in the ISA, but not with the change in the AL. The mean postoperative corrections of the ISA and AL were 15° from full extension and 1.7 mm, and the changes in the RLA and SLA were 18° and 12° from full extension, respectively. The change in the RLA correlated with the corrections of the ISA and AL. Although the change in the SLA did not correlate with either of them, the mean postoperative SLA was not significantly different from the mean value of the uninjured side. The degree of humpback deformity of the scaphoid correlated with the degree of carpal malalignment. The corrective bone graft resulted in the expected recovery of carpal alignment according to the preoperative plan. Prognostic IV.

Joint Leveling for Advanced Kienböck's Disease

The use of joint leveling procedures to treat Kienböck's disease have been limited by the degree of disease advancement. This study was designed to compare clinical and radiographic outcomes of wrists with more advanced (stage IIIB) Kienböck's disease with those of wrists with less advanced (stage II/IIIA) disease following radius-shortening osteotomy. This retrospective study enrolled 31 adult wrists (30 patients; mean age, 39 y), treated with radius-shortening osteotomy at 2 institutions for either stage IIIB (n = 14) or stage II/IIIA (n = 17) disease. Evaluation was performed at a mean of 74 months (IIIB, 77 mo; II/IIIA, 72 mo). Radiographic assessment determined disease progression. Clinical outcomes were determined by validated patient-based and objective measures. Patient-based outcome ratings of wrists treated for stage IIIB were similar to those with stage II/IIIA (shortened Disabilities of the Arm, Shoulder, and Hand score, 15 vs 12; modified Mayo wrist score, 84 vs 87; visual analog scale pain score, 1.2 vs 1.7; visual analog scale function score, 2.6 vs 2.1). The average flexion/extension arc was 102° for wrists with stage IIIB and 106° for wrists with stage II/IIIA Kienbock's. Grip strength was 77% of the opposite side for stage IIIB wrists versus 85% for stage II/IIIA. Postoperative carpal height ratio and radioscaphoid angle were worse for wrists treated for stage IIIB (0.46 and 65°, respectively) than stage II/IIIA (0.53 and 53°, respectively) disease. Radiographic disease progression occurred in 7 wrists (6 stage II/IIIA, 1 stage IIIB). The one stage IIIB wrist that progressed underwent wrist arthrodesis. In this limited series, clinical outcomes of radius shortening using validated, patient-based assessment instruments and objective measures failed to demonstrate predicted clinically relevant differences between stage II/IIIA and IIIB Kienböck's disease. Given the high percentage of successful clinical outcomes in this case series of 14 stage IIIB wrists, we believe that static carpal malalignment does not preclude radius-shortening osteotomy. Therapeutic IV.

Open Reduction for Perilunate Injuries—Clinical Outcome and Patient Satisfaction

Perilunate injuries cause severe carpal malalignment. Open reduction and internal fixation of these injuries has become the treatment of choice. This study evaluated clinical outcome and the patients' perception of disability in activities of daily living after open reduction, ligament reconstruction, and/or internal fixation of the scaphoid. In addition, potential prognostic factors for functional outcome and individual perceptions of disability were analyzed and compared with radiologic findings. This study consisted of a retrospective analysis of patients with perilunate dislocations or fracture dislocations (Mayfield stage 3/4) who were treated in a single institution from 1995 to 2004. Evaluation focused on postoperative radiologic results, range of motion, pain, sensitivity, grip strength, Mayo and Krimmer wrist scores, arthrosis, and the patients' disability in performing activities of daily living (according to the Disabilities of the Arm, Shoulder, and Hand score). Of the 72 patients treated in the study period, 39 patients (all men) were available for complete follow-up (average, 65.5 mo). Thirty injuries were fracture dislocations; the dominant hand was injured in 14 cases. Normal scapholunate (SL) angles and Gilula arcs were achieved intraoperatively in 34 and 25 cases, respectively. At follow-up, 18 patients had larger than normal SL angles, and 6 patients had ulnar shifting of the carpus. Twenty patients were diagnosed with radiocarpal arthrosis. According to the Visual Analog Scale, pain was 1.8 at rest and 4.8 with activities. Average extension/flexion was 77°; radial/ulnar abduction was reduced to 42°. Average grip strength was reduced to an average of 36.6 kg (compared with 51.6 kg on the opposite side). Twenty-seven patients returned to their former occupations. Average Mayo and Krimmer wrist scores were both 70. The average Disabilities of the Arm, Shoulder, and Hand score was 23. Satisfactory results can be achieved with open reduction for perilunate injuries. However, despite this treatment, loss of reduction and arthrosis are frequent findings. Radiologic results do not necessarily correlate with functional outcome; high patient satisfaction was observed in this study. Therapeutic IV.

Scapholunate post-traumatic instability: Classification and treatment

Scapholunate instability is the most common form of dissociative carpal instability and it represents the first stage of perilunate dislocations. From a biomechanical point of view the injury of the scapholunate ligament is the first step towards an abnormal carpal kinematics with a progressive joint degeneration. Clinical history and physical examination are very important for the diagnosis but imaging techniques, such as plain radiographs and arthro-MR, play a fundamental role. In early and mild stages only arthroscopy allows a correct diagnosis. An early diagnosis and treatment correspond usually to a better functional result but, unfortunately, a delay often occurs. Four stages of scapholunate lesions, increasing in severity, can be recognized: predynamic instability, dynamic instability, static instability and scapholunate advanced collapse (SLAC). According to the parameters established by Garcia-Elias (the integrity of dorsal scapholunate ligament, the healing potential of the ligament after surgery, the alignment of the scaphoid, the reducibility of the carpal malalignment, the presence of a cartilage damage), scapholunate dissociations can be grouped in 6 different classes of severity and prognosis and an algorithm of treatment is proposed. The surgery ranges from conservative treatments, such as K-wire fixation, ligament suture, capsulodesis, tendon reconstruction with different techniques, to demolitive procedures as proximal row carpectomy or bone fusion that can be either partial or total. The aim of this article is to review the different surgical treatments than can be performed in the evolution of scapholunate instability and to underline the importance of an adequate and early management.

Evaluation of Corrective Osteotomy of the Malunited Distal Radius on Midcarpal and Radiocarpal Malalignment

To quantify 2 patterns of carpal malalignment, midcarpal malalignment (type 1) and radiocarpal malalignment (type 2), and to evaluate the effect of distal radius osteotomy on these malalignment patterns. In a retrospective review, we studied 31 wrists treated with corrective osteotomy for distal radius malunion after Colles' fracture, in 31 patients (mean age, 44 y). The patients were divided on the basis of effective radiolunate flexion (ERLF) into 2 patterns of carpal malalignment as measured on preoperative radiographs. There were 20 patients with midcarpal malalignment (ERLF < or = 25 degrees ) and 11 with radiocarpal malalignment (ERLF > 25 degrees ). Measurements of alignment were repeated after distal radius osteotomy and compared with preoperative values. Both groups had correction of radial tilt and ulnar variance with distal radius osteotomy. In the midcarpal malalignment group, carpal alignment improved to normal parameters. In the radiocarpal malalignment group, we observed a notable effect on the ERLF. Neither age of the subject nor delay between fracture and osteotomy correlated with improvement in carpal alignment. Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and both radiocarpal and midcarpal malalignment. Therapeutic IV.

Association Between Decreased Bone Mineral Density and Severity of Distal Radial Fractures

The role of osteoporosis and osteopenia in the etiology of fractures of the distal part of the radius is well established, but any link between osteoporosis and the severity of the distal radial fracture has not been extensively investigated. The aim of this study was to investigate the association between the degree of osteoporosis and the severity of distal radial fractures. All patients over fifty-five years of age with a low-energy distal radial fracture were offered dual x-ray absorptiometry scanning of the hip. Data on the 137 consecutive patients were collected prospectively. Plain radiographs of the fractured distal part of the radius were assessed for angulation, metaphyseal and articular comminution, carpal malalignment, ulnar variance, AO/OTA group and subgroup classification, early and late displacement, and malunion. Fracture severity was quantified with use of previously published algorithms for calculating the probability of early and late displacement, late carpal malalignment, and malunion. These severity scores were correlated with the dual x-ray absorptiometry T-scores, which represent the number of standard deviations by which the measured bone density differs from the mean value in healthy controls. There was a significant linear correlation between increasingly negative T-scores and increasing likelihood of early instability, late carpal malalignment, and malunion. Patients with osteoporosis (a T-score of less than -2.5) had a 43% probability of having early instability, a 39% probability of having late carpal malalignment, and a 66% probability of having malunion. Patients with osteopenia (a T-score of more than -2.5 but less than -1) had a 35% probability of having early instability, a 31% probability of having late carpal malalignment, and a 56% probability of having malunion. This compared with a 28% probability of early instability, a 25% probability of late carpal malalignment, and a 48% probability of malunion in patients with normal bone mineral density (a T-score of more than -1). There is a definite correlation between bone mineral density and the severity of distal radial fractures.

Can carpal malalignment predict early and late instability in nonoperatively managed distal radius fractures?

The purpose of this study was to assess the frequency of carpal instability as a concomitant lesion in distal radius fractures and identify other factors including carpal malalignment in an attempt to predict the final radiological outcome more accurately following conservative treatment of distal radius fractures. An observational study from patient records and standardised radiological follow-up examinations as data sources was used. The alignment of each wrist was checked radiographically immediately post-reduction and subsequently at 1- and 6-week follow-up assessments. Serial measurements of radial length, dorsal tilt, radial inclination, scapho-lunate, radio-lunate, radioscaphoid, scapho-capitate angles and effective radiolunate flexion angle were made. Regression analysis showed high correlation among the severity of axial shortening, pre-reduction dorsal angulation and radio-carpal malalignment pattern with early loss of reduction at 1 week. We found the age, severity of axial radial shortening, dorsal angulation, presence of dorsal comminution and radio-carpal malalignment pattern to be significant predictors of adverse radiological outcome at 6 weeks (late instability). Our study highlights the importance of radio-carpal instability pattern on post-reduction radiographs as a predictor of early and late instability.

Radiologische Frühdiagnostik der skapholunären Dissoziation (SLD)

The partial tear of the scapholunate ligament (pre-dynamic stage of SLD) as well as the complete tear (dynamic stage) does not lead to carpal malalignment. However, if the completely ruptured ligament is accompanied by lesions of the extrinsic ligaments, both the scaphoid and the lunate are malaligned already at rest (static stage of SLD). Later, osteoarthritis will develop, beginning in the radioscaphoid compartment, progressing to the midcarpal joint, and ending in a carpal collapse (osteoarthrotic stage of SLD). Dynamic SLD is detectable only in stress views and in cinematography. The high utility of MRI for directly visualizing the injured ligament is emphasized: reparation tissue is focally enhanced at the rupture site by intravenously applied contrast agent; the individual segments of the scapholunate ligament can be visualized in direct MR arthrography, therefore allowing differentiation of partial and complete ligamentous tears.

Three-Ligament Tenodesis for the Treatment of Scapholunate Dissociation: Indications and Surgical Technique

Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.

Correction of Madelung’s deformity by the Ilizarov technique

We present our experience with correction of Madelung's deformity by the Ilizarov technique. Seven patients (eight deformities) were treated by osteotomy of the radius with subsequent lengthening and angular correction. They were reviewed at a mean of 30 months (1.5 to 5.5 years). At the time of operation their mean age was 19 years (9 to 44). At follow-up all were free from pain and supination had improved by a mean of 34 degrees and pronation by 9 degrees. Flexion had increased in most cases with a median increase of 15 degrees, but only one patient gained further extension. Radial and ulnar deviation were increased by a mean of 6 degrees and 9 degrees, respectively. Radiographic measurements showed that the mean volar angulation had been reduced from 25 degrees to 11 degrees, ulnar inclination from 45 degrees to 30 degrees and carpal malalignment (volar translation) from 7 to 2 mm. The mean lengthening of the radius was 12 mm (6 to 25). All the patients were satisfied with the functional and cosmetic results.

Nontraumatic multidirectional instability of the scaphotrapeziotrapezoid joint: a cause of scaphotrapeziotrapezoid osteoarthritis and static distal intercalated segment instability

We report a case of bilateral multidirectional instability of the scaphotrapeziotrapezoid joint associated with osteoarthritis of the same joint and static dorsal intercalated segment instability. Because there is no previous trauma it is likely that this is a case of nontraumatic instability at the scaphotrapeziotrapezoid joint causing a dorsal intercalated segment instability deformity of carpal malalignment and secondary scaphotrapeziotrapezoid osteoarthritis.