References

1 Sprague NF III, O'Connor RL, Fox JM. Arthroscopic treatment of postoperative knee arthrofibrosis. Clin Orthop Relat Res 1982 66 165-72. 2 Hughston JC. Complications of anterior cruciate ligament surgery. Orthop Clin North Am 1985 16 237-40. 3 Parisien JS. The role of arthroscopy in the treatment of postoperative fibroarthrosis of the kneejoint. Clin Orthop Relat Res 1988 229 185-92. 4 Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis in acute anterior cruciate ligament...

Jeffrey Luo MD Edward Diao MD

Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedic Surgery, University of California San Francisco, 500 Parnassus Avenue, MU-320W, San Francisco, CA 94143, USA In 1910, Robert Kienbock published his seminal article on traumatic malacia of the lunate 1,2 . Kienbock, a Viennese radiologist, presented radiographic evidence of changes in the proximal portion of the lunate and the radiolunate articulation 3 . He described collapse of the lunate, and believed the...

Axial dislocations

Wringer Injuries

Axial-loading or longitudinal dislocations of the carpus describe carpal dislocations oriented along the long axis of the forearm. Also termed ''capitohamate diastasis,'' ''carpal arch disruption,'' or ''columnar dislocations,'' they involve a traumatic disruption of the carpus in which it is longitudinally split and displaced. These are rare carpal dislocations, with an incidence of only 1.4 to 2.08 of patients with carpal fracture-dislocations or subluxations 7 . Axial dislocations usually...

Carpal tunnel syndrome

Carpal tunnel syndrome CTS occurs infrequently in children. Several groups of children show increased susceptibility to CTS, including those who have lysosomal storage diseases, muco-polysaccharidoses, mucolipidoses, hemophilia, hemangiomas, macrodactyly, and familial CTS. In addition, children engaging in sports such as weight lifting and skiing are more prone to developing CTS. Most children present with complaints of clumsy hands, wrist pain, and hand pain. Older children experience symptoms...

Natural history

The value of any staging system of a clinical condition lies in its ability to guide treatment however, mention should be made first of the natural history of the disease. In short, the natural history of Kienbock's disease is not known. Because of the difficulty of performing a definitive study to answer questions about this, few studies have been undertaken, each with low numbers and systematic flaws that the authors acknowledged 5,26 . No prospective data have yet been obtained. Keith and...

Box 2 Pisiform summary

Tumor Flexor Carpi Ulnaris

Special radiographs CT scan still often necessary 1. Reverse oblique 45 supination - Non- to minimally displaced SAC x 4-6 weeks - Widely displaced with loss of FCU continuity pisiform excision and FCU repair 2. Chronic, symptomatic nonunion or arthritic pisotriquetral joint pisiform excision Abbreviations FCU, flexor carpi ulnaris SAC, short-arm cast. were caused by motor vehicle collisions and one was caused by a fall. Four out of 11 patients had associated Bennett fractures and 2 had...

Treatment

Kienbock Avn

The treatment of idiopathic AVN of the scaphoid remains a confusing and often frustrating dilemma for the treating surgeon. Currently, there is no standardized treatment algorithm for patients affected by Preiser's disease. Because of the lack of treatment protocols many patients are treated conservatively until degeneration of the carpus or pain require that a salvage procedure be performed. Adding to the confusion from the paucity of treatment guidelines is the number of different Fig. 5. PA...

Box 3 Trapezium summary

Lunate Fracture

Vertical intra-articular Fig. 5 Type 2. Horizontal rare Type 3. Dorsoradial tuberosity Type 4. Palmar ridge Fig. 4 b. Type II. Tip Type 5. Comminuted metacarpal Type 2. Horizontal shear Type 3. Vertical shear on radial styloid Type 4. Direct blow or avulsion of transverse carpal ligament Type 5. Axial compression from 1st metacarpal Special radiographs CT scan still often necessary 1. Bett's or Gedda's view see text 2. Carpal tunnel view for palmar ridge fractures - Nondisplaced SATSC x...

Box 4 Lunate summary

Visi Wrist Injury

Hyperextension, possible ligamentous avulsion fracture Type II. Shear Type III. Shear from capitate or ligamentous scapholunate avulsion fracture Type IV. Shear during radiocarpal fracture-dislocation Type V. a. Hyperextension with capitate forcing dorsal half of lunate into extension and short radiolunate ligament forcing palmar half into flexion. Fracture in mid-section results b. Shear with palmar displacement of capitate in palmar perilunate injury Type VI. Axial compression between...

Carpal boss

Metacarpal Boss

Multiple descriptions and case reports of carpal boss exist in the literature 57-60 . A carpal boss may be confused with a ganglion or an accessory bone such as an accessory capitate 61 however, a true carpal boss is a bony protuberance on the dorsum of the wrist at the base of the second and third metacarpals. It may be a degenerative osteophyte or an accessory ossification center known as an os styloideum. This ossicle is thought to develop early in embryogenesis, and trivial injury to this...

Isolated carpal dislocations

Carpal Dislocations

Isolated dislocations of the carpal bones are relatively rare injuries. More often individual carpal bone dislocation is associated with a more global wrist dislocation pattern, such as progressive per-ilunate instability or the axial dislocations patterns. Because of their rarity, most of our information on isolated dislocations comes from a relatively small amount of case reports and technique papers. Although it is critically important to recognize the clinical and radiologic features of...

Box 5 Triquetrum summary

Hamate Lateral View Hook

- Hyperextension during fall with impaction by ulnar styloid - Extreme palmar flexion twist with avulsion by dorsal ligaments DRC, DIC - Small fragment, no instability wrist splint vs. SAC x 4-6 weeks. Excision if symptomatic after 6 months - Signs of carpal instability ORIF - Nondisplaced body fracture SAC x 4-6 weeks - Displaced body fracture CRIF vs ORIF - Small fragment, no instability Wrist splint vs. SAC x 4-6 weeks - Ligamentous avulsion with carpal instability ORIF - Shear from pisiform...

Kienbock Disease Garcia

1 Garcia-Elias M, Cooney WP, An KN, et al. Wrist kinematics after limited intercarpal arthrodesis. J Hand Surg Am 1989 14 791-9. 2 Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972 54 1612-32. 3 Landsmeer JM. Studies in the anatomy of articulation. I. The equilibrium of the intercalated bone. Acta Morphol Neerl Scand 1961 3 287-303. 4 Moojen TM, Snel JG, Ritt MJ, et al. Scaphoid kinematics in...

Down syndrome

Palmaflexion

Very little has been written about wrist abnormalities in Down syndrome. The senior author TRL has treated two patients who had Down syndrome who developed nondissociative midcarpal subluxation with palmar flexion of the proximal carpal row secondary to ligamentous laxity Fig. 15A-D . One patient underwent inter-carpal arthrodesis and eventually developed ra-diocarpal subluxation, suggesting that total wrist arthrodesis may be necessary to ensure long-term stability in patients who have this...

Multiple hereditary exostoses

Multiple Exostoses

Multiple hereditary exostoses MHE is a benign autosomal dominant skeletal dysplasia that typically presents in the first decade of life 67 . In children, early exostoses appear as asymmetrical overgrowths of the cortex adjacent to a physis Fig. 8A, B . Because these lesions are partially cartilaginous, MRI may be needed to accurately determine their size and location 68 . The forearm is affected in approximately 60 of patients who have MHE 68 . When the ulna is affected, its longitudinal growth...

Volar exposure of the schaphoid specific

Humpback Deformity

The volar approach to the scaphoid was popularized by Russe after his description of scaphoid fracture nonunion repair 26-28 . This approach is primarily indicated for the open reduction and fixation of scaphoid waist or distal pole fractures. The advantages of this approach include preservation of the vascularity of the scaphoid by avoiding the dorsal distal blood supply, and an easier ability to correct apex dorsal angulations humpback deformity of scaphoid waist non-unions or malunions 29...

Anatomic motion planes

Pictures Kienbock Disease

Most wrist kinematic studies have analyzed carpal bone behavior during wrist motion in the traditional anatomic planes the sagittal plane flexion-extension motion FEM and the coronal plane radioulnar deviation RUD . During wrist FEM, most studies have found that scaphoid motion occurs predominantly within the sagittal plane 11,21,22,25,26,39 . In FEM, the scaphoid and lunate follow the direction of wrist motion, but have less excursion because global wrist motion is composed of contributions...

Carpal coalition

Lunotriquetral Coalition

Carpal coalitions are the result of incomplete or absent joint formation between cartilaginous carpal precursors. Case reports have documented coalition between virtually every combination of adjacent carpal bones Fig. 3A,B . In addition, ra-diocarpal and carpometacarpal fusions have been documented. Lunatotriquetral fusion is the most common carpal coalition, with an incidence of approximately 0.1 Fig. 4 10 , followed by capi-tohamate fusions. Because the carpus ossifies throughout childhood,...

Michael J Gardner MDa Joseph J Crisco PhDb Scott W Wolfe MDa

ADepartment of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA hDepartment of Orthopaedics, Brown Medical School Rhode Island Hospital, Coro West, Suite 404, 1 Hoppin Street, Providence, RI02903, USA The motion of the eight carpal bones is extremely complex, and their accurate measurement has been hampered by their multiplanar rotations and translations, the irregularity of their shape, and the small magnitudes of movements. However, an accurate...

Dorsal exposure of the schaphoid specific

Lunate Blood Supply Images

The dorsal approach to the scaphoid provides better access to the proximal scaphoid, and is indicated in the fixation of proximal scaphoid fractures. There is a concern with injury to the vascular supply of the scaphoid however, recent reports have not shown a significant difference in the union rates when compared with the volar approach 31 . Fig. 14. A Perilunate fracture dislocation injury Mayfield Stage IV demonstrating lunate dislocation on lateral radiograph. B The lunate is seen lying in...

Reverse perilunar dislocations

Much less common and less recognized are the ulnar sided perilunar injuries, which predominantly involve the LT, UT, and UL ligaments. Through biomechanical cadaver studies, a three-stage progressive perilunar instability pattern was noted to initiate on the ulnar side of the wrist 20 . Stage I involves a tear of the LT ligament. Stage II is disruption of the volar ulnar ligament complex and DRC and DIC ligaments. Stage III is a tear of the SL ligament and subsequent development of a perilunate...

Intraosseous ganglion

Intraosseous Well Differentiated

The most common carpal lesion is the intra-osseous ganglion IOG . Also known as a subchon-dral bone cyst, the IOG is a benign, mucin-filled, cystlike lesion that arises within the subchondral medullary bone. IOGs are regularly seen on wrist radiographs obtained to evaluate wrist pain or other problems. In a radiographic study of 280 cadaveric wrists, Schrank and colleagues 1 identified an overall 9.6 incidence of carpal ganglion cysts. In patients who have dorsal wrist ganglions, the prevalence...

Ryan J Grabow MDa Louis Catalano III MDb

Intrinsic Carpal Ligaments

ANevada Orthopedic amp Spine Center, 2650 North Tenaya Way, Suite 301, Las Vegas, NV 89128, USA bC.V. Starr Hand Surgery Center, Saint Luke's-Roosevelt Hospital, 1000 Tenth Avenue, New York, NY 10019, USA Carpal dislocations are rare injuries. They most often occur from high-energy trauma such as motor vehicle accidents, falls from a height, or industrial-related accidents. Usually occurring in young males in their twenties or thirties, these injuries may be missed initially because of...

Anthony J Lauder MD Thomas E Trumble MD

Carpal Bones Kinematics

Hand and Microvascular Surgery Program, University of Washington Hand Surgery Institute, Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA 98195, USA Idiopathic avascular necrosis of the bones making up the carpus is a relatively rare, albeit often debilitating, condition that most frequently affects the lunate. In 1910, Robert Kienbock 1 initially described a classic case of lunatomalacia, which he believed was caused...

Mitsuhiko Nanno MD PhDa Rita M Patterson PhDb Steven F Viegas MDb

ADivision of Hand Surgery, Department of Orthopaedic Surgery, Nippon Medical School, Musashikosugi Hospital 1-396, Kosugicho, Nakahara-ku, Kawasaki 211-8533, Japan bDepartment of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0165, USA Although many articles have examined the anatomy and function of the carpal ligaments 1-20 , these remain incompletely understood. Visualization all of the ligaments of the wrist during...

What Is Jvl Cerebral Palsy

1 Kienb ck R. ber traumatische Malazie des Mondbeins und ihre Folgezustande Entartungsformen und Kompressionsfrakturen. Fortschr Roetgenstr 1910 16 78-103 in German . 2 Peltier LF. The classic. Concerning traumatic mala-cia of the lunate and its consequences degeneration and compression fractures. Privatdozent Dr. Robert Kienbock. Clin Orthop Relat Res 1980 149 4-8. 3 Wagner JP, Chung KC. A historical report on Robert Kienbock 1871-1953 and Kienbock's Disease. J Hand Surg Am 2005 30 6 1117-21....

Madelungs deformity

Fractures The Triquetrum Children

Madelung's deformity reflects asymmetric growth of the distal radial physis. As the radial and dorsal portions of the physis continue to grow, several abnormalities manifest. Increased palmar and ulnar tilt of the distal radial articular surface leads to volar translation of the hand and wrist. Although the reduction of growth is most prominent along the ulnar and volar distal radial physis, an overall reduction of growth occurs along the entire physis compared with normal, resulting in a...

Dysplasia epiphysealis hemimelica Trevor disease

Dysplasia Epiphysealis Hemimelica

Dysplasia epiphysealis hemimelica DEH , or Trevor disease, is a developmental disorder of unknown origin characterized by osteocartilaginous Fig. 6. Radiocarpal dislocation in a patient who has Morquio's wrist. Fig. 6. Radiocarpal dislocation in a patient who has Morquio's wrist. overgrowth of one or more epiphyses. Common sites of presentation include the distal tibia, distal femur, and talus 49-52 . Although upper extremity involvement is rare, several cases of DEH were reported involving the...

Approach to distal radioulnar joint specific

Volar Approach Scaphoid

The distal radioulnar joint can be exposed dorsally through a 4 cm longitudinal skin incision made between the fifth and sixth extensor Fig. 15. A Skin incision for volar exposure of the scaphoid angled line is centered around the scaphoid tuberosity circle . B The superficial branch of the radial artery and its venae comitantes will cross the incision and will require division. C The superficial surface of the flexor carpi radialis tendon sheath is incised longitudinally dashed line to allow...

Patricia A Hsu MD Terry R Light MD

Loyola Department of Orthopaedic Surgery and Rehabilitation, 2160 South First Avenue, Maguire, Room 1700, Carpal disorders in children are often associated with developmental abnormalities of structures surrounding the wrist. Conditions that alter the function and position of the arm, forearm, and hand will also ultimately influence carpal development and function. Because the immature carpus is composed of unossified cartilage, carpal abnormalities in young children are frequently undetectable...

The dart throwers motion

Dart Thrower Motion

Considerable controversy remains and conflicting reports exist regarding carpal bone motion in the traditional planes of FEM and RUD. Although some of the discrepancy may be related to variations in measurement techniques and anatomic variability among human subjects, no clear unifying theory has explained carpal kinematics in the planes of flexion-extension and radioulnar deviation. The vision of carpal kinematics may be obscured by the constraint of carpal motion into arbitrary and orthogonal...

Fracture

Scaphocapitate Syndrome Photo

The scaphoid is the most commonly injured carpal bone in children, followed by the capitate 81 . Combined injury of these carpal bones is a well-documented entity in children and is referred to as scaphocapitate syndrome. The most common mechanism of injury, which is the same for children and adults, is a fall onto an outstretched hand. Because the carpus is unossified through most of childhood, MRI may be needed in addition to plain radiographs to detect injuries of the immature carpus Fig....

Volar carpal exposure carpal tunnel approach

Dorsal Approach Distal Radius

There are essentially two types of volar carpal exposures, one that divides the transverse carpal ligament and one that uses a modified Henry approach. The volar carpal exposure is most commonly used to reduce difficult carpal dislocations perilunar and for repair or reconstruction of the palmar wrist capsule and the palmar carpal ligaments. Volar approaches are also useful for reduction and fixation of palmar fragments of difficult distal radius fractures. The volar approach is often used in...

Accessory carpal bones

Causes Kienbock Disease

Because true accessory carpal bones are uncommon, with an incidence of 0.4 -1.6 17,18 , these small bones are often mistaken for fractures of normal carpal bones 2,19,20 . Accessoria have been given various names eg, os triangulare, os epitriquetrum, os hypotriquetrum, os lunatotri-quetrum, os centrale, os ulnostyloideum to reflect either the shape or presumed phylogenic derivation of the bone 2 . Disorders that have been associated with accessory carpals include Holt-Oram syndrome 21 ,...

Benign bone tumors

Intraosseous Ganglion Lunate Mri

Primary bone tumors of the carpus are rare 14 . The two most common lesions, osteoid oste-oma and enchondroma, may be easily misdiag-nosed as IOG. Enchondromas may cause pathologic fractures, especially of the scaphoid, just as they do in the phalanges. The giant cell tumor, although more often originating from the distal radius instead of the carpus, routinely causes carpal destruction. Other benign bone tumors, including osteochondroma, chrondroblas-toma, chondromyxoid fibroma, hemangioma,...

Preisers disease scaphoid ischemic necrosis

Although Preiser 100 has been criticized for including patients who have a history of trauma in his original 1910 publication 101 , scaphoid is-chemic necrosis without trauma is still commonly referred to as Preiser's disease. Although atrau-matic ischemic necrosis of the scaphoid has been associated with systemic lupus erythematosus, systemic sclerosis, steroid ingestion, and cytotoxic chemotherapy 102-105 , several cases have been reported in which no apparent cause could be identified...

Ulnar dimelia

Pisiform Abnormalities

Ulnar dimelia is a very rare congenital abnormality with approximately 60 cases documented worldwide 59 . Also known as ''mirror hand,'' the forearm and hand are essentially symmetrical about the mid-line with duplication of the ulna and ulna rays and an absence of the radius and radial rays. The condition is typically unilateral, although instances of bilateral ulnar dimelia have been documented 60,61 . No specific genetic abnormality has been linked to ulnar dimelia. Spontaneous mutation has...

Clinical implications

Dart Thrower Motion

The clear and comprehensive derivation of normal carpal kinematics has potentially significant implications in pathologic and postsurgical states. For example, to evaluate the effects of external fixation and traction on carpal kinematics, Ishikawa and colleagues 20 applied a cadaver model that was used previously to study normal wrist kinematics. They found that wrist extension under traction had a greater effect on the proximal radiocarpal ligaments, which limited scaphoid and overall wrist...

A more detailed ligament anatomy

Ligaments Stabilising The Trapezium

Using 3-D digitization and CT reconstructions with careful dissection, researchers were recently able visualize and quantify the anatomy and specific area and locations of ligament attachments on the individual carpal bones, metacar-pals, and distal radius. Nagao and colleagues 3 and Nanno and colleagues 22,23 took CT images of the hands they researched and then recreated the bone structure in a 3-D image. They also rendered the ligament attachment sites and areas in 3-D. The images of the bone...

Shian Chao Tay MDa b Alexander Y Shin MDa

Lister Tubercle Pain

ADepartment of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA bDepartment of Hand Surgery, Singapore General Hospital, Outram Road, Singapore 169608 Nowhere else in the body are the general principles of surgical exposures which include adequate access, extensibility, preservation of vital structures, minimizing collateral tissue trauma to reduce the healing load , maximizing primary wound healing, and cosmesis more...

Volar carpal exposure modified Henry approach

The modified Henry or trans-flexor carpi radialis FCR approach is a popular approach for exposure of the volar surface of the distal radius. Appropriate capsulotomies from the origins of the radiocarpal ligaments could also provide access to the radiocarpal joint, proximal scaphoid, and lunate. A longitudinal incision over the FCR tendon is carried proximally for 3 to 4 cm. Care must be taken not to cross the ulnar border of the FCR tendon, because the palmar cutaneous branch of the median...