Scaphoid Facet Research Articles

Morphometric Analysis of Distal End of Dry Human Radius in Northern India and Its Clinical Implications in Relation to Wrist Joint and Inferior Radioulnar Joint Arthroplasty: A Cross-sectional Study

Introduction: The lower end of the radius is involved in the formation of the wrist joint and inferior radioulnar joint. Its morphometry is crucial for surgical procedures related to wrist arthroplasty. Aim: To measure the various morphometric parameters of the distal end of the radius and the distal articular surface of the radius. Materials and Methods: The present cross-sectional study was conducted in the Department of Anatomy, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, from April 2023 to July 2023. The following parameters were measured: Length (LR) and Weight of Radius (WR), Length of Styloid Process (L-SP), Anteroposterior Length (APL-UN), Height (H-UN) and Depth (D-UN) of Ulnar Notch, Transverse Width (TW-DR), Oblique Width (OW-DR) and Anteroposterior Diameter (APD- DR) of the Distal Radius, Dorsal Tubercle Distance from the styloid process (DTD-SP) and from the Ulnar Notch (DTD-UN), Anteroposterior Length (APL-SF) and Transverse Length (TL- SF) of Scaphoid Facet, Anteroposterior Length (APL-LF) and Transverse Length (TL-LF) of Lunate Facet, Radial Inclination (RI) and Palmar Tilt (PT). Statistical analysis was performed using International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) software version 22.0. The values of the right and left sides were compared with a Student’s t-test. Results: Various morphometric parameters were measured on 80 dry adult radii (44 right and 36 left). The mean LR was 23.27±2 cm, WR was 39.24±9.84 gm, and L-SP was 10.9±2.40 mm. APL-UN, H-UN and D-UN were 14.29±1.80 mm, 7.75±2.07 mm and 1.68±0.63 mm, respectively. TW-DR, OW-DR and APD-DR of the distal end of the radius were 27.22±3.55 mm, 29.17±3.09 mm and 18.29±2.36 mm, respectively. The mean DTD-SP and DTD-UN were 20.66±2.40 mm and 16.29±2.53 mm, respectively. Mean values of the scaphoid facet and lunate facet were 11.75±1.44 mm (APL-SF), 15.16±2.165 mm (TL-SF), and 15.96±1.92 mm (APL-LF), 10.20±1.52 mm (TL-LF), respectively. The mean angles of RI and PT were 24.48±5.06˚ and 10.91±3.179˚, respectively. No significant difference was found between the right and left side values (p-value>0.05). Among the 80 radii, 43.8% had four grooves, 42.5% had three grooves, and 13.8% had only two grooves present on the dorsal surface of the lower end of the radius. Out of 262 observed grooves in 80 radii, 50 (19.09%) were vertical and 212 (80.91%) were oblique. The groove medial to the dorsal tubercle was oblique in 70 (87.5%) radii and vertical in 10 (12.5%) radii. A highly positive correlation was found between the oblique and transverse width of the distal radius (r-value=0.74 and p-value=0.01). Conclusion: The present study found no significant difference between the values of the right and left sides. The parameters identified may assist surgeons in selecting the appropriate size of the prosthesis or in corrective surgeries related to the lower end of the radius.

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

Clinical Results of Nonvascularized Metatarsal Articular Bone Grafting for Osteochondral Defects of the Radiocarpal and Distal Radioulnar Joint.

Background Treatment of post-traumatic osteochondral defects in the radiocarpal and distal radioulnar joint with nonvascularized metatarsal articular bone grafting is an option to restore the joint (cartilage) surface and wrist function. Purpose To evaluate the clinical midterm results of 10 consecutive patients who were treated with a nonvascularized metatarsal bone graft for cartilage bone defects of the lunate facet, scaphoid facet, sigmoid notch, or the radial part of the ulnar head. Patients and Methods Patients with isolated osteochondral defects of the lunate facet, scaphoid facet, sigmoid notch, or radial part of the ulnar head, respectively, as a result of wrist trauma were retrospectively identified in a prospectively collected database. The patients symptoms were limited wrist motion and/or pain. Clinical results and complications were extracted from patient's medical files and two questionnaires consisting of the Patient-Rated Wrist Evaluation and additional questions regarding patient satisfaction and return to work and/or hobby. Results Minor complications occurred in three cases and required surgery. In five cases an acceptable donor site foot morbidity was seen at 1 year. One patient was not satisfied due to persistent wrist pain despite adequate range of motion. One patient could not return to its prior work. Another patient could not resume its hobby. Conclusion Retrospective evaluation of 10 cases with resurfacing of the scaphoid facet, sigmoid notch, and/or lunate facet, or radial part of the ulnar head has shown that osseointegration was possible without a vascular pedicle to the graft in all cases with a (mean) follow-up of 5 years. This technique may become an alternative treatment when implants become less available. Level of Evidence Level III.

Biomechanics of Proximal Hamate Autograft in Scaphoid Nonunion.

Purpose Treatment of proximal scaphoid fractures remains a challenge with a risk of nonunions and avascular necrosis due to its retrograde blood supply. The ipsilateral proximal hamate has been described as a viable autograft option for osteochondral reconstruction of the proximal scaphoid. Our study evaluated the changes in the contact area and pressure of the radioscaphoid joint after proximal hamate autograft reconstruction. Methods Thin sensors (Tekscan Inc., Boston, MA) were placed in the radiocarpal joints of six fresh-frozen cadaveric forearms. Each specimen's tendons were loaded to 150 N in neutral, 45-degree flexion/extension positions through five cycles. Through a dorsal wrist approach, the proximal 10 mm of the scaphoid and hamate was excised. The proximal hamate autograft was affixed to the scaphoid with K-wires. Peak contact pressures and areas at the scaphoid facet were determined and averaged across loading cycles. Results At the radioscaphoid facet, peak contact pressures were equivalent, although an increasing trend in the neutral and extended wrist position was seen. At the radiolunate facet, contact pressure had an increasing trend in the hamate reconstructed wrists in all wrist positions. Contact areas had a decreasing trend and were nonequivalent at the radioscaphoid facet in the hamate reconstructed wrist. Conclusion After hamate autograft, the contact areas were not equivalent between the native and reconstructed wrists but contact pressures were equivalent in the facets. The proximal hamate has a more pointed morphology compared with the proximal scaphoid, which would explain the change in contact area in the hamate autografted wrist. Our study suggests hamate autograft may present a viable reconstruction for the proximal pole of the scaphoid without significantly altering peak contact pressures at the radioscaphoid facet.

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Anatomical Description and Quantification of Articular Surface Area Visualized in a Cadaveric Model

Distal radius (DR) fracture repair using the volar locked plating technique typically involves indirect fracture reduction, assessed using fluoroscopy, without direct visualization of the articular surface. This method of fracture repair may be guided by the rationale that volar radiocarpal ligament disruption may cause radiocarpal instability, although direct articular visualization may facilitate improved fracture reduction. This study investigated anatomical feasibility and articular surface visualization using volar ligament-sparing radiocarpal arthrotomy pertinent to DR fracture repair. Ten fresh-frozen cadaveric specimens of the upper extremity underwent volar arthrotomy via the standard flexor carpi radialis approach with partial longitudinal sectioning of the long radiolunate and partial transverse sectioning of the short radiolunate ligaments to visualize the articular surface of the DR. Following arthrotomy, the visible surface of the DR was analyzed using digital photography. The wrist was disarticulated, and the fully exposed articular surface was photographed. The visible area of the articular surface was quantified using digital imaging software by calculating the ratio of the surface area visualized using the arthrotomy to the total articular surface area. The percentage of the articular surface area of the DR visualized using the volar arthrotomy was 76% ± 7.6% (range, 69%-90%), including both the scaphoid facet, lunate facet, and scapholunate ridge. Volar radiocarpal arthrotomy allows clinically relevant visualization of the articular surface of the DR, including the scaphoid and lunate facets. Radiocarpal arthrotomy may facilitate improved articular reduction during DR fracture repair via the volar approach.

Facet Inclinations and Interfacet Angle of the Distal Radius on Posteroanterior Radiographs: Clinical Associations With 3 Carpal Pathologies

The radiographic interfacet angle (IFA), scaphoid facet inclination (SFI), and lunate facet inclination (LFI) of the distal radius were measured in patients with 3 distinct wrist pathologies to determine whether there is an association between these radiographic measurements and these conditions. Posteroanterior wrist radiographs were compiled from patients with 3 types of common wrist pathologies (scaphoid waist fracture [n= 54], scapholunate [SL] dissociation [n= 23], and dorsal ganglion [n= 51]). The patients were all Caucasians aged 20 to 45 years who met strict radiographic criteria. The IFA, SFI, and LFI values of these patients were compared with those obtained from 400 normal wrist radiographs of subjects who met the same selection criteria. In men with a scaphoid waist fracture, the IFA and SFI were significantly greater than in normal men, whereas the LFI was significantly lower. In the SL dissociation group, for all patients and for subgroups stratified according to sex, the IFA and SFI were significantly lower than in the normal matched groups. In the dorsal ganglion group, differences were found in the IFA and SFI for women, but not for men. The facet orientations of the distal radius in patients with scaphoid fracture, SL dissociation, and dorsal ganglion differed from those in the normal population. The IFA alone is most likely to be associated with all 3 pathologies. The SFI and LFI are less likely to be associated with patients with carpal pathologies. Patients with a greater IFA may be susceptible to scaphoid fractures when they fall on an overstretched hand. Patients with a smaller IFA may be susceptible to SL dissociation when they fall on an overstretched hand.

Association of the Interfacet Angle and the Lunate Facet Inclination Angle With Kienböck Disease

The etiology of Kienböck disease remains unclear, although mechanical, vascular, and metabolic risk factors have been suggested. We aimed to investigate the association of the angle between the curvatures of the distal radius and the development of Kienböck disease. The lunate facet inclination (LFI), scaphoid facet inclination, and interfacet angle (IFA) values were measured using posteroanterior plain radiographs of 82 patients diagnosed with Kienböck disease. The results were compared with normative angular reference values published based on an analysis of 400 wrists of Caucasian patients aged between 20 and 45 years. The posteroanterior radiographs were divided into 3 categories: negative, neutral, and positive based on ulnar variance, and the relationship between ulnar variance and facet angles was evaluated. The IFA value was significantly higher than the normative angular reference value in the patients with Kienböck disease. Conversely, the LFI values were significantly lower in the Kienböck patient group. There were no statistically significant differences in the IFA and LFI values among the ulnar variance groups. Measuring IFA and LFI allows the evaluation of the bifacet curvature of the distal radius articular surface in the coronal plane. Steep IFA and shallow LFI are associated with Kienböck disease. Increased IFA may lead to abnormal load transmission to the intermediate column, which might eventually lead to increased stress on the lunate. Prognostic IV.

Impacted intraarticular fragments of distal radius fractures: A radiographic characterization and analysis of reliability and diagnostic accuracy

BackgroundReduction using ligamentotaxis may not be effective enough to treat impacted intraarticular fragments of distal radius fractures. Articular incongruence resulting from the loss of reduction is a risk factor for postoperative osteoarthritis and worse clinical outcome. This study aimed to analyze the radiographic characterization of the impacted intraarticular fragments of distal radius fractures using two/three-dimensional computed tomography (CT). Further, we assessed the reliability and diagnostic accuracy in detecting the fragments using plain radiographs. MethodsWe analyzed 167 three-dimensional CT images of the intraarticular distal radius fractures and selected 12 fractures with impacted intraarticular fragments. We recorded the location, size, and displacement of the fragment using CT images. In addition, six examiners evaluated 25 fractures including those 12 fractures having the fragments using plain radiographs for detecting the fragments and their displacements. Further, we evaluated the reliability and diagnostic accuracy of the plain radiographs in the detection of the fragment. ResultsFifteen impacted intraarticular fragments were found in 12 wrists. The displacement of the scaphoid facet fragment was significantly larger than that of the lunate facet fragment in CT measurement (7.0 mm and 3.6 mm). Inter and intraobserver reliability of the diagnosis for the fragment in plain radiographs were poor and fair (κ: 0.14 and κ:0.27). Diagnostic accuracy in detecting the fragment in plain radiographs generated mean sensitivity: 0.4, mean specificity: 0.73, and mean accuracy: 0.58. The mean sensitivity in detecting a lunate facet fragment was lower than that of a scaphoid facet fragment in plain radiographs (0.24 and 0.44). ConclusionImpacted intraarticular fragments were found in 7% of intraarticular distal radius fractures. We observed low reliability and sensitivity in detecting the fragment using plain radiographs. Preoperative recognition of the fragments using plain radiograph were difficult, even though the magnitude of step-off of the scaphoid facet fragment was large.

Development and Testing of a Novel Locking Pin Cap to Create a Fixed-Angle K-Wire Plate Construct

To test the effectiveness of a novel locking pin cap to attach a K-wire rigidly to a volar locking plate and resist fracture displacement compared with commercially available alternatives. Two different methods of fracture fixation were tested on a total of 12 Sawbones models with volar shear distal radius fracture (6/group). The fragments were fixed with either 2 commercially available pin plates (industry standard) or a volar plate with 2 locking screws fixing the scaphoid facet and 2 pins locked to the plate with a novel locking pin cap in the lunate facet. Axial load conditioning was performed followed by sinusoidal loading to 250 N at 50 mm/s. A motion capture system was used to assess the relative movement of the fracture fragments relative to the intact shaft. The strength of the fixation construct was quantified by (1) the force required to achieve a 2-mm gap between the shaft and fracture fragments and (2) ultimate load to failure. One industry standard pin plate demonstrated disassociation of the pin from the plate after fatigue conditioning. This did not occur in the locking pin cap group. The locking pin cap construct group was able to sustain a significantly higher load compared with the industry standard when the construct was displaced to the 2-mm gap. The locking pin cap also significantly increased the ultimate load to failure compared with the industry standard. The novel locking pin cap creates a fixed-angle attachment of a K-wire to an existing locking screw hole in a plate. This fixed-angle K-wire is significantly stronger in preventing gap formation and resisting ultimate failure than commercially available plates that use bent K-wires. The development of novel techniques to secure small articular fragments may ultimately improve clinical outcomes.

Scapholunate Diastasis in Distal Radius Fractures: Fracture Pattern Analysis on CT Scans.

Objectives Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort ( n = 12; 46%) had a high-energy mechanism of injury. The majority of the patients ( n = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence This is a Level III, diagnostic study.

Computer-aided 3D analysis of anatomy and radiographic parameters of the distal radius.

This study applied mathematical modeling to examine the anatomy of the distal radius; to define the radiographic parameters in a 3D imaging modality; and to report their normal ranges in the uninjured radius. A series of 50 cone-beam computed tomography (CBCT) scans of uninjured radii were analyzed using computer-aided image processing. The radius shape model was used to determine the optimal location for measuring the longitudinal axis. With the axis determined, the volar tilt and radial inclination angles and the areas of the articular facets and their reference points were analyzed. The optimal location for determining the longitudinal axis was between 28.8 and 53.3 mm proximally from the articular surface. The mean radial inclination angle was 21.8°. The mean volar tilt angle via the most distal tips of the volar and dorsal rims was 13.0°; along the lunate and scaphoid facets it was 9.1° and 11.2°, respectively. The scaphoid facet was larger than the lunate facet and 25% of it was convex. Computer-aided CBCT image processing offers an advanced tool to record 3D geometry and the radiographic parameters of the osseous structures of the wrist. Analysis of the distal radius' anatomy showed that the longitudinal axis was affected by its measurement location and subsequently also affected the determination of the angular parameters. We also report the variation of the volar tilt along the articular surface and the shapes and sizes of the articular facets.

Three-dimensional analysis of displacement characteristics of dorsally angulated intra-articular distal radial fractures.

Understanding the complex fragmentation of intra-articular distal radial fractures contributes to achieving anatomical reduction during surgery. This study aimed to clarify three-dimensional displacement patterns of intra-articular fragmentation in dorsally angulated, intra-articular distal radial fractures. We identified five characteristic intra-articular fragments: a key fragment, dorsal ulnar corner, dorsal wall, radial column and anterior radial column. The key fragment was displaced with radial deviation, pronation and extension and with dorsal, proximal and radial translations. The dorsal ulnar corner displacement resulted in a gap, a step-off and a deepened concavity for the lunate facet and sigmoid notch. The dorsal wall displacement resulted in a deepened concavity, a gap and a step-off of the dorsal scaphoid facet. The displacements of the radial column and anterior radial column caused a step-off between the scaphoid and lunate facets. The five characteristic intra-articular fragments each created a characteristic gap and step-off in the articular surface. Level of evidence: IV.

Autologous Osteoarticular Transfer From the Lateral Femoral Condyle to the Scaphoid Facet in the Treatment of a Malunited Pediatric Distal Radius Fracture With Physeal Bar

Background: Injury to the articular surface of the distal radius commonly occurs after a fall onto an outstretched hand. Intra-articular fractures that cause joint depression require operative intervention and can be especially challenging in skeletally immature patients. Methods: This case report describes the use of an osteoarticular autograft in the treatment of a 13-year-old boy with a malunited distal radius fracture. Results: Osteoarticular transfer from the lateral femoral condyle provided definitive treatment of the malunion and physeal bar and resulted in significant improvement in range of motion. Conclusions: Osteoarticular autograft can be safely used to treat malunions of distal radius articular surface depression fractures in skeletally immature patients.

Facet Inclinations and Interfacet Angle of the Distal Radius on Posteroanterior Radiographs

To determine the lunate facet inclination (LFI), scaphoid facet inclination (SFI), and interfacet angle (IFA) of the distal radius on posteroanterior (PA) radiographs; evaluate the reliability of the IFA measurements; and define normative reference values for all 3 parameters. The IFA was defined as the angle between the lines tangential to the scaphoid and the lunate facets. The reliability of the IFA measurements was investigated using 2 serial measurements made by 3 observers. Three parameters (the IFA, LFI, and SFI) were measured on PA wrist radiographs of 400 normal Caucasians. Between-side and -sex differences among the 3 parameters were analyzed statistically. The inter- and intraobserver reliability of the IFA measurements was excellent. The mean values were as follows: IFA, 20°; LFI, 14°; and SFI, 34°. Although no statistically significant difference was found between the right and the left wrists, sex-based analyses revealed significant differences between the wrists of women and men. Based on the standard distribution of IFAs, 3 groups of distal radii were defined as follows: slightly, moderately, and steeply angled. The LFI, SFI, and IFA are easily measured radiographic parameters of the distal radius. Although a moderate correlation was evident between the IFA and the LFI, the IFA is a novel parameter to evaluate the carpal articular shape of the distal radius. The IFA measurement on PA radiographs is reliable. The LFI has been accepted as a parameter for Madelung deformity andradiocarpal force transmission. The IFA may be considered as a parameter to evaluate radiocarpal coronal stability that could potentially be affected by changes in bifacet curvature.

Dorsal Scaphoid Subluxation on Sagittal Magnetic Resonance Imaging as a Marker for Scapholunate Ligament Tear

To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings. Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples ttests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients. Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray. An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear. Diagnostic II.

Anatomic Variation in Volar Tilt of the Scaphoid and Lunate Facet of the Distal Radius

The aim of distal radial fracture treatment is to achieve optimal function through the restoration of normal anatomy, including volar tilt. The accuracy of assessing volar tilt on standard lateral radiographs compared with anatomic tilt lateral (ATL) radiographs is uncertain. This study aimed to investigate the anatomy of the articular surface of the distalradius, in particular measuring the angle between the dorsal and volar rims at severalpoints from radial to ulnar, to ascertain whether volar tilt is uniform between the scaphoid and lunate facet and to explore consistency between standard lateral and ATL views. We studied 38 dry cadaveric specimens of radii. The distal articular surface of each specimen was marked at 5 intervals and placed in a customized jig. A 1.5-mm stylus was placed at each marker to represent the articular surface angle, and was photographed in standard lateral and ATL projections. An on-screen protractor was used to measure each angle from the digital photographs. The volar tilt measurements at the lunate facet demonstrated a significantly shallower angle than those at the scaphoid facet. The measurements between the standard lateral and ATL were found to have no significant difference. Adjusting the projection angle between a simulated standard lateral and ATL view did not significantly change the volar tilt measurements in this anatomic study. The lunate facet was found to have a significantly shallower volar tilt than the scaphoid facet. Variance in radiographic volar tilt may relate to different anatomic sagittal planes, reflecting the anatomic variation between the scaphoid and lunate facets. A detailed understanding of distal radius anatomy is required by the surgeon for accurate radiologic interpretation and anatomic fracture reduction and fixation.

The Etiology and Pathogenesis of Kienböck Disease.

Kienböck disease is a condition that typically occurs in the "at-risk" patient, in the "at-risk" aspect of the proximal condyle of the "at-risk" lunate. In the active male, repetitive loading causes the stress fracture that commences in the single layer proximal subchondral bone plate. The lunate fracture commences at the point the lunate cantilevers over the edge of the distal radius, and then takes on the shape of the radius. We postulate that the stress fracture violates the parallel veins of the venous subarticular plexus-leading to localized venous hypertension and subsequent ischemia and edema of the fatty marrow. The increased osseous compartment pressure further potentiates the venous obstruction, producing avascular necrosis. If the fracture remains localized, it can heal or settle into a stable configuration, so that the wrist remains functional. Fractures of the subchondral bone plate produce irregularity of the lunate articular surfaces and secondary "kissing lesions" of the lunate facet and capitate, and subsequent degeneration. The lunate collapses when the fracture is comminuted, or there is disruption of the spanning trabeculae or a coronal fracture. The secondary effect of the lunate collapse is proximal migration of the capitate between the volar and dorsal fragments, producing collapse of the entire central column. The proximal carpal row is now unstable, and is similar to scapholunate instability, where the capitate migrates between the scaphoid and lunate. The scaphoid is forced into flexion by the trapezium, however, degeneration of the scaphoid and scaphoid facet only occurs in late disease or following failed surgery. In Kienböck disease, the secondary effects of the collapsing lunate are a "compromised" wrist, including: deformity and collapse of the central column, degeneration of the central column (perilunate) articulations, proximal row instability (i.e., between the central and radial columns), and degeneration of the radial column.

Proximal carpal row carpectomy

Resection of the proximal carpal row, termed proximal row carpectomy (PRC), is performed in order to treat pathologies of the proximal carpal row or radiocarpal joint between the scaphoid and scaphoid facet. It entails the articulation of the capitate and the lunate facet. Lunate necrosis, carpal collapse, joint infection with concomitant intercarpal ligament lesions. Severe cartilage lesions of the lunate facet and the capitate, wrist capsule laxity, rheumatoid arthritis, neuromuscular dysbalance of the wrist-covering soft tissue structures. Dorsal approach to the wrist, incision of the third and fourth extensor compartments, resection and coagulation of the dorsal interosseous nerve, usage of aligament-sparing capsule incision, identification of the proximal carpal row and inspection of cartilage of the lunate facet and capitate, mobilization and excision of the lunate, scaphoid and triquetrum, articulation of lunate facet and capitate is controlled clinically and fluoroscopically, wound closure, application of plaster slabs. Immobilization of the wrist on plaster slabs for 2weeks, removal of sutures after 14days. PRC is asurgical procedure with few complications. Satisfactory range of motion and grip strength could be preserved without limiting function of the upper extremity. Postoperative osteoarthritis of capitate and lunate facet did not correlate with the good clinical outcome.

Clinical Faceoff: Controversies in the Management of Distal Radius Fractures.

D istal radius fractures are among the most common fractures of the upper extremity, and account for approximately 20% of all fractures seen within the emergency room. The distal radius comprises of three articular surfaces, namely the scaphoid facet, lunate facet, and sigmoid notch. Treatment goals are centered on restoration of articular congruity, and where appropriate, early ROM with minimal complications to permit early functional recovery. Numerous fracture classifications exist which aim to define the fracture and guide treatment [1] (Fig. 1). Despite the frequency of these injuries, controversy exists about how best to manage them. The American Academy of Orthopaedic Surgeons practice guidelines on treatment of distal radius fractures recommend operative fixation for radial shortening greater than 3 mm, dorsal tilt greater than 10 from neutral, or intraarticular displacement greater than 2 mm [4]. To explore the controversies that are abound in terms of how to manage these injuries, it is my distinct pleasure to introduce two experts in the field of hand surgery. Ghazi Rayan MD is a Professor of Orthopaedic Surgery at University Oklahoma College of Medicine. Martin Boyer MD is the Jerome T. Loeb Professor of Orthopaedic Surgery at Washington University Medical School, St. Louis.

Vascularized Graft From the Metatarsal Base for Reconstructing Major Osteochondral Distal Radius Defects

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. 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. 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). 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.