World Clinics - Orthopedics - Hand Surgery 1st Edition

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World Clinics
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Hand
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Editors-in-Chief
e k eer s
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b ooookMatthew S Austin MD
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o o k Asif M Ilyas MD FACS
eeb Gregg R Klein MD

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March 2016 Volume 3 Number 1
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This issue has been published in good faith that the contents provided by contributors contained herein are original,
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the drug or device.
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Cover images: (Left ) Open release of trigger digit. The A1 pulley is completely released. Courtesy: Daniel E Choi,
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Harsh A Shah, Irfan Ahmed. (Middle ) The reduction association of the scapholunate joint technique. Courtesy: Mark
L Wang, Michael M Vosbikian. (Right ) Isolation of a group fascicle from the ulnar nerve (red loop) for transfer to the
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musculocutaneous branch to the biceps muscle (yellow loop). Courtesy: Joshua M Abzug, Kevin J Little.
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WORLD CLINICS ORTHOPEDICS : Hand Surgery
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Digital Version 2017, Volume 3, Number 1
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ISSN: 2348-702X
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ISBN: 978-93-86107-31-2
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Contributors
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Editors-in-Chieft t
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Matthew S Austin MD
Associate Professor, Department of Orthopedic Surgery
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Thomas Jefferson University
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b ooook Rothman Institute
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eeb Philadelphia, Pennsylvania, USA
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Gregg R Klein MD
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Vice-Chairman, Department of Orthopedic Surgery
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Hackensack University Medical Center
Hackensack, New Jersey, USA
Guest Editor
keerrss Asif M Ilyas MD FACS

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b ooook Program Director of Hand Surgery
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eeb Rothman Institute
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Associate Professor of Orthopedic Surgery
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Philadelphia, Pennsylvania, USA
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Contributing
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Joshua M Abzug MD
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e University of Maryland School of Medicine
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Assistant Professor, Department of Orthopedics and Pediatrics
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o o k Baltimore, Maryland, USA
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eebb Irfan Ahmed MD ee/ e
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Assistant Professor, Department of Orthopedic Surgery
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Rutgers New Jersey Medical School
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Newark, New Jersey, USA t
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Hand Surgery
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o o k Daniel E Choi MD
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Resident Physician, Department of Orthopedic Surgery
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Rutgers New Jersey Medical Schoolbb
Newark, New Jersey, USA
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John R Fowler MD
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Assistant Professor, Department of Orthopedics
University of Pittsburgh
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Pittsburgh, Pennsylvania, USA
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rs Christopher R Jockel MD
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Attending Surgeon, Department of Orthopedic Surgery
b ooook Colorado Permanente Medical Group

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eeb Denver, Colorado, USA
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Siddharth B Joglekar MD
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Clinical Instructor, Department of Orthopedic Surgery : /
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VAMC Fresno and UCSF Fresno
Fresno, California, USA hhttt
Christopher M Jones MD
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Rothman Institute at the Thomas Jefferson University
b ooook Philadelphia, Pennsylvania, USA

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eeb Matthew T Kleiner MD ee/ e
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Orthopedic Surgeon, Department of Orthopedic Surgery
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Southern California Permanente Medical Group
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Fontana, California, USA t
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Kevin J Little MD
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University of Cincinnati College of Medicine
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eebb Neil R MacIntyre III MD
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Chief of Orthopedic Traumatology, OrthoWilmington
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Wilmington, North Carolina, USA
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Contributors
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o o k Jung H Park MD
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Attending Surgeon, Department of Orthopedic Surgery
eebb Bucks County Orthopedic Specialists
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Doylestown, Pennsylvania, USA
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Harsh A Shah BA
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Medical, Department of Orthopedic Surgery
Rutgers New Jersey Medical School
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k eers
rs Michael M Vosbikian MD
Hand and Microvascular Surgery Fellow,
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b ooook Department of Orthopedic Surgery
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Harvard Medical School – Beth Israel Deaconess Medical Center
Boston, Massachusetts, USA
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Mark L Wang MD PhD
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Rothman Institute at the Thomas Jefferson University
keerrss Christopher J Williamson MD

Chief Resident, Department of Orthopedics
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b ooook Einstein Medical Center
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Justin C Wong MD
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Hand Surgery Fellow, Department of Orthopedic Surgery
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Thomas Jefferson University Hospital
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Dan A Zlotolow MD
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e Shriners Hospital for Children
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Associate Professor, Pediatric Hand and Upper Extremity Surgery
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Contents
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Editorial......................................................................................................... xi
Asif M Ilyas
Abbreviations................................................................................................. xiii
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rs Locking Technology in the Upper Extremity:
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Evolution and Indications.............................................................................. 1
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eeb Siddharth B Joglekar, Asif M Ilyas
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Wrist Dislocations: Anatomy, Biomechanics, and Treatment....................... 18
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John R Fowler, Jung H Park
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Forearm Fractures: Operative Indications and Techniques........................... 47
Neil R MacIntyre III
keerrss Matthew T Kleiner

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Radial Head Arthroplasty.............................................................................. 59
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Scaphoid Nonunion: Does Vascularized Bone Graft
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Improves Outcomes?...................................................................................... 69
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Christopher J Williamson, John R Fowler
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Controversies in the Management of Chronic t
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Nondegenerative Scapholunate Instability.................................................... 82
Mark L Wang, Michael M Vosbikian
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Trigger Finger: The Controversies................................................................. 101
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The Controversial Role of Diagnostic Studies for
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Carpal Tunnel Syndrome............................................................................... 115
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Justin C Wong, Christopher M Jones
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Hand Surgery
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Pediatric and Adolescent Scaphoid Fractures................................................ 133
Christopher R Jockel, Dan A Zlotolow, Joshua M Abzug
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Treatment of Upper Brachial Plexus Birth Palsy Injuries:
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Joshua M Abzug, Kevin J Little
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Neuroma Excision and Grafting or Nerve Transfers.................................... 147
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World Clin Orthoped. 2016;3(1):xi.
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b ooook Asif M Ilyas MD FACS
Guest Editor
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We are practicing through an exciting time in hand surgery. Over the past several
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years, we are seeing an explosion in evidence-based studies challenging old practice
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dogma, exciting new treatment paradigms, the incorporation of new technologic
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innovations, and the increase in research evaluation of biologic solutions for old
problems.
In this issue of the World Clinic of Orthopedics, we are fortunate to have
several leading authors presenting various challenging problems in hand surgery.
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Topics will include the role and indication of locking technology, challenging
b ooook role of diagnostic studies.

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hand surgery fractures, common tendon and nerve problems, and the evolving
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This issue will not attempt to be comprehensive to all aspects of hand surgery,
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but rather explore some of the more challenging and interesting areas of discussion.
. . . m
t ppss : / t ppss : / Asif M Ilyas MD FACS
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Rothman Institute
Associate Professor of Orthopedic Surgery
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Email: Asif.Ilyas@rothmaninstitute.com
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/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/
Abbreviations
e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /

t
hht
1,2 ICSRA
t
1,2 intracompartmental
supraretinacular artery

t
hht t
DISI Dorsal intercalated
segmental instability
3D Three-dimensional DRC Dorsal radiocarpal
A1 First annular DRUJ Distal radioulnar joint
A2 Second annular DTM Dart-throwing motion
k eers
rs AAEM American Association of
Electrodiagnostic Medicine

k er
ers
ECRL Extensor carpi radialis
s longus
b ooook AAN American Academy of

Neurology

b ooookEDT Electrodiagnostic testing
EMG Electromyography
eeb AANEM American Association
ee/ e
/
e b FCR Flexor carpi radialis
of Neuromuscular and
// t .tm
. m
Electrodiagnostic Medicine
: /
FDS Flexor digitorum
: / /t
superficialis
/.tm. m

t ppss :
AAOS American Academy of
/
s : /
ICBG Iliac crest bone graft
tpp s
hhttt hhttt
Orthopaedic Surgeons IOM Interosseous membrane
AAPMR American Academy of K-wire Kirschner wire
Physical Medicine and LCP Locking compression plate
Rehabilitation LISS Less invasive stabilization
AMS Active movement scale system
AO Association for the Study of LRL Long radiolunate ligament
keerrss Internal Fixation
k e rrss
LT Lunotriquetral
e
b ooook APGAR Appearance, pulse, grimace,
activity, and respiration

b o ook
o
MCN Musculocutaneous nerve
MCP Metacarpophalangeal
eeb

AVN Avascular necrosis
BMI Body mass index
ee/ e

/
e b MRI Magnetic resonance imaging
NSAID Nonsteroidal anti-

: / / / .
BMRC British Medical Research
t t m
. m inflammatory drugs
: / / t
/ .
t m
. m

Council
t p
CH Capitohamate
pss : /

p ss : /
NVBG Nonvascularized bone graft
ORIF Open reduction and internal
t p

t
hhtt
CI Confidence interval
CL Capitolunate
CMC Carpometacarpal

t
hhtt
fixation
PA Posteroanterior
PC-Fix Point contact fixator
CPG Clinical Practice Guidelines PH Pisohamate
CRL Extensor carpi radialis PIP Proximal interphalangeal
k e rrss
e
longus
CSA Cross-sectional area

rrss
PM Pisometacarpal
e
PRUJ Proximal radioulnar joint
k e
o o
o o k CT Computed tomography
o o
o k
PSSD Pressure-specified
o
eebb b
CTR Carpal tunnel release sensorimotor devices

CTS Carpal tunnel syndrome
DASH Disabilities of the arm,
ee/ e

/
e b PT Pisotriquetral
RA Rheumatoid arthritis
/
shoulder, and hand
: / t
/ .
t m
. m
: / / t. m. m
RASL Reduction association of the
/ t

t ss:
p /
DIC Dorsal intercarpal
p
DIP Distal interphalangeal
t p
RC Radiocarpalss:
scapholunate
p /
t
hht t t
hht t
k e r
e s
rs k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 10:33:38 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Hand Surgery
k e r
e s
rs k eers
r s
o o
o o k

ROM
RSC
Range-of-motion
Radioscaphocapitate
o o
o o k

STT
TC
Scaphotrapeziotrapezoid
Trapezocapitate
eebb

RSL
RSS
ee e
/ebb
Radioscapholunate ligament
/
Rotatory subluxation of the

TCL
TFCC
Transverse carpal ligament
Triangular fibrocartilage
: / / t
scaphoid
/ .
t m
. m complex
: / / t
/ .
t m
. m

t p ss : /
SAN Spinal accessory nerve
SC Scaphocapitate
p

p /
TH Triquetrohamate
ss :
THC Triquetrohamatecapitate
t p

t
hht t
SCL Scaphocapitolunate
SL Scapholunate
t
hht t complex
TLEF Trapeziolunate external
SLAC Scapholunate advanced fixation
collapse TT Trapeziotrapezoid
SLD Scapholunate dissociation UC Ulnocapitate
k eers
rs SLIL Scapholunate interosseous
ligament
k er
ers
s

UL Ulnolunate
UT Ulnotriquetral
b ooook SNAC Scaphoid nonunion

advanced collapse
b ooook

VBG Vascularized bone graft
VISI Volar intercalated segmental
eeb
/ e
/ e b
SRL Short radiolunate ligament
ee
SSN Suprascapular nerve
instability
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs
xiv
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k World Clin Orthoped. 2016;3(1):1-17.
eebb Locking Technology e

in e
/ e
/ebb
the Upper Extremity:
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
:
Evolution
t p p /
ss and Indications t p ss
p : /
t
hht t t
hht t
1
Siddharth B Joglekar MD, 2,*Asif M Ilyas MD FACS
1
Department of Orthopedic Surgery, VAMC Fresno and UCSF Fresno,
Fresno, California, USA
k eers
rs 2
k er
erss
Program Director of Hand Surgery, Rothman Institute, Associate Professor of Orthopedic Surgery
Thomas Jefferson University, Philadelphia, Pennsylvania, USA
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t ppss : / ABSTRACT
tppss : /
hhttt hhttt
The technique of locked plating has been the next major advance in orthopedic
fracture surgery and has had a significant impact on the management of
upper extremity fractures. The recognition of the role of vascularity and
soft tissues in fracture healing was central to the research and development
keerrss k eerrss
of newer plate designs that left minimal footprints on the surface of the
b ooook b ook
bone. Subsequently, innovative locking technology has improved our ability
o o
to manage cases with extensive comminution, inadequate bone stock, and
eeb / e
/ e b
periarticular fractures. This article will review the role of locking technology
ee
: / / t
/ t m
in the management of fractures of the upper extremity.
. . m : / / t
/ .
t m
. m
t
INTRODUCTION
hhtt t
hhtt
The technique of locked plating has been the next major advance in orthopedic
fracture care since the intramedullary nails and Perren’s introduction of dynamic
compression plates to the world of fracture care. Its evolution and development
k e rrss
e k
principles over the last few decades.1 rrss
was driven by the tectonic shift that took place in the philosophy of fracture care
e e
o o
o o k o o
o o k
eebb Historical Background
ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
Over the last 60 years, the principles of fracture fixation as laid out by the Association
p ss:
p / t p ss: /
for the Study of Internal Fixation (AO) group have undergone fundamental
t p
hhtt t
*Corresponding author
t
hht t
Email: asif.ilyas@rothmaninstitute.com
k e r
e s
k eerrss
o o
o o k o o
o o k
eebb WC Ortho Hand Surgery issue 4.indd 1
/ebb
/e 7/22/2016 11:29:25 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Joglekar and Ilyas
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee e
/ e b
Figure 1: A locked limited contact dynamic compression plate
/
showing the placement of a locked screw in the plate versus a
: // t . m
. m
nonlocked screw.
/ t : / /t/.tm. m
hhttt hhttt
changes in order to promote biological osteosynthesis.2 The recognition of the
role of vascularity and soft tissue conservation in fracture healing was central to
the research and development of newer plate designs that left minimal footprints
on the surface of the bone. This lead to the search for “internal fixators” devices
that would provide locked fixation while maintaining little or no contact with the
keerrss k eerrss
bone (Figure 1). The internal fixators required new screw designs which could lock
b ooook b o ook
into these devices and negating the need for friction between the conventional
o
eeb ee / e b
plate and the bone surface.3,4 The Schuli nut, the point contact fixator (PC-Fix),
/ e
and the less invasive stabilization system (LISS) plate were born out of such
t . m
. m t . m
. m
endeavors. Current plate designs offer flexible options to the surgeon in terms
: / / / t : / / / t
t pp ss : / t ppss : /
of locked versus nonlocked, plating, fixed angle versus variable angle locking and
t
hhtt
open versus percutaneous placement.5
t
hhtt
Biomechanics
When standard nonlocking plates are used, tightening of the screw leads to
k e rrss
e e rrss
compression of the plate against the bony surface. The friction between the plate
k e
o o
o o k o o
o o k
and the bone provides stability to the construct. The screw heads are free to toggle
eebb e / / b
in the plate holes and hence, bicortical purchase is needed to prevent loss of
e e b
stability.6,7 The disadvantage of this system is that the periosteal blood supply
e
: / / t
/ .
t m m : / / t
/.tm. m
along the undersurface of the plate is lost. Locked plates act as fixed angle devices
.
t ss:
p / t p ss:
p /
by allowing the screw heads to lock into the plate holes. Thus, they can function as
p
internally applied external fixators which do not have to rely on the friction at the
t
hht t t
hht t
plate bone interface for stability. This becomes an important issue when dealing
k e r
e s
rs
2
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Locking Technology in the Upper Extremity: Evolution and Indications
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
with comminuted fractures which are commonly treated with bridge plating.
Bridge plates span long segments of comminution and hence, have a long working
eebb ee/ e
/ebb
length. The working length of a plate bone construct is the length of the plate
/ / t
/ t m
. m / / t
/ t m
which is unsupported by screws. A long working length reduces the stability of the
. . . m
construct.8 Such plates are frequently needed in periarticular locations with short
: :
t p ss
p : / t p ss : /
end segments to bridge metaphyseal comminution. The short end segments with
p
t
hht t t
hht t
cancellous bone, adjacent to joints, further reduce the stability of the plate bone
construct.5,9,10 It is especially in these situations that locked plating offers the most
advantages. While nonlocked plates can function efficiently in the case of simple
diaphyseal fracture patterns with good cortical contact for load sharing, they can
k eers
rs k er
ers
fail in the case of osteopenic bone or bone loss and/or comminution at the fracture
s
site. Locked plating overcomes these weaknesses by providing angularly stable
b ooook o ook
fixation of the plate bone construct. They can be inserted percutaneously with or
b o
eeb ee e
/ e b
without jigs, further adding to their usefulness by preserving vascularity. Since
/
these devices function as internally applied fixators in the locking mode, their
: // t/.tm
. m : / /t/.tm. m
ability to sit closer to the mechanical axis of the bone increases the stability over
t ppss : /
that provided by external fixators.11
tppss : /
httt
Innovationsh
hhttt
The Schuli nut was one of the earliest attempts at providing angular stability to
keerrss k eerrs
the screws placed in nonlocking plates. It was a threaded washer which locked the
s
screw head into the hole and also kept the plate off the bone surface.12 Koval et
b ooook b o ook
al. modified a condylar buttress plate to provide locked fixation for distal femur
o
eeb ee e
/ e b
fractures in elderly patients. Cadaveric study demonstrated that this construct was
/
more stable as compared to conventional plates.13 The PC-Fix was one of the
t . m
. m t
earliest implants designed to be an internal fixator using Morse taper locking
: / / / t : / / / .
t m
. m
between the screw head and the plate holes.14 The LISS was the first commercially
t
hhtt t
hhtt
available locked plate for periarticular fixation.6 Both the LISS plate and PC-
Fix provide only locking screws options and were designed for unicortical screw
fixation in the diaphysis. The confluence of design principles of the compression
plates and the early locking plates led to the development of the combination
hole which allows for both locked and nonlocked fixation.15 These holes have
k e rrss
e e rrss
been universally adopted in newer generations of periarticular implants and the
k e
o o
o o k o o
o o k
locking compression plates (LCPs). The threaded hole used for locking allows
eebb e / / b
for only a fixed trajectory of the locking screw and this may be a problem in
e e b
periarticular locations or preexisting lag screws because of screw traffic. The
e
: / / / .
t m m : / / /.
variable angle locking screws have been designed to overcome this disadvantage.
t . t tm. m
t p ss:
p / t p ss:
p /
These screws depend on hoop stress or some additional interface with the screw
hole for locking. No studies are currently available comparing the variable angle
t
hht t
locking screw designs to the threaded locking hole.16 t
hht t
k e r
e s
rs k eerrss
3
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Joglekar and Ilyas
k e r
e s
rs k eers
r s
o o
o o k INDICATIONS AND TECHNIQUES
o o
o o k
eebb ee/ e
/ebb
Locking plates have been in use mainly for periarticular fractures which are
associated with problems of comminution, short bone segments, inability to gain
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
bicortical purchase, and inadequate bone stock. Straight LCPs are also available
t p ss
p : / ss : /
and these can be used when bridge plating diaphyseal comminuted and segmental
t p p
t
hht t t
hht t
fractures or in treating geriatric fractures with osteopenia. The additional cost
of using locking screws cannot be justified in case of simple fracture patterns
involving areas that have been treated successfully with conventional systems.
These include diaphyseal fractures of the humerus and forearm.17 In contrast, a
k eers
rs k er
ers
more appropriate indication for locked plating in the upper extremity is proximal
s
humerus and distal radius fractures.16
b ooook b ooook
eeb Indications
ee/ e e b
16,18
/
•
: // t/.tm
. m
Intra-articular fractures
: / /t/.tm. m
•
Periarticular fractures (i.e., proximal humerus, distal humerus, olecranon,
• h httt distal radius)

hhttt
Extra-articular metaphyseal fractures with comminution
• Comminuted/segmental fractures
• Periprosthetic fractures
• Geriatric fractures/osteoporosis.
keerrss k eerrss
b ooook Techniques b o ook
o
eeb ee/ e
/ e b
Certain technical details are helpful when using these locked plating systems:18
•
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Ensure that the correct inventory is available well in advance of the surgery
•
t ppss : / t p ss : /
Ensure familiarity with the system that is going to be used. Refer to product
p
• h
t
htt manuals if needed t
hhtt
Plan approaches and intraoperative steps of reduction before surgery
• Reduction and/or compression must be achieved before locking screws are
applied on both sides of the fracture. Once locking screws are positioned in
k eerrss possible
k rrss
a fracture fragment, no further manipulation of that particular fragment is
e e
b oooo k •
b o o o k
Temporary reduction may be maintained by multiple K-wires passed
o
eeb • / e e
independently or through the plate
ee / b
/ / t
/ t m
. m / / t
/ tm
When compression or reduction using the plate is needed, locking screws may
. . . m
be added after placement of compression or nonlocking screws for improving
: :
p ss: /
the strength of the construct
t p t p ss:
p /
• t
hht t t
hht t
Indirect reduction techniques with the help of distractors and percutaneously
applied clamps are useful in minimally invasive plate application
k e r
e s
rs
4
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
r
• s k eers
r s
o o
o o k o o
o o k
The fixed angle locking screws must be used with the jigs or drill guides
provided by the manufacturer, otherwise cross-threading can occur with
eebb resultant reduction of stability
ee/ e
/ebb
•
:
of screws into plate holes
/ / t
/ t m
Torque limiting screwdriver attachments must be used to prevent cold welding
. . m : / / t
/ .
t m
. m
t p ss
p : / t p ss : /
• Intraoperative fluoroscopy to obtain orthogonal views is helpful to prevent
p
t
hht t
joint penetration when placing periarticular screws. t
hht t
LOCKED PLATING IN THE UPPER EXTREMITY
k eers
r s
Proximal Humerus
k er
erss
b ooook b ooook
Proximal humerus fractures are relatively common and account for 5–9% of all
eeb / e
/ e b
fractures. Approximately more than 70% of proximal humerus fractures occur in
ee
: // t/.tm
. m : / /t/.tm
individuals 60 years old or over with women being affected 3 times more than
. m
t pp ss / tp ss : /
men.19 The incidence of proximal humerus fractures is increasing in the elderly
:
and is expected to triple over the next 3 decades.20 The treatment of nondisplaced
p
hhttt hhttt
fractures has historically been nonoperative management with good outcomes
whereas displaced fractures have generally been treated surgically.21,22 A plethora
of surgical techniques has been described which includes percutaneous fixation,
conventional plating, intramedullary fixation with rods or pins, tension band
keerrss k eerrss
fixation with or without plates or rods, modified blade plate constructs, and
hemiarthroplasty.23 There is no consensus regarding the optimal treatment for
b ooook o ook
o
these fractures. The vast array of available surgical options only proves the challenge
b
eeb ee/ e
/ e b
faced by surgeons in treating these fractures and the rate of complications is high.16
/ / t
/ t m
The osteopenic bone in the elderly patients combined with the short proximal
. . m / / t
/
segments and comminution provides very poor stability for fixation constructs.
: : .
t m
. m
The poor results associated with internal fixation have prompted authors to
t
hhtt t
hhtt
recommend hemiarthroplasty for displaced 3- and 4-part fractures in the past.24-27
Early results with the use of newer angle stable locking implants in these fractures
have been encouraging and the use of such implants has extended the ability to
preserve and retain the humeral head in greater number of patients (Figure 2).28
k e rrss
e k rrss
Locked plates designed specifically for the proximal humerus are anatomically
e e
contoured to fit the proximal humerus and provide multiple fixed-angle points
o o
o o k o o o k
of fixation into the humeral head. Each screw acts as a miniature blade plate,
o
eebb ee/ e b
e b
with the added benefit of providing fixed-angle support in multiple planes.16
/
Open reduction and internal fixation (ORIF) with a locked plate is indicated
/ / t
/ .
t m
. m / / t
/.tm. m
for displaced 2-part surgical neck fractures, 2-part anatomic neck fractures in the
: :
t p ss:
p / t p ss:
p /
patient younger than age 40 years, 3-part surgical neck fractures with involvement
t
hht t t
hht t
of the greater or lesser tuberosity, and most 4-part fractures. In the case of a fracture
dislocation, ORIF is advisable in patients younger than 40 years. However, the
k e r
e s
rs k eerrss
5
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Joglekar and Ilyas
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
Figure 2: Locked plate on a proximal humerus.
3- and 4-part fractures or fracture dislocations in the elderly may be better treated
with hemiarthoplasty.28 Biomechanical data support the use of locked plating for
keerrss bone.29-31
k eerrs
proximal humerus fractures and recommend it especially for use in osteoporotic
s
b ooook o ook
Despite the improved fixation offered by the locked implants, the failure of
b o
eeb / e e b
such constructs has been reported. The usual modes of failure are secondary to
ee /
collapse of the osteoporotic head around the plate, screw cutout, failure of the
: / / t .
t m
. m : / / t .
t m
. m
locking interface or failure of the plate along the working length of the plate.32,33
/ /
Inferomedial screw placement has been recently shown to reduce the risk of varus
t
hhtt t
hhtt
collapse in these fractures.34 The early results with the use of locked implants
have been promising in the treatment of these fractures. The incidence of fixation
failure is between 3 and 12%; that of infection being around 8% and other
complications; like impingement and nonunion, reported infrequently.35-38 The
k e rrss
e rrss
low rates of complications associated with satisfactory clinical outcomes (constant
e e
scores between 72 and 77) makes these implants very promising.35,38,39 The risk
k
o o
o o k o o o k
of osteonecrosis is considered to be one of the indications for recommending
o
eebb ee/ e
/ b
e b
shoulder hemiarthroplasty in 3- and 4-part fractures and fracture dislocations. The
incidence of osteonecrosis in these types of fractures treated with locked plating is
: / / t
/ .
t m
. m : / / t
/.tm. m
up to 16%.40,41 Recent data is also available to help determine which fractures are at
t p ss:
p / t p ss:
p /
an increased risk for developing osteonecrosis or other complications.42 However,
t
hht t t
hht t
the functional results obtained with locked plating are better than those obtained
with arthroplasty for 3- and 4-part fractures of the humerus. Constant scores
k e r
e s
rs
6
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:25 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
following hemiarthroplasty for these fractures are between 46 and 68 compared
to average constant scores between 57 and 78 for locked plating.35,38,41,43-45 Except
eebb / e
/ebb
for one study, no other direct comparisons with other implants have yet been
ee
: / / t
/ t m
. m
view of the potential benefits.16,28
: / / t
/ t m
reported.46 Despite this, surgeons have widely adopted the locked implants in
. . . m
t p ss
p : / t p ss
p : /
t
hht
Distal Humerus t t
hht t
Fractures of the elbow constitute about 7% of adult fractures with distal humerus
fractures constituting less than half of all elbow fractures.47 However, recent
k eers
rs k er
erss
epidemiologic data showed the number of osteoporotic fractures of the distal
b ooook oook
humerus in elderly women is increasing more rapidly than can be accounted for
o
by the demographic changes alone. It is significant to note that if the current
b
eeb ee/ e
/ e b
trends continue; a threefold rise in the number of distal humerus fractures
: // t/ tm
. m : / /t/
and comminution of the joint, semiconstrained total elbow arthroplasty is tm
is projected by the year 2030.48 In elderly patients with significant osteopenia
. . . m
the recommended treatment if the elbow joint cannot be reconstructed.49 For
hhttt hhttt
displaced, unstable distal humerus fractures amenable to stable fixation, ORIF is
indicated to provide the best outcomes.47,50,51 It has been shown that functional
results after treatment of these fractures correlate negatively with the degree of
intra-articular involvement and the period of immobilization. The treatment
keerrss k eerrss
of these fractures is also associated with a high rate of complications which
include loss of fixation and implant failure. Stable implant anchorage provides
b ooook o ook
the necessary fixation to start early range of motion and prevent complications
b o
eeb ee/ e
/ e b
in these challenging fractures with good to excellent outcomes in most patients
/ / t
/ t m
in both the short-term as well as the long-term period.52-58 While in good bone
. . m / / t
/ .
t m
. m
quality, implant choice is not critical, biomechanical laboratory results have shown
: :
that locking plate constructs help maintain anatomical reduction in the presence
t
hhtt t
hhtt
of comminution and poor bone quality in a low intra-articular fracture of the
distal humerus.59 Various anatomically preshaped angular stable implants are now
available which facilitate operative reduction and stabilization of the fractures of
the distal humerus. Studies have also suggested that plate configuration may also
k e rrss
e k rrss
assume importance in providing stable osteosynthesis.60 Double plating has been
e e
shown to provide more rigid fixation than a single-locked plate for fixation of
o o
o o k o o o k
extra-articular comminuted distal humeral fractures.61 Studies have demonstrated
o
eebb / e b b
that stiffness in anterior/posterior bending and torsional loading is significantly
ee / e
increased by using LCPs in a 90° configuration as compared with dorsally applied
: / / t
/ .
t m
. m : / / t
/.tm. m
plates. However, this difference between the different plate types is insignificant if
t p ss:
p / t p ss:
p /
applied in the same configuration.60 While traditionally the construct promoted
t
hht t t
hht t
by the AO group involves plate application on the two pillars of the distal
humerus in a perpendicular configuration (90-90 construct),62-64 recent studies by
k e r
e s
rs k eerrss
7
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:25 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Joglekar and Ilyas
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
O’Driscoll et al. have claimed that this concept is unsubstantiated and incorrect.
Several studies claim that a construct with two locking plates placed in a parallel
eebb / e
/ebb
configuration on either column in the sagittal plane with interdigitating screws
ee
: / / t
/ t m
. m : / / t
/ t m
linking the two columns distally in the form of an arch is a stronger construct as
. . . m
compared to the 90-90 construct.65-68 Since only retrospective clinical data from
t p ss
p : / t p ss : /
only specialized centers is available currently without any prospective randomized
p
t
hht t t
hht t
trials comparing the two methods, firm conclusions cannot be drawn regarding
the superiority of one method over another.
Proximal Radius and Ulna
k eers
rs k er
erss
b ooook b oook
Olecranon fractures are intra-articular injuries requiring accurate restoration
o
of the joint surface. These injuries range from simple nondisplaced fractures
eeb / e
/ e b
to comminuted fracture dislocations. Numerous fixation methods have been
ee
: // t/.tm
. m : / /t/.tm
described and include screw fixation, cerclage wiring, modified tension band
. m
t ppss / tp ss : /
wiring, and plate fixation. The surgical technique depends on a combination of
:
patient factors, the fracture pattern, and the mechanical stability of the fixation
p
hhttt hhttt
construct. Fixation must be stable enough to permit early mobilization to avoid
significant elbow stiffness.69-71 Plate fixation is commonly recommended with
comminuted fractures and fractures distal to the midpoint of the trochlear notch,
those involving the coronoid process and olecranon fractures associated with
keerrss k eerrss
Monteggia fracture dislocations of the elbow. Tension band wiring or conventional
b ooook b ook
plating may not provide adequate stability in these situations.72,73 A plate applied
o o
over the dorsal tension surface of the olecranon with an intramedullary screw
eeb e / e
/ e b
through the proximal hole has been shown to be most stable construct in
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
biomechanical studies and may, therefore, be the preferred method of fixation
t ppss / t ppss : /
for comminuted olecranon fractures.74 Several precontoured and congruent plate
:
constructs are available for olecranon plating with the option of locking screws
t
hhtt t
hhtt
for added stability. Plate fixation has been shown effective treatment option for
displaced olecranon fractures with a good functional outcome and a low incidence
of complications.75,76
While ideal treatment of radial head fractures is associated with controversy,
k e rrss
e k e rrss
radial head ORIF is currently the preferred method of treatment, whenever
e
o o
o o k o o
o o k
feasible, to restore elbow alignment and stability.77-79 Several studies have shown
eebb e / / b
favorable results with the use of plate fixation for radial head fractures.78,80-83
e e b
Biomechanical studies have shown comparable or even higher stability in unstable
e
: / / t
/ .
t m m : / / t
/.tm. m
radial head fractures with angle stable implants as compared to crossed screws
.
t p ss:
p / t p ss:
p /
or nonlocking plates.84,85 The role of locking plate technology in these fractures
t t t t
needs to be clarified with biomechanical testing and randomized prospective
hht hht
studies with a focus on validated outcome instruments.
k e r
e s
rs
8
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:25 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k eers
r s k eers
r s
o k Distal Radius
o k
eebbooo ee/ e o
bb o o
The lifetime risk of developing a distal radius fracture is 15% for women and 2%
/e
for men.86 These fractures represent the second most common fractures in the
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
elderly after hip fractures and account for one-sixth of all the fractures treated in
ss : / ss : /
the emergency department.87 The attitude towards the treatment of this common
t p p t p p
t
hht t t
hht t
injury is changing as it is becoming clear that the restoration of anatomical articular
congruity is critical.88 There is a correlation between the functional outcome
following a distal radial fracture and the restoration of both the radiocarpal and
the radioulnar relationships.89,90 In cases of fractures of the distal radius in elderly
k eers
rs k er
ers
patients with osteopenic bone, obtaining stable fixation and maintaining reduction
s
till fracture healing represents a challenge. Theoretically, locked plating represents
b ooook o ook
a perfect solution for the problems associated with these fractures since many
b o
eeb ee e
/ e b
of them are associated with short end segments, metaphyseal, and/or articular
/
comminution and osteopenia (Figure 3). Indications include any distal radius
: // t/.tm
. m : / /t/.tm. m
fractures whose potential for collapse or loss of articular reduction exceeds the
level of stabilization that can be provided with closed reduction and smooth wire
hhttt hhttt
stabilization. The more osteopenic or metaphyseally deficient the bone, the more
advantageous is the volar fixed-angle plating.91 There has been a marked trend in
favor of plate and screw fixation for fractures of the distal radius. The proportion
of fractures that are stabilized with open surgical treatment have increased from
42% in 1999 to 81% in 2007.92 Biomechanical studies have shown better stability
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
Figure 3: Volar locked plate on a distal radius.
k e r
e s
rs k eerrss
9
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:25 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Joglekar and Ilyas
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
in osteopenic distal radius fractures with locked plate fixation.93-96 However, there
is little level-I or II evidence to support open reduction and locked plating for
eebb / e
/ebb
distal radius fractures.97-100 The Cochrane Musculoskeletal registry after a recent
ee
: / / t
/ t m
. m : / / t
/ t m
review of randomized controlled studies, concluded that the literature does not
. . . m
provide robust evidence for most of the decisions regarding surgical intervention
t p ss
p : / t p ss : /
in the case of distal radius fractures.101 Despite lack of evidence, the popularity
p
t
hht t t
hht t
and use of locked plating for distal radius fractures continues to surge. Implant
manufacturers offer more than 30 different designs of locked plate implants with
multiple screw options (locking vs. nonlocking, variable angle vs. fixed angle
locking, and smooth pegs vs. screws) and the market for distal radius implants
k eers
rs alone grosses $250 million.102
k er
erss
Mechanical failures are rare in cases of distal radius fixation constructs because
b ooook ooook
of the reduced loads about the wrist. However, minor amounts of settling of the
b
eeb ee/ e
/ e b
distal fragment have been reported. Placement of the distal screws or pegs just
// t/ tm
. m / /t/ tm
beneath the subchondral bone is supposed to improve the stability and prevent
. . . m
settling or redisplacement.103,104 Volar locked plating for osteopenic or high
: :
energy comminuted distal radius fractures has provided satisfactory outcomes and
hhttt hhttt
times to union even with institution of early range of motion as compared to other
modalities.91 Times to union have generally been between 7 and 8 weeks with an
average range of motion which was better than fractures treated with external
fixation.105,106 Satisfactory results with locked plating of distal radius fractures
keerrss k eerrs
have also been obtained with the use of validated outcome instruments like the
s
Disabilities of the arm, shoulder, and hand (DASH) score for assessment. An
b ooook o ook
average DASH score from 8.3 to 16 (range 0–100, with a lower score better than a
b o
eeb ee/ e
/ e b
higher score) and an average grip strength of around 75–77% may be expected.103,106
Complications related to tendon and soft tissue irritation are uncommon with
: / / t .
t m
. m : / / t .
t m
. m
volar plating as the flexor tendons are not in contact with the plate. Also, the
/ /
pronator quadrates acts as a soft tissue cushion between the tendons and the plate.
t
hhtt t
hhtt
Complications have been reported due to overpenetration of screws through the
dorsal cortex, intra-articular penetration, and radial artery injury. Variable angle
locking screws may help in prevention of joint penetration and interference with
other hardware.107 Fracture settling due to inadequate support of the subchondral
k e rrss
e rrss
bone by the distal screws can also occur.91,108-112
e e
Studies have proven that external fixation augmented with percutaneous pins
k
o o
o o k o o o k
provides superior radiographic results compared to closed treatment or pin fixation
o
eebb ee/ e
/ b
e b
alone.113,114 Comparable results have also been obtained with external fixation
augmented with pin fixation versus open treatment in terms of radiographic
: / / t
/ .
t m
. m : / / t
/.tm. m
outcomes and clinical results.106,115 While external fixation with or without
t p ss:
p / t p ss:
p /
percutaneous pins is a definite improvement over closed techniques of treatment,
t
hht t t
hht t
it is associated with complications. Tightness of the digital extensors, wrist
capsular stiffness, osteopenia, radial sensory nerve problems, malunion, nonunion,
k e r
e s
rs
10
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
pin-tract infections, and regional pain syndrome are common problems and final
range of motion, pain, grip strength, and outcome scores can be adversely affected
eebb / e
/ebb
in direct proportion to distraction and duration of external fixation.116,117 The
ee
: / / t
/ t m
. m : / / t
/
the common tendency of these fractures to displace dorsally. However, dorsalt m
dorsal plating approach to distal radius fractures evolved as a means to buttress
. . . m
t p ss
p : / t p ss : /
plating is associated with complications related to extensor tendon irritation and
p
t
hht t t
hht t
rupture.118-120 The enthusiasm for volar locked plating is also driven by the various
reports documenting excellent results with the volar locked plate fixation of the
common dorsally displaced fractures.105,121-123 However, it still remains unclear
if the use of locked plating translates into clinical benefits when compared with
k eers
rs k er
erss
nonlocked plating, dorsal plating, or external fixation modalities in the long
term. While the surge in popularity of locked plating continues, the need for
b ooook oo ook
randomized controlled trials with the use of validated outcome measures to prove
b
eeb ee/ e
/ e b
the superiority of this technique over other modalities remains.
: // t/.t m
. m : / /t/.tm. m
t pps s : /
Advantages, Disadvantages, and Complications
tppss : /
hhttt hhttt
Surgeons develop a sense of tactile feedback with regular nonlocking screws
to determine screw purchase. This is essential in order to determine the overall
stability of the construct. No such feedback is available for the surgeon in case
of locking screws. Traditional screws allow the plate to be sucked down to the
keerrss k eerrs
bone or vice versa. This quality is frequently used to aid reduction of fractures
s
to the plate. Since locked plating does not offer this advantage, it can only be
b ooook o ook
used to maintain reduction and not to gain it. When locked plates are used for
b o
eeb ee/ e
/ e b
percutaneous application, the inability to gain reduction may lead to a higher rate
of malalignment compared to open reduction. Attempts to contour the locking
: / / t .
t m
. m : / / t .
t m
. m
plates can lead to loss of screw head fixation within the holes, leading to decrease in
/ /
stability of the construct. This is a problem when using precontoured locking plates
t
hhtt t
hhtt
for periarticular fractures as the bony anatomy varies between individuals in terms
of shape and size. Hardware removal can become difficult if the screw heads get
cold welded into the locking holes, especially in the case of titanium plates. Torque
limiting attachments are available for the screw drivers and power tools so that the
k e rrss
e rrss
incidence of this complication can be decreased. The use of fixed trajectory locking
e e
plates in periarticular locations has a potential disadvantage of screw penetration
k
o o
o o k o o o k
into the joint or interference of the screw with other screws, especially in complex
o
eebb ee/ e
/ b
e b
fractures. Use of nonlocking screws through locking holes is not advisable as the
round locking holes do not allow a great freedom in terms of screw direction and
: / / t
/ .
t m
. m : / / t
/.tm.
the screw heads can be too prominent. Variable angle locking plates are availablem
t p ss:
p / t p ss:
p /
but the stability provided by such designs has not been well established. Early
t
hht t t
hht t
locking plate designs meant for percutaneous insertion used unicortical screws in
the diaphysis and this was associated with fixation failure. The locking screws also
k e r
e s
rs k eerrss
11
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:25 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Joglekar and Ilyas
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
do not allow any compression at the fracture site as the screw heads cannot move
within the hole. These disadvantages have been overcome with the development
eebb / e
/ebb
of newer plate design which allow for both bicortical fixation and the option of
ee
: / / t
/ t m
. m : / / t
/ t m
using nonlocking screws if needed. Locked plate constructs are also much more
. . . m
expensive than their conventional counterparts. A significant part of this cost
t p ss
p : / t p ss : /
increase can be accounted for by the cost of locking screws. The remaining cost
p
t
hht t t
hht t
increase arises from the need to maintain additional inventory and implants apart
from training of personnel and staff. While these plates are commonly used in the
developed countries, the use of these techniques and availability of opportunity for
training and skill development in locked plating is not universally available in the
k eers
rs k er
erss
rest of the world. Universal availability of industry support and implants may also
be a problem in developing countries.
b ooook b ooook
eeb Conclusion
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Locking technology has revolutionized the management of fractures of the upper
extremity especially in cases with extensive comminution, inadequate bone stock,
hhttt hhttt
and periarticular fractures. The use of locked plating, minimally invasive and
biological techniques of fracture fixation have allowed orthopedic surgeons to
provide optimal outcomes in challenging fracture care scenarios. Despite the many
advantages and popularity of locked plated, there are certain distinct limitations
keerrss k eerrss
with these implants which need to be understood prior to successful incorporation
of these plates into the surgical armamentarium.
b ooook b o ook
o
eeb Editor’s Comment
ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Locking technology has seen rapid incorporation in orthopedic fracture repair
surgery. In particular, locking technology has a number of specific indications that
t
hhtt t
hhtt
are well suited for the management of upper extremity fractures. These indications
include but are not limited to cases with extensive comminution, poor bone quality,
and periarticular fractures. In this article, the authors review these indications and
discuss how they are best incorporated in various fractures of the upper extremity.
k e rrss
e Asif M Ilyas
k e rrss
e
o o
o o k o o
o o k
eebb REFERENCES ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / Ortop Pol. 2006;71:275-9.
t p ss:
p /
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hht t t
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s
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b oook
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11. Behrens F, Johnson W. Unilateral external fixation. Methods to increase and reduce frame stiffness. Clin
ee
: // t tm
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b
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e / e
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t . m
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o k e
23. Badman BL, Mighell M. Fixed-angle locked plating of two-, three-, and four-part proximal humerus fractures.
k e
o
eebb o o b o o o
24. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal
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ee/ e
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/
25. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus
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/.t . m
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t ss:
p t t p
t ss:
26. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head
p
replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995;4:81-6.
hht hht
27. Moeckel BH, Dines DM, Warren RF, Altchek DW. Modular hemiarthroplasty for fractures of the proximal part
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e s
rs k eerrss
13
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:26 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
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World Clin Orthoped. 2016;3(1):18-46.
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Wrist Dislocations:
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Anatomy,
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Biomechanics, and Treatment t p ss
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1,
*John R Fowler MD, 2Jung H Park MD
1
Department of Orthopedics, University of Pittsburgh
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Department of Orthopedic Surgery, Bucks County Orthopedic Specialists
Doylestown, Pennsylvania, USA
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Wrist dislocations are a spectrum of severe wrist injuries that include
dislocation of the radiocarpal joint, distal radioulnar joint, midcarpal joint,
and carpometacarpal joint. A closed reduction should be attempted in all
cases to relieve tension on the median nerve and other soft tissues. However,
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definitive treatment with closed reduction alone is rarely acceptable. Repair
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of the affected ligaments and stabilization with temporary K-wire fixation
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is the treatment of choice in most cases. Missed or delayed treatment may
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results in poor outcomes due to post-traumatic arthritis and stiffness.
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INTRODUCTION
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Wrist dislocations vary from a simple carpometacarpal dislocation of the fifth
metacarpal base to perilunate and lunate dislocations. Prompt diagnosis and
treatment offers the best chance of successful outcome. Attention must be focused
on treating both the dislocation and the soft tissue injury. The relevant anatomy
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and treatment of wrist dislocations is reviewed in this article.
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eebb ANATOMY
Osseous Anatomy ee/ e
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The wrist is comprised of the distal radius and ulna, the eight carpal bones, and
hhtt t *Corresponding author

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the proximal ends of the five metacarpals. The carpal bones are arranged in two
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Email: johnfowler10@gmail.com
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Wrist Dislocations: Anatomy, Biomechanics, and Treatment
k e r
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rows, proximal, and distal. The proximal row is formed by the scaphoid, lunate,
and triquetrum and the distal row includes the trapezium, trapezoid, capitate,
eebb / e
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and hamate. The pisiform, although anatomically located in the proximal row, is
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a sesamoid bone of the flexor carpi ulnaris muscle and does not form part of the
. . . m
functional proximal row. The scaphoid is unique in that it is the only carpal bone
t p ss
p : / t p ss : /
that spans both rows and, therefore, functions as a mechanical link and provides
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t
hht t
coordinated motion of the proximal and distal rows. t
hht t
There are four major articulations of the wrist: (i) the distal radioulnar
joint (DRUJ), (ii) the radiocarpal joint, (iii) the midcarpal joint, and (iv) the
carpometacarpal (CMC) joints.
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r r ss
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ookeer
In the DRUJ, the concave sigmoid notch of the radius articulates with the
semicylindrical ulnar head, and facilitates pronation and supination. The
b
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sigmoid cavity is shallow, with a radius of curvature of 15 mm, whereas the ulnar
b
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head has a convexity of 220° with radius of curvature of 10 mm.1 This difference
m e m
: ///t/.t. m : / /
/t/.t . m
in curvature allows the ulna to translate volarly in supination (5.4 mm from
neutral position) and dorsally in pronation (2.8 mm from neutral position).2
t ppss : tppss :
The triangular fibrocartilage complex (TFCC) is the primary stabilizer of
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the DRUJ. Additional stability is provided by the joint capsule, interosseous
membrane, pronator quadratus, and extensor carpi ulnaris
• In the radiocarpal joint, the articular surface of the distal radius is biconcave
and triangular with the radial styloid forming the apex of the triangle.3 The
keerrss k eerrss
scaphoid fossa is triangular, while the lunate fossa is ovoid and they articulate
b ooook b ook
with their respective bones.4 The scaphoid fossa has a smaller radius of curvature
o o
than lunate fossa, and thus, increased motion is allowed. The bony congruency
eeb / e
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of the scaphoid on the scaphoid fossa may provide structural support when the
ee
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scapholunate (SL) ligament is torn.5 Motions at the radiocarpal joint include
. . . m
t ppss /
flexion, extension, radial, and ulnar deviation
: t ppss : /
• The midcarpal joint is the articulation between the two carpal rows and allows
t
hhtt t
hhtt
motion in both sagittal and coronal planes. Laterally, the scaphoid articulates
with the trapezium and the lateral aspect of capitate. Centrally, the convex head
of the capitate articulates with the concave scaphoid and lunate. Medially, the
triquetrum articulates with the hamate and forms an ovoid or helicoid joint.
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The midcarpal joint is stabilized by both the extrinsic and intrinsic carpal
e e
ligaments. The proximal row has no tendinous attachments, therefore, motion
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is allowed as an independent intercalated segment.
eebb ee/ e
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Carpal Ligaments
: / / t
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The majority of carpal ligaments are found within the joint capsule as organized
t p
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thickenings composed of longitudinally arranged parallel collagen fibers called
fascicles. Their orientation is collinear with the course of the ligament. Surrounding
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Fowler and Park
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these fascicles are the areolar connective tissues that transmits small caliber nerves
and blood vessels, and together form the perifascicular space.6
eebb / e
/ebb
In order to simplify description of the carpal ligaments, they can be divided
ee
: / / t
/ t m
. m : / / t
/ t m
as intrinsic versus extrinsic based on their attachment sites. Extrinsic ligaments
. . . m
connect the radius or ulna to the carpal bones. The intrinsic ligaments have their
t p ss
p : / t p ss : /
origin and insertion within the carpal bones. Based on their location, they can
p
t
hht t t
hht t
be further categorized as palmar versus dorsal and radiocarpal versus midcarpal.
The palmar extrinsic ligaments are the strongest of the extrinsic ligaments and
are the main stabilizers of the radiocarpal joint.7,8 If a ligament spans a joint,
they are named in the order of proximal to distal or radial to ulnar. Additional
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nomenclature is based on the location of the ligament, dorsal versus palmar.7 For
descriptive purposes, Berger groups the carpal ligaments by region to include
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palmar radiocarpal, ulnocarpal, dorsal radiocarpal (DRC), and intercarpal,
b
eeb ee/ e
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palmar midcarpal, proximal interosseous, distal interosseous, and distal radioulnar
ligaments.
: // t/.tm
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t p ss : /
Palmar Radiocarpal Ligaments
p tppss : /
hhttt hhttt
Four ligaments are found in this region and they all have their origin in the radius.
From radius to ulna, these include: (i) the radioscaphocapitate (RSC) ligament,
(ii) the long radiolunate ligament (LRL), (iii) radioscapholunate ligament (RSL),
and (iv) short radiolunate ligament (SRL). The RSC ligament originates from
keerrss k eerrss
the tip of the radial styloid to the middle of the scaphoid fossa and attaches to
b ooook b ook
the distal pole of the scaphoid and in the midcarpal joint, it interdigitates with
o o
fibers of the ulnocapitate (UC) and palmar scaphotriquetral ligaments to end at
eeb e / e
/ e b
the body of the capitate. During this oblique course, it serves as a fulcrum for
e
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t m
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scaphoid flexion and it is the primary restraint to ulnar translation of the carpus.
t pp : / t pp s : /
The LRL originates from the remaining portion of the volar rim of the scaphoid
ss s
fossa and attaches at the radial aspect of the lunate. This ligament is a true capsular
t
hhtt t
hhtt
ligament and forms a strong tether to lunate displacement. The RSL does not
share the mechanical and histological findings described for other ligaments and
studies found that it contains terminal branches of the anterior interosseous nerve
and vessels from the distal radial arch.9,10 The SRL originates from the entire
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volar rim of the lunate fossa and attaches onto the radial half of the lunate. This
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strong attachment of the lunate to the radius on the palmar side prevents dorsal
eebb ee/ / b
dislocation of the lunate in hyperextension injuries.
e e b
Ulnocarpal Ligaments
: / / t
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/.tm. m
t p ss:
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Three ligaments are found in this region: (i) UC, (ii) ulnotriquetral (UT), and
t t t t
(iii) ulnolunate (UL). The UC is the most superficial and originates from the fovea
hht hht
of the ulna, an area of depression at the base of the ulnar styloid. It passes through
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the lunotriquetral (LT) joint reinforcing the palmar portion of the LT interosseous
ligament and finally interdigitates with the fibers of the RSC ligament to form the
eebb / e
/ebb
arcuate ligament as it attaches to the capitate. Proximal to the arcuate ligament
ee
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/
capitates or lunate may dislocate. The UT and UL ligaments form the anteriort m
is the area of capsular weakening called the space of Poirier, through which the
. . . m
t p ss
p : / t p ss : /
and ulnar aspects of the ulnocarpal joint capsule. The proximal origin of these
p
t
hht t t
hht t
two ligaments is indistinguishable in the palmar radioulnar ligament, but their
nomenclature is based on distal attachments. The UL ligament is also continuous
with the SRL ligament at the lunate attachment.
k eers
rs Dorsal Radiocarpal and Dorsal Intercarpal Ligaments
k er
erss
b ooook o ook
The DRC ligaments originate from the dorsal rim of the distal radius from the
b o
eeb ee e
/ e b
sigmoid notch to the Lister’s tubercle. It is oriented obliquely and ulnarly as it
/
attaches to the dorsal cortices of the lunate and triquetrum, preventing its ulnar
: // t/.tm
. m : / /t/.tm. m
translation. The dorsal intercarpal (DIC) ligament attaches to the dorsal tubercle
of the triquetrum and passes radially with its proximal fibers attaching on the radial
hhttt hhttt
surface of the distal pole of the scaphoid and the distal band of fibers attaches on
the dorsal cortex of the trapezoid. The intersection angle between DRC and DIC
ligaments at the triquetrum changes from acute angle during wrist dorsiflexion to
perpendicular during palmarflexion.
keerrss Palmar Midcarpal Ligaments

k eerrss
b ooook b o ook
o
eeb e / e b
The four ligaments in this region consist of: (i) scaphotrapeziotrapezoid (STT),
/ e
(ii) scaphocapitate (SC), (iii) triquetrocapitate, and (iv) triquetrohamate (TH).
e
: / / t
/ .
t m m : / / t
The latter two ligaments are also grouped together as triquetrohamatecapitate
. / .
t m
. m
complex (THC) and are also known as the ulnar leg of the distal V or arcuate
t
hhtt t
hhtt
ligament. The midcarpal ligaments connect the scaphoid and triquetrum to the
distal carpal row. The lunate does not have a direct connection to the distal row;
however, the central portion of the capsule is composed of the interdigitating
fibers of the RSC and UC ligaments forming the arcuate ligament, by which
its transverse orientation supports the capitates without directly attaching to
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it. The STT ligament runs from the radial and ulnar aspects of the distal pole
k e
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of the scaphoid to the palmar and radial aspects of the trapezium and to the
eebb e / / b
e b
palmar surface of the trapezoid via its respective fibers. The SC ligament courses
e
obliquely and ulnarly from the distal pole of the scaphoid to the palmar cortex
e
t . m
. m t. m
of the body of the capitates. This orientation is parallel to the RSC ligament,
: / / / t : / / / t . m
t p ss:
p / t p ss:
p /
which only 10% of its fiber actually attaches to the capitate. The triquetrocapitate
t t t t
originates proximally from the distal and radial corner of the triquetrum and
hht hht
attaches to the ulnar aspect of the body of the capitate. The TH originates from
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Fowler and Park
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the distal margin of the palmar cortex of the triquetrum and attaches to the
o
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palmar aspect of the body of the hamate.
ee/ e
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t m m
Proximal Interosseous Ligaments
t . : / / t
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. m
ss : / ss : /
As the proximal row has no tendon insertions, it is an intercalated segment that
t p p t p p
t t t t
relies on the integrity of the stout interosseous ligaments for its coordinated
hht hht
motion. The two ligaments in this region are the SL and LT. They cover the dorsal,
proximal, and palmar aspects, thus, allowing communication with the midcarpal
joint. The thickest portion of the SL ligament is the dorsal component, while
the thickest region in LT ligament is the palmar portion. The proximal portions
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rs k er
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of both ligaments are formed by fibrocartilage with no collagen, nerve, or blood
b ooook b ooook
vessels. The scaphotriquetral ligament is an extension of the SL and LT ligaments
eeb ee/ / e b
and passes along the dorsal margins of the scaphoid, lunate, and triquetrum.
e
: // t . m
. m
Distal Interosseous Ligaments
/ t : / /t/.tm. m
There are three ligaments in this region connecting the bones of the distal row
hhttt hhttt
and they consist of: (i) trapeziotrapezoid (TT), (ii) trapezocapitate (TC), and
(iii) capitohamate (CH) ligaments. Each ligament consists of dorsal and volar
portions that run transversely as nearly continuous sheets of fibers. The TT
ligament spans almost the entire joint edges. The TC ligament extends only to
keerrss k eerrs
the body of the capitate. This ligament also has a strong deep portion that crosses
s
the central region of the joint. The CH ligament crosses only the distal portion
b ooook o ook
of the joint due to the proximal extension of the pole of the hamate and the head
b o
eeb / e e b
and neck of the capitate. This ligament also has a large deep portion that extends
ee /
distally to the third and fourth metacarpals.11
: / / t
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t m
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t pp
BIOMECHANICSss : / t ppss : /
t
hhtt t
hhtt
From historical prospective, the study of the kinematics of the wrist evolved from
descriptive models based on anatomical studies to advances in analytical science
and radiographic images with three-dimensional (3D) reconstruction images to
k e rrss
e
study in vivo carpal motion.
k e rrss
e
Johnston in 1907 recognized the presence of proximal and distal carpal
o o
o o k o o o k
rows and proposed that each row functions as a rigid unit that moves about two
o
eebb ee/ e b
e b
transverse joints (radiocarpal and midcarpal). Although the bones in the distal
/
carpal row are securely connected via the interosseous ligaments and acts as a
: / / t .
t m
. m : / / t.tm. m
functional unit, this theory fails to recognize that the bones in the proximal row
/ /
t p ss:
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p /
behave in a more complicated manner. In 1935, Navarro introduced the concept of
t
hht t t
hht t
carpal bones arranged in three vertical independent columns. The central column
composed of lunate, capitate, and hamate, controls flexion-extension; the lateral
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t t p
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column consisting of scaphoid, trapezium, and trapezoid controls the load transfer
across the wrist joint; and the medial column composed of the triquetrum and
eebb / e
/ebb
pisiform controls supination-pronation. This columnar theory was later modified
ee
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/ t m
by Taleisnik in 1978, by including trapezium and trapezoid as part of the central
. . .
column and recognizing that the pisiform does not function as a carpal bone due m
t p ss
p : / t p ss : /
to its nature of being a sesamoid bone of the flexor carpi ulnaris and he excluded
p
t
hht t t
hht t
the pisiform from the model. This columnar theory recognized the importance of
the scaphoid as a link between the proximal and distal carpal motion, and even to
date, this simplified model can be used for understanding of the wrist kinematics.
Later, Weber proposed the two columnar theory of load-bearing column
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(capitate, trapezoid, scaphoid, and lunate) and the control column (triquetrum
and hamate). In 1981, Lichtman presented the idea of the carpal function as an
b ooook ooook
oval ring that is formed by four interdependent elements that are connected by a
b
eeb ee/ e
/ e b
complex ligamentous system. They are: (i) distal row, (ii) scaphoid, (iii) lunate, and
(iv) triquetrum.
// t/.tm
. m / /t/.tm. m
The most recent studies emphasize on functional kinematics and introduced
: :
the concept of dart-throwing motion (DTM). Proponents claim that most of the
hhttt hhttt
activities of daily living involve carpal motions in an oblique axis that includes a
combination of wrist extension with radial deviation and wrist flexion with ulnar
deviation. They extend this theory by claiming that the true axis of motion of the
wrist should take into account these combined motion rather than the previously
keerrss k eerrs
noted anatomical axis.12 Li et al. found that during circumduction of the wrist,
s
it forms an “egg shape”, which is asymmetric with respect to the anatomically
b ooook o ook
defined flexion-extension and radial-ulnar deviation axes.13
b o
eeb ee/ e
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Recent Studies
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t m
. m
Although the pisiform has traditionally been excluded from the wrist kinematic
t
hhtt t
hhtt
studies because it is a sesamoid bone of the flexor carpi ulnaris, the association of
ulnar-sided wrist pain with pisotriquetral (PT) joint instability has promoted more
studies of the PT joint. The ligaments around the pisiform include the pisohamate
(PH), pisometacarpal (PM), transverse carpal ligament (TCL), and PT ligaments.
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The PH ligament inserts on either the palmar or the radial aspect of the pisiform
e e
and it is thicker and shorter than the PM ligament, which inserts on the palmar
o o
o o k o o o k
aspect of the pisiform, deeper than the PH ligament. The TCL was found to
o
eebb / e b b
have a small insertion on the distal pisiform in only 50% of specimens, whereas
ee / e
the remaining 50% inserted onto the hook of the hamate. The PT ligament has
: / / t
/ .
t m
. m : / / t
/.tm.
two components: radial and ulnar. The ulnar component is thicker than the radial m
t p ss:
p / t p ss:
p /
portion. Biomechanical studies on cadaver specimens found that the PH ligament
t
hht t t
hht t
is the primary stabilizer of ulnar displacement. The PM ligament is the primary
constraint of proximal displacement of the pisiform. The ulnar PT ligament is the
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Fowler and Park
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primary restraint against radial translation. Transection of the TCL in cadaveric
models does not lead to pisiform instability and the same clinical correlation is
eebb / e
/ebb
observed in patients undergoing carpal tunnel release. Despite the importance of
ee
: / / t
/ t m
. m : / / t
/ t m
the PT joint stability to prevent degenerative changes and associated pain, it is
. . . m
unclear whether the pisiform itself contributes to the overall stability of the ulnar
t p ss
p : / t p ss : /
column of the wrist as pisiform excision has not proven to have any adverse effects
p
t
hht t t
hht t
on strength or motion.14 However, in vivo carpal kinematic studies demonstrate
that the pisiform comes into contact with the triquetrum during extension,
preventing anterior dislocation.15
k eers
rsMotion of the Carpal Bones
k er
erss
b ooook o ook
The motion of the wrist as well as its stability can be viewed from the context of
b o
eeb / e e b
proximal carpal row instability. The central column is inherently unstable and it
ee /
is dynamically stabilized by the counterbalancing forces of the scaphoid, which
: // t .tm
. m : / /t .tm. m
tends to flex and the triquetrum, which has a tendency to extend. This simplified
/ /
t pps s : / tppss : /
model explains the results of dorsal intercalated segmental instability (DISI)
hhttt hhttt
and volar intercalated segmental instability (VISI) deformities that are observed
with scaphoid fracture or SL ligament disruption and LT ligament disruption,
respectively.
The scaphoid’s natural tendency is to flex when compressive force is applied
keerrss k eerrs
during flexion or radial deviation. In doing so, it also brings the lunate into flexion
s
due to its strong ligamentous attachments. The capitate also has ligamentous
b ooook o ook
attachments to the scaphoid and it is slightly pronated and translated palmarly
b o
eeb ee e
/ e b
when the scaphoid flexes. Recent in vitro and in vivo studies demonstrate that the
/
scaphoid flexes 61–82%, while the lunate flexes 31–63% when the wrist is flexed
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
to 60°. At 20° of radial deviation, the scaphoid flexes 8–15°. During extension
and ulnar deviation, the scaphoid extends, however, the lunate responds to the
t
hhtt t
hhtt
torsional force applied via the LT ligament as the triquetrum extends. When the
wrist is extended to 60°, the scaphoid extends 85–99%, while the lunate extends
38–66%. At 20° of ulnar deviation, the scaphoid extends 11–20°. Additionally, in
vivo studies using 3D models also demonstrated that during flexion, the degree
of ulnar deviation is 6° for the scaphoid, 6.5° for the lunate, and 7.5° for the
k e rrss
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triquetrum. In addition, small degree of pronation is also associated with flexion
k e
o o
o o k o o
o o k
as the scaphoid comes into contact with the radial styloid.15 During extension,
eebb ee/ e
/ b
e b
the scaphoid and the lunate deviate ulnarly, 3.6° and 3.4°, respectively, while the
triquetrum radially deviates 7.8°. During radial deviation, all carpal bones in the
: / / t
/ . m
. m : / / t. m. m
proximal row deviate radially and flex, while the distal carpal bones extend in
t / t
t p ss:
p / t p ss:
p /
order to maintain the hand in the frontal plane. The opposite occurs during ulnar
t t t t
deviation, with the proximal carpal row undergoing extension compensated by
hht
flexion of the distal carpal row.16 hht
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
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r s
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o o k o o
o o k
While the proximal row has high degree of motion, the distal row has
traditionally been viewed as rigid unit, with very little motion in between the bones
eebb / e
/ebb
of the distal carpal row. However, recent studies have challenged this concept and
ee
: / / t
/ t m
. m : / / t
/ t m
demonstrated movement within distal carpal bones in all three axes of rotation.
. . . m
Recently, attention has been directed towards the more natural oblique rotation
t p ss
p : / t p ss : /
of the wrist, so-called DTM. This oblique plane, 30–45° in the sagittal plane,
p
t
hht t t
hht t
allows wrist motion with minimal muscle force and it is observed in activities
of daily living, such as hammering a nail, tying a shoe, and pouring a pitcher.
This clinical finding is supported by the joint geometry congruency, ligamentous
support, muscular vector force, and proprioceptive factors.
k eers
rs k er
erss
The motion at the STT joint is directed by the obliquely oriented ridge of the
distal scaphoid surface. The lateral facet of the head of the capitate that articulates
b ooook ooook
with the scaphoid is less convex, facilitating flexion-extension along the DTM
b
eeb ee/ e
/ e b
axis. In addition, the SL distal concavity is obliquely shaped in the horizontal
// t/ tm
. m / /t/ tm
plane, paralleling the DTM axis. The TH joint helps in guiding midcarpal rotation,
. . .
which in a semisupinated (DTM axis) position, serves as a smooth surface for
: : m
t ppss : / tppss
distal carpal row to shift from radial extension to ulnar flexion. : /
hhttt hhttt
In order to provide constrains to the oblique motion of the STT joint, the SC
and STT ligaments are oriented perpendicular to the oblique sagittal ridge of the
STT joint, suggesting their function as collateral ligaments. On the medial aspect,
the THC ligamentous complex has little role in controlling DTM.
keerrss k eerrs
The flexor carpi ulnaris on the anteromedial side and the extensor carpi
s
radialis brevis and longus on the posterolateral aspect are the two motor groups
b ooook o ook
that contribute to DTM. In addition, the extensor carpi ulnaris and flexor carpi
b o
eeb ee/ e
/ e b
radialis (FCR) are also antagonists that guide DTM. The location of the tendinous
portion of these muscles at the midcarpal joint coincides with the oblique DTM
axis.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Finally, abundant amount of mechanoreceptors were found in the ligaments
t
hhtt t
hhtt
that control the DTM motion, namely the SC and STT ligaments, as well as the
THC ligamentous complex and DIC ligament.
This oblique sagittal axis of motion is supported by several investigators.
Li et al. demonstrated that during circumduction of the wrist, maximal extension
k e rrss
e rrss
was achieved with radial deviation and maximal flexion was achieved with slight
e e
ulnar deviation. Goto et al. and Morimoto et al. demonstrated that the STT joint
k
o o
o o k o o o k
axis of motion is similar to the DTM axis and proposed that this is the axis that
o
eebb ee/ e
/ b
e b
provides the most stability as the direction and rotation of the midcarpal and
radiocarpal joints were similar and synergistic during movement at the DTM
: / / t
/ . m
. m : / / t.
plane. Werner et al. showed from in vitro studies that movement along the DTM
t / tm. m
t p ss:
p / t p ss:
p /
axis caused little movement of the scaphoid and lunate relative to the global wrist
t t t t
motion. This finding was also supported by Crisco et al., who stated that motion
hht hht
at the DTM axis could be used as rehabilitation protocols that require minimal
k e r
e s
rs k eerrss
25
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
movement of the radiocarpal joint. Upal et al. proved in his in vivo study that
there was little elongation of the SL ligament during motion along the DTM
eebb ee/ e
/ebb
plane, further supporting the previous findings that there is little scaphoid and
: / / t
/ t m
lunate motion when the wrist is moved along this oblique axis.
. . m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
TREATMENT
t
t Technique
hReduction
Closedh
t
hht t
Closed reduction technique should be attempted emergently in all patients who
k eers
rs k er
ers
present within a few days of injury. It relieves pressure on the median nerve and
s
other soft tissues, reducing swelling and relieving pain while the patient awaits
b ooook o ook
definitive management. Acceptable closed reduction optimizes the healing
b o
eeb ee e
/ e b
potential for the torn ligaments and fractured bones. If successful, surgery can be
/
delayed 3–4 days while swelling decreases.1
: // t/.tm
. m : / /t/.tm. m
A true lateral radiograph should demonstrate restoration of the colinearity
between the radius, lunate, and capitate. Signs of SL dissociation are widening
hhttt hhttt
(Terry Thomas sign) or loss of parallel alignment between the scaphoid and
lunate articular surfaces, continued volar flexion of the scaphoid (scaphoid ring
sign), and an abnormal SL angle on a lateral film. The normal intercarpal angle
between the scaphoid and lunate is 30–60°. When the SL connection has been
keerrss angulation greater than 70°.1

k eerrs
torn, the scaphoid tilts volarly and the lunate tilts dorsally, creating an intercarpal
s
b ooook b o ook
Closed reduction is attempted by suspending the arm using finger traps
o
eeb ee e
/ e b
and 10–15 pounds of traction. Analgesia and/or conscious sedation is employed
/
to facilitate reduction. Longitudinal traction is applied for 5–10 minutes
: / / t
/ . m
. m : / / t . m
. m
to regain length and helps to overcome muscle spasm. For dorsal perilunate
t / t
dislocations, one hand is used to manipulate the dislocated carpus while the
t
hhtt t
hhtt
other hand stabilizes the lunate. The lunate is palpated volarly and the thumb
is used to stabilize it by providing dorsally directed pressure. A volarly directed
force is applied to the carpus while dorsally directed counterpressure is applied
to the lunate. Palmar flexion of the carpus is used to reduce the capitate into
the concavity of the lunate.1 A similar method, but accomplished by reversing
k e rrss
e e rrss
the pressure and counterpressure forces, is carried out for reduction of volar
k e
o o
o o k perilunate fracture-dislocations.1,2
o o
o o k
eebb e / / b
e b
For lunate dislocations, the wrist is flexed to take tension off the volar
e
ligaments. The lunate is reduced into its fossa using thumb pressure applied to the
e
t . m
. m t. m. m
volar lunate and the hook of the hamate, followed by wrist extension. The capitate
: / / / t : / / / t
t p ss:
p / t p ss:
p /
is then reduced onto the lunate with traction and wrist flexion, maintaining volar
t t t t
pressure on the lunate to prevent its redislocation. Following reduction, a sugar-
hht hht
tong splint is applied with the wrist in neutral alignment.2
k e r
e s
rs
26
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
Closed reduction of pure radiocarpal fracture-dislocations is usually easily
accomplished with longitudinal traction. An external fixator may be applied to
eebb hold the joint reduced.3
ee/ e
/ebb
: / / t
/ t m
. m : / / t
/ t
carpal instability or fracture malalignment persists.1 Most authors now agree m
Closed reduction, however, rarely produces permissible alignment as residual
. . . m
t p ss
p : / t p ss : /
that open reduction and internal fixation (ORIF) is indicated in all radiocarpal
p
t
hht t t
hht t
dislocations.1,2,4-6,17-32 If an anatomic reduction is not achieved or is lost, internal
fixation should be considered rather than repeat closed reduction.4 Progressive signs
of median nerve dysfunction despite adequate closed reduction require immediate
surgery. Failure to achieve a closed reduction necessitates an open reduction.1,2
k eers
rs k er
erss
Unless the patient’s comorbidities preclude surgical management, surgery
should be performed within a few days or emergently if closed reduction fails
b ooook ooook
or cannot be maintained in a splint. Current standard of care is open reduction,
b
eeb ee/ e
/ e b
ligament repair, and internal fixation. Nonprogressive median nerve dysfunction
// t/ tm
. m / /t/ t
and does not mandate emergent release. However, carpal tunnel syndrome may
: : m
may be due to contusion from the initial trauma, not due to swelling and hemorrhage
. . . m
develop in up to 25% of cases and delayed-onset or progressively worsening
hhttt hhttt
median nerve dysfunction is suggestive of acute carpal tunnel syndrome and
surgical release combined with open reduction and stabilization is recommended.
Although a considerable delay between the injury and its treatment worsens the
prognosis, results may be acceptable even if delayed up to 45 days.
keerrss k eerrss
b ooook Perilunate Dislocations
b o ook
o
eeb ee/ e
/ e b
Surgical approaches that can be used include: volar, dorsal, and combined volar-
/ / t
/ t m
. m / / t
/ t m
dorsal approaches. The dorsal method yields the best exposure of the carpus for
. . . m
restoration of alignment and interosseous ligament repair. In addition, fractures
: :
t pp s s : / t ppss : /
of the scaphoid and capitate can be secured with antegrade fixation devices. The
t
hhtt t
hhtt
volar approach allows decompression of the carpal tunnel and direct repair of the
palmar capsular ligament tear. The combined approach offers the advantages of
both, but increases surgical time and dissection.1
k e rrss
e
Closed Reduction and Percutaneous Pinning
k e rrss
e
o o
o o k o o
o o k
Kozin1 describes a technique of closed reduction and percutaneous pinning,
eebb e / / b
e b
which can be a viable option if acceptable carpal alignment can be achieved by
e
closed reduction, but is lost when the reduction maneuver is withdrawn. The
e
t . m
. m
recommended technique is to stabilize the carpus by reversing the mechanism
: / / / t : / / t
/.tm. m
t p ss:
p / t p ss:
p /
of injury. Under fluoroscopic guidance, the dorsally tilted lunate is derotated by
t t t t
passive wrist flexion. The lunate is then maintained in a neutral lateral position by
hht hht
percutaneous insertion of a 0.045 inch Kirschner wire (K-wire) placed through the
k e r
e s
rs k eerrss
27
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
radius. This restores the intercalated lunate to normal rotation and provides the
foundation for the remaining carpus. The triquetrum is then pinned to the lunate
eebb / e
/ebb
to stabilize the ulnar side of the perilunar carpus. If the radial side of the carpus
ee
: / / t
/ t m
. m : / / t
/ t m
has been destabilized by SL dissociation or a scaphoid fracture, it is considerably
. . . m
more difficult to reduce. The volar-flexed scaphoid must be realigned to the lunate
t p ss
p : / t p ss : /
by wrist extension, ulnar deviation, and direct pressure applied to the scaphoid
p
t
hht t t
hht t
tuberosity. If reduction is achieved, K-wires are placed across the SL and SC
articulations. If the scaphoid is fractured, closed reduction is virtually impossible.1
Volar Approach
k eers
rs k er
erss
An extended carpal tunnel incision is performed. The TCL and antebrachial
b ooook b ooook
fascia are incised. The flexor tendons and median nerve are retracted. The volar
eeb e / e b
wrist ligaments are visualized and the tear across the midcarpal joint is identified.
/ e
Anatomic studies have shown that the volar ligaments are much more substantial
e
t . m
. m t . m. m
than the dorsal ligaments. The general configuration of the volar ligaments is
: // / t : / / / t
V-shaped, with an area of potential weakness over the space of Poirier. There is
hhttt hhttt
usually a transverse rent in the capsule and ligaments. The configuration of this
rent is always an upside down smile and is repaired using nonabsorbable sutures.
Although it is impossible to identify and repair the individual ligaments, an
adequate repair of the volar ligamentous complex can be easily accomplished by
suturing the transverse rent.1
keerrss k eerrss
b ooook Dorsal Only Approach
b o ook
o
eeb / e e b
Adkison et al.,4 in their series of 55 patients, used a comprehensive dorsal
ee /
approach to achieve anatomic reduction and secure fixation. The authors did not
: / / t .
t m
. m : / / t .
t m
. m
find the volar approach and/or repair to be necessary as none of the patients in
/ /
their series lost reduction using the comprehensive dorsal approach. The authors
t
hhtt t
hhtt
emphasize that maintenance of anatomic position has proved sufficient to restore
perilunate ligamentous integrity without individual ligament repair or associated
augmentation procedures. The skin incision is made transversely on the dorsal
aspect of the wrist, connecting the tips of the radial and ulnar styloids. The skin
k e rrss
e k rrss
is undermined at the level of the deep fascia and the dorsal veins and sensory
e e
nerves are mobilized. A longitudinal incision in the extensor retinaculum is
o o
o o k o o o k
made just ulnar to the dorsal tubercle of Lister, and enters the compartment of
o
eebb ee/ e
/ b
e b
the extensor digitorum communis. Dissection is carried out through the dorsal
wrist capsule, thus extending from the base of the metacarpals to a point 2 cm
: / / t
/ .
t m
. m : / / t
/.tm. m
proximal to the radius. The dorsal wrist capsule is sharply reflected, en masse, off
t p ss:
p / t p ss:
p /
the distal radius and carpal bones until the lunate, scaphoid, and proximal two-
t
hht t t
hht t
thirds of the capitate are exposed. Wide reflection of the dorsal wrist capsule is
the key to this exposure. Insertion of four handheld or two self-retaining retractors
k e r
e s
rs
28
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
provides excellent exposure. Reduction of the perilunate complex is then achieved.
Dorsal perilunate injuries are usually easily reduced with longitudinal traction and
eebb / e
/ebb
volarly directed pressure on the distal carpal row. Volar lunate dislocations may
ee
: / / t
/ t m
. m : / / t
/ t
radius. Reduction can be achieved by first applying traction to open the spacem
be confusing as the proximal dome of the capitate will be found lying against the
. . . m
t p ss
p : / t p ss : /
between the capitate and radius. The lunate can then be popped into place with
p
t
hht t t
hht t
manual manipulation with the assistance of a joker elevator. To obtain anatomical
position, all three bones must be simultaneously reduced and the SL dissociation
fixed first. The insertion of a stiff K-wire into the lunate and scaphoid, respectively,
provides two levers with which the bones can be manipulated, greatly facilitating
k eers
rs k er
erss
reduction. The K-wire is inserted into its dorsoradial surface in the perpendicular
plane, taking care not to violate the capitate sulcus, and is placed sufficiently deep
b ooook ooook
to secure a good hold without exiting volarly. A similar wire is placed in a like
b
eeb ee/ e
/ e b
manner into the scaphoid or, in the presence of a fracture, the distal pole of the
// t/ tm
. m / /t/ tm
scaphoid. These wires can then be manipulated, to reduce and hold the fracture.
. . . m
The lunate should be rotated such that the capitate dome is no longer visible and
: :
the capitolunate ligament is approximated. In SL dissociation, the SL juncture
hhttt hhttt
should be anatomically reduced with the scapholunate interosseous ligament
(SLIL) lying in approximation. A second surgeon then drives two K-wires
percutaneously from the anatomic snuffbox along the longitudinal axis of the
scaphoid into the lunate avoiding the capitate and radius. Two K-wires, positioned
keerrss k eerrs
in slightly different directions, provide good fixation. The entrance point for these
s
wires can be accurately determined by viewing through the dorsal incision. The
b ooook o ook
stability of the wrist should then be checked by a gentle push-pull on the hand.
b o
eeb ee/ e
/ e b
If malrotation of the lunate on the capitate occurs, then a third K-wire should be
placed from the dorsal pole of the lunate into the capitate. After verifying proper
: / / t .
t m
. m : / / t .
t m
. m
positioning fluoroscopically, the two pins are removed and the other wires are cut
/ /
ss : /
off just beneath the skin to facilitate removal.
t pp t ppss : /
t
hhtt t
hhtt
Budoff also argues that only an isolated dorsal approach is required unless the
carpal tunnel requires release. In his experience, after reduction and fixation of the
carpus, the tear of the volar join capsule is anatomically apposed and, therefore,
should heal during the time of wrist immobilization. Suturing the volar ligaments
k e rrss
e rrss
is not mandatory for optimum healing, provided a good reduction is obtained. In
e e
addition, a second volar incision in a swollen wrist may cause additional swelling,
k
o o
o o k o o o k
difficult wound closure, and a slower recovery of digital flexion and grip strength.2
o
eebb ee/ e
/ b
e b
Inoue et al.22 described the following dorsal only approach. A percutaneous
K-wire fixation was inserted under image intensification if a satisfactory reduction
: / / t
/ .
t m
. m : / / t.
was achieved. A 1.5 mm K-wire was inserted from the scaphoid to the lunate to
/ tm. m
t p ss:
p / t p ss:
p /
maintain this position. A second pin inserted from the triquetrum to the lunate
t
hht t t
hht t
was used to provide additional stability. If the midcarpal joint was not stable, a
third pin was placed to stabilize the lunate and capitate. The K-wires were left
k e r
e s
rs k eerrss
29
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
protruding through the skin and were bent at right angles to facilitate later removal.
Open reduction was indicated if an anatomical reduction was not achieved by
eebb / e
/ebb
closed manipulation or was lost. This was done through a dorsal approach. A 5 cm
ee
: / / t
/ t m
. m : / / t
/ t m
transverse incision centered over Lister’s tubercle was used. The distal portion of
. . . m
the extensor retinaculum was then longitudinally incised, exposing the third and
t p ss
p : / t p ss : /
fourth compartments. Retracting the tendons of the fourth compartment ulnarly
p
t
hht t t
hht t
and the extensor pollicis longus radially, the carpal bones were brought into view
through the torn dorsal capsule. The proximal pole of the scaphoid, having lost
its ligamentous support, protruded vertically into the wound. It was rotated back
down into normal anatomical position using K-wire joysticks placed into the
k eers
rs k er
erss
scaphoid and lunate to facilitate manipulation. This position was maintained by
K-wire fixation. The torn SLIL was identified and repaired using a 4/0 braided
b ooook ooook
nonabsorbable suture. If the ligament was avulsed from the bone, it was sutured
b
eeb ee/ e
/ e b
back to the bone, passing the suture through drill holes in either the proximal pole
// t/ tm
. m / /t/ tm
of the scaphoid or the lunate. Associated radial styloid and ulnar styloid fractures
. . . m
were also stabilized with K-wire or screw fixation in an anatomical position.
: :
Adequacy of reduction, wire placement and carpal relationship were checked
hhttt hhttt
under the image intensifier. The torn dorsal capsule, extensor retinaculum, and
skin were closed. All wrists were immobilized in a short-arm cast for an average of
7 weeks after closed or open reduction of dislocations. The K-wires, used for carpal
bone stabilization, were removed at an average of 8 weeks (range, 5–12 weeks).
keerrss Combined Volar-dorsal Approaches

k eerrss
b ooook b o ook
o
eeb • ee / e b
Planned operative sequence is as follows:
/ e
/ / t t m
Expose the carpus through both volar and dorsal approaches
. . m
• Reduce the lunate and repair the volar capsular ligaments
: / : / / t
/ .
t m
. m
• Reduce the capitate and scaphoid from the dorsal side and secure the position
t
hhtt
of all three bones with K-wires
• Repair the dorsal ligaments
t
hhtt
• Carefully assess the adequacy of the reduction and the position of the pins
with fluoroscopy.33
k e rrss
e k rrss
Several authors1,21,22,30 prefer the combined volar-dorsal approaches with
e e
anatomic reduction and repair of the disrupted structures. The dorsal approach
o o
o o k o o o k
is performed first unless there is an irreducible volar lunate dislocation that is
o
eebb ee/ e b
e b
trapped within the carpal tunnel. Kozin prefers to elevate flaps of the capsule for
/
exposure of the carpus. Herzberg19 prefers a dorsal “Z” capsulotomy instead of
: / / t .
t m
. m : / / t.tm. m
the standard longitudinal capsulotomy. The carpus is inspected to assess chondral
/ /
t p ss:
p / t p ss:
p /
damage and the adequacy of closed reduction. Adequate closed reduction is
t
hht t t
hht t
judged at the midcarpal level. The lunate should completely cover the capitate
head. An exposed capitate head implies incomplete reduction due to a dorsiflexed
k e r
e s
rs
30
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
lunate. The LT ligament is usually torn too severely for primary repair. The SL
ligament often tears from the scaphoid and sufficient tissue is available for repair.
eebb ee/ e
/ebb
The SL and LT intervals are gently curetted to facilitate healing. Before this
: / / t
/ t m
repair is accomplished, 0.045 inch K-wires are placed percutaneously across
. . m : / / t
/ .
t m
. m
the SL articulation, prior to reduction, and adjusted to just below the articular
t p ss
p : / t p ss : /
surface in anticipation of fixation immediately after reduction. K-wires are then
p
t
hht t t
hht t
placed into the triquetrum. K-wires are placed into the nonarticular surfaces of
the lunate and scaphoid and used as joysticks to assist with reduction of the SL
joint. The wires should not penetrate volar to the carpus. Budoff recommends
reducing the scaphoid to the lunate with extension and compressing it with a
k eers
rs k er
ers
towel clip.2 Nonabsorbable 3-0 braided polyester sutures are placed through the
s
torn interosseous ligament for reattachment to the scaphoid. The sutures are
b ooook o ook
then passed into the remaining cuff of ligament still attached to the scaphoid, or
b o
eeb / e e b
through the scaphoid to the waist level with drill holes. In addition, suture anchors
ee /
can be placed in the scaphoid to facilitate ligament repair.29 The sutures are not
: // t .tm
. m : / /t .tm
tied until SL reduction has been accomplished and the previously positioned
/ / . m
ss : /
K-wires have been passed across the joint.
t pp tppss : /
hhttt hhttt
An additional percutaneous pin across the SC joint is frequently added to
help maintain appropriate scaphoid position. After SL repair is completed, LT
joint is reduced and pinned with the help of K-wire joysticks. The SL is usually
repaired first because it is more difficult and can be taken the advantage of
keerrss k eerrs
lunate’s mobility if done first. Attention is then directed to the volar side. An
s
extended carpal tunnel incision is performed. The TCL and antebrachial fascia
b ooook o ook
are incised. The flexor tendons and median nerve are retracted. The volar wrist
b o
eeb ee e
/ e b
ligaments are visualized and the tear across the midcarpal joint is identified.
/
The configuration of this rent is always an upside down smile and is repaired
: / / t
/ . m
. m : / / t .
using nonabsorbable sutures. After closure, the extremity is placed in a sugar-
t / t m
. m
tong splint with the wrist in slight extension. Elevation and finger motion is
t
hhtt t
hhtt
encouraged. Sutures are removed at 2 weeks and a long-arm cast is placed. At
4 week, long-arm cast is changed to a short-arm cast, which is kept until pin
removal at 10–12 weeks.1
Interosseous Wire Technique
k e rrss
e k e rrss
e
Weil et al.32 and Trumble et al.31 recommended an interosseous wire technique
o o
o o k o o o k
through a standard dorsal approach. The extensor retinaculum is identified, the
o
eebb / e b b
third dorsal compartment is released, and the extensor pollicis longus is retracted
ee / e
radially. The fourth dorsal compartment is sharply elevated off the capsule and
/ / t .
t m
. m
a longitudinal capsulotomy is made to expose the SL and LT ligaments. A
: / : / / t
/.tm. m
t p ss:
p / t p ss:
p /
separate 8 cm palmar approach using an extended carpal tunnel incision that
t
hht t t
hht t
crosses the wrist crease is made. The TCL is released, and the carpus is internally
stabilized with an interosseous wire technique. Small bone anchors are placed
k e r
e s
rs k eerrss
31
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:26 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
for later SLIL repair. The suture anchors are routinely placed in the scaphoid,
as this is where the SL ligament usually avulses. Occasionally, the SL ligament
eebb / e
/ebb
avulses from the lunate and the suture anchors are placed in the lunate. The
ee
: / / t
/ t m
. m : / / t
/ t m
hollow metal cannula of an 18 G intravenous catheter is placed on a power
. . . m
driver after removing the plastic hub. The hollow needle is then drilled from
t p ss
p : / t p ss : /
dorsal to volar through the proximal pole of the scaphoid as if the scaphoid was
p
t
hht t t
hht t
reduced. A 20 G wire is then passed through the needle from dorsal to volar. The
cannula is removed and drilled through the lunate from dorsal to volar as if the
lunate were reduced. To avoid retracting the flexor tendons, it is easier to pass
the scaphoid wire first. The wire is then passed from volar to dorsal through the
k eers
rs k er
erss
hollow cannula to complete the circle. The bone anchor sutures are then passed
through the torn SLIL. Dorsal K-wires are then placed in the scaphoid and
b ooook ooook
lunate as joysticks. The cerclage wire is tightened with the scaphoid reduced to
b
eeb ee/ e
/ e b
the lunate. The bone anchor sutures are then tied to repair the ligament without
// t/ tm
. m / /t/ tm
tension. Bone anchors are inserted to repair the LT ligament if there is sufficient
. . . m
ligament available for repair. Using fluoroscopy, two 0.045 inch K-wires are then
: :
passed across the triquetrum and into the lunate with the bones reduced. The LT
hhttt hhttt
ligament bone suture anchors are then tied to complete the repair. Tears in the
volar capsule at the space of Poirier are repaired with interrupted sutures. The
K-wires are cut to retract under the skin and patients are placed in a sugar-tong
splint, after skin closure.32
keerrss k eerrss
Reconstruction of the Scapholunate Interosseous Ligament
b ooook o ook
o
Minami et al.27 looked at the repair of the SLIL in lunate and perilunate
b
eeb ee/ e
/ e b
dislocations and found that repair and/or reconstruction of the SLIL can prevent
: / / t
/ t m
. m : / / t
/ t m
or reduce the occurrence of carpal instability and improve clinical results. The
. . . m
authors used the standard dorsal approach to the extensor retinaculum, elevating
the third dorsal compartment and incising the joint in line with Lister’s tubercle.
t
hhtt t
hhtt
The volar approach is through the usual extended carpal tunnel approach. The
consistent rent in the volar capsule is repaired with nonabsorbable sutures.
Returning to the dorsal exposure, the SLIL is usually torn from its scaphoid
attachment. Minimum debridement of the torn end of the SLIL is performed,
k e rrss
e k rrss
and then three drill holes are made at the notch of the lunate facet. Nonabsorbable
e e
sutures are tied to approximate the edge of the torn SLIL through drill holes
o o
o o k o o o k
in the scaphoid. Three K-wires are inserted to stabilize the three key elements
o
eebb /
(scaphoid, lunate, and capitate).
ee e
/ b
e b
Reconstruction of the SLIL is also described by Minami.27 From the dorsal
: / / t
/ .
t m
. m : / / t
/.tm. m
incision, the gap between the scaphoid and lunate is often filled with fibrous
t p ss:
p / t p ss:
p /
tissue, and extensive soft-tissue dissection may be required to free up the scaphoid
t
hht t t
hht t
adequately to permit correction of the subluxation. Excessive soft-tissue stripping
may create further instability and result in devascularization of the scaphoid.
k e r
e s
rs
32
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
A 10 cm strip of the ulnar half of the extensor carpi radialis longus (ECRL) is
prepared, leaving the distal end attached to its insertion. A hole is drilled from the
eebb / e
/ebb
dorsal aspect of the proximal pole of the scaphoid emerging on the SL interarticular
ee
: / / t
/ t m
. m : / / t
/ t m
surface palmar to its center. A similar hole is drilled from the dorsal aspect to the
. . . m
lunate, emerging opposite to the scaphoid tunnel. The final diameter of this tunnel
t p ss
p : / t p ss : /
should be large enough to accept a 4 m Hunter tendon implant, which is used as the
p
t
hht t t
hht t
tendon passer. A curved ligature carrier can also be used. The graft is then passed
from the scaphoid to the lunate, prior to actual reduction and fixation of the bones.
After the bones have been reduced and stabilized with K-wires, the graft is pulled
through the tunnel snugly and placed under slight tension. The graft, which then
k eers
rs k er
erss
emerges from the dorsal opening of the lunate, is then brought back across the SL
interval, sutured to itself, and further reinforced by tacking it to the strong dorsal
b ooook ooook
capsular fibers over the triquetrum or into the dorsal periosteum of the distal
b
eeb ee/ e
/ e b
radius. All possible repairs of available ligamentous tissues are then carried out to
// t/ tm
. m / /t/ tm
further reinforced the dorsal capsule.27 A bulky above elbow dressing was applied
. . . m
with short-arm splint until the swelling subsided, at which time it was converted
: :
to a thumb spica cast. The K-wires are removed at 6–8 weeks, followed by part-
hhttt hhttt
time splinting for an additional 6 weeks. Rehabilitation requires 6–12 months.
Van den Abbeele et al.34 described reconstruction of the SLIL using a modified
Brunelli procedure. A palmar incision is made over the scaphoid tubercle to expose
the distal pole of the scaphoid and the sheath of the FCR tendon. The sheath is
keerrss k eerrs
then incised and a tendon grasping forceps is passed in this sheath about 10 cm
s
proximally along the FCR within the sheath. A second proximal palmar incision
b ooook o ook
is then made over the grasping forceps and a strip about one-third of the FCR
b o
eeb ee/ e
/ e b
tendon is then detached from the main body of the tendon on its anterior surface
and stripped from proximal to distal, delivering the tendon strip into the distal
: / / t .
t m
. m : / / t .
t m
. m
tubercle incision. A dorsal 5 cm transverse incision is then made at the level of the
/ /
SL joint. The SL joint is exposed as well as the STT joint. Scar tissue is excised
t
hhtt t
hhtt
from both joints. The rotatory subluxation of the scaphoid is reduced, if necessary,
using temporary K-wires as joysticks in the scaphoid and lunate to manipulate the
bones into a reduced position (extending the scaphoid and flexing the lunate). A
K-wire is then drilled from the front of the scaphoid tubercle to the posterior bare
k e rrss
e rrss
area to confirm the right direction of the tunnel through which the FCR tendon
e e
slip will run. A cannulated AO 3.5 mm drill is then passed over the correctly
k
o o
o o k o o o k
positioned K-wire. Fluoroscopy may be used to ensure accurate placement of
o
eebb ee/ e
/ b
e b
the guide. Next, the FCR-tendon slip is passed through this tunnel. The slip is
tightened to ensure that the scaphoid is reduced. The tendon slip was attached
: / / t
/ .
t m
. m : / / t
/.t
to the lunate with an Acufex tag or passed under the dorsal radio-LT ligament.m. m
t p ss:
p / t p ss:
p /
The slip was pulled through this ligament close to the dorsal ulnar border of the
t
hht t t
hht t
radius. After adequate tension was achieved the tendon was sutured back on itself.
Care is taken not to damage the posterior interosseous nerve. Skin closure is
k e r
e s
rs k eerrss
33
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:26 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k oo oo k
done with a subcuticular 3-0 Prolene suture. A supportive bandage and a palmar
plaster of Paris slab, which includes the thumb, is applied. A scaphoid plaster is
eebb / e
/ebb
applied 3 days later. The stitches are removed 2 weeks postoperatively and another
ee
: / / t
/ t m
. m : / / t
/ t m
scaphoid plaster is then applied for 4 weeks. Six weeks postoperatively gentle
. . . m
range-of-motion (ROM) exercises are started and a splint is worn for another
t p ss
p : / t p ss :
6 weeks. After 12 weeks grip strengthening exercises are started.
p /
hht t t t
hht t
Dorsal Transscaphoid Perilunate Dislocation
In this injury, the midcarpal dislocation is accompanied by a fracture through the
k eers
rs k er
erss
waist of the scaphoid, and the distal pole of the scaphoid displaces dorsally with
b ooook oook
the capitate, leaving the proximal pole attached to the lunate. Reduction of the
o
midcarpal dislocation is usually easy to accomplish, but must carefully check the
b
eeb ee/ e
/ e b
scaphoid. If radiographs show good reduction of midcarpal joint and anatomic
: // t/ tm
. m : / /t/ tm
reduction of the scaphoid, a thumb spica cast is applied with the wrist in neutral
. . . m
or slight flexion. Serial radiographs must be taken to verify no loss of reduction
of the scaphoid. Cooney et al.35 stated that an irreducible or malreduced scaphoid
hhttt hhttt
fracture is an indication for operative treatment.
Some authors recommended excision of the proximal fragment or proximal
row carpectomy. Wagner36 reported uniformly poor results with ORIF and advised
primary arthrodesis if the scaphoid could not be reduced adequately. Few authors
keerrss k eerrss
share that extreme of pessimism. Green et al.33 advise ORIF occur as soon as
possible, but preferably within 2 weeks, believing that this enhances the potential
b ooook o ook
for healing and revascularization of the proximal pole of the scaphoid. Campbell
b o
eeb ee/ e
/ e b
et al.,17 in 1965, recommended ORIF if anatomical reduction of the scaphoid
/ / t
/ t m
fracture could not be obtained and maintained in plaster.33
. . m / / t
/ .
t m
. m
Kirschner-wires have been favored by most authors for additional stability.
: :
Worland and Dick37 advocated a dorsal approach for primary open reduction,
t
hhtt t
hhtt
since it necessitates no further dissection of the soft tissues because they were
already stripped by the perilunate dislocation. They reserved the volar approach
for the fractures that needed bone grafting. Green et al. used the limited Russe
approach to directly visualize the fracture site during the insertion of K-wires and
k e rrss
e k rrss
did not use screw fixation of the scaphoid in acute cases.33
e e
Weil et al.32 use a dorsal approach with screw fixation of the scaphoid in all
o o
o o k o o o k
patients. A volar incision is made only in patients that require a simultaneous
o
eebb / e b b
carpal tunnel release or if the proximal pole of the scaphoid and lunate become
ee / e
buttonholed through the volar capsule. A longitudinal incision is made over the
: / / t
/ .
t m
. m : / / t
/.tm. m
dorsum of the wrist, just ulnar to Lister’s tubercle. The extensor pollicis longus is
t p ss:
p / t p ss:
p /
released and retracted medially with the ECRL. A longitudinal incision is then
t
hht t t
hht t
made in the capsule to expose the scaphoid. The scaphoid is reduced and held with
a 0.045 inch K-wire parallel to the path of the screw. K-wires can also be used as
k e r
e s
rs
34
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:27 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
joysticks to assist in fracture reduction. The scaphoid is then fixed using a cannulated
screw system. If the scaphoid is comminuted, the authors recommend using bone
eebb / e
/ebb
graft obtained from the distal radius through the same dorsal incision. Once the
ee
: / / t
/ t m
. m : / / t
/ t m
scaphoid has been stabilized, the SL and LT ligaments are inspected. According to
. . . m
Weil, the SL ligament is usually not disrupted in a transscaphoid perilunate injury.
t p ss
p : / t p ss : /
However, the LT ligament usually is disrupted, requiring repair. The LT joint can
p
t
hht t t
hht t
be exposed by elevating the fourth dorsal compartment. Repair of the ligament is
performed using a 1.8 mm bone anchor. The anchor is then inserted into the lunate,
and the sutures are used to grasp the ligament attached to the triquetrum. The LT
joint is then reduced and stabilized with K-wires inserted percutaneously from the
k eers
rs k er
erss
ulnar side, prior to tying the sutures. The K-wires are buried under the skin for 6–8
weeks and then removed. Patient placed in a long-arm splint for 2 weeks, then
b ooook ooook
transitioned into a short-arm cast for an additional 4 weeks.32
b
eeb ee/ e
/ e b
Kozin1 uses the dorsal approach for fracture fixation. The scaphoid fracture is
// t/ tm
. m / /t/ tm
reduced and antegrade fixation applied. Joysticks placed in the proximal and distal
. . . m
fragments may be necessary for reduction. A Herbert screw is then inserted over
: :
a guidewire. Bone graft from the distal radius is commonly used. After scaphoid
hhttt hhttt
fixation, K-wires are advanced across the LT joint to stabilize the ulnar carpus. A
volar approach can be added to repair the torn volar ligaments.
Oztuna et al.38 recommended trapeziolunate external fixation for trans
scaphoid perilunate dislocations. The authors preferred not to perform ligament
keerrss k eerrs
reconstruction to avoid shortening of the carpal ligaments and because limited
s
open reduction without ligament reconstruction has been reported in the literature.
b ooook o ook
They felt internal fixation is an extensive approach, increasing the chances of
b o
eeb / e e b
avascular necrosis (AVN) of the scaphoid and also necessitating postoperative
ee /
immobilization. Compression external fixation has been shown to simulate limited
intercarpal arthrodesis.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Inoue et al.23 preferred Herbert’s palmar approach combined with a carpal
t
hhtt t
hhtt
tunnel release to give better exposure of the carpus and also facilitate repair of the
palmar ligament. Reductions of the midcarpal joint and scaphoid fracture were
performed and a K-wire was inserted across the fracture to maintain reduction.
The jig was then applied and Herbert screw inserted. The group did this through a
k e rrss
e k rrss
dorsal approach in two of their patients, but felt that the purchase was not as good.
e e
Bone grafting was also used in one patient. Immobilization was with a short- or
o o
o o k long-arm casts for 4–8 weeks.
o o
o o k
eebb ee/ e
/ b
e b
Knoll et al.24 believe that K-wires alone have been unsatisfactory in maintaining
LT alignment, resulting in the development of a volar intercalated instability
: / / t
/ .
t m
. m : / / t
/.t
deformity. Furthermore, isolated injury of the LT ligament can be symptomatic.m. m
t p ss:
p / t p ss:
p /
Therefore, the authors included LT ligament repair along with internal fixation
t
hht t t
hht t
of the scaphoid. Dorsal approach with open reduction using a scaphoid screw
and LT ligament repair with bone anchors. A volar approach was not performed
k e r
e s
rs k eerrss
35
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:27 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
on any patient, only on those requiring a simultaneous carpal tunnel release. The
goal was to minimize additional trauma to the flexor tendons and median nerve,
eebb / e
/ebb
quoting Sotereanos et al.30 and their report of flexor tendon adhesions following
ee
: / / t
/ t m
. m : / / t
/ t m
a volar approach combined with volar ligament exploration and repair. In knoll’s
. . . m
series, the SLIL ligament was not usually disrupted in the transscaphoid perilunate
t p ss
p : / t p ss : /
injury. The LTIL was always disrupted, however, requiring repair. The LT joint can
p
t
hht t t
hht t
be exposed by elevating the fourth extensor compartment. The ligament repair is
accomplished using small bone anchors. The LT joint is reduced and stabilized
with K-wires inserted percutaneously from the ulnar side of the wrist before tying
the sutures. K-wires are buried under the skin for 6–8 weeks and then removed
k eers
rs k er
erss
surgically. Long-arm splint for 2 weeks, followed by suture removal and conversion
to a short-arm cast for 4 additional weeks.
b ooook b ooook
eeb Volar Perilunate
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Only a few isolated cases of volar perilunate dislocation have appeared in the
t pp ss : / tppss : /
literature.39,40 Aitken et al.39 were able to reduce the volar perilunate dislocation
hhttt hhttt
by applying traction to a flexed hand, which was then extended, easily obtaining
reduction. This is the reverse of the reduction technique for dorsal perilunate
dislocations in which the hand starts extended and then is flexed to accomplish
reduction.
keerrss k eerrss
b ooook Lunate Dislocation
b o ook
o
eeb ee/ e
/ e b
If the lunate can be reduced by closed means, then only a dorsal approach is
: / / t
/ t m
. m / / t
/ t m
necessary as described for perilunate dislocations.32 If the lunate cannot be reduced
. . . m
closed, an extended carpal tunnel approach will expose the dislocated lunate and
:
t pps s : / t ppss : /
facilitate reduction of the lunate and repair of the volar ligaments.32
t
hhtt t
hhtt
For cases requiring open reduction of a dislocated lunate or carpal tunnel release,
a standard carpal tunnel incision, in line with the third web space, is extended in
zigzag fashion across the wrist. The brachial fascia and TCL are incised, with care
taken to protect the median nerve, ulnar nerve, and superficial arch. The median
k e rrss
e k rrss
nerve and digital flexor tendons are retracted radially to expose the volar wrist
e e
capsule. An elevator is used to lever the lunate back into its fossa. The author
o o
o o k o o o k
repairs the transverse tear in the joint capsule after the carpus is anatomically
o
eebb / e b b
reduced and stabilized via the dorsal approach.2
ee / e
: / / t
/ .
t m
. m : / / t
/.tm. m
t p p /
Naviculocapitate Syndrome
ss: t p ss:
p /
hhtt t t
hht t
Naviculocapitate syndrome, coined by Fenton18 in 1956, is a relatively uncommon
variation of midcarpal dislocation in which the capitate is fractured with the
k e r
e s
rs
36
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:27 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
proximal pole rotating 90–180°. During a fall, with the hand in the position of
dorsiflexion and radial deviation, the pointed radial styloid process impinges on
eebb / e
/ebb
the scaphoid laterally at its waist and the sturdy capitate supports the scaphoid
ee
: / / t
/ t m
medially. When the force of a blow from a fall is only moderately strong, the
. . m : / / t
/ .
t
scaphoid alone will be fractured (usually through the waist). When the blow ism
. m
t p ss
p : / t p ss : /
particularly sharp and violent, the capitate will also be fractured. The force from the
p
t
hht t t
hht t
blow is transmitted in a direct line from the radial styloid, through the scaphoid,
to the capitate.18 Fenton advocated excision of the proximal pole as primary
treatment because he believed AVN and nonunion were inevitable. A transverse,
dorsal incision was made at the midcarpal level and the capitate fragment is easily
k eers
rs excised as there are no ligamentous attachments.18
k er
erss
Meyers et al.26 described ORIF with K-wires and argued against Fenton’s
b ooook ooook
recommendation for excision of the fragment as his results demonstrated that the
b
eeb ee/ e
/ e b
proximal pole of the capitate can be revascularized if it is replaced anatomically
// t/ tm
. m / /t/ tm
and immobilized until the fracture heals. Weseley and Warenfeld41 used ORIF
. . . m
and bone grafting and emphasized that treatment of the displaced capitate fracture
: :
should be determined on the basis of other associated carpal injuries. Green et al.33
hhttt hhttt
believed that persistent displacement of a capitate fracture after closed reduction
is an indication for ORIF and tried to achieve anatomic reduction of both the
scaphoid and capitate through a dorsal approach.33 In his series, Vance reported
good results with ORIF.42
keerrss k eerrss
b ooook Percutaneous and Arthroscopic-assisted
b oo ook
Techniques
eeb ee/ e
/ e b
Arthroscopy allows direct inspection and manual testing of volar and intracarpal
/ / t
/ t m
. m / / t
/ t m
ligaments, as well as the grading and treatment of partial ligament injuries. If
. . . m
fluoroscopy and arthroscopy confirm persistent carpal instability after fracture
: :
fixation, then complete disruption of the carpal interosseous and volar capsular
t
hhtt t
hhtt
ligaments require direct repair. If persistent gapping is viewed on fluoroscopy after
attempted reduction, arthroscopy can be used to remove any interposed tissue that
may be blocking the reduction.32
The first priority should be reduction of the carpal dislocation, which can
k e rrss
e k rrss
usually be accomplished with longitudinal traction. If closed reduction cannot be
e e
accomplished, open reduction is indicated through dorsal and/or volar approach.
o o
o o k o o o k
A 0.062 inch K-wire or a hemostat can be inserted percutaneously to assist with
o
eebb / e b b
reduction of the fragments. After reduction has been achieved, a 0.045 inch
ee / e
guidewire is placed down the central axis of the carpal bone and is driven across
: / / t
/ .
t m
. m : / / t
/.tm. m
the fracture site to capture and maintain reduction. The wires are introduced into
t p ss:
p / t p ss:
p /
the distal fragment prior to final reduction. Once reduction is accomplished,
t
hht t t
hht t
the guidewire is driven proximally to capture the proximal fragment and retain
reduction.
k e r
e s
rs k eerrss
37
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:27 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o o k
With grossly unstable fractures, a second parallel antirotation guidewire
o
eebb bb
is introduced dorsal at the proximal scaphoid pole while the capitate wire is
ee/ e
/e
introduced between either the second or third web space. It is important to place
: / / t
/ .
t m
. m : / / t
/ .
t m
the wires down the central axis to decrease risk of thread penetration. In order
. m
t p ss
p : / t p ss
p : /
to place the guidewire along the central scaphoid axis, the wrist is flexed and the
forearm is pronated. With this view, the scaphoid appears as a dense circle, which
t
hht t t
hht t
corresponds to the cortex around the long axis. The K-wire is then inserted dorsal
to volar along the central axis of the circle and driven through the trapezium
until it penetrates the skin at the base of the thumb. It may be necessary to place
a second K-wire parallel to the first to prevent rotation about the long-axis. The
k eers
rs k er
erss
authors recommend taking care not to flex the wrist until the K-wire clears the
b ooook b oook
radiocarpal joint, in order to prevent bending of the K-wire.32
o
To place the guidewire along the central capitate axis, the wire must be
eeb e / e
/ e b
introduced between the second and third web space, through the base of the
e
: // t/.tm
. m : / /t/.tm. m
long finger CMC joint. The guidewire passes through the CMC joint into the
t ppss / tppss : /
capitate to secure fracture reduction and provide path for hand drilling and screw
:
implantation. The introduction of the screw through the web space is critical for
hhttt hhttt
proper placement of the screw along the central axis.32
After fracture reduction and guidewire placement, the tourniquet is inflated
for arthroscopic survey. The hand is placed in 5 kg of traction using finger
traps and a traction tower. The mini C-arm is used to identify the radiocarpal
keerrss k eerrss
and midcarpal portal sites. The 18 G needles are inserted under fluoroscopy
b ooook b ook
and small longitudinal incisions are made. A small, curved hemostat is used
o o
to spread the subcutaneous tissue away from the capsule and enter the joint.
eeb e / e
/ e b
A blunt trocar is then placed into the 3–4 portal and a 19 G needle is left for
e
: / / t
/ .
t m m : / / t
/ .
t m
. m
outflow at the 6 R portal. A small arthroscopic camera and shaver is inserted
.
through the 4 R, 5 R, or 6 R portal to clear blood clot and/or synovial tissue.
t
hhtt t
hhtt
The volar radiocarpal, interosseous ligaments, and TFCC are visualized and
stressed using a 2 mm probe. Next, the midcarpal row is entered in a similar
manner at the radial and ulna midcarpal portals. The radial midcarpal portal is
best for viewing the scaphoid and capitate. Partial ligament tears are graded and
debrided. Complete tears with carpal instability are identified for later repair
k e rrss
e after carpal reduction.32
k e rrss
e
o o
o o k o o
o o k
After fracture reduction is deemed adequate, screw length is established. The
eebb e / / b
e b
central axis guidewire is advanced well past the far cortex to avoid loss of position
e
with reaming. Proximal pole fractures of the scaphoid require dorsal implantation
e
t . m
. m t. m. m
of a headless screw. Dorsal implantation of the screw requires that the wrist remain
: / / / t : / / / t
t p ss:
p / t p ss:
p /
flexed during driving and screw placement to avoid bending of the wire. Once the
t t t t
screw has been placed, guidewires are removed and position is confirmed. Portals
hht
are closed with 4-0 nylon sutures.32 hht
k e r
e s
rs
38
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k Radiocarpal Fracture-dislocations
o o
o o k
eebb ee e
/ebb
Dumontier et al.43 divided patients with radiocarpal dislocations into two groups.
/
Group I had pure radiocarpal dislocations and only a fracture of the tip of the
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
styloid process. Group II had radiocarpal dislocations with associated fracture of
ss : / ss : /
the styloid process that involved more than one-third of the width of the scaphoid
t p p t p p
hhtt t t
hht t
fossa. Recommend open reduction and ligamentous repair through a volar approach
for group I, with K-wire fixation of the lunate under the radius for 2 months. Group
II patients are more likely to have the radiocarpal ligaments intact and, therefore,
underwent ORIF through a dorsal approach with K-wire fixation of the radial
styloid. This is thought to stabilize the fracture because all the radiocarpal ligaments
k eers
rs k er
erss
are attached along the volar rim of the scaphoid fossa and styloid process. Therefore,
b ooook b ooook
fixation of the styloid process will confer stability through these ligaments.
eeb ee / e b
Successful management of radiocarpal fracture-dislocations requires
/ e
evaluation and treatment of the columns of the wrist, while taking into account
t . m
. m t . m. m
the direction of dislocation and the presence of any intercarpal injuries. Three
: // / t : / / / t
treatment principles are recommended: (i) concentric reduction of the radiocarpal
hhttt hhttt
joint, (ii) identification and treatment of intercarpal injuries, and (iii) stable repair
of the osseous-ligamentous avulsions. To better direct surgical treatment and
to address all aspects of the injury, we have adopted the columnar concept of
the carpus as described by Navarro and modified by Taleisnik,44 as well as the
columns of the distal radius and ulna as described by Rikli and Regazzoni.45 Each
keerrss k eerrss
column of the distal radius and ulna, namely, the radial, the intermediate, and
b ooook b o ook
the ulnar, is approached separately in a stepwise fashion to achieve radiocarpal
o
eeb e / e b
stability.45 Concomitantly, the columns of the carpus, which include the mobile
/ e
lateral column (i.e., scaphoid), the flexion-extension central column (i.e., lunate,
e
: / / t
/ .
t m m : / / t
/ .
t m
. m
distal carpal row), and the rotatory medial column (i.e., triquetrum), are evaluated
.
for intercarpal ligamentous injury and resultant carpal instability.44 By addressing
t
hhtt t
every column individually, radiocarpal and intercarpal stability can be achieved.
hhtt
Although closed reduction and cast immobilization have been reported to yield
satisfactory results in the management of radiocarpal dislocations,46-48 we consider
these injuries to be complex and unstable conditions that routinely warrant
surgical reduction and fixation to attain a stable, concentric, and congruent wrist.
k e rrss
e k e rrss
All irreducible dislocations, open injuries, and cases involving neurovascular
e
o o
o o k embarrassment require surgical treatment.49-52
o o
o o k
eebb 1. ee/ e
/
Provisional radiocarpal joint reduction
b
The steps in surgical treatment of radiocarpal fracture-dislocation are:
e b
2.
: / / t
/ .
t m
. m
Decompression of neurovascular structures
: / / t
/.tm. m
3.
t p ss:
p /
Exposure and debridement of the joint
t p ss:
p /
4.
5.
t
hht t
Treatment of intercarpal injuries
Fracture fixation and/or soft-tissue repair.
t
hht t
k e r
e s
rs k eerrss
39
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o o k
Use of general anesthesia is recommended. The wrist is provisionally reduced
o
eebb bb
with longitudinal traction. An external fixator may be applied to hold the joint
ee/ e
/e
reduced. An extensile volar approach ulnar to the flexor tendons and median nerve
: / / t
/ .
t m
. m : / / t
/ .
t m
is used so that both the carpal tunnel and Guyon’s canal can be decompressed
. m
t p ss
p : / t p ss : /
as needed. The radiocarpal joint is examined through the volar capsular site of
disruption. The joint is irrigated and debrided of any loose cartilage or bone
p
t
hht t t
hht t
fragments. Stay sutures or suture anchors are then placed in the area of capsular
and ligament disruption but are not tied down. Fluoroscopy is used to identify
any carpal fractures or interosseous ligament injuries, particularly of the SL or LT
ligaments.
k eers
rs k er
erss
Intercarpal ligament injuries are confirmed and treated through a separate
b ooook b oook
dorsal capsular incision. A subperiosteal approach through the floor of the third
o
extensor compartment is used. The columns of the joint are approached sequentially.
eeb / e
/ e b
Beginning with the radial column, the fractured radial styloid is accurately reduced
ee
: // t/.tm
. m : / /t/.tm
and internally fixed. Fixation options include a K-wire, compression screw, or
. m
t ppss / tp ss : /
plate application. Either a K-wire or screw fixation can provide stable fixation
:
of the radial styloid. Screw fixation provides the added benefit of compression,
p
hhttt hhttt
assuming that the styloid fragment is large enough to accommodate a screw
without requiring later removal and pin-tract complications. Volar, radial, or
dorsal plating is selected based on the fracture personality and surgeon preference.
Moving to the intermediate (i.e., central) column, fractures of the lunate facet that
keerrss k eerrss
are amenable to fixation should be repaired with internal fixation using screws or
b ooook b ook
a tension band wire loop.53 When fractures of the radial styloid and/or the lunate
o o
facet are not amenable to fixation, soft-tissue repair is undertaken by direct suture
eeb / e
/ e b
repair or with suture anchors. Stay sutures that previously were placed to repair
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
the extrinsic volar ligaments are tied. The origins of the SRL and RSC ligaments
. m
t
respectively.
ppss / t ppss : /
are repaired in particular to avoid late volar subluxation or ulnar translocation,
:
t
hhtt t
hhtt
Reduction and stability of the fixation is confirmed both visually and
radiographically. The ulnar column is approached in the presence of injury
to the DRUJ and ulnar support ligaments (i.e., UL, UT) or when instability
persists after fixation of the radial and intermediate (i.e., central) columns.
k e rrss
e k e rrss
Large ulnar styloid fractures require internal fixation with screws or tension
e
o o
o o k o o o k
band wiring. This procedure usually restores a concentric DRUJ. In the presence
o
eebb b
of persistent instability, the DRUJ is examined and evacuated of any interposed
ee/ e
/ e b
tissue, followed by repair of the ulnocarpal ligaments. Persistent instability can
: / / t
/ .
t m
. m : / / t
/.tm. m
be addressed by pinning the DRUJ in midsupination. Additional stability to the
t p ss:
p / t p ss:
p /
construct can be provided with the use of an external fixator or radiolunate pin.
The external fixator is especially useful in situations in which daily care of an open
t
hht t t
hht t
wound is needed. Application of a radiolunate pin can be used intraoperatively
k e r
e s
rs
40
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:27 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o o k
to maintain stable reduction of the radiocarpal joint while fracture fixation and
o
eebb bb
soft-tissue repair are undertaken. If necessary, the external fixator or radiolunate
ee/ e
/e
pin may be left in situ postoperatively for 4–6 weeks to reinforce reduction of
the radiocarpal joint.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss : /
Bilos et al.54 recommend immediate closed reduction to prevent/restore
vascular compromise. Open reduction was required in four of the five cases. Once
p
t
hht t t
hht t
the fracture was reduced, fixation was accomplished using a second incision over
the tip of the styloid process to insert a K-wire. Small fragments of the dorsal rim
of the radial articular surface were excised or removed. Fracture of the scaphoid
was seen in three of the five cases and was fixed using a lag screw.
k eers
rs k er
erss
Howard et al.55 described an isolated palmar radiocarpal dislocation and ulnar
b ooook b oook
translocation managed with closed reduction and percutaneous pinning. The
o
authors stated that this case emphasizes the problem of ulnar translocation after
eeb / e
/ e
reduction of palmar radiocarpal dislocations.
ee b
: // t/.tm
Mudgal and Jupiter50 describe the operative method for radiocarpal
. m : / /t/.tm. m
t ppss / tp ss : /
dislocations. After the initial closed reduction, additional radiographs are obtained
:
to help assess the fracture and plant the subsequent surgery. In the operating room,
p
hhttt hhttt
an external fixator is applied to restore length and obtain control of the unstable
extremity. When there is evidence of neurological compromise, an extended palmar
approach is used to decompress the median and/or ulnar nerves and to release
the flexor retinaculum. The radiocarpal joint is examined through the rent in the
keerrss k eerrss
palmar capsule and the extent of capsular injury is noted. The joint is irrigated and
b ooook b ook
any entrapped soft tissue or osteochondral fragments are extracted. The intercarpal
o o
relationships are examined next, both under direct vision and with the use of an
eeb / e
/ e b
image intensifier. If there is injury to the intercarpal ligaments, the affected carpal
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
bones are reduced and fixed with K-wires. Next, sutures are placed in the palmar
. m
t ppss / t ppss : /
capsule, using nonabsorbable material. These are not tied at this point. The radial
:
styloid is then accurately repositioned and fixed securely, using screws or K-wires.
t
hhtt t
hhtt
The sutures in the palmar capsule are then tied. If the capsular avulsion involves
bony fragments, these are fixed with wire sutures or nonabsorbable sutures,
through drill holes made in the volar aspect of the distal radius. When the dorsal
rim of the distal radius is involved, a second incision is made dorsally and the
k e rrss
e k e rrss
radiocarpal joint is approached through the bed of the third dorsal compartment.
e
o o
o o k o o o k
Impacted articular rim fragments are elevated and bone grafted as necessary, using
o
eebb b
iliac crest bone graft. If necessary, dorsal buttress plating is done. The ulnar styloid
ee/ e
/ e b
is then reduced through a separate incision and fixed with K-wires or a screw.
: / / t
/ .
t m
. m : / / t
/.tm. m
The stability of the DRUJ is tested. The external fixator is then either removed or
t p ss:
p / t p ss:
p /
maintained as an additional form of immobilization to protect the repair. All the
dorsal dislocations in their series had a capsular avulsion from the palmar lip of
the radius. t
hht t t
hht t
k e r
e s
rs k eerrss
41
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k Delayed Treatment
o o
o o k
eebb ee/ e
/ebb
Late treatment options include ORIF, lunate excision, proximal row carpectomy,
and wrist fusion. Open reduction and internal fixation seems to have the best
: / / t
/ .
t m
.
outcomes.32m : / / t
/ .
t m
. m
t p ss
p : / ss : /
Rettig et al.56 performed proximal row carpectomies of 48 patients with
t p p
hhtt t t
hht t
chronically untreated or incompletely reduced perilunate injuries using a dual
dorsal and volar approach. The volar approach was done first to decompress
the median nerve, address pathology around the lunate, and assess the volar
carpal ligaments. The authors state that there was a consistently observed severe
k eers
rs k er
ers
contracture of the volar radiocarpal ligaments. Complete release of all remaining
s
scaphoid and lunate soft-tissue attachments was performed to facilitate
b ooook o ook
reduction. The lunate was excised and then attention was turned to the dorsal
b o
eeb ee e
/ e b
approach to complete the proximal row carpectomy and ensure alignment of the
/
capitate within the lunate fossa. Temporary K-wire radius-capitate fixation to
: // t/.tm
. m : / /t/.tm. m
secure carpal alignment was used to allow early ligamentous healing and prevent
postoperative ulnar carpal translocation. All patients were placed in a short-arm
hhttt hhttt
cast for 4 weeks, followed by removal of the K-wire and progressive physical
therapy.
Wagner36 recommended wrist arthrodesis for a delayed perilunate dislocation
associated with a scaphoid fracture when adequate closed reduction could not be
accomplished, believing that the extensive stripping necessary for reduction would
keerrss result in a painful, stiff wrist.

k eerrss
b ooook b o ook
Howard et al.57 felt that in general, a closed reduction can be carried out
o
eeb e / e b
within 2 weeks of injury. The gray area occurs between 2 and 6 weeks. If acceptable
/ e
reduction is obtained, internal fixation with percutaneous K-wires is recommended
e
t . m
. m t . m
. m
to avoid the progressive subluxation of the scaphoid. After 6 weeks, the authors
: / / / t : / / / t
think that open reduction is necessary using the combined dorsal and palmar
t
hhtt t
hhtt
approach. The dorsal approach allows the surgeon to determine precise reduction
under direct visualization. The palmar approach allows for direct repair of the
strong radiocarpal ligaments where possible, decompression of the carpal tunnel,
and use of the Herbert screw for internal fixation of the scaphoid. Dorsally, any
fibrous tissue should be removed and reduction obtained under direct visualization.
k e rrss
e e rrss
The SLIL is usually still attached to at least one bone and can be reattached to the
k e
o o
o o k o o
o o k
bare-surface of the other bone. Repair of the dorsal arcuate ligament and other local
eebb e / / b
tissue is recommended. K-wires are mandatory to maintain reduction. Ligament
e e b
reconstruction may be necessary. The authors recommend long-arm cast for 4–6
e
: / / t
/ .
t m m : / / t
/.tm. m
weeks after the injury, followed by short-arm cast for an additional 4–6 weeks.
.
t p ss:
p / t p ss:
p /
K-wires are removed after 6–8 weeks. A functional wrist without significant pain
t
hht
with good results. t
should be the goal. Gellman et al.58 treated a late perilunate injury with ORIF
t hht t
k e r
e s
rs
42
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
Inoue et al.59 described ORIF with temporary K-wire fixation through a
combined dorsal and palmar approach with internal fixation of scaphoid fractures
eebb / e
/ebb
using a Herbert screw, proximal row carpectomy through a dorsal approach, lunate
ee
: / /
partial excision of the lunate. t
/ t m
excision through a palmar approach, and carpal tunnel release accompanied by
. . m : / / t
/ .
t m
. m
t p ss
p : / t p ss : /
Wyrick et al.60 described the technique for four-corner arthrodesis. A dorsal
p
t
hht t t
hht t
longitudinal incision through the dorsal compartment is used. The entire scaphoid
is excised sharply or piecemeal, and the opposing surfaces of the capitate, lunate,
triquetrum, and hamate are decorticated to cancellous bone. The normal anatomic
position of the bones is maintained and held with K-wires or staples. The
k eers
rs k er
erss
interstices are then filled with cancellous bone graft from the distal radius or iliac
crest. Short-arm cast for 6 weeks, then the K-wires are removed. Strengthening
b ooook and ROM exercises are then initiated.

b ooook
eeb ee/ e
/ e b
Wyrick et al.60 describe technique for proximal row carpectomy. Exposure is
// t/ tm
. m / /t/ tm
the same as that for four-corner arthrodesis. The triquetrum, lunate, and scaphoid
. . . m
are sharply excised when possible, otherwise they are removed piecemeal. A radial
: :
styloidectomy can be performed if necessary. The dorsal wrist capsule is then
hhttt hhttt
repaired with nonabsorbable sutures and without interposition of tissue between
the radius and distal carpal row. The wrist is immobilized for 4 weeks in a short-
arm cast.
keerrss
Conclusion
k eerrss
b ooook o ook
Dislocation of the wrist articulations often occur due to high energy mechanisms.
b o
eeb ee/ e
/ e b
These are complex injuries resulting in disruption of both the ligamentous and
/ / t
/ t m
. m / / t
/ t m
bony anatomy. Proper treatment requires expedient diagnosis and restoration of
. . . m
articular congruity and ligamentous balance. Inadequate treatment may result in
: :
post-traumatic arthritis and stiffness of the hand and fingers.
t
hhtt t
hhtt
Editor’s Comment
Wrist dislocations incorporate both radiocarpal and intercarpal injuries of the
k e rrss
e e rrss
wrist. These injuries are typically high energy injury often resulting in some
k e
o o
o o k o o
o o k
amount of permanent wrist derangement including but not limited to stiffness and
eebb e / / b
e b
post-traumatic arthritis. Successful management requires restoration of articular
e
alignment, fracture healing, and joint stability. In this article, the authors review
e
t . m
. m t. m.
the anatomy of the wrist, the mechanism of injury, diagnosis, and subsequently
: / / / t : / / / t m
surgical management.
t p ss:
p / t p ss:
p /
Asif M Ilyas t
hht t t
hht t
k e r
e s
rs k eerrss
43
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k REFERENCES
o o
o o k
eebb

1.
2.
ee/ e
/ebb
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p

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rs 2001(383):32-40.
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10. Berger RA, Kauer JM, Landsmeer JM. Radioscapholunate ligament: a gross anatomic and histologic study
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// t/.tm
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11. Ritt MJ, Berger RA, Kauer JM. The gross and histologic anatomy of the ligaments of the capitohamate joint.
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ss : /
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o o
16. Kobayashi M, Garcia-Elias M, Nagy L, Ritt MJ, An KN, Cooney WP et al. Axial loading induces rotation of the
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17. Campbell RD, Thompson TC, Lance EM, Adler JB. Indications for open reduction of lunate and perilunate
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hhtt
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23. Inoue G, Tanaka Y, Nakamura R. Treatment of trans-scaphoid perilunate dislocations by internal fixation with
o
eebb ee/ e
/ b
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: / / t
/ .
t m m : / / t
/.tm. m
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.
p ss: /
Clin. 2000;16(3):439-48.
t p t p ss:
p /
25. Melone CP, Murphy MS, Raskin KB. Perilunate injuries. Repair by dual dorsal and volar approaches. Hand
t
hht t t
hht t
26. Meyers MH, Wells R, Harvey JP. Naviculo-capitate fracture syndrome. Review of the literature and a case
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e s
rs
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o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:27 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
27. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and
perilunate dislocations. J Hand Surg Am. 1993;18:1099-106.
eebb / eebb
28. Park MJ, Ahn JH. Arthroscopically assisted reduction and percutaneous fixation of dorsal perilunate
ee /
dislocations and fracture-dislocations. Arthroscopy. 2005;21:1153.
t . m
. m t . m
. m
29. Reddy KJ, Packer GJ. Stabilization of an acute perilunate dislocation using the “TAG” suture anchor. J Hand
: / / / t : / / / t
Surg Br. 1998;23:262-3.
t p ss
p : / t p ss : /
30. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and
p
t
hht t t
hht t
fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22:49-56.
31. Trumble T, Verheyden J. Treatment of isolated perilunate and lunate dislocations with combined dorsal and
volar approach and intraosseous cerclage wire. J Hand Surg Am. 2004;29:412-7.
32. Weil WM, Slade JF, Trumble TE. Open and arthroscopic treatment of perilunate injuries. Clin Orthop Relat
Res. 2006;445:120-32.
k eers
rs 1980;(149):55-72.
k er
ers
33. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop Relat Res.
s
b ooook b oook
34. Van Den Abbeele KL, Loh YC, Stanley JK, Trail IA. Early results of a modified Brunelli procedure for
o
scapholunate instability. J Hand Surg Br. 1998;23:258-61.
eeb / e
/ e b
35. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of
ee
: // t tm
the wrist. Clin Orthop Relat Res. 1987;(214):136-47.
. . m : / /t .tm. m
36. Wagner CJ. Perilunar dislocations. J Bone Joint Surg Am. 1956;38-A:1198-207.
/ /
37. Worland RL, Dick HM. Transnavicular perilunate dislocations. J Trauma. 1975;15:407-12.
hhttt hhttt
38. Günal I, Oztuna V, Hazer B. Trapeziolunate external fixation for transscaphoid perilunate dislocations of the
wrist: report of 2 cases. J Hand Surg Am. 1998;23:158-61.
39. Aitken AP, Nalebuff EA. Volar transnavicular perilunar dislocation of the carpus. J Bone Joint Surg Am.
1960;42-A:1051-7.
40. Pournaras J, Kappas A. Volar perilunar dislocation. A case report. J Bone Joint Surg Am. 1979;61:625-6.
41. Weseley MS, Barenfeld PA. Trans-scaphoid, transcapitate, transtriquetral, perilunate fracture-dislocation of
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the wrist. A case report. J Bone Joint Surg Am. 1972;54:1073-8.
ook ook
42. Vance RM, Gelberman RH, Evans EF. Scaphocapitate fractures. Patterns of dislocation, mechanisms of
b
eeboo e b o
injury, and preliminary results of treatment. J Bone Joint Surg Am. 1980;62:271-6.
b o
43. Dumontier C, Meyer zu Reckendorf G, Sautet A, Lenoble E, Saffar P, Allieu Y. Radiocarpal dislocations:
/
e / e
classification and proposal for treatment. A review of twenty-seven cases. J Bone Joint Surg Am.
m e m
2001;83‑A:212-8.
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/ t
/ .
t . m : / /
/ t
/
44. Taleisnik J. The ligaments of the wrist. J Hand Surg Am. 1976;1:110-8. .
t . m
45. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function.
p
hhtt hhtt
A preliminary report of 20 cases. J Bone Joint Surg Br. 1996;78:588-92.
46. Fehring TK, Milek MA. Isolated volar dislocation of the radiocarpal joint. A case report. J Bone Joint Surg Am.
1984;66:464-6.
47. Freund LG, Ovesen J. Isolated dorsal dislocation of the radiocarpal joint. A case report. J Bone Joint Surg
Am. 1977;59:277.
rrss rrss
48. Penny WH, Greene TL. Volar radiocarpal dislocation with ulnar translocation. J Orthop Trauma. 1988;2:322-6.
o k e
k e Orthop Relat Res. 1985;(192):199-209.
o k e
49. Moneim MS, Bolger JT, Omer GE. Radiocarpal dislocation--classification and rationale for management. Clin
k e
o
eebb o o b o o o
50. Mudgal CS, Psenica J, Jupiter JB. Radiocarpal fracture-dislocation. J Hand Surg Br. 1999;24:92-8.
e b
ee/ e
51. Nyquist SR, Stern PJ. Open radiocarpal fracture-dislocations. J Hand Surg Am. 1984;9:707-10.
/
52. Fernandez DL. Irreducible radiocarpal fracture-dislocation and radioulnar dissociation with entrapment of
m m
/ t . . m / t. . m
the ulnar nerve, artery and flexor profundus II-V-case report. J Hand Surg Am. 1981;6:456-61.
: / / / t : / / / t
t t p
t ss:
p
Surg Am. 1999;24:525-33.
t t p
t ss:
53. Chin KR, Jupiter JB. Wire-loop fixation of volar displaced osteochondral fractures of the distal radius. J Hand
p
hht hht
54. Bilos ZJ, Pankovich AM, Yelda S. Fracture-dislocation of the radiocarpal joint. J Bone Joint Surg Am.
1977;59:198-203.
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e s
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o o k o o
o o k
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/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Fowler and Park
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
55. Howard RF, Slawski DP, Gilula LA. Isolated palmar radiocarpal dislocation and ulnar translocation: a case
report and review of the literature. J Hand Surg Am. 1997;22:78-82.
eebb / eebb
56. Rettig ME, Raskin KB. Long-term assessment of proximal row carpectomy for chronic perilunate dislocations.
ee /
J Hand Surg Am. 1999;24:1231-6.
t . m
. m t . m
. m
57. Howard FM, Dell PC. The unreduced carpal dislocation. A method of treatment. Clin Orthop Relat Res.
: / / / t : / / / t
t p ss
p : /
1986;(202):112-6.
t p ss : /
58. Gellman H, Schwartz SD, Botte MJ, Feiwell L. Late treatment of a dorsal transscaphoid, transtriquetral
p
t
hht t t
hht t
perilunate wrist dislocation with avascular changes of the lunate. Clin Orthop Relat Res. 1988;(237):196-203.
59. Inoue G, Shionoya K. Late treatment of unreduced perilunate dislocations. J Hand Surg Br. 1999;24:221-5.
60. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced
collapse wrist: proximal row carpectomy versus four-corner arthrodesis. J Hand Surg Am. 1995;20:965-70.
k eers
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erss
b ooook b ooook
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o
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rs
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k e r
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o o
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o
eebb Forearm Fractures: ee/ e
/ebb
Operative
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:
Indications
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ss and Techniques t p ss
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Neil R MacIntyre III MD
Chief of Orthopedic Traumatology, OrthoWilmington
Wilmington, North Carolina, USA
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b ooook b ooook
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. m
ABSTRACT
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The forearm consists of two long bones, the radius and ulna, that form a “ring”
along with soft tissue and capsular structures including the interosseous
membrane, triangular fibrocartilage complex, and the proximal and distal
radioulnar joints. Fractures of the forearm can result in disruption of any
or multiple of these ring structures. Management of forearm fractures
keerrss k eerrs
relies on identification of which structure(s) are disrupted, and anatomic
s
restoration of the structures of the forearm restoring the “ring.”
b ooook b o ook
o
eeb INTRODUCTION
ee/ e
/ e b
: / / t .
t m
. m : / / t .
t m
. m
The forearm consists of two long bones forming a ring, the radius and the ulna.
/ /
These two bones function symbiotically as a unit. As such, their anatomy and
t
hhtt t
hhtt
movement should be viewed as a single dynamic process as opposed to two
isolated anatomic structures. Both bones are connected by the distal radioulnar
joint (DRUJ), proximal radioulnar joint (PRUJ), and the interosseous membrane
(IOM). The IOM is a fibrous sheath that separates the anterior and posterior
k e rrss
e rrss
compartments and is a secondary restraint to proximal migration of the radius
e e
relative to the ulna. According to Skehen et al., this sheath, which originates on
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o o
o o k o o o k
the radius and inserts onto the ulna, consists of central band, accessory band, a
o
eebb ee/ e
/ b
e b
proximal band, and a membranous portion.1 The average length of both the radius
origin and ulna insertion is approximately 10.6 cm.1 The IOM serves primarily
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/ .
t m
. m : / / t
/.tm. m
as a ligament and is critical in the maintenance of longitudinal forearm stability.
t p ss:
p / t p ss:
p /
According to Hotchkiss et al., the IOM contributes approximately 71% of the
t
hht t t
hht t
longitudinal forearm stiffness when the radial head is excised.2 The radial head
Email: macinnrm@yahoo.com
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k eerrss
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/ t
/ .t.
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p
hht hht
MacIntyre
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serves as the primary restraint to proximal migration of the radius with the central
band of the IOM and the triangular fibrocartilage complex (TFCC) acting as
eebb ee/ e
/ebb
secondary restraints. These structures together facilitate transition of stress and
/ / t
/ t m
permits fluid motion of the forearm from pronation to supination.
. . m / / t
/ .
t m
. m
The radius, ulna, IOM, TFCC, DRUJ, and PRUJ form the forearm ring.3 This
: :
t p ss
p : / t p ss : /
ring works in concert to allow for forearm pronation and supination. A disruption
p
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hht t
of this ring at any site can result in loss of normal forearm motion. Therefore, the
goal of forearm fracture management is anatomic maintenance of the ring in order
to preserve motion and function.
k eers
rsDIAGNOSIS
k er
erss
b ooook o ook
A patient with a forearm fracture typically presents with a painful right arm.
b o
eeb ee/ e
/ e b
Tenderness is noted and is worsened with hand motion and forearm rotation.
: // t/ tm
. m / /t/ tm
Vigilant evaluation of the radial, median, and ulnar nerves is warranted. The radial
. . . m
and ulnar artery must also be evaluated. If palpable pulses are not felt, Doppler
:
examination is warranted. Neurovascular injury in closed radius and ulna fractures
hhttt hhttt
is an uncommon but serious complication. Compartment syndrome of the forearm
is second only to the leg and must be considered in all cases of forearm fractures with
significant swelling, pain out of proportion, and altered neurovascular examinations.
The risk for neurovascular embarrassment is increased with open fractures.
keerrss k eerrs
All wounds should be diligently evaluated with the understanding that the site of
s
a wound and fracture may not be at the same level at presentation but may have
b ooook b o ook
communicated at the time of injury. Most nerve injuries are neuropraxic, however,
o
eeb ee e
/ e b
hard signs of a nerve injury should be treated accordingly.
/
Thorough radiographic evaluation of the forearm should include antero
: / / t
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. m
posterior and lateral views of the forearm, as well as dedicated views of the wrist
t / t
and elbow. The radius and ulna must be examined thoroughly across their entire
t
hhtt t
hhtt
lengths including the DRUJ and PRUJ. Traction views can aid in characterization
of a fracture. Radiographs can readily make the diagnosis of forearm fractures,
and advanced imaging modalities including computed tomography or magnetic
resonance imaging are rarely necessary except in cases of pathologic lesions.
k e rrssFRACTURES
e k e rrss
e
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o o k o o
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Forearm fractures can be divided into four distinct fracture patterns:
e
1. Isolated radius or ulna fracture
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. m
2. Galeazzi fracture
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/.tm. m
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3. Combined radius and ulna fracture
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t
hht t 4. Monteggia fractures. t
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Each fracture is discussed including treatment principles and techniques.
k e r
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rs
48
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hht hht
Forearm Fractures: Operative Indications and Techniques
k e r
e rss k eers
r s
o o
o o k Isolated Radius Fractures
o o
o o k
eebb ee/ e
/ebb
Isolated radius shaft fractures are controversial and are typically assumed to be a
Galeazzi fracture until proven otherwise (Figure 1). Standard treatment involves
: / / t
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/ .
t m
. m
an anterior approach to the radius with plate fixation. Recently, we have come to
ss : / ss : /
realize that not all isolated radial shaft fractures necessarily involve the DRUJ.
t p p t p p
hhtt t t
hht t
Rettig et al. reviewed 40 patients with a Galeazzi fracture at an average period of
38 months who underwent fracture stabilization via the anterior approach and
standard plate fixation. They found that fractures of the shaft within 7.5 cm of the
midarticular surface of the radius were at high risk for DRUJ involvement whereas
those beyond 7.5 cm were not so and acted as an isolated radial shaft fracture.4
k eers
rs k er
erss
Similarly, Ring et al. reviewed their series of 36 patients with radial shaft
b ooook b ooook
fractures.5 They used a DRUJ disruption with greater than 5 mm of positive ulnar
eeb e / e b
variance as an indicator of a Galeazzi fracture. Nine such patients were treated with
/ e
plate fixation and DRUJ repair with either temporary pinning and/or large ulnar
e
t . m
. m t . m. m
styloid repair, whereas the remaining 27 patients only underwent plate fixation
: // / t : / / / t
without DRUJ stabilization and early mobilization with good results. They identified
h httt hhttt
that isolated radial shaft fractures are more common than Galeazzi fractures.
Galeazzi Fracture
A Galeazzi fracture consists of a fracture of the shaft of the radius with an associated
keerrss k eerrs
DRUJ disruption. The extent of DRUJ injury can be classified as either stable,
s
partially unstable (subluxable), or unstable (dislocated).6 Macule et al. further
b ooook o ook
classified Galeazzi fractures based on the location of the radius fracture relative to
b o
eeb ee/ e
/ e b
: / / t
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t m
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t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
A
: / / t
/ .
t m
. m B
: / / t
/.tm. m
t p ss:
p / t p ss:
p /
Figure 1: “Galeazzi fracture” of the forearm. Note the fracture of the proximal radial shaft
t
hht t t
hht t
and secondary disruption of the PRUJ. A, Pre-operative and B, Post-operative views.
Courtesy: Asif M Ilyas, MD.
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/ .t.
t t p
t ss:
p t t p
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p
hht hht
MacIntyre
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the radial styloid—type 1: 0–10 cm, type 2: 10–15 cm, and type 3: >15 cm from
styloid.7 Again, Rettig et al. identified that the risk for DRUJ injury is greatest
eebb ee/ e
/ebb
when the radial shaft fracture is within 7.5 cm from the articular surface.4
/ / t
/ t m
. m / / t
/ t m
Closed treatment of this fracture has been uniformly poor with Hughston et
. . . m
al. citing a 92% unsatisfactory outcome in a group of 38 patients treated without
: :
t p ss
p : / t p ss : /
operative intervention.8 Operative fixation is the treatment of choice, hence, its
p
t
hht t t
hht t
eponym “fracture of necessity”. The preferred technique is an anterior approach
followed by plate fixation of the radius and reduction of the DRUJ. Plate fixation is
best achieved with a dynamic compression plate and screw purchase of 6–8 cortices
on each side of the fracture. Concentric reduction and stability of the DRUJ is
k eers
rs k er
ers
best achieved by anatomic reduction of the radius. Residual DRUJ instability after
s
radius fixation can be treated with temporary pinning of the DRUJ in supination
b ooook o ook
and/or repair of an ulnar styloid fracture, size permitting.
b o
eeb ee e
/ e b
Mohan et al. reviewed 50 Galeazzi fractures treated only with anatomic plate
/
fixation and without DRUJ repair that resulted in 40 good, 8 fair, and 2 poor
: // t/.tm
. m : / /t/.tm. m
results.9 Similarly, Strehle and Gerber identified that anatomic plate fixation of
the radius and indirect reduction of the DRUJ was sufficient.10 Bhan and Rath
hhttt hhttt
reviewed their experience with Galeazzi fractures and recommended that fractures
with delayed treatment should be immobilized in supination in a long-arm cast
after open plate fixation of the radius and DRUJ reduction.11
keerrssIsolated Ulna Fractures

k eerrss
b ooook b ook
The isolated ulna fracture, also known as a “night stick” fracture, is a common
o o
injury usually resulting from a direct blow to the ulna. The treatment of such
eeb / e
/ e b
injuries is highly variable and is based on the fracture’s stability. Fractures are
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
deemed unstable if there is more than 10° angulation, more than 50% displacement
. m
t pps s / t p ss : /
of ulnar shaft, proximal one-third ulnar shaft involvement, and DRUJ or PRUJ
:
instability.12 Multiple nonoperative measures have been shown to be effective in
p
t
hhtt t
hhtt
the management of isolated ulnar fractures including ace wraps, forearm braces,
short-arm casts, or long-arm casts.13-16
Atkin et al.14 studied patients with isolated stable forearm fractures and
compared ace wrap versus short-arm cast versus long-arm cast. They found that
k e rrss
e k rrss
all fractures united by 7.2 weeks, although 6 out of 9 patients initially treated with
e e
an ace wrap were converted to short-arm casts secondary to pain. They concluded
o o
o o k o o o k
that short-arm casting for 8 weeks is sufficient for closed treatment of ulnar shaft
o
eebb ee/ e b
e b
fractures.14 Pollack et al. treated 71 patients with isolated ulna fractures. They
/
showed that a long-arm cast for 10.5 weeks resulted in an 8% nonunion rate and
: / / t .
t m
. m : / / t.tm. m
cast less than 2 weeks along with motion as tolerated after cast removal resulted in
/ /
t p ss:
p / t p ss:
p /
a 100% union rate. A 5% loss of forearm rotation was noted.13 Zych et al. reported
t
hht t t
hht t
a 100% union rate with 2 weeks of long-arm casting followed by forearm bracing.
The necessity of an interosseous mold within the brace was stressed in order to limit
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e s
rs
50
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r s
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radial angulation.15 Sarmiento et al. studied 287 patients treated with functional
bracing and reported a 12° loss of pronation and 1° loss of supination in proximal
eebb ee/ e
/ebb
fractures, a 10° loss of pronation and 2° loss of supination in middle third fractures,
/ / t
/ t m
. m / / t
/ t m
and 5° loss of pronation and 7° loss of supination in distal third fractures.16
. . . m
Operative intervention should be reserved for unstable fractures. The goal of
: :
t p ss
p : / t p ss : /
operative intervention is avoidance of malunions or nonunions and preservation
p
t
hht t t
hht t
of forearm rotation with anatomic reduction and plate fixation. Open reduction
and internal fixation (ORIF) with dynamic compression plates has resulted in
consistently good outcomes. Leung and Chow performed on 29 isolated ulnar
shaft fractures and noted a 100% union rate.17
k eers
rs k er
erss
b ooook Combined Radius and Ulna Fracture
b ooook
eeb e e / e
/ e b
Combined radius and ulna fractures of the forearm, also known as a “both bones
// t/ tm
. m / /t/ tm
fracture” are defined as an isolated diaphyseal fracture of both the radius and ulna
. . . m
with no injury to the DRUJ or PRUJ (Figure 2). Closed treatment of both bones
: :
fractures has routinely led to poor outcomes with significant losses in forearm
hhttt hhttt
rotation. In 1951, Evans et al. reviewed his series of 50 patients treated with closed
reduction under general anesthesia and reported on the high incidence of residual
loss of forearm rotation with residual malalignment.18 Thus, closed treatment
should be reserved for critically injured patients or for those with substantial
keerrss medical comorbidities.
k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
A
: / / t
/ .
t m
. m B
: / / t
/.tm. m
t p ss:
p / t p ss:
p
Figure 2: “Both bones fracture” of the forearm. /
t
hht t t
hht t
A, Anteroposterior and B, lateral views. Courtesy: Asif M
Ilyas, MD.
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51
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t t p
t ss:
p t t p
t ss:
p
hht hht
MacIntyre
k e r
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r s
o o
o o k o o
o o k
The goal of operative intervention for both bones fractures is stable anatomic
reduction and plate fixation of both the radius and ulna with restoration of radial
eebb / e
/ebb
bow and forearm rotation. Restoration of the radial bow is particularly imperative
ee
: / / t
/ t m
. m : / / t
/ t m
and is defined as the maximal height of the radius arch and is on average around
. . . m
15 mm. The usual location is 60% of radial length distal to the radial ulnar joint.
t p ss
p : / t p ss : /
Mathews et al. showed that a 10° malreduction of the radius will not limit anatomic
p
t
hht t t
hht t
forearm rotation; however, a 20° loss of forearm rotation was shown to limit range
of motion.19
Multiple surgical treatment options exist for the treatment of both bones
fractures, and include open reduction and plate fixation, external fixation, and
k eers
rs intramedullary rodding.
k er
erss
External fixation is typically reserved for management of open fractures or
b ooook ooook
associated soft tissue injuries. Intramedullary fixation will be discussed at greater
b
eeb length in the last section.
ee/ e
/ e b
// t/ tm
. m / /t/ tm
Open reduction and fixation with dynamic compression plates has become
. . . m
the workhorse for management of both bones fractures (Figure 3). Principles of
: :
fixation include restoring length, radial bow, and preservation of forearm rotation.
hhttt hhttt
Complications include loss of forearm rotation, shortening, and wrist pain. To
ensure stable fixation and minimize the risk for nonunions, 6–8 cortices should
be obtained on each site of the fracture. In addition, separate incisions should be
placed to approach both the radius and ulna individually to avoid postoperative
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
tA
m
. m B
: / / t
/.tm. m
t p ss:
p / t p ss:
p /
Figure 3: Both bones fracture after fixation with
t
hht t t
hht t
dynamic compression plate fixation. A, Anteroposterior
and B, lateral views. Courtesy: Asif M Ilyas, MD.
k e r
e s
rs
52
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
synostosis formation. Anderson et al. reviewed 330 fractures of the radius, ulna, or
both bones. All were treated with compression plating. They reported union rates
eebb / e
/ebb
of 97.9 and 96.3% for radius and ulna fractures, respectively. Only 11% of this
ee
: / / t
/ t m
patient group was observed to have a poor functional outcome.20
. . m : / / t
/ .
t m
. m
t p
Monteggia Fracturess
p : / t p ss
p : /
hht t t t
hht t
A Monteggia fracture consists of a fracture of the proximal ulna with an
associated dislocation of the radial head (Figure 4).21 It has been estimated that
the Monteggia fracture pattern represents approximately 1–2% of all forearm
fractures.21 The associated radial head fracture implies an inherent violation of
k eers
rs k er
erss
the annular ligament, which binds the radius to the ulna.3 The Bado classification
b ooook b ooook
has divided Monteggia fractures into four distinct categories with respect to the
eeb ee e
/ e b
location of the radial head:22 (i) type I is an anterior dislocation of radial head,
/
and occurs with excessive forearm pronation; (ii) type II is a posterior dislocation
t . m
. m t . m. m
of radial head, and occurs with excessive axial loading of the forearm along with
: // / t : / / / t
elbow flexion; (iii) type III is a lateral dislocation of the radial head, and occurs
hhttt hhttt
with forced abduction of the elbow; and (iv) finally, type IV represents both a
proximal ulna and radius fracture. This dislocation occurs with excessive forearm
pronation and subsequent fracture through the radial neck. Jupiter et al. further
subdivided the Bado type II fracture into four groups.23 In type IIa, the fracture of
the ulna involves the distal part of the olecranon and the coronoid process; in type
keerrss k eerrss
IIb, the fracture is at the metaphyseal-diaphyseal juncture, distal to the coronoid
b ooook to the proximal half of the ulna.

b ook
process; in type IIc, the fracture is diaphyseal; and in type IId, the fracture extends
o o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
A
: / / t
/ .
t m
. m B
: / / t
/.tm. m
t p ss:
p / t p ss:
p /
Figure 4: “Monteggia rracture” of the forearm. Note the fracture of the radial shaft
t
hht t t
hht t
and secondary disruption of the DRUJ. A, Pre-operative and B, Post-operative views.
Courtesy: Asif M Ilyas, MD.
k e r
e s
rs k eerrss
53
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o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
MacIntyre
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
Ring et al. reviewed their experience with 48 Monteggia fractures with an
average follow-up of 6.5 years that were treated with plate fixation or tension-
eebb ee/ e
/ebb
band wiring of the ulna and closed reduction of the radial head.24 According to
/ / t
/ t m
. m / / t
/ t m
the Broberg and Morrey system, they yielded 38% excellent, 46% good, 4% fair,
. . . m
and 12% poor outcomes. Three quarters of the fair and poor outcomes were Bado
: :
t p ss
p : / t p ss :
type II injuries with concomitant fractures of the radial head.
p /
t
hht t t
hht t
Konrad et al. reviewed their experience with 47 Monteggia fractures with an
average follow-up of 8.4 years that were treated with plate fixation or tension-
band wiring of the ulna and closed reduction of the radial head.25 According to
the Broberg and Morrey system, they yielded 47% excellent, 26% good, 19% fair,
k eers
rs k er
ers
and 8% poor outcomes. The poor outcomes were correlated with Bado type II,
s
Jupiter type IIa, radial head, and coronoid fractures. All radial head and coronoid
b ooook o ook
fractures were treated with screw fixation. Their results support the hypothesis that
b o
eeb ee e
/ e b
posterior radial head dislocations and the more proximal ulna fracture ( Jupiter IIa)
/
might be a poor prognostic indicator. In contrast, Bado type I fractures are less
: // t/.tm
. m : / /t/.tm. m
common in adults but consistently yielded superior results to Bado type II. Both
t ppss : / tppss :
of these results are consistent with Ring et al.’s findings./
hhttt hhttt
Anatomic reduction of the radiocapitellar joints and PRUJs are vital to
successful treatment of this fracture pattern. Bado type II patterns are needed
to be approached cautiously, particularly if associated with a radial head or
coronoid fracture. Closed reduction should be limited to patients with significant
comorbidities that preclude operative intervention.
keerrss k eerrss
b ooook NEW DIRECTIONS b o ook
o
eeb Intramedullary Fixation
ee/ e
/ e b
: / / t
/ .
t m
. m / / t
/ .
t m
. m
Intramedullary fixation of forearm fractures is an old concept that has recently
:
t pps s : / t ppss : /
regained popularity. Although open reduction and plate fixation has well-
t
hhtt t
hhtt
established success in forearm fracture management, complications secondary to
extensive open dissection, disruption of periosteal blood supply, and the risk for
refracture at the end of the plates exists.
Intramedullary fixation was used routinely prior to open plating techniques
k e rrss
e k rrss
for both bones fracture but fell out of favor due to inadequate fracture reduction
e e
and failure to restore forearm motion. The first intramedullary nail results were
o o
o o k o o o k
reported by Sage et al. Postoperatively, the intramedullary nail was protected with
o
eebb ee/ e b
e b
a long-arm cast for 3 months.26 A 6.2% nonunion rate was reported as well as
/
difficulty in restoring normal forearm motion.
: / / t .
t m
. m : / / t.tm. m
More recently, improved designs for intramedullary nails for forearm fracture
/ /
t p ss:
p / t p ss:
p /
has been introduced with precontoured fluted designs and interlocking screws.
t
hht t t
hht t
These newer designs afford better restoration of normal anatomy, particularly
radial bow, and fracture rotational control with interlocking screws. Weckbach
k e r
e s
rs
54
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:28 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
et al. treated 33 forearms with fractures of the radius, ulna, or both bones with a
new intramedullary nail and they reported a 97.5% union rate at 4.4 months with
eebb / e
/ebb
an average disabilities of the arm, shoulder, and hand (DASH) score of 13.7, and
ee
: / / t
/ t m
full range of motion restored in 86% of cases.27 Radial bow was maintained by
. . m : / / t
/ .
t m
. m
prebending of the nail prior to insertion. Lee at al. applied precontoured fluted
t p ss
p : / t p ss : /
intramedullary nails in 38 patients with either isolated or combined fractures of the
p
t
hht t t
hht t
radius and ulna.28 All fractures healed within 14 weeks except for one nonunion in
the case of an open fracture. They achieved 92% good to excellent results with an
average DASH score of 15.
k eers
rs
Locked Plate Technology
k er
erss
b ooook ooook
Locked plating technology has become ubiquitous in orthopedic fracture
b
eeb ee/ e
/ e b
management. The first broad application of this technology was with the less
: // t/ tm
. m : / /t/ tm
invasive stabilization system (LISS). The LISS system involved a titanium alloy
. . . m
plate and utilized unicortical self-drilling, self-locking screws placed through an
external jig. Improved rates of union were noted for distal femur fractures when
hhttt hhttt
compared to traditional plates.29 Today, there are two types of locked plate systems,
either fixed trajectory or variable trajectory locking systems.
The earlier designs with fixed trajectory screws promoted unicortical locked
screw constructs, but yielded proximal plate pull-out with torsion.30 Limitations
keerrss k eerrss
in screw placement with fixed trajectory screws harkened the development of
variable trajectory screws. This design is particularly useful in periprosthetic and
b ooook o ook
periarticular fractures where the ability to redirect screws is critical for adequate
b o
eeb ee/ e
/ e b
fixation. The variable trajectory plates allow angulation of screw placement
/ / t
/ t m
followed by end-point tightening. These designs rely on hoop stresses and
. . m / / t
/ .
t m
. m
additional interface between the screw head and plate.31 Unfortunately, no studies
: :
to date compare the strength of either the fixed or variable trajectory construct to
the other. t
hhtt t
hhtt
Indications for locked fixation include osteopenic bone, segmental bone loss,
or excessive comminution.32,33 Specific fracture applications with support for its
use in the literature includes periarticular fractures (specifically the distal femur,
k e rrss
e k rrss
proximal tibia, proximal humerus, and distal radius), periprosthetic fractures, and
e e
nonunions.34 Several complications also exist with locking plate technology which
o o
o o k o o o k
include but are not limited to nonunion, malunion, fracture distraction, loss of
o
eebb / e b b
diaphyseal fixation, and difficulty with hardware removal.34 The cost, estimated
ee / e
to be as much as three times for conventional systems, is also a major concern.34
: / / t
/ .
t m
. m : / / t
/.tm. m
Unlike periarticular fractures of the forearm where the management of fracture
t p ss:
p / t p ss:
p /
fixation has been improved with locking technology, its role in the treatment of
t
hht t t
hht t
shaft fractures of the radius and ulna remains unclear. Fulkerson et al., using a
synthetic ulna, compared strength of either conventional or locked plates when
k e r
e s
rs k eerrss
55
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:28 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
MacIntyre
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
place under repetitive axial loads.32 They concluded that the bicortical locked screw
configuration was superior to conventional nonlocked screws in comminuted
eebb / e
/ebb
osteopenic bone. The use of only unicortical locked screws was not recommended.
ee
: / / t
/ t m
. m : / / t
/ t m
In contrast, Weiss et al. studied the role of locking plate technology in an ulna
. . . m
osteotomy model with a 1 cm residual fracture gap and they did not identify a
t p ss : /
mechanical advantage with the locked plates.35
p t p ss
p : /
t
hht t t
hht t
We recommend routine consideration of the use of locking plate technology
in the management of periarticular fractures of the forearm, such as with distal
radius of olecranon fractures. In the case of radius and ulna shaft fractures, we
recommend considering its use in cases with advanced osteopenia, bone loss,
k eers
rs k er
erss
and extensive comminution. In applying a locked plate, the same approaches are
utilized as with traditional plates. Locked plates do not require intimate contact
b ooook ooook
between the plate surface and bone. To avoid malreduction of the bone and to
b
eeb ee/ e
/ e b
maximize plate to bone contact, locking plates can be precontoured and should
// t/ tm
. m / /t/ tm
initially be fixed with nonlocking screws. To avoid deformation of the locked
. . . m
screw sites, contouring is done with all locking guides in place. The placement
: :
of nonlocking screws first allows for the plate to be pulled down to bone. This is
hhttt hhttt
followed by placement of locking screws. Once locking screws are placed, further
reduction of the plate down to bone cannot be achieved. Lastly, 6 cortices should
still preferably be obtained on both sides of the fracture.
keerrssConclusion
k eerrss
b ooook o ook
The most common forearm fractures include isolated radius and ulna fractures,
b o
eeb ee/ e
/ e b
combined fractures, Galeazzi fracture, and Monteggia fractures. When the “ring”
: / / t
/ t m
. m / / t
/ t m
of the forearm is disrupted with a fracture, anatomic restoration of the injured
. . . m
structures is required, most commonly with plate and screw fixation.
:
t
hhtt t
hhtt
Editor’s Comment
Forearm fractures are common injuries that routinely require surgical treatment.
k e rrss
e e rrss
Successful management is predicated upon accurate diagnosis, timely intervention,
k e
o o
o o k o o
o o k
and anatomic reduction. Surgical treatment has remained consistent over time
eebb e / / b
e b
but various circumstances warrant special considerations. In this article, the
e
author reviews isolated radius and ulna fractures, combined fractures, Monteggia
e
: / / t
/ .
t m m : / / t
/.tm. m
fractures, and Galeazzi fractures. In addition, a review of the indication for locking
.
t p ss:
p / t p ss:
technology and intramedullary fixation is also presented.
p /
t
hht t
Asif M Ilyas t
hht t
k e r
e s
rs
56
k eerrss
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o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k REFERENCES
o o
o o k
eebb ee/ e
/ebb
1. Skehen JR, Palmer AK, Werner FW, Fortino MD. The interosseous membrane of the forearm: anatomy and
function. J Hand Surg Am. 1997;22:981-5.
t . m
. m t . m
. m
2. Hotchkiss RN, An KN, Sowa DT, Basta S, Weiland AJ. An anatomic and mechanical study of the interosseous
: / / / t : / / / t
t
1989;14:256-61.
p ss
p : / t p ss
p : /
membrane of the forearm: pathomechanics of the proximal migration of the radius. J Hand Surg Am.
t
hht t t
hht t
3. Eathiraju S, Mudgal CS, Jupiter JB. Monteggia fracture-dislocations. Hand Clin. 2007;23:165-77.
4. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg
Am. 2001;26:228-35.
5. Ring D, Rhim R, Carpenter C, Jupiter JB. Isolated radial shaft fractures are more common than Galeazzi
fractures. J Hand Surg Am. 2006;31:17-21.
k eers
rs k er
erss
6. Bruckner JD, Lichtman DM, Alexander AH. Complex dislocations of the distal radioulnar joint. Recognition
and management. Clin Orthop Relat Res. 1992;(275):90-103.
b ooook o ook
7. Maculé Beneyto F, Arandes Renú JM, Ferreres Claramunt A, Ramón Soler R. Treatment of Galeazzi fracture-
b o
eeb dislocations. J Trauma. 1994;36:352-5.
e / e
/ e b
8. Hughston JC. Fracture of the distal radius shaft; mistakes in management. J Bone Joint Surg Am. 1957;39-
e
A:249-64.
// t/.tm
. m / /t/.tm. m
9. Mohan K, Gupta AK, Sharma J, Singh AK, Jain AK. Internal fixation in 50 cases of Galeazzi fracture. Acta
: :
ss : /
Orthop Scand. 1988;59:318-20.
t pp tppss : /
hhttt hhttt
10. Strehle J, Gerber C. Distal radioulnar joint function after Galeazzi fracture-dislocations treated by open
reduction and internal plate fixation. Clin Orthop Relat Res. 1993;(293):240-5.
11. Bhan S, Rath S. Management of the Galeazzi fracture. Int Orthop. 1991;15:193-6.
12. Sauder SJ, Athwal GS. Management of isolated ulnar shaft fractures. Hand Clin. 2007;23:179-84.
13. Pollock FH, Pankovich AM, Prieto JJ, Lorenz M. The isolated fracture of the ulnar shaft. Treatment without
keerrss k eerrs
immobilization. J Bone Joint Surg Am. 1983;65:339-42.
s
14. Atkin DM, Bohay DR, Slabaugh P, Smith BW. Treatment of ulnar shaft fractures: a prospective randomized
b ooook study. Orthopedics. 1995;18:543-7.
b o ook
o
15. Zych GA, Latta LL, Zagorski JB. Treatment of isolated ulnar shaft fractures with prefabricated functional
eeb / e e b
braces. Clin Orthop Relat Res. 1987;(219):194-200.
ee /
16. Sarmiento A, Latta LL, Zych G, McKeever P, Zagorski JP. Isolated ulnar shaft fractures treated with functional
: / / t
/ .
t m
. m
braces. J Orthop Trauma. 1998;12:420-3.
: / / t
/ .
t m
. m
17. Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate
t
hhtt t
with the point contact fixator for forearm fractures. J Bone Joint Surg Am. 2003;85-A:2343-8.
hhtt
18. Evans EM. Fractures of the radius and ulna. J Bone Joint Surg Br. 1951;33-B:548-61.
19. Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect of supination-pronation of angular
malalignment of fractures of both bones of the forearm. J Bone Joint Surg Am. 1982;64:14-7.
20. Anderson LD, Sisk D, Tooms RE, Park WI. Compression-plate fixation in acute diaphyseal fractures of the
radius and ulna. J Bone Joint Surg Am. 1975;57:287-97.
k e rrss
e k e rrss
21. Montaggia GB. Instutuzioni Chirurgiche. Milano, Italy: Maspero; 1814.
e
o o
o o k o o o k
22. Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71-86.
23. Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. The posterior Monteggia lesion. J Orthop Trauma. 1991;5:395-
o
eebb 402.
ee/ e
/ b
e b
24. Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am. 1998;80:1733-44.
: / / t
/ .
t m m : / / t
/.tm. m
25. Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP. Monteggia fractures in adults: long-term results
.
p ss:
p /
and prognostic factors. J Bone Joint Surg Br. 2007;89:354-60.
t p ss: /
26. Sage FP, Smith H. Medullary fixation of forearm fractures. J Bone Joint Surg Am. 1957;39-A:91-8.
t p
t
hht t t
hht t
27. Weckbach A, Blattert TR, Weisser Ch. Interlocking nailing of forearm fractures. Arch Orthop Trauma Surg.
2006;126:309-15.
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e s
rs k eerrss
57
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:28 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
MacIntyre
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
28. Lee YH, Lee SK, Chung MS, Baek GH, Gong HS, Kim KH. Interlocking contoured intramedullary nail fixation
for selected diaphyseal fractures of the forearm in adults. J Bone Joint Surg Am. 2008;90:1891-8.
eebb / eebb
29. Zlowodzki M, Bhandari M, Marek DJ, Cole PA, Kregor PJ. Operative treatment of acute distal femur
ee /
fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005). J Orthop Trauma.
2006;20:366-71.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
30. Kregor PJ, Stannard J, Zlowodzki M, Cole PA, Alonso J. Distal femoral fracture fixation utilizing the Less
Invasive Stabilization System (LISS): the technique and early results. Injury. 2001;32:C32-47.
t
hht t t
hht t
31. Haidukewych G, Sems SA, Huebner D, Horwitz D, Levy B. Results of polyaxial locked-plate fixation of
periarticular fractures of the knee. J Bone Joint Surg Am. 2007;89:614-20.
32. Fulkerson E, Egol KA, Kubiak EN, Liporace F, Kummer FJ, Koval KJ. Fixation of diaphyseal fractures with
a segmental bone defect: a biomechanical comparison of locked and conventional plating techniques. J
Trauma. 2006;60:830-5.
k eers
rs k er
er
Orthop (Belle Mead NJ). 2004;33:439-46.ss
33. Gardner MJ, Helfet DL, Lorich DG. Has locked plating completely replaced conventional plating? Am J
b ooook o ook
34. Haidukewych GJ, Ricci W. Locked plating in orthopaedic trauma: a clinical update. J Am Acad Orthop Surg.
b o
eeb 2008;16:347-55.
e / e
/ e b
35. Weiss DB, Kaar SG, Frankenburg EP, Karunakar MA. Locked versus unlocked plating with respect to plate
e
: // t/.tm
. m : / /t/.tm. m
length in an ulna fracture model. Bull NYU Hosp Jt Dis. 2008;66:5-8.
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs
58
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:28 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o o k
o
eebb Radial Head ee/ e
/ebb
Arthroplasty
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / Matthew T Kleiner MD
t p ss
p : /
t
hht t t
hht t
Department of Orthopedic Surgery, Southern California Permanente Medical Group
Fontana, California, USA
k eers
rs k er
erss
b ooook ABSTRACT bo oook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Radial head arthroplasty is a reliable solution for the treatment of complex,
t ppss / tp ss : /
comminuted radial head fractures, especially fractures with three or more
:
fragments which are not amenable to open reduction internal fixation. The
p
hhttt hhttt
indications for radial head arthroplasty depend on the severity of the injury
and associated injuries. Radial head implants have undergone a significant
evolution in design and durability. Successful surgical treatment can be
optimized by careful surgical dissection, avoiding inadvertent nerve injury,
placement of appropriately sized implants, repair of associated injuries, and
keerrss k eerrss
early protected range of motion in the postoperative period.
b ooook INTRODUCTION b o ook

o
eeb ee/ e
/ e b
t . m
. m t . m
. m
Radial head fractures are common fractures involving the elbow. They can often be
: / / / t : / / / t
treated nonoperatively. However, when surgery is indicated, a number of options
t
hhtt t
hhtt
exist including fracture repair versus replacement. Radial head arthroplasty for
the treatment of radial head fractures is an evolving technique. Because radial
head fractures account for approximately one-third of fractures about the elbow,1,2
a proper understanding of management options is essential. Additionally, these
injuries can result in functional limitations and debilitating pain. For this reason,
k e rrss
e k e rrss
appropriate treatment early in the course of this injury is essential to reduce long-
e
o o
o o k o o
o o k
term complications and significant morbidity to the patient.3
eebb / / b
Radial head fractures can occur both in isolation and in association with
e e b
other soft tissue injuries and/or fractures. The overall injury complex will direct
ee
: / / t
/ .
t m
. m : / / t
/.
treatment and influence the recovery process. The radial head itself provides
tm. m
t p ss: / t p ss: /
intrinsic stability to the elbow, particularly in regards to longitudinal forearm,
posterolateral rotatory, and valgus stability.4 Commonly encountered associated
p p
t
hht t t
hht t
Email: kleinerm@gmail.com
k e r
e s
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Kleiner
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
injuries include lateral and medial collateral ligament injuries, distal radioulnar
joint, and interosseous membrane injuries as seen in Essex-Lopresti injuries as
eebb ee/ e
/ebb
well as coronoid and capitellar fractures.5
/ / t
/ t m
. m / / t
/ t m
Depending on the severity of the radial head fracture, several treatment
. . . m
modalities exist. In 1954, Mason concluded that “the axiom in the treatment of
: :
t p ss
p : / t p ss : /
fractures of the head of the radius should be: if in doubt—resect”.1 Over time, the
p
t
hht t t
hht t
sequelae of longitudinal forearm instability with Essex-Lopresti injuries following
radial head excision had prompted the trend towards open reduction internal
fixation (ORIF) of displaced radial head fractures (Figure 1). Despite overall
good success with ORIF of radial head fractures,6-8 cases with multiple fragments,
k eers
rs k er
ers
comminution, and nonunions continue to pose a difficult problem.9 In particular,
s
radial head fractures with more than three fracture fragments have been shown to
b ooook o ook
be difficult to fix and have a high predilection towards hardware complications,
b o
eeb ee e
/ e b
malunions, nonunions, and the need for reoperation after ORIF.9
/
In response to these difficulties, radial head arthroplasty is quickly gaining
: // t/.tm
. m : / /t/.tm. m
popularity for the treatment of comminuted radial head fractures (Figure 2).
Many types of radial head prostheses exist that have been used over the years.
hhttt hhttt
While there was some early literature describing the use of metallic implants,10
the widespread use of metallic implants has only more recently gained universal
favor. Cherry described the use of an acrylic prosthesis in 1953. While he noted
that this device may prevent proximal migration of the radius and the subsequent
strain on the distal radioulnar joint that could result from excision,11 it proved to
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss: /
Figure 1: Radial head fracture in a terrible triad injury
p
t
hht t t
hht t
of the elbow treated with open reduction internal fixation.
Courtesy: Jesse Jupiter, MD.
k e r
e s
rs
60
k eerrss
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Radial Head Arthroplasty
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
er
B
ss
b ooook b ooook
Figure 2: A, Radial head fracture B, radial head fracture treated with radial head
eeb ee/ / e b
arthroplasty. Courtesy: Asif M Ilyas, MD.
e
: // t/.tm
. m : / /t/.tm. m
lack durability. Silicone implants were initially advocated by several authors,12-15
t ppss / tppss : /
but were later noted to possess limitations, such as silicone synovitis, debris,16
:
fracture, and changes in ulnar variance secondary to the excessive flexibility of the
hhttt hhttt
implants.17 Metallic radial head implants have supplanted the popularity of silicone
implants due to their demonstrated superiority in their functional outcomes.3,18-23
ANATOMY
keerrss k eerrss
b ooook ook
The radial head is fully covered in articular cartilage and is concave at its center
o o
and elliptical in cross section. It angles approximately 15° from its shaft. The
b
eeb / e
/ e b
radial head rotates around the capitellum. With pronation, the radial head moves
ee
: / / t
/ t m
anteriorly and medially. With supination, it moves posteriorly and laterally.
. . m : / / t
/ .
t m
. m
The blood supply to the radial head is tenuous and is akin to the femoral head.
There is an arcade of vessels that travel proximally from the capsular base that
t
hhtt t
hhtt
is supported by the interosseous blood supply. As such, much like the femoral
head, fractures of the radial head with comminution and displacement exhibit a
tendency towards nonunions and osteonecrosis.
k e e ss
rPATHOPHYSIOLOGY
r OF ELBOW/FOREARM STABILITY
k e rrss
e
o o
o o k o o o k
The radial head provides stability to the elbow in multiple directions. The radial
o
eebb / e b b
head provides longitudinal stability of the radius by blocking its proximal
ee / e
migration. Additional longitudinal stabilizers are the interosseous membrane
: / / t
/ .
t m
. m : / / t
/.tm. m
and the triangular fibrocartilage complex (TFCC); however, these are secondary
t p ss:
p / t p ss:
p /
restraints. If the interosseous membrane or TFCC also sustains trauma in cases
hhtt t t
hht t
with concomitant injury to the radiocapitellar joint, treatment must be focused on
reconstruction about the elbow to prevent longitudinal instability.
k e r
e s
rs k eerrss
61
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Kleiner
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
The radial head additionally plays an important role in the inherent varus/
valgus stability of the elbow. The primary stabilizer to valgus instability of the
eebb ee/ e
/ebb
elbow is an intact ulnar collateral ligament. The radial head is a secondary stabilizer
/ / t
/ t m
. m
ligament deficient elbow improves lost stability.
: : / / t
/ t m
to valgus stress. Replacement of the radial head in an otherwise ulnar collateral
. . . m
t p ss
p : / t p ss : /
Finally, the radial head in combination with the anterior band of the lateral
p
t
hht t t
hht t
collateral ligament provides posterolateral stability to the elbow. The radial head acts
by tensioning the ligament, so that the elbow does not dislocate in a posterolateral
direction. In addition, care must be taken during surgical approaches to maintain
the integrity of the lateral collateral ligament. If it is damaged during dissection, it
k eers
rs k er
ers
should be repaired prior to closing.
s
b ooook TYPES OF RADIAL HEAD IMPLANTSbooook
eeb ee/ e
/ e b
: // t/.tm
. m / /t/ tm
Most implants today are fabricated from either cobalt-chromium or titanium.
. . m
While silicone implants have been used, they have fallen out of favor due to
:
factors, such as lack of durability and silicone inflammatory synovitis. Several
hhttt hhttt
types of radial head replacements are available. They can broadly be separated into
following three types:
1. Monoblock
2. Modular
keerrss 3. Bipolar.
k eerrss
b ooook o ook
Modular implants provide for increased flexibility in implant selection and
b o
eeb ee e
/ e b
sizing as well as increased ease of implant insertion. Bipolar implants provide the
/
theoretical advantage of less capitellar wear and stem-shaft loosening with the
: / / t
/ .
t
additional axis of motion. m
. m : / / t
/ .
t m
. m
The type of stem is also an important consideration. Loose-fitting stems
t
hhtt t
hhtt
function as a spacer and allow for motion between the stem and shaft. Fixed
stems, either press fit or cemented, do not afford for proximal motion and demand
diligent anatomic placement to adequately restore normal joint alignment.
k e r
e s
rsSURGICAL INDICATIONS
k e rrss
e
o o
o o k o o o k
The indications for radial head arthroplasty depend largely on the severity of the
o
eebb ee/ e
/ b
e b
injury. Once again, the degree of bony and soft tissue injury is important factors
in determining the need for replacement over excision or ORIF. In defining
: / / t
/ .
t m
. m : / / t
/.tm. m
the indications for radial head arthroplasty, it may be helpful to distinguish
t p ss:
p / t p ss:
p /
between acute and chronic conditions. Acute injuries that benefit most from
hhtt t t
hht t
radial head arthroplasty include injuries resulting in comminution with three
or more parts, such as those characteristic of Mason type III injuries,19 or those
k e r
e s
rs
62
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
that are otherwise deemed unreconstructible due to other injuries resulting in
instability.18,22,24,25 Mason type IV injuries, radial head fractures of any type
eebb / e
/ebb
combined with dislocation of the elbow, also demonstrate marked improvement
ee
: / / t
/ t m
. m : / / t
/ t m
when treated with arthroplasty over excision. Third, radial head arthroplasty is
. . . m
indicated in radial head fractures associated with medial collateral, lateral collateral,
t p ss
p : / t p ss : /
or interosseous ligament injuries.26-29 Finally, arthroplasty is indicated when the
p
t
hht t t
hht t
fracture is associated with capitellar fractures also requiring internal fixation.30
As mentioned, there is also a role for radial head arthroplasty in the treatment of
chronic conditions of the elbow. These conditions include radial head malunions
and nonunions as well as possibly in the treatment of the rheumatoid elbow.
k eers
rs k er
erss
However, complications such as the accelerated prosthetic degeneration have been
described.16 In addition to treating malunions and nonunions, metallic radial head
b ooook ooook
arthroplasty has also shown promise in the treatment of elbows formerly treated
b
eeb with excision of the radial head.31
ee/ e
/ e b
// t/ tm
. m / /t/ tm
As is the case for other joint replacement procedures, whenever there is a
. . . m
feasible chance that the native radial head can be preserved, radial head arthroplasty
: :
should not be performed. The use of ORIF for the treatment of reconstructible
hhttt hhttt
radial heads should not be ignored. Arthroplasty should be reserved for cases in
which the radial head is not salvageable due to factors such as severe comminution
or debilitating pain.
keerrss
TECHNIQUE
k eerrss
b ooook o ook
Radial head arthroplasty can be performed through either a posterior or a lateral
b o
eeb ee e
/ e b
incision. A posterior incision affords access to both the medial and lateral side of
/
the elbow depending on the surgical needs of the case. In addition, the posterior
: / / t
/ .
t m
. m : / /
approach provides a cosmetically pleasing incision and results in the least
t
/ .
t m
. m
cutaneous nerve disturbance. In contrast, the lateral approach provides a direct
t
hhtt t
hhtt
approach to the radial head with typically a smaller incision and potentially less
surgical dissection. It does not afford the ability to approach the elbow medially if
necessary through the same incision.
Deep surgical dissection can be facilitated through a number of muscular
intervals. In cases with acute injuries, there may often be a violation of the lateral
k e rrss
e e rrss
extensor muscle mass origin that can be developed to expose the radial head.
k e
o o
o o k o o
o o k
Otherwise, there are three common intervals that can be utilized. Beginning from
eebb • The Kocher approach ee/ / b

posterolateral to anterolateral, they include:
e e b
• The midlateral approach
: / / t
/ .
t m
. m : / / t
/.tm. m
• The Wagner approach.
t p ss:
p / t p ss:
p /
t
hht t t
hht t
The Kocher approach involves development of interval between the anconeus
and extensor carpi ulnaris. It inherently involves violation of the lateral ulnar
k e r
e s
rs k eerrss
63
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Kleiner
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
collateral ligament complex and therefore, requires a diligent repair with closure.
The midlateral approach involves identifying the center of the radiocapitellar axis
eebb ee/ e
/ebb
through the extensor origin and placing a full thickness muscle-splitting incision
/ / t
/ t m
. m / / t
/ t m
down to the radiocapitellar joint. The interval can be increased by raising the
. . . m
origin of the extensor mass origin proximally along the supracondylar ridge of
: :
t p ss
p : / t p ss : /
the lateral distal humerus. Posterior dissection of the distal humerus is avoided in
p
t
hht t t
hht t
order to spare the origin of the lateral ulnar collateral ligament complex. Lastly, the
Wagner approach utilizes the interval between the extensor carpi radialis longus/
brevis and the extensor digitorum communis. This approach provides an anterior
approach to the radiocapitellar joint and also minimizes injury to the lateral ulnar
k eers
rs collateral ligament.
k er
erss
Once the radial head is exposed, the specific surgical implant insertion
b ooook o ook
techniques and instructions should be followed. As such, certain principles should
b o
eeb • ee e
/ e b
be considered during the arthroplasty:
/
// t/ tm
. m / /t/ tm
The posterior interosseous nerve is at risk for iatrogenic injury. To avoid injury,
. . . m
retraction of tissue superior to the radial head and neck should be performed
: :
gently. Similarly, dissection beyond 2 cm distal to the radial neck should be
hhttt hhttt
avoided. Lastly, the forearm should be kept pronated to maximize the distance
of the nerve from the surgical field
• During excision of a fractured radial head, all fractured fragments should be
removed and saved. If fragments or portions of the radial head remain attached
keerrss k eerrs
to the shaft, they should be removed sharply with an oscillating saw in order to
s
avoid fracturing or destabilizing the remaining radial neck
b ooook b o ook
• When the radial head implant is being broached and sized, the anatomic
o
eeb ee e
/ e b
goal should be to restore longitudinal length to the forearm so that normal
/
proximal and distal radioulnar joint relationships are restored while not
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
“overstuffing” the joint. Placing too large of an implant can result in elbow and
wrist pain, increased capitellar wear, and decreased motion. With the implant
t
hhtt t
hhtt
or trial in place, range of motion of the elbow under direct visualization
should demonstrate approximately 1 mm of space between the implant and
capitellum through the range of motion
• With the implant in place, the integrity of the lateral ulnar collateral ligament
complex should be judged and repaired or reconstructed as needed.
k e rrss
e k e rrss
e
o o
o o k OUTCOMES o o
o o k
eebb ee/ e
/ b
e b
The use of radial head arthroplasty has proven to be a successful means of
: / / t
/ .
t m
. m : / / t
/.tm. m
treating complex, unstable radial head fractures not amenable to excision or
t p ss:
p / t p ss:
p /
ORIF. Overall, patients report subjectively favorable results, including good pain
t
hht t t
hht t
scores and functional range of motion. Recovery from radial head replacement
generally occurs by 6 months.24 Grewal et al. followed 26 patients who sustained
k e r
e s
rs
64
k eerrss
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o o k
comminuted fractures of the radial head for 2 years and found that overall patient
o
eebb
satisfaction was high and that treatment with radial head arthroplasty is a safe,
/ e
/ebb
viable treatment option.24 Similarly, Shore et al. demonstrated that radial head
e
/ t .
t m
. m e / t .
t m
arthroplasty provides good range of motion and pain relief over a 5–10 year period
. m
p ss: /
: / p ss: /
: / /
when used for the treatment of recalcitrant post-traumatic elbow disorders.32
/
Moro et al. demonstrated the short-term benefits of radial head arthroplasty
t
hhtt t p t
hhtt t p
for the treatment of severely comminuted radial head fractures.3 While some
impediments to elbow mechanics were noted in this study, the overall judgment
is that radial head arthroplasty which is an effective treatment modality for
irreparable fractures. Similarly, Ashwood et al. showed in their review of patients
k eers
rs k er
erss
treated with radial head arthroplasty that replacement of the radial head should
be accompanied by early range of motion and exercise in order to achieve optimal
b ooook results.33
b ooook
eeb ee/ e
/ e b
Despite the overall success of radial head arthroplasty, well-documented
// t/ tm
complications have been reported. Some of the more frequently encountered
. . m / /t/.tm. m
problems in radial head arthroplasty include stiffness, osteoarthritis, posterior
: :
t p ss : /
interosseous nerve injury, and implant failure.
p tppss : /
hhttt hhttt
Stiffness accounts for a large fraction of the postoperative morbidity observed.
Stiffness can be caused for a variety of reasons. These include capsular contracture,
heterotopic ossification- or retained fragments within the joint space.34-36
Contractures and limited range of motion can improve dramatically with stretching
keerrss k eerrs
exercises and physical therapy. Specific limitations, such as loss of flexion and
s
extension, respond to measures such as turnbuckle splinting.37 Patients who fail
b ooook o ook
nonsurgical management can be treated with capsular releases. Contracture caused
b o
eeb ee/ e
/ e b
by heterotopic ossification can be treated by local excision and a one-time dose of
/ / t
/ t m
500 cGy radiation therapy or indomethacin to prevent recurrence.
. . m / / t
/ .
t m
. m
Injury to the posterior interosseous nerve can occur with dissections distal to
: :
the radial tuberosity and with unscrupulous placement of retractors around the
t
hhtt t
hhtt
radial neck.38,39 It has been suggested that this injury can be avoided by pronation
of the forearm during surgical exposure, which increases the distance between
the surgical field and the nerve itself, thus mitigating the risk of injury.40 Another
important surgical hazard to consider is potential damage to the ulnar lateral
k e rrss
e k rrss
collateral ligament, an important posterolateral stabilizer. This ligament should be
e e
preserved and if damaged during the exposure, be repaired.41-43
o o
o o k o o o k
Implant failure is a potential complication of radial head arthroplasty for
o
eebb / e b b
several reasons. Aseptic loosening can occur leading to symptomatic instability
ee / e
or poor range of motion with the use of several designs.44,45 Another technical
: / / t .
t m
. m : / / t.tm. m
downfall leading to implant failure is the so-called “overstuffing” of the joint due
/ /
t p ss:
p / t p ss:
p /
to improper oversizing of the prosthesis and subsequent erosion of the capitellar
t
hht t t
hht t
surface. This may be avoided by taking preoperative radiographs of the opposite
elbow in order to better judge the size of the native radial head.46
k e r
e s
rs k eerrss
65
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Kleiner
k e r
e s
rs k eers
r s
o o
o o k CONCLUSION
o o
o o k
eebb ee/ e
/ebb
To conclude, radial head fractures with three or more fragments have a high
incidence of complications when treated with ORIF including hardware failure,
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
malunion, nonunion, and the need for reoperation. Radial head arthroplasty has
t p ss
p : / ss : /
demonstrated good success in the treatment of complex, comminuted radial head
t p p
t
hht t t
hht t
fractures which are not amenable to nonoperative treatment or ORIF. Success can
be optimized by diligent surgical dissection, avoiding inadvertent nerve injury,
placement of an appropriately sized implant, repair of associated injuries, and early
protected motion.
k eers
rs k er
erss
b ooook Editor’s Comment b ooook
eeb e / e
/ e b
Radial head fractures are common fractures of the elbow. The majority can be
e
: // t/.tm
. m : / /t/.tm. m
treated nonoperatively, but when displaced or with multiple parts, surgery is
often necessary in the form of either fracture repair or radial head replacement.
Replacement or arthroplasty of the radial head warrants a number of considerations
hhttt hhttt
including fracture configuration and elbow stability. In this article, the author
presents a review of the technique of radial head arthroplasty including indications,
implant types, and techniques.
keerrss Asif M Ilyas
k eerrss
b ooook b o ook
o
eeb REFERENCES
ee/ e
/ e b
: / / t
/ .
t m
. m / / t
/ .
t m
. m
1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases.
:
t ppss : / Br J Surg. 1954;42:123-32.
t ppss : /
t
hhtt t
hhtt
2. Jackson JD, Steinmann SP. Radial head fractures. Hand Clin. 2007;23:185-93.
3. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for
unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001;83-A:1201-11.
4. Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory
stabilizers of the elbow. J Bone Joint Surg Am. 2004;86-A:975-82.
5. Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation; report of two cases. J Bone
k e rrss
e
Joint Surg Br. 1951;33B:244-7.
k e rrss
e
o o
o o k o o
o o k
6. Hausmann JT, Vekszler G, Breitenseher M, Braunsteiner T, Vécsei V, Gäbler C. Mason type-I radial head
fractures and interosseous membrane lesions--a prospective study. J Trauma. 2009;66:457-61.
eebb ee/ e b
e b
7. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. Comparison of
/
resection and internal fixation. J Bone Joint Surg Am. 2005;87:76-84.
t . m
. m t. m. m
8. Furry KL, Clinkscales CM. Comminuted fractures of the radial head. Arthroplasty versus internal fixation. Clin
: / / / t : / / / t
t p ss: /
t p ss: /
9. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone
p p
t
hht t
Joint Surg Am. 2002;84-A:1811-5.
t
hht t
10. Speed K. Ferrule caps for the head of the radius. Surg Gynecol Obstet. 1941;73:845-50.
k e r
e s
rs
66
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:29 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k Br. 1953;35-B:70-1.
o o
o o k
11. Cherry JC. Use of acrylic prosthesis in the treatment of fracture of the head of the radius. J Bone Joint Surg
eebb / eebb
12. Mackay I, Fitzgerald B, Miller JH. Silastic replacement of the head of the radius in trauma. J Bone Joint Surg
Br. 1979;61-B:494-7.
ee /
t . m
. m t . m
. m
13. Swanson AB, Jaeger SH, La Rochelle D. Comminuted fractures of the radial head. The role of silicone-
: / / / t : / / / t
t p ss
p : / t p ss
p : /
implant replacement arthroplasty. J Bone Joint Surg Am. 1981;63:1039-49.
14. Morrey BF, Askew L, Chao EY. Silastic prosthetic replacement for the radial head. J Bone Joint Surg Am.
t
hht
1981;63:454-8.
t t
hht t
15. Berger M, Urvoy P, Mestdagh H. [Comparative study of the treatment of fractures of the head of the radius
by resection or by Swanson’s silastic implant]. Ann Chir. 1991;45:418-25.
16. Trepman E, Ewald FC. Early failure of silicone radial head implants in the rheumatoid elbow. A complication
of silicone radial head implant arthroplasty. J Arthroplasty. 1991;6:59-65.
k eers
rs Clin Orthop Relat Res. 1986;(209):259-69.
k er
erss
17. Carn RM, Medige J, Curtain D, Koenig A. Silicone rubber replacement of the severely fractured radial head.
b ooook o ook
18. Harrington IJ, Tountas AA. Replacement of the radial head in the treatment of unstable elbow fractures.
b o
eeb Injury. 1981;12:405-12.
e / e
/ e b
19. Smets S, Govaers K, Jansen N, Van Riet R, Schaap M, Van Glabbeek F. The floating radial head prosthesis
e
: // /.tm
. m : / /t/.tm. m
for comminuted radial head fractures: a multicentric study. Acta Orthop Belg. 2000;66:353-8.
t
20. Popovic N, Gillet P, Rodriguez A, Lemaire R. Fracture of the radial head with associated elbow dislocation:
results of treatment using a floating radial head prosthesis. J Orthop Trauma. 2000;14:171-7.
hhttt hhttt
21. Knight DJ, Rymaszewski LA, Amis AA, Miller JH. Primary replacement of the fractured radial head with a
metal prosthesis. J Bone Joint Surg Br. 1993;75:572-6.
22. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head
implants in the treatment of unstable elbow fractures: a long-term review. J Trauma. 2001;50:46-52.
23. Chapman CB, Su BW, Sinicropi SM, Bruno R, Strauch RJ, Rosenwasser MP. Vitallium radial head prosthesis
keerrss Surg. 2006;15:463-73.

k eerrs
for acute and chronic elbow fractures and fracture-dislocations involving the radial head. J Shoulder Elbow
s
b ooook b ook
24. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJ. Comminuted radial head fractures
o o
treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg Am.
eeb 2006;88:2192-200.
ee/ e
/ e b
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/ t m
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/ t m
25. Dotzis A, Cochu G, Mabit C, Charissoux JL, Arnaud JP. Comminuted fractures of the radial head treated by
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the Judet floating radial head prosthesis. J Bone Joint Surg Br. 2006;88:760-4.
26. Davidson PA, Moseley JB, Tullos HS. Radial head fracture. A potentially complex injury. Clin Orthop Relat Res.
t
hhtt
1993;(297):224-30.
t
hhtt
27. Schofer MD, Peterlein CD, Kortmann HR. [Radial head prosthesis - treatment of comminuted radial head
fractures combined with elbow instability]. Z Orthop Unfall. 2008;146:760-7.
28. Pomianowski S, Morrey BF, Neale PG, Park MJ, O’Driscoll SW, An KN. Contribution of monoblock and bipolar
radial head prostheses to valgus stability of the elbow. J Bone Joint Surg Am. 2001;83-A:1829-34.
29. King GJ, Zarzour ZD, Rath DA, Dunning CE, Patterson SD, Johnson JA. Metallic radial head arthroplasty
k e rrss
e k e rrss
improves valgus stability of the elbow. Clin Orthop Relat Res. 1999;(368):114-25.
e
o o
o o k o o
o o k
30. King GJ, Patterson SD. Metallic radial head arthroplasty. Tech Hand Up Extrem Surg. 2001;5:196-203.
31. Judet T, Massin P, Bayeh PJ. [Radial head prosthesis with floating cup in recent and old injuries of the elbow:
eebb / e b b
preliminary results]. Rev Chir Orthop Reparatrice Appar Mot. 1994;80:123-30.
ee / e
32. Shore BJ, Mozzon JB, MacDermid JC, Faber KJ, King GJ. Chronic posttraumatic elbow disorders treated
t . m
. m t. m. m
with metallic radial head arthroplasty. J Bone Joint Surg Am. 2008;90:271-80.
: / / / t : / / / t
t p ss: / t p ss: /
33. Ashwood N, Bain GI, Unni R. Management of Mason type-III radial head fractures with a titanium prosthesis,
ligament repair, and early mobilization. J Bone Joint Surg Am. 2004;86-A:274-80.
p p
t
hht t t
hht t
34. Pike JM, Athwal GS, Faber KJ, King GJ. Radial head fractures--an update. J Hand Surg Am. 2009;34:557-65.
35. King GJ. Management of radial head fractures with implant arthroplasty. J Am Soc Surg Hand. 2004;4:1-26.
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e s
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/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Kleiner
k e r
e s
rs k eers
r s
o o
o o k 1991;5:21-8.
o o
o o k
36. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma.
eebb / eebb
37. Gelinas JJ, Faber KJ, Patterson SD, King GJ. The effectiveness of turnbuckle splinting for elbow contractures.
ee /
J Bone Joint Surg Br. 2000;82:74-8.
t . m
. m t . m
. m
38. Strachan JC, Ellis BW. Vulnerability of the posterior interosseous nerve during radial head resection. J Bone
: / / / t : / / / t
t p ss
p : /
Joint Surg Br. 1971;53:320-3.
t p ss : /
39. Mekhail AO, Ebraheim NA, Jackson WT, Yeasting RA. Vulnerability of the posterior interosseous nerve during
p
t
hht t t
hht t
proximal radius exposures. Clin Orthop. 1995;(315):199-208.
40. Diliberti T, Bottle MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve
during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg Am. 2000;82:809-13.
41. Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Ligamentous stabilizers against posterolateral
rotary instability of the elbow. J Bone Joint Surg Am. 2001;83-A:1823-8.
k eers
rs 1991;73:440-6.
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ers
42. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotary instability of the elbow. J Bone Joint Surg Am.
s
b ooook b oook
43. O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin
o
Orthop Relat Res. 1992;(280):186-97.
eeb / e
/ e b
44. Stoffelen DV, Holdsworth BJ. Excision or Silastic replacement for comminuted radial head fractures. A long-
ee
: // t tm
term follow-up. Acta Orthop Belg. 1994;60:402-7.
. . m : / /t .tm. m
45. Lim YJ, Chan BK. Short-term to medium-term outcomes of cemented Vitallium radial head prostheses after
/ /
early excision for radial head fractures. J Shoulder Elbow Surg. 2008;17:307-12.
hhttt hhttt
46. Doornberg JN, Linzel DS, Zurakowski D, Ring D. Reference points for radial head prosthesis size. J Hand
Surg Am. 2006;31:53-7.
keerrss k eerrss
b ooook b o ook
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eebb Scaphoid Nonunion: ee/ e

/ebb
Does Vascularized
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Bonet p :
Graft
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ss Improves Outcomes? t p ss
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1
Christopher J Williamson MD, 2,*John R Fowler MD
1
Department of Orthopedics, Einstein Medical Center
k eers
rs 2
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Department of Orthopedics, University of Pittsburgh,
b ooook b ooook
eeb ee/ e
/ e b
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. m : / /t/.tm. m
t ppss : / ABSTRACT
tppss : /
hhttt hhttt
Scaphoid nonunion is a challenging clinical problem. Failure of treatment
may lead to scaphoid nonunion advanced collapse degenerative changes.
The purpose of this review article is to examine the available evidence
regarding the use of different bone graft options for scaphoid nonunion
keerrss k eerrss
repair using union rate as the primary outcome. This review found no
b ooook b ook
significant difference between vascularized and nonvascularized bone
o o
grafts for scaphoid nonunion.
eeb ee/ e
/ e b
INTRODUCTION
: / / t
/ .
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/ .
t m
. m
Scaphoid fractures account for 60% of carpal bone fractures and 11% of all hand
t
hhtt t
hhtt
fractures.1 The majority of scaphoid fractures heal with nonoperative or operative
treatment. However, estimates of nonunion in the literature are around 10%.2
Nonunion is problematic as scaphoid fractures occur most frequently in a younger,
male, working population between the ages of 15 and 40 years with an average age
k e rrss
e k e rrss
of 25 years.3 Nondisplaced fractures have a union rate near 100%, but displaced
e
o o
o o k o o o k
fractures may have nonunion rates over 50%.2,4,5 Untreated or unsuccessfully
o
eebb b
treated scaphoid nonunions predictably lead to scaphoid nonunion advanced
ee/ e
/ e b
collapse (SNAC), requiring salvage procedures, such as limited carpal arthrodesis,
: / / t
/ .
t m
. m : / / t
/.
radial styloidectomy, proximal row carpectomy, wrist denervation, distal pole
tm. m
t p ss: / t p ss:
suboptimal compared to successful union of a scaphoid nonunion.2,3,9
p p /
excision, or wrist fusion.6-8 The results and durability of these procedures are likely
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t t
hht t
Email: johnfowler10@gmail.com
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p
hht hht
Williamson and Fowler
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o o k
The scaphoid is particularly vulnerable to nonunion because of its intra
synovial position and poor blood supply.1 While the distal pole receives blood
eebb / e
/ebb
supply directly from the radial artery and superficial palmar branch of the radial
ee
: / / t
/ t m
. m : / / t
/ t m
artery, the proximal pole relies on retrograde flow through intraosseous branches
. . . m
that are disrupted in waist and proximal pole fractures.1,10 This tenuous blood
t p ss
p : / t p ss : /
supply results in a higher risk of avascular necrosis (AVN) and nonunion in
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hht t t
hht t
these fractures.11 The majority of its surface is covered by cartilage and therefore,
scaphoid fractures must heal by primary bone healing. Primary bone healing
requires stability since fracture callus will not form, however, scaphoid fractures
are unstable by nature due to the bending and rotatory forces that occur during
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rs k er
erss
wrist motion.9 Further contributing to instability, the scaphoid acts to link the
proximal and distal carpal rows and the fracture site can be levered open by
b ooook ooook
its capsular attachments, the scapholunate ligament, and the volar intercarpal
b
eeb ee/ e
/ e b
ligaments.9 This lack of stability results in micromotion at the fracture site and
nonunion.9
: // t/ tm
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disruption of the healing process, possibly contributing to the development of
. . . m
Slade and colleagues9 identified three requirements for scaphoid union
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to occur. First, perfusion must be restored to the fracture fragments. Second,
osteoinductive and osteoconductive cells must be delivered to the nonunion
site. Third, stability must be achieved through rigid fixation. Bone graft is often
recommended as scaphoid nonunion can result in bone loss, cystic changes, and
keerrss k eerrs
loss of alignment. Restoration of perfusion may appear to require a vascularized
s
bone graft (VBG); however, neovascularization occurs during the bone healing
b ooook o ook
process and nonvascularized bone graft (NVBG) may be adequate in many cases.
b o
eeb ee/ e
/ e b
In addition, there is likely some level of avascularity in any scaphoid waist or
proximal pole fracture, but relatively few of these fracture result in AVN of the
: / / t .
t m
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t m
. m
proximal pole. There is also evidence that avascular bone will revascularize if
/ /
rigidly fixed to well-perfused bone.9 Osteoconductive and osteoinductive cells can
t
hhtt t
hhtt
be obtained from either VBG or NVBG such as cancellous or iliac crest bone graft
(ICBG). Rigid fixation is often obtained with the use of compression screws, with
some studies suggesting that union rates using compression screws is higher than
using K-wires.
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e rrss
The diagnosis of scaphoid nonunion may be delayed as many patients may
e e
have a scaphoid nonunion that remains asymptomatic or minimally symptomatic
k
o o
o o k o o o k
for years before presentation to a hand surgeon.2 Clinical symptoms that may
o
eebb ee/ e
/ b
e b
prompt evaluation and clinical suspicion for scaphoid nonunion include pain
with end range extension, dorsal wrist swelling, decreased wrist range of motion,
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/ .
t m
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/.tm. m
decreased grip strength, and tenderness over the scaphoid tubercle or anatomic
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p / t p ss:
p /
snuffbox.2,3 Radiographic diagnosis of nonunion includes sclerotic fracture
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hht t t
hht t
edges, cyst formation, and a fracture gap.12 The definition of scaphoid nonunion
is debated, but typically requires an interval of 6–12 months after injury or
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t t p
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p t t p
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p
hht hht
Scaphoid Nonunion: Does Vascularized Bone Graft Improves Outcomes?
k e r
e s
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o o
o o k the fracture site.13 o o
o o k
surgical intervention without radiographic evidence of bridging callous across
eebb / e
/ebb
There remains considerable debate over the optimal type of bone graft in
ee
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/ t m
scaphoid nonunion. High union rates have been achieved using NVBG, although
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. m
the results appear less promising for proximal pole fractures with established AVN.
t p ss
p : / t p ss : /
While local VBG may allow for increased blood supply,14 it is unclear if it increases
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hht t t
hht t
the union rate and may potentially increase the morbidity of the procedure.
Several authors have proposed free VBG from the medial femoral condyle and
have documented high union rates in cases of proximal pole AVN. The optimal
treatment option will depend on many factors, including the fracture gap, amount
k eers
rs k er
erss
of bone loss, presence or absence of AVN, and location of the nonunion.9 As
more than 150 studies and two systematic reviews have been published on these
b ooook ooook
topics, a complete review of every study is beyond the scope of this article.15,16 The
b
eeb e e/ e
/ e b
purpose of this article is to review the available literature on the use of NVBG and
: // t/ tm
VBG for the treatment of scaphoid nonunion.
. . m : / /t/.tm. m
hhttt hhttt
NONVASCULARIZED BONE GRAFT
The premise behind the use of bone graft for the treatment of scaphoid nonunion
is to address bone loss and to correct the humpback deformity that is often found
in chronic scaphoid nonunion. Correction of the humpback deformity has been
keerrss k eerrs
hypothesized to be beneficial in decreasing pain and the risk of osteoarthritis
s
after nonunion repair.17 The ideal bone graft would offer structural support while
b ooook o ook
providing osteogenic and osteoinductive cells. Options for NVBG have included
b o
eeb forms of allograft. ee/ e
/ e b
ICBG,18-22 corticocancellous bone from the distal radius,23,24 and other various
: / / t
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/ .
t m
. m
Iliac crest bone graft was a popular choice for NVBG because of its structural
t ppss : / t ppss :
properties and osteoinductive, osteoconductive, and osteogenic potential./
t
hhtt t
hhtt
In an early technique, Russe addressed the shortening and volar collapse of
the scaphoid through a volar approach and used a cancellous iliac crest peg
from the iliac crest that was packed tightly with corticocancellous chips in
an effort to provide structural support while correcting the deformity.21 This
k e rrss
e rrss
technique was later modified by using cortical and cancellous graft through a
e e
dorsal approach to provide further structural stability.20 Matsuki et al. achieved
k
o o
o o k o o o k
union in all 11 patients with a proximal pole nonunion treated with ICBG
o
eebb ee/ e
/ b
e b
and compression screws.25 Leung et al. described a technique using trephine
bone biopsy forceps to obtain ICBG in 11 patients with waist nonunions.26 The
: / / t
/ .
t m
. m : / / t
/.t
graft was stabilized with a headed screw and all patients obtained union by 25m. m
t p ss:
p / t p ss:
p /
weeks. Stark et al.22 used ICBG with K-wire fixation to achieve union in 97% of
t
hht t t
hht t
151 scaphoid nonunions and Finsen et al.19 used the same technique to achieve
a 90% union rate in 39 nonunions. Most authors have described the use of
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71
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: / /
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t t p
t ss:
p t t p
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p
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k e r
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r s
o o
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o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A B
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erss C
b ooook ooook
Figure 1: A, Preoperative anteroposterior radiograph showing a scaphoid nonunion. B, Radiograph
b
eeb / e e b
after compression screw fixation and cancellous chip bone grafting through a dorsal approach. C, Healed
ee /
nonunion 3 months postoperatively.
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
ICBG as an internal strut or have described using corticocancellous chips from
the iliac crest. In contrast, Bindra et al.18 and Eggli et al.27 described the use
of volar wedge grafting using ICBG with good results. Eggli et al.27 reviewed
37 patients with scaphoid nonunion treated with NVBG using a volar approach
keerrss k eerrs
and wedge graft from the iliac crest stabilized using compression screws and/or
s
K-wires, achieving union in 35 patients (95%). Unfortunately, not all series have
b ooook o ook
reported excellent union rates with NVBG. Ramamurthy et al. achieved union
b o
eeb ee/
using ICBG and compression screws.
e
/ e b
in only 71% of 126 cases28 and Robbins et al.29 reported a union rate of only 53%
: / / t .
t m
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t m
. m
While ICBG provides good structural stability and osteoprogenitor cells, it
/ /
results in significant patient morbidity, notably donor site pain. Multiple studies
t
hhtt t
hhtt
have found no difference between distal radius autograft (Figure 1) and ICBG.
Cohen and colleagues treated 12 patients using a volar approach, placement
of a distal-proximal compression screw, followed by cancellous autograft.23 All
patients in this series achieved successful union, but it should be noted that 9
k e rrss
e rrss
out of 12 patients were younger than 17 years at the time of surgery. Tambe and
e e
colleagues retrospectively reviewed 68 scaphoid nonunions, 44 treated with ICBG,
k
o o
o o k o o o k
and 24 treated with corticocancellous graft from the distal radius.24 Union rates
o
eebb ee/ e
/ b
e
of 24 (67%) using distal radius graft.
b
were similar between the two groups, 29 out of 44 (66%) using ICBG and 16 out
: / / t
/ .
t m
. m : / / t
/.tm. m
Proximal pole AVN has been associated with low union rates when using
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p / t p ss:
p /
NVBG. Ramamurthy et al.28 reported a union rate of 31% and Robbins et al.29
t
hht t t
hht t
reported a union rate of 9 out of 17 (53%) for proximal pole fractures with AVN.
However, Stark et al.22 treated 32 proximal pole nonunions with ICBG and
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: / /
/ t
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/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
K-wires and achieved union in 31 out of 32, but it is not clear how many of these
proximal pole fractures had AVN. Finsen19 achieved union in all 14 proximal pole
eebb / e
/ebb
nonunions and Matsuki found a 100% union rate with proximal pole nonunions
ee
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/ t m
. m
proximal pole AVN using anterior wedge grafting.27
: / / t
/ t m
in a pediatric population.25 Eggli achieved union in 12 out of 13 patients with
. . . m
t p ss
p : / t p ss : /
The type of fixation used has been shown to affect union rates. Russe did not
p
t
hht t t
hht t
use any internal fixation, relying on the properties of the structural graft to achieve
stability.21 Christodoulou et al.30 reviewed 93 patients treated with NVBG and
achieved an overall union rate of 76%. The authors noted that the union rate in
patients treated with compression screws was 85%, compared to 55% in those
k eers
rs compression screws.25
k er
erss
treated with K-wires. Matsuki et al. reported a union rate of 100% using headless
b ooook ooook
Union rate has been the primary outcome measurement in nearly all studies
b
eeb ee/ e
/ e b
related to scaphoid nonunion. Union has been theoretically linked to prevention
// t/ tm
. m / /t/ tm
of degenerative changes at long-term follow-up. Eggli et al.27 found that 18 out
. .
of 37 patients had developed mild degenerative changes and 12 out of 37 had
: : . m
developed osteophytes and moderate degenerative changes in the radioscaphoid
hhttt hhttt
joint at an average of 5.7-year follow-up, despite successful nonunion repair.
Reigstad et al.31 also reviewed patients at long-term follow-up after treatment of
scaphoid nonunion treated with NVBG. The authors achieved union in 45 out of
50 (90%) patients but noted that half of the patients demonstrated degenerative
keerrss k eerrs
arthritis on radiographs at average follow-up of 12 years.
s
b ooook VASCULARIZED BONE GRAFT b o ook
o
eeb ee/ e
/ e b
/ / t
/ t m
. m / / t
/ t m
Vascularized bone graft with internal fixation has been proposed as a treatment
. . . m
option for scaphoid nonunion. The vascularized graft is obtained from various
: :
sites including the distal radius, iliac crest, and medial femoral condyle.
t
hhtt t
hhtt
Vascularized bone graft has been postulated to provide osteogenic, osteoinductive,
and osteoconductive stimuli to encourage healing.32 Hori et al. found that VBG
resulted in neovascularization and osteogenesis in an animal model. 33 Tu et al.14
used a canine model to demonstrate that reverse-flow pedicled VBG retain blood
k e rrss
e k rrss
flow at least 2 weeks after implantation while NVBG demonstrated minimal flow.
e e
The VBG group had a higher flow rate than the contralateral control distal radius,
o o
o o k o o o k
showing that there is increased blood flow after fracture. The authors placed the
o
eebb / e b b
grafts in a methyl methacrylate bed to show that the differences were due to
ee / e
hyperemia rather than surrounding neoangiogenesis.
: / / t
/ .
t m
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/.tm. m
Several authors have reported on retrospective case series using the 1,2 intra
t p ss:
p / t p ss:
p /
compartmental supraretinacular artery (1,2 ICSRA) pedicled VBG (Figure 2)
t
hht t t
hht t
from the distal radius, credited to Zaimdemberg.34 The majority of authors have
reported high union rates using this technique, ranging from 71 to 100%.34‑37
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p t t p
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p
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e s
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r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
A B
Figure 2: A, Preoperative radiograph demonstrating a proximal pole scaphoid

nonunion. B, Postoperative radiograph demonstrating 1,2 intracompartmental
supraretinacular artery harvest site and K-wire holding the graft in place.
keerrss k eerrss
b ooook o ook
Zaidemberg et al. treated 11 nonunions with the 1,2 ICSRA VBG and
b o
eeb ee/ e
/ e b
achieved union in all patients. Steinmann et al.36 reviewed 14 patients treated
with 1,2 ICSRA VBG and reported a 100% union rate. Waitayawinyu et al.37
: / / t .
t m
. m : / / t .
t m
. m
retrospectively reviewed 30 patients who underwent VBG using the 1,2 ICSRA
/ /
graft for treatment of scaphoid nonunions with proximal pole AVN. Union was
t
hhtt t
hhtt
achieved in 28 out of 30 (93%) of cases and the remaining two cases healed after
a secondary procedure using NVBG. In contrast, Straw et al.38 reported a union
rate of 27% in 22 nonunions treated with the 1,2 ICRSA graft. Notably, 16 out
of 22 patients in this series had proximal pole AVN. Boyer also reported poor
k e rrss
e rrss
results using the 1,2 ICSRA VBG, with union rate of 60% in 10 patients with
e e
proximal pole AVN.39 Chang et al.35 reviewed 50 scaphoid nonunions from the
k
o o
o o k o o o k
Mayo Clinic and reported union in 34 out of 48 (71%) using the 1,2 ICRSA
o
eebb ee/ e
/ b
e b
graft. However, as previous studies have demonstrated, the type of fixation appears
to affect union rates. Nonunions treated with screw fixation united in 23 out of
: / / t
/ .
t m
. m : / / t
/.tm. m
26 (88%) cases compared to 8 out of 15 (53%) in those stabilized with K-wires.
t p ss:
p / t p ss:
p /
Only 12 out of 24(50%) nonunions with AVN achieved union after repair. The
t
hht t t
hht t
authors concluded that “a successful outcome is not universal and depends on
careful patient and fracture selection and appropriate surgical techniques”.
k e r
e s
rs
74
k eerrss
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
Other dorsal VBG grafts have been described, including the 2,3 ICSRA and
a capsular-based flap. Chen et al.40 reviewed 11 cases of proximal pole nonunion
eebb / e
/ebb
with AVN treated with the 2,3 ICSRA VBG and achieved union in 11/13 (85%).
ee
: / / t
/ t m
Sotereanos et al.41 described the use of a capsular-based VBG for treatment of
. . m : / / t
/ .
t m
.
scaphoid nonunions. The authors reviewed 13 patients treated with this techniquem
t p ss
p : / t p ss : /
and found 10 out of 13 (77%) went on to union and 8 out of 10 (80%) of cases
p
t
hht t
with AVN of the proximal pole went on to union. t
hht t
Vascularized grafts from the volar aspect of the radius have also been described
(Figure 3). Mathoulin and Haerle42 prospectively evaluated the use of VBG from
the volar ulnar distal radius, based off the palmar carpal artery, in 17 patients
k eers
rs k er
erss
with scaphoid waist nonunions. The authors reported a 100% union rate in an
average of 8.5 weeks and grip strength returned to 100% of the contralateral side
b ooook ooook
in 13 out of 17 patients. Dailiana et al.41 used VBG from the volar ulnar distal
b
eeb ee/ e
/ e b
radius, based on a pedicle at the distal edge of the pronator quadratus, in 9 patients
// t/ tm
. m / /t/ tm
with scaphoid waist nonunion and reported a 100% union rate. Motion and grip
. . . m
strength at final follow-up was in the 80th percentile for all outcomes measured.
: :
The Mayo wrist score improved to an average of 92 and no patients reported pain
hhttt hhttt
at final follow-up. The authors noted that an anterior approach preserves the blood
supply to the scaphoid and also allows for correction of the humpback deformity.
A magnetic resonance imaging obtained 3 months postoperatively in 6 out of
9 patients, showed vascularity of the graft. Noaman et al.43 treated 45 patients
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
A B
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
Figure 3: A, Planned incision site for
: / / t
/ .
t m
. m t. m.
volar approach to scaphoid nonunion.
: / / / t m
t p ss:
p / t p ss:
p /
B, Nonunion site exposed and cancellous
autograft harvested from volar distal radius.
C
t
hht t t
hht t
C, Immediate postoperative radiographs
showing compressions screw in position.
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
with scaphoid nonunion (25 with AVN of the proximal pole) using VBG from the
volar distal radius and reported union in 43 out of 45 (96%).
eebb / e
/ebb
Free VBG from either the iliac crest or the medial femoral condyle/trochlea
ee
: / / t
/ t m
. m : / / t
/ t m
has emerged as a treatment option for proximal pole nonunion with AVN.
. . . m
Burger and colleagues44 performed a chart review of 16 consecutive patients
t p ss
p : / t p ss : /
treated with VBG from the medial femoral trochlea. In this technique, excision
p
t
hht t t
hht t
of the proximal pole was performed and it was replaced with a free VBG from
the medial femoral trochlea. Union was confirmed with computed tomography
(CT) between 12 and 16 weeks and was achieved in 15 out of 16 patients. Doi
et al.45 treated 10 patients with free VBG harvested from the supracondylar
k eers
rs k er
erss
femur, using the articular branch of the descending geniculate artery as the
pedicle. All 10 patients achieved union, despite the presence of AVN in all cases
b ooook ooook
and 8/10 patients having already undergone an unsuccessful procedure. Despite
b
eeb ee/ e
/ e b
100% union, the Mayo wrist score was excellent in 4, good in 4, and fair in 2.
// t/ tm
. m / /t/ tm
Gabl et al.46 harvested a free VBG from the iliac crest, based off a pedicle from
. . . m
branches of the deep circumflex iliac vessels, in 15 patients with an avascular
: :
proximal pole nonunion and reported union in 12 out of 15 (80%). Degenerative
hhttt hhttt
changes in the radioscaphoid joint were noted in 5 out of 12 patients despite
fracture union. Graft displacement occurred in 2 patients in this series. Shin
and colleagues47 reviewed 12 patients with scaphoid nonunion and AVN who
underwent free VBG from the medial femoral condyle. The authors reported a
keerrss k eerrs
100% union rate, but 5 out of 12 patients underwent repeat operation (1 radial
s
styloidectomy, 4 K-wire removals, and 1 donor site stitch abscess) and 2 patients
b ooook o ook
required electrical stimulation due to delayed healing.
b o
eeb ee/ e
/ e b
Some series have found decreased wrist range of motion after 1,2 ICSRA
grafting of scaphoid nonunions, with some suggesting that the pedicle of the graft
: / / t .
t m
. m : / / t .
t m
. m
may impinge into the radioscaphoid joint.34,48 Hankins and Budoff49 performed
/ /
a cadaver study using the 1,2 ICSRA graft and found no correlation between
t
hhtt t
hhtt
graft placement and wrist range of motion. The authors hypothesized that the
loss of motion must be due to other factors, such as tendon adhesion and joint
contractures that would not occur in a cadaveric model. The question of whether
or not the 1,2 ICSRA harvest or placement reduces postoperative motion is
k e rrss
e rrss
not definitively answered. All this study can say is that graft impingement
e e
does not appear to occur. Malizos et al.48 found no difference between the pre-
k
o o
o o k o o o k
and postoperative ranges of motion using the 1,2 ICSRA VBG. Noaman and
o
eebb ee/ e
/ b
e b
colleagues43 felt that using their pronator quadratus graft preserved flexion-
extension axis better than dorsal grafts.
: / / t
/ .
t m
. m : / / t
/.tm. m
One disadvantage of VBG is the possibility of graft extrusion due to lack
t p ss:
p / t p ss:
p /
of fixation. Chang35 reported graft extrusion in 4/48 (8%) when using the 1,2
t
hht t t
hht t
ICSRA graft. Sotereanos41 reported using suture anchors to hold the VBG in
place.
k e r
e s
rs
76
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o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k COMPARATIVE STUDIES
o o
o o k
eebb ee/ e
/ebb
Braga-Silva et al.32 performed a prospective, randomized trial comparing using
the 1,2 ICRSA vascularized graft to nonvascularized iliac crest autograft. The
: / / t .
t m
. m : / / t .
t m
. m
authors randomized 80 patients, 35 to the vascularized group and 45 to the
/ /
ss : / ss : /
nonvascularized group. Of note, the VBGs were fixed with K-wires and the
t p p t p p
hhtt t t
hht t
nonvascularized grafts were fixed with headless compression screws. This could be
an important confounding variable as previous studies found a higher nonunion
rate in nonunions treated with K-wires.15,16 There were no statistical differences
in wrist range of motion, grip strength, or radiographic union at mean follow-
k eers
rs k er
ers
up of 2.8 years. Union rate was 32 out of 35 (91%) in the vascularized group
s
and all 45(100%) in the nonvascularized group, p >0.05. The authors attributed
b ooook o ook
the failures of union in the vascularized group as technical failures where the 1,2
b o
eeb ee e
/ e b
ICRSA flap underwent necrosis. Grip strength was approximately 60% of the
/
contralateral side regardless of the technique used.
: // t/.tm
. m : / /t
Munk and Larsen16 performed a systematic review of 147 articles that
/.tm. m
included 5,246 cases of scaphoid nonunion. The authors found a union rate of
hhttt hhttt
80% using NVBG without internal fixation and 84% using NVBG with internal
fixation compared to 91% using VBG with or without internal fixation. Notably,
at the time of the systematic review, there were no prospective randomized trials
comparing vascularized and nonvascularized grafting. There was also a large
keerrss using CT or plain radiographs.

k eerrs
variation in the definition of successful union with respect to radiographic criteria
s
b ooook o ook
Merrell et al.15 performed a “meta-review” of the literature concerning
b o
eeb ee e
/ e b
operative treatment of scaphoid nonunion. The authors noted that time to
/
treatment correlated with union rates. Nonunions treated within 12 months had
: / / t
/ .
t m
. m : / / t
a union rate of 90% compared to 79% in nonunions treated after 60 months. In
/ .
t m
. m
patients with AVN confirmed preoperatively, patients treated with VBG had a
t
hhtt t
hhtt
union rate of 88% compared to 47% in patients treated with NVBG. As expected,
waist nonunions had a union rate of 85% compared to 67% in proximal pole.
Patients younger than 20 years of age had union rate of 95%, but this dropped
to 80% between ages 30 and 39 years. Screw fixation had union rate of 94%
k e rrss
e rrss
compared to 77% with K-wires and wedge grafting. There were no comparative
e
studies between the two fixation methods. Garg et al.50 compared two methods
k e
o o
o o k o o
o o k
of NVBG, distal radius autograft and ICBG, in a prospective randomized trial.
eebb ee/ e
/ b
e b
Distal radius autograft was used in 50 patients and ICBG was used in 50 patients.
There was no difference in union rate, wrist range of motion, functional scores, or
: / / t
/ .
t m
. m : / / t.
pain scores at minimum 3-year follow-up. The authors concluded that there was
/ tm. m
t p ss:
p / t p ss:
p /
no advantage to ICBG over distal radius graft. Union was achieved in 87% of
t
hht t t
hht t
cases in each group, first suggested in a biomechanical study by Jarrett et al.51 that
found comparable biomechanical strength between ICBG and distal radius graft.
k e r
e s
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77
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k FUTURE DIRECTIONS
o o
o o k
eebb ee /ebb
To date, there is only one prospective randomized trial comparing VBG to
/ e
NVBG for the treatment of scaphoid nonunion.32 Therefore, further prospective
: t . m
. m t . m
. m
randomized trials comparing VBG to NVBG will be necessary to determine if
/ / / t : / / / t
t p ss
p : / ss : /
VBG is necessary to achieve high union rates. Specifically, studying proximal pole
t p p
t
hht t t t
scaphoid nonunion with and without AVN would be the most valuable subgroup
hht
of patients. Studies examining risk factors for AVN would be beneficial, as nearly
all proximal pole scaphoid fracture have some degree of lost blood supply, yet only
some develop AVN. Free VBG from the medial femoral condyle is more similar to
proximal scaphoid replacement rather than a bone grafting procedure.
k eers
rs k er
erss
Grewal et al.52 showed that remodeling of the scaphoid occurs for over
b ooook b ooook
3 years after injury or fixation. Therefore, determining union rate radiographically,
eeb e / e b
especially at early follow-up of 3–6 months, may be inaccurate. Future studies to
/ e
determine the best way to document union would be valuable. Long-term follow-
e
t . m
. m t . m. m
up studies will be necessary to determine if this procedure prevents degenerative
: // / t : / / / t
changes after successful nonunion repair. Buijze and colleagues2 point out that
hhttt hhttt
most studies focus on union rate, but provide little data to determine if scaphoid
nonunion surgery reduces symptoms and prevents arthrosis.
CONCLUSION
keerrss k eerrss
It is important to compare apples to apples. Patients with documented AVN on
b ooook b o ook
preoperative imaging or based on intraoperative findings clearly have a different
o
eeb ee / e b
prognosis compared to patients with waist fractures and no evidence of AVN.
/ e
Based on the preceding review of the literature, there appears to be no significant
t . m
. m t . m
. m
benefit of VBG for the treatment of scaphoid waist nonunion without evidence
: / / / t : / / / t
of AVN. In fact, there are several studies that suggest that these fractures will
t
hhtt t
hhtt
heal with screw fixation alone in select patient groups. Mahmoud and Koptan
questioned if scaphoid nonunions with extensive resorption need bone graft at
all, showing union in all patients treated using percutaneous compression screw
fixation from a volar approach without the use of bone graft, despite a nonunion
gap of greater than 5 mm in more than half of their patients.53 Extensive dissection
k e rrss
e e rrss
for exposure of the nonunion site may further disrupt the already tenuous blood
k e
o o
o o k o o
o o k
supply to the scaphoid, meaning limited exposure with screw fixation might be
eebb ee/ e
/ b
e b
preferred in some cases. Even proximal pole fractures, without AVN, have a high
union rate with screw fixation with or without NVBG.54 Nonunions with AVN
: / / t
/ . m
. m : / / t. m. m
represent a special challenge. Reports of the use of free VBG from the medial
t / t
t p ss:
p / t p ss:
p /
femoral condyle may represent a viable option in the difficult cases where AVN
t t t t
has resulted in the resorption or disintegration of proximal pole. Simply placing
hht hht
NVBG into a shell of proximal scaphoid would appear to have a low chance of
k e r
e s
rs
78
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o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o o k
successful healing. However, pedicled VBG from the distal radius also has variable
o
eebb bb
results for proximal pole AVN. The long-term outcomes of free VBG for treatment
ee/ e
/e
of scaphoid nonunion with proximal pole AVN remain unknown. It is possible
: / / t
/ .
t m
. m : / / t
/ .
t m
that despite union of the free VBG to the intact scaphoid, radioscaphoid arthritis
. m
still develops.
t p ss
p : / t p ss : /
It is important to recognize that each type of bone graft carries its own set of
p
t
hht t t
hht t
disadvantages. Vascularized bone graft might cause stiffness, can become dislodged,
and since K-wires are commonly used to stabilize these grafts, this may contribute
to a lower union rate compared to compression screws. Free tissue transfer from
the medial femoral condyle is technically challenging, may require two teams and
k eers
rs k er
erss
specialized skills, and also causes donor site morbidity to a previously healthy knee.
Nonvascularized bone graft, while simple and cost-effective, may not adequately
b ooook ooook
address proximal pole AVN. The majority of scaphoid nonunions can be treated
b
eeb ee/ e
/ e b
successfully with compression screw fixation without bone graft. Nonunions with
// t/ tm
. m / /t/ tm
extensive bone resorption or cysts may benefit from NVBG. Proximal pole AVN
. . . m
represents a special case that may benefit from VBG, although the difference in
: :
union rates between VBG and NVBG is debatable and conflicting. The ideal
hhttt hhttt
VBG for proximal pole AVN remains unclear, but free VBG from the medial
femoral condyle should likely be reserved for severe cases where only a shell of
bone remains at the proximal pole.
keerrss
Editor’s Comment
k eerrss
b ooook b o ook
o
Scaphoid nonunions pose a significant challenge. Successful treatment is predicated
eeb e / e
/ e b
upon early diagnosis and thoughtful surgical intervention. A number of variables
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
must be considered including the site and duration of the nonunion, as well as
t ppss / t ppss : /
vascularity of the proximal fragment. To manage avascular nonunions, vascularized
:
grafts have been introduced to improve the potential for healing. In this article, the
t
hhtt t
hhtt
authors present a review of scaphoid nonunion evaluation as well as a review of
both VBG and NVBG options.
Asif M Ilyas
k e e ss
rREFERENCES
r k e rrss
e
o o
o o k o o
o o k
eebb ee/ e b
e b
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/
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/ .
t m
. m : / / t
/.tm. m
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p / t p ss:
p /
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p
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15. Merrell GA, Wolfe SW, Slade JF. Treatment of scaphoid nonunions: quantitative meta-analysis of the
ee /
literature. J Hand Surg Am. 2002;27:685-91.
t . m
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16. Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including
: // / t : / / / t
t pp : / tp s : /
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21. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment.
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22. Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone
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: / / t
/ . m
. m : / / t . m
. m
23. Cohen MS, Jupiter JB, Fallahi K, Shukla SK. Scaphoid waist nonunion with humpback deformity treated
t / t
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s
24. Tambe AD, Cutler L, Murali SR, Trail IA, Stanley JK. In scaphoid non-union, does the source of graft affect
t
hhtt t
hhtt
outcome? Iliac crest versus distal end of radius bone graft. J Hand Surg Br. 2006;31:47-51.
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26. Leung YF, Ip SP, Cheuk C, Sheung KT, Wai YL. Trephine bone grafting technique for the treatment of scaphoid
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27. Eggli S, Fernandez DL, Beck T. Unstable scaphoid fracture nonunion: a medium-term study of anterior
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wedge grafting procedures. J Hand Surg Br. 2002;27:36-41.
o o
o o k o o
o o k
28. Ramamurthy C, Cutler L, Nuttall D, Simison AJ, Trail IA, Stanley JK. The factors affecting outcome after
eebb b
non-vascular bone grafting and internal fixation for nonunion of the scaphoid. J Bone Joint Surg Br.
2007;89:627-32.
ee/ e
/ e b
: / / t
/ t m
. m : / / t
/ tm
29. Robbins RR, Ridge O, Carter PR. Iliac crest bone grafting and Herbert screw fixation of nonunions of the
. . . m
scaphoid with avascular proximal poles. J Hand Surg Am. 1995;20:818-31.
t p ss:
p / t p ss:
p /
30. Christodoulou LS, Kitsis CK, Chamberlain ST. Internal fixation of scaphoid non-union: a comparative study of
t
three methods. Injury. 2001;32:625-30.
hht t t
hht t
31. Reigstad O, Grimsgaard C, Thorkildsen R, Reigstad A, Rokkum M. Long-term results of scaphoid nonunion
surgery: 50 patients reviewed after 8 to 18 years. J Orthop Trauma. 2012;26:241-5.
k e r
e s
rs
80
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
32. Braga-Silva J, Peruchi FM, Moschen GM, Gehlen D, Padoin AV. A comparison of the use of distal radius
vascularised bone graft and non-vascularised iliac crest bone graft in the treatment of non-union of scaphoid
eebb / eebb
fractures. J Hand Surg Eur Vol. 2008;33:636-40.
ee /
33. Hori Y, Tamai S, Okuda H, Sakamoto H, Takita T, Masuhara K. Blood vessel transplantation to bone. J Hand
Surg Am. 1979;4:23-33.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p
Am. 1991;16:474-8.ss
p : / t p ss
p : /
34. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg
t
hht t t
hht t
35. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental
supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am.
2006;31:387-96.
36. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a
vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am. 2002;27:391-401.
k eers
rs k er
ers
37. Waitayawinyu T, McCallister WV, Katolik LI, Schlenker JD, Trumble TE. Outcome after vascularized bone
s
grafting of scaphoid nonunions with avascular necrosis. J Hand Surg Am. 2009;34:387-94.
b ooook b oook
38. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based
o
on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg Br. 2002;27:413.
eeb / e
/ e b
39. Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with avascular necrosis of the proximal pole.
ee
: // t tm
. m : / /t tm
Treatment with a vascularized bone graft from the dorsum of the distal radius. J Hand Surg Br. 1998;23:686-90.
. . . m
40. Chen AC, Chao EK, Tu YK, Ueng SW. Scaphoid nonunion treated with vascular bone grafts pedicled on the
/ /
dorsal supra-retinacular artery of the distal radius. J Trauma. 2006;61:1192-7.
hhttt hhttt
41. Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN. A capsular-based vascularized distal radius
graft for proximal pole scaphoid pseudarthrosis. J Hand Surg Am. 2006;31:580-7.
42. Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid
nonunion. J Hand Surg Br. 1998;23:318-23.
43. Noaman HH, Shiha AE, Ibrahim AK. Functional outcomes of nonunion scaphoid fracture treated by pronator
quadratus pedicled bone graft. Ann Plast Surg. 2011;66:47-52.
keerrss k eerrss
44. Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap
ook ook
reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am. 2013;38:690-700.
b
eeboo Am. 2000;25:507-19.
/ e b o
45. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg
b o
e / e
46. Gabl M, Reinhart C, Lutz M, Bodner G, Rudisch A, Hussl H, et al. Vascularized bone graft from the iliac crest
m e m
: / /
/
Surg Am. 1999;81:1414-28. t
/ .
t . m : / /
/ t
/ .
t . m
for the treatment of nonunion of the proximal part of the scaphoid with an avascular fragment. J Bone Joint
47. Jones DB, Moran SL, Bishop AT, Shin AY. Free-vascularized medial femoral condyle bone transfer in the
p
hhtt hhtt
treatment of scaphoid nonunions. Plast Reconstr Surg. 2010;125:1176-84.
48. Malizos KN, Dailiana ZH, Kirou M, Vragalas V, Xenakis TA, Soucacos PN. Longstanding nonunions of
scaphoid fractures with bone loss: successful reconstruction with vascularized bone grafts. J Hand Surg Br.
2001;26:330-4.
49. Hankins CL, Budoff JE. Analysis of wrist motion following vascularized bone graft to the proximal scaphoid.
rrss rrss
J Hand Surg Am. 2011;36:583-6.
o k e
k e o k e
50. Goyal T, Sankineani SR, Tripathy SK. Local distal radius bone graft versus iliac crest bone graft for scaphoid
k e
nonunion: a comparative study. Musculoskelet Surg. 2013;97:109-14.
o
eebb o o b o o o
51. Jarrett P, Kinzel V, Stoffel K. A biomechanical comparison of scaphoid fixation with bone grafting using iliac
e b
ee/ e
bone or distal radius bone. J Hand Surg Am. 2007;32:1367-73.
/
52. Grewal R, Boyd KU, Macdermid J, McMurtry RY. A qualitative evaluation of scaphoid remodeling in bone-
m m
/ t . . m
grafted scaphoid nonunions. Hand (N Y). 2010;5:430-3.
: / / / t : / /
/ t
/.t . m
t t p
t ss:
p t t p
t ss:
53. Mahmoud M, Koptan W. Percutaneous screw fixation without bone grafting for established scaphoid
p
nonunion with substantial bone loss. J Bone Joint Surg Br. 2011;93:932-6.
hht hht
54. Capo JT, Orillaza NS, Slade JF. Percutaneous management of scaphoid nonunions. Tech Hand Up Extrem
Surg. 2009;13:23-9.
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theeManagement of Chronic
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ss :
Nondegenerative
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1
Mark L Wang MD PhD, 2,*Michael M Vosbikian MD
1
Department of Orthopedic Surgery, Rothman Institute at the Thomas Jefferson University
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Department of Orthopedic Surgery, Harvard Medical School – Beth Israel Deaconess Medical Center
Boston, Massachusetts, USA
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t ppss : / ABSTRACT
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Scapholunate dissociation is the most common form of carpal instability,
and without appropriate management, this condition can lead to the
development of chronic wrist pain and dysfunction. Moreover, chronic
scapholunate instability, in the absence of arthritis, frequently results from
keerrss k eerrss
a delay in diagnosis and represents a particularly complex entity. Without
b ooook b ook
appropriate timely management, this vexing clinical scenario may lead to
o o
enduring pain and disability. The challenges presented to the treating hand
eeb / e
/ e b
surgeon is multifactorial—providing adequate pain relief, reestablishing
ee
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/ t m
. m / / t
/ t m
functional carpal mechanics, and avoiding the early onset of wrist arthritis.
. . . m
Important prognostic factors include the integrity of secondary scaphoid
: :
stabilizers and the ability to easily achieve and maintain normal carpal
t
hhtt t
hhtt
alignment. These important parameters should be carefully considered
and may aid in the selection of an appropriate procedure, potentially
minimizing early clinical failure. Despite proposed treatment algorithms to
facilitate the selection of the most appropriate procedure, great variability
in the treatment of nondegenerative chronic scapholunate (SL) instability
k e rrss
e k e rrss
exists amongst hand surgeons, and the optimal treatment strategy for this
e
o o
o o k o o
o o k
spectrum of injury remains controversial. Future long-term studies on
these various management protocols may provide further insight into this
eebb ee/ e b
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challenging problem and potentially diminish existing arguments. This
/
article reviews the various treatment strategies for chronic nondegenerative
: / / t
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SL instability, highlighting the controversies associated with the most
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popular surgical procedures.
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Email: michael.vosbikian@gmail.com.
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: / /
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Controversies in the Management of Chronic Nondegenerative Scapholunate Instability
k e r
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o o
o o k INTRODUCTION
o o
o o k
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/ebb
Scapholunate dissociation (SLD) is the most common form of carpal instability,
and without appropriate management, this condition can lead to the development
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
of chronic wrist pain and dysfunction. The hand surgeon is tasked with multiple
ss : / ss : /
challenges, including providing adequate pain relief, reestablishing functional
t p p t p p
t
hht t t
hht t
carpal mechanics, and avoiding the early onset of wrist arthritis.1-3 Chronic
scapholunate (SL) instability, with the absence of arthritis, frequently results
from a delay in diagnosis and represents a particularly challenging scenario.
The management of this condition is wide ranging and remains controversial.2,4
k eers
rs k er
ers
Previously, Garcia-Elias has proposed a six-stage classification system (Table 1)
based on five prognostic factors, which are as follows:s
b ooook 1. The status of the SL ligament
b ooook
eeb 2.
/ e
/ e b
The healing potential of the disrupted ligaments
ee
3.
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The integrity of the secondary scaphoid stabilizers
. . m : / /t/.tm. m
4.
5.
p ss : /
The reducibility of the carpal malalignment
The presence of cartilaginous injury.2
t p tppss : /
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In this classification system, stages 3, 4, and 5 describe a spectrum of
nondegenerative chronic SL instability (Figure 1). Prior to selecting the optimal
treatment strategy, the surgeon is often confronted with unique challenges; the
ruptured SL ligament is frequently irreparable due to retraction or degeneration,
keerrss k eerrss
while chronic fibrosis at the SL interval may prevent easy reducibility of the
b ooook b o ook
carpal malalignment.2 Despite proposed treatment algorithms to facilitate the
o
eeb e / e b
selection of the most appropriate procedure, great variability in the treatment of
/ e
nondegenerative chronic SL instability exists amongst hand surgeons. In 2004,
e
: / / t
/ .
t m m
Zarkadas et al. surveyed 468 North American hand surgeons and reported a
. : / / t
/ .
t m
. m
wide variation of surgical procedures for chronic SL instability, ranging from
t
hhtt t
hhtt
capsulodesis, soft tissue reconstruction (single and combined), and partial
Table 1: Garcia-Elias Classification of Scapholunate Dissociations

Scapholunate dissociation stage 1 2 3 4 5 6
k e rrss
e
Is there a partial rupture with a normal dorsal SL
ligament?
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e
Yes No No No No No
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o o k o o o k
If ruptured, can the dorsal SL ligament be repaired?
o
Yes Yes No No No No
eebb Is the scaphoid normally aligned

(radioscaphoid angle ≤45°)?
ee/ e
/ b
e b Yes Yes Yes No No No
: / / t
/ .
t m
. m
Is the carpal malalignment easily reducible? Yes
:
Yes
/ / t
/.tm.
Yes
m Yes No No
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Are the cartilages at both RC and MC joints normal?
t
Yes
p ss:
p
Yes
/ Yes Yes Yes No
t
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SL, scapholunate; RC, radiocarpal; MC, midcarpal.
t
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From: Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate
dissociation: indications and surgical technique. J Hand Surg Am. 2006;31:125-34, with permission.
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
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rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
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b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
hhttt A
hhttt B
Figure 1: Chronic scapholunate dissociation in the

absence of arthritic changes. From: Zarkadas PC, Gropper
PT, White NJ, Perey BH. A survey of the surgical management
of acute and chronic scapholunate instability. J Hand Surg Am.
keerrss k eerrss
2004;29:848-57, with permission.
b ooook b o ook
o
eeb ee e
/ e b
intercarpal arthrodesis.5 This article reviews the various treatment strategies for
/
chronic nondegenerative SL instability, highlighting the controversies associated
: / / t
/ .
t m
. m
with the most popular surgical procedures.
: / / t
/ .
t m
. m
Stage 3 SL instability describes a complete and irreparable SL ligament
t
hhtt t
hhtt
rupture, without cartilaginous injury. Intact secondary scaphoid stabilizers,
including the scaphotrapeziotrapezoid (STT) and scaphocapitate (SC) ligaments,
result in a normally aligned scaphoid.6 In the absence of degenerative changes,
there have been several proposed strategies to recreate the stability, imparted by
the native SL ligament, utilizing bone-soft tissue-bone autografts, as well as the
k e rrss
e e rrss
dorsal intercarpal (DIC) ligament for capsulodesis. These techniques have much
k e
o o
o o k o o
o o k
variability and have various results at mid- and long-term follow-up.
eebb ee/ e
/ b
e b
: / / t
/ t m
BONE-SOFT TISSUE-BONE PROCEDURES
. . m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
Encouraged by the earlier success of anterior cruciate ligament reconstruction
hhtt t t
hht t
with bone-patellar tendon-bone grafts, several authors have proposed the use of
bone block autografts, obtained from various donor sites, for SL reconstruction.7-9
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
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rs k eers
r s
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o o k o o
o o k
The theoretical advantages of such techniques include creating a bone-to-bone,
rather than a bone-to-soft tissue healing interface which may potentially lose
eebb / e
/ebb
strength at the bone-soft tissue interface during healing process.10 However, the
ee
: / / t
/ t m
. m : / / t
/ t m
challenge of bone-to-bone reconstruction strategies has been finding the optimal
. . . m
donor site, in an effort to maximize biomechanical strength and durability, while
t p ss : /
minimizing donor site morbidity.
p t p ss
p : /
t
hht t t
hht t
AUTOGRAFTS FROM THE FOOT
The utilization of various autografts harvested from the foot has been previously
k eers
rs k er
erss
described. Svoboda et al. examined the biomechanical properties of several
b ooook b oook
ligaments within the foot, as a potential sources for a bone-tissue-bone autograft;
o
including the dorsal ligament of the fourth and fifth metatarsals, the dorsal third
eeb / e
/ e b
tarsometatarsal ligament, and the calcaneocuboid ligament.11 They reported that
ee
: // t/.tm
. m : / /t/.tm
all of the grafts experienced midsubstance failure, thus demonstrating insufficient
. m
t ppss / tppss : /
strength for SL reconstruction. Similarly, Davis et al. investigated the navicular-
:
first cuneiform ligament.10 However, this ligament was found to have decreased
hhttt hhttt
stiffness, excursion to failure, and peak load to failure when compared to the SL
ligament.
Reconstruction techniques utilizing grafts harvested from the foot remain
controversial. Issues include remote donor site morbidity, increased operative
keerrss k eerrss
time, and unknown long-term effects on the biomechanics of the foot.9,11-14
b ooook outweigh their potential advantages.

b oook
Subsequently, the morbidity associated with the use of remote autografts may
o
eeb ee/ e
/ e b
BONE-PERIOSTEUM-BONE
: / / t
/ .
t m
.
FROMm THE ILIAC CREST
: / / t
/ .
t m
. m
t
hhtt t
hhtt
Previously, Lutz et al. reported that bone-periosteum-bone graft is biomechanically
similar to that of the native SL ligament, demonstrating good or excellent outcomes
in 6 cases, while 5 had fair outcomes with a mean follow-up of 29 months.15,16
Radiologically, 9 had excellent or good results and 2 had poor results. As with the
use of autografts harvested from the foot, the advantages of this technique may be
k e rrss
e e rrss
limited by donor site morbidity and increased operative time.9
k e
o o
o o k o o
o o k
eebb BONE-RETINACULUM-BONE AUTOGRAFTS
ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
In order to minimize remote donor site morbidity, several studies have
t p ss:
p / t p ss:
p /
investigated local sources of autograft. In 1998, Weiss et al. described the use of
hhtt t t
hht t
a bone-retinaculum-bone autograft (Figure 2), harvested from Lister’s tubercle
and placed into bone troughs created on the dorsal surface of the scaphoid
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
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rs k eers
r s
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o o k o o o k
Bone-retinaculum-bone autograft
o
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
b ooook o ook
Figure 2: A, A bone-retinaculum-bone graft is fitted into bone
b o
eeb / e e b
troughs on the dorsal proximal aspect of the scaphoid and lunate.
ee /
B, The graft is transfixed with Kirschner wires. From: Weiss AP.
: // t/. m
. m : / /t . m. m
Scapholunate ligament reconstruction using a bone-retinaculum-bone
t / t
autograft. J Hand Surg Am. 1998;23:205-15, with permission.
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
A
: / / t
/ .
t m
. m B
: / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
Figure 3: Scapholunate recons truction
with bone-retinaculum-bone autograft.
o o
o o k o o
o o k From: Soong M, Merrell GA, Ortmann F, Weiss
eebb ee/ e
/ b
e b AP. Long-term results of bone-retinaculum-bone
autograft for scapholunate instability. J Hand
C
: / / t
/ .
t m
. m : / / t
/.tm
Surg Am. 2013;38:504-8, with permission.
. m
t p ss:
p / t p ss:
p /
and lunate.17 An advantage of this technique includes the ease of accessibility
t
hht t t
hht t
through a single incision in the approach to the SL articulation (Figure 3). The
authors reported encouraging midterm results, with improved grip strength and a
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
slight decrease in postoperative motion. Biomechanical testing of this autograft,
performed by Shin et al., demonstrated that the overall strength of the bone-
eebb / e
/ebb
retinaculum-bone autograft was inferior to that of the SL ligament; however,
ee
: / / t
/ t m
the failure stress and strength per cross-sectional area was not significantly
. . m : / / t
/ .
t m
.
different.18 The authors concluded that the autograft could potentially undergo m
t p ss
p : / t p ss : /
remodeling and hypertrophy after implantation, and the use of this graft was a
p
t
hht t t
hht t
viable option. In a long-term follow-up, most patients experienced diminished
radiographic and clinical outcomes similar to what was observed with the use of
other techniques.19
k eers
r s
CARPOMETACARPAL AND INTRACARPAL
k er
erss
b ooook LIGAMENT AUTOGRAFTS
b ooook
eeb / e
/ e b
Harvey et al. proposed another source of autograft from the second or third
ee
: // t/.tm
. m : / /t/.tm
carpometacarpal (CMC) ligament.9,12 In a biomechanical analysis, the second
. m
t ppss / tp ss : /
and third CMC ligaments were compared to both the native SL ligament, as
:
well as the autograft reconstruction described by Weiss et al.17 Strength testing
p
hhttt hhttt
revealed that the CMC autografts had greater or equal strength than the SL
ligament, and the retinacular graft reconstruction was noted to have possessed
only 26% of that strength. These findings were in contrast to that of Weiss et
al., which suggested the bone-retinaculum-bone graft as the ideal graft, due to
keerrss k eerrss
the ease of accessibility and biomechanical similarity to the native SL ligament.
Additional advantages included a relatively expendable donor graft, given the
b ooook o ook
o
relative inherent stability of the joint, as well as the presence of a cartilaginous
b
eeb ee/ e
/ e b
surface on the bone blocks.13 These findings were in accordance with Cuenod
/ / t
/ t m
et al., reporting that the second CMC ligament was stronger and stiffer than
. . m / / t
/ .
t
the SL ligament.20 This group has also explored the utilization of intracarpal
: : m
. m
t ppss : / t ppss :
ligament for reconstruction and examined the mechanical properties of the/
t
hhtt t
hhtt
trapeziocapitate ligament, demonstrating mechanical properties similar to the
SL ligament.20 Moreover, others have noted that the lunotriquetral and the
capitolunate (CL) ligament exhibit a higher load to failure than the native SL
ligament and may represent another viable option for reconstruction with a
k e rrss
e k rrss
bone-tendon-bone autograft.21-23 However, at present, the enthusiasm of these
e e
procedures have diminished due to concerns over issues, such as loss of bone
o o
o o k o o o k
block fixation, graft creep, and a paucity of long term results.3
o
eebb ee/ e
/ b
e b
VASCULARIZED AUTOGRAFTS
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
With the advent of bone-soft tissue-bone options, graft stretch leading to
t
hht t t
hht t
failure has been well-documented, and previous groups have posited that this
loss of biomechanical integrity may occur during the revascularization phase
k e r
e s
rs k eerrss
87
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
of healing, potentially resulting in a weakened graft state, vulnerable to creep
phenomenon.3,9,10,12,13 In an effort to obviate this phenomenon, Harvey et al.
eebb / e
/ebb
proposed a graft from the third CMC ligament with a vascularized pedicle from
ee
: / / t
/ t m
. m : / / t
/ t m
the radial-sided intermetacarpal artery of the radial artery, and subsequently,
. . . m
docked to the bone troughs, as previously described by Weiss et al.13,17
t p ss
p : / t p ss : /
Critics have argued the limitations to this procedure, including its technically
p
t
hht t t
hht t
challenging nature and lack of established long-term results. However, despite
these criticisms, this strategy may theoretically avoid the late complications
associated with the use of avascular grafts, and proponents of this technique
have suggested that even if the patency of the pedicle cannot be consistently
k eers
rs k er
erss
sustained, the avascular CMC ligament autograft remains a viable option.9,12,13
b ooook DORSAL INTERCARPAL LIGAMENTbPROCEDURES

ooook
eeb ee/ e
/ e b
: // t/ tm
. m / /t/ tm
Dorsal capsulodesis remains a well-established treatment strategy for SL
. . . m
instability, with the goal of addressing the subsequent rotatory subluxation of
:
the scaphoid (RSS). Early work by Blatt and Lavernia et al. reported favorable
hhttt hhttt
results with respect to pain relief.24,25 Recently, long-term studies have reported
that radiographic outcomes deteriorate, range of motion becomes diminished,
and pain relief is unpredictable.26-28 As a result, authors have reported
satisfactory early results, with the reduction of the SL angle and interval,
keerrss k eerrs
both with dynamic and static cases. However, over time, there is a progressive
s
trend towards an increase in these parameters, ultimately leading to a static
b ooook o ook
SL instability pattern.27,29 As a result, in an effort to prevent the progressive
b o
eeb ee/ e
/ e b
loss of alignment and stability, several modifications of the dorsal capsulodesis
technique, utilizing the DIC, have been proposed.30-33 However, while these
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
short- and intermediate-term follow-up have reported promising results, long-
term results remain undetermined, and further investigation of these techniques
t
hhtt
may provide additional insight into their efficacy. t
hhtt
RADIALLY-BASED DORSAL INTERCARPAL LIGAMENT
TECHNIQUES (MAYO CAPSULODESIS)
k e rrss
e e rrss
e
Previously, Berger has described a dorsal capsulodesis (Figure 4), longitudinally
k
o o
o o k o o o k
dividing the DIC and dorsal radiocarpal (DRC) ligaments in line with their
o
eebb ee/ e
/ b
e b
fibers and reflecting the ligamentous flaps from their triquetral convergence, thus
providing adequate exposure to facilitate the reduction of the SL interval.34 The
: / / t
/ .
t m
. m : / / t
/.tm. m
mobilized proximal portion of the DIC is rotated, positioned dorsal to the SL joint,
t p ss:
p / t p ss:
p /
and attached to the dorsal aspect of the distal radius, with reinforcement to local soft
t
hht t t
hht t
tissues.31 In addition, a modification to this technique has been described, where
the flap is attached to the lunate in order to prevent tethering of the radiocarpal
k e r
e s
rs
88
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
erss
DRC, dorsal radiocarpal; DIC, dorsal intercarpal.
b ooook o ook
Figure 4: Dorsal radial capsulotomy with full thickness flaps allowing
b o
eeb exposure to the wrist.
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
(RC) joint.30 Kobayashi et al. have reported positive short-term results utilizing a
hhttt hhttt
modified Mayo capsulodesis, reporting a mean disabilities of the arm, shoulder, and
hand (DASH) score of 16.3, with good grip strength, and preserved reduction of
the SL angle and interval upon radiographic evaluation.35 The authors concluded
that this technique showed potential for the management of both subacute and
keerrss k eerrs
chronic instability.35 A study by Baxamusa et al. concurred with these findings,
s
noting consistent pain relief, despite diminished wrist motion, particularly with
b ooook o ook
wrist flexion. However, studies utilizing similar capsulodesis techniques (Figure 5)
b o
eeb ee e
/ e b
have noted the radiographic deterioration of the reconstruction, comparable to
/
that of bone-soft tissue-bone autografts.28,30 Moran et al. compared the outcomes
: / / t
/ .
t m
. m : / / t
/ .
t m
.
from a modified Mayo capsulodesis with a Blatt capsulodesis. This study included m
reconstructions for both dynamic and static SL instability, reporting decreased
t
hhtt t
hhtt
range of motion and radiographic deterioration, without significantly sacrificing
grip strength. In a later study, these findings were reproduced by the same group,
and while the outcomes were good for pain relief, the universal loss of reduction
did not allow the recommendation of a particular technique.27,36 The association
k e rrss
e rrss
of radiographic deterioration with this technique was further reinforced by a study
e e
by Megerle et al., which also reported the development of arthritis in their series.37
k
o o
o o k o o o k
While DASH scores were increased in this study compared to that of short-
o
eebb ee/ e
/ b
e b
term series, final SL angle and interval did not significantly differ from that of
preoperative measurements.38 The mean carpal height index decreased, trending
: / / t
/ .
t m
. m : / / t
/.tm. m
towards progressive carpal collapse; furthermore, degenerative arthritis was noted
t p ss:
p / t p ss:
p /
in 78% of cases, yet the patients were noted to have adequate satisfaction and
t
hht t t
hht t
symptom relief, suggesting that radiographic and clinical outcomes may not be
directly correlated.38
k e r
e s
rs k eerrss
89
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B C
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
D E
Figure 5: Various capsulodesis strategies. A, Traditional capsulodesis. B, Scapholunate interosseous
keerrss k eerrss
ligament repair and traditional capsulodesis. C, Dorsal ligament-sparing dorsal capsulotomy described
b ooook capsulodesis by Berger et al.

b ook
by Berger et al. D, Dorsal intercarpal ligament capsulodesis by Szabo et al. E, Dorsal intercarpal ligament
o o
eeb ee/ e
/ e b
/
ULNAR-BASED DORSAL
: / t
/ .
t m
. m
INTERCARPAL
: / / t
/ .
t m
. m
t p ss : /
LIGAMENT TECHNIQUES
p t ppss : /
t
hhtt t
hhtt
In 1999, a modification of the Berger capsulodesis was described, which
employed a radially elevated flap, allowing for the exposure of both the SC and
STT joints.31,33 In this technique, following the reduction of the SL interval, the
k e rrss
e rrss
radial flap is secured to the distal pole of the scaphoid, beyond the axis of flexion,
e e
maintaining extension.31,33 Proponents of this technique have suggested that
k
o o
o o k o o o k
the transverse orientation of the flap prevents scaphoid pronation, while linking
o
eebb ee/ e
/ b
e b
the proximal carpal row as a unit, thus sparing the RC joint. Additionally, the
authors have suggested that by traversing the proximal pole of the capitate, a
: / / t
/ .
t m
. m : / / t
/.tm. m
secondary pulley is created, preventing scaphoid flexion.31,33 Slater et al. reported
t p ss:
p / t p ss:
p /
that the DIC capsulodesis outperformed the Blatt capsulodesis in an ex vivo
t
hht t t
hht t
model.33 While these preliminary case reports have reported excellent outcomes,
cadaveric studies have had mixed results.34 In a cyclically loaded cadaver model,
k e r
e s
rs
90
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
Short et al. reported that this technique was insufficient for static instability,
concluding that this technique was ineffective for treating static SLD.39 To
eebb / e
/ebb
date, whether the biomechanical limitations reported in this study are clinically
ee
significant, remains unknown.
: / / t
/ .
t m
. m : / /
A series by Szabo et al. has documented that at mid-term evaluation, t
/ .
t m
. m
t p ss
p : / t p ss : /
both SL angle and interval remain significantly improved compared to that of
p
t
hht t t
hht t
preoperative parameters.38 Favorable clinical results were associated with this
procedure, as patients reported excellent postoperative function and satisfaction
with their overall outcomes. However, there was no improvement in grip strength,
and range of motion was comparable to that reported by Blatt, despite the
k eers
rs k er
erss
fact that this reconstruction spares the RC joint.24 A subsequent study by the
same group reviewed outcomes at an average of 86 months, and as with other
b ooook ooook
techniques, the authors noted radiographic deterioration.30 Nevertheless, despite
b
eeb ee/ e
/ e b
exhibiting degenerative changes on half of the radiographs, patients remained
// t/ tm
. m / /t/ tm
satisfied with their procedure, reporting good wrist function with decreased pain
. . .
symptomatology.37 As with bone-soft tissue-bone autografts, the radiographic
: : m
t ppss : / tp
and clinical results of DIC procedures are not well correlated.
pss : /
hhttt hhttt
With regards to these various reconstruction techniques, the consensus is that
such strategies should be reserved for a prearthritic injury pattern, and in the
presence of degenerative changes, pain relief is not predictable. Additionally, in
the case of irreducible SLD, these techniques are prone to failure. Interestingly, the
keerrss k eerrss
literature shows that while radiographic results will deteriorate over time, these
b ooook ook
findings may not correlate clinically, as most patients continue to be satisfied with
o o
their functionality and pain relief. At present, the optimal technique to best treat
b
eeb / e
/ e b
stage 3 SL instability remains unresolved. Future long-term studies are warranted
ee
: / / t
/ t m
. m : / / t
/ t m
to better elucidate which patients are most appropriate for the various treatment
. . . m
options.
t tt
hhASSOCIATION
REDUCTION OF THE
t
hhtt
SCAPHOLUNATE JOINT PROCEDURE
k e rrss
e rrss
Stage 4 SL instability describes an irreparable SL ligament injury with reducible
e e
RSS. The reduction association of the scapholunate (RASL) joint technique
k
o o
o o k o o o k
(Figure 6), introduced by Rosenwasser et al., aims to create a SL pseudoarthrosis
o
eebb ee/ e
/ b
e b
augmented by a cannulated Herbert screw in an effort to reconstruct the SL
linkage.40 This technique has been reported to improve pain and function, while
: / / t
/ .
t m
. m : / / t
/.tm.
maintaining SL alignment. In 2007, Aviles et al. introduced arthroscopic-assistedm
t p ss:
p / t p ss:
p /
RASL as an alternative to soft tissue reconstruction of the SL interval.41 Potential
t
hht t t
hht t
advantages of this arthroscopic technique included improved debridement and
preparation of the SL pseudoarthrosis site, facilitation of precise anatomical
k e r
e s
rs k eerrss
91
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t ppss : / tp ss : /
Figure 6: The reduction association of the scapho
lunate joint technique. From: Kuo CE, Wolfe SW.
p
hhttt hhttt
Scapholunate instability: current concepts in diagnosis and
management. J Hand Surg Am. 2008;33:998-1013, with
permission.
keerrss k eerrs
reduction of the SL interval, and improved precision in placing the cannulated
s
screw.41 Utilizing arthroscopic-assisted RASL techniques, Caloia et al. reported
b ooook o ook
encouraging preliminary results, specifically the preservation of postoperative grip
b o
eeb ee e
/ e b
strength (78% of the contralateral side), while preserving 80% of preoperative
/
motion.42 However, these findings were limited by a small sample size and relatively
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
short follow-up. Complications of this technique included screw loosening and
pain with high-impact activity, necessitating screw removal.42 Criticisms of this
t
hhtt t
hhtt
technique have included a fixed rotational axis which does not reproduce the
normal SL mechanics, bringing into question the maintenance of reduction over
time.3 At present, the long-term durability of this reconstruction and its impact
on halting the progression of arthritis is unknown, warranting a larger series with
k e rrss
e k eerrss
long-term follow-up to confirm the preliminary findings.42
o o
o o k BRUNELLI AND MODIFIED BRUNELLIo
ooo k
eebb ee/ e
/ b
e bTECHNIQUES
In 1990, Brunelli et al. proposed to reconstruct the scaphoid stabilizers using
: / / t .
t m
. m : / / t.tm. m
a portion of the flexor carpi radialis tendon, specifically the compromised
/ /
t p ss:
p / t p ss:
p /
scaphotrapezial and SL ligaments, in an effort to correct RSS.43 Since its
hhtt t t
hht t
advent, several authors have modified the Brunelli technique to eliminate the
tether across the RC joint, and reestablishing both the intrinsic and extrinsic
k e r
e s
rs
92
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
stabilizers.4,6,44-47 van Den Abbeele et al. have reported encouraging short-term
results on 22 cases of SL instability following reconstruction with a modified
eebb / e
/ebb
Brunelli technique, reporting improved pain relief, and preservation of grip
ee
: / / t
/ t m
strength and motion in the majority of patients.47 These findings have been
. . m : / / t
/ .
t m
. m
supported by a series of 19 cases by Chabas et al., reporting a relatively pain free
t p ss
p : / t p ss : /
wrist with preserved grip strength (78% of contralateral side) and no significant
p
t
hht t t
hht t
diastasis at the SL interval.4 However, at mean follow-up of 3 years, the authors
noted decreased postoperative wrist range of motion and loss of correction
of sagittal alignment with recurrence of lunate dorsiflexion.4 Nienstedt et al.
reported more favorable results, at a mean follow-up of 14 years, documenting
k eers
rs k er
erss
good to excellent functional outcome scores in 7 of 8 patients, as well as average
wrist motion and grip strength of 85% of the contralateral side.45 In an effort
b ooook ooook
to reestablishing the STT, SL, and DRC ligamentous restraints, Garcia-Elias
b
eeb ee/ e
/ e b
utilized a tri-ligament tenodesis modification of the original Brunelli technique
// t/ tm
(Figure 7), and presented satisfactory results.6
. . m / /t/.tm
Stage 5 SL instability describes a chronic and irreparable SL ligament
: : . m
injury with irreducible scaphoid instability due to intra-articular fibrosis or joint
hhttt hhttt
deformity.2 In the absence of degenerative changes, such a condition in a younger
and active patient presents the hand surgeon with manifold complexities and
challenges to reestablish alignment, preserve functional motion, provide overall
pain relief, and slow the progression of the scapholunate advanced collapse wrist.
keerrss k eerrs
Several methods of partial intercarpal arthrodesis have been described with the
s
technical goals of maintaining carpal height and restoring the load-bearing
b ooook o ook
column, while ultimately preserving motion at the RC joint. Previously studied
b o
eeb ee/ e
/ e b
partial fusion strategies have included STT, SC, SL, and radioscapholunate
arthrodesis with distal scaphoidectomy.2,48-54 A recent survey on the management
: / / t .
t m
. m : / /
of chronic SL instability among North American hand surgeons has reported a
/ t
/ .
t m
. m
wide variability in management decisions and treatment strategies, highlighting
t
hhtt t
hhtt
the complexity of this clinical scenario and the controversies associated with such
diverse treatment options.5 In this survey, STT arthrodesis was the most popular
limited intercarpal fusion strategy (12%), followed by SC arthrodesis (6%) and
4-corner arthrodesis (4%).5
k e e ss
rSCAPHOTRAPEZIOTRAPEZOID
r ARTHRODESIS ke
rrss
e
o o
o o k o o
o o k
eebb / e b b
First described over 4 decades ago by Peterson and Lipscomb, STT arthrodesis
ee / e
has been utilized for the treatment of chronic static and dynamic SL instability.55
: / / t
/ .
t m
. m : / / t
/.tm. m
Several authors have reported potential advantages of this technique, including
t p ss:
p / t p ss:
p /
the reduction of wrist pain and the preservation of functional wrist range of
t
hht t t
hht t
motion.49,52,54-57 Watson et al. have presented one of the largest series of STT
arthrodesis over a 20-year period for the treatment of chronic SL instability with
k e r
e s
rs k eerrss
93
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb C
ee/ e
/ e b D
t . m
. m t . m
. m
Figure 7: Tri-ligament tenodesis for the treatment of scapholunate dissociation.
: / / / t : / / / t
t pp : / t pp s : /
A, The flexor carpi radialis strip is passed from palmar scaphoid tuberosity to the
ss s
dorsal scaphoid where the dorsal scapholunate ligament inserts. B, The graft is set
t
hhtt t
hhtt
across the SL joint and buried in a trough on the dorsal lunate and secured with
suture anchor. C, The graft is passed through a slit in the distal portion of the dorsal
radiocarpal. D, The graft is sutured onto itself and the SL and scaphocapitate joints
are transfixed with two Kirschner wires. From: Garcia-Elias M, Lluch AL, Stanley JK.
rrss rrss
Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and
o k e
k e o k e
surgical technique. J Hand Surg Am. 2006;31:125-34, with permission.
k e
o
eebb o o e b o
b o o
m ee/ / e
irreducible RSS, reporting favorable postoperative wrist function compared to the
m
: /
/ t
/ .
t . m : /
/ t
/.t . m
preoperative status, and mean power key and tip pinch grips at approximately
/ /
t t p
t ss:
p t t p
t ss:
80% of the unaffected side.57 However, painful radial styloid impingement after
p
hht hht
successful triscaphe arthrodesis has also been reported.58 Moreover, patients that
underwent this limited fusion for RSS tended to develop impingement more
k e r
e s
rs
94
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
commonly than those receiving treatment for Kienböck’s disease or degenerative
arthritis.58 Up to one-third of patients were believed to have radial styloid
eebb / e
/ebb
impingement presenting with radial-sided wrist pain and limited wrist motion
ee
: / / t
/ t m
. m : / / t
/ t
that of Kleinman’s study of 47 cases of STT arthrodesis for chronic static andm
in both the flexion and radial deviation planes.58 These findings correlate with
. . . m
t p ss
p : / t p ss : /
dynamic SL instability over a 10-year period, which revealed a complication rate
p
t
hht t t
hht t
of up to 52%.52 Despite successful limited STT fusion, complications included
radial styloid-scaphoid impingement, carpal osteomyelitis, lunate avascular
necrosis, pin tract infection, medial translation of the carpus, and chronic pain
without evidence of wrist arthrosis.52 The authors concluded that failure to
k eers
rs k er
erss
obtain appropriate scaphoid reduction was a key contributing factor to persisting
incapacitating pain.51,52 Kleinman has also suggested that, while successful limited
b ooook ooook
STT arthrodesis may reestablish carpal column load-bearing, normal carpal
b
eeb ee/ e
/ e b
mechanics and load-bearing patterns are significantly altered.51,52
// t/ tm
Altered load-bearing mechanics have been suggested as a contributing
. . m / /t/.tm. m
factor to the progression of adjacent degenerative joint disease. Fortin et al.
: :
presented a series of 19 consecutive patients undergoing STT fusion, reporting
hhttt hhttt
a high-complication rate including RC arthrosis, trapeziometacarpal arthrosis,
and nonunion.49 They concluded that the development of a painful degenerative
thumb CMC joint may occur as isolated phenomenon after successful STT
fusion.49 They also concluded that successful fusion without a proper reduction
keerrss k eerrs
of the scaphoid to a normal orientation is predictive of a poor result; however,
s
the reestablishment of normal scaphoid positioning did not preclude the
b ooook o ook
development of arthrosis.49 These observations have been supported by cadaveric
b o
eeb ee/ e
/ e b
studies, utilizing pressure sensitive films, demonstrating that STT arthrodesis
significantly altered the contact characteristics of the wrist, resulting in abnormal
: / / t .
t m
. m : / / t .
t
load transfer and pressure to the area of the radial scaphoid joint compared to
/ / m
. m
that of a tendon weave reconstruction that produced characteristics similar to
t
hhtt
those of a normal joint.59 t
hhtt
SCAPHOCAPITATE ARTHRODESIS
k e rrss
e k rrss
Over the past 40 years, SC intercarpal arthrodesis has also been utilized for the
e e
treatment of chronic RSS without arthrosis, although it has not enjoyed the
o o
o o k o o o k
popularity and wider use of STT fusion.60,61 Similar to STT fusion, the technical
o
eebb / e b b
objectives to SC fusion aim to maintain scaphoid reduction and restore carpal
ee / e
height in an effort to reestablish the load-bearing column and retard the early onset
: / / t
/ .
t m
. m : / / t
/.tm. m
of arthritis. Luegmair et al. have assessed the long-term efficacy of SC arthrodesis
t p ss:
p / t p ss:
p /
for the treatment of chronic SL instability and high-demand workers.60 They
t
hht t t
hht t
retrospectively analyzed the clinical and radiographic results of 20 manual laborers
undergoing SC fusion (Figure 8), reporting an average arc of motion of 87° in the
k e r
e s
rs k eerrss
95
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
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o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
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k eers
rs A
k er
erss B
b ooook ooook
Figure 8: Scaphocapitate (SC) arthrodesis for scapholunate instability.
b
eeb / e e b
The articular cartilage and subchondral bone is removed from the dorsal
ee /
two-thirds of the SC articulation. The reduction is maintained with a 4-hole
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plate and a Kirschner wire transfixing the SC interval. From: Luegmair M,
/ /
Saffar P. Scaphocapitate arthrodesis for treatment of scapholunate instability in
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manual workers. J Hand Surg Am. 2013;38:878-86, with permission.
flexion-extension plane, and 41° in the radial-ulnar deviation plane. Postoperative

average grip strength was approximately 60% of the contralateral side with
keerrss k eerrs
reportedly significant pain relief and a return to work rate of 90%.60 Despite a 30%
s
rate of RC arthrosis, radiographic analysis demonstrated successful arthrodesis
b ooook o ook
and complete union in all cases.60 Prior reports on SC fusions have reported less
b o
eeb ee e
/ e b
favorable results. Pisano et al. examined 17 cases of SC arthrodesis, reporting up
/
to 50% reduction in postoperative motion, persistent pain with heavy use, and a
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/ .
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/ .
t m
. m
12% nonunion rate, requiring revision surgery.61 These findings are in accordance
with previously reported nonunion rates which have ranged from 0 to 23%.60,61
t
hhtt t
hhtt
Proponents of SC fusion have suggested several advantages of SC fusion over STT
arthrodesis, including greater technical ease in achieving scaphoid reduction and
fusion site preparation, a larger fusion interface with less joints to fuse (1 vs. 3), and
permitting a free thumb column.60,61 These authors suggested that such potential
k e rrss
e rrss
advantages may diminish adjacent degenerative trapeziometacarpal disease and
e
promote lower nonunion rates, subsequently concluding that SC limited carpal
k e
o o
o o k o ooo k
arthrodesis represented an efficacious treatment strategy for chronic RSS, and its
eebb continued use was warranted.60

ee/ e
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e b
/ /
SCAPHOCAPITOLUNATE
: t
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. m
ARTHRODESIS
: / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
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Scaphocapitolunate (SCL) arthrodesis is a viable treatment strategy for chronic
SL instability with RSS associated with low nonunion rates and predictable pain
k e r
e s
rs
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
relief. Rotman et al. evaluated 21 SCL fusions, reporting a 19% nonunion rate,
preserved grip strength of 70% of the contralateral side, and an 80% reduction in
eebb / e
/ebb
pain.53 However, postoperative motion was decreased 50%, and early degenerative
ee
: / / t
/ t m
changes were noted in approximately 10% of the treated wrists.53 The authors
. . m : / / t
/ .
t
noted 80% return to work.53 These findings correlate with clinical results of m
. m
t p ss
p : / t p ss : /
common intercarpal arthrodesis. Biomechanical studies by Viegas have noted a
p
t
hht t t
hht t
more proportionate load transmission across both the scaphoid and lunate fossae
associated with SCL and CL fusions compared to that of STT and SC fusions,
which transmitted load almost exclusively via the scaphoid fossa.62 While these
findings suggest that SCL fusion may offer a greater biomechanical efficacy,
k eers
rs k er
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whether these mechanical benefits yield the clinical advantages of decelerated
early wrist arthrosis is unknown and warrants future investigation.
b ooook b ooook
eeb SCAPHOLUNATE ARTHRODESIS /e
ee/ e b
: // t/.tm
. m : / /t/.tm. m
Scapholunate arthrodesis for the treatment of chronic SLD has been associated
with poor results including low fusion rates, decreased motion and grip
hhttt hhttt
strength as well as persistent pain. Hom et al. reported on an retrospective
review of 7 patients with chronic SLD treated with SL arthrodesis.50 Of this
series only 1 patient demonstrated radiographic evidence of osseous fusion.50
Additionally, this procedure was associated with failure to maintain alignment
keerrss k eerrss
and fusion requiring salvage procedures for pain relief.50 They reported grip
strength averaging 80% of the unaffected side.50 The authors concluded that
b ooook o ook
this procedure was unpredictable and did not present an efficacious treatment
b o
eeb alternative.50
ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
CONCLUSION
t
hhtt t
hhtt
Chronic nondegenerative SL instability is a complex entity, which may lead to
chronic pain and disability without appropriate and timely management. Important
prognostic factors, as previously described by Garcia-Elias, include the integrity of
secondary scaphoid stabilizers and the ability to easily achieve and maintain normal
k e rrss
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carpal alignment. These important parameters should be carefully considered and
e e
may aid in the selection of an appropriate procedure and possibly minimize early
o o
o o k o o o k
clinical failure. However, at present, there is great variability among hand surgeons
o
eebb ee/ e b
e b
regarding the preferred treatment of chronic nondegenerative SL instability, and
/
the optimal treatment strategy for this spectrum of injury remains controversial.
/ / t
/ .
t m
. m / /
Future long-term studies on these various management protocols may provide
: : t
/.tm. m
p ss:
p / t p ss: /
further insight into this challenging problem and potentially diminish existing
t p
controversies. t
hht t t
hht t
k e r
e s
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97
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o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wang and Vosbikian
k e r
e s
rs k eers
r s
o o
o o k Editor’s Comment o o
o o k
eebb e / e
/ebb
Scapholunate dissociation is the most common form of both carpal instability and
e
: / t . m
. m t . m
. m
subsequent wrist arthritis. Despite its prevalence, it remains a challenging problem
/ / t : / / / t
t p ss
p : / ss : /
to treat with considerations that include restoring carpal alignment, avoiding wrist
t p p
hhtt t t t
arthritis, and delivering pain relief. Treatment options highly vary with several
hht
indications and considerations. In this article, the authors present a detailed review
of carpal mechanics as well as the indications and techniques for different treatment
options.
k eers
rs Asif M Ilyas
k er
erss
b ooook b ooook
eeb REFERENCES
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/ e b
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3. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg
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17. Weiss AP. Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft. J Hand Surg Am.
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18. Shin SS, Moore DC, McGovern RD, Weiss AP. Scapholunate ligament reconstruction using a bone-
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19. Soong M, Merrell GA, Ortmann F, Weiss AP. Long-term results of bone-retinaculum-bone autograft for
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ss t p ss
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20. Cuenod P, Charriere E, Papaloizos MY. A mechanical comparison of bone-ligament-bone autografts from the
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wrist for replacement of the scapholunate ligament. J Hand Surg Am. 2002;27:985-90.
21. Berger RA. The anatomy and basic biomechanics of the wrist joint. J Hand Ther. 1996;9:84-93.
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24. Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and
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25. Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate dissociation by ligamentous repair and
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27. Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate
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28. Wyrick JD, Youse BD, Kiefhaber TR. Scapholunate ligament repair and capsulodesis for the treatment of
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32. Luchetti R, Zorli IP, Atzei A, Fairplay T. Dorsal intercarpal ligament capsulodesis for predynamic and dynamic
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scapholunate instability. J Hand Surg Eur Vol. 2010;35:32-7.
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33. Slater RR, Szabo RM, Bay BK, Laubach J. Dorsal intercarpal ligament capsulodesis for scapholunate
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Extrem Surg. 1997;1:2-10. t
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34. Berger RA, Bishop AT. A fiber-splitting capsulotomy technique for dorsal exposure of the wrist. Tech Hand Up
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36. Moran SL, Ford KS, Wulf CA, Cooney WP. Outcomes of dorsal capsulodesis and tenodesis for treatment of
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37. Megerle K, Bertel D, Germann G, Lehnhardt M, Hellmich S. Long-term results of dorsal intercarpal ligament
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38. Szabo RM, Slater RR, Palumbo CF, Gerlach T. Dorsal intercarpal ligament capsulodesis for chronic, static
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43. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a
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preliminary report. J Hand Surg Am. 1995;20:S82-5.
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44. De Smet L, Van Hoonacker P. Treatment of chronic static scapholunate dissociation with the modified
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Brunelli technique: preliminary results. Acta Orthop Belg. 2007;73:188-91.
45. Nienstedt F. Treatment of static scapholunate instability with modified brunelli tenodesis: results over 10
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years. J Hand Surg Am. 2013;38:887-92. t
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46. Talwalkar SC, Edwards AT, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. Results of tri-ligament tenodesis: a
modified Brunelli procedure in the management of scapholunate instability. J Hand Surg Br. 2006;31:110-7.
47. van Den Abbeele KL, Loh YC, Stanley JK, Trail IA. Early results of a modified Brunelli procedure for
scapholunate instability. J Hand Surg Br. 1998;23:258-61.
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48. Chantelot C, Becquet E, Leconte F, Lahoude-Chantelot S, Prodomme G, Fontaine C. [Scaphocapitate arthrodesis
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49. Fortin PT, Louis DS. Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis. J Hand Surg Am.
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eeb 1993;18:675-81.
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50. Hom S, Ruby LK. Attempted scapholunate arthrodesis for chronic scapholunate dissociation. J Hand Surg
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Am. 1991;16:334-9.
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51. Kleinman WB. Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid
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1987;3:113-33.
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52. Kleinman WB, Carroll CT. Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and
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53. Rotman MB, Manske PR, Pruitt DL, Szerzinski J. Scaphocapitolunate arthrodesis. J Hand Surg Am.
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54. Watson HK, Belniak R, Garcia-Elias M. Treatment of scapholunate dissociation: preferred treatment--STT
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o o
55. Peterson HA, Lipscomb PR. Intercarpal arthrodesis. Arch Surg. 1967;95:127-34.
eeb / e
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56. Watson HK, Ryu J, Akelman E. Limited triscaphoid intercarpal arthrodesis for rotatory subluxation of the
ee
: / / t
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scaphoid. J Bone Joint Surg Am. 1986;68:345-9.
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t m
. m
57. Watson HK, Weinzweig J, Guidera PM, Zeppieri J, Ashmead D. One thousand intercarpal arthrodeses. J
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Hand Surg Br. 1999;24:307-15.
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t
hhtt
1989;14:297-301. t
hhtt
58. Rogers WD, Watson HK. Radial styloid impingement after triscaphe arthrodesis. J Hand Surg Am.
59. Augsburger S, Necking L, Horton J, Bach AW, Tencer AF. A comparison of scaphoid-trapezium-trapezoid
fusion and four-bone tendon weave for scapholunate dissociation. J Hand Surg Am. 1992;17:360-9.
60. Luegmair M, Saffar P. Scaphocapitate arthrodesis for treatment of scapholunate instability in manual
workers. J Hand Surg Am. 2013;38:878-86.
k e rrss
e k e rrss
61. Pisano SM, Peimer CA, Wheeler DR, Sherwin F. Scaphocapitate intercarpal arthrodesis. J Hand Surg Am.
e
o o
o o k 1991;16:328-33.
o o
o o k
62. Viegas SF, Patterson RM, Peterson PD, Pogue DJ, Jenkins DK, Sweo TD, et al. Evaluation of the biomechanical
eebb / e b b
efficacy of limited intercarpal fusions for the treatment of scapho-lunate dissociation. J Hand Surg Am.
1990;15:120-8.
ee / e
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
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hht t
k e r
e s
rs
100
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o o k
/ebb
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: / /
/ t
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t t p
t ss:
p t t p
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p
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k e r
e s
rs k eers
r s
o o
o o k o o o k
o
eebb Trigger Finger: ee
The
/ e
/ebb
Controversies
: / / t
/ .
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/ .
t m
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p : / t p ss
p
*Daniel E Choi MD, Harsh A Shah BA, Irfan Ahmed MD : /
hhtt t t
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Department of Orthopedic Surgery, Rutgers New Jersey Medical School
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b ooook ABSTRACT bo oook
eeb ee/ e
/ e b
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. m : / /t/.tm. m
Trigger finger is a common condition that often leads to significant hand
t ppss / tp ss : /
dysfunction. Treatment of trigger finger involves either noninvasive or
:
surgical interventions. First line treatment for mild symptoms include
p
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activity modification and nonsteroidal anti-inflammatory drugs. Splinting
is acceptable for symptoms in one finger present for less than six months.
Corticosteroid injections is commonly used but are less curative in patients
with insulin dependent diabetes, multiple affected digits, and symptoms
persisting greater than six months. Open release of the first annular pulley
keerrss k eerrss
is the standard operative treatment with low reported complication rates.
b ooook b ook
Percutaneous release is relatively safe and effective with high success rates
o o
and few complications. Patients with persistent triggering may be treated
eeb / e
/ e b
with resection of the ulnar slip of the superficialis tendon or reduction
ee
: / / t
/ t m
. m : / / t
/ t m
flexor tenoplasty. This article presents a comprehensive review of the
. . . m
current literature on trigger finger treatment options addressing some of
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the controversies associated with management.
p t ppss : /
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hhtt
INTRODUCTION
Trigger finger in adults is a common condition well known to the hand surgeon
k e rrss
e k rrss
that was first described by Notta in 1850.1 It has an incidence of 28 cases per
e e
100,000 people per year with a lifetime risk of trigger finger development of about
o o
o o k o o o k
2.6% in the United States.2 The incidence of trigger finger is greatest in women
o
eebb aged 52–62 years.3
ee/ e
/ b
e b
The patient presents with painless locking or clicking of a finger or thumb
: / / t .
t m
. m : / /
which often progresses to painful triggering. Secondary contractures at the
/ t
/.tm. m
t p ss:
p / t p ss:
p /
proximal interphalangeal (PIP) joint can result due to reluctance to range the
t
hht
t t
hht t
Email: ahmedi2@njms.rutgers.edu
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e s
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Choi et al
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
joint fully because of pain or locking. The most common digit to be involved is
the ring finger, followed by the thumb, then the middle, index, and small fingers.4
eebb / e
/ebb
A patient can present often times with multiple trigger fingers in one hand or in
ee
: / /
one digit is involved.5t
/ t m
. m : / / t
/ t m
both hands. However, hand function can be seriously compromised even if only
. . . m
t p ss
p : / t p ss : /
Trigger finger is caused by a mismatch between the diameter of the flexor
p
t
hht t t
hht t
tendon and the first annular (A1) pulley. Hueston and Wilson early on described
how inflammation and constriction of the A1 pulley can lead to the spiral fibers of
the flexor tendon to unfurl and bunch up causing a nodule on the distal side of the
pulley. They made the comparison to the fraying that would occur at the end of an
k eers
rs k er
erss
oversized thread trying to pass through the eye of a small needle.6
Histopathologic studies have shown triggering superficialis tendons to
b ooook ooook
undergo fibrocartilaginous metaplasia with chondrocytes found at the site of
b
eeb ee/ e
/ e b
injury to the tendons. The tendons stain positively for S 100 protein, which is
// t/ tm
. m / /t/ tm
present in chondrocytes. The A1 pulley can hypertrophy up to 2–3 times its usual
. . . m
thickness. The histology of the inner gliding layer of the A1 pulley is initially
: :
a biphasic population of spindle-shaped fibroblasts and ovoid cells but as they
hhttt hhttt
become diseased, the ovoid cells increase in number and look histologically more
similar to chondrocytes.7,8 A recent histologic study by Drossos et al. observed
that as trigger finger became clinically more severe that the inner gliding surface
begins to wear and is replaced by a secondary invasive hyperplasia from the outer
keerrss layer.9
k eerrss
Trigger finger can be classified either as “nodular” or “diffuse”, based on
b ooook o ook
findings on palpation of the swelling of the tendon sheath. Contained swelling
b o
eeb ee/ e
/ e b
where a definite nodule is palpated is considered to be nodular and inflammation
is present as spindle-shaped thickening in a localized area just distal to the A1
: / / t .
t m
. m : / / t .
t m
. m
pulley. In diffuse trigger digits, the swelling is much more diffuse and less defined
/ /
t ppss : / t ppss
and the inflammation may extend well beyond the A1 pulley.4,6 : /
t
hhtt t
hhtt
Trigger finger is treated in a variety of ways including activity modification,
nonsteroidal anti-inflammatory drugs (NSAIDs), splinting, corticosteroid
injections, and surgical release. Much of the controversy regarding trigger finger
is related to the choice and methodology of treatment methods which will be
k e rrss
e k e rrss
explored further in this article.
e
o o
o o k o o
o o k
eebb b
NONINVASIVE MEASURES
ee/ e
/ e b
In mild cases of trigger finger, observation combined with avoidance of
: / / t
/ .
t m
. m : / / t
/.tm. m
exacerbating activities may resolve symptoms. Repetitive trauma to the hands
t p ss:
p / t p ss:
p /
with activities, such as gardening, cutting with scissors, and bongo playing, may
t
hht t t
hht t
be associated with the onset of triggering. Avoidance of these activities may result
in spontaneous resolution of triggering. However, there is no causative activity
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Trigger Finger: The Controversies
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
that can be identified in most cases.5 Nonsteroidal anti-inflammatory drugs can
also be added to an initial treatment regimen for patients who do not have a
eebb / e
/ebb
contraindication such as renal disease or peptic ulcer disease.
ee
: / / t
/ t m
. m : / /
trigger finger. Various methods of splinting have been described includingt
/ t m
Splinting is another noninvasive treatment option that can help to resolve
. . . m
t p ss
p : / t p ss : /
metacarpophalangeal (MCP) joint blocking splint with 0° of flexion of the
p
t
hht t t
hht t
MCP joint, MCP blocking splint with 10–15° of MCP joint flexion, and a distal
interphalangeal (DIP) joint blocking splint.10-13 Splints can either be prefabricated
(i.e., stack splints) or tailored for individual patients (i.e., thermoplast) (Figure 1).
The reported success rates of each of these splinting methods vary and the
k eers
rs k er
erss
number of subjects studied with such splinting methods is limited. Colbourn
et al. followed 28 trigger finger patients treated with 53.6% of participants having
b ooook ooook
total resolution of their symptoms.10 Patel et al. followed 50 trigger fingers treated
b
eeb ee/ e
/ e b
by splinting of the MCP joint in 10–15° of flexion for an average of 6 weeks
// t/ tm
. m / /t/ tm
with treatment being successful in 66% of the subjects, but found higher rates of
. . .
failure in patients with symptoms more than 6 months, marked triggering, and
: : m
multiple involved digits.11 Evans et al. followed 55 trigger digits immobilized at
hhttt hhttt
0° of extension at the MCP joint with no further treatment necessary for 73% of
the patients.12 A recent prospective trial compared MCP joint splint with DIP
extension splint and found that MCP joint immobilization had a higher rate of
symptom resolution, but both splint designs had complete resolution of symptoms
keerrss in only 24–29% of patients.13
k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
A
t
hht t B
t
hht t
Figure 1: Metacarpophalangeal blocking splint at 0° of flexion.
C
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/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Choi et al
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
In summarizing noninvasive treatment options, activity modification and
NSAIDs are acceptable first line treatments for mild trigger finger. Splinting is
eebb / e
/ebb
also an acceptable treatment option for mild trigger finger but should be reserved
ee
: / / t
/ t m
. m : / / t
/ t m
only for those who have been symptomatic for less than 6 months and have only
. . . m
one digit involved. Only the MCP joint should be immobilized for at a minimum
t p ss
p : / t p ss : /
of 6 weeks but may require up to 4 months of immobilization. However, the fairly
p
t
hht t t
hht t
high number of patients who fail splinting treatment may justify a clinician’s
decision to forego splinting altogether and initiate corticosteroid injection instead
as a first line treatment.
k eers
rsCorticosteroid Injections
k er
erss
b ooook ooook
Corticosteroid injections are often recommended as first line treatment or after
b
eeb ee/ e
/ e b
noninvasive treatments have failed. The success of corticosteroid injections
: // t/ tm
. m : / /t/ tm
have varied in the literature with different studies reporting long-term relief of
. . . m
symptoms ranging from 60 to 92% of patients.4,14 A recent review of level I and
t pp s s : / tppss : /
II studies that pooled data from multiple studies found corticosteroids to improve
hhttt hhttt
symptoms long term in only 57% of patients. Several studies have identified factors
associated with poor prognosis with corticosteroid injections as involvement of
multiple digits, symptoms that were present for greater than 4 months, younger
patient age, and history of other tendinopathies of the upper extremity.15-17
keerrss k eerrss
Insulin dependent diabetes has also been identified as a factor associated with
poor prognosis. In a prospective study of 138 patients treated with triamcinolone
b ooook o ook
injections by Rozenthal et al., all six of the insulin dependent diabetics in the series
b o
eeb ee/ e
/ e b
failed injections.17 Nimigan et al. reported a success rate of 41% for corticosteroid
/ / t
/ t m
injections in insulin dependent diabetic patients.18
. . m / / t
/ .
t m
. m
Various techniques have been described for corticosteroid injection. Different
: :
types of corticosteroids, such as triamcinolone (insoluble) or dexamethasone
t
hhtt t
hhtt
(soluble) with lidocaine, can be delivered either subcutaneously or into the tendon
sheath. In addition, either the more conventional palmar approach through the
palm over the A1 pulley or a midaxial approach can be used (Figure 2).
When choosing which type of corticosteroid to inject, many hand surgeons
k e rrss
e k rrss
prefer dexamethasone because it is water soluble and believed to be less likely to
e e
leave a deposit in the flexor tendon sheath resulting in tenosynovitis. Ring et al.
o o
o o k o o o k
studied both triamcinolone and dexamethasone in a prospective trial and found
o
eebb / e b b
that triamcinolone had a more rapid effect but that there were no differences
ee / e
between the two at the final 3-month evaluation. However, in long-term follow-
: / / t
/ .
t m
. m : / / t
/.tm. m
up, triamcinolone had a higher rate of recurrence of trigger finger.19 No study
t p ss:
p / t p ss:
p /
to our knowledge has studied the optimal amount of corticosteroid to inject
t
hht t t
hht t
but injections ranging from 0.1 to 1.0 mL have all resulted in similar success
rates.4,16,20
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs
A
k er
ersB
s
b ooook b ooook
Figure 2: Corticosteroid injection given through the conventional volar method.
eeb ee/ e
/ e b
The corticosteroid can either be placed into the tendon sheath at the A 1
// t/ tm
pulley or the subcutaneous tissues overlying the A1 pulley can instead be
. . m / /t/.tm. m
infiltrated. Taras et al. divided patients into two groups to either receive placement
: :
of the corticosteroid in the subcutaneous tissue or into the tendon sheath. There
hhttt hhttt
was a trend towards more patients having a good response to injection in the
subcutaneous group but this difference was not statistically significant and the
study concluded that true intrasheath injection offers no apparent advantage over
subcutaneous injection.20
keerrss k eerrs
Jianmongkol et al. carried out a prospective, randomized trial for patients to
s
either receive corticosteroid injections through the palm over the A1 pulley or
b ooook o ook
through a midaxial approach. Their results showed lower pain and lower recurrence
b o
eeb rates with the midaxial technique.21
ee/ e
/ e b
A recent prospective, randomized, double-blinded controlled study by Shakeel
: / / t .
t m
. m : / / t .
t
et al. compared injectable NSAIDs with triamcinolone injection. A total of 100
/ / m
. m
patients were followed and assessed at 3 weeks and 3 months and found that
t
hhtt t
hhtt
corticosteroid injection gave much more effective relief at 3 weeks, however, both
were equally effective at 3 months. Due to the concern of injecting corticosteroid
in diabetics, the study recommended the use of injectable NSAIDs in diabetics
with trigger finger.22
k e rrss
e k rrss
In summary, patients can be advised that corticosteroid injections will improve
e e
symptoms in around 60% of patients but will be less likely to be curative if
o o
o o k o o o k
symptoms are present in more than one finger, if symptoms have persisted for
o
eebb ee/ e
/ b
e b
longer than 6 months, if the patient has history of other tendinopathies, and if
the patient has a history of insulin dependent diabetes. A direct palmar approach
: / / t
/ .
t m
. m : / / t
/.tm.
is typically used although a midaxial approach can be considered if the clinicianm
t p ss:
p / t p ss:
p /
is comfortable with the technique. Although the injection can be attempted to be
t
hht t t
hht t
made intrasheath, subcutaneous injection is also acceptable. Nonsteroidal anti-
inflammatory drugs injection can be considered in diabetics.
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/ t
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/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Choi et al
k e r
e s
rs k eers
r s
o o
o o k INVASIVE MEASURES
o o
o o k
eebb Open First Annular Pulley Release b
ee / e
/e b
: t . m
. m t . m
. m
Open release of the A1 pulley has been a treatment option for over a century. It is
/ / / t : / / / t
t p ss
p : / ss : /
considered the standard operative treatment with its high success rate with most
t p p
hhtt t t t
studies reporting low morbidity. A transverse, longitudinal, or oblique incision is
hht
used on the volar aspect of the hand over the MCP joint and A1 pulley. The A 1
pulley is visualized by blunt dissection to the level of the flexor tendon and caution
is used to protect the neurovascular bundles located on the radial and ulnar sides
of the flexor tendon. The A1 pulley must be completely released in order to fully
k eers
rs treat the trigger finger (Figure 3).23
k er
erss
b ooook b oook
Adverse event rates vary widely in the literature, ranging from less than 1 to 31%.
o
The most serious potential complications of open treatment include bowstringing
eeb e / e
/ e b
if the second annular (A2) pulley is inadvertently released and digital nerve injury.
e
: // t/.tm
. m : / /t/.tm. m
In a recent retrospective review of 1,598 trigger finger releases by Bruijnzeel et
t ppss / tppss : /
al., none of these serious complications were observed. The overall adverse event
:
rate was 5% with the most common adverse events being slow recovery of motion
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
A
t ppss : / t pps
B
s : /
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
C
: / / t
/ .
t m
. m
D
: / / t
/.tm. m
t ss:
p / t p ss:
p /
Figure 3: Open release of trigger digit. A, A transverse, longitudinal, or oblique incision
p
over the metacarpophalangeal joint or first annular (A1) pulley. B, The A1 pulley is visualized
t
hht t t
hht t
by blunt dissection. C, The A1 pulley is completely released. D, The skin is reapproximated
with 5-0 nylons.
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o o k o o
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
(2% of patients), wound problems such as superficial infection (2%), persistent
postoperative triggering (0.6%), and recurrent triggering after symptom relief for
eebb ee/ e
/ebb
more than 6 months (0.3%). Although this study had a large number of patients,
/ / t
/ t m
. m / / t
/ t m
it was weakened by its arbitrarily chosen minimal follow-up threshold of 5 days.24
. . . m
Lange-Riess et al. had a large retrospective review of 254 digits with average
: :
t p ss
p : / t p ss : /
follow-up of 14 years that found no recurrences in all their patients with an
p
t
hht t t
hht t
adverse event rate of 3.5% including 2 superficial wound infections and 6 transient
digital neurapraxias.25 Lim et al. studied 483 digits with a low adverse event rate
of 1% with 1 patient developing superficial wound dehiscence, 2 digits developing
an extension lag at the PIP joint, and 4 digits developing postoperative stiffness.
k eers
rs by its short maximum follow-up of 6 months.26
k er
ers
Although they reported no recurrences in their patient set, the study was limited
s
b ooook o ook
These low rates of adverse events are in contrast to studies by Thorpe et al. and
b o
eeb / e e b
Will et al. The latter performed a retrospective review of 43 patients with 78 open
ee /
trigger finger releases with an average follow-up of 16 months with an overall
// t/.tm
. m / /t/.tm. m
complication rate of 31%. Two major complications (3%) were reported: a synovial
: :
fistula that required a reoperation for excision and a PIP joint arthrofibrosis that
hhttt hhttt
required cast treatment for pain relief and resulted in a 30° extension lag. Twenty
seven minor complications (28%) including decreased range of motion less than
20°, scar tenderness, swelling, and pain, wound erythema, or infections were
reported.27 Thorpe et al. followed 43 patients who underwent 53 open A1 pulley
keerrss k eerrs
releases performed by house officers with an overall complication rate of 26%.
s
Recurrence developed in 6 digits (11%) and major complications occurred in three
b ooook o ook
releases including two nerve lacerations and one stiff joint following injection.28
b o
eeb ee e
/ e b
Most large series investigating open A1 pulley release report low complication
/
rates less than 5%. The studies reporting high complication rates ranging from
: / / t
/ .
t m
. m : / / t
28 to 31% were much smaller series and one of the studies involved procedures
/ .
t m
. m
performed by house officers with less experience. The definition of an adverse
t
hhtt t
hhtt
event also varied widely among studies with Will et al. classifying postoperative
pain and swelling as a complication while other studies did not classify this as a
complication.27
k e r
e s
r s
Percutaneous Release
k e rrss
e
o o
o o k o o o k
Percutaneous release, first described by Lorthioir in 1958, is performed by using
o
eebb ee/ e
/ b
e b
an 18 or 21 G needle or other device at the proximal aspect of the A1 pulley and
can be performed in the ambulatory setting.29 The needle can be inserted into
: / / t
/ .
t m
. m : / / t
/.tm. m
the tendon and position is confirmed when the patient flexes and extends the
t p ss:
p / t p ss:
p /
distal phalanx. The needle is then withdrawn until the needle motion stops which
t
hht t t
hht t
confirms the position of the needle in the A1 pulley. The A1 pulley is transected
by moving the needle forwards and backwards in line with the axis of the flexor
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/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Choi et al
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
tendon sheath and the surgeon should feel a grating sensation. The needle is
removed once the surgeon feels that the A1 pulley is completely released and the
eebb / e
/ebb
patient actively flexes and extends the digit to confirm complete release of the
ee
pulley (Figure 4).23
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
The studies that investigate percutaneous A1 pulley release have been
t p ss
p : / t p ss : /
completed with smaller numbers of subjects in comparison to studies of open A1
p
t
hht t t
hht t
pulley release. The most common complications noted were superficial tendon
abrasions and incomplete releases and major complications, such as nerve
lacerations or tendon bowstringing, were not reported with use of percutaneous
release.
k eers
rs k er
erss
Eastwood et al. performed percutaneous release using the “scratch-cut” method
described earlier on 35 trigger fingers with 33 (94%) of the digits having complete
b ooook ooook
relief of symptoms and partial symptomatic relief in the remaining 2 digits. There
b
eeb ee/ e
/ e b
were no recurrences with an average follow-up of 13 months.30 Lyu et al. used a
// t/ tm
. m / /t/ tm
modified aneurysm needle and a #11 scalpel blade to percutaneously release the
. . . m
A1 pulley in 63 digits. Seven digits (11.1%) required a subsequent open release
: :
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
A
t ppss : / B
t ppss : /
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
C
: / / t
/ .
t m
. m
D
: / / t
/.tm. m
t p ss: / t p ss: /
Figure 4: Percutaneous release using an 18 G needle at the first annular (A1) pulley.
A, Release is planned for over the A1 pulley. B, Care is taken to not extend the release
p p
t
hht t t
hht t
distal to A1 pulley. C and D, A1 pulley is transected by moving the needle forwards and
backwards in line with the axis of the flexor tendon sheath.
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
and one patient developed a hypertrophic scar in the palm.31 Ha et al. used a
specially designed hooked knife to perform percutaneous release in 185 trigger
eebb / e
/ebb
fingers with 12 digits (6.5%) in which treatment failed to relieve symptoms with
ee
: / / t
/ t m
. m : / / t
/ t m
persistent triggering.32 Calleja et al. performed percutaneous release of 25 trigger
. . .
fingers using a 19 G needle, then subsequently performed an open trigger releasem
t p ss
p : / t p ss : /
and found that only 6 out of 25 (24%) had a complete A1 pulley release with
p
t
hht t
superficial tendon abrasions in 15 digits (60%).33 t
hht t
Two cadaver studies also showed incomplete pulley release and tendon
abrasions. Habbu et al. used a number 15 blade scalpel to perform percutaneous
release in 54 fresh frozen cadaver fingers and noted complete release in 72% of the
k eers
rs k er
erss
fingers and longitudinal scoring of the tendons in 20%. There was a 22% incidence
of release of the proximal edge of the A2 pulley, however, no bowstringing of
b ooook ooook
flexor tendon was seen.34 Pope et al. used a 19 G needle to perform percutaneous
b
eeb ee/ e
/ e b
release in 25 cadaver fingers. Over 90% of the length of each finger and thumb’s
// t/ tm
. m / /t/ tm
A1 pulley was successfully released with any remaining fibers being at the distal
. . . m
aspect of the pulley. The A2 pulley was not released at all in any of the digits
: :
and superficial abrasions were noted in 4 digits. The authors noted also that the
hhttt hhttt
radial digital nerve was within 2–3 mm of the needle site for the majority of the
thumb and index fingers and recommended against percutaneous techniques in
the thumb and index fingers. In general, percutaneous release of thumb trigger
finger is considered riskier because the radial digital nerve crosses at the level of
keerrss the thumb A1 pulley.35
k eerrss
Ragoowansi et al. used a “lift and cut” percutaneous technique which is similar
b ooook o ook
to the previously described “scratch-cut” technique except instead of a forward
b o
eeb ee/ e
/ e b
and backward movement of the needle, the pulley is divided by a gentle but firm
lifting action from distal to proximal. In authors’ literature search, this was the
: / / t .
t m
. m : / / t .
t m
. m
largest series of percutaneous release with 240 trigger digits that underwent this
/ /
procedure. Ten patients (4.2%) underwent a subsequent open release for persistent
t
hhtt t
hhtt
symptoms or triggering and in all of these cases, incomplete distal release of the
A1 pulley was found.36
In summary, percutaneous release has been shown to be a relatively safe and
effective method of treating trigger finger that has fairly high rates of success.
k e rrss
e rrss
No major complications are typically associated with percutaneous release and
e e
its most commonly reported complications of incomplete release and tendon
k
o o
o o k o o o k
abrasions have no permanent negative sequelae.
o
eebb ee/ e
/ b
e b
: / / t
/ t m
Percutaneous Versus Open Release
. . m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
There are several randomized trials that have been carried out comparing open
t
hht t t
hht t
to percutaneous A1 pulley release. The largest trial comparing the two techniques
was performed by Gilberts et al. who randomized 100 patients to open trigger
k e r
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release or percutaneous trigger release using an 18 G needle. Postoperative pain
was reported for fewer days in the percutaneous group (3.1 vs. 5.7 days, p = 0.039)
eebb / e
/ebb
and the percutaneous group returned to work sooner (3.9 vs. 7.5 days, p <0.0001).
ee
: / / t
/ t m
.
the digit during movement.37 m : / / t
/ t m
One patient in the open group needed revision surgery for recurrent crepitus of
. . . m
t p ss
p : / t p ss : /
Dierks et al. randomized 36 patients to either open release or percutaneous
p
t
hht t t
hht t
release with a #15 blade scalpel. There was greater range of motion at 1 week
in the percutaneous group, but equivalent pain, grip strength at 1 and 12 weeks
and equivalent range of motion at 12 weeks.38 Sato et al. randomized 150 trigger
fingers to corticosteroid injection, open release, or percutaneous release. There
k eers
rs k er
erss
was 100% relief of triggering in both the percutaneous and open groups with
no complications reported.39 A recent meta-analysis performed by Wang et al.
b ooook ooook
used these previously mentioned randomized trials and found no differences in
b
eeb ee/ e
/ e b
the failure rate or complication rate between open and percutaneous techniques.
: // t/ tm
. m : / /t/ tm
However, a great deal of heterogeneity existed between the studies.40
. . . m
hhttt hhttt
Persistent Triggering
After surgical release of trigger digits, the patient may have persistent triggering
and function is not fully regained. These patients usually have long-standing
disease and marked degeneration of the flexor digitorum superficialis (FDS)
keerrss k eerrss
tendon causing it to lose its normal smoothness, fraying of its fibers, and formation
of a nodule. This prevents the tendon from gliding smoothly under the A2 pulley.
b ooook o ook
Treatment is challenging as release of A1 pulley does not improve function and
b o
eeb ee/ e
/ e b
release of A2 pulley is not an option due to risk of bowstringing. Options in these
flexor tenoplasty.
: / / t
/ t m
. m : / / t
/ t m
cases include resection of the ulnar slip of the superficialis tendon or reduction
. . . m
La Viet et al. described 228 fingers in 172 patients treated with resection
t
hhtt t
hhtt
of the ulnar slip and 11 of these patients had previous A1 pulley release that
was unsuccessful. All patients with a fixed preoperative PIP flexion deformity
of less than 30° achieved full extension after resection while those with greater
than 30° deformity improved their PIP joint extension by an average of 30°.
k e rrss
e k rrss
Conclusions from this study, however, were limited due to lack of a control group
e e
with preoperative PIP flexion contracture treated traditionally.41
o o
o o k o o o k
Reduction flexor tenoplasty involves removal of a central core from the
o
eebb / e b b
enlarged FDS nodule. Although this could be used in any location with bulbous
ee / e
hypertrophy of the tendon, it is generally used when triggering occurs by a nodular
: / / t
/ .
t m
. m : / / t
/.tm. m
swelling at the proximal or distal edge of A2 pulley. Access is gained to proximal
t p ss:
p / t p ss:
p /
edge of A2 pulley through an A1 pulley release and to the distal edge by resection
t
hht t t
hht t
of second cruciform pulley. A tenotomy is performed, the central core is excised
until remaining tendon glides smoothly and tenotomy closed with a running
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suture. Seradge and Kleinert used the technique to treat patients with nodular
triggering distal to the A1 pulley.42
eebb ee/ e
/ebb
CARPAL TUNNEL SYNDROME
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
Trigger digits are often associated with carpal tunnel syndrome. Though there is
t
hht t t
hht t
predisposition to both these conditions with endocrine and metabolic diseases,
it is also seen with idiopathic trigger digit. The hypothesis is that the association
between these two conditions may be due to an inflammatory condition at both
the carpal tunnel and A1 pulley. Patients presenting with one of these conditions
k eers
rs k er
erss
must be evaluated for the other.43
b ooook RHEUMATOID ARTHRITIS b ooook

eeb ee/ e
/ e b
: // t/ tm
. m : / /t/ tm
Rheumatoid arthritis is a systemic condition affecting synovial tissues and causing
. . . m
an actual tenosynovitis resulting in triggering of the digits. Treating rheumatoid
patients, however, requires a different approach than idiopathic trigger digits.
hhttt hhttt
Surgical treatment of rheumatoid flexor tenosynovitis involves tenosynovectomy
with preservation of the annular pulleys. Subsequent persistent triggering is treated
with ulnar slip of FDS excision of flexor tenoplasty. Although it may respond
temporarily to corticosteroid injection, early surgical intervention in the form of
keerrss k eerrss
flexor tenosynovectomy with decompression of the carpal tunnel is recommended
by many investigators to prevent flexor tendon rupture and irreversible damage
b ooook o ook
to the median nerve.44 The A1 pulley release is not recommended in rheumatoid
b o
eeb ee/ e
/ e b
patients as it increases the tendency of digital ulnar drift.
DIABETES MELLITUS ://t /.tm. m : / / t

/ .
t m
. m
t
hhtt t
hhtt
Diabetic patients have significantly higher incidences of developing carpel
tunnel syndrome, Dupuytren’s disease, and trigger finger in comparison to
nondiabetics.45 Additionally, diabetic patients with trigger finger have been
noted to be less responsive to treatment. Griggs et al. reported low success rates
k e rrss
e k rrss
treating trigger finger in diabetics with corticosteroid injections with an overall
e e
success rate of only 50% with corticosteroids injections in 54 diabetic patients
o o
o o k o o o k
with 121 trigger digits.46 A randomized, prospective trial by Baumgarten et al.
o
eebb / e b b
showed that nondiabetics were significantly more likely to avoid surgery than
ee / e
were diabetic patients after treatment with corticosteroid injection (10 vs. 36%,
: / / t
/ .
t m
. m : / / t
/.tm
surgical rate). The trial also showed that corticosteroid injection was no more
. m
t p ss:
p / t p ss:
p /
efficacious than an injection of anesthetic only in diabetics calling into question
t
hht t t
hht t
whether or not to even use corticosteroid injections as a treatment method in
diabetic patients.47 Most clinicians still use corticosteroid injections in diabetics
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Choi et al
k e r
e s
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r s
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o o k
as it is a low risk treatment option that has little to no long-term detrimental
effect on glycemic control.48
eebb ee/ e
/ebb
CONCLUSION
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
Trigger finger is a condition that is encountered by the hand clinician routinely.
t
hht t t
hht t
Treatment modalities include noninvasive measures, such as splinting and activity
modification, corticosteroid injections, and open and percutaneous release.
Noninvasive measures are an acceptable first line treatment modality but have
a fairly high rate of failure. Corticosteroids have been shown to have positive
k eers
rs k er
erss
outcomes in the treatment of trigger finger but have shown less optimal results in
b ooook oook
patients if symptoms are present in more than one finger, if symptoms have persisted
o
for longer than 6 months, if the patient has history of other tendinopathies, and
b
eeb ee/ e
/ e b
if the patient has a history of insulin dependent diabetes. Special considerations
: // t/ tm
. m : / /t/
with carpal tunnel syndrome, rheumatoid arthritis, and diabetes.tm
must be given in terms of treatment planning regarding trigger finger patients
. . . m
Much controversy still exists regarding whether the most optimal surgical
hhttt hhttt
treatment of trigger finger is open versus percutaneous release. Both methods have
been shown to be highly effective with low risk of complications. There are few large
prospective randomized trials that compare patients treated with either method
and larger studies with more homogenous groups of patients would help determine
keerrss k eerrss
if there is a significant difference between open and percutaneous release.
b ooook Editor’s Comment b o ook

o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Trigger fingers are among the most common conditions encountered by the hand
surgeons. The diagnosis can be readily made by history and physical examination
t
hhtt t
hhtt
alone. A number of treatment options exist including medications, splinting,
injections, and release. In this article, the authors present a detailed review of the
noninvasive and invasive treatment options available to manage this condition.
Asif M Ilyas
k e rrssREFERENCES
e k e rrss
e
o o
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e b
1. Notta A. Recherches sur une affection particuliere des gaines tendineuses de la main. Arch Gen Med.
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1850;24:142.
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2. Strom L. Trigger finger in diabetes. J Med Soc N J. 1977;74:951-4.
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3. Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I and II
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systematic review. J Am Acad Orthop Surg. 2007;15:166-71.
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4. Freiberg A, Mulholland RS, Levine R. Nonoperative treatment of trigger fingers and thumbs. J Hand Surg Am.
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5. Saldana MJ. Trigger digits: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9:246-52.
6. Hueston JT, Wilson WF. The aetiology of trigger finger explained on the basis of intratendinous architeture.
eebb Hand. 1972;4:257-60.
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7. Sampson SP, Badalamente MA, Hurst LC, Seidman J. Pathobiology of the human A1 pulley in trigger finger.
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t m
J Hand Surg Am. 1991;16:714-21.
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8. Meachim G, Roberts C. The histopathology of stenosing tendovaginitis. J Pathol. 1969;98:187-92.
9. Drossos K, Remmelink M, Nagy N, de Maertelaer V, Pasteels JL, Schuind F. Correlations between clinical
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presentations of adult trigger digits and histologic aspects of the A1 pulley. J Hand Surg Am. 2009;34:1429-35.
10. Colbourn J, Heath N, Manary S, Pacifico D. Effectiveness of splinting for the treatment of trigger finger. J
Hand Ther. 2008;21:336-43.
11. Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg Am.
1992;17:110-3.
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rs Hand Ther. 1988;1:59-68.
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12. Evans RB, Hunter JM, Burkhalter WE. Conservative management of the trigger finger: a new approach. J
s
b ooook Surg Am. 2012;37:243-249.e1.
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13. Tarbhai K, Hannah S, von Schroeder HP. Trigger finger treatment: a comparison of 2 splint designs. J Hand
o
eeb Surg Am. 1989;14:722-7.
ee/ e
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14. Marks MR, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J Hand
: // t/.tm m : / /t/.tm. m
15. Rhoades CE, Gelberman RH, Manjarris JF. Stenosing tenosynovitis of the fingers and thumb. Results of a
.
t ppss / tppss : /
prospective trial of steroid injection and splinting. Clin Orthop Relat Res. 1984;(190):236-8.
:
16. Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J Hand Surg Am.
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1990;15:748-50.
hhttt
17. Rozental TD, Zurakowski D, Blazar PE. Trigger finger: prognostic indicators of recurrence following
corticosteroid injection. J Bone Joint Surg Am. 2008;90:1665-72.
18. Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med
Rehabil. 2006;85:36-43.
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19. Ring D, Lozano-Calderón S, Shin R, Bastian P, Mudgal C, Jupiter J. A prospective randomized controlled
s
trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger. J Hand Surg Am.
b ooook 2008;33:516-22.
o ook
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20. Taras JS, Raphael JS, Pan WT, Movagharnia F, Sotereanos DG. Corticosteroid injections for trigger digits: is
b
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intrasheath injection necessary? J Hand Surg Am. 1998;23:717-22.
21. Jianmongkol S, Kosuwon W, Thammaroj T. Intra-tendon sheath injection for trigger finger: the randomized
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t m m
controlled trial. Hand Surg. 2007;12:79-82.
. : / / t
/ .
t m
. m
t p ss /
outcomes. J Hand Surg Am. 2012;37:1319-23.
p t ppss : /
22. Shakeel H, Ahmad TS. Steroid injection versus NSAID injection for trigger finger: a comparative study of early
:
t
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2006;31:135-46. t
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23. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am.
24. Bruijnzeel H, Neuhaus V, Fostvedt S, Jupiter JB, Mudgal CS, Ring DC. Adverse events of open A1 pulley
release for idiopathic trigger finger. J Hand Surg Am. 2012;37:1650-6.
25. Lange-Riess D, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of trigger finger and
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trigger thumb in adults. Arch Orthop Trauma Surg. 2009;129:1617-9.
o k e
k e Surg Eur Vol. 2007;32:457-9.
o k e
26. Lim MH, Lim KK, Rasheed MZ, Narayanan S, Beng-Hoi Tan A. Outcome of open trigger digit release. J Hand
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27. Will R, Lubahn J. Complications of open trigger finger release. J Hand Surg Am. 2010;35:594-6.
ee/
28. Thorpe AP. Results of surgery for trigger finger. J Hand Surg Br. 1988;13:199-201.
/ e
29. Lorthioir J. Surgical treatment of trigger-finger by a subcutaneous method. J Bone Joint Surg Am. 1958;40-
m m
A:793-5.
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p
Hand Surg Am. 1992;17:114-7.
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t ss:
30. Eastwood DM, Gupta KJ, Johnson DP. Percutaneous release of the trigger finger: an office procedure. J
p
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31. Lyu SR. Closed division of the flexor tendon sheath for trigger finger. J Bone Joint Surg Br. 1992;74:418-20.
32. Ha KI, Park MJ, Ha CW. Percutaneous release of trigger digits. J Bone Joint Surg Br. 2001;83:75-7.
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t t p
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33. Calleja H, Tanchuling A, Alagar D, Tapia C, Macalalad A. Anatomic outcome of percutaneous release among
patients with trigger finger. J Hand Surg Am. 2010;35:1671-4.
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34. Habbu R, Putnam MD, Adams JE. Percutaneous release of the A1 pulley: a cadaver study. J Hand Surg Am.
2012;37:2273-7.
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35. Pope DF, Wolfe SW. Safety and efficacy of percutaneous trigger finger release. J Hand Surg Am.
: / / / t : / / / t
1995;20:280-3.
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36. Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger finger release: the ‘lift-cut’ technique. Br J Plast
p
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Surg. 2005;58:817-21.
t
hht t
37. Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JC. Prospective randomized trial of open versus
percutaneous surgery for trigger digits. J Hand Surg Am. 2001;26:497-500.
38. Dierks U, Hoffmann R, Meek MF. Open versus percutaneous release of the A1-pulley for stenosing
tendovaginitis: a prospective randomized trial. Tech Hand Up Extrem Surg. 2008;12:183-7.
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39. Sato ES, Gomes Dos Santos JB, Belloti JC, Albertoni WM, Faloppa F. Treatment of trigger finger: randomized
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clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery.
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Rheumatology (Oxford). 2012;51:93-9.
o
40. Wang J, Zhao JG, Liang CC. Percutaneous release, open surgery, or corticosteroid injection, which is the
eeb / e
/ e b
best treatment method for trigger digits? Clin Orthop Relat Res. 2013;471:1879-86.
ee
// t tm
. m
resection (USSR). J Hand Surg Br. 2004;29:368-73.
: / : / /t/ tm
41. Le Viet D, Tsionos I, Bouloudenine M, Hannouche D. Trigger finger treatment by ulnar superficialis slip
. . . m
42. Seradge H, Kleinert HE. Reduction flexor tenoplasty. Treatment of stenosing flexor tenosynovitis distal to the
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first pulley. J Hand Surg Am. 1981;6:543-4.
43. Lipscomb PR. Tenosynovitis of the hand and the wrist: carpal tunnel syndrome, de Quervain’s disease,
trigger digit. Clin Orthop Relat Res. 1959;13:164-81.
44. Ferlic DC, Clayton ML. Flexor tenosynovectomy in the rheumatoid finger. J Hand Surg Am. 1978;3:364-7.
45. Chammas M, Bousquet P, Renard E, Poirier JL, Jaffiol C, Allieu Y. Dupuytren’s disease, carpal tunnel
syndrome, trigger finger, and diabetes mellitus. J Hand Surg Am. 1995;20:109-14.
keerrss k eerrss
46. Griggs SM, Weiss AP, Lane LB, Schwenker C, Akelman E, Sachar K. Treatment of trigger finger in patients
ook ook
with diabetes mellitus. J Hand Surg Am. 1995;20:787-9.
b
eeboo 2008;33:980-1.
/ e b o
47. Baumgarten KM. Current treatment of trigger digits in patients with diabetes mellitus. J Hand Surg Am.
b o
e / e
48. Wang AA, Hutchinson DT. The effect of corticosteroid injection for trigger finger on blood glucose level in
m e m
: / /
/ t
/ .
t . m
diabetic patients. J Hand Surg Am. 2006;31:979-81.
: / /
/ t
/ .
t . m
t t ppss : t t ppss :
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e
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/ b
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: / / t
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p / t p ss:
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: / /
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eebb The Controversial ee/

Role
e
/ebb
of Diagnostic
: / / t
/ .
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/ .
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Studies
t p for
p : /
ss Carpal Tunnel Syndrome ttp ss
p : /
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hht t hht t
1,
*Justin C Wong MD, 2Christopher M Jones MD
1
Department of Orthopedic Surgery, Thomas Jefferson University Hospital
k eers
rs 2
k er
erss
Department of Orthopedic Surgery, Rothman Institute at the Thomas Jefferson University
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t ppss : / ABSTRACT
tppss : /
hhttt hhttt
The role of diagnostic testing in patients suspected of having carpal tunnel
syndrome (CTS) remains controversial. Part of this dilemma stems from
the lack of a gold standard for the diagnosis of CTS to which other tests
can be compared. Electrodiagnostic testing (EDT) can provide crucial
keerrss k eerrss
information in patients with atypical presentations, to evaluate for
b ooook b ook
other nerve conditions such as radiculopathy, neuropathy, or plexopathy.
o o
However, because of the false negative rate up to 34% with EDT, it cannot
eeb / e
/ e b
be exclusively relied upon as a confirmatory test for CTS. For patients with
ee
/ / t
/ t m
. m / / t
/ t
between patients with EDT positive and negative studies, thus raising
: : m
a high clinical likelihood of having CTS, the response to surgery is similar
. . . m
the question of whether confirmatory testing is required in this subset of
t
hhtt t
hhtt
patients. Newer technologies, such as ultrasound and magnetic resonance
imaging (MRI) are being investigated and have shown promise as simpler,
more accurate, and less invasive tools for screening and confirmatory
testing. Although these imaging studies do not provide neurophysiologic
information or evaluate for alternative diagnoses, they can demonstrate
k e rrss
e k e rrss
anatomic abnormalities causing CTS. Despite some recent evidence
e
o o
o o k o o
o o k
supporting their value in accurately diagnosing CTS, ultrasound, and MRI
are not currently recommended by the American Academy of Orthopaedic
eebb ee/ e
/ b
e b
Surgeons for routine evaluation of CTS.
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
hht
t t
hht t
Email: jcwong330@gmail.com
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e s
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: / /
/ t
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/ t
/ .t.
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hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k INTRODUCTION
o o
o o k
eebb ee/ e
/ebb
What criteria are used to establish the diagnosis of carpal tunnel syndrome
(CTS)? This is a topic of ongoing controversy. The diagnosis has traditionally been
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
based on history and physical examination, with electrodiagnostic tests (EDT)
t p ss
p : / ss : /
for confirmation. Recently, the routine use of EDT to guide treatment has come
t p p
t
hht t t
hht t
under question. Since there is no “gold standard” test to diagnose CTS, newer
modalities, such as ultrasound and magnetic resonance imaging (MRI), have
been investigated in search of a more accurate diagnostic tool which is simpler,
quicker, and less invasive. In this article, we explore the evolving controversies in
diagnosing CTS.
k eers
rs k er
erss
Carpal tunnel syndrome was first described by Sir James Paget in 18541 and is
b ooook b ooook
the most commonly diagnosed compressive neuropathy.2 Estimates of prevalence
eeb e / e b
are wide, ranging from 2.73 to 16%,4 in parts due to the lack of consensus on
/ e
diagnostic criteria. Various surgical specialists including orthopedic, hand, plastic,
e
t . m
. m t . m. m
and neurosurgeons, in addition to neurologists, rheumatologists, and general
: // / t : / / / t
practitioners diagnose and treat CTS. This diversity in training backgrounds,
hhttt hhttt
practice models, and governing organizations also contributes to the lack of
uniformity in defining CTS.5
Significant variations in the accuracy of physical examination provocative
tests have been reported,2,6 attributed in parts to inconsistencies in examination
method and interpretation.7 For example, a recent study suggested that Phalen’s
keerrss k eerrss
and Tinel’s tests were actually more diagnostic for tenosynovitis than CTS, with
b ooook b ook
sensitivities for detecting CTS of 46% and 30%, respectively.8 D’arcy et al. in
o o
their systematic review of the literature published in 2000 found that several
eeb / e
/ e b
traditional clinical findings have little or no diagnostic value, including nocturnal
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
paresthesias; Phalen and Tinel signs; thenar atrophy; and 2-point, vibratory and
. m
t ppss / t p ss : /
monofilament sensory testing.9 Since the accuracy and reliability of these and
:
other clinical findings have been questioned, some authors have emphasized the
p
t
hhtt t
hhtt
importance of obtaining an objective study, such as EDT, to help clarify or confirm
the diagnosis.6,8,9
As stated by the American Academy of Orthopaedic Surgeons (AAOS) in
their CTS Clinical Practice Guidelines (CPGs) published in 2007, the literature
k e rrss
e k rrss
does not permit calculation of the actual operating characteristics of any CTS
e e
diagnostic test due to lack of a true gold standard.6 The guidelines assert that
o o
o o k o o o k
history and examination or EDT alone do not reliably diagnose CTS, though
o
eebb ee/ e b
e b
a combination of these correlates with positive surgical outcomes6 (Figure 1).
/
Perhaps, a positive response to surgery is the best available gold standard. However,
: / / t .
t m
. m : / / t.tm. m
this clinical reference could only be applied in a research setting as it requires the
/ /
t p ss:
p / t p ss:
p /
patient to have had surgery to retrospectively confirm the diagnosis. Moreover, this
t
hht t t
hht t
gold standard can be confounded by the placebo effect, recall bias, or the influence
of postoperative splinting, rehabilitation, and activity modification. Use of this
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
The Controversial Role of Diagnostic Studies for Carpal Tunnel Syndrome
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb B
ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
C
t p ss:
p / t p ss:
p /
t t t t
Figure 1: Correlation of surgical outcome with A, clinical tests, B, electrodiagnostic tests, or C, both.
hht hht
From: Keith MW, Masear V, Chung K, Maupin K, Andary M, Amadio PC, et al. Diagnosis of carpal tunnel
syndrome. J Am Acad Orthop Surg. 2009;17:389-96, with permission.
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e s
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
standard also implies a complete release and an otherwise uncomplicated surgery
which might be hard to prove in a patient who has not improved postoperatively.
eebb ee/ e
/ebb
The AAOS CPGs delineate the “appropriate information gathering and
: / / t
/ t m
. m : / / t
/ t m
decision-making process in managing the diagnosis of CTS”, recognizing that
. . . m
arriving at the diagnosis itself is controversial.6 They recommend EDT be obtained
t p ss
p : / t p ss : /
when clinical and/or provocative tests are positive and surgery is being considered.
p
t
hht t t
hht t
Electrodiagnostic tests have been used successfully since 195610 with sensitivity
and specificity as high as 92 and 99%, based on a clinical diagnosis reference.11 The
test, however, adds expense, can delay definitive treatment, is not well tolerated by
patients, and has been argued to not change the probability of diagnosing CTS to
k eers
rs k er
erss
an extent that is clinically relevant.12,13 The false-negative rate of EDT is reported
to range from 8 to 34%.11,14 In light of this and the usually consistent clinical
b ooook o ook
presentation in CTS patients, Graham proposed that, for the majority who are
b o
eeb ee/ e
/ e b
considered to have CTS based on the CTS-6, a validated clinical diagnostic tool,
// t/ tm
EDT is unnecessary and not helpful.13
. . m / /t/.tm. m
The AAOS guidelines recommend against routinely evaluating patients with
: :
newer technologies. Magnetic resonance imaging, computed tomography (CT),
hhttt hhttt
and pressure-specified sensorimotor devices (PSSDs) are mentioned; ultrasound
is conspicuously absent from this list.6 It is these newer technologies, however, that
have garnered much interest lately in search of a quicker, cheaper, more accurate,
and more patient friendly alternative to EDT. The following is a summary of the
keerrss diagnostic modalities for CTS:

k eerrs
specific features, protocols, accuracy, and accepted uses of the three most common
s
b ooook 1. Electrodiagnostic tests
b o ook
o
eeb 2. Ultrasound
ee/
3. Magnetic resonance imaging.
e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t ppss :
ELECTRODIAGNOSTICS/ t ppss : /
t
hhtt t
hhtt
It was first recognized in 1956 that median nerve conduction across the wrist
was slowed in patients with CTS.10 Since then, EDT has been the mainstay of
diagnostic tests to evaluate CTS. In 1993, the Quality Assurance Committee of
k e rrss
e rrss
the American Association of Electrodiagnostic Medicine (AAEM) published its
e e
literature review on the usefulness of nerve conduction studies in the diagnosis
k
o o
o o k o o
o o k
of CTS.15 The review determined the incidence of test abnormalities in patients
eebb ee/ e
/ b
e b
clinically diagnosed with CTS utilizing a variety of specific EDTs. They concluded
that: (i) median nerve sensory latencies are more sensitive than median motor
: / / t
/ . m
. m : / / t. m. m
latencies, and (ii) long segment (13–14 cm) median sensory or mixed nerve
t / t
t p ss:
p / t p ss:
p /
conduction is less sensitive than either short segment (7–8 cm) conduction or
t t t t
comparison of conduction to radial sensory or ulnar nerves in the same limb.
hht hht
This led to the development of guidelines for performing EDTs for CTS, which
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o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
have been adopted by the American Academy of Neurology (AAN), American
Academy of Physical Medicine and Rehabilitation (AAPMR), American
eebb ee/ e
/ebb
Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)
/ / t
/ t m
Guidelines and endorsed by the AAOS (AAN/AAPMR/AANEM guidelines,
. . m /
AAOS CPG, Journal of Bone and Joint Surgery, and Journal of the American
: : / t
/ .
t m
. m
t p ss : /
Academy of Orthopaedic Surgeons.16
p t p ss
p : /
t
hht t t
hht t
One of the problems with assessing the utility of EDT is the wide variation
in the reported sensitivities of the various methods of measuring median nerve
function. In their review of the literature, the AANEM guidelines listed the range
of sensitivities for individual tests: median nerve distal motor latency (60–74%),
k eers
rs k er
ers
sensory latency over long (13–14 cm) segments (49–66%), and sensory or mixed
s
nerve conduction over short (7–8 cm) segments (69–84%), short segment
b ooook o ook
incremental stimulation (54–81%), and comparison of median sensory conduction
b o
eeb ee/ e
/ e b
with ulnar or radial sensory nerve conduction in the same limb (60–82%).15
The current AANEM recommendation is used for initial evaluation with long-
: // t .tm
. m : / /t .tm. m
segment sensory conduction latency with comparison to another sensory nerve if
/ /
the results are abnormal (sensitivity 65%, specificity 98%). If long-segment sensory
hhttt hhttt
conduction is normal, this should be confirmed with one of the following three
tests: (i) short-segment sensory conduction latency (sensitivity 71%, specificity
97%); (ii) comparison of sensory latency across wrist for radial or ulnar nerves
(sensitivity 65–85%, specificity 97–99%); or (iii) comparison of median nerve
keerrss specificity 98%).16

k eerrs
conduction across wrist to conduction in the finger or forearm (sensitivity 85%,
s
b ooook o ook
Although EDT has been shown to be a reliable tool for diagnosing CTS
b o
eeb ee e
/ e b
and detecting other nerve pathology (e.g., radiculopathy, polyneuropathy, brachial
/
plexopathy), there is still debate whether EDT should be performed routinely on
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
all patients, in particular those with classic signs and symptoms of CTS. Currently,
the AAOS recommends EDT: (i) to help differentiate between diagnoses; (ii) in
t
hhtt t
hhtt
the presence of persistent numbness and thenar atrophy (to help rule out other
serious nerve problems and guide treatment); and (iii) if provocative tests are
positive and surgery is being considered. However, it is unclear whether EDT is
useful in patients with a high pretest probability of having CTS, correlates with
symptom severity, or provides prognostic information. Critics of routine use of
k e rrss
e e rrss
EDT commonly cite the 16–34% rate of false-negative test results and question
k e
o o
o o k its value in guiding treatment.14,15,17
o o
o o k
eebb ee/ e
/ b
e b
Several authors have questioned the value of EDT in the management of
CTS in patients with classic symptoms.12,18-20 In 1994, Braun and Jackson
t . m
. m t.
retrospectively evaluated 151 workers compensation patients who had presented
: / / / t : / / / tm. m
t p ss:
p / t p ss:
p /
with moderate severity CTS.18 The patients were stratified into three groups
t t t t
which all underwent open carpal tunnel release (CTR): (i) CTS diagnosis based
hht hht
upon history and physical examination alone, (ii) clinical diagnosis of CTS but
k e r
e s
rs k eerrss
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o o k
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/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
normal EDT, and (iii) clinical diagnosis of CTS confirmed with abnormal EDT.
A sensory latency of more than 3.5 ms was utilized as the EDT threshold. The
eebb / e
/ebb
authors observed no significant differences in recovery of hand function, return to
ee
: / / t
/ t m
. m : / / t
/ t m
work, or persistence of impairing pain or numbness between the three groups. They
. . . m
found that 13–20% of patients continued to have persistent pain or numbness that
t p ss
p : / t p ss : /
impaired work function 6 months after surgery. This led the authors to conclude
p
t
hht t t
hht t
that EDT was not prognostic for recovery of function or return to work after
CTR. However, this study has been criticized for utilizing nonspecific outcome
measures, excluding patients with severe disease, and failing to utilize the full
complement of EDT tests as outlined in the AAEM guidelines.
k eers
rs k er
erss
Glowacki et al. similarly stratified 167 patients (227 hands) who had undergone
open CTR into three groups.19 They correlated EDT findings with clinical
b ooook ooook
outcome and found no difference in clinical outcome among patient groups; 93%
b
eeb ee/ e
/ e b
of patients in each group had complete resolution or improved but occasional
// t/ tm
. m / /t/ tm
symptoms. The authors concluded that in patients who meet clinical criteria for
. . . m
CTS, EDT did not correlate with symptom resolution and was not necessary.
: :
Other authors who have evaluated the utility of EDT suggest that it has
hhttt hhttt
little effect on altering the probability of diagnosing CTS in many patients.13
In a prospective, blinded study of 143 patients referred to an electrodiagnostic
laboratory for evaluation of a variety of upper extremity peripheral nerve disorders,
a clinical evaluation tool (CTS-6) was used to calculate a pretest probability for
keerrss k eerrs
the diagnosis of CTS, which was then compared to EDT short-segment sensory
s
latencies. For the 73% of patients with a pretest probability more than 80%, there
b ooook o ook
was little change in the post-test probability based upon EDT results. The authors
b o
eeb CTS. ee/ e
/ e b
assert that EDT may not be useful in patients with high clinical suspicion for
: / / t .
t m
. m : / / t .
t m
. m
Proponents of EDT argue that these tests can be prognostic when patients
/ /
are stratified by severity based on nerve conduction study findings.21,22 Aulisa
t
hhtt t
hhtt
et al. prospectively evaluated 50 hands treated with open CTR, with pre- and
postoperative EDTs.21 Patients were divided into three groups based on the
severity of their EDT findings. The authors found that all patients demonstrated
measurable improvements in EDT parameters postoperatively, with greater and
k e rrss
e rrss
more complete resolution of median nerve electrophysiologic function in the mild
e e
cases of CTS. Symptom resolution also correlated with the grading scale; 6.7%
k
o o
o o k o o o k
of mild cases reported persistent discomfort compared with 16.7 and 29.4% of
o
eebb ee/ e
/ b
e b
moderate and severe cases, respectively.
Similarly, Bland developed a 7-grade scale of CTS severity based on EDT
: / / t
/ .
t m
. m : / / t
/.tm. m
and compared it with symptom improvement as assessed by a questionnaire in
t p ss:
p / t p ss:
p /
998 patients22,23 (Table 1). The author found a nonlinear relationship between
t
hht t t
hht t
CTS severity and symptom resolution.22 Patients with no neurophysiologic
abnormality (grade 0) reported similar success rate after surgery as patients with
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e s
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
Table 1: Proposed Carpal Tunnel Severity Grading
o o k
eebb Grade
0
Definition
Normal
ee e
Examples
/ /ebb
No neurophysiologic abnormality
1 Very mild CTS
: / / t
/ .
t m
. m / / t .
t m
. m
Abnormality in only two sensitive tests (e.g., inching, palm/
: /
t p ss
p : / ss : /
wrist median/ulnar comparison, ring finger “double peak”)
t p p
2
t
hht
Mild CTS
t t
hht t
Orthodromic sensory conduction velocity (index to wrist)
<40 m/s; motor terminal latency from wrist to APB <4.5 ms
3 Moderately severe Wrist to APB, motor latency between 4.5 and 6.5 ms;
CTS preserved index finger sensory nerve action potential
4 Severe CTS Wrist to APB motor latency between 4.5 and 6.5 ms; absent
k eers
rs k er
erss
index finger sensory nerve action potential
b ooook 5 Very severe CTS
b ooook
Wrist to APB motor latency >6.5 ms
eeb b
6 Extremely severe Unrecordable sensory or motor nerve potentials
e / e
/ e
CTS, carpal tunnel syndrome; APB, abductor pollicis brevis.
e
// t/.tm
. m / /t/.tm. m
extremely severe CTS (grade 6) (51.2 vs. 46.6% success), respectively. Patients with
: :
moderate-to-severe (grades 2 through 4) demonstrated the greatest improvement
hhttt hhttt
with success rates of 74.1–77.0%. The author suggested that the lower success rate
observed in grade 0 patients may be due to incorrect diagnosis. In patients with
grade 6 severity, Bland attributed the lower success rate to permanent nerve injury
correlating with absent motor or sensory potentials.
keerrss k eerrs
The decision on whether or not to perform needle electromyography (EMG)
s
in addition to surface electrode nerve conduction studies is controversial, according
b ooook o ook
to the AAEM guidelines. Needle EMG can be uncomfortable for the patient and
b o
eeb ee/ e
/ e b
may not add to the clinical evaluation of a patient except in cases of suspected
radiculopathy or plexopathy.11 The AAEM has suggested that the overall rate of
: / / t .
t m
. m : / /
EMG abnormalities in CTS patients ranges between 25 and 41%.15 In patients
/ t
/ .
t m
. m
with normal median nerve conduction velocities across the wrist, the additional
t
hhtt t
hhtt
value of needle EMG is very low and EMG is probably unnecessary.11,24
Portable EDT devices have also been evaluated as potential screening tools
for CTS with mixed reviews.25-27 These devices incorporate a portable battery,
recording and stimulating surface electrodes and a liquid crystal display that
k e rrss
e rrss
shows the calculated motor or sensory latencies. A recent meta-analysis of
e e
5 studies, including 448 hands, comparing portable nerve conduction studies to
k
o o
o o k o o o k
a formal EDT reference demonstrated a pooled sensitivity and specificity of 0.88
o
eebb ee/ e
/ b
e b
[95% confidence interval (CI) = 0.83–0.91] and 0.93 (95% CI = 0.88–0.96).28
The prime advantage of these devices is their portability, facilitating their use as a
: / / t
/ .
t m
. m : / / t
/.tm. m
screening tool. However, these devices have several limitations such as: (i) inability
t p ss:
p / t p ss:
p /
to control for body temperature, distances from stimulating and recording points,
t
hht t t
hht t
and patient age, and (ii) inability to evaluate for associated conditions such as
peripheral neuropathy, radiculopathy or brachial plexopathy.29
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e s
rs k eerrss
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/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k ULTRASOUND
o o
o o k
eebb ee/ e
/ebb
In 1988, Molitor published the first record of ultrasound used for the diagnosis of
CTS with a reported 90% correlation with the EMG results.30 With the advent of
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
high resolution ultrasonography, Buchberger in 1991 was able to observe swelling
t p ss
p : / ss : /
and flattening of the nerve as well as bowing of the flexor retinaculum.31 Since
t p p
t
hht t t
hht t
then, there has been a rapidly growing interest in the value of ultrasound as a
complimentary study or possibly an alternative to EDT. A PubMed search of
“ultrasound” and “CTS” in May 2013 returned 455 citations with a remarkable
50% published within the past 5 years. Over 100 studies have been published
k eers
rs k er
ers
specifically on the utility of ultrasound for diagnosing compressive neuropathies.32
s
In reviewing the literature, it appears that ultrasound is more widely used in
b ooook o ook
European, Middle Eastern, and Asian countries as a majority of research arises
b o
eeb from these regions.
ee/ e
/ e b
While EDT is a functional study of the nerve, ultrasound is an imaging
: // t/.tm
. m : / /t/.tm. m
technique which allows direct observation of the nerve and its surrounding
structures (Figure 2). Ultrasound can provide complimentary information to
hhttt hhttt
EDT and potentially reveal an anatomic explanation for entrapment (tumor, cyst,
abscess, gouty tophus, or aberrant muscle) or anatomic anomalies (bifid median
nerve or persistent median artery).32 Finding evidence of the above might alter the
therapeutic approach or surgical plan. Ultrasound can accurately detect many nerve
properties including size, shape, echotexture, fascicle size, vascularity, and changes
keerrss k eerrss
in nerve mobility—all of which have shown some correlation with CTS.33-37
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
Figure 2: Ultrasonographic axial view of carpal tunnel
t
hht t t
hht t
where M stands for median nerve and arrows indicate
transverse carpal ligament.
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
The diagnostic value of nonnerve parameters, such as bowing and thickness of the
flexor retinaculum, elastic properties of the overlying soft tissues, and subsynovial
eebb / e
/ebb
tendon connective tissue thickness have also been investigated.38-40
ee
: / / t
/ t m
The most common and reproducible finding upon ultrasound evaluation of
. . m : / / t
/ .
t m
. m
the carpal tunnel is a fusiform median nerve enlargement just proximal to the site
t p ss
p : / t p ss : /
of entrapment.32 This is thought to develop from axoplasmic damming in addition
p
t
hht t t
hht t
to an inflammatory component.41,42 The measured cross-sectional area (CSA) of
the nerve at the inlet to the carpal tunnel has repeatedly been found to be the most
reliable parameter for diagnosing CTS.43-45 Ratios of the inlet to forearm CSA
also correlate well with the diagnosis.33 However, the CSA threshold above which
k eers
rs k er
ers
the diagnosis of CTS is made—the diagnostic cutoff value—is controversial.
s
Though many studies use inlet CSA cutoff values between 9 and 11 mm2,33
b ooook o ook
recommendations vary widely, ranging from 6 to 15 mm2, potentially due to a lack
b o
eeb ee/ e
/ e b
of standardization in measurement technique.46 A recent meta-analysis which
included 28 studies and 3,995 wrists recommended a CSA cutoff of 9 mm² which
: // t/.tm
. m : / /t/.tm. m
yielded the best diagnostic accuracy with overall sensitivity and specificity of 87
and 83%, respectively.33 Adjusting the CSA cutoff value to preferentially improve
hhttt hhttt
the sensitivity or specificity can make the test more suitable as either a screening
or confirmatory test. The AANEM guidelines recommend that each testing
laboratory establish their own CSA reference values based on their equipment
and testing protocols.44
The specific role of ultrasound in the diagnosis of CTS, whether used as a
keerrss k eerrss
stand-alone test or in conjunction with EDT, is contested. The AANEM convened
b ooook b o ook
an expert multispecialty panel of physicians to help answer this question. They
o
eeb e / e b
graded the quality of 67 ultrasound studies, identifying 4 AAN class I level of
/ e
the evidence studies.44 The range of sensitivity from these class I studies was 65–
e
t . m
. m
97%. Specificity ranged from 73–98%. Accuracy ranged from 79–97%. The panel
: / / / t : / / t
/ .
t m
. m
concluded that ultrasound is accurate for the diagnosis of CTS, implying its use as
t
hhtt t
a stand-alone test. Furthermore, they found that ultrasound adds diagnostic value
hhtt
when used in conjunction with EDT, particularly in patients with an atypical
clinical presentation, in detecting structural abnormalities potentially responsible
for CTS. Wong and colleagues proposed a treatment algorithm based on ultrasound
as an initial test with EDT follow-up when ultrasound was inconclusive.47 Based
k e rrss
e k e rrss
on the bulk of recently published studies, many authors support the routine use
e
o o
o o k o o
o o k
of ultrasound as an accurate and reliable stand-alone test for the diagnosis of
eebb b
CTS.33,43,44,46
ee/ e
/ e b
Yet, not all are convinced that ultrasound is poised to replace EDT. Fowler and
: / / t
/ .
t m
. m : / / t
/.tm
associates, in their 2010 meta-analysis, found that despite composite sensitivity
. m
p ss:
p / t p ss: /
of 78% (95% CI = 72–84%) and specificity of 87% (95% CI = 79–95%), the wide
variations in ultrasound studies, including heterogeneity in study design, prevent
t p
t
hht t t
hht t
meaningful analysis of the data.45 They concluded that ultrasound might not
replace EDT as a more accurate test, but may be considered as an alternative
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e s
rs k eerrss
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
to EDT as a first line confirmatory test. Two other recent meta-analyses arrive
at a similar conclusion suggesting its value as a screening tool48 and to provide
eebb ee/ e
/ebb
complimentary information to EDT.49 A 2007 German treatment guideline
/ / t
/ t m
. m / / t
/ t m
recommends ultrasound should be regarded as an “optional supplementary
. . . m
investigation”.50 Other authors share this conclusion, noting that EDT is more
: :
t p ss
p : / t p ss : /
accurate and robust, providing valuable information regarding the severity and
p
t
hht t
etiology of the symptoms.51-54 t
hht t
The concurrent use of color Doppler ultrasound to measure intraneural blood
flow is a promising new technique that might improve the accuracy of the test
compared to using CSA alone. Recent studies have demonstrated improved
k eers
rs k er
ers
sensitivity and specificity in the range of 83–90% and 89–90%, respectively.55-57
s
Mallouhi and colleagues evaluated 206 wrists with color Doppler and found a
b ooook o ook
95% accuracy using EDT as the reference.35 Joy et al. showed a sensitivity of 90%
b o
eeb ee e
/ e b
using CSA + Doppler blood flow criteria versus 83% for EDT using a clinical
/
diagnosis reference.56 Though there is some concern that the accuracy might
: // t/. m
. m : / /t . m. m
diminish during routine clinical use related to differences in machine settings and
t / t
t ppss : /
operator dependence.58
tppss : /
hhttt hhttt
Edema in the median nerve is suggested to be an earlier CTS clinical finding
than signal latency across the wrist by EDT.59 Therefore, ultrasound might be
of value in diagnosing patients with early CTS or in those with positive clinical
findings but negative EDT. One study looked at 59 EDT negative CTS patients
and identified 30% with abnormal swelling in the nerve, using a 10.5 mm2 CSA
keerrss k eerrss
cutoff, with only 3% false-positive rate.60 Another study found median nerve
b ooook b ook
enlargement and hyperemia in 77% of patients with “clinically indeterminate”
o o
CTS compared with only 47% who had EDT findings.56
eeb e / e
/ e b
It is generally accepted that EDT can quantify the severity of nerve injury,
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
though the correlation with symptoms is not well established.61,62 Whether
t ppss / t ppss : /
ultrasound is a reliable measure of injury severity is debated. According to Bayrak et
:
al., there is a close correlation of CSA with electrophysiologic stage and estimated
t
hhtt t
hhtt
number of axons.38 Similarly Karadag et al. reported a Cohen’s kappa coefficient
of 0.62 of agreement between severity of EDT and ultrasound findings based on a
pain visual analog scale and Boston carpal tunnel questionnaire.63 They suggested
CSA thresholds of 10–13 mm for mild, 13–15 mm for moderate, and greater
k e rrss
e k rrss
than 15 mm for severe CTS. Others have shown a high concordance of CSA
e e
with disease severity.64,65 Moreover, many recent studies suggested that intraneural
o o
o o k o o o k
vascularity as measured by Doppler ultrasound might have the strongest parallel
o
eebb ee/ e b
e b
with CTS severity.55,56,66,67 Conversely, many studies have not identified any
/
clinically significant correlation of ultrasound with CTS severity.54,68-72
: / / t .
t m
. m : / / t.tm. m
There is concern for the accuracy of ultrasound in certain subsets of patients.
/ /
t p ss:
p / t p ss:
p /
Median nerve atrophy resulting in a smaller CSA is possible in patients with
t
hht t t
hht t
severe and chronic CTS. It has been reported previously that the severity of CTS
increases with age73,74 and this might explain why ultrasound was less accurate in
k e r
e s
rs
124
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o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
one study in the elderly.64 This conclusion is refuted by Kasius et al., who found
the median nerve to still be abnormally enlarged in 11 out of 14 elderly patients
eebb ee/ e
/ebb
with clinically and electrophysiologically severe CTS.75 Carpal tunnel patients
/ / t
/ t m
. m / /
and diagnostic CSA compared to RA patients without CTS.76 In patients with
: : t
/ t m
with rheumatoid arthritis (RA) and other inflammatory arthritides have increased
. . . m
t p ss
p : / t p ss : /
diabetes mellitus, ultrasound has shown to be accurate except in the presence of
p
t
hht t
concomitant polyneuropathy.77,78 t
hht t
Ultrasound is indispensable in evaluating patients after failed CTR, readily
identifying and localizing fibrosis around the nerve, incomplete release, and
extensive tenosynovitis, which are considered the primary causes for continued or
k eers
rs k er
ers
recurrent symptoms.79,80 One report found an ultrasound identifiable cause of failed
s
CTR in 7 out of 14 patients.81 Additionally, ultrasound can reliably demonstrate a
b ooook o ook
decrease in nerve CSA and vascularity as soon as 3 weeks postoperatively (or after
b o
eeb ee e
/ e b
steroid injection).36,82-86 Documenting an objective positive response to treatment
/
can be valuable in assessing the cause of failed CTR, particularly when secondary
gain is a factor.
: // t/.tm
. m : / /t/.tm. m
Lastly, one argument against the widespread use of ultrasound is its
hhttt hhttt
dependence on the experience and skill of the ultrasound technician to produce
reliable results. According to Kluge, inter- and intraobserver agreement from
two observers evaluating the CSA of 50 asymptomatic wrists was excellent with
Cronbach’s a-values ranging from 0.75 to 0.94 and 0.92 to 0.99, respectively.87
Another study showed intra-rater reliability correlation coefficients more than 0.9,
keerrss k eerrss
but inter-rater reliability was more varied.32 In addition to technician–dependent
b ooook b o ook
factors, there is variability in testing devices, scanning protocols, and accepted
o
eeb e / e b
reference ranges, though this is not unlike EDT. Clearly, the most accurate study
/ e
will be performed by an experienced ultrasound technician in an established
e
: / / t
/ .
t m m : / / t
/ .
t m
. m
laboratory who have developed and validated their own testing protocols.44
.
t
hhtt
MAGNETIC RESONANCE IMAGING t
hhtt
Because of the measurable incidence of electrodiagnostically negative CTS, MRI
has also been investigated as an alternative diagnostic modality (Kamil).88-98 The
ability to visualize the soft tissue contents of the carpal canal with high resolution
k e rrss
e e rrss
allows MRI to detect anatomic anomalies that may result in persistent symptoms
k e
o o
o o k o o
o o k
after CTR, such as median neuritis, persistent median artery, or incomplete CTR,
eebb ee/ e
/ b
e b
making it invaluable in the evaluation of patients with failed CTR.88,99 Compared
to other diagnostic modalities, MRI is better tolerated than EDT,90 but is also
: / / t . m
. m
more expensive and more time consuming than both EDT and ultrasound.91
/ t : / / t
/.tm. m
t p ss:
p / t p ss:
p /
Routine use of MRI as an alternative to EDT is not yet established, in parts,
t
hht t t
hht t
because reliable assessment of the diagnostic accuracy of various MRI findings is
difficult due to heterogeneity between research studies.92
k e r
e s
rs k eerrss
125
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:34 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k o o o k
The typical observable characteristics of CTS on MRI include: increased
o
eebb bb
signal of the median nerve and flexor tendon sheaths on T2 weighted imaging,
ee/ e
/e
swelling of the median nerve at the entrance of the carpal canal, flattening of
: / / t
/ .
t m
. m : / / t
/ .
t m
the median nerve within the carpal canal, and palmar bowing of the transverse
. m
t p ss
p : / t p ss
p : /
carpal ligament (TCL).88,93 However, some authors have found no significant
differences in median nerve or carpal canal morphology between CTS patients
t
hht t t
hht t
and controls.100 While others have found only some of these parameters correlate
with CTS in case-control series.94,95,101 There continues to be evolution in
defining parameters to asses abnormalities of the carpal tunnel. Authors have
described the ratio of carpal canal contents to carpal canal area;102,103 findings of
k eers
rs k er
erss
muscle atrophy in median-innervated muscles;97 and variation in the angle of the
b ooook b oook
TCL bowing observed in CTS.96 Part of the discrepancy in determining which
o
imaging characteristics correlate best with CTS may be related to selection bias
eeb e / e
/ e b
and variation in MRI equipment. There is also some evidence to suggest that
e
: // t/.tm m : / /t/.tm. m
the median nerve morphology and signal characteristics differ between early and
.
advanced CTS stages,98 with more advanced stages exhibiting decreased signal
hhttt hhttt
intensity and retrograde swelling compared to early stages exhibiting generalized
increased signal intensity, absence of nerve flattening, and swelling of the median
nerve within the carpal canal.
A recent systematic review of 13 MRI studies including 509 hands found that
increased median nerve signal on T2 weighted imaging was the most sensitive
keerrss k eerrss
parameter (sensitivity 75% and specificity 66%).92 Interestingly, unlike median
b ooook b o ook
nerve CSA by ultrasound which demonstrates a reasonably high sensitivity, CSA
o
eeb ee / e b
by MRI showed only 35% sensitivity but 84% specificity. Flattening of the median
/ e
nerve showed 54% sensitivity and 95% specificity and TCL bowing showed 70%
t . m
. m t . m
. m
sensitivity and 93% specificity. These results are admittedly limited by study
: / / / t : / / / t
heterogeneity.
t
hhtt t
hhtt
The MRI parameters of median nerve signal intensity length and TCL
bowing have been suggested to correlate with clinical outcome in one study.90
In this prospective trial, 105 patients were evaluated with MRI, EDT, clinical
examination, and validated questionnaires and reevaluated at 1-year follow-
k e rrss
e rrss
up after operative or nonoperative treatment. A clinician blinded to the MRI
e e
results determined treatment. Thirty of the 105 patients underwent CTR and
k
o o
o o k o o o k
demonstrated greater improvement than patients treated nonoperatively. Using
o
eebb ee/ e
/ b
e b
multivariate analysis, the authors found that the length of the MRI signal intensity
in the median nerve and TCL bowing correlated with greater improvement
: / / t
/ .
t m
. m : / / t
/.tm. m
in patients treated operatively compared to those treated nonoperatively. The
t p ss:
p / t p ss:
p /
EDT parameter of median-ulnar nerve sensory latency difference demonstrated
t
hht t
similar predictive value. t
hht t
k e r
e s
rs
126
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:34 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o o k
Only one study has directly compared MRI with other diagnostic modalities
o
eebb bb
and found that MRI has comparable accuracy to EDT, ultrasound, and CT.91
ee/ e
/e
Using clinical diagnosis as a reference standard, 69 patients were evaluated with
: / / t
/ .
t m
a combination of MRI, EDT, ultrasound, or CT and the authors constructed
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p :
Magnetic resonance imaging parameters investigated included median nerve/
receiver-operating characteristic curves to determine diagnostic accuracy.
t
hht t t
hht t
CSA and signal intensity both proximally and distally in the carpal canal, which
was compared with CSA and nerve density or echogenicity by CT or ultrasound.
There was no statistically significant difference in area under the curve between
the modalities when distal median nerve area was compared with EDT.
k eers
rs k er
erss
Despite promising reports on the use of MRI in diagnosing CTS, the
b ooook b oook
diagnostic accuracy of the various imaging parameters is still not well-
o
established. According to the AAOS, MRI should not be used routinely for the
eeb / e
/ e b
evaluation of patients suspected of having CTS because of the absence of data
ee
: // t/ tm
to show improved diagnostic accuracy over EDT.6 Although MRI has shown
. . m : / /t/.tm. m
utility in identifying morphologic changes of the median nerve and carpal tunnel
contents, its role in the initial diagnosis of CTS still remains undetermined.
hhttt hhttt
Because of the expense and time associated with MRI studies, the key hurdles
to establishing it as an alternative to EDT include better defining the diagnostic
accuracy and demonstrating its ability to diagnose CTS in patients with false-
negative EDTs.
keerrss k eerrss
b ooook CONCLUSION
b o ook
o
eeb ee e
/ e b
The role of diagnostic testing in patients, suspected of having CTS, remains
/
controversial. Part of this dilemma stems from the lack of a gold standard for
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
the diagnosis of CTS to which other tests can be compared. Electrodiagnostic
testing can provide crucial information in patients with atypical presentations,
t
hhtt t
hhtt
to evaluate for other nerve conditions, such as radiculopathy, neuropathy, or
plexopathy. However, because of the false-negative rate up to 34% with EDT,14
it cannot be exclusively relied upon as a confirmatory test for CTS. For patients
with a high clinical likelihood of having CTS, the response to surgery is similar
between patients with EDT positive and negative studies,12,18-20 thus, raising the
k e rrss
e e rrss
question of whether confirmatory testing is required in this subset of patients.
k e
o o
o o k o o
o o k
Newer technologies, such as ultrasound and MRI, are being investigated and have
eebb e / / b
e b
shown promise as simpler, more accurate, and less invasive tools for screening
e
and confirmatory testing. Although these imaging studies do not provide
e
: / / t
/ .
t m m : / / t
neurophysiologic information or evaluate for alternative diagnoses, they can
. /.tm. m
t p ss:
p / t p ss:
p /
demonstrate anatomic abnormalities causing CTS. Despite some recent evidence
t
hht t
supporting their value in accurately diagnosing CTS, ultrasound, and MRI are not
t hht
currently recommended by the AAOS for routine evaluation of CTS. t
k e r
e s
rs k eerrss
127
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:34 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Wong and Jones
k e r
e s
rs k eers
r s
o o
o o k
eebb e / e
/ebb
Carpal tunnel syndrome (CTS) is the most common diagnosis evaluated and
e
: / t . m
. m t . m
. m
treated by hand surgeons. The diagnosis can readily be made by history and physical
/ / t : / / / t
t p ss
p : / ss : /
examination. However, a number of diagnostic studies have been utilized including
t p p
hhtt t t t
electrodiagnostic tests, ultrasound, and magnetic resonance imaging. In this article,
hht
the authors present a detailed review of the various diagnostic studies available in
the diagnosis of CTS including their efficacy and accuracy.
Asif M Ilyas
k eers
rs k er
erss
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t t p
t ss:
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s
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o
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eeb / e e b
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ee /
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t . m
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: // / t : / / / t
t pp : / tp s : /
49. Descatha A, Huard L, Aubert F, Barbato B, Gorand O, Chastang JF. Meta-analysis on the performance of
ss s
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p
hhttt hhttt
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eeb / e
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ee / e b
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63. Karada� YS, Karada� O, Ciçekli E, Oztürk S, Kiraz S, Ozbakir S, et al. Severity of Carpal tunnel syndrome
/
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66. Mohammadi A, Ghasemi-Rad M, Mladkova-Suchy N, Ansari S. Correlation between the severity of carpal
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studies. J Clin Ultrasound. 2009;37:125-31.
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69. Kaymak B, Ozçakar L, Cetin A, Candan Cetin M, Akinci A, Hasçelik Z. A comparison of the benefits of
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: // t tm
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/ /
70. Mhoon JT, Juel VC, Hobson-Webb LD. Median nerve ultrasound as a screening tool in carpal tunnel
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71. Klauser AS, Halpern EJ, De Zordo T, Feuchtner GM, Arora R, Gruber J, et al. Carpal tunnel syndrome
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72. Naranjo A, Ojeda S, Araña V, Baeta P, Fernández-Palacios J, García-Duque O, et al. Usefulness of clinical
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73. Kouyoumdjian JA, Zanetta DM, Morita MP. Evaluation of age, body mass index, and wrist index as risk
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factors for carpal tunnel syndrome severity. Muscle Nerve. 2002;25:93-7.
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74. Blumenthal S, Herskovitz S, Verghese J. Carpal tunnel syndrome in older adults. Muscle Nerve. 2006;34:
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75. Kasius KM, Claes F, Verhagen WI, Meulstee J. Ultrasonography in severe carpal tunnel syndrome. Muscle
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76. Hammer HB, Haavardsholm EA, Kvien TK. Ultrasonographic measurement of the median nerve in
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77. Hassan A, Leep Hunderfund AN, Watson J, Boon AJ, Sorenson EJ. Median nerve ultrasound in diabetic
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78. Chen SF, Huang CR, Tsai NW, Chang CC, Lu CH, Chuang YC, et al. Ultrasonographic assessment of carpal
o k e
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tunnel syndrome of mild and moderate severity in diabetic patients by using an 8-point measurement of
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median nerve cross-sectional areas. BMC Med Imaging. 2012;12:15.
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79. Jones NF, Ahn HC, Eo S. Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed
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80. Tan TC, Yeo CJ, Smith EW. High definition ultrasound as diagnostic adjunct for incomplete carpal tunnel
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/ t . . m
release. Hand Surg. 2011;16:289-94.
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81. Botchu R, Khan A, Jeyapalan K. Pictorial essay: Role of ultrasound in failed carpal tunnel decompression.
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82. Jeong JS, Yoon JS, Kim SJ, Park BK, Won SJ, Cho JM, et al. Usefulness of ultrasonography to predict
response to injection therapy in carpal tunnel syndrome. Ann Rehabil Med. 2011;35:388-94.
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83. Kim JY, Yoon JS, Kim SJ, Won SJ, Jeong JS. Carpal tunnel syndrome: Clinical, electrophysiological, and
ultrasonographic ratio after surgery. Muscle Nerve. 2012;45:183-8.
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84. Mondelli M, Filippou G, Aretini A, Frediani B, Reale F. Ultrasonography before and after surgery in carpal
tunnel syndrome and relationship with clinical and electrophysiological findings. A new outcome predictor?
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Scand J Rheumatol. 2008;37:219-24.
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85. Colak A, Kutlay M, Pekkafali Z, Saraçoglu M, Demircan N, Simşek H, et al. Use of sonography in carpal tunnel
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86. Smidt MH, Visser LH. Carpal tunnel syndrome: clinical and sonographic follow-up after surgery. Muscle
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88. Mesgarzadeh M, Schneck CD, Bonakdarpour A, Mitra A, Conaway D. Carpal tunnel: MR imaging. Part II.
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90. Jarvik JG, Comstock BA, Heagerty PJ, Haynor DR, Fulton-Kehoe D, Kliot M, et al. Magnetic resonance
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94. Monagle K, Dai G, Chu A, Burnham RS, Snyder RE. Quantitative MR imaging of carpal tunnel syndrome. Am
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95. Uchiyama S, Itsubo T, Yasutomi T, Nakagawa H, Kamimura M, Kato H. Quantitative MRI of the wrist and
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nerve conduction studies in patients with idiopathic carpal tunnel syndrome. J Neurol Neurosurg Psychiatry.
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magnetic resonance imaging parameter for the evaluation of carpal tunnel. Clin Neurol Neurosurg.
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97. Britz GW, Haynor DR, Kuntz C, Goodkin R, Gitter A, Kilot M. Carpal tunnel syndrome: correlation of magnetic
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99. Taghizadeh R, Tahir A, Stevenson S, Barnes DE, Spratt JD, Erdmann MW. The role of MRI in the diagnosis of
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Aesthet Surg. 2011;64:1250-2.
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100. Bak L, Bak S, Gaster P, Mathiesen F, Ellemann K, Bertheussen K, et al. MR imaging of the wrist in carpal
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tunnel syndrome. Acta Radiol. 1997;38:1050-2.
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101. Martins RS, Siqueira MG, Simplicio H, Agapito D, Medeiros M. Magnetic resonance imaging of idiopathic
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carpal tunnel syndrome: correlation with clinical findings and electrophysiological investigations. Clin Neurol
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t m
Neurosurg. 2008;110:38-45.
/ . : / /
/ t
/.t . m
102. Cobb TK, Bond JR, Cooney WP, Metcalf BJ. Assessment of the ratio of carpal contents to carpal tunnel
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t ss:
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hht hht
103. Oge HK, Acu B, Gucer T, Yanik T, Savlarli S, Firat MM. Quantitative MRI analysis of idiopathic carpal tunnel
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r s
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o o kWorld Clin Orthoped. 2016;3(1):133-46.
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Scaphoid Fractures
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*Christopher R Jockel MD, 2Dan A Zlotolow MD, 3Joshua M Abzug MD
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Department of Orthopedic Surgery, Colorado Permanente Medical Group
Denver, Colorado, USA
2
Pediatric Hand and Upper Extremity Surgery, Shriners Hospital for Children
3
Department of Orthopedics and Pediatrics, University of Maryland School of Medicine
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Baltimore, Maryland, USA
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Management of pediatric and adolescent scaphoid fractures presents
specific challenges and considerations distinct from the adult injury.
Fracture patterns are related to the development and maturation of
the immature carpus. Recent studies have shown changes in patient
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demographics and fracture patterns suggesting that historical assumptions
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may no longer apply when treating this population. While nondisplaced
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distal pole scaphoid fractures have typically been described, current
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evidence suggests that scaphoid waist fractures are more common.
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These injuries require special consideration as waist fractures have
e
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prolonged healing times and higher rates of nonunion. The indications
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changing epidemiology.
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for operative and nonoperative care continue to evolve along with the
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INTRODUCTION
Scaphoid fractures are the most common carpal bone fractures in the pediatric
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and adult populations. The annual incidence of scaphoid fractures in children
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less than 15 years of age is reported to be 0.6 per 10,000. These injuries represent
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approximately 0.4% of all pediatric fractures and 0.45% of pediatric upper
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extremity fractures.1 While the youngest reported scaphoid fracture is believed
12 and 16 years of age.2

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to have been in a 4-year-old child, studies suggest the typical patient is between
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Email: Christopher.r.jockel@kp.org
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Jockel et al
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Scaphoid fracture patterns are related to the development and maturation of
the immature carpus. The scaphoid develops by endochondral ossification with
eebb / e
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the ossific nucleus first appearing in the distal pole typically between 4 and 5 years
ee
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of age. The bone ossifies from distal to proximal along the primary blood supply,
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which comes from a branch of the radial artery at the dorsal ridge. Ossification is
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usually complete between 13 and 15 years of age.3 During this time of scaphoid
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maturation, the location of injury is related to patient age, degree of ossification,
and mechanism. The predominance of distal pole fractures in the pediatric
population is attributed to this pattern of development.
Multiple mechanisms of injury to the scaphoid have been described in children
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erss
and adolescents. Injuries can result from a fall on an outstretched hand, punching,
or crush mechanism. Overall, sports such as football, basketball, skateboarding,
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and snowboarding have been reported as the most common precipitating activities
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Studies have shown a changing trend in the patterns of pediatric scaphoid
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fractures.4,5 Historical reports of this injury have typically described nondisplaced
: :
fractures in the distal third of the scaphoid.6 In the report of 108 pediatric scaphoid
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fractures by Vahvanen et al., 87% occurred at the distal pole, 12% at the waist, and
1% at the proximal pole.7 The predominance of distal pole injuries has been related
to scaphoid development.
A more recent study of scaphoid fractures in children and adolescents,
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however, suggests that the patterns of injury have changed to more closely
s
resemble adult scaphoid injuries. In the report of 312 pediatric scaphoid
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fractures by Gholson et al., the most common fracture location was the waist in
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71% of patients, with 23% and 6% of fractures at the distal and proximal poles,
respectively.4 Additionally, only 8% of fractures occurred at the distal pole when
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t m
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t m
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the physis was closed. The authors attributed this changing epidemiology in the
/ /
pediatric population to a variety of factors including the emergence of extreme
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sports, to an increased body mass index, and to more intense participation in
sports at a younger age.
The changing pattern and demographics of pediatric scaphoid fractures has
important considerations for treating these injuries. The classic nondisplaced,
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distal third scaphoid fracture in the pediatric patient has been shown to reliably
e e
heal with nonoperative treatment and to rarely require extended follow-up.6
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In contrast, multiple reports show that scaphoid waist fractures require special
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consideration, as these fractures take longer to heal with immobilization and more
commonly progress to nonunion.8 Male sex, an elevated body mass index, a high-
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t m
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energy mechanism of injury, and closed physis have been associated with fractures
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of the scaphoid waist in children.4 As pediatric and adolescent fractures more
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hht t
closely resemble adult scaphoid injuries, historical assumptions about the most
appropriate treatment and outcomes of these injuries should be reexamined.
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rs
134
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o o k
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/e 7/22/2016 11:29:35 AM
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Pediatric and Adolescent Scaphoid Fractures
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Multiple classifications have been proposed for pediatric and adolescent scaphoid
fractures. The simplest classification describes the fracture according to the
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t m
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anatomic location in the bone. Scaphoid fractures can be classified as occurring at
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the tuberosity, transverse distal pole, avulsion distal pole, waist, and proximal pole.8
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t
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hht t
A 3-part classification scheme has also been suggested for scaphoid fractures
in children. This classification is based on the age of the child and the presumed
degree of ossification.9 Type 1 lesions are purely chondral or involve a part of the
ossific nucleus. These rare injuries occur in children less than 8 years of age and
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rs k er
ers
are difficult to diagnose with standard radiographs. Advanced imaging studies,
s
such as magnetic resonance imaging (MRI), may be necessary to fully characterize
b ooook o ook
these fractures. Type 2 lesions occur in patients 8–11 years of age. These injuries
b o
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are osteochondral fractures. Type 3 fractures are common and typically occur in
/
patients over 12 years of age when scaphoid ossification is nearing completion.
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HISTORY AND EXAMINATION
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Pediatric and adolescent scaphoid fractures may be challenging to diagnose
based on subtle clinical signs, lack of distinct radiographic findings, rarity of the
injury, and difficulty in interpreting the partially ossified carpus.8,10 This injury
keerrss k eerrs
should be differentiated from congenital bipartite scaphoid.11 A high index of
s
suspicion is necessary when evaluating the immature patient for a suspected
b ooook scaphoid injury.

b o ook
o
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/ e b
Based on clinical history, a scaphoid fracture may be suspected after a high-
/
energy injury, fall on the outstretched hand, punching, or crush injury to the wrist.
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. m : / / t .
Symptoms of pain may be subtle or nonexistent at presentation. On examination,
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. m
the most common sign of scaphoid fracture is snuffbox tenderness. Evenski et
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hhtt t
hhtt
al. have identified volar tenderness over the scaphoid, pain with radial deviation,
and pain with active wrist motion as significant predictors of scaphoid fracture
in children.10 Other findings may include snuffbox swelling and pain with axial
loading.12
k e e ss STUDIES
rIMAGING
r k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
Radiographic imaging of suspected scaphoid injuries should include anteroposterior,
lateral, oblique, and scaphoid views.13 A comparison film of the contralateral wrist
: / / t
/ . m
. m : / / t. m. m
can provide additional information. The sensitivity of radiographs for detecting
t / t
t p ss:
p / t p ss:
p /
pediatric scaphoid fractures is variable, however, with reports between 21 and
t
hht t t t
97%.8 Additional work has shown that approximately 13% of fractures do not
hht
appear until 1–2 weeks after injury, further complicating the diagnosis.1 Based on
k e r
e s
rs k eerrss
135
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Jockel et al
k e r
e s
rs k eers
r s
o o
o o k to identify the injury. o o
o o k
these findings, advanced imaging studies may be necessary when radiographs fail
eebb / e
/ebb
Multiple imaging modalities provide further information in the setting of
ee
: / / t
/ t m
. m : / / t
/ t m
nondiagnostic radiographs. Computed tomography (CT), ultrasonography, bone
. . . m
scintigraphy, and MRI have all been used. The radiation associated with CT scan
t p ss
p : / t p ss : /
and bone scintigraphy makes these modalities less favorable. Ultrasonography can
p
t
hht t t
hht t
also provide useful information but is highly user-dependent. Despite having the
highest associated cost, MRI is the definitive test of choice due to a reported 100%
negative predictive value, lack of radiation, and is less operator-dependent.14
k eers
rsTREATMENT
k er
erss
b ooook ooook
Most pediatric scaphoid fractures can be managed with nonoperative care.
b
eeb ee/ e
/ e b
Historically, these fractures often are nondisplaced, in the distal third of the
: // t/ tm
. m : / /t/ tm
scaphoid, and can be treated with cast immobilization.6,15 Indications for operative
. . . m
intervention, however, continue to evolve along with the changing epidemiology
t pps s : /
(Figures 1 and 2).
tppss : /
hhttt hhttt
Nonoperative Management
Nondisplaced scaphoid fractures in the pediatric population are usually treated
keerrss k eerrss
with cast immobilization. Immobilization should begin at the time of initial
diagnosis or if there is concern of an acute scaphoid fracture with nondiagnostic
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k
eebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
t
hht t
ORIF, open reduction and internal fixation.
t
hht t
Figure 1: Basic algorithm for the treatment of scaphoid waist fractures. Courtesy: Dan A Zlotolow, MD.
k e r
e s
rs
136
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
: // t . m
. m
ORIF, open reduction and internal fixation.
/ t : / /t/.tm. m
Figure 2: Basic algorithm for the treatment of scaphoid proximal pole fractures. Courtesy: Dan A Zlotolow, MD.
hhttt hhttt
radiographs. Casting should be continued until the diagnosis can be confirmed
with repeat radiographs at 2-week follow-up or until MRI clarifies the injury.
keerrss injuries.1,6
k eerrs
Union rates greater than 90% have been reported with immobilization of acute
s
b ooook b o ook
The optimal regiment of cast immobilization remains unclear. Long-arm
o
eeb ee e
/ e b
thumb spica casting is often the initial choice in children due to the difficulty
/
with cast wear, the greater degree of immobilization, and the active patient
: / / t
/ . m
. m : / / t
population. In contrast, short-arm thumb spica casting has also been used and
t / .
t m
. m
may be appropriate in the treatment of incomplete or avulsion fractures.8 Patients
t
hhtt t
hhtt
may also be initially treated with a long-arm thumb spica cast and transitioned
to short-arm casting after several weeks.4 While there are no studies comparing
short- and long-arm castings for the treatment of pediatric scaphoid fractures,
there is limited literature on adults to suggest a potential advantage with long-arm
casting. In the report by Gellman et al., adult scaphoid fractures treated with long-
k e rrss
e e rrss
arm thumb spica casting had a shorter time to fracture union (9.5 and 12.7 weeks)
k e
o o
o o k o o
o o k
and a lower nonunion rate (0 and 7%) compared to short-arm immobilization.16
eebb e / / b
e b
In the absence of strong evidence, we currently favor the use of a long-arm thumb
e
spica cast for the initial 3–6 weeks, followed by a short-arm thumb spica cast until
e
fracture union.
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
The duration of casting necessary for scaphoid healing is also poorly defined.
t t t t
Fracture healing can be influenced by multiple factors including the open physis,
hht hht
fracture location, displacement, and the acuity of the injury.4 While an open
k e r
e s
rs k eerrss
137
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Jockel et al
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
physis is associated with shorter healing times, injuries presenting with fracture
displacement, chronic fractures, and a more proximal location are correlated with
eebb / e
/ebb
greater times to union.4 Healing times for acute fractures have been reported to
ee
: / / t
/ t m
. m
fractures progressing to nonunion at 6 months.7,9,17
: / / t
/ t m
vary widely from 3 weeks to more than 15 weeks, with a small percentage of
. . . m
t p ss
p : / t p ss
p : /
t t
hhtManagement
Operative t
hht t
The operative indications for pediatric and adolescent scaphoid fractures continue
to evolve. Although uncommon, scaphoid fractures with significant comminution,
k eers
rs k er
erss
displacement, or failed cast immobilization are indicated for surgical fixation.4,5
With the changing pattern of scaphoid fractures in children, many relative
b ooook o ook
indications for surgery should also be considered. These indications include
b o
eeb / e e b
nondisplaced scaphoid waist or proximal pole fractures, high-level athletes, and in
ee /
patients with a delayed presentation or chronic injury.
// t/.tm
. m / /t/.tm. m
Surgical fixation of scaphoid waist and proximal pole fractures should be
: :
considered, especially as patients approach skeletal maturity. While these injuries
hhttt hhttt
often heal with nonoperative care, multiple studies report an increased risk of
nonunion with cast immobilization. In the study by Henderson et al., 20 scaphoid
waist fractures failed to heal after immobilization for a mean of 4.2 months.18
Likewise, in the report by Southcott et al., all observed pediatric scaphoid nonunions
keerrss k eerrs
were nondisplaced waist fractures.19 While there are no studies comparing union
s
rates of cast immobilization to surgical repair in children, the adult literature
b ooook o ook
supports a higher rate of union with screw fixation of scaphoid injuries.20 As
b o
eeb e
injuries remains controversial.
e e
/ e b
patients approach skeletal maturity, the most appropriate management of these
/
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
High-level athletes may seek operative intervention for scaphoid fractures.
Potential advantages of surgical fixation include a shorter time to fracture union,
t
hhtt t
hhtt
a limited period of immobilization, and an accelerated rehabilitation program.
In adults, reports have shown a decreased time to fracture union and an earlier
return to work or sports with surgical fixation of nondisplaced scaphoid fractures
in comparison to cast immobilization.21,22 In the pediatric and adolescent
population, there is currently limited data addressing this issue. We speculate that
k e rrss
e e rrss
the advantages observed in the adult population may translate to the pediatric
k e
o o
o o k o o
o o k
population, especially as children approach skeletal maturity. Interestingly, one
eebb e / / b
e b
study of pediatric and adolescent scaphoid fractures failed to show a significantly
e
shorter time to healing in association with surgical fixation of acute injuries.4
e
t . m
. m t. m. m
Pediatric and adolescent scaphoid fractures are often encountered with a
: / / / t : / / / t
t p ss:
p / t p ss:
p /
delayed presentation or late diagnosis. In the report by Gholson et al., 29% of
t t t t
fractures were evaluated for more than 6 weeks after initial injury.4 The most
hht hht
appropriate management of these injuries is poorly defined. An attempt should
k e r
e s
rs
138
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
be made to distinguish the late-presenting fracture from a chronic scaphoid
nonunion, but differentiating the two may be difficult. Multiple studies have
eebb ee/ e
/ebb
reported successful outcomes with both operative and nonoperative treatment.
: / / t
/ t m
Some authors advocate a trial of cast immobilization before considering
. . m : / / t
/ .
t
surgical fixation of late-presenting pediatric scaphoid fractures and delayed m
. m
t p ss
p : / t p ss : /
unions.23 This recommendation is based on multiple reports of successful casting of
p
t
hht t t
hht t
fracture nonunions.6,24,25 While it is unclear how long a course of immobilization
should be attempted before considering surgery, 3 months has been suggested as
a reasonable time period.6
Other reports are less optimistic about the outcomes of casting late-presenting
k eers
rs k er
ers
injuries. In the study by Gholson et al., only 23% of fractures presenting more
s
than 6 weeks after injury, healed with cast immobilization. This report showed
b ooook o ook
that late-presenting fractures took a mean of 9 weeks longer to heal than acute
b o
eeb / e e b
injuries and were almost 30 times less likely to heal than acute fractures treated
ee /
with casting. Furthermore, they reported a healing rate of approximately 96%
: // t .tm
. m : / /t .
with the surgical treatment of chronic nonunions, suggesting the efficacy
/ / tm. m
of operative repair.4 In this population, the high rate of fracture union with
hhttt hhttt
surgical fixation needs to be balanced against the potential for healing with cast
immobilization, while also considering the inherent risks of surgery, delayed
union, and cast intolerance.
Multiple factors should be considered when evaluating late-presenting
keerrss k eerrs
scaphoid fractures in the pediatric population. The presence of fracture instability,
s
displacement, cavitary defects, humpback deformity, corticated margins, avascular
b ooook o ook
necrosis, anatomic location, skeletal maturity, and patient’s preference should be
b o
eeb ee e
assessed as part of the treatment algorithm.
/ / e b
Scaphoid fractures that present between 4 and 8 weeks and have never been
: / / t
/ . m
. m : / / t . m
. m
immobilized can still be considered active fractures. In some cases, these injuries
t / t
are identified by a careful history. Often, recent minor trauma worsens pain
t
hhtt t
hhtt
that had been present before and prompts the patient to seek medical advice.
Radiographically, the scaphoid typically develops a cavitary lesion at the fracture
site without evidence of cortication (Figure 3A). The area of bony resorption can
be confused with a pathologic fracture, which should remain in the differential
if there is only a history of minor trauma. Posteroanterior (PA), lateral, ulnar
k e rrss
e e rrss
deviation (scaphoid view), and pronated oblique radiographs should be adequate
k e
o o
o o k for diagnosing most subacute injuries.
o o
o o k
eebb e / / b
e b
For minimally or nondisplaced fractures, treatment options include cast
e
immobilization and percutaneous screw fixation. We offer most of our patients in
e
: / / t
/ .
t m m : / / t
/.tm
this setting percutaneous screw fixation (Figure 3B). Although surprisingly high
. . m
t p ss:
p / t p ss:
p /
union rates can be achieved with a minimum of 12 weeks of immobilization, the
t
hht
a difficult time maintaining a cast for that long. t
risk of developing a true nonunion is higher with cast fixation. Children also have
t hht t
k e r
e s
rs k eerrss
139
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Jockel et al
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb A
ee/ e
/ e b B
// t/ tm
. m / /t/ tm
Figure 3: A, A posteroanterior radiograph of a subacute scaphoid waist fracture in an
. . . m
adolescent male shows a complete nondisplaced fracture with a central cavitary lesion.
: :
B, A follow-up radiograph 6 weeks after volar percutaneous screw fixation shows healing
hhttt hhttt
of the fracture with near complete filling of the cavitary lesion without bone grafting.
Courtesy: Dan A Zlotolow, MD.
keerrss k eerrs
If there is a humpback deformity, treatment options are limited to operative
s
fixation of some type. An open reduction with screw fixation has become the most
b ooook b o ook
common treatment, usually with some form of bone graft. Cross-pinning the
o
eeb ee e
/ e b
lunate to the distal radius in a neutral position combined with thumb finger-trap
/
traction is usually sufficient to reduce the scaphoid (Figure 4). For waist fractures,
t . m
. m t . m
. m
authors use distal-radial bone graft even in skeletally immature patients. The graft
: / / / t : / / / t
harvest site is deep to the pronator quadratus and therefore, proximal to the physis
t
hhtt t
hhtt
which is at the level of the watershed line (Figure 5). A corticocancellous piece
can be harvested to fill in whatever impaction defect remains after correcting the
humpback deformity. In children, the distal radius cancellous bone is dense and
replete with active osteoprogenitor cells. Extensive curetting of the bone is both
unnecessary and ill-advised, given the proximity of the physis to the harvest site.
k e rrss
e e rrss
Dorsal distal radius bone graft harvest is contraindicated in children with
k e
o o
o o k o o
o o k
open physes since the physis is at the level of Lister’s tubercle. If performing a
eebb e / / b
dorsal approach to the scaphoid (as in the case of a proximal pole fracture) in
e e b
skeletally immature patients, bone graft needs to be harvested from outside of the
e
: / / t
/ .
t m
. m : / / t
/.tm. m
wrist. Other graft options include the proximal ulna, the tibia, and the iliac crest.
t p ss:
p / t p ss:
p /
For those with extensive wrist arthroscopy experience, an arthroscopically
assisted reduction, percutaneous bone grafting, and percutaneous screw fixation
t
hht t
is another option. t
hht t
k e r
e s
rs
140
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb A
ee/ e
/ e b B
t . m
. m t . m. m
Figure 4: A, Lateral fluoroscopic images show passage of a radiocarpal Kirschner wire
: // / t : / / / t
t pp : / tpp s : /
into the lunate with the wrist in flexion. B, When the wrist is brought into extension, the
ss s
humpback and dorsiflexed intercalated segment instability deformities get corrected.
hhttt hhttt
Courtesy: Shriners Hospital for Children, Philadelphia, PA, USA.
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
A B
k e rrss
e rrss
Figure 5: A, Intraoperative photograph of the volar distal radius bone graft harvest
e e
site. A corticocancellous graft is harvested proximal to the watershed line deep to the
k
o o
o o k o o
o o k
pronator quadratus. B, An anteroposterior radiograph shows a safe distance of the harvest
eebb Philadelphia, PA, USA.

ee/ / b
e b
site (asterisk) from the distal radial physis (arrow). Courtesy: Shriners Hospital for Children,
e
: / / t
/ .
t m
. m : / / t
/.tm. m
t p ss:
p / t p ss:
p /
Once the fracture fragments become corticated at the fracture site, closed
t
hht t t
hht t
treatment methods are unlikely to succeed (Figure 6). An established nonunion
typically requires either an open or arthroscopic reduction with removal of
k e r
e s
rs k eerrss
141
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Jockel et al
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Figure 6: An oblique radiograph shows an established
hhttt hhttt
nonunion of the scaphoid. Courtesy: Shriners Hospital for
Children, Philadelphia, PA, USA.
interposed fibrous material and decortication of the fragment ends. Humpback
keerrss k eerrss
deformities are the norm for waist fractures. Nonvascularized grafts, as described
b ooook b ook
above, are most commonly used in children. Proximal pole nonunions are more
o o
complicated with a lower union rate after fixation and grafting. Vascularized grafts
eeb e / e
/ e b
remain an option in this population, particularly for chronic nonunions or those
e
: / / / .
t m m
with demonstrated avascular necrosis.
t . : / / t
/ .
t m
. m
t ppss / t ppss : /
Vascularized graft options for skeletally mature children include the
:
1,2-intercompartmental supraretinacular artery graft from the dorsal wrist and
t
hhtt t
hhtt
the volar carpal artery graft.26 Both of these grafts are contraindicated with open
physes since there is a high risk of physeal bar formation. For skeletally immature
children undergoing a volar approach, we prefer our modification of the Hori
technique as described by Tang and Fischer (Figure 7).27,28 A similar vascularized
k e rrss
e approach.29
k rrss
pedicle transfer has also been described by Fernandez and Eggli for a dorsal
e e
o o
o o k o o
o o k
eebb Surgical Technique
ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/.tm. m
The optimal approach and choice of fixation for the management of pediatric
t p ss:
p / t p ss:
p /
scaphoid fractures is poorly defined. The volar, dorsal, and percutaneous surgical
t
hht t t
hht t
approaches, each have specific advantages and limitations. The different implants
for scaphoid fixation may also have unique benefits in the immature carpus. While
k e r
e s
rs
142
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
b ooook b ooook
Figure 7: Vascularized graft options are limited in children with open physes. A vascularized
eeb e / e b
pedicle transfer from the superficial volar branch of the radial artery is a simple technique
/ e
to add vascularity to the scaphoid. Intraoperative photographs show: A, the vessels (arrow)
e
: // t/.tm
. m : / /t/.tm
isolated from the surrounding fat and thenar musculature and B, inserted into the fracture
. m
site (arrow) of the scaphoid. Courtesy: Shriners Hospital for Children, Philadelphia, PA, USA.
hhttt hhttt
there are no specific studies in the pediatric population addressing these issues,
reports from the adult literature have provided relevant information to consider
when treating this injury.
keerrss k eerrss
The choice of surgical approach for scaphoid fractures depends on multiple
b ooook b o ook
factors including fracture location, deformity, displacement, surgeon’s experience,
o
eeb ee / e b
and the need for bone grafting. A prospective report by Jeon et al. revealed no
/ e
difference in fracture union rates or function in adults based on the use of a dorsal
or volar entry point.30
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
The volar approach is most appropriate for distal third and displaced waist
t
hhtt t
hhtt
fractures because it provides direct visualization for fracture reduction. This
approach allows for placement of bone graft to address a humpback deformity
and does not violate the radiocarpal joint. Screw placement from this approach,
however, may be eccentric to the axis of the scaphoid and occasionally requires
entry through the trapezium to attain the optimal starting point.31,32 While in
k e rrss
e e rrss
adults, violation of the scaphotrapezial joint has been hypothesized to lead to
k e
o o
o o k o o
o o k
scaphotrapezial arthritis, the long-term effects on the immature carpus are
eebb unknown.33,34
ee/ e
/ b
e b
The dorsal approach to the scaphoid can be used to address proximal pole
: / / t
/ . m
. m : / / t. m. m
and nondisplaced waist fractures. This approach provides visualization of proximal
t / t
t p ss:
p / t p ss:
p /
fractures, but can also be used as a percutaneous technique for screw insertion. The
t t t t
advantages of a dorsal technique include a direct entry point for screw insertion and
hht hht
a screw trajectory along the central axis of the scaphoid. This placement optimizes
k e r
e s
rs k eerrss
143
o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Jockel et al
k e r
e s
rs k eers
r s
o o
o o k o o o k
implant length and fracture stability to promote bone healing.31,35 Limitations of
o
eebb bb
this approach include violation of the radiocarpal articulation with screw insertion
ee/ e
/e
and potential for injury to the extensor tendons and the dorsally-based blood
supply of the scaphoid.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss : /
The implants of choice for scaphoid fixation in the pediatric population
include Kirschner wires (K-wires) and headless compression screws. While most
p
t
hht t t
hht t
recent reports of scaphoid fixation have focused on the use of screw fixation,
K-wires may still have a role. Although poorly studied, K-wires can be more
easily removed after fracture union limiting the amount of retained hardware in
the developing carpus. Kirschner wires can also be used in situations where screw
k eers
rs k er
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purchase may be limited such as with significant comminution, in the setting of
b ooook b oook
revision surgery, or with the use of a vascularized bone graft. Furthermore, the
o
narrow diameter of K-wires at the fracture site preserves a larger surface area for
eeb / e
/ e b
union and may potentially improve healing in the immature scaphoid.
ee
: // t/.tm
. m : / /t/.tm
Scaphoid fixation is most often performed with headless compression
. m
t ppss / tp ss : /
screws. These screws provide improved fracture stability and compression in
:
comparison to the use of K-wires.36 Multiple implant options are available and
p
hhttt hhttt
may influence fracture outcomes. While there is little clinical evidence to suggest
that any single implant is superior to the rest, some data suggests that not all
implants may be equal in the pediatric population. In the report by Gholson
et al., scaphoid fractures treated with the Synthes headless compression screw
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healed approximately 4–5 weeks sooner than those treated with the Acutrak or
b ooook b ook
Herbert screws.4 The authors propose that although the implants may provide
o o
similar compression, the Synthes screw may allow a greater surface area for
eeb / e
/ e b
osseous healing and decrease disruption of the blood supply due to the narrower
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
diameter at the fracture site. This report is in contrast to a biomechanical study
. m
t ppss / t ppss : /
showing that the Acutrak screw offers a more reliable compression than the
:
Synthes headless compression screw which may translate to more predictable
t
hhtt t
hhtt
bony union.37 Further work in this area is necessary to clarify the most appropriate
implant for fixation of the immature scaphoid.
CONCLUSION
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e
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o o k o o
o o k
Pediatric and adolescent scaphoid fractures are challenging injuries to manage.
eebb e / / b
The changing patterns of injury and patient demographics are important to
e e b
consider because historical assumptions may no longer apply when treating this
e
: / / t
/ .
t m
. m : / / t
/.tm. m
population. At this time, there is limited evidence to guide the management of
t p ss:
p / t p ss:
p /
pediatric scaphoid fractures, especially in patients at or near skeletal maturity.
Further study is necessary to clarify the most appropriate approach to treating
t
hht t these injuries. t
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p t t p
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p
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Scaphoid fractures are common fractures in the pediatric and adolescent populations,
e
t . m
. m t . m
. m
occurring most commonly from a fall on the outstretched hand. Scaphoids do
: / / / t : / / / t
ss : / ss : /
not have a physis nor is it covered in periosteum, but rather entirely covered by
t p p t p p
t
hht t t t
articular cartilage. Although analogous to adult fractures, the pediatric variant has
hht
demonstrated a unique pattern of both injury and treatment. In this article, the
authors present a detailed review of these challenging injuries including operative
and nonoperative treatments.
k eers
rs Asif M Ilyas
k er
erss
b ooook b ooook
eeb REFERENCES ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t ppss / tppss : /
1. Christodoulou AG, Colon CL. Scaphoid fractures in children. J Pediatr Orthop. 1986;6:37-9.
:
2. Bloem JJ. Fracture of the carpal scaphoid in a child aged 4. Arch Chir Neerl. 1971;23:91-4.
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3. Stuart HC, Pyle SI, Cornoni J, Reed RB. Onsets, completions and spans of ossification in the 29 bonegrowth
centers of the hand and wrist. Pediatrics. 1962;29:237-49.
4. Gholson JJ, Bae DS, Zurakowski D, Waters PM. Scaphoid fractures in children and adolescents: contemporary
injury patterns and factors influencing time to union. J Bone Joint Surg Am. 2001;93:1210-9.
5. Stanciu C, Dumont A. Changing patterns of scaphoid fractures in adolescents. Can J Surg. 1994;37:214-6.
keerrss Belg. 2001;67:121-5.

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6. Fabre O, De Boeck H, Haentjens P. Fractures and nonunions of the carpal scaphoid in children. Acta Orthop
s
b ooook b ook
7. Vahvanen V, Westerlund M. Fracture of the carpal scaphoid in children. A clinical and roentgenological study
o o
of 108 cases. Acta Orthop Scand. 1980;51:909-13.
eeb / e e b
8. Anz AW, Bushnell BD, Bynum DK, Chloros GD, Wiesler ER. Pediatric scaphoid fractures. J Am Acad Orthop
Surg. 2009;17:77-87.
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/ . m
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9. D’Arienzo M. Scaphoid fractures in children. J Hand Surg Br. 2002;27:424-6.
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t pp : /
children. J Pediatr Orthop. 2009;29:352-5.
t pp s : /
10. Evenski AJ, Adamczyk MJ, Steiner RP, Morshcer MA, Riley PM. Clinically suspected scaphoid fractures in
ss s
t
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hhtt
11. Doman AN, Marcus NW. Congenital bipartite scaphoid. J Hand Surg Am. 1990;15:869-73.
12. Wulff RN, Schmidt TL. Carpal fractures in children. J Pediatr Orthop. 1998;18:462-5.
13. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J
Bone Joint Surg Am. 1960;42-A:759-68.
14. Cook PA, Yu JS, Wiand W, Cook AJ, Coleman CR, Cook AJ. Suspected scaphoid fractures in skeletally
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e rrss
immature patients: application of MRI. J Comput Assist Tomogr. 1997;21:511-5.
e e
15. Stewart MJ. Fractures of the carpal navicular (scaphoid); a report of 436 cases. J Bone Joint Surg Am.
k
o o
o o k 1954;36-A:998-1006.
o o
o o k
eebb b
16. Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. Comparison of short and long thumb-spica casts for
ee/ e
/ e b
non-displaced fractures of the carpal scaphoid. J Bone Joint Surg Am. 1989;71:354-7.
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/ t m
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/ tm
17. Mussbichler H. Injuries of the carpal scaphoid in children. Acta Radiol. 1961;56:361-8.
. . . m
18. Henderson B, Letts M. Operative management of pediatric scaphoid fracture nonunion. J Pediatr Orthop.
2003;23:402-6.
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p / t p ss:
p /
19. Southcott R, Rosman MA. Non-union of carpal scaphoid fractures in children. J Bone Joint Surg Br.
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hht
1977;59:20-3. t t
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/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Jockel et al
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e s
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r s
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o o k
20. Suh N, Benson EC, Faber KJ, Macdermid J, Grewal R. Treatment of acute scaphoid fractures: a systematic
review and meta-analysis. Hand (N Y). 2010;5:345-53.
eebb ee/ e
/ebb
21. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced
scaphoid fractures. J Bone Joint Surg Am. 2001;83-A:483-8.
t . m
. m t . m
. m
22. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of nondisplaced scaphoid
: / / / t : / / / t
t p ss :
2007;127:39-46.
p / t p ss
p : /
fractures: making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg.
t
hht t t
hht t
23. Wilson-MacDonald J. Delayed union of the distal scaphoid in a child. J Hand Surg Am. 1987;12:520-2.
24. Pick RY, Segal D. Carpal scaphoid fracture and non-union in an eight-year-old child. Report of a case. J Bone
Joint Surg Am. 1983;65:1188-9.
25. De Boeck H, Van Wellen P, Haentjens P. Nonunion of a carpal scaphoid fracture in a child. J Orthop Trauma.
1991;5:370-2.
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26. Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid
s
nonunion. J Hand Surg Br. 1998;23:318-23.
b ooook Surg Am. 1979;4:23-33.

b oook
27. Hori Y, Tamai S, Okuda H, Sakamoto H, Takita T, Masuhara K. Blood vessel transplantation to bone. J Hand
o
eeb / e e b
28. Tang P, Fischer CR. A new volar vascularization technique using the superficial palmar branch of the radial
ee /
artery for the collapsed scaphoid nonunion. Tech Hand Up Extrem Surg. 2010;14:160-72.
t . m
. m t . m. m
29. Fernandez DL, Eggli S. Non-union of the scaphoid. Revascularization of the proximal pole with implantation
: // / t : / / / t
t pp : / tp s : /
of a vascular bundle and bone-grafting. J Bone Joint Surg Am. 1995;77:883-93.
ss s
30. Jeon IH, Micic ID, Oh CW, Park BC, Kim PT. Percutaneous screw fixation for scaphoid fracture: a comparison
p
hhttt hhttt
between the dorsal and the volar approaches. J Hand Surg Am. 2009;34:228-36.e1.
31. Dodds SD, Panjabi MM, Slade JF. Screw fixation of scaphoid fractures: a biomechanical assessment of
screw length and screw augmentation. J Hand Surg Am. 2006;31:405-13.
32. Geurts GF, Van Riet RP, Meermans G, Verstreken F. Volar percutaneous transtrapezial fixation of scaphoid
waist fractures: surgical technique. Acta Orthop Belg. 2012;78:121-5.
keerrss J Hand Surg Br. 2002;27:42-6.

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33. Yip HS, Wu WC, Chang RY, So TY. Percutaneous cannulated screw fixation of acute scaphoid waist fracture.
b ooook b o ook
34. Bedi A, Jebson PJ, Hayden RJ, Jacobson JA, Martus JE. Internal fixation of acute, nondisplaced scaphoid
o
eeb e /
Hand Surg Am. 2007;32:326-33.
e e b
waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes. J
/ e
: / / t t m
. m : / / t t m
35. McCallister WV, Knight J, Kaliappan R, Trumble TE. Central placement of the screw in simulated fractures of
. . . m
the scaphoid waist: a biomechanical study. J Bone Joint Surg Am. 2003;85-A:72-7.
/ /
36. Panchal A, Kubiak EN, Keshner M, Fulkerson E, Paksima N. Comparison of fixation methods for scaphoid
t
hhtt t
hhtt
nonunions: a biomechanical model. Bull NYU Hosp Jt Dis. 2007;65:271-5.
37. Grewal R, Assini J, Sauder D, Ferreira L, Johnson J, Faber K. A comparison of two headless compression
screws for operative treatment of scaphoid fractures. J Orthop Surg Res. 2001;6:27.
k e rrss
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e
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eebb Treatment oft.Upper ee/ e
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Brachial Plexus
: / / / tm. m : / / t
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t m
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BirthtPalsy
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ssInjuries: Neuroma Excision ttp ss
p : /
t
ht Grafting or Nerve Transfers hht
hand t
1,
*Joshua M Abzug MD, 2Kevin J Little MD
k eers
rs 1
k er
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Department of Orthopedics and Pediatrics, University of Maryland School of Medicine
b ooook 2
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Baltimore, Maryland, USA
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Department of Orthopedic Surgery, University of Cincinnati College of Medicine
eeb ee/ e
/ e b
Cincinnati, Ohio, USA
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. m : / /t/.tm. m
hhttt ABSTRACT
hhttt
Brachial plexus birth palsies can be permanent injuries, with the upper trunk
keerrss k eerrs
being affected most commonly. As shoulder function is needed for many
s
activities of daily living, these injuries can be devastating. Therefore, when
b ooook o ook
functional spontaneous recovery does not occur, traditional intervention
b o
eeb e e
/ e b
includes neuroma excision and nerve grafting to restore axonal flow to
/
the motor endplates. However, new techniques, such as nerve transfers,
e
: / / t
/ .
t m m : / / t
/ .
t m
are improving our ability to treat this condition. Most commonly, nerve
. . m
t ppss / t p ss : /
transfers are performed to obtain specific motor function. The results of
:
targeted nerve transfers are very promising with future studies needed
p
t
hhtt t
hhtt
to see if function is ultimately better with nerve transfer procedures as
opposed to neuroma excision and grafting.
INTRODUCTION
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Brachial plexus birth palsy is potentially a devastating injury for both the child and
o o
o o k o o o k
their family if recovery does not occur early. The incidence of this injury is fairly
o
eebb ee/ e b
e b
high, with 1–2 per 1,000 live births having a brachial plexus birth palsy.1-3 While
/
the vast majority of children spontaneously recover in the first 2 months, those that
/ / t
/ .
t m
. m / / t
/.tm. m
do not recover by 3 months of age will have permanent deficits including decreased
: :
t p ss:
p / t p ss:
p /
t
hht
t t
hht t
Email: jabzug@umoa.umm.edu
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Abzug and Little
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range of motion, strength, size, and girth of the affected limb.4-6 Significant debate
regarding the best treatment for those children who do not recover by 3 months of
eebb / e
/ebb
age exists. The focus of this article will be on treatment utilizing neuroma excision
ee
: / / t
/ t m
and grafting and/or nerve transfers for upper plexus lesions.
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t m
. m
t p ss
p : / t p ss
p : /
t t
NERVE INJURY
hht t
hht t
Understanding the various types of injuries that can occur to a nerve is critical to
understanding why significant debate exists regarding the timing of nerve surgery
for brachial plexus birth palsy patients. The mechanism of injury is traction or
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rs k er
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stretch, which can be the result of shoulder dystocia, however more than 50% of
b ooook oook
cases have been reported to occur without the presence of shoulder dystocia or
o
any known risk factors.1 The amount of injury that occurs to the nerves is a result
b
eeb ee/ e
/ e b
of the force experienced by the nerve as well as the position of the arm and neck
: // t/ tm
when the force was applied.
. . m : / /t/.tm. m
The most common area of the brachial plexus affected by injury is the upper
trunk (C5-6) and is known as the classic Erb’s palsy. This occurs in approximately
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60% of cases. Extended Erb’s palsy affects C5-7, occurring in 20–30% of cases,
and global plexus injuries affects C5-T1, occurring in 15–20% of brachial plexus
birth palsy patients. Isolated lower trunk (C8-T1) injuries are extremely rare in
brachial plexus birth palsy.7
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Injuries that occur proximal to the dorsal root ganglion are termed preganglionic
nerve root avulsions and are much less common than postganglionic peripheral
b ooook o ook
nerve injuries. Currently, no surgical intervention can restore normal anatomy
b o
eeb ee/ e
/ e b
once a preganglionic nerve avulsion occurred.
/ / t
/ t m
. m / / t
/ t m
Normal peripheral nerve consists of axons surrounded by myelin sheath.
. . . m
Surrounding multiple axons and myelin is endoneurium. Perineurium surrounds
: :
nerve fascicles and provides the bulk of nerve tensile strength. The area surrounding
t
hhtt t
hhtt
the entire nerve is epineurium, which provides the vast majority of nourishment
for the nerve.8 Knowledge of what type of peripheral nerve injury occurred may
aid in predicting the natural recovery of a brachial plexus birth injury.
The most common description of peripheral nerve injuries utilized is that
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proposed by Seddon.9 Neuropraxia occurs when there is damage to the myelin
e e
sheath surrounding the axons. As no damage occurs to the axons themselves, the
o o
o o k o o o k
nerve is able to repair itself quickly. For brachial plexus birth palsies, neuropraxia
o
eebb / e b b
injuries typically recover during the 1st weeks to months of life and there are no
ee / e
long-term sequelae of these injuries. Axonotmesis injuries have disruption of
: / / t
/ .
t m
. m : / / t
/.tm. m
some axons, with variable preservation of the connective tissue in the nerve. These
t p ss:
p / t p ss:
p /
injuries account for a significant number of brachial plexus birth palsies and are
t
hht t t
hht t
the most difficult to determine the best treatment for. Partial recovery of a nerve
in a brachial plexus birth palsy patient is due to axonotmesis injury as some axons
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148
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/ t
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t t p
t ss:
p t t p
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p
hht hht
Treatment of Upper Brachial Plexus Birth Palsy Injuries: Neuroma Excision...
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were disrupted while others remained in continuity. Recovery may occur in a way
o
eebb bb
that is not a classic anatomical pattern and the extent of recovery may not be
ee/ e
/e
known until 1–3 years of life.4,10 Neurotmesis is the entire disruption of a nerve,
: / / t
/ .
t m
. m : / / t
/ .
with discontinuity occurring between all axons and the epineurium. No recovery
t m
. m
t p ss
p : / t p ss
p
Distinguishing between an axonotmetric and neurotmetric injury is: /
will occur in these injuries and therefore, surgical intervention is warranted.
t
hht t t
hht t
only possible based on repeated physical examination determining recovery.
Electrodiagnostic testing has failed to add additional information beyond clinical
examination for brachial plexus birth palsies as needle electromyography can fail
to estimate or overestimate clinical recovery in the proximal musculature of the
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arm and shoulder.11 Understanding that differentiation between axonotmetric
b ooook b oook
and neurotmetric injuries relies on repeated physical examination permits one to
o
comprehend the significant debate that exists regarding the need for and timing
eeb e / e
/ e b
of surgical intervention for patients with brachial plexus birth palsy.
e
: // t/.tm
. m : / /t/.tm. m
Further complicating the discussion on timing for surgical intervention for
t ppss / tppss : /
brachial plexus birth palsy patients is an understanding of what happens distal to
:
an axonal injury. Once an axon is disrupted, damage occurs in both the proximal
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and distal directions from the site of injury. Proximally, degeneration of the axon
occurs back to the next node of Ranvier. Distally, Wallerian degeneration, which
is the process of breakdown of the axon distal to the site of injury, begins within
2–4 days following injury. The myelin deteriorates, the axon becomes disorganized,
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and the elements of the myelin and axon are phagocytized by Schwann cells.12
b ooook b
occur by 18–24 months following injury. ook
The neuromuscular junction will be irreversibly damaged if reinnervation does not
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/ e b
GROSS ANATOMY
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t m
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/ .
t m
. m
t
hhtt t
hhtt
In order to care for children with brachial plexus birth palsy, one must have a
thorough knowledge of the anatomy of the brachial plexus and surrounding
structures. The brachial plexus is composed of the ventral rami of the C5-T1 nerve
roots. This “normal” pattern occurs in approximately 75% of the population. About
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e
20% of the population has a prefixed plexus where an additional contribution
e rrss
comes from the ventral ramus of C4 and approximately 1% of the population
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o o
o o k o o o k
has a postfixed plexus where an additional contribution comes from the ventral
o
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/ b
e b
ramus of T2.13 The brachial plexus branches in a predictable pattern with the roots
forming trunks, the trunks forming divisions, the divisions forming cords, and the
: / / t
/ .
t m
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/.t
cords forming terminal branches. Additional branches originate at each portionm. m
t p ss:
p / t p ss:
p /
of the brachial plexus except for at the level of the divisions. Branches that arise
t
hht t t
hht t
at the level of the roots include the long thoracic nerve, the dorsal scapular nerve,
and the phrenic nerve via the C5 contribution.
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t t p
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p t t p
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Abzug and Little
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eebb ee/ e
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: / / t
/ .
t m
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/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
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rs k er
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b ooook b ooook
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Figure 1: Cadaveric dissection demonstrating the trifurcation
: // t/.tm
. m : / /t/.tm. m
of the upper trunk into anterior and posterior divisions and the
suprascapular nerve. Courtesy: Joshua M Abzug, MD.
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The ventral rami of C5 and C6 combine to form the upper trunk, the ventral
ramus of C7 continues as the middle trunk, and the ventral rami of C8 and T1
combine to form the lower trunk. Branches that occur at the trunk level include
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the suprascapular nerve (SSN) and nerve to subclavius, both of which arise from
the upper trunk. The SSN has a very distal take off with it appearing to have a
b ooook o ook
trifurcation of the upper trunk into the SSN and anterior and posterior divisions
b o
eeb (Figure 1).14
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/ e b
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/ t m
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/ t m
Each trunk divides into anterior and posterior divisions. There are no branches
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that arise from the level of the divisions. The anterior divisions of the upper and
: :
middle trunks combine to form the lateral cord, while the anterior division of
t
hhtt t
hhtt
the lower trunk continues to form the medial cord. All three posterior divisions
combine to form the posterior cord. The lateral pectoral nerve arises from the
lateral cord while the medial pectoral nerve arises from the medial cord. Additional
branches from the medial cord include the medial brachial cutaneous nerve and
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the medial antebrachial cutaneous nerve. Three branches arise from the posterior
e e
cord including the upper subscapular nerve, the thoracodorsal nerve, and the lower
o o
o o k subscapular nerve.
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/ b
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The terminal branches of the brachial plexus are the five major peripheral
nerves of the upper extremity, including the axillary, radial, musculocutaneous,
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t m
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/.tm. m
median, and ulnar nerves. Portions of the lateral and medial cords combine to
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p /
form the median nerve, with the portion from the lateral cord being primarily
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hht t t
hht t
afferent sensory fibers and the portion from the medial cord being primarily
efferent motor fibers. Additionally, the lateral cord gives off the musculocutaneous
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/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
nerve (MCN) while the medial cord gives off the ulnar nerve. The posterior cord
gives off both the axillary and radial nerves.
eebb ee/ e
/ebb
CLINICAL EVALUATION .m m . m m
ss: /
: /
/ t
/ t . ss: /
: /
/ t
/ t .
hhtt t p
t p t
hhtt p
t p
The clinical evaluation of a child with a presumed brachial plexus birth palsy
begins with observation of the child’s limbs. Classic positioning of a child with
Erb’s palsy is shoulder internal rotation, elbow extension, forearm pronation, and
wrist flexion. This occurs due to injury to the upper trunk (C5-6), which results in
no active external rotation, elbow flexion, supination, or wrist extension.
k eers
rs k er
erss
Knowledge of which nerve roots innervate which muscles and each muscle’s
b ooook oook
function is critical to understanding and performing the clinical evaluation. For
o
example, the aforementioned positioning occurs due to the C5-6 injury. The
b
eeb ee/ e
/ e b
shoulder external rotators (supraspinatus, infraspinatus, and teres minor) are not
: // t/ tm
. m : / /t/ tm
working due to a lack of efferent motor innervation through the axillary nerve,
. . .
which innervates teres minor, and the SSN, which innervates supraspinatus andm
infraspinatus. However, several shoulder internal rotators are receiving normal
hhttt hhttt
or partial innervation via C7-T1, including the pectoralis major, subscapularis,
latissimus dorsi, and teres major.
We assess the following active movements against gravity to quickly
determine the level and extent of injury: elbow flexion for C5-6, elbow extension
keerrss k eerrss
and finger metacarpophalangeal extension for C7, and finger flexion for C8-T1.
Tactile stimulation may aid in eliciting these movements. Alternatively, one can
b ooook o ook
assess neonatal reflexes to induce elbow flexion and wrist and digit extension. The
b o
eeb ee/ e
/ e b
Moro reflex, which is typically present until about 6 months of age, is elicited
/ / t
/ t m
. m / / t
/ t
to abduct and the elbows and digits to extend. Additionally, the fingers spread
: : m
by introducing a sudden extension of the child’s neck. This causes the shoulders
. . . m
apart.15,16 The asymmetric tonic neck reflex is elicited by turning the child’s head
t
hhtt t
hhtt
to the side. This results in extension of the arm and leg on the side to which the
head was turned and flexion of the upper and lower extremities on the contralateral
side, creating the appearance of a fencer.
The child also needs to be assessed for a clavicle and/or humerus fracture
k e rrss
e k rrss
(pseudopalsy), which can mimic or coexist with a brachial plexus birth palsy
e e
(Figure 2). These fractures heal with abundant callus within the first 3 weeks of
o o
o o k o o o k
life, so any delayed movement beyond that time is concerning for a concomitant
o
eebb brachial plexus birth palsy.
ee/ e
/ b
e b
Evaluation of the child’s face for a Horner’s syndrome and chest for paralysis
: / / t
/ .
t m
. m : / / t
/.tm. m
of the hemidiaphragm are needed to aid in identification of a preganglionic lesion.
t p ss:
p / t p ss:
p /
Horner’s syndrome consists of ptosis (eye drooping), miosis (pupil constriction),
t
hht t t
hht t
and anhidrosis (decreased sweating). The presence of Horner’s syndrome is
associated with lower root injury and a poor prognosis.7,17
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rs k eerrss
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k WL: -816 WW:3178
o o
o o k
X: 1108 px Y: 2955 px Value: -65535.00
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb Position: AP.
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Figure 2: Humerus fracture that occurred in conjunction with a
brachial plexus birth palsy. Courtesy: Joshua M Abzug, MD.
hhttt hhttt
Lastly, it is imperative to rule out associated or alternative diagnoses that
can mimic a brachial plexus palsy or coexist with one. These include cervical
spine injury and cerebral anoxia, which can be diagnosed by assessment of the
contralateral upper extremity and both lower extremities by evaluating for signs of
keerrss k eerrss
spasticity. As shoulder dystocia is a risk factor for both brachial plexus birth palsy
b ooook b ook
and cerebral anoxia, the history should include obtainment of the appearance,
o o
pulse, grimace, activity, and respiration (APGAR) scores.
eeb e / e
/ e b
Sequential physical examinations are the most reliable method for determining
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
and monitoring the extent of injury. It is helpful to obtain multiple examinations
t ppss / t p ss : /
by various providers during each visit to obtain a complete and accurate assessment
:
of the nerve damage and/or recovery. Occupational and physical therapists are
p
t
hhtt t
hhtt
invaluable members of the team that care for and assess these children.
Multiple scoring methods have been developed to permit classification of
these injuries as well as to determine indications for microsurgical intervention.
The Toronto score grades five movements (elbow flexion, elbow extension, wrist
k e rrss
e k rrss
extension, finger extension, and thumb extension) on a score from 0 to 2 based
e e
on the amount of motion present. A grade 0 is no joint movement whereas a
o o
o o k o o o k
grade 2 is full range of motion (Table 1). The Hospital for Sick Children Active
o
eebb ee/ e
/ b
e b
Movement Scale assesses 15 different upper extremity movements for a more
/ / t
/ t m
. m / / t
/ tm
thorough assessment of the entire brachial plexus. Each movement is first assessed
. . . m
with gravity eliminated and then against gravity, with a score from 0 to 7 assigned
: :
t p ss:
p / t p ss:
p /
based on the amount of motion present (Table 2).18 Bae et al. have shown that
t
hht t t
hht t
both of these outcome tools have positive intra- and interobserver reliability with
aggregate scores. Additionally, the internal consistency (test-retest reliability) is
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e s
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o o
o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k Table 1: Toronto Score
o o
o o k
eebb Movement*
ee/ e
/ebb
Clinical grade Numerical weighting
No joint movement
: / / t
/ .
t m
. m
0
: / / t
/ .
t m
.
0
m
Flicker of movement
t p ss
p : / 0 +
t p ss
p : / 0.3
t
<50% range of motion
hht
50% range of motion
t 1
1
–
t
hht t 0.6
1.0
>50% range of motion 1+ 1.3
Good but not full range of motion 2– 1.6
k eers
rs Full range of motion
k er
er
2ss 2.0
b ooook *
extension.
b ooook
Five movements assessed: elbow flexion, elbow extension, wrist extension, finger extension, and thumb
eeb ee/ e
/ e b
: // /.tm m
Table 2: Hospital for Sick Children Active Movement Scale
t . : / /t/.tm. m
Movement
t ppss : / Motion
tppss : / Score
hhttt
Shoulder abduction
Shoulder adduction hhttt
Gravity eliminated
Shoulder flexion No contraction 0
Shoulder external rotation Contraction, no motion 1
keerrss Shoulder internal rotation

k ee
<50% motionrrss 2
b ooook Elbow flexion

b o ook
o
>50% motion 3
eeb Elbow extension

ee/ e
/ e b
Full motion 4
Forearm supination
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Forearm pronation
t ppss : / Against gravity
t ppss : /
Wrist flexion
Wrist extension
t
hhtt <50% motion
>50% motion
t
hhtt 5
6
Finger flexion Full motion 7
rrss rrss
Finger extension
o k e
k e Thumb flexion
o k e
k e
o
eebb o o Thumb extension
e b o
b o o
m ee/ / e m
: /
/ t
/ .
t . m / t.
excellent for the aggregate Toronto score.19 Another test that has been proposed
/ : / / / t . m
t t p
t ss:
p t t p
t ss:
to determine the need for microsurgical intervention is the “cookie test”, where
p
hht hht
the child is assessed to determine if they are able to bring a cookie to their mouth
with the affected extremity.18
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rs k eerrss
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k SURGICAL INDICATIONS
o o
o o k
eebb ee/ e
/ebb
Currently, the role of microsurgical intervention, the timing of intervention, and
the type of nerve surgery to perform, all remain controversial despite a plethora
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
of literature about the topic.20-23 Some have advocated against any microsurgical
t p ss
p : / ss : /
intervention and rather advocate for secondary tendon procedures, while others
t p p
hhtt t t
hht t
recommend early neuroma excision and grafting. Between these options exist
the concepts of neurolysis, direct repair, and nerve transfers. Direct repair is not
possible as the initial injury causes stretching of the nerve, which results in a large
area of injury and neuroma formation. Neurolysis has inferior outcomes compared
to neuroma resection and nerve grafting.18,24,25 Therefore, the majority of current
k eers
rs k er
erss
opinion leaders feel that neuroma resection and nerve grafting, nerve transfers,
b ooook b ooook
or no microsurgical intervention should be performed, however, currently the
eeb e / e b
gold standard is arguably neuroma resection and nerve grafting. No microsurgical
/ e
intervention is warranted if the child has return of upper trunk function by
e
t . m
. m t . m. m
2 months of age, typically assessed by elbow flexion against gravity.
: // / t : / / / t
One of the most controversial points is the timing of intervention, with
hhttt hhttt
proponents arguing for early intervention (3 months of age) and others feeling
it is acceptable to wait longer (9 months of age).18,26-31 As noted earlier, the
neuromuscular junction will be irreversibly damaged if reinnervation does not
occur by 18–24 months following injury. Therefore, surgical intervention needs to
supply neural input by this time.
keerrss k eerrss
Michelow and colleagues have stated that a combined Toronto score of less
b ooook b ook
than 3.5 by 3 months of age is an indication for microsurgery.17 Others have
o o
just assessed whether or not elbow flexion against gravity is present by 3 months
eeb / e
/ e b
of age.32 Alternatively, the presence of Horner’s syndrome or evidence of lower
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
root avulsions has been used to suggest that early surgical intervention should be
. m
t ppss / t ppss : /
undertaken. Failure to perform the cookie test by 9 months of age has also been
:
utilized as an indication to proceed with microsurgical intervention.18
t
hhtt t
hhtt
However, outcomes utilizing these techniques will differ based on the type
and severity of injuries present during the analysis of a subset of patients. Fisher
and colleagues showed that the absence of elbow flexion against gravity alone at
3 months of age is not always reliable as a subset of patients will go on to have
k e rrss
e k rrss
spontaneous recovery of useful upper extremity function.33 Waters showed that
e e
children who underwent microsurgical intervention for a lack of elbow flexion at
o o
o o k o o o k
6 months age had better outcomes than children who had spontaneous recovery
o
eebb ee/ e b
e
of elbow flexion by 5 months age.16,34
/ b
The utilization of nerve transfers is an evolving concept without clearly defined
: / / t .
t m
. m : / / t.tm. m
recommendations at present. Introduction of these procedures into the brachial
/ /
t p ss:
p / t p ss:
p /
plexus birth palsy will further cloud the picture as to the optimal treatment and
t
hht t t
hht t
its timing for these injuries. Nerve transfers have been discussed in detail in the
following sections.
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k NEUROMA RESECTION AND
o o
o o k
eebb GRAFTING SURGICAL TECHNIQUE
ee/ e
/ebb
The child is placed supine on the operating room table and general anesthesia
/ / t
/ .
t m
. m / / t
/ .
t m
. m
without neuromuscular blockade is induced. As sural nerve grafts from both lower
: :
t p ss
p : / t p ss : /
extremities may be needed, the prepping and draping should include bilateral
p
hhtt t t
hht t
lower extremities and the affected upper limb, including the hemithorax and neck
up to the level of the lower ear. The head is turned and tilted towards the unaffected
extremity and a small bump is placed in the midline to allow the shoulders to fall
into an extended posture. A Langer’s line just superior to the clavicle is identified
k eers
rs k er
ers
that extends from the posterior border of the sternocleidomastoid to the anterior
s
border of the trapezius. Anesthetic with epinephrine is injected into this area to
b ooook o ook
permit vasoconstriction and decrease bleeding. The skin is incised sharply along
b o
eeb ee/ e
/ e b
this line and the supraclavicular fascia is incised in line with the skin incision. As
the platysma is often underdeveloped in infancy, it is difficult to identify. Care
: // t .tm
. m : / /t .tm.
should be taken to preserve the supraclavicular cutaneous nerves if possible.
/ / m
Dissection is begun from a medial to lateral direction working from the
hhttt hhttt
sternocleidomastoid laterally. The external jugular vein and its branches are present
and may need to be ligated. A large fat pad is now visible and needs to be elevated
in a lateral direction. Care should be taken to leave some fat on the carotid sheath
to avoid entering this structure. Once the fat pad is elevated, the anterior scalene
keerrss k eerrs
muscle should be identified. On the anterior aspect of this muscle is the phrenic
s
nerve. If significant scarring is present superficially, a cutaneous nerve can be
b ooook o ook
traced to the region of the phrenic nerve to facilitate its identification.
b o
eeb ee/ e
/ e b
The omohyoid muscle should now be visible in the inferior wound, as this
is the “door” to the upper plexus. Often it is necessary to divide this muscle to
: / / t
/ .
t m
. m : / / t
/ .
t
permit better visualization and complete access to the upper plexus. The C5 andm
. m
C6 roots should now be able to be dissected out between the anterior and middle
t
hhtt t
hhtt
scalene muscles. A vessel loop can be placed around each root to facilitate with
identification of these structures later in the procedure (Figure 3). In the inferior
portion of the wound, the transverse cervical artery is noted to cross over the C7
root. Once the C7 root is identified and tagged with a vessel loop, a vein retractor
k e rrss
e rrss
can be placed on the clavicle to permit better visualization of the more distal plexus.
e e
Additionally, gentle traction on the arm can be utilized to aid with visualization.
k
o o
o o k o o o k
The neuroma is easily identified now and dissection should now begin from
o
eebb ee/ e
/ b
e b
distal to proximal beginning with apparent normal anatomy (Figure 4). In upper
plexus lesions, the trifurcation of the upper trunk is identified which includes the
: / / t
/ .
t m
. m : / / t
/.tm
anterior and posterior divisions and the SSN. Once normal anatomy is identified
. m
t p ss:
p / t p ss:
p /
proximally and distally, the neuroma is excised and sent to pathology (Figure
t
hht t t
hht t
5). The roots and distal parts are tagged with 6-0 prolene to make identification
easier after obtaining the nerve graft. With the utilization of the microscope, it
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e s
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
Figure 3: Identification of roots and normal distal structures utilizing
: // t/.tm
. m
vessel loops. Courtesy: Joshua M Abzug, MD.
: / /t/.tm. m
hhttt hhttt
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
Figure 4: Identification of the neuroma that formed secondary to
the brachial plexus birth injury. Courtesy: Joshua M Abzug, MD.
k e rrss
e k e rrss
e
is imperative to identify whether good fascicles are present both proximally and
o o
o o k o o o k
distally (Figure 6). This is the critical point in the procedure to determine whether
o
eebb / e b b
to proceed with nerve grafting or nerve transfers.
ee / e
Attention is now turned to the lower extremities to harvest one or both sural
: / / t
/ .
t m
. m : / / t
/.tm. m
nerves (typical scenario) depending on the size of the defect present. Under
t p ss:
p / t p ss:
p /
tourniquet control, a longitudinal incision is made over the lateral ankle, midway
t
hht t t
hht t
between the lateral malleolus and Achilles tendon, and the sural nerve is identified
next to the lesser saphenous vein. The nerve is isolated with a vessel loop and
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o o k o o
o o k
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
Figure 5: Traumatic neuroma of the brachial plexus. Microscopically,
: // t/.tm
. m : / /t/.tm. m
the tissue consists of a segment of peripheral nerve (*) with a
surrounding haphazard proliferation of variably-sized regenerating
hhttt hhttt
nerve twigs in a background of fibrous stroma. (40× magnification).
Courtesy: Joshua M Abzug, MD.
keerrss k eerrss
b ooook b o ook
o
eeb ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt t
hhtt
k e rrss
e e rrss
Figure 6: Cut nerve root showing the presence of good fascicles.
k e
o o
o o k o o
o o k
Courtesy: Shriners Hospital for Children, Philadelphia, Pennsylvania, USA.
eebb ee/ e
/ b
e b
traced from distal to proximal until just distal to the level of the knee flexion crease.
: / / t
/ .
t m
. m : / / t
/.tm.
One longitudinal incision can be made or the nerve can be harvested via multiple m
t p ss:
p / t p ss:
p /
transverse incisions, endoscopically, or with a tendon stripper. The wounds are now
t
hht t t
hht t
closed with absorbable sutures, wrapped with sterile dressings, and the tourniquet
deflated.
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
Figure 7: Cable sural nerve graft coapted into defect utilizing fibrin glue.
: // t/. m
. m : / /t . m. m
Courtesy: Shriners Hospital for Children, Philadelphia, Pennsylvania, USA.
t / t
hhttt hhttt
Attention is now turned back to the neck wound and the defect is remeasured.
The grafts are cut to the appropriate lengths and coapted proximally and distally
under the microscope. Approximately 0.5–1 cm of extra length should be used per
graft to ensure no tension is present. The coaptation can be performed with suture
keerrss k eerrs
or fibrin glue, with or without the aid of nerve conduits (Figure 7). The incision is
s
now closed with absorbable suture and the child’s upper extremity is placed in a
b ooook Velpeau dressing for 3 weeks.

b o ook
o
eeb ee e
/ e b
Results following neuroma resection and grafting are limited as there are few
/
long-term studies assessing outcomes and the surgery has often been combined with
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
other methods of treatment. However, the data that is present does demonstrate
that neuroma resection and nerve grafting of the upper plexus has excellent results
t
hhtt t
hhtt
with 80–100% of patients obtaining return of elbow flexion against gravity and
60–80% of patients obtaining good return of shoulder function.23,35-37
NERVE TRANSFERS
k e rrss
e e rrss
e
Nerve transfers in brachial plexus palsy were originally described in 1903 by
k
o o
o o k o o o k
Harris and Low,38 who inserted damaged fascicles of C5 into normal C6 or C7
o
eebb ee/ e
/ b
e b
in 3 patients. While we do not know the long-term results of these operations,
they laid the groundwork for forthcoming generations of surgeons to refine this
: / / t
/ .
t m
. m : / / t
/.tm. m
procedure such that it has now become common practice in pediatric and adult
t p ss:
p /
brachial plexus surgery.
t p ss:
p /
t
hht t t
hht t
The use of nerve transfers in brachial plexus palsy requires the same
preoperative forethought as tendon transfers. Donor nerves, or fascicles thereof,
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o o k
should be predominantly motor for motor nerve transfers, close to the recipient
o
eebb bb
nerve, and expendable, in that the muscle function is either redundant or there
ee/ e
/e
is inherent redundancy in the nerve fascicle due to fascicular crossover.39 The
: / / t
/ .
t m
. m : / / t
/ .
t m
coaptation should be placed as close as possible to the motor endplate of the nerve
. m
t p ss
p : / t p ss
p : /
to which the desired muscle function is needed to improve the speed of recovery.
Reanimation of the muscle can be seen as early as 3 months after surgery, although
t
hht t t
hht t
it may take as long as 2 years to demonstrate full recovery. Additionally, brain
plasticity allows for rapid neural integration of the transfer, where difficulty with
activating the transfer to perform the desired function is not seen as frequently as
in tendon transfers.
k eers
rs k er
erss
In upper trunk brachial plexus palsies, nerve transfers have focused on
b ooook b oook
shoulder and elbow reinnervation. Typically, these transfers target the axillary
o
nerve to the deltoid for abduction and the SSN to the supra- and infraspinatus for
eeb e / e
/ e b
the initiation of abduction and external rotation, or the musculocutaneous branch
e
: // t/.tm
. m : / /t/.tm. m
to the biceps and brachialis muscles for elbow flexion. Simultaneous, combined
t ppss / tppss : /
transfers to all three recipient nerves have been performed in the setting of nerve
:
root avulsions during brachial plexus exploration. This has been advocated mostly
hhttt hhttt
in adult brachial plexus injuries, where the mechanism of injury is more severe,
and the likelihood of functional recovery from brachial plexus nerve grafting is
poor due to the long distances the nerve must travel to reinnervate the muscle.
While these transfers have demonstrated encouraging early results in neonatal
keerrss k eerrss
brachial plexus palsy, suggesting that there may be clinical equipoise between
b ooook b ook
traditional nerve grafting and combined nerve transfers in children, they have not
o o
been proven to be superior in recovery at this time.
eeb e / e
/ e b
The recovery of elbow flexion is important for functional use of the arm
e
: / / t
/ .
t m m : / / t
/ .
t m
. m
following brachial plexus injury, allowing for the ability to bring the hand to the
.
mouth and head, as well as lift and carry objects. The brachialis muscle is the
t
hhtt t
primary elbow flexor, and provides more elbow flexion torque than the biceps
hhtt
brachii. The biceps acts as a primary forearm supinator and can be recruited for
additional elbow flexion torque, especially in supination. The MCN innervates
both muscles and has been the primary reanimation recipient for nerve transfer
surgery to restore elbow flexion. Specific reinnervation of the brachialis and
k e rrss
e e rrss
biceps branches of the MCN via fascicles of the median and ulnar nerve has been
k e
o o
o o k advocated as well.
o o
o o k
eebb e / / b
e b
The largest series of ulnar nerve fascicle transfer to the biceps (Oberlin
e
nerve transfer) (Figure 8) in brachial plexus birth palsy reported on the results of
e
t . m
. m t. m.
seven patients who presented late (11–24 months).40 Five patients in that series
: / / / t : / / / t m
t p ss:
p / t p ss:
p /
obtained antigravity flexion, and the two failures were in patients who had surgery
t t t t
at 19 and 24 months of age. Al Qattan41 reported on two patients with a delayed
hht hht
presentation and stable shoulder function who were treated with ulnar fascicular
k e r
e s
rs k eerrss
159
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb ee/ e
/ e b
Figure 8: Isolation of a group fascicle from the ulnar nerve (red loop)
: // t/.tm
. m : / /t/.tm. m
for transfer to the musculocutaneous branch to the biceps muscle
(yellow loop). Courtesy: Shriners Hospital for Children, Philadelphia,
hhttt hhttt
Pennsylvania, USA.
transfer at the ages of 16 and 18 months. Both patients obtained full elbow flexion
after 5 months, without ulnar nerve deficits noted. Shigematsu42 reported on one
keerrss k eerrs
patient who underwent ulnar nerve fascicle transfer to biceps as well as spinal
s
accessory nerve (SAN) to SSN transfer at 8 months of age. The patient obtained
b ooook o ook
full elbow flexion and 90° shoulder abduction after 5 months. Combining these
b o
eeb ee e
/ e b
studies, antigravity elbow flexion recovery was seen in 8 out of 10 patients.
/
Intercostal nerve transfers to the MCN have been used in pediatric and adult
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
brachial plexus patients. Transfer of the intercostal nerves requires an extensive
dissection along the anterior chest, and is not recommended for patients with
t
hhtt t
hhtt
phrenic nerve palsy.43 Additionally, care must be taken to preserve the fourth
intercostal sensory branch in females to avoid sensory denervation of the nipple.44
Kawabata45 reported on intercostal nerve transfers in 31 patients at an average
age of 5.8 months and reported 84% antigravity elbow recovery.45 El Gammal et
al. reported good results in pediatric patients, with 94% of patients (average age:
k e rrss
e e rrss
14 months) obtaining at least antigravity elbow flexion.46 Luo4 reported on 24
k e
o o
o o k o o
o o k
patients that underwent intercostal to upper trunk or MCN transfer at an age
eebb ee/ e
/ b
e b
of 5 months and reported 71% British Medical Research Council (BMRC) M4
strength recovery. However, intercostal nerves cannot reach the individual motor
t . m
. m t. m. m
branches of the biceps and brachialis muscles, placing the nerve coaptation further
: / / / t : / / / t
t p ss:
p / t p ss:
p /
from the motor endplate. This approach also allows regenerating motor axons
t t t t
to proceed along the lateral antebrachial cutaneous nerve. Additionally, cortical
hht hht
representation for elbow flexion may be initially impaired, and many patients
k e r
e s
rs
160
k eerrss
o o
o o k o o
o o k
/ebb
/e 7/22/2016 11:29:38 AM
: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
develop a “breathing arm”. Cortical plasticity typically occurs, however, and elbow
flexion that is independent of respiration generally is observed.47 We prefer to
eebb ee/ e
/ebb
use this transfer in global plexus palsies, where the ulnar and median nerves are
/ / t
/ t m
unsuitable, as opposed to using it for upper trunk lesions.
. . m / / t
/ .
t m
. m
Like the ulnar nerve, the medial pectoral nerve is almost exclusively derived
: :
t p ss
p : / t p ss : /
from the lower trunk and is preserved in all but global palsies. Blaauw and Slooff48
p
t
hht t t
hht t
reported on 25 cases of brachial plexus birth palsy that were treated with medial
pectoral nerve transfer at an average age of 5.3 months. Antigravity elbow flexion
was obtained in 17 patients (68%), although it is unclear from their study whether
or not full motion against gravity was achieved. Wellons et al.49 reported on
k eers
rs k er
ers
20 patients averaging 7 months old who underwent medial pectoral nerve transfer
s
to the MCN; 16 patients (80%) regained the ability to bring their hand to their
b ooook o ook
mouth against gravity. However, similar to intercostal nerve transfers, selective
b o
eeb ee e
/ e b
transfer to the motor branch of the biceps or brachialis cannot be performed.
/
Additional nerve transfers have been utilized to restore elbow flexion in
: // t/. m
. m : / /t . m. m
pediatric patients. The SAN has been used as a donor,50 but the coaptation is far
t / t
from the motor endplate of the biceps and may require a nerve graft. Furthermore,
hhttt hhttt
the SAN is often required for restoration of shoulder function and is, therefore, not
typically available, unless dissociative recovery is noted. Transfer of the hypoglossal
nerve has seen some success, but the resultant loss of donor nerve function can
be severe. Moreover, unwanted elbow flexion can occur during mouth and tongue
movements.51
keerrss k eerrss
The SAN has long been used as a donor nerve in brachial plexus injuries
b ooook b ook
because it is an extraplexal cranial nerve that is almost always intact, and most
o o
transfers typically denervate only the lower trapezius. Most commonly, the SAN
eeb e / e
/ e b
has been used to reinnervate the SSN (Figure 9). This nerve transfer can be
e
: / / / .
t m m : / / / .
performed using an anterior approach, where the SSN is identified as it braches
t . t t m
. m
t ppss / t ppss : /
off the upper trunk, or using a posterior approach, where the SSN is found
:
traversing the suprascapular notch. In both approaches, the SSN is identified
t
hhtt t
hhtt
along the anterior border of the trapezius along with branches of the transverse
cervical artery and vein.
Kawabata et al.50 reported on 2 patients that underwent SAN-SSN transfer
in a report on 13 patients with accessory nerve transfer to various targets in the
k e rrss
e k rrss
brachial plexus. They reported that 88% of transfers, including those to the C5
e e
and C6 roots had M4 reinnervation of the infraspinatus muscle. Another study
o o
o o k o o
o o k
by van Ouwerkerk52 demonstrated that 72% 39 out of 54 of patients recovered
eebb ee/ e
/ b
e b
active external rotation to 20° at an average surgical age of 21.7 months. Similarly,
/ / t
/ t m
Grossman et al.53 demonstrated good recovery of external rotation in 92% 24
. . m / /
out of 26 using an end-to-side technique and interposition nerve graft for
: : t
/.tm. m
t p ss:
p / t p ss:
p /
SSN reconstruction. In a follow-up from the same group, Ruchelsman et al.54
t
hht t t
hht t
demonstrated a mean postsurgical external rotation of 69.6°. These patients had
dissociative recovery, where shoulder abduction and elbow flexion recovered
k e r
e s
rs k eerrss
161
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
eebb ee/ e
/ebb
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
eeb e / e
/ e b
Figure 9: Transfer of the spinal accessory nerve to the suprascapular
e
: // t/.tm
. m : / /t/.tm. m
nerve via an anterior approach. Courtesy: Kevin Little, MD
hhttt hhttt
spontaneously, but external rotation remained deficient. While the reinnervation
pathway of the SSN should improve both supra- and infraspinatus functions, the
authors did not see consistent improvement in shoulder abduction commensurate
with the recovery of external rotation.
Pondaag and colleagues55 demonstrated statistically equivalent outcomes from
keerrss k eerrss
SSN transfer using either nerve graft from C5 nerve root or anterior SAN-SSN
b ooook b ook
transfer. However, in their combined series only 20% 17 out of 86 of patients
o o
recovered external rotation beyond 20°, and less than half of the patients (48%) in
eeb / e
/ e b
the SAN-SSN group recovered active external rotation to neutral. Interestingly,
ee
: / / t
/ .
t m
. m : / / t
/ .
t m
functional shoulder recovery, i.e., bringing hand to mouth (88%) or hand to
. m
t ppss / t p ss : /
neck (75%)—was significantly better than true range of motion measurements,
:
suggesting that compensatory mechanisms utilized by children allow for small
p
t
hhtt
improvements in motion to have greater impact. t
hhtt
Reinnervation of the deltoid is another method to improve shoulder abduction,
but does not affect external rotation. Thus, in the flail shoulder, combined transfers
utilizing the axillary nerve and SSN as recipient targets have been advised.39,56
k e rrss
e k rrss
The most common donor nerve for axillary nerve reconstruction has been a
e e
branch of the radial nerve to the long or lateral head of the triceps, which was first
o o
o o k o o o k
described by Lurje in 1948.57 Other donors, including the medial pectoral nerve,
o
eebb ee/ e b
e b
fascicles of the median and ulnar nerves, SAN, and intercostal nerves have been
/
reported with overall satisfactory results. Nerve transfer to the axillary nerve can
: / / t .
t m
. m : / / t.tm. m
be performed from a posterior or axillary approach to identify the axillary nerve
/ /
t p ss:
p /
and the appropriate donor nerve.
t p ss:
p /
t
hht t t
hht t
There are limited results of nerve transfer to the axillary nerve in children
with brachial plexus birth palsy. Additionally, as this surgery is often performed
k e r
e s
rs
162
k eerrss
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
concomitantly with SSN reconstruction of the supraspinatus muscle, the results
of pure deltoid reinnervation are difficult to extract. The most recent pediatric
eebb ee/ e
/ebb
series included 2 brachial plexus birth injuries and 3 traumatic injuries, treated less
/ / t
/ t m
. m / / t
/ t
They noted that all 5 patients obtained full abduction with gravity eliminated
: : m
than 1 year after injury with radial-to-axillary nerve transfer and SSN transfer.58
. . . m
t p ss
p : / t p ss : /
[active movement scale (AMS) >4], and both brachial plexus birth palsy injuries
p
t
hht t t
hht t
recovered more than 50% of antigravity shoulder abduction (AMS = 6). Terzis
and Kokkalis59 reported on axillary nerve reconstruction in 56 neonatal brachial
plexus injuries, where 5 patients had a total of 9 intercostal nerve transfers to
the axillary nerve. The results of shoulder abduction in this transfer were slightly
k eers
rs k er
ers
inferior to those demonstrated using nerve graft from the posterior cord of the
s
brachial plexus, however, concomitant SAN-SSN nerve transfers were performed
b ooook o ook
in 50 of the 56 injuries in this group. Miller et al.60 reported on a single patient
b o
eeb ee e
/ e b
with a traumatic shrapnel wound to the brachial plexus treated with long head of
/
the triceps branch of radial nerve to axillary nerve transfer. He recovered BMRC
: // t/.tm
. m : / /t/.tm. m
grade 4 shoulder abduction function in the setting of a 6 month delay in surgical
t ppss : /
treatment while awaiting spontaneous recovery.
tppss : /
hhttt hhttt
The literature supporting the use of radial to axillary nerve transfers is much
more robust in adult patients. However, similar to the pediatric literature, many
of the series included concomitant SAN-SSN transfers. Leechavengvongs and
colleagues61 reported on 7 patients following combined shoulder nerve transfers,
all of whom recovered BRMC M4 deltoid strength and 124° of active shoulder
keerrss k eerrss
abduction. An additional 10 patients reported by Bertelli and Ghizoni62 had less
b ooook b o ook
robust results, with only 3 obtaining M4 deltoid strength and 7 obtaining M3
o
eeb ee e
/ e b
strength, although they showed improved results in 3 patients treated via axillary
/
approach.63 Lee et al.64 demonstrated an average deltoid strength of 3.4 following
t . m
. m t . m
. m
21 radial-to-axillary nerve transfers following isolated axillary nerve injury. While
: / / / t : / / / t
only 12 (57%) obtained at least grade M4 and 16 (76%) obtained at least M3
t
hhtt t
hhtt
strength, they correlated improved results in patients with decreased denervation
time, younger age, and lower body mass index (BMI).
CONCLUSION
k e rrss
e e rrss
e
While nerve transfers have shown early reliable outcomes, they have not yet
k
o o
o o k o o o k
replaced brachial plexus exploration and grafting, and are used for selected
o
eebb ee/ e
/ b
e b
indications. In patients with nerve root avulsions, where there are no useful axonal
donors for nerve grafting, combined transfers to the shoulder have shown success
: / / t
/ .
t m
. m : / / t
/.t
in recovering function. Currently, there are two patients with known return tom. m
t p ss:
p / t p ss:
p /
normal function after SAN-SSN, radial-axillary and Oberlin nerve transfers at
t
hht t t
hht t
3 months of age for nerve root avulsions (personal unpublished data). Return of
normal function is theorized to occur in nerve root avulsions due to the presence
k e r
e s
rs k eerrss
163
o o
o o k o o
o o k
/ebb
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: / /
/ t
/ .t. : / /
/ t
/ .t.
t t p
t ss:
p t t p
t ss:
p
hht hht
Abzug and Little
k e r
e s
rs k eers
r s
o o
o o k o o
o o k
of intact sensory stimuli to the muscles, which may dissipate or prevent muscular
atrophy from motor neuron denervation, but, at this time, cannot be applied to
eebb / e
/ebb
all instances of brachial plexus injury until the biology and pathophysiology of
ee
: / / t
/ t m
brachial plexus injuries can be established.
. . m : / / t
/ .
t m
. m
Brachial plexus birth palsy continues to be a frequent injury that can be
t p ss
p : / t p ss : /
potentially devastating. Current treatment typically consists of neuroma resection
p
t
hht t t
hht t
and nerve grafting; however, nerve transfers are gaining in popularity and usage.
Most commonly, these are being performed to obtain specific motor function as
opposed to treating the constellation of limitations seen in early brachial plexus
birth injuries. Future studies are needed to determine the best procedure(s) and
k eers
rs k er
erss
their timing for the treatment of brachial plexus birth injuries.
b ooook Editor’s Comment b ooook

eeb ee/ e
/ e b
: // t/.tm
. m : / /t/.tm
Brachial plexus birth palsy is potentially debilitating injury that can be devastating
. m
to both the child and the family. Unfortunately, the incidence of this injury remains
high, but fortunately, majority of the patients does not require treatment and
hhttt hhttt
recover spontaneously. However, ongoing controversy remains as to how to manage
patients who have not demonstrated spontaneous recovery by 3 months. Treatment
options include continued observation, delayed tendon transfers, or primary
surgical intervention in the form of exploration with neurolysis, surgical excision of
keerrss k eerrss
neuroma with nerve grafting, or nerve transfers. In this article, the authors present
b ooook ook
a review of the diagnosis, anatomy, and pathophysiology of nerve injury. They also
o o
provide a detailed comparative review of neuroma excision and nerve grafting
b
eeb versus nerve transfers.
ee/ e
/ e b
Asif M Ilyas
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t
hhtt
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t
hhtt
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t t p
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k e r
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9. Seddon HJ. Surgical Disorders of the Peripheral Nerves. Baltimore, MD, USA: Williams & Wilkins; 1972. pp.
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10. De Grandis D, Fiaschi A, Michieli G, Mezzina C. Anomalous reinnervation as a sequel to obstetric brachial
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11. Heise CO, Siqueira MG, Martins RS, Gherpelli JL. Clinical-electromyography correlation in infants with
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t p ss : /
12. Lee SK, Wolfe SW. Peripheral nerve injury and repair. J Am Acad Orthop Surg. 2000;8:243-52.
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t
hht t t
hht t
13. Lee HY, Chung IH, Sir WS, Kang HS, Lee HS, Ko JS, et al. Variations of the ventral rami of the brachial plexus.
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15. Bleck EE. Orthopaedic Management in Cerebral Palsy. Philadelphia, PA, USA: JB Lippincott Company; 1987.
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16. Waters PM. Obstetric brachial plexus injuries: evaluation and management. J Am Acad Orthop Surg.
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17. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical
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eeb / e
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18. Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin. 1995;11:563-81.
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19. Bae DS, Waters PM, Zurakowski D. Reliability of three classification systems measuring active motion in
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20. van Ouwerkerk WJ, van der Slujis JA, Nollet F, Barkhof F, Slooff AC. Management of obstetric brachial plexus
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ook ook
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b o
25. Clarke HM, Al-Qattan MM, Curtis CG, Zuker RM. Obstetrical brachial plexus palsy: results following neurolysis
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e / e
of conducting neuromas-in-continuity. Plast Reconstr Surg. 1996;97:974-84.
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: / /
/ t
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26. Marcus JR, Clarke HM. Management of obstetrical brachial plexus palsy: evaluation, prognosis, and primary
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p
hhtt hhtt
28. Sherburn EW, Kaplan SS, Kaufman BA, Noetzel MJ, Park TS. Outcome of surgically treated birth-related
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29. Slooff AC. Obstetrical brachial plexus lesions and their neurosurgical treatment. Clin Neurol Neurosurg.
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30. Al-Qattan MM. The outcome of Erb’s palsy when the decision to operate is made at 4 months of age. Plast
rrss rrss
Reconstr Surg. 2000;106:1461-5.
o k e
k e o k e
31. Kawabata H, Masada K, Tsuyuguchi Y, Kawai H, Ono K, Tada R. Early microsurgical reconstruction in birth
k
palsy. Clin Orthop Relat Res. 1987;(215):233-42. e
o
eebb o o b o o o
32. Gilbert A, Khouri N, Carlioz H. [Birth palsy of the brachial plexus--surgical exploration and attempted repair
e b
ee/ e
in twenty one cases (author’s transl)]. Rev Chir Orthop Reparatrice Appar Mot. 1980;66:33-42.
/
33. Fisher DM, Borschel GH, Curtis CG, Clarke HM. Evaluation of elbow function as a predictor of outcome in
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62. Bertelli JA, Ghizoni MF. Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve
transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral
head branch to axillary nerve. J Hand Surg Am. 2004;29:131-9.
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World Clinics - Orthopedics - Hand Surgery 1st Edition

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: / /

eeb Gregg R Klein MD

b ooook Fax: +02-03-0086180

keerrss Website: www.jaypeebrothers.com

keerrss Asif M Ilyas MD FACS

b ooook Colorado Permanente Medical Group

b ooook Philadelphia, Pennsylvania, USA

keerrss Christopher J Williamson MD

keerrss Matthew T Kleiner

b ooook role of diagnostic studies.

b ooook AAN American Academy of

keerrss Internal Fixation

b ooook SNAC Scaphoid nonunion

eebb Locking Technology e

• h httt distal radius)

Proximal Radius and Ulna

b ooook Scand. 2004;75:741-5.

keerrss Oper Orthop Traumatol. 2005;17:25-50.

keerrss Res. 1993;(292):26-36.

hhtt t *Corresponding author

keerrss Palmar Midcarpal Ligaments

keerrss angulation greater than 70°.1

keerrss Combined Volar-dorsal Approaches

Interosseous Wire Technique

keerrss result in a painful, stiff wrist.

b ooook and ROM exercises are then initiated.

keerrssIsolated Ulna Fractures

keerrss medical comorbidities.

b ooook to the proximal half of the ulna.

b ooook study. Orthopedics. 1995;18:543-7.

b ooook INTRODUCTION b o ook

eebb • The Kocher approach ee/ / b

keerrss Asif M Ilyas

keerrss Surg. 2006;15:463-73.

eebb Scaphoid Nonunion: ee/ e

Figure 2: A, Preoperative radiograph demonstrating a proximal pole scaphoid

keerrss using CT or plain radiographs.

b ooook Surg Am. 2000;25:46-54.

Table 1: Garcia-Elias Classification of Scapholunate Dissociations

eebb Is the scaphoid normally aligned

Figure 1: Chronic scapholunate dissociation in the

b ooook outweigh their potential advantages.

b ooook DORSAL INTERCARPAL LIGAMENTbPROCEDURES

Figure 5: Various capsulodesis strategies. A, Traditional capsulodesis. B, Scapholunate interosseous

b ooook capsulodesis by Berger et al.

flexion-extension plane, and 41° in the radial-ulnar deviation plane. Postoperative

eebb continued use was warranted.60

keerrss Surg. 2005;9:35-41.

keerrss in only 24–29% of patients.13

keerrss the thumb A1 pulley.35

b ooook RHEUMATOID ARTHRITIS b ooook

DIABETES MELLITUS ://t /.tm. m : / / t

b ooook Editor’s Comment b o ook

eebb Hand. 1972;4:257-60.

eebb The Controversial ee/

keerrss diagnostic modalities for CTS:

keerrss specificity 98%).16

b ooook 5 Very severe CTS

keerrss J Am Acad Orthop Surg. 2009;17:389-96.

keerrss Nerve. 2003;27:378-85.

b ooook J Roentgenol. 1999;172:1581-6.

eebb Pediatric and Adolescent ee/ e

12 and 16 years of age.2