Carpal Ligament Injuries and Instability E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 721

Veröffentlichungsjahr: 2023

Beschreibung

An up-to-date, instructional resource on open and arthroscopic management of wrist injuries

Major advances have been made in the field of wrist surgery, including the use of arthroscopy and better rehabilitation protocols. In addition, understanding of proprioception has changed conservative management, often preventing surgery. Nevertheless, the assessment and management of a myriad of wrist dysfunctions remains daunting, due in part to complicated anatomy and mechanics and a lack of high-quality prospective clinical studies. Carpal Ligament Injuries and Instability: FESSH Instructional Course Book 2023 edited by renowned hand surgeons Fernando Corella, Carlos Heras-Palou, and Riccardo Luchetti covers the investigation, diagnosis, staging, and management of ligament injuries and the latest open and arthroscopic techniques to treat carpal instabilities.

The first two sections lay a solid foundation, with eight chapters encompassing anatomy and biomechanics, clinical and arthroscopic examination of the wrist, and imaging. Section three includes 10 chapters on scapholunate injury and instability, with discussion of open and arthroscopic repair, reinforcement, reconstruction, and resection techniques. Section four features five chapters on lunotriquetral injury and instability, including acute and chronic open and arthroscopic injury management. Section five includes four chapters on extrinsic ligament injuries, from perilunate injuries to staging and treatment of nondissociative proximal row instability. The book concludes with a final section comprising two chapters on other types of injuries.

Key Highlights

• An impressive group of renowned global experts describe new treatment algorithms and surgical techniques
• Clinical pearls throughout the text provide guidance on preventing complications and improving outcomes
• A wealth of high-quality operative photos, imaging scans, illustrations, and videos enhance understanding of impacted anatomy and techniques

This resource provides trainees, surgeons, and therapists with current thinking and up-to-date evidence-based treatment for wrist ligament injuries and carpal instabilities, with the goal of improved patient outcomes.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

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Carpal Ligament Injuries and Instability

FESSH Instructional Course Book 2023

Fernando Corella, PhDAssociate ProfessorDepartment of SurgeryComplutense University of Madrid;Hand SurgeonWrist and Hand UnitTraumatology ServiceUniversity Hospital Quirónsalud MadridMadrid, Spain

Carlos Heras-Palou, MD, FRCS (Tr & Orth) Consultant Hand and Wrist SurgeonPulvertaft Hand CentreRoyal Derby HospitalDerby, UK

Riccardo Luchetti, MDPrivate Practice Hand SurgeonRimini Hand Surgery and Rehabilitation CenterRimini, Italy

550 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG

Rüdigerstrasse 14, 70469 Stuttgart, Germany

+49 [0]711 8931 421, [email protected]

Cover design: © Thieme

Cover image source: © Thieme/Massimiliano Crespi

Typesetting by TNQ Technologies, India

Printed in Germany by Beltz Grafische Betriebe5 4 3 2 1

DOI: 10.1055/b000000804

ISBN: 978-3-13-245189-6

Also available as an e-book: eISBN (PDF): 978-3-13-245190-2eISBN (epub): 978-3-13-245191-9

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Contents

Videos

Preface

Contributors

Section I: Anatomy and Biomechanics

1.Anatomy and Histology of Wrist Ligaments

Elisabet Hagert, Frantzeska Zampeli, and Susanne Rein

1.1Wrist Ligaments: Overview of Anatomy and Histology

1.1.1Anatomy Overview

1.1.2Histology Overview

1.2Extrinsic Ligaments

1.2.1Anatomy

1.2.2Volar Radiocarpal Ligaments

1.2.3Volar Ulnocarpal Ligaments

1.2.4Dorsal Radiocarpal Ligament

1.3Intrinsic Ligaments

1.3.1Anatomy

1.3.2Midcarpal Ligaments

1.3.3Intercarpal Ligaments

References

2.Biomechanics of the Wrist

Jonathan P. Compson

2.1Introduction

2.2Functions of the Wrist

2.2.1Optimum Position for Finger Function/ Arthrodesis

2.2.2Functional Range of Movement

2.2.3Dart-Throwing Motion

2.3Basic Functional Anatomy of the Wrist

2.3.1Osteology

2.3.2Ligaments

2.4Wrist Stability

2.4.1Trabecular Patterns

2.4.2Pressure and Forces Across Wrist

2.4.3General Aspects and the Importance of Locking

2.4.4Locking of the Midcarpal Joint

2.4.5Locking Mechanisms in the Radiocarpal Joint

2.4.6Isolated Joints

2.5Carpal Movement

2.5.1Historical Perspective

2.5.2Wrist Movement

2.6Hydromechanics of the Wrist

2.7Conclusions and Future Developments

References

3.Role of Muscles in Wrist Stabilization and Clinical Implications

Mireia Esplugas, Alex Lluch, Guillem Salva-Coll, and Marc Garcia-Elias

3.1Introduction

3.2Interosseous Ligament–Competent Wrist (Normal Wrist)

3.2.1Kinetic Effect of the Axial Loading on the Carpal Bones Alignment: How Does a Normal Carpus Adapt to the Axial Loading to Avoid Any Collapse?

3.2.2Kinetic Effect on the Carpal Bones Alignment of the Isometric Muscle Loading

3.3Scapholunate Joint Ligament–Deficient Wrist

3.3.1Kinetic Effect of the Axial Loading: How Does an SLL-Incompetent Carpus Adapt to the Axial Loading?

3.3.2Muscle Control of the Carpal Bones Alignment When the SLL Is Incompetent

3.4Lunotriquetral Joint Ligaments (LTqL) Deficient Wrist

3.4.1Kinetic Effect of the Axial Loading on the Carpal Bones Alignment: How Does a Deficient LTqL Carpus Adapt to the Axial Loading?

3.4.2Muscle Control of the Carpal Bones Alignment When the LTqj Ligaments Are Incompetent

3.5Volar Nondissociative Proximal Carpal Row Dysfunction Secondary to the Midcarpal and Dorsal Radiocarpal Ligaments Incompetence

3.5.1Normal Wrist Proximal Carpal Row Kinematics During Wrist Inclinations

3.5.2Proximal Carpal Row Kinematics During Wrist Radial/Ulnar Inclination When the Radial MC Ligaments Are Incompetent

3.5.3Muscular Control of the Volar Proximal Carpal Row Dyskinesia

References

4.Ligament Injury and Carpal Instability

Carlos Heras-Palou and Ezequiel Zaidenberg

4.1Introduction

4.2Ligament Tears

4.3Biomechanical Studies

4.4Carpal Instability

4.5Conclusions

References

5.Surgical Approaches to the Carpus

M. Rosa Morro-Marti and Manuel Llusa-Perez

5.1Introduction

5.2Dorsal Approach

5.2.1Skin and Subcutaneous

5.2.2Retinaculum

5.2.3Capsule

5.2.4Exposure

5.2.5Modifications

5.2.6Closure

5.3Volar Approach

5.3.1Skin Incision and Subcutaneous Tissue

5.3.2Retinaculum

5.3.3Capsule

5.3.4Modifications

5.3.5Closure

5.4Volar Approach to the Scaphoid

5.4.1Skin Incision and Subcutaneous Tissue . . .

5.4.2Deeper Dissection

5.4.3Capsulotomy

5.4.4Closure

5.5Dorsal Approach to the Scaphoid

5.5.1Skin Incision

5.5.2Retinaculum

5.5.3Capsule

5.5.4Exposure

5.5.5Closure

References

Section II: Assessment of the Wrist

6.Physical Examination of the Wrist.

Guillem Salva-Coll

6.1Medical History

6.2Inspection

6.3Palpation

6.4Range of Motion

6.5Specific Tests

6.5.1Scapholunate Dysfunction

6.5.2Lunotriquetral Instability

6.5.3Midcarpal Instability

6.6Other Specific Tests

6.6.1Hamate Hook Pull Test

References

7.Arthroscopic Examination of the Wrist

Fernando Corella, Jane Messina, Montserrat Ocampos, and Pietro Randelli

7.1Introduction

7.2Arthroscopic Portals and General Joint Exploration

7.2.1Radiocarpal Joint

7.2.2Midcarpal Joint

7.3Scapholunate

7.3.1Generalities and Normal Arthroscopic Anatomy

7.3.2Arthroscopic Pathological Exploration

7.3.3Arthroscopic Classifications

7.4Lunotriquetral

7.4.1Generalities and Normal Arthroscopic Anatomy

7.4.2Specific Pathological Evaluation

7.4.3Arthroscopic Classifications

7.5Extrinsic Ligaments

7.5.1Generalities and Normal Arthroscopic Anatomy

7.5.2Specific Pathological Evaluation and Arthroscopic Classification

7.6Conclusions

References

8.Imaging of the Wrist.

Luis Cerezal and Diogo Roriz

8.1Imaging Techniques

8.1.1Conventional Radiographs

8.1.2Fluoroscopy

8.1.3Ultrasound

8.1.4Computed Tomography

8.1.5Magnetic Resonance Imaging

8.2Imaging in Carpal Instability Dissociative

8.2.1Scapholunate Dissociation

8.2.2Lunotriquetral Dissociation

8.3Imaging in Carpal Instability Nondissociative

8.3.1Extrinsic Ligaments

8.4Conclusions

References

Section III: Scapholunate Injury and Instability

9.Scapholunate Ligament Injury Etiology and Classification

Alex Lluch, Ana Scott-Tennent, Mireia Esplugas, and Marc Garcia-Elias

9.1Introduction

9.2Natural History of Scapholunate Dysfunction

9.3Scapholunate Ligament Injury Pathomechanics

9.3.1Injury Mechanisms

9.3.2Associated Injuries to SLL Tears

9.4Scapholunate Ligament Injury Classifications

9.4.1Scapholunate Ligament Injury Classifications

9.4.2Stages of Scapholunate Joint Dysfunction

9.5Conclusion

References

10.The “4R” Algorithm of Treatment

Riccardo Luchetti and Fernando Corella

10.1Introduction

10.2Defining the Type and Stage of Injury Through the Arthroscopic Exploration

10.2.1Gap Between the Bones

10.2.2Acute vs Chronic

10.2.3Quality of the Ligament

10.2.4Dorsal Displacement of the Scaphoid

10.2.5Reducibility

10.2.6Combined Injuries

10.2.7Degenerative Changes

10.3Organizing the Treatments: The 4R

10.3.1Repair

10.3.2Reinforcement

10.3.3Reconstruction

10.3.4Resection

10.4Conclusion

References

11.Acute “R”epair: Open Treatment

Riccardo Luchetti, Sara Montanari, Andrea Atzei, and Frank Nienstedt

11.1Introduction

11.2Clinical Signs

11.3Instrumental Diagnostics

11.4Arthroscopy

11.5Traditional Surgical Technique

11.5.1Advantages and Limits of the Traditional Technique

11.6Preferred Method

11.7Discussion

References

12.Acute “R”epair: Arthroscopic Treatment

Vicente Carratalá Baixauli, Fernando Corella, Francisco J. Lucas García, Eva Guisasola Lerma, and Cristóbal Martínez Andrade

12.1Introduction

12.2Indications

12.3Technique

12.4Scapholunate Dorsal Capsuloligament Reattachment

12.4.1Step 1: Insertion of the Anchor and Ligamentous Suture

12.4.2Step 2: Dorsal Capsulodesis (Dorsal Capsular Reinforcement)

12.5Scapholunate Volar Capsuloligament Reattachment

12.5.1Step 1: Volar Portal Establishment

12.5.2Step 2: Anchor Placement

12.5.3Step 3: Capsuloligamentous Suture and Knotting

12.6Postoperative Period

12.7Discussion

12.8Conclusions

References

13.Chronic “R”einforcement (Capsulodesis): Open Treatment of Chronic

SL Injury Weston Ryan and Robert M. Szabo

13.1Introduction and Historical Perspective 120

13.1.1Scapholunate Injury Overview

13.1.2Overview of Open Surgical Techniques and Indications

13.2Capsulodesis: Literature Review and Surgical Considerations

13.3Author’s Preferred Technique; The Dorsal Intercarpal Ligament Capsulodesis

13.3.1Approach

13.3.2Scapholunate Reduction

13.3.3Dorsal Intercarpal Ligament Fixation

13.4Essential Rehabilitation Points

13.5Conclusion

References

14.Chronic “R”einforcement (Capsulodesis): Arthroscopic Scapholunate Repair

Max Haerle, Jean-Baptiste de Villeneuve Bargemon, Florian Lampert, and Lorenzo Merlini

14.1Introduction

14.2Indications

14.3Surgical Technique

14.3.1Classic Arthroscopic Repair

14.4Results

14.4.1Classic Arthroscopic Repair

14.4.2Arthroscopic Scapholunate Capsulodesis

14.5Discussion

14.6Conclusion

References

15.Chronic “R”econstruction (Ligamentoplasties): Open Treatment

Rupert Wharton and Mike Hayton

15.1Introduction

15.2Ligamentoplasties

15.2.1The Brunelli Procedure

15.2.2The Three-Ligament Tenodesis (3LT)

15.2.3Volar Scapholunate Ligament Reconstruction

15.2.4The 360 Tenodesis (SLITT)

15.3The Author’s Preferred Technique and Pitfalls

15.4Conclusion

References

16.Chronic “R”econstruction (Ligamentoplasties): Arthroscopic Treatment

Pak Cheong Ho and Jeffrey Justin Siu Cheong Koo

16.1Introduction and Historical Perspective 139

16.2Literature Review and Different Surgical Techniques

16.3Indications and Contraindications for Surgery

16.4Authors’ Preferred Technique

16.5Patient Preparation and Positioning

16.6Exploration of Radiocarpal Joint and Midcarpal Joint

16.7Taking-Down of Intra-Articular Fibrosis

16.8Identification of Scaphoid and Lunate Bone Tunnel Sites

16.9Correction of DISI Deformity

16.10Preparation of Lunate Bone Tunnel

16.11Preparation of Scaphoid Bone Tunnel

16.12Passing the Palmaris Longus Tendon Graft Through the Scaphoid and Lunate Bone Tunnel

16.13Assessment Through Midcarpal Joint Arthroscopy and Scapholunate Interval Reduction with Palmaris Longus Tendon Graft

16.14Closure and Postoperative Care

16.15Clinical Outcome

16.16Tips and Tricks

16.17Conclusion

References

17.Chronic “R”esection (Palliative): Open Salvage Surgery after SL Degeneration

Hermann Krimmer

17.1Introduction

17.1.1Carpal Collapse—SLAC Pattern

17.2Indication for Treatment

17.3Operative Procedures

17.3.1Denervation

17.3.2Proximal Row Carpectomy (PRC)

17.3.3Four-Corner Fusion

17.4Results

17.5Conclusion

References

18.Chronic “R”esection (Palliative): Arthroscopic Salvage Surgery after

Scapholunate Degeneration Eva-Maria Baur and Jean-Baptiste de Villeneuve Bargemon

18.1Introduction

18.2Styloidectomy

18.2.1Tips and Tricks

18.3Radiocarpal Interposition

18.3.1Tips and Tricks

18.4Scaphocapitate Arthrodesis

18.4.1Tips and Tricks

18.5Partial Arthrodesis

18.5.1Radioscapholunate Arthrodesis

18.5.2Intracarpal Arthrodesis

18.6First-Row Carpal Bone Resection

18.6.1Tips and Tricks

18.7Total Arthrodesis under Arthroscopy (SLAC 4)

18.8Authors’ Preferred Technique

18.9Conclusion

References

Section IV: Lunotriquetral Injury and Instability

19.Isolated Lunotriquetral Interosseous Ligament Ruptures

Teun Teunis, David Ring, Liron Duraku, and Marco J.P.F. Ritt

19.1Introduction

19.2Definition of the Key Concepts

19.3LTIL Rupture in Carpal Dislocations

19.3.1Consequences of LTIL Rupture

19.4Prevalence of Wrist Pain

19.4.1Prevalence of LTIL Variations

19.4.2The Association of LTIL Variations and Discomfort and Incapability

19.5Diagnosis and Treatment of LTIL Variations as the Cause of Wrist Pain

19.6Potential Harms Associated with the Concept of LTIL Variations as a Cause of Wrist Pain

References

20.Acute Management: Open Treatment of LT Injury and Instability

Lauren E. Dittman and Alexander Y. Shin

20.1Introduction and Historical Perspective

20.2Surgical Anatomy

20.3Indications and Contraindications for Surgery

20.4Literature Review and Different Surgical Techniques

20.4.1Debridement

20.4.2Direct Ligament Repair

20.4.3Ligament Reconstruction

20.4.4Arthrodesis

20.4.5Augmentation

20.5Authors’ Preferred Technique/Tips and Tricks

20.5.1Acute Lunotriquetral Ligament Repair vs Reconstruction with Distally Based Extensor Carpi Ulnaris Strip

20.5.2Tips and Tricks

20.6Essential Rehabilitation Points

20.7Conclusion

References

21.Chronic Injury Management of the LT Joint: Open Treatment

Thomas Pillukat, Martin Langer, and Jörg van Schoonhoven

21.5Classification

21.6Surgical Treatment

21.6.1Soft Tissue Procedures

21.6.2Lunotriquetral Fusion

21.6.3Radiolunate (RL) and Radioscapholunate (RSL) Fusion

21.6.4Total Wrist Fusion

21.6.5Wrist Denervation

21.7Literature Review

21.7.1Soft Tissue Procedures

21.7.2Lunotriquetral Fusion

21.7.3Salvage Procedures

21.8Authors’ Preferred Technique

21.8.1Ligament Reconstruction

21.8.2Postoperative Treatment

21.8.3Tips and Tricks

21.8.4Lunotriquetral Fusion

21.8.5RL/RSL Fusion

21.8.6Midcarpal and Total Wrist Fusion

21.8.7Wrist Denervation

21.9Conclusion

References

22.Acute and Chronic Management of LT Ligament Injury: Arthroscopic

Treatment Jan Ragnar Haugstvedt and István Zoltán Rigó

22.1Introduction

22.2Acute Injury

22.3Acute Management

22.4Subacute Management

22.5Chronic Management

22.5.1Ligament Reconstruction

22.5.2Arthrodesis

References

23.LT Ligament Injury (Disorders) and Instability Associated to Ulnocarpal

Abutment Syndrome: Ulnar-Shortening Osteotomy Toshiyasu Nakamura

23.1Ulnocarpal Abutment Syndrome

23.2Lunotriquetral Ligament (LT) Injury

23.3Symptom of the LT Ligament Injury with the Ulnocarpal Abutment Syndrome

23.4Diagnosis of the LT Injury with Ulnocarpal Abutment Syndrome

23.5Treatments

23.5.1Conservative Treatment

23.5.2Surgical Treatment

References

Section V: Extrinsic Ligament Injuries

24.Perilunate Injuries

Bo Liu and Feiran Wu

24.1Introduction

24.2Classification

24.3Assessment and Investigations

24.4Treatment

24.4.1Perilunate Dislocations

24.4.2Perilunate Fracture Dislocations

24.4.3Postoperative Care

24.5Clinical Results

24.6Conclusion

References

25.Perilunate Injuries Non-Dislocated

Guillaume Herzberg, Marion Burnier, and Lyliane Ly

25.1Introduction

25.2Acute PLIND Cases

25.3Chronic PLIND Cases

25.4Discussion

References

26.Axial Carpal Dislocations and Fracture Dislocations

Alex Lluch, Ana Scott-Tennent, Mireia Esplugas, and Marc Garcia-Elias

26.1Introduction

26.1.1Mechanism of Injury

26.1.2Historical Perspective and Classification

26.2Indications and Contraindications for Surgery

26.3Literature Review and Different Surgical Treatment

26.4Essential Rehabilitation Points

26.5Conclusion

References

27.Classification and Treatment of Nondissociative Proximal Row Instability

Andrea Atzei, Riccardo Luchetti, Pedro J. Delgado, and Carlos Heras-Palou

27.1Introduction and Historical Perspective

27.2Kinematic Dysfunction of the Unstable Proximal Row

27.3Classification of Proximal Row Instability

27.4Clinical Presentation of Proximal Row Instability

27.4.1Physical Examination

27.4.2Advanced Investigations

27.5Options of Treatment for Proximal Row Instability.

27.5.1Treatment of Volar Proximal Row Instability (V-PRI)

27.5.2Treatment of Dorsal Proximal Row Instability (D-PRI)

27.5.3Treatment of Combined Proximal Row Instability (C-PRI)

27.6Conclusions

References

Section VI: Other Injuries

28.Ligament Injuries Associated to Distal Radius Fractures

Tommy R. Lindau

28.1Introduction

28.2Indications for Arthroscopy

28.2.1The Arthroscopic Procedure—“Dry” or Wet?

28.2.2The Arthroscopic Procedure—Arthroscopic Assessment

28.2.3Triangular Fibrocartilage Complex (TFCC) Injuries

28.2.4Intercarpal Ligament Injuries

28.2.5Scapholunate (SL) Ligament Injuries

28.2.6Lunotriquetral (LT) Ligament Injuries

28.2.7Chondral Lesions

28.3Outcomes

28.4Conclusion

References

29.Pisotriquetral Instability

Eduardo R. Zancolli III

29.1Introduction

29.2The Underwater Part of the Iceberg: Three Components

29.2.1The Whole Territory of the Ulnar Side

29.2.2Biomechanics: Need of New Biomechanical Considerations

29.2.3Grades of Instability

29.3Anatomy

29.4Symptoms

29.5Physical Examination

29.6Imaging Studies

29.7Pathology and Classification

29.8Treatment

29.9Surgical Technique

29.10Postoperative

29.11Discussion

29.12Conclusion

References

Index

Videos

Video 7.1

Arthroscopic view of the radiocarpal joint.

Video 7.2

Arthroscopic view of the midcarpal joint.

Video 7.3

Acute and chronic injury of the SL ligament.

Video 7.4

Hook test to assess the dorsal portion of the SL ligament.

Video 7.5

Arthroscopic scaphoid 3D test.

Video 7.6

Reducibility of the scaphoid.

Video 7.7

The “rocking chair sign.”

Video 7.8

EWAS classification of SL ligament tears.

Video 7.9

View of the LT ligament through the 6R portal.

Video 7.10

Arthroscopic ballottement test of the LT ligament.

Video 7.11

Arthroscopic classification of LT ligament tears.

Video 11.1

Scapholunate repair and reinforcement.

Video 12.1

Arthroscopic volar capusloligament reattachment: surgical technique.

Video 13.1

Dorsal intercarpal ligament capsulodesis.

Video 17.1

Four corner fusion with circular plate.

Video 20.1

Lunotriquetral ligament repair and reconstruction.

Video 22.1

This video shows an acute injury of the carpus. The first part shows changes in the SL interval where a probe can be inserted, however not twisted. Over the LT interval there is a widening, and the dorsal part of the LT interval shows signs of an acute injury. (Copyright Jan Ragnar Haugstvedt.)

Video 22.2

The trocar is used to reduce the LT interval. The trocar is kept in the right position till the K-wires are drilled across the LT joint. At the end of the video some bubbles come up from the interval as the K-wires are crossing. The trocar can be moved and the LT interval has been reduced. (Copyright Jan Ragnar Haugstvedt.)

Video 22.3

Testing of an old injury of the carpus. The traction is reduced. The SL interval is stable, may be some rotation of the lunate, however, there is widening of the LT interval and the triquetrum could be moved from the lunate. This is found to be an isolated LT ligament lesion. (Copyright Jan Ragnar Haugstvedt.)

Video 22.4

When drilling the guidewire through the lunate, we use a needle to find the best entry point. This could be checked from either the 1-2 portal or from the 6-R portal. We can keep the needle in place while the wire is drilled through the lunate aiming for the pisiform. (Copyright Jan Ragnar Haugstvedt.)

Video 22.5

The graft is out of the lunate, and we pull the graft to have a tight reconstruction. (Copyright Jan Ragnar Haugstvedt.)

Video 22.6

From the midcarpal joint we can view the LT interval while pulling the graft to see if the LT joint has been reduced and stabilized. (Copyright Jan Ragnar Haugstvedt.)

Video 22.7

This video shows an animation of the arthroscopic assisted LT lig procedure. It starts with harvesting one half of the ECU tendon. Then a guidewire is drilled through the lunate and when the position is good a 2.8 mm hole is drilled. A guide is placed in the hole in lunate, the guide is used to drill a second hole through the triquetrum. The tendon graft is then pulled through the bones using a tendon shuttle and we perform fixation of the graft using interference screws. Outside the capsule, the graft is then brought back to triquetrum where then tendon graft is sutured back to the ECU tendon. The reconstruction is finalized by reconstructing the DRC ligament. (Copyright Jan Ragnar Haugstvedt.)

Video 22.8

In a patient with coalition, we don’t expect any motion across the LT interval. This video displays synovitis and motion in the joint that should have been stable. We find these changes to be signa of instability after a trauma. The patient complains of pain and in these special, seldom cases, we perform arthrodesis. (Copyright Jan Ragnar Haugstvedt.)

Video 22.9

After having resected the dorsal part of the LT joint, grafted bone into the resected part of the joint and have performed osteosynthesis to stabilize the joint, we check the stability from the midcarpal joint. (Copyright Jan Ragnar Haugstvedt.)

Video 26.1

Arthroscopically assisted reduction and fixation in an axial carpal dislocation. (Courtesy Dr. Fernando Corella and Dr. Montserrat Ocampos.)

Preface

Despite incredible advances in the field of wrist surgery, the assessment and management of wrist dysfunctions remain demanding tasks. History taking and clinical examination are still essential for diagnosis, confirmed and staged by imaging including radiographs, computed tomography scans, and magnetic resonance imaging, with or without contrast. Wrist arthroscopy has a well-established role in diagnosis and staging of wrist conditions, and an expanding role in therapeutic procedures.

The fast pace of growth of our knowledge of the precise anatomy and function of the wrist creates new and better treatments for our patients. Our understanding of proprioception is changing the options in conservative management of many wrist disorders and can prevent unnecessary surgery. The rehabilitation for our patients is developing and improving, with more and better protocols that are becoming evidence based.

Understanding detailed anatomy of the wrist allows us to have a better grasp of the mechanics of the wrist and stimulates the imagination of surgeons to improve some existing techniques and describe some new ones. In our careers, we have seen the standard treatment for most wrist conditions change several times; this will continue. Our clinical practice must keep up to date with advancements.

Wrist surgery is still a confusing field for surgeons and therapists, even more so for trainees trying to make sense of the myriad of treatments available. There are three reasons for this: first, the anatomy and mechanics are complicated; second, the semantics we use are misleading; and third, the dearth of published solid clinical outcomes and lack of high quality prospective clinical studies.

In this book we have tried to throw some light on the basic sciences as well as the management of wrist conditions, and for that we have brought together an amazing group of experts from all over the world who have shared their vast experience and knowledge. We are extremely grateful to all of them.

As the field of wrist surgery evolves, some treatments become obsolete and others turn into the standard of care. With this book we have tried to provide an update on ligament injuries of the wrist and the assessment and management of wrist instability. As a community of surgeons, it is important that we continue learning, improving, and innovating. We still have a lot to discover; everything is there to be done and everything is possible.

Fernando Corella, PhD

Carlos Heras-Palou, MD, FRCS (Tr & Orth)

Riccardo Luchetti, MD

Contributors

Cristóbal Martínez Andrade, MD

Hand and Upper Limb Unit

Hospital Quirónsalud Valencia

Valencia, Spain

Andrea Atzei, MD

Pro-Mano, Hand Surgery and Rehabilitation

Treviso, Italy

Vicente Carratalá Baixauli, MD

Hand and Upper Limb Unit

Hospital Quirónsalud Valencia

Valencia, Spain

Jean-Baptiste de Villeneuve Bargemon, MD

Hand and Limb Reconstructive Surgery

AP-HM Hospital de la Timone

Marseille, France

Eva-Maria Baur, MD

Practice

Department for Plastic and Hand Surgery Murnau

Penzberg, Germany

Marion Burnier, MD

Wrist Surgery Unit

Department of Orthopaedics

Claude-Bernard Lyon 1 University

Herriot Hospital

Lyon, France

Luis Cerezal, MD, PhD

Diagnóstico Médico Cantabria (DMC)

Santander, Spain

Jonathan P. Compson, MBBS, BSc, FRCS (Orth)

Consultant Orthopaedic Surgeon

Orthopaedic Department

King’s College Hospital

London, UK

Fernando Corella, PhD

Associate Professor

Department of Surgery

Complutense University of Madrid;

Hand Surgeon

Wrist and Hand Unit

Traumatology Service, University Hospital Quirónsalud Madrid

Madrid, Spain

Pedro J. Delgado, MD

Head of Orthopaedic Surgery and Traumatology Department

Head of Hand Surgery and Microsurgery Unit

Hospital Universitario HM Montepríncipe

Hospital Universitario HM Nuevo Belén;

Associate Professor of Orthopaedics

Universidad San Pablo CEU College of Medicine

Madrid, Spain

Lauren E. Dittman, MD

Resident

Department of Orthopaedic Surgery

Mayo Clinic

Rochester, Minnesota, USA

Liron Duraku, MD

Fellow

The Peripheral Nerve Injury Service

University Hospitals Birmingham NHS Foundation Trust

Birmingham, UK;

Plastic, Reconstructive and Hand Surgery Department

Amsterdam University Medical Center

Amsterdam, The Netherlands

Mireia Esplugas, MD

Institut Kaplan

Barcelona, Spain

Francisco J. Lucas García, MD

Hand and Upper Limb Unit

Hospital Quirónsalud Valencia

Valencia, Spain

Marc Garcia-Elias, MD, PhD

Institut Kaplan

Barcelona, Spain

Max Haerle, MD, PhD

Professor

Director of Hand and Plastic Surgery Department

Orthopädische Klinik Markgröningen

Markgröningen, Germany

Elisabet Hagert, MD, PhD

Aspetar Orthopedic and Sports Medicine Hospital

Doha, Qatar;

Department of Clinical Science and Education

Karolinska Institutet

Stockholm, Sweden

Jan Ragnar Haugstvedt, MD, PhD

Senior Consultant

Østfold Hospital Trust

Moss, Norway

Oslo Hand Center

Oslo, Norway

Mike Hayton, Bsc (Hons), MBChB, FRCS (Trauma and Orth), FFSEM (UK)

Consultant Orthopaedic Hand Surgeon

Wrightington Hospital

Lancashire, UK

Carlos Heras-Palou, MD, FRCS (Tr & Orth)

Consultant Hand and Wrist Surgeon

Pulvertaft Hand Centre

Royal Derby Hospital

Derby, UK

Guillaume Herzberg, MD, PhD

Professor of Orthopaedic Surgery

Lyon Claude Bernard University

Herriot Hospital

Lyon, France

Pak Cheong Ho, MBBS, FRCS (Edinburgh), FHKAM (Orthopaedic Surgery), FHKCOS

Chief of Service

Department of Orthopaedic & Traumatology

Prince of Wales Hospital

Chinese University of Hong Kong

Hong Kong SAR

Jeffrey Justin Siu Cheong Koo, MBBS (HK), FHKCOS, FHKAM (Orthopaedic Surgery), FRCSEd (Orth), MHSM (New South Wales), MScSMHS (CUHK)

Associate Consultant (Orthopaedics Traumatology)

Department of Orthopaedics & Traumatology

Alice Ho Miu Ling Nethersole Hospital

Tai Po, Hong Kong

Hermann Krimmer, MD, PhD

Professor

Hand Center

Ravensburg, Germany

Florian Lampert, PD, MD

Senior Consultant

Orthopädische Klinik Markgröningen

Markgröningen, Germany

Martin Langer, MD

Professor

Department of Traumatology and Hand Surgery

University Clinic Münster

Münster, Germany

Eva Guisasola Lerma, MD

Hand and Upper Limb Unit

Hospital Quirónsalud Valencia

Valencia, Spain

Tommy R. Lindau, MD, PhD (Hand Surgery)

Professor

Consultant Hand Surgeon

Pulvertaft Hand Centre

Derby, UK;

Past President, European Wrist Arthroscopy Society (EWAS)

Bo Liu, MD

Department of Hand Surgery

Beijing Jishuitan Hospital

Peking University

Beijing, China

Alex Lluch, MD

Institut Kaplan;

Hand & Wrist Unit, Orthopaedics Department

Vall d’Hebron University Hospital

Barcelona, Spain

Manuel Llusa-Perez, MD, PhD

Full Professor

Department of Human Anatomy, Faculty of Medicine

University of Barcelona;

Orthopaedic SurgeonDepartment of Orthopaedic SurgeryHospital Vall d’HebronBarcelona, Spain

Riccardo Luchetti, MD

Private Practice Hand Surgeon

Rimini Hand Surgery and Rehabilitation Center

Rimini, Italy

Lyliane Ly, MD

Department of Orthopedic Surgery of the Upper Limb–SOS mains

Edouard Herriot Hospital

Lyon, France

Lorenzo Merlini, MD

International Wrist Center

Institut de la Main

Paris, France

Jane Messina, MD, PhD

ASST Gaetano Pini-CTO Orthopaedic Institute

Milan, Italy

Sara Montanari, MD

Rimini Hand Surgery and Rehabilitation Center

Rimini, Italy

M. Rosa Morro-Marti, MD, PhD

Associate Professor

Department of Human Anatomy, Faculty of Medicine

University of Barcelona;

Orthopaedic Surgeon

Department of Orthopaedic Surgery 

Hospital Vall d’Hebron

Barcelona, Spain

Toshiyasu Nakamura, MD, PhD

Professor

Department of Orthopaedic Surgery

School of Medicine

International University of Health and Welfare

Tokyo, Japan

Frank Nienstedt, MD

Center for Surgery St. Anna

Merano, Italy

Montserrat Ocampos, PhD

Department of Orthopedics and Trauma

Hospital Universitario Infanta Leonor

Madrid, Spain

Thomas Pillukat, MD, PhD

Clinic for Hand Surgery

Rhön Klinikum AG

Bad Neustadt an der Saale, Germany

Pietro Randelli, MD

Professor of Trauma and Orthopaedic Surgery

Università degli Studi di Milano;

Direttore Scientiffico

Instituto Orthopedico Gaetano PiniMilan UniversityMilan, Italy

Susanne Rein, MD, PhD, MBA

Department of Plastic and Hand Surgery, Burn Unit

Hospital Sankt Georg

Leipzig, Germany;

Martin-Luther-University Halle-Wittenberg

Halle, Germany

István Zoltán Rigó, MD, PhD

Østfold Hospital Trust

Moss, Norway

Oslo Hand Center

Oslo, Norway

David Ring, MD

Professor

Dell Medical School

The University of Texas at Austin

Austin, Texas, USA

Marco J.P.F. Ritt, MD

Professor

Plastic, Reconstructive and Hand Surgery Department

Amsterdam University Medical Center

Amsterdam, The Netherlands

Diogo Roriz, MD

JCC Diagnostic Imaging

Viana do Castelo, Portugal

Weston Ryan, MD

Orthopaedic Surgery Resident

Department of Orthopaedics

University of California, Davis School of Medicine

Sacramento, California

Guillem Salva-Coll, MD, PhD

Hand Surgery Unit, Orthopaedics Department

Hospital Universitari Son Espases;

IBACMA Hand Surgery Institute

Palma de Mallorca, Spain

Ana Scott-Tennent, MD

Upper Limb Unit, Trauma & Orthopedics Department

Arnau de Vilanova University Hospital

Lleida, Spain

Alexander Y. Shin, MD

Orthopedic Surgery

Mayo Clinic

Rochester, Minnesota, USA

Robert M. Szabo, MD, MPH

Distinguished Professor of Orthopaedics and Plastic Surgery

Department of Orthopaedics

University of California, Davis School of Medicine

Sacramento, California

Teun Teunis, MD

Assistant Professor

Department of Plastic Surgery

University Pittsburgh Medical Center

Pittsburgh, Pennsylvania, USA

Jörg van Schoonhoven, MD

Professor and Senior Consultant

Clinic for Hand Surgery

Rhön Klinikum AG

Bad Neustadt an der Saale, Germany

Rupert Wharton, BM, BSc, FRCS (Tr and Orth), Dip Hand Surg (Br and Eur)

Locum Consultant Trauma and Orthopaedic Surgeon

Kingston Hospital NHS Foundation Trust

Kingston, UK

Feiran Wu, MD

Birmingham Hand Centre

Queen Elizabeth Hospital

University Hospitals Birmingham

Birmingham, UK

Ezequiel Zaidenberg, MD

Consultant Hand and Wrist Surgeon

Sanatorio Otamendi

Buenos Aires, Argentina

Frantzeska Zampeli, MD, PhD

Hand-Upper Limb-Microsurgery Department

General Hospital “KAT”

Athens, Greece;

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Eduardo R. Zancolli III, MD

Professor in Hand Surgery

Argentine Association for Hand Surgery Specialists’ Career

Buenos Aires, Argentina;

Past President, Southamerican Federation for Surgery of the Hand

Past President, Argentine Association for Surgery of the Hand

President, 13th Triennial Congress of the IFSSH 2016

Section I

Anatomy and Biomechanics

1Anatomy and Histology of Wrist Ligaments

2Biomechanics of the Wrist

3Role of Muscles in Wrist Stabilization and Clinical Implications

4Ligament Injury and Carpal Instability

5Surgical Approaches to the Carpus

1 Anatomy and Histology of Wrist Ligaments

Elisabet Hagert, Frantzeska Zampeli, and Susanne Rein

Abstract

A thorough appreciation of the anatomy and histology of wrist ligaments is the foundation to understand wrist biomechanics and the effects of trauma on wrist function. Wrist ligaments are divided into extra- and intracapsular ligaments, as well as extrinsic, connecting the forearm and the carpus, or intrinsic, connecting bones within the carpus, ligaments. The extrinsic ligaments of the wrist are: the volar radiocarpal, the volar ulnocarpal, and the dorsal radiocarpal ligaments. The intrinsic ligaments consist of the volar and dorsal midcarpal ligaments and the proximal and distal intercarpal ligaments. Ligaments generally have three main functions: (1) to provide passive mechanical stability to joints, thus guiding joints through their normal range of motion when tensile or compressive loads are applied; (2) viscoelasticity, which helps in preserving joint homeostasis; and (3) sensory function, where ligaments are recognized as sensory organs, capable of monitoring and supplying afferent kinesthetic and proprioceptive information. The principal function of a ligament is reflected in its histology, through varied contents of collagen and elastic fibers, as well as presence or absence of innervation. This chapter provides a review of wrist ligament anatomy and histology, with accompanying imaging of all wrist ligaments and microscopic imaging of different histology types.

Keywords: anatomy, carpus, histology, ligaments, wrist

1.1 Wrist Ligaments: Overview of Anatomy and Histology

1.1.1 Anatomy Overview

Wrist ligaments can be described according to their relation with the joint capsule. Three extracapsular ligaments are located outside the wrist capsule: (1) the transverse carpal ligament, (2) the pisohamate, and (3) the pisometacarpal ligaments. The majority of wrist ligaments are intracapsular or intra-articular. Intra-articular ligaments, those found entirely within the joint cavity, are distinguished from the intracapsular ligaments, ligaments composing, in part, the joint capsule, by the degree of coverage by a thin layer of synovial tissue, called synovial stratum. Intra-articular ligaments are covered entirely by synovial stratum, whereas intracapsular ligaments have the synovial stratum only on their deep or joint surface. Depending on which articulations are being linked, these ligaments have been classified as extrinsic or intrinsic.

Extrinsic ligaments originate from the distal epiphyses of forearm bones and insert on the carpal bones, while intrinsic ligaments have their origin and insertion on carpal bones, either of different (midcarpal ligaments) or the same row (intercarpal or interossei ligaments). Different histology of these ligaments accounts for different elastic properties and modes of failure. Extrinsic ligaments mainly insert on bones, are longer, more elastic, and less resistant to tension traction, i.e., lower yield strength, as compared to most intrinsic ligaments, and sustain more midsubstance ruptures rather than avulsions. On the contrary, intrinsic ligaments insert mostly on cartilage and are more frequently avulsed than ruptured. Interossei ligaments show similar failure pattern and are the shortest and stiffest of all ligament types1,3 (▶Fig. 1.1).

Fig. 1.1 Carpal ligament system. The carpal ligament system is shown, dividing them into extra- and intracapsular ligaments. The latter are subdivided into extrinsic and intrinsic ligaments. CH, capitate-hamate ligament; DIC, dorsal intercarpal ligament; DRC, dorsal radiocarpal ligament; LRL, long radiolunate ligament; LT, lunotriquetral; LTIL, lunotriquetral interosseous ligament; PH, pisotriquetral; PT, pisohamate; RSC, radioscaphocapitate; RSL, radioscapholunate; SC, scaphocapitate; SL, scapholunate; SRL, short radiolunate ligament; STT, scapho-trapezial-trapezoidal ligament; TC, trapezocapitate ligament; TqC, triquetrocapitate ligament; TqH, triquetrohamate ligament; TT, trapezial-trapezoidal ligament; UC, ulnocapitate ligament; UL, ulnolunate ligament; UTq, ulnotriquetral ligament.

1.1.2 Histology Overview

The morphology of connective tissue components reflects their biomechanical functions, and histology may thus offer insight into their biomechanical functions and significance in wrist stability. In addition, knowledge of ligament structure is important for the reconstruction of injured ligaments in order to choose a similar substitute graft.4

Ligaments generally have three main functions: (1) to provide passive mechanical stability to joints, thus guiding joints through their normal range of motion when tensile or compressive loads are applied; (2) viscoelasticity, which helps in preserving joint homeostasis, which means that intraligamentous tension decreases if constant ligamentous deformation is applied and “creep” occurs as a result of elongation under a constant or cyclically repetitive load; and (3) sensory function, where ligaments are recognized as sensory organs, capable of monitoring and supplying afferent kinesthetic and proprioceptive data.5,6,7,8

The surface of ligaments is often covered up to the periosteum by a well-vascularized and innervated layer, the epiligament or epifascicular region (▶Fig. 1.2a).6,9,10 The arrangement of the collagen fibers reveals interlaced connective tissue types on the one hand and parallel-fibered tight connective tissue types on the other. In densely packed, interlaced, connective tissues, the collagen fibers run as tightly interwoven, parallel, and slightly wavy bundles. The course of the ligamentous collagen fibers is examined through polarized microscopy, which enables to distinguish between parallel and interlacing collagen fiber course (▶Fig. 1.3b, h).6,11,12 If the collagen fibers are arranged crosswise/interlaced or spirally with alternating sense of rotation, i.e., in scissors lattice order, the ribbon adapts to the changing shape of its content according to a stocking by changing the mesh lattice angle. Under the polarizing microscope, collagen fibers appear anisotropic, are positively uniaxially birefringent, and therefore light up in the diagonal between crossed polars (▶Fig. 1.3b).6,12,13

Fig. 1.2 Densely packed parallel collagen bundles. The densely packed parallel collagen fiber structure of an ulnocarpal ligament is shown in the hematoxylin-eosin staining (a,b) in the transmission (a) and polarization mode (b). The epifascicular region (black two-sided arrow in a), which contains nerves and blood vessels, is clearly distinguishable from the fascicular region (white two-sided arrow in a). The wavelike structure (white arrows in b) enables distension during tensile loads. This feature, as well as the absence of interstitial septa and elastic fibers in the fascicular region, indicates resistance to high tensile forces. Elastic fibers are analyzed in the Elastica van Gieson staining (c–e). No elastic fibers are visible in the overview magnification (c). Elastic fibers are seen in the epifascicular region in the high-power field analysis (e, arrows). In contrast, there are no elastic fibers in the fascicular region (d). Scale bar: 1000 µm (a–c), 100 µm (d,e). Original magnification: 40 × (a–c), 400 × (d,e).

Fig. 1.3 Structural topography of the lunotriquetral ligament. A comparative histological analysis of the collagenous fiber arrangement of the dorsal (a–e) and volar (f–j) lunotriquetral ligament (dLT, vLT) is shown in the hematoxylin-eosin staining (a,b,f,g) in transmission (a,f) and polarization mode (b,g). While the vLT has a densely packed parallel structure (f,g), the dLT has a densely packed interlaced structure (a,b), reflecting the high range of movement occurring in the triquetrum during wrist motion. The densely packed parallel collagenous structure of the vLT (arrow in g) indicates mainly unidirectional tensile forces. No elastic fibers are seen in the overview magnification (c,h) or in the high-power field (d,e,i,j). Absence of elastic fibers in both vLT/dLT indicates high resistance and less elasticity, pointing out the important mechanical function of the lunotriquetral ligament. Scale bar: 1000 µm (a,b,c,f,g,h), 100 µm (d,e,i,j). Original magnification: 20 × (f,g), 40 × (a,b,c,h), 400 × (d,e,i,j).

Depending on the ligament type, loose interstitial connective tissue runs through the collagenous bundles. This tissue can contain nerves, vessels, and even immunocompetent cells, and thus it serves as a water reservoir and displacement layer. Therefore it is important for defense and regeneration processes.6

Furthermore, an undulating collagen fiber course indicates that a ligament can be lengthened without injuring it while applying tension.14 Collagen fibers can be stretched by about 5% and, due to their slightly wavelike arrangement in the connective tissue, can be lengthened by about 3%.15 The undulating collagen fiber course is generated by the molecular structure of the collagen fibers, which can withstand a tensile force of about 6 kg/mm2 cross-section. If a stronger tension is applied, it leads to irreversible elongation by 10% and ultimately to the rupture of the ligament.15,16

Crimps in ligaments are composed of parallel, densely packed, collagen fibrils that suddenly change direction in the region of the top angle of each crimp forming 3D special local arrays described as fibrillar crimps. The fibrillar crimps are thought to be the microscopic structure responsible for the mechanical functions of crimps in absorbing/transmitting loads and recoiling of collagen fibers in tendons and ligaments.17 Crimping makes collagen fibers highly extensible under low tension, protecting them from tearing.18 The angle of collagen crimping defines its properties for resisting tensile forces and viscoelasticity.19,20 Therefore, the crimping of collagen fibers of the joint capsule or ligaments plays a crucial role in viscoelasticity of the joints. ▶Table 1.1 gives a clear overview of the structural collagenous composition in wrist ligaments.

Table 1.1 Wrist ligaments assigned to the morphological types of collagen ligaments structure

Features

Ligament composition

Densely packed

Mixed tight and loose

Parallel

Interlaced

Parallel

Interlaced

Course of collagen fiber bundles

Tightly packed, unidirectional, and parallel

Tightly packed, multidirectional

Loosely packed, parallel

Loosely packed, multidirectional, interrupted by loose connective tissue

Loose connective tissue

In thin septa at the ligamentous insertion

Mainly not

Between collagen fiber bundles throughout the structure

Between collagen fiber bundles throughout the structure

Wrist ligaments

DIC, DRC, dSL, CH, TC, TT, UC, RSC, LRL, SRL, vLT, LTIL

dLT, STT, UTq, UL, vSL

TqC, TqH

–

Abbreviations: CH, capitate-hamate ligament; DIC, dorsal intercarpal ligament; DRC, dorsal radiocarpal ligament; dLT, lunotriquetral ligament, dorsal part; dSL, scapholunate ligament, dorsal part; LRL, long radiolunate ligament; LTIL, lunotriquetral interosseous ligament; RSC, radioscaphocapitate; SRL, short radiolunate ligament; STT, scapho-trapezial-trapezoidal ligament; TC, trapezocapitate ligament; TqC, triquetrocapitate ligament; TqH, triquetrohamate ligament; TT, trapezial-trapezoidal ligament; UC, ulnocapitate ligament; UL, ulnolunate ligament; UTq, ulnotriquetral ligament; vLT, lunotriquetral ligament, volar part; vSL, scapholunate ligament, volar part.

The distribution of elastic fibers in the tissue reflects its function.21 The variability of elastic fiber densities implicates the different adaptability of structures against strain.22 Elastic fibers lie as accompanying structures of the collagen fibers in the interstitial connective tissue and usually have a netlike structure. The elastic fiber arrangement contributes to the tissue architecture and allows passive contraction to the retraction to the original size after mechanical stress exposure.5 Elastic fibers serve to rearrange collagen after stretching a ligament or skin.5,23

By applying a tensile force of approximately 20 kg/cm2 cross-section, the reversibly highly stretchable elastic fiber networks can be lengthened up to 150%.15

The distribution of elastic fibers depends on the age and the mechanical stress of the respective ligament.24,25

The amount of elastic fibers in the fascicular collagenous tissue and its surrounding loose epifascicular connective tissue can be analyzed with the Elastica van Gieson staining. The quantity of elastic fibers is classified as many, few, or none. Many fibers lie in thick bundles and are visible with an overview magnification of 40 × under the microscope. Thin, single fibers are only detectable in the high-power field (400 ×), which are classified as “few elastic fibers.” Ligaments with no elastic fibers appear neither in the 40 × nor in the 400 × magnification (▶Fig. 1.2d, ▶Fig. 1.3e, f, i, j).11,13,26 Nearly no elastic fibers are found in the fascicular region of carpal ligaments (DIC, dSL, dLT, CH, TC, STT, TT, UC, UTq, RSC, LRL, SRL, TqC, TqH, vLT, vSL, LTIL). In addition, elastic fibers are observed only occasionally in the epifascicular region of carpal ligaments (DRC, CH, STT, UC, RSC, SRL, TqH, vSL, LTIL). This indicates that the carpal ligaments have low stretching capacity but high resistance against tensile forces.

1.2 Extrinsic Ligaments

1.2.1 Anatomy

Extrinsic ligaments consist of three groups: (1) the volar radiocarpal ligaments, (2) the volar ulnocarpal ligaments, and (3) the dorsal radiocarpal ligament.

1.2.2 Volar Radiocarpal Ligaments

The volar radiocarpal ligaments originate from the volar rim of the distal radius and include, radially to ulnarly, the radioscaphocapitate (RSC), long and short radiolunate ligaments (LRL and SRL). The radioscapholunate (RSL) ligament of Testut-Kuentz that lies between LRL and SRL is a bundle of loose connective tissue including nutrient vessels to the volar corner of the proximal pole of the scaphoid, rather than a true ligament (▶Fig. 1.4, ▶Fig. 1.5).

Fig. 1.4 View of the volar extrinsic and volar triquetral ligaments of the wrist. The extrinsic ligaments are the radio-scapho-capitate (RSC), the long radiolunate (LRL), and the short radiolunate (SRL) ligaments. The volar triquetral ligaments include the ulnotriquetral (UTq) and triquetro-hamate-capitate (TqHC) ligaments. C, capitate; L, lunate; P, pisotriquetral articular surface; R, radius; S, scaphoid; U, ulna.

Fig. 1.5 Radiovolar view of the volar wrist ligaments. C, capitate; HH, hook of hamate; L, lunate; LRL, long radiolunate; LTIL, lunotriquetral interosseous ligament; P, pisotriquetral articular surface; R, radius; RSC, radioscaphocapitate; S, scaphoid; SRL, short radiolunate; T, triquetrum; TqC, triquetrocapitate; TqH, triquetrohamate; U, ulna.

The RSC has a broad origin that extends from the tip of radial styloid to the middle of scaphoid fossa. It courses distally and obliquely and its fibers display multiple attachments: onto the proximal part of distal scaphoid pole, to the waist of scaphoid, onto the palmar cortex of capitate body, and finally passing around the distal lunate to merge with fibers from the ulnocapitate, triquetrocapitate, and palmar scaphotriquetral ligaments to form the arcuate ligament. With its course around the palmar concavity of the scaphoid, the RSC forms a sling over which the scaphoid rotates (▶Fig. 1.6).

Fig. 1.6 Radial view of the scapho-trapezial-trapezoidal (STT) ligament, in particular the scaphoid-trapezium ligament. Note how the radioscaphocapitate (RSC) ligament curves around the volar scaphoid. L, lunate; LRL, long radiolunate ligament; RS, radius styloid; S, scaphoid; Tz, trapezium.

The LRL is an intracapsular ligament that originates from the volar rim of the remaining aspect of the scaphoid fossa, courses obliquely anteriorly to the proximal pole of the scaphoid, and inserts on the radial volar surface of the lunate. The diverging RSC and LRL ligaments are separated by the “interligamentous sulcus,” the so-called space of Poirier, a weak zone of the joint capsule with clinical importance in perilunate dislocations.

The RSL lacks true mechanical and histological characteristics of a ligament. It carries small caliber vessels and nerves and travels with a dorsally oriented course, piercing the volar radiocarpal capsule to insert on the interosseous scapholunate ligament.

The most ulnarly located of the volar radiocarpal ligaments, the SRL, originates from the volar rim of the lunate fossa region of the distal radius and has a longitudinal orientation to its insertion on the radial half of the volar lunate. The LRL and SRL form a strong connection of the lunate to the distal radius.

1.2.3 Volar Ulnocarpal Ligaments

There are three volar ulnocarpal ligaments that span the ulnocarpal space palmarly and ulnarly: one superficial (ulnocapitate, UC) and two deep (ulnotriquetral, UTq; ulnolunate, UL) (▶Fig. 1.4, ▶Fig. 1.7).

Fig. 1.7 A dorsoulnar view of the ulnocarpal joint, illustrating the relationship between the ulnocarpal ligaments and the dorsal radiocarpal (DRC) ligaments. DRUL, dorsal radioulnar ligament; L, lunate; R, radius; S, scaphoid; T, triquetrum; U, ulna.

The UC ligament originates from the fovea of the ulnar head. It courses distally and attaches to the volar region of the lunotriquetral interosseous ligament (LTIL); few fibers attach to the capitate body after blending with fibers of the triquetro-hamate-capitate (TqHC) ligament, while the majority of fibers converge with the fibers of the RSC forming the “arcuate” ligament. The UC serves as an ulnar anchor for the wrist.

The UL and UTq ligaments originate from the volar radioulnar ligament and they form the volar and ulnar part of the ulnocarpal joint capsule. The UL attaches along the ulnar part of the proximal lunate just ulnarly to SRL attachment. Due to the indirect origin of the UL and UTq, the forearm rotation does not affect the tightness of these ligaments. The UTq originates from the volar radioulnar ligament. It has a longitudinal orientation and attaches to the proximal and ulnar aspects of the triquetrum. The pisotriquetral orifice divides the UTq in medial and lateral bands, while a second perforation, the prestyloid recess has also been described. It forms as a part of the triangular fibrocartilage complex and acts as a dynamic stabilizer of both the wrist and the distal radioulnar joint (DRUJ) along with the extensor carpi ulnaris tendon system.

1.2.4 Dorsal Radiocarpal Ligament

The dorsal radiocarpal ligament (DRC), also called the dorsal radiotriquetral ligament, has a wide origin from the dorsal rim of the radius extending from the Lister’s tubercle to the sigmoid notch. Its width is reduced as it courses obliquely distally and ulnarly, offering some attachment to the dorsal lunate and finally inserting on the dorsal ridge of the triquetrum. At this final insertion it merges with fibers from the dorsal intercarpal ligament (DIC). The DRC reinforces the dorsal LTIL and constrains ulnar translocation of the carpus and ulnocarpal supination (▶Fig. 1.8, ▶Fig. 1.9, ▶Fig. 1.10).

Fig. 1.8 Dorsal carpal ligaments: the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments. C, capitate; H, hamate; L, lunate; S, scaphoid; T, triquetrum.

Fig. 1.9 Dorsal and flexed view of the dorsal carpal ligaments, illustrating the tension in the dorsal radiocarpal (DRC) ligament and the transverse expansion of the dorsal intercarpal (DIC). C, capitate; L, lunate; H, hamate; S, scaphoid; T, triquetrum.

Fig. 1.10 The lateral V-construct, showing how the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments insert onto the triquetrum (T) and span across the wrist to provide stability to both the dorsal radiocarpal and midcarpal joints. H, hamate; L, lunate; S, scaphoid; U, ulna.

1.3 Intrinsic Ligaments

1.3.1 Anatomy

Intrinsic ligaments may be either midcarpal that connect the bones across the midcarpal joint, or intercarpal (referred by some authors as interosseous2) that connect the bones within the same carpal row (either proximal or distal).

1.3.2 Midcarpal Ligaments

The midcarpal joint is crossed by four volar and one dorsal ligament.

Volar Midcarpal Ligaments

The four volar midcarpal ligaments are intracapsular and connect scaphoid and triquetrum with the distal row: scaphotrapeziotrapezoid (STT), scaphocapitate (SC), triquetrocapitate (TqC), and triquetrohamate (TqH). The TqC and TqH ligaments form almost mirror images of the STT and SC ligaments. Interestingly, the lunate does not have a connection to the distal carpal row itself.

The STT ligament complex includes four components: the radiopalmar scapho-trapezial ligament (rpSTL), the palmar scapho-trapezial-trapezoidal capsule (pSTTC), the dorsal scapho-trapezial-trapezoidal capsule (dSTTC), and the SC ligament. The rpSTL has been described as the main stabilizer of the STT joint27 (▶Fig. 1.6).

The SC originates from the distal pole of the scaphoid at the ulnar half of its volar cortex, courses obliquely, and inserts on the proximal and radial half of volar aspect of capitate body. The SC has the same orientation as the RSC ligament, and this explains the common false impression that the latter inserts on the capitate body.

The TqC and TqH ligaments are important structures for the midcarpal joint stability. The TqC originates from the distal and radial corner of the triquetrum and inserts on the ulnar cortex of the capitate body. The TqH lies just ulnarly to the TqC, originates from the distal volar cortex of the triquetrum, and attaches on the volar cortex of the hamate body. The TqCH complex is also known as the ulnar arm of the arcuate ligament.

Dorsal Midcarpal Ligament

Dorsally the midcarpal joint is coursed by one of the bands of the DIC. Ulnarly it originates from the dorsal tubercle of the triquetrum and courses radially along the dorsal edges of the proximal row bones, distal to the dorsal scaphotriquetral ligament, separated in two bands: the proximal band attaches to the dorsal ridge and radial surface of the distal pole of the scaphoid and the distal band attaches to the dorsal cortex of trapezium and trapezoid.

1.3.3 Intercarpal Ligaments

Proximal intercarpal ligaments include the scapholunate (SL), the lunotriquetral (LT), and the pisotriquetral (PT) and pisohamate (PH) ligaments. Distal intercarpal ligaments include trapeziotrapezoid (TT), trapezocapitate (TC), capitohamate (CH) ligaments (▶Fig. 1.11).

Fig. 1.11 Proximal view of the proximal carpal row, with the interosseous ligaments—the scapholunate (SL) and lunotriquetral (LT) ligaments. DRUL, dorsal radioulnar ligament; L, lunate; LF, lunate fossa; Lt, Lister’s tubercle; RSC, radioscaphocapitate; S, scaphoid; SF, scaphoid fossa; T, triquetrum; U, ulna.

Proximal Intercarpal Ligaments

The SL joint is stabilized by the three regions of the respective ligament: the volar and dorsal SL (vSL and dSL, respectively) and the proximal fibrocartilaginous membrane that connects them. The dSL is the thickest part and has the greatest yield strength, followed by the thinner vSL and the proximal membrane. The dSL connects the dorsal–distal corners of the scaphoid and lunate bones. It lies deep to the dorsal capsule from which it is clearly differentiated. Its fibers are slightly obliquely oriented and has significant contribution in maintaining scaphoid stability. The vSL is thinner and can be differentiated from the overlying LRL. Its fibers are more obliquely oriented allowing substantial flexion and extension of the scaphoid relative to the lunate. The proximal fibrocartilaginous membrane follows the proximal arc of scaphoid and lunate, separating the radiocarpal and midcarpal joint spaces. It is composed of fibrocartilage, with no collagen orientation, blood vessels, or nerves28 (▶Fig. 1.11, ▶Fig. 1.12).

Similar to the SL, the LT joint is stabilized by the three parts of LT ligament: the volar, and dorsal that connect the respective surfaces of the two bones, and the proximal fibrocartilaginous membrane that covers the dorsal, proximal, and volar aspects of the LT joint leaving the distal aspect open to the midcarpal joint. Contrary to the SL joint, the volar component (vLT ligament) is thicker and stronger than the dorsal LT (dLT) ligament followed again by the weakest proximal membrane. The vLT is composed of transversely oriented collagen fibers that interdigitate with fibers of the UC. The dLT courses transversely the LT joint and is clearly separated from the DRC. The proximal membrane is composed of fibrocartilage, but lacks collagen orientation, blood vessels, and nerves and prevents communication between the radiocarpal and midcarpal joint spaces (▶Fig. 1.11, ▶Fig. 1.12).

Fig. 1.12 Distal view of the proximal carpal row, with the interosseous ligaments—the dorsal and volar scapholunate (dSL, vSL) and dorsal and volar lunotriquetral (dLT, vLT) ligaments. L, lunate; S, scaphoid; SP, distal scaphoid pole; T, triquetrum.

Both vLT and dLT are under greater tension throughout the range of motion compared to SL ligaments. The most distal fibers of both vLT and dLT blend with the respective distal fibers of the vSL and dSL, forming the palmar and dorsal scaphotriquetral ligament. The dorsal scaphotriquetral ligament forms a labral extension into the dorsal midcarpal joint and along with the DIC contributes to the stability of the lunocapitate joint.

The PT ligament is a U-shape ligament that covers the radial, distal, and ulnar aspects of the pisotriquetral joint with its radial part being reinforced by fibers of the UC. The proximal part of the pisotriquetral joint, however, is open and communicates with the radiocarpal joint through the pisotriquetral orifice in the UTq. The PH extends from the palmar surface of the pisiform to the hook of the hamate and is formed from the flexor carpi ulnaris tendon.

Distal Intercarpal Ligaments

The stout transverse intercarpal ligaments, i.e., TT, TC, CH strongly connect the bones of the distal carpal row. Each of these ligaments consists of a transversely oriented dorsal and volar component. In the trapezocapitate and capitohamate joints, the respective ligaments attach only onto the body of the capitate crossing only the distal half of the joint because of the proximal extensions of the pole of the hamate and the head and neck of the capitate. For these two latter joints, an intra-articular component exists in addition to the dorsal and palmar components (▶Fig. 1.13).

Fig. 1.13 Proximal view of the distal carpal row, with the stout interosseous ligaments—the trapezotrapezoid (TT), trapezoid-capitate (TC), and capitohamate (CH) ligaments. C, capitate; H, hamate; HH, hook of hamate; Tz, trapezium; Tzd, trapezoid.

1.4 Acknowledgment

We wish to express our sincere gratitude to Dr. Theodorakys Fermin, Mr. Ahmad Al Mojaber, and the Surgical Skills Lab of Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar for invaluable assistance with anatomical dissections and imaging. Furthermore, we thank Christian Retschke and Rami Al Meklef (both Leipzig, Germany) for logistic support.

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2 Biomechanics of the Wrist

Jonathan P. Compson

Abstract

Carpal mechanics has been an area of great interest and controversy for many years but for nonacademic wrist surgeons it is a difficult subject to understand. This view on the subject has been written from the perspective of a surgeon who had to try and extrapolate what was known about biomechanics in the past to useful knowledge for treating acute injuries and their complications rather than treating chronic nontraumatic instabilities. The emphasis is therefore on the functional anatomy and the mechanics of injury causation and treatment. It arose as with other surgeons over a hundred years from a particular interest in fractures of the scaphoid, their fracture patterns, and how they and the carpus collapse in nonunion.

Keywords: wrist, carpal mechanics theory, anatomy, scaphoid fractures, hydromechanics

2.1 Introduction

The anatomy of the eight carpal bones and their soft tissue connections is complex and when united into a single compound joint, the wrist, their combined relationship and function becomes even more complex. How they work together is not yet fully understood, and though this is absolutely fascinating for a few surgeons especially those treating nontraumatic instabilities, for many surgeons it is daunting and confusing. However, for diagnosis and treatment, most wrist surgeons particularly those treating acute trauma require a knowledge of the complex 3D anatomy, both bony and ligamentous, in order to restore normal anatomy and then hopefully function. With this a working knowledge of mechanics is all that is needed as long as one isn’t drawn into the minutiae and often arguments and confusing language which dominates the subject. However, a deeper understanding of the mechanics is needed when treating posttraumatic complications due to secondary malalignment and especially for multidirectional instabilities secondary to hyperlaxity and congenital abnormalities.

It is difficult to describe in words alone how things move, particularly about a wrist that has a complex 3D anatomy. However, the advent of the 3D computerized tomography (CT) (▶Fig. 2.1a, b) has been probably the most important advance for describing, understanding, and treating carpal pathology since wrist arthroscopy was developed.1,2 By using it to understand and visualize the underlying 3D anatomy it is easy to extrapolate it to the surface anatomy which before such imaging was difficult.3,4 A good knowledge of surface anatomy is essential not only for diagnosis but also to feel how the normal carpus moves, for instance, the scaphoid flexing and extending on radial and ulnar deviation. In future carpal mechanics will be taught with the aid of moving 3D images, both of bone and eventually with soft tissue additions to the model. Unfortunately, many descriptions of carpal mechanics are still based on fairly unrealistic views of 3D soft tissue anatomy. At the moment the best way to learn is still by dissecting cadaveric hands, observing open carpal surgery and wrist arthroscopy despite the limited views, and radiologically screening one’s own patients.

Fig. 2.1 Dorsal (a) and palmar (b) 3D computed tomography (CT) views of left wrist.

2.2 Functions of the Wrist