Clinical and arthroscopic assessment of wrist ligament injuries and instability

摘要

Wrist ligament injuries are commonafter trauma, especially when concomitantdislocated radius fractures arepresent. The diagnostics of scapholunate(SL), lunotriquetral (LT) and triangularfibrocartilage complex (TFCC) injuries arechallenging and most often dependenton magnetic resonance imaging (MRI)examination or invasive arthroscopy. Insome circumstances, missed ligamentinjuries can lead to devastating sequelae,in terms of pain, reduced grip strength,range of motion and subsequent degenerative arthritis. In certain cases andunder certain conditions, the choice oftreatment for wrist ligament injuries cansometimes be the subject of debate.An updated review of diagnostic accuracy,a higher awareness of the injuriesamong orthopaedic surgeons, a surgicallyadaptable classification of the injuriesand objective and clinically easily adapteddiagnostic tools are essential.This thesis demonstrates that a negativeresult from MRI cannot rule out thepossibility of a clinically relevant injuryto the SL ligament, the LT ligament or theTFCC. Clinical provocation wrist tests areof limited diagnostic value. The currentgold standard, wrist arthroscopy, remainsthe preferred diagnostic technique withsufficient conclusive properties when itcomes to wrist ligament injuries. Due tolow accuracy and high costs, MRI canmost often be abandoned, when it comesto wrist ligament injuries. The cost ofwrist MRI is three times higher than thatof a clinical examination at the Hand SurgeryDepartment, Sahlgrenska University Hospital.The thesis emphasises the increased diligence required when dealing with wristtrauma in children and adolescents, asa substantial amount of delayed presentationof distal radio-ulnar joint (DRUJ)instability after wrist fractures or sprainsin children and adolescents is found.The most striking finding is that severalchildren and adolescents present withDRUJ instability with isolated TFCC tears.The long delay from injury to diagnosisand the severity of the injury in termsof solving the DRUJ instability problemamong young people is also interestingand somewhat surprising.Four distinct SL injury types can be identifiedand classified. This classification can be used in both open and arthroscopicsurgery and in acute, subacute andchronic injuries. An arthroscopically assistedSL capsuloplasty and suture may notbe possible in all patients, particularly notwhen the ligament has been completelyavulsed from the bone (in approximately60% of patients; Andersson-Garcia-EliasType 1 and 2), leaving no ligament remnanton one side. Most patients with an SLinjury will require ligament re-attachmenttechniques using transosseous sutures,bone anchors, or ligament reconstruction.Distal radio-ulnar joint instability with anarthroscopically confirmed TFCC injury isassociated with a 30% loss of pre-operativepeak torque strength in pronation andsupination – a measurement techniqueeasily adapted in the clinical pre-operativesetting.