மணிக்கட்டுத் தசைநார்க் காயங்கள் (Wrist Ligament Injuries)

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¶

Biomechanics and Anatomy¶

• Studies on wrist biomechanics have provided clinically relevant information about normal anatomy and functional mechanics of the wrist [1].
• These biomechanical studies have provided guidelines for the treatment of a number of different fractures and ligament injuries [1].
• The dorsal radiocarpal ligament should be spared during surgical approaches to the carpus [33].

Diagnosis and Imaging¶

• The increased use of arthroscopic examination of the wrist is advisable in wrist trauma to establish a correct diagnosis, prognosis, and treatment of all lesions [14].
• Arthroscopic examination of the wrist may help prevent degenerative arthritis [14].
• Arthroscopic classification of lesions of the dorsal capsulo-scapholunate septum allows for adapting the best ligament repair possible [7].
• Inside-out methods to develop volar arthroscopic portals of the wrist are easy to perform, safe, and useful for indications for ligament or bony intracarpal repairs [57].
• Four-part fractures of the distal radius should be studied carefully before deciding on management and sub-classified into those with and those without associated carpal ligamentous injury [11].
• In the setting of isolated radial styloid fractures, intercarpal ligament injuries must be suspected because the intra-articular fracture line may extend into the joint at that level [24].
• A patient with a moderately severe wrist injury resulting in an unusual wrist fracture disturbing the origins of important carpal ligaments may present with volar intercalary carpal instability [2].
• Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes [4].
• Under circumstances where a clinical fracture of the carpal scaphoid is an illusionary diagnosis, the patient should be treated as a soft tissue injury of the wrist and followed up appropriately [6].

Associated Injuries¶

• Fractures of the distal radius are among the most common fractures seen in the emergency department [24].
• Patients of advanced age with osteoporosis have an increased fracture risk during low-energy falls [24].
• Fracture patterns of the distal radius vary depending on the mechanism of injury [24].
• Fractures with associated intercarpal ligament injuries are an indication for surgical treatment [24].
• Fractures with associated neurovascular injuries are an indication for surgical treatment [24].
• Median nerve injuries at the wrist leave serious sequelae and have a reserved prognosis [22].

Treatment Principles¶

• The goals of all treatment for distal radius fractures are to optimize comfort and function [24].
• Options for the management of distal radius fractures include closed reduction and cast immobilization, closed reduction and percutaneous pinning with or without external fixation, and open reduction internal fixation (ORIF) [24].
• Most open fractures and volar shearing fractures are best treated operatively [24].
• Surgical treatment indications relate to infirmity, functional demands, tolerance of deformity, and personal preferences [24].
• Injury and patient characteristics meriting a discussion of surgical treatment include loss of reduction, including ulnar variance 5 mm or more positive, dorsal articular tilt ≥15° (ie, volar apex angulation), and loss of radial inclination >10° [24].
• Injury and patient characteristics meriting a discussion of surgical treatment include an articular gap or step of 2 mm or more [24].
• Injury and patient characteristics meriting a discussion of surgical treatment include unstable volar extra-articular fractures (Smith fracture) [24].
• Injury and patient characteristics meriting a discussion of surgical treatment include multiple trauma, such as bilateral distal radius fractures or the need to use crutches for a leg injury, which is a relative indication [24].
• Current best evidence suggests initial displacement determines the final alignment regardless of the time of immobilization [24].
• 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 [24].
• Displaced fractures are immobilized for 4 to 6 weeks after acceptable closed reduction [24].
• 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 [24].
• Nondisplaced distal radius fractures are associated with occasional extensor pollicis longus rupture, usually about 4 to 6 weeks after injury [24].
• Bridging external fixation can be used to protect pin fixation or to provide ligamentotaxis [24].
• 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 [24].
• The external fixator and pins typically remain in place for 6 to 8 weeks [24].
• Bone graft or bone void fillers can be used to structurally support bone defects and perhaps allow earlier removal of the fixator [24].
• Volar locking plates make it possible to stabilize dorsally displaced fractures from through the volar Henry approach (through the sheath of the flexor carpi radialis tendon) [24].
• Potential pitfalls of volar plate application include intra-articular screw placement and application to inappropriate fracture patterns with prominent implant placement which may lead to tendon rupture [24].
• 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 [24].
• Dorsal tendons such as the extensor pollicis longus and extensor digitorum communis can fray and rupture from prominent screw tips following volar insertion [24].
• Dorsal plates or constructs are now preferred for dorsal shearing fractures and complex articular fractures (in combination with volar plates) [24].
• Distraction (or bridge) plate fixation is increasingly utilized for complex articular fracture, those with complex metaphyseal or diaphyseal fragmentation in particular [24].
• A distraction plate is applied between the index or long finger metacarpal and the shaft of the radius (as with external fixation), applied with distraction, and removed about 3 months after injury [24].
• Application of the bridge/distraction plate should not be a substitute for accurate ORIF [24].
• 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 [24].
• Volarly displaced extra-articular fractures (Smith fractures) are usually treated surgically with a volar plate and screws [24].
• If the fracture of the radial styloid is nondisplaced or minimally displaced, it may be treated nonsurgically [24].
• Intra-articular displacement (or diastasis) greater than 2 mm in radial styloid fractures is an indication for surgery [24].
• 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 [24].
• Alternative fixation options for radial styloid fractures include K-wires and fragment-specific pin plate and screw fixation [24].
• The distal radioulnar joint is assessed following stabilization of the radius [24].
• Slightly greater laxity than the opposite uninjured wrist (based on preoperative examination) is to be expected in the distal radioulnar joint [24].
• Only frank dislocation with forearm rotation—very uncommon—merits surgery to stabilize the distal radioulnar joint [24].
• The presence of a displaced fracture at the base of the ulnar styloid is not in itself an indication for surgical fixation [24].
• Clinical stability of the distal radioulnar joint must be elucidated and compared with the normal contralateral side when possible [24].
• 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 [82].
• The findings regarding dorsal intercarpal ligament avulsion emphasize the need for comprehensive evaluation and diverse treatment approaches to improve outcomes for patients with wrist ligament injuries [20].
• Arthroscopic midcarpal suture anchor repair of dorsal intercarpal ligament avulsion is a treatment approach for wrist ligament injuries [20].
• Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears offers a minimally invasive and easily reproducible solution [86].
• Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears addresses a challenging set of ulnar wrist injuries [86].
• Patients must understand their wrists are not rendered “normal" by scapholunate dissociation reconstructive procedures [23].
• For the properly selected patient, the DILC may be an excellent option for scapholunate dissociation [23].
• If the long-term outcome of a new technique to correct carpal instability with scaphoid rotary subluxation is as promising as the short-term results seem to indicate, this method could replace tendon ligamentoplasties and partial wrist arthrodeses [28].
• Provided all the technical principles are respected, complications such as ulnocarpal impingement or nonunion are rare in radioscapholunate arthrodesis with excision of the scaphoid [81].
• The second most common complication of scaphocapitate arthrodesis is persistent wrist pain despite radiographic evidence of scaphocapitate bony union, occurring in 4/30 patients (13%) [12].
• Proximal row carpectomy has become a popular “motion-preserving" procedure for the treatment of various degenerative and posttraumatic conditions of the wrist [197].
• Trapézectomies secondaires après l’échec d’arthroplastie are a reliable procedure in the long term with a low risk of complications for patients wishing to preserve the mobility of the wrist [26].
• 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 [40].
• Surgery does not appear to improve mobility of the wrist in Madelung's deformity of dyschondrosteosis [68].
• 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 [27].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The wrist is the anatomic region between the forearm and the hand, including the distal radioulnar, radiocarpal, and ulnocarpal joints and the eight carpal bones [90].
• The proximal carpal row consists of the scaphoid, lunate, triquetrum, and pisiform [90].
• The distal carpal row consists of the trapezium, trapezoid, capitate, and hamate [90].
• The pisiform and trapezoid are the smallest carpal bones, while the capitate is the largest [90].
• The radiocarpal joints are formed by the articulation of the distal radius with the scaphoid and lunate through their respective concave facets, and the triquetrum on the triangular fibrocartilage [90].
• The distal concave articular surfaces of the proximal carpal row form the midcarpal articulations with the distal row [90].
• The distal ulnar convexity articulates at the lesser sigmoid notch of the distal radius [90].
• The sigmoid notch articular surface accommodates the ulnar head through two thirds of its arc [90].
• There is about a 20-degree inclination of the distal ulna at its articulation with the radius [90].
• The ulnar styloid lies dorsal to the ulnar head and extends distally [90].
• The distal radial articular surface has a double obliquity of 12–15 degrees in the lateral view and 15–20 degrees in the anteroposterior view [100].
• The posterior lip and the radial styloid have a buttressing effect on the distal radial articular surface [100].
• The carpal articular surface has a smaller diameter of curvature than the radius [100].
• The carpus is more stable in flexion than extension due to its anterior concavity [100].
• The distal row of the carpus is quite rigid, while the three proximal row bones are relatively mobile [100].
• The triquetrum is not in contact with the ulnar head; a fibro-cartilage disc separates the two bones [100].
• The scaphoid presents a long axis inclined by 45 degrees to the long axis of the radius [100].
• The lunate sits on the capitate and has anterior and posterior horns [100].
• A line drawn between the anterior and posterior horns of the lunate lies perpendicular to the long axis of the wrist in neutral position [100].
• The ulnar head sits proximal to the distal radius and has only an indirect effect on stability of the wrist [100].
• The triangular ligament extends the distal radial articular surface to the ulnar styloid and forms the principal link between the two bones [100].
• The scaphoid's primary vascular supply is a branch of the radial artery at the dorsal ridge [91].
• A group of smaller vessels enters the palmar tubercle of the scaphoid and supplies the distal 30% [91].
• The transverse carpal ligament attaches to the palmar tubercle of the scaphoid [91].
• A dorsal and a palmar vascular supply are found in 80% of wrists for the lunate; in 20% of wrists, only a palmar supply is found [91].
• The lunate is broader palmarly than dorsally [91].
• The triquetrum articulates with the hamate distally, the lunate radially, and the pisiform volarly [91].
• The triquetrum is stabilized to the fovea of the ulna through the ulnotriquetral ligament [91].
• 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 [91].
• The head of the capitate often relies on a retrograde vascular supply [91].
• 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 [91].
• The trapezoid has two distal facets, which articulate with the metacarpal of the index finger [91].
• The trapezium has a saddle-shaped articulation with the base of the thumb metacarpal [91].
• 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 [91].
• The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon [91].
• The pisiform is the origin for the abductor digiti minimi [91].

Ligamentous Anatomy¶

• The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [91].
• The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [91].
• The scapholunate interosseous ligament is C-shaped in the sagittal plane [91].
• The dorsal third of the scapholunate interosseous ligament is the thickest, strongest portion of the ligament [91].
• The volar portion of the lunotriquetral ligament is the thickest [91].
• The triangular fibrocartilage complex (TFCC) 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 [91].
• The TFCC 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 [91].
• The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [91].
• Only the peripheral 10% to 40% of the volar, ulnar, and dorsal TFCC has a vascular supply [91].
• The chondroligamentous supports attaching the distal radius and ulnar side of the carpus to the distal ulna are designated as the triangular fibrocartilage complex [90].
• The TFCC 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 [90].
• The interosseous ligaments include the scapholunate and lunotriquetral interosseous ligaments connecting the proximal carpal row [90].
• The interosseous ligaments include the ligaments connecting the trapezium to the trapezoid, the trapezoid to the capitate, and the capitate to the hamate in the distal carpal row [90].
• The extrinsic or crossing ligaments include the radial collateral ligament from the radial styloid to the scaphoid waist [90].
• The extrinsic or crossing ligaments include the ulnar collateral ligament from the base of the ulnar styloid attaching to the pisiform [90].
• The extrinsic or crossing ligaments include the transverse carpal ligament [90].
• The volar extrinsic or crossing ligaments include the radioscapocapitate ligament, the radiolunotriquetral ligament, and the radioscapolunate ligament on the radial side [90].
• The volar extrinsic or crossing ligaments include the ulnolunate and ulnotriquetral components of the TFCC on the ulnar side [90].
• 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 [90].
• The dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa, from the Lister tubercle to the lesser sigmoid notch [90].
• The dorsal radiocarpal ligament spans the lunotriquetral joint and inserts on the dorsal surface of the triquetrum [90].
• 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 [90].
• The major volar radiocarpal ligaments include the radioscaphoid, radioscaphocapitate, long radiolunate, and short radiolunate ligaments [142].
• The major volar ulnocarpal ligaments include the ulnocapitate, ulnolunate, and ulnotriquetral ligaments [142].
• The volar ligaments form an inverted V-configuration to prevent dorsovolar subluxation of the carpus [142].
• An intraligamentous sulcus between the radioscaphocapitate and long radiolunate ligaments exists, known as the space of Poirier, that is a well-described area of capsular weakness frequently affected in perilunate injuries [142].
• Only dorsal radiocarpal ligaments exist as no defined ligaments are found between the ulna and carpus dorsally [142].
• The main dorsal radiocarpal ligaments include the dorsal radial triquetrum (aka dorsal radiocarpal) and dorsal intercarpal ligament [142].
• The dorsal intercarpal ligament traverses between the triquetrum, trapezoid, capitate, lunate, and scaphoid [142].
• The scapholunate ligament is composed of the dorsal (strongest), proximal (membranous), and volar segments [142].
• Disruption of the scapholunate ligament leads to dorsal intercalated segmental instability [142].
• The lunotriquetral ligament is composed of the dorsal, proximal (membranous), and volar (strongest) segments [142].
• Disruption of the lunotriquetral ligament leads to volar intercalated segmental instability [142].
• The distal radioulnar joint is principally stabilized statically by the triangular fibrocartilage complex and the interosseous membrane [142].
• The extensor carpi ulnaris and deep head of the pronator quadratus act as dynamic stabilizers of the distal radioulnar joint [142].
• The primary soft-tissue restraint of the distal radioulnar joint, the TFCC, is composed of the ulnocarpal ligaments, ECU tendon subsheath, volar and dorsal radioulnar ligaments, proper articular disk, and the meniscus homologue [142].
• The primary ligamentous stabilizers of the distal radioulnar joint are the volar and dorsal radioulnar ligaments that originate from the sigmoid notch and traverse ulnarly to divide into superficial and deep limbs [142].
• The superficial limbs of the volar and dorsal radioulnar ligaments attach at the base and midportion of the ulnar styloid [142].
• The deep limbs of the volar and dorsal radioulnar ligaments attach to the ulnar fovea [142].
• The foveal attachments are the most important for conferring stability to the distal radioulnar joint [142].
• The scapholunate interosseous ligament is the primary stabilizer of the scapholunate joint [135].
• The proximal or membranous portion of the scapholunate interosseous ligament has no significant strength [135].
• The dorsal portion of the scapholunate interosseous ligament is the strongest portion and prevents translation [135].
• The palmar portion of the scapholunate interosseous ligament acts as a rotational constraint [135].
• Distal scaphoid stabilizers include the scaphotrapezial interosseous ligaments [135].
• The radioscapholunate ligament (ligament of Testut) is a volar intra-articular neurovascular structure and provides little mechanical stability [135].
• The palmar stabilizers of the scaphoid include the radioscaphocapitate ligament, long radiolunate ligament, and short radiolunate ligament [135].
• The radioscaphocapitate ligament, long radiolunate ligament, and short radiolunate ligament are all thought to be secondary stabilizers of the scaphoid [135].
• The dorsal stabilizers of the scaphoid are the dorsal radiocarpal ligament and the dorsal intercarpal ligament [135].
• The radial collateral ligament originates from the radius 0 mm from the radial styloid and inserts on the scaphoid waist and distal palmar trapezium [91].
• The radioscaphocapitate ligament originates from the radius 4 mm from the radial styloid and inserts on the scaphoid waist and midpalmar capitate [91].
• The radiolunatotriquetral ligament originates from the radius 10 mm from the radial styloid and inserts on the lunate ± triquetrum [91].
• 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 [91].
• The short radiolunate ligament originates from the volar-ulnar margin of the radius and inserts on the lunate [91].
• The ulnotriquetral ligament originates from the volar radioulnar ligament and inserts on the triquetrum [91].
• The ulnolunate ligament originates from the volar radioulnar ligament and inserts on the lunate [91].
• The ulnocapitate ligament originates from the volar margin of the ulnar head and inserts on the capitate [91].
• The dorsal radiocarpal ligament originates from the dorsal radius at the Lister tubercle and inserts on the lunate and triquetrum [91].
• The dorsal intercarpal ligament originates from the triquetrum and inserts on the scaphoid, trapezoid, and capitate [91].

Vascular Anatomy¶

• 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 [93].
• The dorsal radiocarpal arch is located at the radiocarpal joint and supplies the lunate and triquetrum [93].
• The dorsal intercarpal arch is the largest dorsal arch, located between the proximal and distal carpal rows, and supplies the distal carpal row and, through anastomoses with the radiocarpal arch, the lunate and triquetrum [93].
• The basal metacarpal arch is located at the base of the metacarpals, is the most variable dorsal arch, and supplies the distal carpal row [93].
• The palmar radiocarpal arch is located at the level of the radiocarpal joint on the palmar surfaces of the lunate and triquetrum [93].
• The intercarpal arch is located between the proximal and distal carpal rows, is the most variable palmar arch, and does not contribute to nutrient vessels in the carpus [93].
• 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 [93].

Kinematics and 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 [92].
• The two principle articulations of the wrist are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [92].
• The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [91].
• With ulnar deviation, the proximal row extends relative to the forearm/distal row [91].
• With radial deviation, the proximal row flexes relative to the forearm/distal row [91].
• With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [91].
• With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [91].
• With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [91].
• In normal wrists, motion occurred equally at the midcarpal and radiocarpal joints [112].
• The normal inclination of the radiocarpal joint surface is an inherently unstable one consisting of ulnar deviation and volar flexion [70].
• In a normal wrist, the unstable condition of the radiocarpal joint is neutralized by a strong and

Classification¶

Ligament Anatomy and Grouping¶

• Wrist ligaments are classified into two groups: extrinsic and intrinsic [132].
• The distal radioulnar ligament is composed of dorsal, palmar, superficial, and deep portions [190].

TFCC Injuries (Palmer Classification)¶

• The Palmer classification categorizes TFCC tears into traumatic (class 1) or degenerative (class 2) [18].
• TFCC tear subtypes are based on the specific location within the TFCC [18].
• Class 1A traumatic TFCC injury is characterized by a central perforation or tear [18].
• Class 1B traumatic TFCC injury is characterized by ulnar avulsion with or without ulnar styloid fracture [18].
• Class 1C traumatic TFCC injury is characterized by distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [18].
• Class 1D traumatic TFCC injury is characterized by radial avulsion involving the dorsal and/or volar radioulnar ligaments [18].
• Class 2A degenerative TFCC tear is characterized by TFCC wear or thinning [18].
• Class 2B degenerative TFCC tear is characterized by TFCC wear plus lunate and/or ulnar chondromalacia [18].
• Class 2C degenerative TFCC tear is characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [18].
• Class 2D degenerative TFCC tear is characterized by TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [18].
• Class 2E degenerative TFCC tear is characterized by TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and distal radioulnar joint arthritis [18].
• Class 1A TFCC tears are inherently stable and treated with débridement if persistently symptomatic because the central area is devoid of vascularity and unable to heal [18].
• Class 1B TFCC tears are amenable to arthroscopic or open repair because the peripheral rim is well vascularized [18].
• Class 1D TFCC tears are frequently associated with distal radius fractures and often respond to reduction of the radius [18].

Scapholunate (SL) Instability and Dissociation¶

• Scapholunate instability may be classified as acute, subacute, or chronic [150].
• Scapholunate dissociation may be classified as predynamic, dynamic, or static [150].
• The Geissler arthroscopic classification grades SL ligament injuries based on the amount of passive joint displacement [150].
• Geissler grade 1 SL injury involves minimal attenuation of the proximal SL membrane with no step-off in the SL joint visible from the midcarpal space [150].
• Geissler grade 2 SL injury involves substantial attenuation of the proximal SL membrane with a narrow SL gap less than the width of a 2 mm probe [150].
• Geissler grade 3 SL injury involves ligament disruption sufficient to allow an arthroscopy probe to enter the SL joint space from both the radiocarpal and midcarpal joints [150].
• The EWAS classification of SL dissociation includes Stage I, characterized by no passage of the probe in the SL space but presence of synovitis [150].
• The EWAS classification of SL dissociation includes Stage IIA, characterized by volar passage in the SL space without widening [150].
• The EWAS classification of SL dissociation includes Stage IIB, characterized by dorsal passage in the SL space without widening [150].
• The EWAS classification of SL dissociation includes Stage IIC, characterized by complete passage in the SL space without widening [150].
• The EWAS classification of SL dissociation includes Stage IIIA, characterized by volar partial widening at dynamic instability test from the midcarpal joint [150].
• The EWAS classification of SL dissociation includes Stage IIIB, characterized by dorsal partial widening at dynamic instability test from the midcarpal joint [150].
• The EWAS classification of SL dissociation includes Stage IIIC, characterized by complete widening of the space at dynamic test [150].
• The EWAS classification of SL dissociation includes Stage IV, characterized by a gap with passage of the arthroscope from the midcarpal to the radiocarpal joint [150].
• A Geissler grade I interosseous ligament injury consists of attenuation or hemorrhage as seen from the radiocarpal joint with no incongruency of carpal alignment in the midcarpal space [180].
• A Geissler grade II interosseous ligament injury adds incongruency to grade I findings as seen from the midcarpal space [180].

Kienböck's Disease¶

• The Lichtman classification for Kienböck's disease has substantial interobserver reliability with a coefficient of 0.63 [182].
• Stage 3A of the Lichtman classification is less reliably identified than the overall classification, with an interobserver reliability coefficient of 0.38 [182].
• A modification of the Lichtman classification using a radioscaphoid angle of 60° to subdivide stage 3 increases overall interobserver reliability to 0.81 [182].
• The same modification increases the interobserver reliability for identifying stage 3A to 0.75 [182].
• Kienböck's disease classification in stages IIIA (without carpal collapse) or IIIB (with carpal collapse) is performed by comparing to the contralateral wrist [175].

General Wrist Instability and Fracture Classifications¶

• A classification system for carpal instabilities can be based on anatomy [29].
• Four-part fractures of the distal radius should be sub-classified into those with and those without associated carpal ligamentous injury [11].
• None of the classification systems for distal radius fractures is ideal [124].
• The longitudinal 'columnar' concept of wrist kinematics does not fit with many recent findings related to carpal instabilities [43].

Clinical Presentation¶

History and Mechanism of Injury¶

• 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 [144].
• Carpal dislocations result from ulnar deviation and intercarpal supination [144].
• Scaphoid fractures result from wrist extension with the dorsal articular margin of the radius serving as a fulcrum [144].
• Flexion and pronation injuries may contribute more to ligament injuries on the ulnar side of the wrist, especially the lunotriquetral ligament [144].
• Lunotriquetral sprains usually occur from hyperextension and twisting of the wrist [60].
• A case of simultaneous dorsal trapezium-scaphoid and trapezoid-carpal subluxations was probably the result of direct trauma followed by a severe wrist extension injury [32].
• Perilunate dislocation typically occurs in young males after violent trauma [59].
• Wrist injuries sustained during sporting events are becoming more prevalent secondary to a heightened participation in athletics [63].
• For long-standing problems, it is important to correlate the problem with factors that cause worsening or relief [144].
• It is important to inquire about the patient’s jobs and hobbies, and whether there has been exposure to repetitive stress, vibrating tools, or potentially dangerous instruments [54].
• Elucidating a history of ligamentous laxity or multiple joint instabilities is important in younger patients presenting with chronic wrist pain [54].

Physical Examination Findings¶

• Swelling is generally moderate in wrist dislocations, and bone displacements may be evident only if the patient is seen immediately after experiencing trauma [54].
• If there has been a delay since the accident, swelling may have increased substantially, making visualization of the displaced bones more difficult [54].
• Skin abrasions, contusions, or ecchymosed areas may be helpful in determining the mechanism of injury and the potential areas of damage [54].
• Range of motion is usually limited by pain in acute injuries, whereas it may be reduced or normal in more chronic cases [54].
• In chronic cases, passive assessment of mobility is valuable for determining the presence of abnormal motion or crepitus and for reproducing the patient’s pain [54].
• 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 [54].
• In acute dislocations, tenderness is seldom elicited at specific points but rather in a diffuse manner due to extensive soft tissue damage [54].
• 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 [54].
• A careful assessment of neural and vascular status is imperative, with particular attention to the median and ulnar nerves [54].
• Median and ulnar nerves may be injured by direct contusion at the moment of impact, by compression from displaced bones, or by swelling within the carpal canal [54].
• Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [54].
• Strength may be diminished due to muscle atrophy, pain inhibition, or learned behaviors [54].
• Rapid alternating grip assessment may be helpful in determining voluntary effort [54].
• A local injection of anesthetic to a painful joint or selected tendon sheath may help normalize dynamometer readings and narrow the diagnostic spectrum [54].
• Sensory testing should always accompany an examination of suspected nerve compression, using threshold or density testing [54].
• The pronator quadratus sign is useful in the diagnosis of acute injuries of the distal radio-ulnar joint [47].
• Clinical examination is paramount in diagnosing wrist pathology [104].
• The natural inclination to study radiographs or special imaging studies prior to a thorough history and physical examination should be avoided, as this introduces cognitive bias [54].

Provocative Maneuvers and Specific Tests¶

• A thorough set of provocative maneuvers should be performed to rule out alternative or concurrent diagnoses [54].
• The examination should begin in a nontender area and proceed rotationally around the carpus, ending at the most symptomatic area [54].
• Watson’s scaphoid shift test is performed at the scaphoid tubercle [54].
• Finkelstein and Eichhoff maneuvers are used for first dorsal compartment tendinopathy [54].
• Manually resisted flexion/radial deviation of the wrist tests for flexor carpi radialis tendinitis [54].
• Ballottment and shear tests are used for lunotriquetral instability [54].
• The synergy test rules out tendinopathy of the extensor carpi ulnaris [54].
• Frank extensor carpi ulnaris instability is assessed with supination while maximally flexed and ulnar deviated [54].
• The triangular fibrocartilage complex must be carefully examined, and the distal radioulnar joint must be assessed for instability in neutral, supination, and pronation [54].
• Ulnar impaction and ulnar styloid impingement must be assessed in pronation and supination [54].
• Osteoarthritis is assessed by compression testing [54].
• Resisted ulnar flexion helps rule out flexor carpi ulnaris tendinopathy [54].
• A pisotriquetral “shuck” test is used for synovitis or osteoarthritis [54].
• Nondissociative instability of the carpus is assessed with Lichtman’s midcarpal shift test and the associated “catch up clunk” [54].
• Louis’ CLIP maneuver is used for midcarpal instability [54].
• The midcarpal shift test involves stabilizing the forearm, positioning the thumb over the dorsal distal capitate region, exerting a palmarly directed force, and ulnarly deviating the wrist while maintaining pressure [121].
• During the midcarpal shift test, either a smooth transition to ulnar deviation occurs or there is clunking as the wrist approaches full ulnar deviation [121].
• The midcarpal shift test is graded I to IV representing increasing degrees of laxity and clunking, with Grade V assigned to individuals who can spontaneously reproduce the clunk without assistance [121].
• Physical examination for lunotriquetral sprains discloses point tenderness, laxity, and often a snap over the lunotriquetral joint [60].
• Dorsopalmar manipulation of the triquetrum on the lunate demonstrates crepitus and laxity in lunotriquetral sprains [60].
• Symptoms of lunotriquetral sprains include pain, weakness, limitation of motion, and a "click" with lateral motions [60].
• Tenderness did not correlate with specific ligament injury in a study of 109 patients with chronic wrist pain [5].
• Both pain at rest and swelling correlated significantly with synovitis [5].
• No significant association was found between the presence of chondromalacia, synovitis, or specific ligament tears and the mechanism of injury, duration of symptoms, presence of clicking, or pain with activity [5].

Imaging and Diagnostic Modalities¶

• Routine radiographic series for a painful wrist consists of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [48].
• Spot views of the carpal bones for detail (carpal tunnel view) are useful in evaluating a painful wrist [48].
• Fluoroscopic spot views of the wrist are useful in evaluating a painful wrist [48].
• A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral/radial/ulnar deviation, lateral in neutral/full flexion/full extension, semipronated oblique 30 degrees from postero-anterior, and semisupinated oblique 30 degrees from lateral [48].
• Diagnostic ultrasound is a useful radiographic technique for evaluating a painful wrist [48].
• Cine or video fluoroscopy is a useful radiographic technique for evaluating a painful wrist [48].
• Bone scanning is a useful radiographic technique for evaluating a painful wrist [48].
• Arthrography of the wrist (triple injection when indicated) is a useful radiographic technique for evaluating a painful wrist [48].
• Computed tomography is a useful radiographic technique for evaluating a painful wrist [48].
• Magnetic resonance imaging should be added for evaluation of the triangular fibrocartilage, distal radioulnar joint, vascularity of carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion [48].
• A high rate of false-positive findings on MR images of normal subjects has been reported [48].
• A dedicated wrist coil provides enhanced resolution of wrist structures [48].
• In purely ligamentous disruptions of the carpus, the definition of damaged soft tissues can at best be inferred with radiographic techniques [34].
• A major limitation of radiographic techniques is the lack of direct imaging of the soft tissues [34].
• Magnetic resonance imaging has held promise for evaluating soft tissue disorders about the wrist due to successful implementation in the knee and shoulder [34].
• Correlations between MR images and actual normal anatomy must be made before MRI can become a useful tool in the evaluation of soft tissue disruptions of the wrist [34].
• A negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the triangular fibrocartilage complex, scapholunate ligament, or lunotriquetral ligament [44].
• Measurements of carpal bone angles on lateral wrist radiographs can be of assistance in the diagnostic evaluation of wrist malalignment [36].
• Normal mean values and ranges for intercarpal bone angles may be of assistance in the diagnostic evaluation of ligamentous injury to the wrist [36].
• The normal radiolunate angle is –1.02 (range –10 to 12) [36].
• The normal radioscaphoid angle is 51.80 (range 35 to 65) [36].
• The normal scapholunate angle is 50.77 (range 36 to 66) [36].
• Lateral radiographs should always be obtained in the same position, preferably zero position, to ensure uniformity when reporting results [36].
• In the clinical situation, a true lateral view of the wrist is often not obtainable [15].
• Computed tomography can characterize carpal fractures and avulsions, evaluate for intra-articular loose bodies, and assess for more subtle joint incongruities [128].
• Wrist arthroscopy has evolved to be an essential diagnostic and therapeutic tool in the armamentarium of every surgeon treating disorders of the wrist [52].
• Wrist arthroscopy allows direct visualization of the wrist joint without disruption of the extrinsic or intrinsic ligaments [61].
• Arthroscopy has surpassed other diagnostic modalities for evaluation of intercarpal pathology [61].
• In the acute wrist instability group, midcarpal arthroscopy added to the radiocarpal diagnosis in 21 of 26 (82%) of the wrists [53].
• In the chronic wrist instability group, midcarpal arthroscopy added to the diagnosis in 46 of 55 (84%) of the wrists [53].
• Wrist arthroscopy allows seeing lesions even at an early stage [35].
• Wrist arthroscopy has allowed an increase in diagnostic acumen and the development of less invasive procedures to treat specific injury patterns [16].
• The arthroscopic criteria for dating a wrist sprain are easy to evaluate during arthroscopy and can lead to a better understanding and management of wrist sprains [50].
• Wrist arthroscopy provides views of and access to the intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches [118].
• A radiocarpal arthrogram is helpful in confirming the diagnosis of lunotriquetral sprains [60].
• In cases of pain on the radial border of the wrist due to trauma and with normal routine radiographs, supplementary radiographs with the wrists kept in maximal ulnar deviation are recommended [64].
• Roentgenograms of both wrists are valuable in the evaluation of patients with chronic bilateral scapholunate dissociation [37].
• Young patients with persistent wrist pain after a distal radial fracture should be investigated for radiological signs of instability [55].
• The diagnosis of lunotriquetral dissociation is usually confounded by the many possible causes of ulnar-sided wrist pain and the frequently normal x-rays [58].
• Perilunate dislocation is a rare and often underdiagnosed wrist lesion [59].
• Diagnosis of chronic peripheral tears of the triangular fibrocartilage complex is difficult, requiring a high index of suspicion, careful physical examination, and judicious use of noninvasive and invasive techniques including wrist arthroscopy [116].
• Analysis of the injured wrist in positions that combine flexion-extension and radial-ulnar deviation may allow noninvasive diagnosis of specific wrist ligament injuries [10].
• A wrist joint should be considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion [42].
• The complex nature of the wrist has hampered the ability to formulate concise, yet thorough, algorithmic approaches to evaluation and treatment [3].

Investigations¶

Clinical Examination¶

• The natural inclination to study radiographs or special imaging studies prior to a thorough history and physical examination should be avoided to prevent cognitive bias that can affect thinking and decision making [54].
• Physical examination must be preceded by a thorough investigation of the patient’s medical history, with special emphasis on the mechanism of injury and acuity [54].
• A thorough set of provocative maneuvers should be performed to rule out alternative or concurrent diagnoses, not just to concentrate on the suspected diagnosis [54].
• Perilunate dislocation is a rare and often underdiagnosed wrist lesion, typically occurring in young males after violent trauma [59].
• A patient with a moderately severe wrist injury resulting in an unusual fracture disturbing the origins of important carpal ligaments may present with volar intercalary carpal instability [2].

Radiography¶

• Routine radiographic series for evaluating a painful wrist consists of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [48].
• Spot views of the carpal bones for detail (carpal tunnel view) are a useful radiographic technique [48].
• Fluoroscopic spot views of the wrist are a useful radiographic technique [48].
• A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral/radial/ulnar deviation, lateral in neutral/full flexion/full extension, semipronated oblique 30 degrees from posteroanterior, and semisupinated oblique 30 degrees from lateral [48].
• Radiography demonstrates no change of the SL interval and no degenerative changes in cases of incomplete ossification of the scaphoid mimicking obvious radiographic scapholunate dissociation [161].
• A clinical fracture of the carpal scaphoid may be an illusionary diagnosis, and under these circumstances the patient should be treated as a soft tissue injury of the wrist and followed up appropriately [6].
• The case of simultaneous dorsal trapezium-scaphoid and trapezoid-carpal subluxations was probably the result of direct trauma followed by a severe wrist extension injury [32].
• The treatment of scaphoid-trapezium-trapezoid subluxation (STTS) is discussed, noting that more interest in wrist ligament injuries will probably show a greater frequency of STTS [8].

Magnetic Resonance Imaging (MRI)¶

• MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint (DRUJ), 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 [48].
• With proper technique, injuries to the triangular fibrocartilage complex (TFCC) can be demonstrated with MRI [106].
• The TFCC is composed of signal-poor fibrocartilage, and perforations in the TFCC appear as linear defects or gaps filled with hyperintense fluid on coronal gradient-echo or T2-weighted pulse sequences [106].
• 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 [106].
• The addition of arthrographic contrast improves the visualization of scapholunate and lunotriquetral ligaments on MR images [106].
• Extrinsic carpal ligaments can be identified with three-dimensional volumetric scanning and subsequent reconstruction, but MRI assessment of these ligaments has less impact on treatment [106].
• MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease or in the scaphoid after fracture [106].
• Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia [106].
• MRI currently has a limited role in the evaluation of carpal tunnel syndrome, although 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 [106].
• MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [106].
• A negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the TFCC, SL ligament, or LT ligament of the wrist [44].
• The inconsequent use of available modern magnetic resonance imaging (MRI) techniques and the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain [155].
• 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 [201].
• The authors recommend that all acute scaphoid fractures should be assessed with MRI scans or tomography and classified as undisplaced and displaced [204].
• The ability to diagnose and classify the various types of carpal instabilities is based on a careful history, various physical examination maneuvers, and imaging techniques [34].
• A major limitation of radiographic techniques is the lack of direct imaging of the soft tissues, meaning that in purely ligamentous disruptions of the carpus, the definition of the damaged soft tissues can at best be inferred [34].
• MRI has held some promise for use in evaluating soft tissue disorders about the wrist, largely due to the successful implementation of MRI in the evaluation of the knee and shoulder [34].
• The paucity of published experience of MRI of the carpus is without anatomic correlation, and correlations between MR images and actual normal anatomy must be made before MRI can become a useful tool in the evaluation of soft tissue disruptions of the wrist [34].
• MRI shows a high incidence of carpal fractures in children with posttraumatic radial-sided wrist tenderness [17].
• The diagnostic accuracy of cross-sectional imaging for detecting acute scaphoid fractures in children has been systematically reviewed [17].
• MRI is controversial for TFCC tears, but newer innovations suggest value in detection and localization of TFCC pathology [18].

Arthroscopy¶

• Wrist arthroscopy has developed from a mostly diagnostic tool into an effective therapeutic tool, useful for the treatment of a variety of wrist disorders from arthritis to acute fractures [31].
• Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many the “gold standard” for evaluation of these conditions, as well as for examination of patients who have wrist pain of unknown origin [31].
• 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 [31].
• Arthroscopy has been found to be more accurate than arthrography in identifying the location and size of triangular fibrocartilage and interosseous ligament injuries [31].
• Arthroscopy is more accurate than triple-injection cinearthrography in detecting tears of the dorsal sensory branch of the ulnar nerve during arthroscopic repair of the triangular fibrocartilage [31].
• Arthroscopy has surpassed other diagnostic modalities for evaluation of intercarpal pathology, because it allows direct visualization of the wrist joint without disruption of the extrinsic or intrinsic ligaments [61].
• Wrist arthroscopy was done for one hundred nine patients with chronic wrist pain, averaging 22.8 months in duration [5].
• Both pain at rest and swelling correlated significantly with synovitis in a study of 109 patients with chronic wrist pain [5].
• Wrist ligament injuries and/or cartilage damage were noted in 96.3% of wrists in a study of 109 patients with chronic wrist pain [5].
• Ligament injuries were frequently multiple, averaging 2.6 ligament injuries per wrist in a study of 109 patients with chronic wrist pain [5].
• No significant association was found between the presence of chondromalacia, synovitis, or specific ligament tears and the mechanism of injury, duration of symptoms, presence of clicking, or pain with activity in a study of 109 patients with chronic wrist pain [5].
• Wrist arthroscopy has allowed for increased diagnostic acumen and the development of less invasive procedures to treat specific injury patterns [16].
• The increased use of arthroscopic examination of the wrist is advisable in wrist trauma in order to establish a correct diagnosis, prognosis and treatment of all the patient’s lesions, possibly preventing degenerative arthritis [14].
• Wrist arthroscopy allows to see the lesions, even at an early stage, and to treat them with a simple K-Wires fixation in acute cases [35].
• Arthroscopy is the gold standard for detection of TFCC tears [18].
• The arthroscopic trampoline test is performed to assess TFCC resiliency by balloting central portion with a small probe [18].
• The arthroscopic hook test can be used to demonstrate peripheral detachment of the TFCC [18].
• The arthroscopic suction test can show laxity of the TFCC when peripherally scarred in or foveal detachment when the DRUJ is clinically unstable [18].
• This study allows completing the spectrum of ligament lesions within injured wrists, to adapt the best ligament repair as possible [7].

Other Imaging and Diagnostic Tests¶

• Diagnostic ultrasound is a useful radiographic technique in evaluating a painful wrist [48].
• Cine or video fluoroscopy is a useful radiographic technique in evaluating a painful wrist [48].
• Bone scanning is a useful radiographic technique in evaluating a painful wrist [48].
• Arthrography of the wrist (triple injection when indicated) is a useful radiographic technique in evaluating a painful wrist [48].
• CT is a useful radiographic technique in evaluating a painful wrist [48].
• A rapid version of the bone scan (15 minutes) is useful as a second line investigation for continuing wrist pain following trauma in the presence of normal radiography [154].
• The fracture of an osteochondral fracture of the triquetrum was diagnosed by tomography and magnetic resonance imaging [187].
• The data provide a better understanding of distal radioulnar ligament-related pathology to perform distal ulnar fixation or ligament repair to recover distal radioulnar joint stability [9].
• The results of biomechanical studies have provided clinically relevant information about the normal anatomy and functional mechanics of the wrist, as well as guidelines for the treatment for a number of different fractures and ligament injuries [1].

Treatment¶

Non-Operative Management¶

• Grade I carpal instability, characterized by attenuation or hemorrhage of the interosseous ligament without midcarpal incongruency, is treated with immobilization in a cast [138].
• Acute traumatic Class 1 TFCC injuries are initially managed with immobilization and NSAIDs [18].
• Nondisplaced or minimally displaced radial styloid fractures may be treated nonsurgically [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 [24].
• Displaced distal radius fractures are immobilized for 4 to 6 weeks after acceptable closed reduction [24].
• Patients with dorsal wrist ganglions are encouraged to use the hand and wrist for light activities of daily living immediately after internal decompression surgery [84].
• After internal decompression of dorsal wrist ganglions, sutures are removed approximately 2 weeks post-surgery and cross friction massage of the portal areas is taught [84].
• Patients undergoing arthroscopic TFCC debridement require no restriction of wrist and forearm motion postoperatively [151].
• Physiotherapy may accelerate the return of strength and range of motion following arthroscopic TFCC debridement [151].
• For dorsal intercarpal augmentation ligamentoplasty, the wrist is immobilized in a short arm cast for 10 to 12 weeks, at which time pins are removed [176].
• Following dorsal intercarpal augmentation ligamentoplasty, the wrist is protected in a removable splint for an additional 4 to 6 weeks [176].
• Most individuals return to strenuous activity at about 6 months after dorsal intercarpal augmentation ligamentoplasty [176].
• Patients undergoing all-suture knotless suture anchor repair of the scapholunate ligament are counseled to expect 2 weeks in a postoperative splint followed by 4 to 6 weeks of casting [181].
• Patients undergoing all-suture knotless suture anchor repair of the scapholunate ligament are counseled to expect an additional 6 weeks of removable bracing with progressive loading until 16 weeks postoperatively [181].
• Early surgical management of multicomponent soft tissue injuries of the wrist requires regular physical therapy to achieve good functional outcomes [178].
• Postoperative rehabilitation after TFCC reconstruction includes specific neuromuscular potential training exercises and proprioceptive hand and wrist exercises [153].

Operative Management: Ligament Repair and Reconstruction¶

• Arthroscopic pinning is the indicated treatment for Grade II carpal instability, characterized by interosseous ligament attenuation with midcarpal incongruency or step-off [138].
• Arthroscopic pinning or open repair is the indicated treatment for Grade III carpal instability, characterized by incongruency or step-off visible from both radiocarpal and midcarpal spaces [138].
• Open repair is the indicated treatment for Grade IV carpal instability, characterized by gross instability where a 2.7-mm arthroscope may be passed through the gap between carpal bones [138].
• Acute tears of the scapholunate or lunotriquetral ligaments less than 4 to 6 weeks old that result in midcarpal incongruence may be arthroscopically reduced and temporarily pinned [67].
• Arthroscopic dorsal capsuloplasty is a proposed technique for chronic scapholunate ligament tears where the scaphoid is well aligned or reducible [77].
• Arthroscopic dorsal capsuloplasty for chronic scapholunate ligament tears may be combined with K-wire fixation of the scapholunate and scaphocapitate joints if the scaphoid is malaligned [77].
• Open reduction and internal fixation for scapholunate disruption involves fixing the reduction with three 0.045-inch (1.16-mm) Kirschner wires directed from the scaphoid into the lunate and capitate [138].
• Ligament reconstruction for scapholunate dissociation can be accomplished with free tendon grafts or tenodesis using prolonged slips of wrist flexors and extensors [138].
• Ligament reconstruction is recommended for patients whose ligament ruptures cannot be maintained with closed reduction or for those diagnosed after about 1 month [138].
• Ligament reconstruction is not indicated in patients with associated degenerative joint disease [138].
• Arthroscopic scapholunate ligament reconstruction reconstructs both the dorsal and volar portion of the ligament with a 3-mm graft from the flexor carpi radialis tendon [184].
• In arthroscopic scapholunate ligament reconstruction, the graft is fixed to the scaphoid and lunate tunnels with interference screws [184].
• Early mobilization rehabilitation for arthroscopic scapholunate ligament reconstruction includes midcarpal motion exercise at 2 weeks, full range of motion exercise at 4 weeks, and proprioception exercises at 6 weeks [184].
• Arthroscopic graft reconstruction for nonrepairable scapholunate ligament injuries re-creates the volar and dorsal SLIL while reconstructing the long radiolunate ligament [189].
• Arthroscopic graft reconstruction for nonrepairable scapholunate ligament injuries allows for earlier mobilization compared with open procedures [189].
• Contraindications for primary repair of the scapholunate ligament include degenerative arthritic changes, unreducible dissociation, inadequate SLIL tissue, and other carpal ligamentous disruptions or fractures [165].
• Contraindications for arthroscopic scapholunate ligament reconstruction include the presence of degenerative lesions or other associated ligament injuries [184].
• Patients suitable for arthroscopic scapholunate ligament reconstruction must have a complete tear of the scapholunate ligament, easily reducible instability, and clinical symptoms [184].
• Repair of a traumatic TFCC tear within 3 months of injury allows a patient to regain 80% of wrist ROM and grip strength [18].
• Class 1B (peripheral) TFCC tears are amenable to arthroscopic or open repair because the rim is well vascularized [18].
• Concurrent fractures of the ulnar styloid with persistent instability in Class 1B TFCC injuries are either excised or fixed [18].
• Class 1C (distal avulsion) TFCC injuries are treated by advancement of the distal volar rim to the triquetrum using a bone anchor [18].
• Class 1D (radial avulsion) TFCC injuries are treated by direct repair to the radius to preserve the TFCC contribution to DRUJ stability [18].
• Class 1D TFCC injuries are frequently associated with distal radius fractures and often respond to reduction of the radius [18].
• Ulnar-sided peripheral tears of the TFCC should be repaired as opposed to débrided [139].
• Arthroscopic midcarpal suture anchor repair is a treatment approach for dorsal intercarpal ligament avulsion [20].
• Anatomical anterior and posterior reconstruction for scapholunate dissociation resulted in no patient requiring secondary surgery or treatment related to carpal stabilization in a preliminary series of ten patients [148].
• Ulnotriquetral augmentation tenodesis for dorsal subluxation of the distal radioulnar joint resulted in improved stability in all patients, with five having complete and three having satisfactory relief of pain [145].
• Dorsal intercarpal augmentation ligamentoplasty for scapholunate dissociation involves immobilization in a short arm cast for 10 to 12 weeks followed by supervised therapy emphasizing range of motion and strengthening [176].
• A new technique to correct carpal instability with scaphoid rotary subluxation could potentially replace tendon ligamentoplasties and partial wrist arthrodeses if long-term outcomes match short-term results [28].
• Volar approach is a feasible and safe procedure to evaluate and treat the volar region of the scapholunate interosseous ligament [141].
• Arthroscopic-assisted volar scapholunate capsulodesis is a new technique for treating scapholunate instability [85].
• Arthroscopic assessment of the volar region of the scapholunate interosseous ligament through a volar portal is feasible and safe [141].
• Inside-out method to develop volar arthroscopic portals of the wrist is easy to perform, safe, and useful for ligament or bony intracarpal repairs [57].
• Arthroscopic dorsal capsuloligamentous repair in chronic scapholunate ligament tears aims to avoid open dissection of the wrist capsule to prevent stiffness [77].
• Open techniques for chronic scapholunate ligament tears often lead to stiffness in the wrist joint [77].
• Arthroscopic dorsal capsuloplasty for chronic scapholunate ligament tears showed encouraging preliminary results in a series of 36 patients [77].
• Arthroscopic midcarpal suture anchor repair of dorsal intercarpal ligament avulsion emphasizes the need for comprehensive evaluation and diverse treatment approaches [20].
• The increased use of arthroscopic examination of the wrist is advisable in wrist trauma to establish correct diagnosis, prognosis, and treatment, possibly preventing degenerative arthritis [14].
• Wrist arthroscopy allows visualization of lesions at an early stage and treatment with simple K-Wires fixation in acute cases [35].
• Arthroscopy is the most valuable tool for the diagnosis and treatment of acute scapholunate dissociation [77].
• Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many the "gold standard" for evaluation of these conditions [31].
• The arthroscopic trampoline test is performed to assess TFCC resiliency by balloting the central portion with a small probe [18].
• MRI is controversial for TFCC pathology, but newer innovations suggest value in detection and localization [18].
• Indications for wrist arthroscopy include 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 [31].
• Indications for diagnostic wrist arthroscopy include assessment of acute ligamentous injuries such as scapholunate, lunotriquetral, and TFCC injuries [134].
• Indications for diagnostic wrist arthroscopy include evaluation of carpal instability [134].
• Indications for diagnostic wrist arthroscopy include assessment of associated soft tissue injury in fracture conditions such as distal radius, scaphoid, and ulnar styloid fractures [134].
• Indications for diagnostic wrist arthroscopy include staging of posttraumatic arthritis such as SLAC and SNAC [134].
• Indications for therapeutic arthroscopy include TFCC debridement, debridement of ligament tears, synovectomy, wrist ganglionectomy, removal of loose body, capsulotomy/capsulectomy, lavage, and arthrolysis [134].
• Indications for therapeutic arthroscopy include bone procedures such as scaphoidectomy, radial styloidectomy, wafer procedure, proximal row carpectomy, and proximal hamate excision [134].
• Indications for therapeutic arthroscopy include cartilage debridement of chondral and osteochondral lesions [134].
• Indications for reparative arthroscopy include peripheral TFCC tear, TFCC foveal avulsion, scapholunate ligament injury, and lunotriquetral ligament injury [134].
• Indications for reparative arthroscopy include arthroscopic-assisted reduction and internal fixation of distal radius and scaphoid fractures [134].
• Indications for reconstructive arthroscopy include arthroscopic TFCC reconstruction with tendon graft and arthroscopic-assisted scapholunate ligament reconstruction with tendon graft [134].
• Indications for reconstructive arthroscopy include arthroscopic bone grafting for scaphoid nonunion, limited carpal fusion, intraosseous bone cyst, and intraosseous ganglion [134].
• Indications for reconstructive arthroscopy include osteochondral grafting [134].
• Wrist arthroscopy has developed into an effective therapeutic tool useful for the treatment of a variety of wrist disorders from arthritis to acute fractures [31].
• Wrist arthroscopy has produced new arthroscopic classifications of disorders such as Kienböck disease, TFCC injuries, and interosseous ligament tears that can help guide treatment [31].
• Arthroscopy has allowed for the development of less invasive procedures to treat specific injury patterns [16].
• Arthroscopy allows completing the spectrum of ligament lesions within injured wrists to adapt the best ligament repair as possible [7].
• The purposes of management of carpal instabilities include reviewing anatomy and kinematics, describing a classification system, discussing pathogenesis, discussing evaluation and treatment (nonsurgical and surgical), and describing postsurgical management [29].
• Biomechanical studies have provided guidelines for the treatment of a number of different fractures and ligament injuries [1].
• Patients must understand their wrists are not rendered "normal" by reconstructive procedures, but for the properly selected patient the DILC may be an excellent option [23].
• It is important to differentiate between SNAC and SLAC-Wrist for classification and preoperative planning in treatment of advanced carpal collapse [71].
• The classification of Kienbock's disease allows surgeons to tailor surgical reconstruction to anatomical findings, such as performing a proximal row carpectomy or radio-scapholunate fusion [69].
• Fractures with associated intercarpal ligament injuries merit a discussion of surgical treatment [24].
• 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 [24].
• Only frank dislocation with forearm rotation merits surgery to stabilize the distal radioulnar joint [24].
• Clinical stability of the DRUJ must be elucidated and compared with the normal contralateral side when possible [24].
• Most open fractures and volar shearing fractures of the distal radius are best treated operatively [24].
• Surgical treatment indications for distal radius fractures relate

Complications¶

Post-operative and Iatrogenic Complications¶

• Application of a volar locking plate for distal radius fractures can lead to flexor pollicis longus tendon rupture if the plate extends volarly beyond the watershed line [24].
• Dorsal tendons, including the extensor pollicis longus and extensor digitorum communis, can fray and rupture from prominent screw tips following volar plate insertion [24].
• Intra-articular screw placement is a potential pitfall during open reduction internal fixation of distal radius fractures [24].
• External fixator pin placement over the radius and index metacarpal carries a risk of iatrogenic injury to the superficial branch of the radial nerve or tethering of the first dorsal interosseous muscle [24].
• A standard carpal boss procedure involving dorsal ligament sectioning approximately doubles the passive range of motion of the carpometacarpal joint, creating instability [205].
• Following a carpometacarpal fracture-dislocation, finger extension may remain poor for over 3 months postoperatively [27].
• The second most common complication of scaphocapitate arthrodesis is persistent wrist pain despite radiographic evidence of bony union, occurring in 4/30 patients (13%) [12].
• Internal decompression of dorsal wrist ganglions can result in diminished motion in rare patients, requiring specific daily exercises to restore normal range [84].
• Revision to another wrist replacement following a failed total wrist replacement appears no worse in the short term [40].

Non-union and Delayed Complications¶

• With every decade of a patient’s life, the odds of scaphoid union are reduced by 1.72 times [195].
• Dominant hand injury reduces the odds of scaphoid union by 7.35 times [195].
• Previous scaphoid surgery reduces the odds of union by 4.24 times [195].
• Functional outcome following bone-grafting for scaphoid non-union was worse when surgery was performed more than 5 years after the original injury [169].
• Late surgery for ununited scaphoid fractures can produce good results if there is no secondary wrist osteoarthritis [169].
• Patient age and delay from acute scaphoid fracture to non-union surgery do not influence the outcome of bone grafting provided there is no secondary wrist osteoarthritis [169].

Chronic Instability and Degenerative Sequelae¶

• Wrist ligament injuries are frequently multiple, averaging 2.6 ligament injuries per wrist in patients with chronic wrist pain [5].
• Wrist ligament injuries and/or cartilage damage were noted in 96.3% of wrists with chronic pain and normal x-ray films [5].
• Chronic bilateral scapholunate dissociation can occur without symptoms [37].
• Concomitant scapholunate dissociation and Kienböck's disease can occur, with x-ray evidence of dissociation present before the onset of lunate osteonecrosis in some patients [87].
• Scapholunate ligament injuries may complicate acute scaphoid fractures more frequently than previously recognized [80].

Recovery¶

Functional Outcomes and Range of Motion¶

• At 1 year after surgery for scapholunate ligament disruption in a skeletally immature patient, preservation of a normal carpal alignment was noted and there was restoration of a full range of motion of the wrist [75].
• The mean active range of motion of the wrist at final follow-up for ligamentous reconstruction of scapholunate dislocation was 44° of flexion and 58° of extension [192].
• The mean hand grip strength at final follow-up for ligamentous reconstruction of scapholunate dislocation was 88% of that of the contralateral hand [192].
• At final follow-up for percutaneous fixation of scaphoid nonunion with bone grafting, there was significant improvement in wrist extension range of movement from 65.8° to 80.8° [171].
• At final follow-up for percutaneous fixation of scaphoid nonunion with bone grafting, there was significant improvement in grip strength from 65.5% to 87.8% of the unaffected side [171].
• Twelve months following a hamate fracture-dislocation, the patient had regained full wrist motion and grip strength and had returned to all activities involving the right hand [191].
• At follow-up 70 months after a palmar dislocation of the trans-scaphoid-lunate unit, there was no osteonecrosis and the wrist function was almost normal [49].
• Postoperatively for an unusual carpometacarpal fracture-dislocation, recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months [27].

Long-Term Stability and Complications¶

• There has been no long-term deterioration of wrist function following costo-osteochondral grafts in the wrist [21].
• Radiographic disease progression occurred in only 2 wrists, rated stage IIIB, at 8 and 10 years follow-up for capitate shortening osteotomy without a bad clinical outcome [207].
• In a small series of failed total wrist replacement revisions, all patients to date appear to have good clinical outcomes, and revision to another wrist replacement appears no worse in the short term [40].
• After one year follow-up for free composite osteochondral-cutaneous flaps for scaphoid and lunate cartilage lesions, the three patients no longer had wrist pain, wrist mobility was good, and patients had no discomfort in their knee [74].
• In a 47-year-old patient with bilateral osteochondroma of the scaphoid causing scapholunate dissociation, a proximal row carpectomy resulted in an excellent result after 43 months [209].
• Radiographic evidence at a 2-year follow-up for arthroscopic repair of radial-sided triangular fibrocartilage complex lesions showed the distal radial ulna joint changing from an open to a normal closed position [211].

Diagnostic and Prognostic Considerations¶

• Wrist ligament injuries and/or cartilage damage were noted in 96.3% of wrists with chronic pain and normal x-ray films and arthrograms [5].
• Ligament injuries in wrists with chronic pain were frequently multiple, averaging 2.6 ligament injuries per wrist [5].
• Tenderness did not correlate with specific ligament injury in wrists with chronic pain [5].
• SLL injuries may complicate acute scaphoid fractures more frequently than previously recognized [80].
• Further prospective studies with standardized diagnostic protocols and long-term follow-up are required to clarify the prognostic impact and optimize management strategies for SLL injuries complicating acute scaphoid fractures [80].

Key Evidence¶

• [Paper] The results of these studies have provided clinically relevant information about the normal anatomy and functional mechanics of the wrist, as well as guidelines for the treatment for a number of different fractures and ligament injuries. [1] (10.1016/s0894-1130(12)80306-1)
• [L5] A patient is presented who sustained a moderately severe injury to the wrist resulting in an unusual wrist fracture disturbing the origins of important carpal ligaments. [2] (10.1016/0266-7681(87)90057-x)
• [Paper] The complex nature of the wrist has plagued us clinically and hampered our ability to formulate concise, yet thorough, algorithmic approaches to evaluation and treatment. [3] (10.1016/s0894-1130(96)80065-2)
• [L5] Early recognition of uncommon carpal disruptions may guide appropriate surgical treatment and improve long-term functional outcomes. [4] (10.1177/15589447261475382)
• [L4] [5] (10.1016/0363-5023(90)90015-j)
• [L4] Under these circumstances the patient should be treated as a soft tissue injury of the wrist and followed up appropriately. [6] (10.1016/s0266-7681(85)80065-6)
• [L4] This study allows completing the spectrum of ligament lesions within injured wrists, to adapt the best ligament repair as possible. [7] (10.1097/bth.0000000000000131)
• [L5] The treatment of STTS is discussed, noting that more interest in wrist ligament injuries will probably show a greater frequency of STTS. [8] (10.1016/0266-7681_86_90174-9)
• [L5] The data provide a better understanding of distal radioulnar ligament-related pathology to perform distal ulnar fixation or ligament repair to recover distal radioulnar joint stability. [9] (10.1177/1558944716660555x)
• [L5] Analysis of the injured wrist in positions that combine flexion-extension and radial-ulnar deviation may allow noninvasive diagnosis of specific wrist ligament injuries. [10] (10.1016/j.jhsa.2005.08.005)
• [L4] Four-part fractures of the distal radius should be studied carefully before deciding on management and sub-classified into those with and those without associated carpal ligamentous injury. [11] (10.1016/0266-7681(90)90104-c)
• [Paper] The second most common complication is persistent wrist pain despite radiographic evidence of scaphocapitate bony union, occurring in 4/30 patients (13%). [12] (10.1097/00130911-200206000-00003)
• [L4] The increased use of arthroscopic examination of the wrist is advisable in wrist trauma in order to establish a correct diagnosis, prognosis and treatment of all the patient’s lesions, possibly preventing degenerative arthritis. [14] (10.1016/j.hansur.2016.10.029)
• [L5] In the clinical situation, however, a true lateral view of the wrist is often not obtainable. [15] (10.1016/s0363-5023(83)80046-x)
• [L4] Wrist arthroscopy has allowed us to increase our diagnostic acumen and subsequently develop less invasive procedures to treat these very specific injury patterns. [16] (10.1097/00130911-199712000-00002)
• [L5] The findings emphasize the need for comprehensive evaluation and diverse treatment approaches to improve outcomes for patients with wrist ligament injuries. [20] (10.1016/j.eats.2024.103028)
• [L4] There has been no long term deterioration of wrist function. [21] (10.1097/00130911-200109000-00008)
• [L4] Median nerve injuries at the wrist leave serious sequelae and have a reserved prognosis. [22] (10.1016/s1297-3203(03)00056-8)
• [L5] Patients must understand their wrists are not rendered “normal" by this or any reconstructive procedure, but for the properly selected patient the DILC may be an excellent option. [23] (10.1097/00130911-199912000-00002)
• [L4] It is a reliable procedure in the long term with a low risk of complications for patients wishing to preserve the mobility of the wrist. [26] (10.1016/j.hansur.2016.10.058)
• [L5] Postoperatively recovery of the wrist was rapid, though extension of the fingers remained poor for over 3 months. [27] (10.1016/0020-1383(94)90161-9)
• [L4] If the long-term outcome of this procedure is as promising as the short-term results seem to indicate, we feel that this method could replace tendon ligamentoplasties and partial wrist arthrodeses. [28] (10.1016/s0363-5023(95)80175-8)
• [L5] The purposes of this paper are to: 1) review anatomy and kinematics of the wrist; 2) describe a classification system based on anatomy; 3) discuss the pathogenesis of carpal instabilities; 4) discuss the evaluation and treatment, both nonsurgical and surgical; and 5) describe postsurgical management. [29] (10.1016/s0894-1130(96)80073-1)
• [L5] The case presented here was probably the result of direct trauma followed by a severe wrist extension injury. [32] (10.1016/0363-5023(92)90422-l)
• [Paper] This study supports the clinical belief that this dorsal wrist ligament should be spared during surgical approaches to the carpus. [33] (10.1053/jhsu.2002.30074)
• [L5] [34] (10.1016/0363-5023(94)90024-8)
• [L5] Wrist arthroscopy allows to see the lesions, even at an early stage, and to treat them with a simple K-Wires fixation in acute cases. [35] (10.1016/j.main.2006.07.027)
• [L4] [36] (10.1016/s0363-5023(10)80156-x)
• [L5] Roentgenograms of both wrists are valuable in the evaluation of patients with this condition. [37] (10.1016/s0363-5023(79)80138-0)
• [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. [40] (10.1016/s0363-5023(10)60131-1)
• [L5] A wrist joint should be considered biomechanically unstable when it is not able to bear loads and does not exhibit normal kinematics throughout its arc of motion. [42] (10.1053/jhsu.1999.0866)
• [L5] The longitudinal 'columnar' concept of wrist kinematics does not fit in with many of the recent findings related to carpal instabilities. [43] (10.1016/s0363-5023(83)80025-2)
• [L2] A negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the TFCC, SL ligament, or LT ligament of the wrist. [44] (10.1016/j.arthro.2015.04.090)
• [L4] The present study indicates that this sign is also useful in the diagnosis of acute injuries of the distal radio-ulnar joint. [47] (10.1016/0266-7681(89)90021-1)
• [L5] At follow-up 70 months after injury there is no osteonecrosis and the wrist function is almost normal. [49] (10.1016/s0266-7681(05)80175-5)
• [L4] The arthroscopic criteria for dating a wrist sprain are easy to evaluate during arthroscopy and can lead to a better understanding and management of wrist sprains. [50] (10.1016/j.main.2012.06.001)
• [Paper] Wrist arthroscopy has evolved to be an essential diagnostic and therapeutic tool in the armamentarium of every surgeon treating disorders of the wrist. [52] (10.1097/00130911-200603000-00007)
• [L3] In the acute wrist instability group, midcarpal arthroscopy added to the radiocarpal diagnosis in 21 of 26 (82%) of the wrists, and in the chronic wrist instability group, it added to the diagnosis in 46 of 55 (84%) of the wrists. [53] (10.1053/jhsu.2001.24973)
• [L5] Young patients with persistent wrist pain after a distal radial fracture should be investigated for radiological signs of instability. [55] (10.1016/s0266-7681(97)80055-1)
• [L5] They were easy to perform, safe, and seemed useful in indications for ligament or bony intracarpal repairs. [57] (10.1177/1558944716660555hr)
• [L5] The diagnosis is usually confounded by the many possible causes of ulnar-sided wrist pain and the frequently normal x-rays. [58] (10.1097/00130911-199803000-00002)
• [L4] Perilunate dislocation is a rare and often underdiagnosed wrist lesion, typically occurring in young males after violent trauma. [59] (10.1016/j.hansur.2017.10.201)
• [L4] [60] (10.1016/s0363-5023(84)80101-x)
• [Paper] Arthroscopy has surpassed other diagnostic modalities for evaluation of intercarpal pathology, because it allows direct visualization of the wrist joint without disruption of the extrinsic or intrinsic ligaments. [61] (10.1097/00130911-200009000-00010)
• [L5] Wrist injuries sustained during sporting events are becoming more prevalent secondary to a heightened participation in athletics. [63] (10.1016/s0278-5919(05)70097-1)
• [L5] In cases of pain on the radial border of the wrist due to trauma and with normal routine radiographs, one would recommend supplementary radiographs with the wrists kept in maximal ulnar deviation. [64] (10.1016/0266-7681(86)90174-9)
• [L4] Surgery does not appear to improve mobility of the wrist. [68] (10.1016/0266-7681(88)90042-3)
• [L4] The classification allows surgeons to tailor surgical reconstruction to anatomical findings, such as performing a proximal row carpectomy or radio-scapholunate fusion. [69] (10.1097/00130911-200603000-00003)
• [L4] We find it important to differentiate between SNAC and SLAC-Wrist for classification and preoperative planning in treatment of advanced carpal collapse. [71] (10.1016/0266-7681(94)90353-0)
• [L4] After one year follow-up, the three patients no longer had wrist pain, wrist mobility were good and patients had no discomfort in their knee. [74] (10.1016/j.hansur.2019.10.029)
• [L5] At 1 year after surgery, preservation of a normal carpal alignment was noted and there was restoration of a full ROM of the wrist. [75] (10.1016/s0363-5023(05)80184-4)
• [L4] [77] (10.1016/j.hcl.2011.07.003)
• [L4] Provided all the technical principles are respected, complications such as ulnocarpal impingement or nonunion, are rare. [81] (10.1016/j.main.2008.08.014)
• [L4] The use of a wrist fixator allows open wound care and permits free access to the wrist for early secondary operations. [82] (10.1016/s0020-1383(99)00267-3)
• [L5] [84] (10.1097/00130911-200209000-00008)
• [L4] [85] (10.1016/j.jhsa.2022.05.018)
• [L5] This method offers a minimally invasive and easily reproducible solution, addressing a challenging set of ulnar wrist injuries. [86] (10.1016/j.eats.2024.102995)
• [L4] Five patients attributed the onset of wrist pain to a single traumatic event, and three had x-ray evidence of scapholunate dissociation before the onset of lunate osteonecrosis. [87] (10.1016/0363-5023(91)90014-3)
• [L5] I emphasize that clinical examination is paramount in diagnosing wrist pathology. [104] (10.1177/1753193411398756)
• [L4] In normal wrists, motion occurred equally at the midcarpal and radiocarpal joints. [112] (10.1016/s0266-7681(97)80050-2)
• [L4] Diagnosis is difficult, requiring a high index of suspicion, careful physical examination, and judicious use of noninvasive and invasive techniques including wrist arthroscopy. [116] (10.1016/s0363-5023(10)80123-6)
• [L5] Wrist arthroscopy can be a useful tool in one’s armamentarium in the diagnosis and treatment of wrist pathology, providing views of and access to the intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches. [118] (10.1016/j.eats.2024.103223)
• [L4] [121] (10.1053/jhsu.1999.0977)
• [L5] None of the classification systems for distal radius fractures is ideal. [124] (10.1016/j.hansur.2016.02.012)
• [L5] [128] (10.1016/j.eats.2024.103350)
• [L5] The ligaments of the wrist can be classified into two groups: extrinsic and intrinsic. [132] (10.1016/s0363-5023(76)80004-4)
• [L4] Volar approach is a feasible and safe procedure to evaluate and treat the volar region of the scapholunate interosseous ligament. [141] (10.1053/jhsu.2003.50020)
• [L4] All patients had improved stability of the distal radioulnar joint; five had complete and three had satisfactory relief of pain. [145] (10.1016/s0363-5023(82)80171-8)
• [L4] No patient required secondary surgery or treatment related to the carpal stabilization. [148] (10.1177/1753193419886536)
• [Paper] [150] (10.1016/j.hansur.2016.09.002)
• [L4] [153] (10.1016/j.jhse.2007.02.170)
• [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. [154] (10.1016/s0020-1383(99)00280-6)
• [L4] The inconsequent use of available modern magnetic resonance imaging (MRI) techniques and the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. [155] (10.1177/1558944716660555hs)
• [L5] Radiography demonstrates no change of the SL interval and no degenerative changes of both wrists. [161] (10.1142/s242483551972010x)
• [L5] Contraindications include degenerative arthritic changes, unreducible dissociation, inadequate SLIL tissue, and other carpal ligamentous disruptions or fractures. [165] (10.1097/00130911-199812000-00007)
• [L4] [169] (10.1016/s0020-1383(00)00059-0)
• [L4] At the final follow-up, there was significant improvement in the wrist extension range of movement (from 65.8° to 80.8°) and grip strength (from 65.5% to 87.8% of the unaffected side). [171] (10.1177/1558944716660555he)
• [L5] The author states that their classification of Kienbock’s disease in stages IIIA (without carpal collapse) or IIIB (with carpal collapse) is done comparing to the contralateral wrist. [175] (10.1177/17531934231205707)
• [L4] [176] (10.1097/00130911-200312000-00005)
• [L4] Early surgical management of multicomponent soft tissue injuries of the wrist, a meticulous approach and regular physical therapy are required to achieve good functional outcomes. [178] (10.1016/j.hansur.2018.02.001)
• [Paper] [180] (10.1016/j.jhsa.2006.08.015)
• [L5] [181] (10.1016/j.eats.2024.103333)
• [L4] [182] (10.1053/jhsu.2003.50035)
• [L4] [184] (10.1016/j.hcl.2017.07.019)
• [L5] The fracture was diagnosed by tomography and magnetic resonance imaging. [187] (10.1053/jhsu.2002.28944)
• [L5] [189] (10.1016/j.eats.2025.103820)
• [L5] The distal radioulnar ligament is composed of dorsal, palmar, superficial, and deep portions. [190] (10.1016/s0363-5023(98)80003-8)
• [L5] Twelve months following the injury, the patient had regained full wrist motion and grip strength and had returned to all activities involving his right hand. [191] (10.1016/s0363-5023(05)80271-0)
• [L4] The mean active range of motion of the wrist at final follow-up was 44° of flexion and 58° of extension and the mean hand grip strength was 88% of that of the contralateral hand. [192] (10.1016/j.jhsb.2006.02.009)
• [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. [195] (10.1177/15589447231219523)
• [Paper] PRC has become a popular “motion-preserving" procedure for the treatment of various degenerative and posttraumatic conditions of the wrist. [197] (10.1097/00130911-199903000-00005)
• [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. [201] (10.1016/j.jhsa.2019.03.003)
• [L3] The authors recommend that all acute scaphoid fractures should be assessed with MRI scans or tomography and classified as undisplaced and displaced. [204] (10.1016/s0363-5023(03)80355-6)
• [L5] [205] (10.1016/s0266-7681(98)80225-8)
• [L4] Radiographic disease progression occurred only in 2 wrist, rated stage IIIB, at 8 and 10 years follow-up without a bad clinical outcome. [207] (10.1016/j.main.2014.10.086)
• [L5] In this 47-year-old patient, a proximal row carpectomy resulted in an excellent result after 43 months. [209] (10.1016/j.main.2007.05.005)
• [Paper] Radiographic evidence at a 2-year follow-up showed the distal radial ulna joint changing from an open to a normal closed position. [211] (10.1097/00130911-199903000-00007)

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