Lesiones de los ligamentos de la muñeca

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes [1].
• Comprehensive evaluation and diverse treatment approaches are needed to improve outcomes for patients with wrist ligament injuries [2].
• Postoperative recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months [3].
• Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears offers a minimally invasive and easily reproducible solution for challenging ulnar wrist injuries [4].
• Most patients treated with a dorsal spanning plate for complex intraarticular distal radius fractures can expect to regain functional wrist range of motion if the distal radius articular surface is well reduced and other principles of fracture fixation are applied [7].
• A series of 36 patients with chronic scapholunate ligament tears treated with arthroscopic dorsal capsuloligamentous repair showed encouraging preliminary results with pain relief, recovery of grip strength, low incidence of postoperative wrist stiffness, and all professional athletes returning to preinjury sports levels [9].
• The use of a wrist fixator allows open wound care and permits free access to the wrist for early secondary operations in the treatment of complex carpal dislocations [10].
• Fractures of the distal radius are among the most common fractures seen in the emergency department [12].
• Patients of advanced age with osteoporosis have an increased fracture risk during low-energy falls [12].
• Fracture patterns vary depending on the mechanism of injury [12].
• The goals of all treatment for distal radius fractures are to optimize comfort and function [12].
• Treatment options for distal radius fractures include closed reduction and cast immobilization, closed reduction and percutaneous pinning with or without external fixation, and open reduction internal fixation [12].
• Most open fractures and volar shearing fractures are best treated operatively [12].
• Surgical treatment indications relate to infirmity, functional demands, tolerance of deformity, and personal preferences [12].
• Loss of reduction including ulnar variance 5 mm or more positive, dorsal articular tilt ≥15°, and loss of radial inclination >10° merits a discussion of surgical treatment [12].
• An articular gap or step of 2 mm or more merits a discussion of surgical treatment [12].
• Unstable volar extra-articular fractures (Smith fracture) merit a discussion of surgical treatment [12].
• Fractures with associated neurovascular injuries merit a discussion of surgical treatment [12].
• Fractures with associated intercarpal ligament injuries merit a discussion of surgical treatment [12].
• Multiple trauma, such as bilateral distal radius fractures or the need to use crutches for a leg injury, is a relative indication for surgical treatment [12].
• Current best evidence suggests initial displacement determines the final alignment regardless of the time of immobilization [12].
• Wrist splints or short arm casts are usually used for distal radius fractures, and the elbow and forearm are usually left free unless there is severe radioulnar joint injury or disruption [12].
• Displaced fractures are immobilized for 4 to 6 weeks after acceptable closed reduction [12].
• It is important to encourage elevation, digital range of motion, and functional use of the limb to avoid stiffness of the fingers and forearm and to limit swelling [12].
• Nondisplaced distal radius fractures are associated with occasional extensor pollicis longus rupture, usually about 4 to 6 weeks after injury [12].
• Bridging external fixation can be used to protect pin fixation or to provide ligamentotaxis [12].
• Full incisions over the radius and index metacarpal at the time of fixator pin placement minimize the risk of iatrogenic injury to the superficial branch of the radial nerve or tethering of the first dorsal interosseous muscle [12].
• The external fixator and pins typically remain in place for 6 to 8 weeks [12].
• Bone graft or bone void fillers can be used to structurally support bone defects and perhaps allow earlier removal of the fixator [12].
• Volar locking plates make it possible to stabilize dorsally displaced fractures from through the volar Henry approach [12].
• Potential pitfalls of volar locking plates include intra-articular screw placement and application to inappropriate fracture patterns with prominent implant placement which may lead to tendon rupture [12].
• The most common tendon to rupture following application of a volar plate is the flexor pollicis longus, due to volar extension of the plate beyond the so-called watershed line [12].
• Dorsal tendons such as the extensor pollicis longus and extensor digitorum communis can fray and rupture from prominent screw tips following volar insertion [12].
• Dorsal plates or constructs are now preferred for dorsal shearing fractures and complex articular fractures in combination with volar plates [12].
• Distraction or bridge plate fixation is increasingly utilized for complex articular fracture, those with complex metaphyseal or diaphyseal fragmentation in particular [12].
• A distraction plate is applied between the index or long finger metacarpal and the shaft of the radius, applied with distraction, and removed about 3 months after injury [12].
• Application of the bridge or distraction plate should not be a substitute for accurate open reduction internal fixation [12].
• Volarly displaced extra-articular fractures (Smith fractures) can be treated with reduction and casting if no comminution is present and a good reduction is obtained [12].
• Volarly displaced extra-articular fractures (Smith fractures) are usually treated surgically with a volar plate and screws [12].
• Fractures of the radial styloid may be associated with scapholunate ligament injuries because the intra-articular fracture line extends into the joint at that level [12].
• In the setting of isolated radial styloid fractures, intercarpal ligament injuries must be suspected [12].
• Nondisplaced or minimally displaced radial styloid fractures may be treated nonsurgically [12].
• Intra-articular displacement or diastasis greater than 2 mm in radial styloid fractures is an indication for surgery [12].
• Compression screw fixation with partially threaded 3.5- or 4.0-mm cancellous screws can effectively compress the fragments and maintain the reduction in radial styloid fractures [12].
• Alternative fixation options for radial styloid fractures include K-wires and fragment-specific pin plate and screw fixation [12].
• The distal radioulnar joint is assessed following stabilization of the radius [12].
• Slightly greater laxity than the opposite uninjured wrist is to be expected following distal radius stabilization [12].
• Only frank dislocation with forearm rotation merits surgery to stabilize the distal radioulnar joint [12].
• The presence of a displaced fracture at the base of the ulnar styloid is not in itself an indication for surgical fixation [12].
• Clinical stability of the distal radioulnar joint must be elucidated and compared with the normal contralateral side when possible [12].
• All patients in a small series of failed total wrist replacement revisions appear to have good clinical outcomes, and revision to another wrist replacement appears no worse in the short term [18].
• No patient required secondary surgery or treatment related to the carpal stabilization in a preliminary outcome study of anatomical anterior and posterior reconstruction for scapholunate dissociation [26].
• Radioscapholunate arthrodesis with compression screws and local autograft is an effective method to perform radioscapholunate arthrodesis in appropriately selected patients with a preserved midcarpal joint [34].
• Radioscapholunate arthrodesis with compression screws and local autograft achieved a 100% union rate at mean follow-up of 12 months with no complications [34].
• Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength as compared to contralateral, or Mayo Wrist Score with regard to surgical approach for acute perilunate injuries [80].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints and the eight carpal bones and their proximal and distal articulations and attached ligaments [47].
• The proximal carpal row contains the scaphoid, lunate, triquetrum, and pisiform [47].
• The distal carpal row contains the trapezium, trapezoid, capitate, and hamate [47].
• The distal radius articular surface has two concave facets, the scaphoid and lunate facets, separated by the scapholunate ridge [48].
• The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [48].
• The ulnar styloid projects distally, and at its base, the fovea is the insertion for the triangular fibrocartilaginous complex [48].
• The primary vascular supply to the scaphoid is a branch of the radial artery at the dorsal ridge [48].
• A group of smaller vessels enters the palmar tubercle of the scaphoid and supplies the distal 30% [48].
• The lunate has a dorsal and a palmar vascular supply in 80% of wrists, while only a palmar supply is found in 20% of wrists [48].
• The lunate is broader palmarly than dorsally [48].
• The triquetrum articulates with the hamate distally, the lunate radially, and the pisiform volarly [48].
• The triquetrum is stabilized to the fovea of the ulna through the ulnotriquetral ligament [48].
• The hamate consists of the body and the hook (hamulus), which serves as an attachment for the transverse carpal ligament and for the origins of the flexor digiti minimi and opponens digiti minimi [48].
• The head of the capitate often relies on a retrograde vascular supply [48].
• Two ridges separate the distal articular surface of the capitate into three facets for articulation with the metacarpals of the index, long, and ring fingers [48].
• The trapezoid has two distal facets which articulate with the metacarpal of the index finger [48].
• The trapezium has a saddle-shaped articulation with the base of the thumb metacarpal [48].
• The trapezium has a palmar groove for the flexor carpi radialis, bordered laterally by a palmar tuberosity and the attachment for the transverse carpal ligament [48].
• The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon and is the origin for the abductor digiti minimi [48].
• The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [48].
• The distal ulnar convexity articulates at the lesser sigmoid notch of the distal radius [47].
• The sigmoid notch articular surface accommodates the ulnar head through two thirds of its arc [47].
• There is about a 20-degree inclination of the distal ulna at its articulation with the radius [47].
• The ulnar styloid lies dorsal to the ulnar head and extends distally [47].

Ligaments¶

• The triangular fibrocartilage complex attaches to the base of the ulnar styloid and separates the hyaline cartilage–covered ulnar head from the styloid [47].
• The triangular fibrocartilage complex includes the ulnar collateral ligament, the dorsal and volar radioulnar ligaments, the articular disc, the meniscal homologue, the extensor carpi ulnaris sheath, and the ulnolunate and ulnotriquetral ligament [47].
• The triangular fibrocartilage complex is formed by the central meniscus homolog, the dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and the volar ulnocarpal ligaments [48].
• The triangular fibrocartilage complex arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [48].
• The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [48].
• Only the peripheral 10% to 40% of the volar, ulnar, and dorsal triangular fibrocartilage complex has a vascular supply [48].
• The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [48].
• The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [48].
• The scapholunate interosseous ligament is C-shaped in the sagittal plane [48].
• The dorsal third of the scapholunate interosseous ligament is the thickest, strongest portion of the ligament [48].
• The volar portion of the lunotriquetral ligament is the thickest [48].
• The interosseous ligaments include the scapholunate and lunotriquetral interosseous ligaments connecting the proximal carpal row and the ligaments connecting the trapezium to the trapezoid, the trapezoid to the capitate, and the capitate to the hamate in the distal carpal row [47].
• The extrinsic or crossing ligaments include the radial collateral ligament from the radial styloid to the scaphoid waist, the ulnar collateral ligament from the base of the ulnar styloid attaching to the pisiform, and the transverse carpal ligament [47].
• The volar extrinsic or crossing ligaments include the radioscapocapitate ligament, the radiolunotriquetral ligament, and the radioscapolunate ligament on the radial side and the ulnolunate and ulnotriquetral components of the triangular fibrocartilage complex on the ulnar side [47].
• On the palmar side of the carpus, between the radiolunotriquetral ligament and the radioscapocapitate ligament, is a relatively thin area, the space of Poirier, overlying the palmar surface of the lunate [47].
• The dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa, from the Lister tubercle to the lesser sigmoid notch [47].
• The dorsal radiocarpal ligament spans the lunotriquetral joint and inserts on the dorsal surface of the triquetrum [47].
• The dorsal intercarpal ligament is attached to the distal, dorsal surface of the triquetrum and passes across the midcarpal joint to attach to the dorsal surfaces of the scaphoid waist and the trapezoid [47].
• The radial collateral ligament originates from the radius 0 mm from the radial styloid and inserts on the scaphoid waist and distal palmar trapezium [48].
• The radioscaphocapitate ligament originates from the radius 4 mm from the radial styloid and inserts on the scaphoid waist and midpalmar capitate [48].
• The radiolunatotriquetral ligament originates from the radius 10 mm from the radial styloid and inserts on the lunate or triquetrum [48].
• The radioscapholunate ligament originates from the mesocapsule with termination of the anterior interosseous nerve and artery and inserts on the ligament of Testut and Kuenz [48].
• The short radiolunate ligament originates from the volar-ulnar margin of the radius and inserts on the lunate [48].
• The ulnotriquetral ligament originates from the volar radioulnar ligament and inserts on the triquetrum [48].
• The ulnolunate ligament originates from the volar radioulnar ligament and inserts on the lunate [48].
• The ulnocapitate ligament originates from the volar margin of the ulnar head and inserts on the capitate [48].
• The dorsal radiocarpal ligament originates from the dorsal radius at the Lister tubercle and inserts on the lunate and triquetrum [48].
• The dorsal intercarpal ligament originates from the triquetrum and inserts on the scaphoid, trapezoid, and capitate [48].

Vascular Supply¶

• The terminal branches of the radial, ulnar, and anterior interosseous arteries provide extraosseous blood supply to the carpus through three dorsal and three palmar transverse arterial arches with longitudinal connections [50].
• The dorsal radiocarpal arch is located at the radiocarpal joint and supplies the lunate and triquetrum [50].
• The dorsal intercarpal arch is located between the proximal and distal carpal rows, is the largest, and supplies the distal carpal row and, through anastomoses with the radiocarpal arch, the lunate and triquetrum [50].
• The basal metacarpal arch is located at the base of the metacarpals, is the most variable, and supplies the distal carpal row [50].
• The palmar radiocarpal arch is located at the level of the radiocarpal joint on the palmar surfaces of the lunate and triquetrum [50].
• The intercarpal arch is located between the proximal and distal carpal rows, is the most variable, and does not contribute to nutrient vessels in the carpus [50].
• The deep palmar arch is located at the level of the metacarpal bases, is consistent, and communicates with the dorsal basal metacarpal arch and the palmar metacarpal arteries [50].

Kinematics & Biomechanics¶

• The wrist can essentially be considered to be a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [49].
• The two principle articulations are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [49].
• The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [48].
• With ulnar deviation, the proximal row extends relative to the forearm/distal row [48].
• With radial deviation, the proximal row flexes relative to the forearm/distal row [48].
• With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius and 20% through the distal ulna [48].
• Of the force transmitted through the distal radius during neutral axial loading, 60% is through the scaphoid facet and 40% is through the lunate facet [48].
• With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [48].
• With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [48].
• The primary function of the scapholunate interosseous ligament is to counteract the extension moment imparted by the lunotriquetral interosseous ligament by transferring the flexion moment from the scaphoid to the lunate [42].
• The scapholunate interosseous ligament ensures that the lunate, capitate, and distal radius are collinear to efficiently transfer force from the hand to the forearm [42].
• The scapholunate interosseous ligament is strongest dorsally, where it is supported by the dorsal intercarpal and dorsal radial carpal ligaments [42].
• The volar scapholunate interosseous ligament is important as a secondary stabilizer and is supported by the volar wrist ligaments [42].
• Activation of muscles that induce midcarpal supination closes the scapholunate gap, while activation of muscles that induce midcarpal pronation opens up the scapholunate gap [71].
• A carpal rotational trauma may be a common injury mechanism for scapholunate injuries [71].
• The pronation-rotation mechanism produces a reversed injury pattern starting at the dorsal side of the scapholunate joint, in contrast to the classic cascade with injury progression from palmar to dorsal [71].

Pathophysiology¶

• Partial injuries to the scapholunate interosseous ligament can lead to attenuation of these structures, ultimately culminating in arthritis [42].
• The precise mechanism of scapholunate interosseous ligament injury is not known, but it is believed that a fall on an extended wrist results in excessive extension of the scaphoid, causing scapholunate interosseous ligament rupture if the scaphoid does not fracture [42].
• The classic pattern of deformity and destruction in rheumatoid arthritis involves the radiocarpal and radioulnar joints with destabilization of the carpus caused by attenuation of the extrinsic wrist ligaments [58].
• The result of rheumatoid arthritis wrist destabilization is ulnar-palmar translocation and wrist supination [58].
• Three main pathophysiological factors play the greatest role in the process of rheumatoid arthritis wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity [58].
• Cartilage thinning in rheumatoid arthritis is caused by cytochemical effects with continuous degradation [58].
• Bony erosion in rheumatoid arthritis arises due to synovial expansion, particularly at the site of vascular penetration into the bone such as the radial origin of the Testut ligament [58].
• Synovial expansion causes stretching of the retaining intrinsic and extrinsic wrist ligaments with deformation [58].
• The scapholunate interval starts to dissociate in rheumatoid arthritis and continues to disintegrate the internal carpal architecture [58].
• The force vector across the rheumatoid arthritis wrist predominately acts in a palmar-ulnar direction [58].
• With ongoing destruction of the rheumatoid arthritis wrist, surrounding muscles lose their physiologic moment arms to produce deforming forces [58].
• Flexion of the scaphoid through the weakening of the scapholunate ligament leads to subsequent collapse of the radial column in rheumatoid arthritis [58].
• Stretching of the wrist ulnar collateral ligament attenuates the ulnar column support in rheumatoid arthritis [58].
• Carpal supination in rheumatoid arthritis leads to the collapse of the radial wrist, which contributes to radial deviation of the metacarpals and accentuates ulnar deforming forces on the fingers at the metacarpophalangeal joints [58].
• A volar flexion of the lunate relative to the scaphoid occurs in 100 early-to-midstage rheumatoid arthritis wrists, caused by intrinsic ligament laxity, mainly of the scapholunate ligament [58].
• The volar flexion of the lunate relative to the scaphoid in early-to-midstage rheumatoid arthritis resembles the volar intercalated segment instability observed in trauma wrist injuries [58].
• At later rheumatoid arthritis stages, the capitate tends to flex dorsally due to midcarpal instability as a result of extrinsic ligament weakening [58].
• Dorsal flexion of the capitate in later rheumatoid arthritis stages leads to a significant decrease in the carpal height of rheumatoid arthritis wrists [58].
• Perilunate dislocations are severe injuries of the wrist often resulting from a high-energy trauma causing forced hyperextension of the wrist [44].
• Perilunate dislocations can be purely ligamentous, referred to as “lesser arc injuries,” or have both ligamentous and bony involvement [44].
• One potential complication of perilunate dislocations is median nerve compression resulting in acute carpal tunnel syndrome [44].

Classification¶

TFCC Injuries¶

• The Palmer classification categorizes TFCC tears into traumatic (class 1) or degenerative (class 2) [24].
• TFCC tear subtypes are based on the specific location within the TFCC [24].
• The class and location of a TFCC tear have important implications for treatment [24].
• Class 1A traumatic TFCC injuries are characterized by central perforation or tear [24].
• Class 1B traumatic TFCC injuries are characterized by ulnar avulsion with or without ulnar styloid fracture [24].
• Class 1C traumatic TFCC injuries are characterized by distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [24].
• Class 1D traumatic TFCC injuries are characterized by radial avulsion involving the dorsal and/or volar radioulnar ligaments [24].
• Class 2A degenerative TFCC tears are characterized by TFCC wear or thinning [24].
• Class 2B degenerative TFCC tears are characterized by TFCC wear plus lunate and/or ulnar chondromalacia [24].
• Class 2C degenerative TFCC tears are characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [24].
• Class 2D degenerative TFCC tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [24].
• Class 2E degenerative TFCC tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and DRUJ arthritis [24].

Scapholunate Ligament Injuries¶

• The Van Overstraeten and Camus extrinsic ligament classification grades the radioscaphocapitate and long radiolunate ligaments from E0 to E3 [76].
• The EWAS classification of scapholunate tears is an anatomical arthroscopic study [77].

Perilunate Dislocations¶

• Perilunate dislocations can be purely ligamentous, referred to as “lesser arc injuries” [44].
• Perilunate dislocations can have both ligamentous and bony involvement, known as greater arc injuries [44].

Clinical Presentation¶

History and Mechanism¶

• The mechanism of injury for carpal injuries depends on loading in three dimensions, duration and amount of forces, hand position at impact, and mechanical properties of the ligaments and bones [66].
• Carpal dislocations result from ulnar deviation and intercarpal supination [66].
• Scaphoid fractures result from wrist extension with the dorsal articular margin of the radius serving as a fulcrum [66].
• Flexion and pronation injuries may contribute more to ligament injuries on the ulnar side of the wrist, especially the lunotriquetral ligament [66].
• A history of ligamentous laxity or multiple joint instabilities is important to elucidate in younger patients presenting with chronic wrist pain [60].
• For long-standing problems, it is important to correlate the problem with factors that cause worsening or improvement [66].
• The mechanism of injury is frequently unknown when obtaining the history of traumatic conditions [66].

Physical Examination¶

• The external appearance of most wrist dislocations may not be dramatic, with generally moderate swelling [60].
• Bone displacements may be evident only if the patient is seen immediately after trauma, as delayed presentation leads to increased swelling that makes visualization more difficult [60].
• Skin abrasions, contusions, or ecchymosed areas may help determine the mechanism of injury and potential areas of damage [60].
• Range of motion is usually limited by pain in acute injuries, whereas it may be reduced or normal in more chronic cases [60].
• Passive assessment of mobility in chronic cases is valuable for determining the presence of abnormal motion or crepitus and for reproducing the patient’s pain [60].
• Palpation for areas of maximal tenderness is one of the most useful tools in the diagnosis of wrist pathology, especially in patients with chronic dysfunctions [60].
• In acute dislocations, tenderness is seldom elicited at specific points but rather in a diffuse manner due to extensive soft tissue damage [60].
• Palpation should be performed methodically, starting from the basal joint of the thumb and proceeding across the proximal carpal row from the scaphoid to the triquetrum, then from the hamate back across the distal row and CMC joints [60].
• A careful assessment of neural and vascular status is imperative, with particular attention to the median and ulnar nerves, which may be injured by direct contusion, compression from displaced bones, or swelling within the carpal canal [60].
• Provocative maneuvers should be performed to rule out alternative or concurrent diagnoses, not just to concentrate on the suspected diagnosis [60].
• The examination should begin in a nontender area and proceed rotationally around the carpus, ending at the most symptomatic area [60].
• Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [60].
• Strength may be diminished due to muscle atrophy, pain inhibition, or learned behaviors [60].
• Rapid alternating grip assessment may be helpful in determining voluntary effort [60].
• A local injection of anesthetic to a painful joint or selected tendon sheath may help normalize dynamometer readings and narrow the diagnostic spectrum [60].
• Sensory testing should always accompany an examination of suspected nerve compression, using threshold or density testing [60].
• Clinical provocation wrist tests were of limited diagnostic value [5].

Specific Findings and Signs¶

• Tenderness over the anatomic snuffbox or pain with resisted pronation prevents the surgeon from ruling out a scaphoid fracture [69].
• In chronic scaphoid injuries, athletes may complain of an inability to perform a push-up [69].
• A positive midcarpal shift test under fluoroscopy should be confirmed before surgery for midcarpal instability [30].
• Indications for midcarpal reconstruction include painful midcarpal clunk with ulnar deviation in daily activities present for greater than 6 months [30].
• Carpometacarpal dislocations producing transient motor neurapraxia of the ulnar nerve are likely to be missed in casualty due to extensive soft tissue swelling, apparent normal anteroposterior X-rays, and technical difficulty in testing the motor branch of the ulnar nerve in the presence of pain [33].
• Os styloideum must be suspected in patients with persistent pain in the dorsal aspect of the hand or wrist [61].
• In patients with continued pain over the radial side of the carpus, attention should be given to the other carpal bones and the distal radius, not just the scaphoid [63].

Imaging and Diagnostic Evaluation¶

• Radiographs are often negative at initial presentation for scaphoid fractures approximately 25% of the time [69].
• Any history of wrist trauma and tenderness or decreased range of motion should increase suspicion for scaphoid fracture [69].
• A scaphoid view with the wrist in 30° of extension and 20° of ulnar deviation, or a clenched-fist PA view, should be obtained for suspected scaphoid fractures [69].
• MRI is useful if radiographs are inconclusive for scaphoid fractures, allowing earlier return to play if no fracture is identified [69].
• MRI is used to assess osteonecrosis of the proximal pole of the scaphoid and can help assess for a scapholunate ligament injury [69].
• MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint, and vascularity of the various carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion [28].
• A high rate of false-positive findings on MR images of normal subjects has been reported [28].
• A dedicated wrist coil provides enhanced resolution of wrist structures [28].
• Routine radiographic series for the wrist consist of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [28].
• Spot views of the carpal bones for detail (carpal tunnel view) are a useful radiographic technique [28].
• Fluoroscopic spot views of the wrist are a useful radiographic technique [28].
• A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral/radial/ulnar deviation, lateral in neutral/full flexion/extension, semipronated oblique 30 degrees from the posteroanterior, and semisupinated oblique 30 degrees from the lateral [28].
• Diagnostic ultrasound is a useful radiographic technique for evaluating a painful wrist [28].
• Cine or video fluoroscopy is a useful radiographic technique for evaluating a painful wrist [28].
• Bone scanning is a useful radiographic technique for evaluating a painful wrist [28].
• Arthrography of the wrist, including triple injection when indicated, is a useful radiographic technique [28].
• CT is a useful radiographic technique for evaluating a painful wrist [28].
• MRI is a useful radiographic technique for evaluating a painful wrist [28].
• Rapid version bone scintigraphy is useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography [8].
• Computed tomography can be performed to characterize carpal fractures and avulsions, evaluate for intra-articular loose bodies, and assess for more subtle joint incongruities [56].
• The natural inclination to study radiographs or special imaging studies prior to a thorough history and physical examination should be avoided as it introduces cognitive bias [60].
• Physical examination always needs to be preceded by a thorough investigation of the patient’s medical history, with special emphasis on the mechanism of injury and acuity [60].

Investigations¶

Clinical Examination¶

• Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions [51].
• Carpometacarpal dislocations are likely to be missed in casualty due to extensive soft tissue swelling, apparent normal appearance of anteroposterior X-rays, and the technical difficulty in testing the motor branch of the ulnar nerve in the presence of pain [33].

Radiography¶

• A routine radiographic series for a painful wrist consists of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [28].
• Spot views of the carpal bones for detail, known as the carpal tunnel view, are a useful radiographic technique for evaluating a painful wrist [28].
• Fluoroscopic spot views of the wrist are a useful radiographic technique for evaluating a painful wrist [28].
• A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral, radial, and ulnar deviation, lateral in neutral and full flexion and extension, semipronated oblique 30 degrees from the posteroanterior, and semisupinated oblique 30 degrees from the lateral [28].
• Ten degrees of supination can drastically alter the developed posteroanterior radiograph of the wrist [29].
• Postoperatively, recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months in a case of unusual carpometacarpal fracture-dislocation [3].

Magnetic Resonance Imaging¶

• MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint, and vascularity of the various carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion and correlate with physical examination findings [28].
• Successful MRI study of the wrist requires high-resolution images that are best obtained with surface coil technique and a high-field system [53].
• With proper technique, injuries to the triangular fibrocartilage complex can be demonstrated with MRI [53].
• The triangular fibrocartilage complex is composed of signal-poor fibrocartilage, and perforations appear as linear defects or gaps filled with hyperintense fluid on coronal gradient-echo or T2-weighted pulse sequences [53].
• Evaluation of the scapholunate and lunotriquetral ligaments is more challenging, but with optimal technique and equipment, the integrity of these structures can be consistently assessed [53].
• The addition of arthrographic contrast improves the visualization of the scapholunate and lunotriquetral ligaments on MR images [53].
• Extrinsic carpal ligaments can be identified with three-dimensional volumetric scanning and subsequent reconstruction [53].
• At present, the MRI assessment of extrinsic carpal ligaments has less impact on treatment [53].
• MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease or in the scaphoid after fracture [53].
• Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia [53].
• MRI currently has a limited role in the evaluation of carpal tunnel syndrome [53].
• Axial imaging with T2 weighting can clearly display masses within the confines of the carpal tunnel, as well as edema and swelling of the median nerve [53].
• Tenosynovitis and tendon injuries in the wrist and hand can be assessed with MRI [53].
• MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [53].
• Dorsal extrinsic ligaments demonstrate MRI signal change suggestive of acute or chronic injury in patients with an SL interval 2 mm or greater more often than in patients with an SL interval less than 2 mm [73].
• A rapid version of bone scintigraphy (15 minutes) is useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography [8].

Arthroscopy¶

• Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many the “gold standard” for evaluation of these conditions [54].
• Arthroscopic assessment is considered the “gold standard” for examination of patients who have wrist pain of unknown origin [54].
• Indications for wrist arthroscopy include the evaluation of ligamentous injuries, examination of joint articular surfaces, removal of loose bodies, biopsy of synovium, irrigation and debridement of joints, and confirmation and supplementation of wrist arthrography [54].
• Arthroscopy has been found to be more accurate than arthrography in identifying the location and size of triangular fibrocartilage and interosseous ligament injuries [54].
• Arthroscopy is more accurate than triple-injection cinearthrography in detecting tears of the triangular fibrocartilage [54].
• To be successful with wrist arthroscopy and mitigate iatrogenic injury, a clear understanding of the topographical and 3-dimensional spatial anatomic relationships in the wrist as well as a patient’s unique anatomic variances is critical [11].

Other Imaging Modalities¶

• Arthrography of the wrist, including triple injection when indicated, is a useful radiographic technique for evaluating a painful wrist [28].
• Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics [27].
• 4DCT extends conventional CT by incorporating the temporal dimension [27].
• A study quantifies a normative range of median radiolunate interosseous proximities during wrist motion using 4DCT-derived radiolunate arthrokinematics [31].

Treatment¶

Non-Operative Management¶

• Clinical provocation wrist tests have limited diagnostic value for wrist ligament injuries [5].
• Grade I scapholunate or lunotriquetral ligament injuries with no joint incongruence typically resolve with immobilization alone [62].
• All acute traumatic triangular fibrocartilage complex (TFCC) injuries are initially managed with immobilization and NSAIDs [24].
• Volarly displaced extra-articular distal radius fractures (Smith fractures) can be treated with reduction and casting if no comminution is present and a good reduction is obtained [12].
• Displaced distal radius fractures are immobilized for 4 to 6 weeks after acceptable closed reduction [12].
• Patients with nondisplaced distal radius fractures are at risk for extensor pollicis longus rupture, usually occurring about 4 to 6 weeks after injury [12].
• A trial of nonsurgical management with hand therapy focusing on proprioceptive training is required prior to surgical intervention for palmar midcarpal instability [30].

Arthroscopic Management¶

• Arthroscopy is the gold standard for the detection of TFCC tears [24].
• The arthroscopic trampoline test assesses TFCC resiliency by balloting the central portion with a small probe [24].
• The arthroscopic hook test can be used to demonstrate peripheral detachment of the TFCC [24].
• Class 1A (central) TFCC tears are treated with débridement if persistently symptomatic because the area is devoid of vascularity and unable to heal [24].
• A 2-mm peripheral rim should be maintained during débridement of central TFCC tears [24].
• Class 1B (peripheral) TFCC tears are amenable to arthroscopic or open repair because the rim is well vascularized [24].
• Concurrent fractures of the ulnar styloid with persistent instability in Class 1B TFCC injuries are either excised or fixed [24].
• Class 1C (distal avulsion) TFCC injuries are treated by advancement of the distal volar rim to the triquetrum using a bone anchor [24].
• Class 1D (radial avulsion) TFCC injuries are treated with direct repair to the radius to preserve the TFCC contribution to distal radioulnar joint stability [24].
• Repair of a traumatic TFCC tear within 3 months of injury allows a patient to regain 80% of wrist range of motion and grip strength [24].
• Acute tears of the scapholunate or lunotriquetral ligaments (less than 4 to 6 weeks) that result in incongruence from the midcarpal space may be arthroscopically reduced and temporarily pinned [62].
• Arthroscopic midcarpal suture anchor repair is a treatment approach for dorsal intercarpal ligament avulsion [2].
• Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears offers a minimally invasive and easily reproducible solution [4].
• Arthroscopic dorsal capsuloligamentous repair in chronic scapholunate ligament tears has shown encouraging preliminary results with pain relief, recovery of grip strength, and low incidence of postoperative wrist stiffness [9].
• All professional athletes in a series of 36 patients treated with arthroscopic dorsal capsuloligamentous repair for chronic scapholunate ligament tears returned to preinjury sports levels [9].
• Arthroscopic-assisted volar scapholunate capsulodesis is a technique for treating scapholunate ligament injuries [40].
• Arthroscopic graft reconstruction is indicated for nonrepairable scapholunate ligament injuries [42].
• Acute scapholunate intercarpal ligament injuries free from arthritis with dynamic instability can often be treated with K-wire stabilization and suture repair [42].
• The use of an interference screw in arthroscopic scapholunate ligament reconstruction makes the reconstruction stronger and allows for early mobilization [39].
• Dartthrowing exercise is used in postoperative mobilization after scapholunate ligament reconstruction to avoid overloading the graft [39].

Open Surgical Management¶

• Class 1B TFCC injuries are amenable to open repair [24].
• Class 1C TFCC injuries are amenable to open repair [24].
• Ligament repairs can be made if closed reduction of rotary subluxation of the scaphoid and other carpal instability patterns cannot be accomplished satisfactorily [64].
• For primary rotary subluxation of the scaphoid, the scaphoid is reduced with the wrist in dorsiflexion and pinned to the capitate and lunate with three 0.045-inch (1.16-mm) Kirschner wires [64].
• After stabilizing the scaphoid in rotary subluxation, the wrist is flexed to allow approximation of the volar wrist ligaments [64].
• Open reduction for carpal instability involves a longitudinal dorsal incision to the medial side of Lister tubercle and a palmar incision parallel to the thenar crease [64].
• The volar radioscaphocapitate and radiolunate ligaments are carefully incised to allow repair at the time of closure during open carpal instability repair [64].
• The scapholunate disruption is reduced and fixed with three 0.045-inch (1.16-mm) Kirschner wires directed from the scaphoid into the lunate and capitate [64].
• The dorsal scapholunate interosseous ligament is repaired during open carpal instability surgery, which is easier if a small osteochondral fragment of bone has been avulsed [64].
• Postoperative care for open carpal ligament repair involves removing sutures in 10 to 14 days and removing all Kirschner wires at the end of 8 to 10 weeks [64].
• Range-of-motion exercises are begun after K-wire removal, followed by progressive strengthening exercises [64].
• Ligament reconstruction can be accomplished with free tendon grafts or tenodesis using prolonged slips of wrist flexors and extensors [64].
• Ligament reconstruction is reserved for patients whose ligament ruptures cannot be maintained with closed reduction or patients diagnosed after about 1 month [64].
• Ligament reconstruction is not indicated in patients with associated degenerative joint disease [64].
• Radioscapholunate arthrodesis with compression screws and local autograft achieves a 100% union rate at mean follow-up of 12 months in appropriately selected patients with a preserved midcarpal joint [34].
• Anatomical anterior and posterior reconstruction for scapholunate dissociation resulted in no patient requiring secondary surgery or treatment related to carpal stabilization in a series of ten patients [26].
• Midcarpal reconstruction is indicated for painful midcarpal clunk with ulnar deviation in daily activities present for greater than 6 months [30].
• A positive midcarpal shift test under fluoroscopy must be confirmed before surgery for midcarpal reconstruction [30].
• The use of a wrist fixator allows open wound care and permits free access to the wrist for early secondary operations in complex carpal dislocations [10].
• A painless wrist can be achieved through prompt recognition and early management of scaphoid fracture dislocations, although range of movement may be limited with loss of grip [14].
• Postoperative recovery of the wrist after treatment of an unusual carpometacarpal fracture-dislocation was rapid, though extension of the fingers remained poor for over 3 months [3].
• Compression screw fixation with partially threaded 3.5- or 4.0-mm cancellous screws can effectively compress fragments and maintain reduction in radial styloid fractures [12].
• Most open fractures and volar shearing distal radius fractures are best treated operatively [12].
• Volar locking plates make it possible to stabilize dorsally displaced distal radius fractures through the volar Henry approach [12].
• The most common tendon to rupture following application of a volar plate is the flexor pollicis longus, due to volar extension of the plate beyond the watershed line [12].
• Dorsal plates or constructs are preferred for dorsal shearing fractures and complex articular fractures [12].
• Distraction or bridge plate fixation is utilized for complex articular fractures with complex metaphyseal or diaphyseal fragmentation [12].
• A distraction plate is applied between the index or long finger metacarpal and the shaft of the radius and removed about 3 months after injury [12].
• Application of a bridge or distraction plate should not be a substitute for accurate open reduction and internal fixation [12].
• Bridging external fixation can be used to protect pin fixation or to provide ligamentotaxis in distal radius fractures [12].
• External fixator pins typically remain in place for 6 to 8 weeks [12].
• Bone graft or bone void fillers can be used to structurally support bone defects and perhaps allow earlier removal of the external fixator [12].
• Loss of reduction including ulnar variance 5 mm or more positive, dorsal articular tilt ≥15°, and loss of radial inclination >10° are indications for surgical treatment of distal radius fractures [12].
• An articular gap or step of 2 mm or more is an indication for surgical treatment of distal radius fractures [12].
• Unstable volar extra-articular fractures (Smith fracture) are an indication for surgical treatment [12].
• Fractures with associated neurovascular injuries are an indication for surgical treatment [12].
• Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes [36].
• Patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of bone grafting surgery, provided that there is no secondary wrist osteoarthritis [37].
• Cases of established scaphoid non-union are less likely to achieve radiographic evidence of union compared to the majority of scaphoid fractures [78].
• Revision to another wrist replacement appears no worse in the short term for failed total wrist replacement [18].
• All patients in a small series of failed total wrist replacement revisions appear to have good clinical outcomes [18].
• The dorsal wrist ganglion is the prototype of all ganglions of the hand and accounts for 60% to 70% of all hand and wrist ganglions [20].
• The main cyst of a dorsal wrist ganglion is usually located directly over the scapholunate ligament [20].
• Failure to identify and excise the pedicle attachment to the scapholunate ligament increases the likelihood of recurrence of a dorsal wrist ganglion [20].
• Most dorsal ganglions can be approached through a transverse incision over the proximal carpal row [20].
• The main cyst and its pedicle are mobilized down to the underlying joint capsule during dorsal wrist ganglion excision [20].
• The joint capsule is opened along the border of the radius and scaphoid's proximal pole with the wrist in volar flexion [20].
• Capsular attachments to the scapholunate ligament are left intact during the dissection of a dorsal wrist ganglion [20].
• The ganglion and its capsular attachments are tangentially excised off the scapholunate ligament [20].
• A small, mucin-filled duct is invariably seen piercing the transverse fibers of the scapholunate ligament, connecting the underlying scapholunate joint with the main cyst [20].
• Synovial and capsular attachments along the distal margin of the scapholunate ligament are excised to give an unobstructed view of the head and neck of the capitate [20].
• The diagnosis of ganglion cyst should be made before commitment to a transverse incision because this incision is not readily incorporated into a limb-sparing incision for malignant soft tissue tumors [20].
• A free needle is used to pass suture tails through the dorsal intact dorsal intercarpal ligament wrist capsule to perform a small dorsal intercarpal ligament proximalization during scapholunate ligament repair [16].
• Dorsal intercarpal ligament proximalization ensures that native wrist capsule is reduced to the dorsal aspect of the repair to resist further scaphoid flexion or lunate extension deformity [16].
• Restoring the relationship of the dorsal scapholunate ligament and the wrist capsule restores native anatomy surrounding the scapholunate ligament [16].
• Hemiresection or interposition arthroplasty maintains the ulnar insertion of the TFCC and prevents radioulnar impingement by soft tissue interposition [24].
• The Sauvé-Kapandji procedure involves distal radioulnar joint arthrodesis with creation of a proximal pseudarthrosis at the ulnar neck [24].
• Ulnar head or total joint implant arthroplasty maintains the relationship between the radius and the ulna [24].
• Ulnar head or total joint implant arthroplasty results show good pain relief at the risk of ulnar head instability, aseptic loosening, and no appreciable change in pronosupination compared to preoperative values [24].
• The one-bone forearm procedure represents the ultimate salvage operation for persistent pain or complications by fusing the proximal ulna to the distal radius shaft [24].
• Painful proximal ulna stump instability and convergence of the radius upon the ulna are complications of distal radioulnar joint procedures [24].

Complications¶

Diagnostic and Follow-up Complications¶

• Inadequate follow-up of treated scaphoid fractures results in delayed diagnosis and treatment of non-union [36].
• Delayed diagnosis and treatment of scaphoid non-union can lead to impaired outcomes secondary to degenerative changes [36].
• Delayed diagnosis and treatment of scaphoid non-union can lead to litigation against the surgeon [36].

Functional and Degenerative Outcomes¶

• A patient with a stage diving injury was left with reduced range of wrist movements [35].
• A patient with a stage diving injury had a markedly increased chance of developing degenerative arthritis in the wrist [35].
• Postoperative recovery of the wrist was rapid in a case of unusual carpometacarpal fracture-dislocation, though extension of the fingers remained poor for over 3 months [3].

Surgical and Implant-Related Complications¶

• Potential pitfalls of volar locking plate application include intra-articular screw placement [12].
• Application of volar locking plates to inappropriate fracture patterns can lead to prominent implant placement and tendon rupture [12].
• Full incisions over the radius and index metacarpal at the time of external fixator pin placement minimize the risk of iatrogenic injury to the superficial branch of the radial nerve [12].
• Full incisions over the radius and index metacarpal at the time of external fixator pin placement minimize the risk of tethering of the first dorsal interosseous muscle [12].
• No complications occurred due to arm and elbow supports or fingertraps in a study of horizontal fingertrap traction in distal radial fractures [79].

Risk Factors for Non-Union¶

• With every decade of a patient’s life, the odds of scaphoid union are reduced by 1.72 times [43].
• Dominant hand injury reduces the odds of scaphoid union by 7.35 times [43].
• Previous scaphoid surgery reduces the odds of scaphoid union by 4.24 times [43].

Recovery¶

• Postoperative recovery of the wrist was rapid following treatment of an unusual carpometacarpal fracture-dislocation [3].
• Extension of the fingers remained poor for over 3 months postoperatively following treatment of an unusual carpometacarpal fracture-dislocation [3].
• Most patients treated with a dorsal spanning plate for complex intraarticular distal radius fractures can expect to regain functional wrist range of motion if the articular surface is well reduced and other principles of fracture fixation are applied [7].
• Arthroscopic dorsal capsuloligamentous repair in chronic scapholunate ligament tears resulted in pain relief and recovery of grip strength in a series of 36 patients [9].
• The incidence of postoperative wrist stiffness was low following arthroscopic dorsal capsuloligamentous repair in chronic scapholunate ligament tears [9].
• All professional athletes returned to preinjury sports levels following arthroscopic dorsal capsuloligamentous repair in chronic scapholunate ligament tears [9].
• Revision to another wrist replacement appears no worse in the short term for patients with failed total wrist replacement [18].
• Patients with failed total wrist replacement appear to have good clinical outcomes following revision surgery [18].
• Proximal migration of the thumb metacarpal does not appear to influence the functional outcome of ligament reconstruction for primary thumb carpometacarpal osteoarthritis [32].

Key Evidence¶

• [L5] Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes. [1] (10.1177/15589447261475382)
• [L5] The findings emphasize the need for comprehensive evaluation and diverse treatment approaches to improve outcomes for patients with wrist ligament injuries. [2] (10.1016/j.eats.2024.103028)
• [L5] Postoperatively recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months. [3] (10.1016/0020-1383(94)90161-9)
• [L5] This method offers a minimally invasive and easily reproducible solution, addressing a challenging set of ulnar wrist injuries. [4] (10.1016/j.eats.2024.102995)
• [L2] Clinical provocation wrist tests were of limited diagnostic value. [5] (10.1016/j.arthro.2015.04.090)
• [L4] Regardless of the construct used, if the distal radius articular surface is well reduced and other principles of fracture fixation are applied, most patients treated with a DSP can expect to regain functional wrist ROM. [7] (10.1177/15589447241247335)
• [L4] We find this rapid version of the bone scan useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography. [8] (10.1016/s0020-1383(99)00280-6)
• [L4] The series of 36 patients shows encouraging preliminary results with pain relief, recovery of grip strength, low incidence of postoperative wrist stiffness, and all professional athletes returning to preinjury sports levels. [9] (10.1016/j.hcl.2011.07.003)
• [L4] The use of a wrist fixator allows open wound care and permits free access to the wrist for early secondary operations. [10] (10.1016/s0020-1383(99)00267-3)
• [L5] To be successful with wrist arthroscopy and mitigate iatrogenic injury, a clear understanding of the topographical and 3-dimensional spatial anatomic relationships in the wrist as well as a patient’s unique anatomic variances is critical. [11] (10.1016/j.eats.2024.103223)
• [L5] Although the range of movement may be limited, with loss of grip, a painless wrist can be achieved through prompt recognition and early management. [14] (10.1016/s0020-1383(97)00020-x)
• [L5] [16] (10.1016/j.eats.2024.103333)
• [L4] All patients in this small series to date appear to have good clinical outcomes, and revision to another wrist replacement appears no worse in the short term. [18] (10.1016/s0363-5023(10)60131-1)
• [L4] No patient required secondary surgery or treatment related to the carpal stabilization. [26] (10.1177/1753193419886536)
• [L5] Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics, extending conventional CT by incorporating the temporal dimension. [27] (10.1177/17531934251326028)
• [Paper] Our results highlight the significant effect of rotation on radiographic landmarks at the wrist, indicating that 10° of supination can drastically alter the developed radiograph. [29] (10.1177/15589447241255705)
• [L4] [30] (10.1016/j.jhsa.2025.02.010)
• [Paper] This study quantifies a normative range of median radiolunate interosseous proximities during wrist motion. [31] (10.1177/15589447251352124)
• [L1] Furthermore, proximal migration of the thumb metacarpal does not appear to influence the functional outcome. [32] (10.2106/jbjs.d.02630)
• [L4] Such injuries are likely to be missed in casualty because of the extensive soft tissue swelling, the apparent normal appearance of anteroposterior X-rays and the technical difficulty in testing the motor branch of the ulnar nerve in the presence of pain. [33] (10.1016/s0020-1383(96)00207-0)
• [L4] This technique is an effective method to perform radioscapholunate arthrodesis in appropriately selected patients with a preserved midcarpal joint, achieving a 100% union rate at mean follow-up of 12 months with no complications. [34] (10.1016/j.jhsa.2013.01.026)
• [L4] The second man has been left with a reduced range of wrist movements and a markedly increased chance of developing degenerative arthritis in the wrist. [35] (10.1016/s0020-1383(05)80016-6)
• [L4] Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome secondary to degenerative changes and even litigation against the surgeon. [36] (10.1016/s0020-1383(02)00162-6)
• [L4] The results of this study suggest that patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of this surgery, provided that there is no secondary wrist osteoarthritis. [37] (10.1016/s0020-1383(00)00059-0)
• [L4] [39] (10.1016/j.hcl.2017.07.019)
• [L4] [40] (10.1016/j.jhsa.2022.05.018)
• [L5] [42] (10.1016/j.eats.2025.103820)
• [L2] With every decade of a patient’s life, dominant hand injury, and previous scaphoid surgery, the odds of union are reduced by 1.72 times, 7.35 times, and 4.24 times, respectively. [43] (10.1177/15589447231219523)
• [L4] [44] (10.1016/j.jhsg.2025.100797)
• [L5] [56] (10.1016/j.eats.2024.103350)
• [L4] Os Styloideum is an infrequent pathology and must be suspected in patients with persistent pain in the dorsal aspect of the hand or wrist. [61] (10.1177/15589447251317232)
• [L4] In patients with continued pain over the radial side of the carpus, attention should be given to the other carpal bones and the distal radius and not just the scaphoid. [63] (10.1016/0020-1383(95)00081-j)
• [L4] [71] (10.1177/17531934211005391)
• [L4] Dorsal extrinsic ligaments demonstrate MRI signal change suggestive of acute or chronic injury in patients with an SL interval 2 mm or greater more often than in patients with an SL interval less than 2 mm. [73] (10.1016/j.jhsa.2019.03.003)
• [L5] [76] (10.1016/j.eats.2024.103174)
• [L5] [77] (10.1016/j.eats.2023.03.005)
• [L4] While this is true for the majority of scaphoid fractures, cases of established non-union are less likely to achieve radiographic evidence of union. [78] (10.1016/s0020-1383(05)80003-8)
• [L4] No complications occurred due to the arm and elbow supports or fingertraps. [79] (10.1016/s0020-1383(99)00161-8)
• [L1] Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. [80] (10.1177/15589447241231291)

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