Osteoarthritis Of Distal Radioulnar Joint Research Articles

Does the distal radioulnar joint orientation influence the outcome of ulnar shortening osteotomy: a retrospective study.

The aim of this retrospective study was to evaluate the long-term outcome of ulnar shortening osteotomy. A total of 66 patients treated with an ulnar shortening osteotomy for a primary or post-traumatic ulnar impaction syndrome were included, with a median follow-up time of 75 months.There was a positive correlation between the sigmoid notch angle and the final QuickDASH score, but no correlation with final range of motion, grip strength or pain level. Radiological signs of osteoarthritis of the distal radioulnar joint were seen in 20% of patients, yet there was no correlation between the development of distal radioulnar joint osteoarthritis and the sigmoid notch angle. No symptomatic distal radioulnar joint osteoarthritis was observed.Ulnar shortening osteotomy is a good option to treat patients with ulnar impaction syndrome regardless of the distal radioulnar joint angle.Level of evidence: IV.

Long-term survivorship of the Herbert ulnar head prosthesis: a multicentre retrospective cohort study.

IV.

Aptis Distal Radioulnar Joint Arthroplasty: A Multicenter Evaluation of Functional Outcomes, Complications, and Patient Satisfaction.

Background The Aptis distal radioulnar joint (DRUJ) implant has been commonly used to replace the DRUJ and restore wrist function in patients with a severely destroyed DRUJ. Objective Promising results have been described in the literature. However, the clinical results in a multicenter setting are sparse and variable. This study evaluates the short- to midterm clinical results of 53 patients with a (mean) follow-up of 51 months. Patients and Methods Fifty-three patients (59 implants) treated between 2011 and 2020 in three different institutions were retrospectively identified in a prospectively collected database. The main indication for Aptis DRUJ arthroplasty was a destroyed DRUJ and gross distal radioulnar instability and isolated DRUJ osteoarthritis. Functional outcome, complications, and patient satisfaction were evaluated. Patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire and an additional questionnaire about patient satisfaction and return to hobby/work. Results Implant survival was 92%, the surgical follow-up showed many complications (64,4%), and revision surgery was needed frequently (40.7%). In 13 cases, the follow-up was longer than 5 years. Three reimplantations had to be performed and two implants were permanently explanted. In spite of this all, wrist and forearm motion as well as pain reduction was adequate and patient satisfaction was reasonable (72.2%). Conclusion The Aptis DRUJ arthroplasty is a viable option that can provide adequate wrist and forearm function after secure patient selection and surgical placement of the implant in the wrist with a good bone stock of the radius. The complication rate was found to be high, yet patient satisfaction was reasonable. In the case of secondary surgery, additional surgery seems to be needed. For primary surgery, the implant seems to be successful without complications. Different complications have been described, but further analysis is warranted to find the causes of complications and to objectify the performance of the Aptis DRUJ implant. Level of Evidence IV.

Hemiresection Capsuloretinacular Interposition Arthroplasty for Distal Radioulnar Joint Osteoarthritis.

Background Hemiresection interposition arthroplasty (HIA), which can preserve triangular fibrocartilage complex (TFCC) and distal radioulnar joint (DRUJ) function, is one of the surgical options for DRUJ osteoarthritis. Description of Technique An arcuate vertical incision of approximately 8 cm was made, and the flap, including both the extensor retinaculum and dorsal DRUJ capsule, was wrapped around the resected ulnar head. In cases where the TFCC was torn, repair or reconstruction was also performed. Patients and Methods Twenty-one wrists in 20 patients with DRUJ osteoarthritis were treated. Patients with rheumatoid arthritis were excluded. Preoperative ulnar variance value averaged 1.8 mm. The average length of follow-up period was 2 years and 10 months. Functional outcomes were evaluated by visual analog scale (VAS) for wrist pain, Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Wrist Evaluation (PRWE), range of wrist and forearm motion (palmar-dorsal flexion and pronation-supination), and grip strength (% of the contralateral value). X-ray parameters (width of the ulnar head, DRUJ distance) were assessed. Results The postoperative grip strength and range of wrist and forearm motion improved significantly, and VAS for pain and PRWE improved larger than minimum clinical important difference. The DRUJ gap distance was maintained sufficiently in average value of 5.3 mm at the final follow-up. Conclusion The current modified HIA procedure combined with TFCC repair or reconstruction provides feasible short-term functional outcomes for treatment of patients with DRUJ osteoarthritis regardless of preoperative ulnar variance.

Ulna hook plate osteosynthesis for ulna head fracture associated with distal radius fracture

BackgroundDistal ulna head or neck fracture is commonly associated with distal radius fracture. Treatment of these fractures remains controversial. Plate osteosynthesis is commonly performed. The purpose of this study was to observe clinical and radiological outcomes in ulna hook plate osteosynthesis for distal ulna fracture associated with distal radius fracture.Materials and methodsThis retrospective study between 2010 and 2018 included patients presenting combined displaced distal ulna fracture and distal radius fracture who were treated with ulna hook plate osteosynthesis. Patient evaluation included pain measurement with the visual analog scale, wrist range of motion, grip and pinch strengths, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and Mayo wrist score. Preoperative radiographs were reviewed to classify the distal ulna fracture according to Biyani. Bone union was evaluated on postoperative X-rays. At final follow-up, the usual radiographic parameters were measured and distal radioulnar joint (DRUJ) osteoarthritis was assessed.ResultsA total of 48 patients were included. Mean age was 63 years old and mean follow-up was 28 months. According to the Biyani classification, there were 12 type I, 4 type II, 8 type III, and 24 type IV distal ulna fractures. Wrist flexion was 60°, extension 57°, pronation 85°, and supination 80°. Grip strength was 21 kg (86% of the uninjured opposite side). Pinch strength was 6.6 kg (92% of the uninjured opposite side). Clinical scores were very good to excellent, with a mean Q-DASH of 12 and a Mayo wrist score of 90. Discomfort or pain due to the implant that required implant removal was reported in 29%, and was higher in younger patients. Nonunion was observed in two cases and secondary implant displacement in one case. These three cases required secondary intervention with ulna head resection, which was higher in Biyani type IV. DRUJ osteoarthritis was observed in 12 patients (31%) and was higher in older patients.ConclusionsUlna hook plate fixation gives good clinical results and a high rate of fracture union, but complications are common. Implant irritation is a frequent complication, especially in young patients, and often requires implant removal.Level of evidence: IV

VAUGHAN JACKSON SYNDROME DUE TO DISTAL RADIOULNAR JOINT OSTEOARTHRITIS: A CASE REPORT

Spontaneous extensor tendons rupture (Vaughan Jackson syndrome) is a common complication of rheumatoid arthritis, but it is also reported sporadically with non-rheumatoid osteoarthritis of the distal radioulnar joint (DRUJ). We described a case of 45 years old female who lost her ability to extend the little, ring and middle fingers sequentially after months of wrist pain and limitation of movement due to osteoarthritis of DRUJ. The condition was treated surgically by tendon transfer and ulnar head excision. The patient did well after surgery.

Preliminary Report of Arthroscopically Assisted Sauvé-Kapandji Procedure for Distal Radioulnar Joint Arthritis.

Background The arthroscopically assisted Sauvé-Kapandji (S-K) procedure has been described as a safe and promising technique for distal radioulnar joint (DRUJ) arthrodesis. Our purpose was to investigate the advantages and disadvantages of the arthroscopically assisted S-K procedure. Methods Eight patients underwent an arthroscopically assisted S-K procedure. All patients were diagnosed as DRUJ osteoarthritis (OA), including six primary DRUJ OA, one OA following a distal radius fracture, and one rheumatoid arthritis (RA). Arthroscopy was performed in neutral forearm rotation with vertical traction. The surface of the DRUJ was debrided through arthroscopy to expose the subchondral surface, and the DRUJ was fixed with a cannulated screw and Kirschner wire (K-wire) with zero or minus ulnar variance in the same posture. Bone graft was not performed. Results Bone union was achieved at 2 to 3.5 months postoperatively. At an average of 17-month follow-up, the pain intensity on 10-point numerical rating scale (NRS) decreased from 10 preoperatively to 0.4 postoperatively, average range of pronation significantly improved from 77 degrees to 89 degrees, and average grip strength as a percentage of contralateral side improved from 76 to 104%. Conclusion Satisfactory outcomes were achieved with the arthroscopically assisted S-K procedure. Advantages of this procedure included the ability to achieve union without bone grafting, preservation of the extensor mechanism integrity, and easy reduction of the ulnar head due to its wrist positioning. No major complications were encountered. Disadvantages included its required use of arthroscopic technique and potential contraindication for cases with severe deformity at the sigmoid notch. Level of Evidence This is a Level IV, therapeutic study.

Computed Tomography-Based Morphologic Analysis of Osteoarthritis of the Distal Radioulnar Joint Associated with Extensor Tendon Ruptures.

BackgroudAlthough the scallop sign is considered the most important risk factor for extensor tendon ruptures (ETRs) in patients with osteoarthritis of the distal radioulnar joint (DRUJ), previous reports provide a limited understanding of the changes at DRUJ, as risk factors were examined in plain radiographs of the wrist. The aim of this study was to assess the changes of DRUJ using axial images of computed tomography (CT) in patients with DRUJ osteoarthritis and associated ETRs and to evaluate the relationship between the changes of DRUJ and ETRs.MethodsTwelve patients with ETRs due to osteoarthritis of the DRUJ were enrolled. The changes of DRUJ were examined on axial images of CT and the following 8 parameters were measured: width of radius, anteroposterior (AP) length of radius, width of sigmoid notch (SN), AP length of SN, AP length of ulnar head, subluxation length of ulnar head, dorsal inclination of SN, and distance from Lister's tubercle to SN. Radiological parameters of the DRUJ were measured in 60 control wrists without trauma or osteoarthritis, and the patient and control groups were statistically compared.ResultsStatistically significant differences were observed between the patient and control groups in all the radiological parameters except for the AP length of SN and AP length of ulnar head. The width of radius, AP length of radius, width of SN, subluxation length of ulnar head, and dorsal inclination of SN were greater and the distance from Lister's tubercle to SN was smaller in the patient group than in the control group. The width of SN, dorsal inclination of SN, and distance from Lister's tubercle to SN were statistically significant risk factors among the 8 parameters.ConclusionsETRs due to osteoarthritis of the DRUJ was related to the changes of DRUJ, especially the changes around SN of the distal radius. In addition to the existing risk factors, a decreased distance from Lister's tubercle to SN and increased dorsal inclination of SN were identified as new risk factors. Axial images of CT were effective to evaluate degenerative changes at the DRUJ.

Evaluation of the modified radio-ulnar line in correlation with imaging features of the distal radio-ulnar joint osteoarthritis, using a 4D CT examination

Purpose: Modified Radio-Ulnar line (mRU) is a previously defined index of the Distal RadioUlnar Joint (DRUJ) and ulnar head alignment. The purpose of our study was to evaluate the association between mRU measurements using Four-Dimensional Computed Tomography (4DCT) examination with clinical symptoms and imaging features of DRUJ osteoarthritis (OA). Methods: In this IRB approved HIPAA compliant study, we scanned 18 wrists (10 patients with unilateral wrist pain and instability). Imaging of the contralateral asymptomatic side was also performed to aid the diagnosis in the symptomatic side. The 4DCT was obtained using a 320-row detector scanner (Aquilion One, Toshiba Medical Systems) in active pronation-supination. Our previous study confirmed the reliability of mRU measurements using 4DCT examination. The mRU measurements were performed in pronation, midpoint and supination by a fellowship trained MSK radiologist. Presence of symptoms (yes vs. no) and the Kellgren-Lawrence grade of OA (0-4) were assessed in correlation with mRU measurements in active motion. Results: The mRU values showed a significantly greater volar motion of the ulnar head in asymptomatic wrists (mRU mean values (P<0.001) in supination. Changes in the mRU measurements from pronation to midpoint (mean change: 0.11 (0.03), P:0.002) and to supination (0.19 (0.03), P<0.001) were significant only in the asymptomatic wrists. Unlike wrists with KL grade >=2, wrists with KL grade <2 had significant changes in the mRU values while moving from pronation to midpoint (mean change: 0.09, P:0.004) and from pronation to supination (0.14, P:0.059). The mRU values in pronation were not associated with the presence of symptoms or DRUJ OA. However, mRU values in supination were significantly correlated with both the presence of symptoms (correlation coefficient: 0.796, P<0.001) and KL grade of DRUJ OA (correlation coefficient: 0.647, P:0.005). Conclusions: while moving from pronation to supination, we observed that presence of clinical symptoms and imaging features of DRUJ OA severity were associated with restricted volar motion of the ulnar head (assessed by the mRU line).

Very Distal Radius Wedge Osteotomy for Kienböck's Disease: Case Series.

Radius osteotomy is one of the standard surgical procedures for the treatment of Kienböck's disease. Unfortunately, radius osteotomy can result in an incongruous distal radio-ulnar joint (DRUj) postoperatively, because the procedure is performed proximal to the DRUj. A very distal radius wedge osteotomy was performed as a 15-degree lateral closing wedge osteotomy with the apex of the wedge distal to that of conventional lateral closing wedge osteotomy; this procedure was developed to avoid postoperative incongruous DRUj. We performed this procedure on 6 patients (stage III-A: 1, stage III-B: 5) with a mean age of 49 years. Clinical and radiographic evaluations were performed at a mean follow-up of 32 months. Wrist pain disappeared in all patients. Mean grip strength improved from 35% to 87% of the contralateral side (p = 0.0255). Mean range of motion, measured as flexion-extension arc, improved from 93 to 128 degrees. Nakamura's score was good in all patient. Mean lunate covering ratio increased from 61% to 90% (p = 0.0151) and mean sigmoid notch inclination angle, a radiographic parameter of DRUj congruency, was not significantly different between pre-operative and final follow-up evaluation. No clinical or radiographic DRUj osteoarthritis findings were observed. Our procedure of very distal radius wedge osteotomy provided satisfactory clinical results without an incongruous DRUj. This technique might prevent the occurrence of postoperative DRUj osteoarthritis.

Extensor Tendon Rupture in Non-Traumatic Osteoarthritis of Distal Radioulnar Joint: Vaughan-Jackson Syndrome – A Rare Case Report from Indian Subcontinent

Osteoarthritis of distal radioulnar joint with rupture of extensor tendon of hand is a rare problem seen in elderly. It was first reported by Vaughen and Jackson in 1948 and the syndrome is named after them. The rupture results from attrition of dorsally dislocated ulnar head during pronation and supination movements. This dislocation of ulnar head is due to dehiscence of dorsal capsule of the distal radioulnar joint. “Scallop sign”1 is a radiological sign which are seen in this condition and signifies impending rupture of extensor tendon. Tendon transfer with excision of ulnar head is a viable option. We present a case of attritional rupture of extensor tendon of 4th and 5th fingers in a patient with non-traumatic osteoarthritis of distal radioulnar joint (DRUJ) in an elderly female. To the best of our knowledge no case of attritional rupture of extensor tendon of hand with osteoarthritis of distal radioulnar joint has been reported from Indian subcontinent.

Long-term functional outcome and patient satisfaction after ulnar head resection

Resection of the ulnar head (Darrach procedure) is still frequently performed in patients suffering from posttraumatic osteoarthritis of the distal radioulnar joint (DRUJ). Ulnar impingement syndrome is sometimes observed with subsequent poor functional outcome. Here, we present a long-term follow-up study after Darrach procedure to evaluate functional results, pain relief, and patient satisfaction. Thirty-seven patients after ulnar head resection who were treated in our clinic between 2006 and 2012 were invited for follow-up investigation. Follow-up included radiologic outcomes, objective measures (active range of motion (AROM) and grip strength), the patients' individual perception of disability (pain, visual analog scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and patient-rated wrist evaluation score (PRWE)). A total of 25 patients with 27 operated wrists were available for clinical evaluation and radiologic follow-up. The AROM of the treated wrists averaged 145.7° (89.7% of the contralateral side) for pronation and supination. The average VAS decreased from 6.5 to 2.3 postoperatively. Mean grip strength was 12.4kg (57.1%). Patients showed satisfying results with an average PRWE of 42 and an average DASH of 25.5. Radiographic radioulnar convergence did not correlate with clinical symptoms. Overall, patient satisfaction was high and 22 patients (88%) would choose to undergo the operation again. In patients with posttraumatic and chronic DRUJ osteoarthritis, the Darrach procedure leads to satisfactory long-term results especially concerning mobility and sustainable pain relief. Symptomatic ulnar impingement and persistent pain of the ulnar stump are rare sequelae of this procedure.

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

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. 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. 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. 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.

Ulnar head replacement and related biomechanics.

A stable distal radioulnar joint (DRUJ) is mandatory for the function and load transmission in the wrist and forearm. Resectional salvage procedures such as the Darrach procedure, Bowers arthroplasty, and Sauvé-Kapandji procedure include the potential risk of radioulnar instability and impingement, which can lead to pain and weakness. Soft tissue stabilizing techniques have only limited success rates in solving these problems. In an attempt to stabilize the distal forearm mechanically following ulnar head resection, various endoprostheses have been developed to replace the ulnar head. The prostheses can be used for secondary treatment of failed ulnar head resection, but they can also achieve good results in the primary treatment of osteoarthritis of the DRUJ. Our experience consists of twenty-five patients (follow-up 30 months) with DRUJ osteoarthritis who were treated with an ulnar head prosthesis, with improvement in pain, range of motion, and grip strength. An ulnar head prosthesis should be considered as a treatment option for a painful DRUJ.

Ulnar sided wrist pain and distal radioulnar joint osteoarthritis; is surgical arthroplasty enough?

Distal radioulnar joint (DRUJ) arthritis is a common cause of ulnar wrist pain in rheumatoid and osteoarthritis. Modified arthroplasty for the DRUJ is a minimally invasive procedure for the treatment of isolated DRUJ osteoarthritis. The purpose of this study was to evaluate the efficacy of the procedure and the incidence of related ulnar wrist pathology as well as the incidence of subsequent ulnar wrist surgeries. All patients having modified arthroplasty for the DRUJ between 1994-2008 were retrospectively reviewed. Measurements included range of motion, grip strength, and subjective status. Data regarding other wrist surgeries was recorded. There were 29 patients, 23 of which had a follow-up of over 8 weeks (average 16 months (SD=24). Fourteen patients had no to minimal pain, 6 had pain with heavier activities (2 severe), and 2 reported constant pain at the surgical site. Of the 4 more painful patients, three had additional surgery after the DRUJ arthroplasty. In all 96% of the patients had another procedure involving the ulnar- wrist complex either prior to surgery, at the time of surgery or following surgery for modified arthroplasty. We suggest that pathology involving the ulnar-wrist complex is often a syndrome consisting of multiple related diagnoses including but not limited to arthritis of the DRUJ. Multiple procedures may be needed, or a more aggressive approach such as ulnar head replacement may be indicated so that pathology at both the distal radioulnar and ulnocarpal joints is addressed concomitantly.

Flexor tendon rupture of small finger due to osteoarthritis of distal radioulnar joint after malunited Colles' fracture: a case report

Flexor tendon rupture of small finger due to osteoarthritis of distal radioulnar joint after malunited Colles' fracture: a case report

Arthroscopically Assisted Sauvé-Kapandji Procedure

Osteoarthritis of distal radioulnar joint (DRUJ) leads to chronic wrist pain, weakness of grip strength, and limitation of motion, all of which affect the quality of life of the patient. Over the years, several procedures have been used for the treatment of this condition; however, this condition still remains a therapeutic challenge for the hand surgeons. Many procedures such as Darrach procedure, Bower procedure, Sauvé-Kapandji procedure, and ulnar head replacement have been used. Despite many advances in wrist arthroscopy, arthroscopy has not been used for the treatment of arthritis of the DRUJ. We describe a novel technique of arthroscopically assisted Sauvé-Kapandji procedure for the arthritis of the DRUJ. The advantages of this technique are its less invasive nature, preservation of the extensor retinaculum, more anatomical position of the DRUJ, faster rehabilitation, and a better cosmesis.

Extensor Tendon Rupture Associated with Osteoarthritis of the Distal Radioulnar Joint

Non-rheumatoid osteoarthritis of the distal radioulnar joint can cause extensor tendon rupture. We analysed the radiographic morphology of the distal radioulnar joint to identify the risk factors for this complication. Forty-one wrist X-rays of 37 patients with extensor tendon rupture caused by distal radioulnar joint osteoarthritis were evaluated retrospectively for the severity of osteoarthritis by the Kellgren/Lawrence scoring system. Measurements were obtained from posteroanterior views. All but one wrist had severe osteoarthritic changes exceeding grade 3. The radiographic features that were different from those of the contralateral wrists included deepening and widening of the sigmoid notch, radial shift of the ulnar head and dorsal inclination of the sigmoid notch. There was no significant association between tendon rupture and the morphology of the ulnar head or ulnar variance. The scallop sign, dorsal inclination of the sigmoid notch and radial shift of the ulnar head are radiological risk factors for extensor tendon ruptures.

Effect of wrist and ulna head position on gliding resistance of the extensor digitorum minimi and extensor digitorum communis III tendons: A cadaver study

While attrition from sharp bony surfaces is the most common cause of extensor digiti minimi (EDM) tendon rupture, the etiology of other cases of spontaneous EDM tendon rupture is still unknown. Friction within the compartment may play a role, especially with ulna dislocation. The purpose of this study was to compare gliding resistance of the EDM tendon with that of a tendon which rarely ruptures spontaneously, the extensor digitorum communis of the middle finger (EDC III) tendon, under various wrist and ulna head positions. Eight fresh frozen cadavers were used. Gliding resistance between the tendon and its sheath in each compartment was measured in five different wrist positions and three different ulna head positions. Gliding resistance of the EDM tendon (0.13 +/- 0.03 N) was significantly greater than the EDC III tendon (0.09 +/- 0.03 N) (p < 0.05). For the EDM tendon, the gliding resistance in ulnar deviation or pronation was higher than the gliding resistance in neutral, radial deviation, or supination (p < 0.05), and the gliding resistance with ulnar lengthening (over 6 mm) or dorsal ulnar dislocation (over 9 mm) was higher than in neutral ulnar head positioning. For the EDC III tendon, the gliding resistance in ulnar deviation was significantly higher than the gliding resistance in neutral, radial deviation, or supination, or dorsal dislocation with ulnar lengthening (p < 0.05). Wrist ulnar deviation, ulnar dorsal dislocation (over 9 mm), and ulnar lengthening (over 6 mm) increased the gliding resistance of the EDM tendon. In patients at risk for EDM rupture, such as those with rheumatoid arthritis or distal radioulnar joint osteoarthritis, avoiding such positions may be advantageous.

Chronic wrist pain.

Nonarticular chronic wrist pain continues to be a challenging subject in which interest and knowledge are increasing. Although many more excellent articles could have been included in this review, an attempt is made to discuss papers that have impact on the recognition, diagnosis, and treatment of various wrist problems. Developments in diagnostic algorithms and refinements in the use of imaging and arthroscopic tools are reviewed. Arthroscopy provides exciting direct visual information and therapeutic opportunities for triangular fibrocartilage complex disruptions and lunatotriquetral ligament pathology. A new carpal instability analysis system is proposed to allow better comparison of results reported in the literature. Comprehensive evaluation and treatment of the rheumatoid wrist are revisited. The effectiveness of operative treatment for midcarpal instability and distal radioulnar joint osteoarthritis continues to be assessed. Sports-related chronic wrist injuries from golf, trampolining, and gymnastics, as well as newer recreational activities such as in-line skating, are rapidly gaining the recognition they deserve.