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Lunotriquetral Injuries

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Lunotriquetral Injuries LUNOTRIQUETRAL INJURIES BY WARREN L. BUTTERFIELD, MD, ATUL B. JOSHI, MD, AND DAVID LICHTMAN, MD Lunotriquetral injury is an important consideration in the evaluation of ulnar- sided wrist pain. An understanding of the anatomy, kinematics, and pathome- chanics of this injury assists in elucidating the diagnosis through history and physical examination. The use of appropriate radiographic imaging may provide additional support for the diagnosis. Arthroscopy has emerged as not only the gold standard for diagnosis of this injury, but also as an effective means of treatment. Treatment decisions must be based on both the degree of severity and acuity of the injury. Although the majority of patients will do well with nonoperative management, the indications for surgery and the varied outcomes of surgical management are discussed. Copyright © 2002 by the American Society for Surgery of the Hand arpal instabilities result from a spectrum of pathomechanics, clinical presentation, and manage- injuries involving both osseous and ligamen- ment of lunotriquetral injuries. tous structures. Early literature on carpal in- C ERMINOLOGY stabilities focused on the scaphoid and the radial side T of the wrist; however, as advances in technology and surgical techniques have developed and a better un- arpal instabilities have been classified as static derstanding of wrist biomechanics has become avail- C(visible deformity on radiographs), dynamic (vis- able, there has been an increased understanding of ible deformity on stress radiographs or fluoroscopic ulnar carpal instabilities. stress tests), or predynamic (ligamentous injury with- As a group, ulnar carpal injuries are about one-sixth out radiographic deformity). In the case of lunotrique- as common as their radial counterparts.1 They are tral injuries, the term dissociation has been used clin- categorized into triquetrohamate, or midcarpal, insta- ically to describe static instability and the term sprain bility and lunotriquetral instability. Lunotriquetral has been used clinically to describe predynamic and injury is an unusual cause of ulnar-sided wrist pain. It dynamic instabilities.2 To avoid confusion, we often results from both traumatic and degenerative etiolo- refer to these injuries as unstable (equivalent of static), gies. This article discusses the anatomy, kinematics, dynamically unstable (equivalent of dynamic), and stable (equivalent of predynamic). We have titled the article as lunotriquetral injuries rather than instabilities to From the Department of Orthopedics, JPS Health Network, Fort emphasize that not all injuries are unstable. Worth, TX. Address reprint requests to Warren L. Butterfield, MD, Department of Orthopedics, JPS Health Network, 1500 S. Main St, Fort Worth, WRIST ANATOMY AND KINEMATICS TX. o achieve a functional range of motion and yet Copyright © 2002 by the American Society for Surgery of the Hand 1531-0914/02/0204-0006$35.00/0 Tstill maintain stability, the wrist requires a com- doi:10.1053/jssh.2002.36790 plex articular configuration that does not readily lend JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND ⅐ VOL. 2, NO. 4, NOVEMBER 2002 195 196 LUNOTRIQUETRAL INJURIES ⅐ BUTTERFIELD ET AL mal, and dorsal surfaces of the bones, leaving the distal aspect of the joint in open communication with the midcarpal joint.3 The 3 regions are distinct.4 The dorsal and palmar interosseous ligaments are true ligaments, but the proximal ligament is actually a fibrocartilaginous membrane and provides little sta- bility. The palmar ligament is the thickest and stron- gest, and it is the most important in resisting palmar translation. The dorsal ligament is the most important for rotational resistance. They are equally responsible for resisting dorsal translation. The scaphotriquetral ligament passes along the distal margins of the dorsal surfaces of the scaphoid, lunate, and triquetrum and is considered a distal extension of the interosseous liga- ments.3 The proximal carpal row moves passively in re- sponse to compressive and tensile forces generated by bony structures and soft-tissue constraints. In the normally constrained wrist, the reactive forces across the midcarpal joint are balanced. In flexion and ex- tension, the proximal carpal row moves in synchrony with the distal carpal row and the metacarpals5; how- FIGURE 1. Palmar ligaments. ever, with ulnar and radial deviation, the dynamics become more complex. With radial deviation, com- pressive forces across the scaphoid-trapezoid-trape- itself to anatomic description and interpretation. In addition to guiding motion of the hand in space, the many intercarpal linkages serve as shock absorbers to diffuse and redirect force transmitted from the hand to the forearm. Aside from the insertion of the flexor carpi ulnaris on the pisiform and hook of the hamate, the carpal bones have no tendinous insertion; there- fore, these functions depend mostly on bony structures and soft-tissue constraints. The ligamentous anatomy of the wrist has been well described.3 Most of the ligaments are thickenings of the joint capsule with longitudinally oriented groups of collagen fibers. They are categorized as extrinsic (insertions on both the carpal bones and on structures external to the carpal bones) and intrinsic (insertions exclusively within the carpal bones). These ligaments are further divided into dorsal and palmar groups. The ligaments pertinent to our discussion are shown in Figures 1, 2, and 3. The intrinsic ligaments, interosseous and scapho- triquetral (Fig 3), tightly constrain the proximal row. The interosseous ligament covers the palmar, proxi- FIGURE 2. Dorsal ligaments. LUNOTRIQUETRAL INJURIES ⅐ BUTTERFIELD ET AL 197 PATHOMECHANICS ultiple cadaveric studies have helped to eluci- Mdate the mechanisms of lunotriquetral injury and to identify relevant anatomic structures. In 1980, Mayfiled et al7 presented a classic study on perilunate instability. They showed that loading in maximal extension, ulnar deviation, and intercarpal supination causes progressive injury (Fig 4). They defined a lesser arc, purely ligamentous, and a greater arc, involving carpal bones, around which injury progresses. This may produce combinations of bone and ligament in- juries. Note that via this mechanism, lunotriquetral injury does not occur until stage III, and would thus have multiple associated injuries. Pin et al8 showed in cadavers that carpal ligament injury forms a spectrum: from elastic elongation to permanent elongation to tear. He showed that extrin- sic ligaments have more capacity for stretch than intrinsics, such that the intrinsic ligaments can be completely disrupted whereas the extrinsic ligaments are only partially injured. He suggested this as the mechanism of the forme fruste injury (lunotriquetral FIGURE 3. Interosseous ligaments. instability as the only clinical manifestation of stage III perilunate injury) proposed by Lichtman et al.9 zium (STT) complex cause the distal pole of the Reagan et al2 described isolated lunotriquetral scaphoid to flex. The lunate and triquetrum follow sprains after wrist trauma. They suggested that hy- passively into flexion, and are forced to translate dor- pothenar loading from a fall on an outstretched hand sally and pronate as the triquetrum interacts with the in maximal extension and radial deviation would re- hamate. With ulnar deviation, the triquetrum en- sult in the reverse order of injury proposed by May- gages the hamate’s helical articular surface. As the filed et al.7 The first stage of this mechanism allows for hamate moves ulnarward, local joint reactive forces isolated lunotriquetral sprain. This group also classi- cause the triquetrum to extend while moving pal- fied lunotriquetral injuries, based on the integrity of marly down the helicoid track of the joint.5 This the interosseous ligaments, into the broad categories results in extension and palmar translation of the of sprains and dissociations. entire proximal row. Alexander and Lichtman10 have postulated that Horii et al5 showed that motion between the lunate isolated lunotriquetral injuries also may occur with and the triquetrum during flexion or extension was similar to motion between the 2 bones during radial the wrist palmar flexed. A dorsally applied force then or ulnar deviation. A clinical study has revealed that causes the interosseous fibers to fail but spares the complete synostosis of the lunate and triquetrum re- palmar radiolunotriquetral ligament. 11 sults in asymptomatic wrist function.6 These 2 points Palmer and Werner identified that ulnar positive support the concept that normal wrist mobility and variance causes increased ulnar loading and degener- stability require an intact lunotriquetral interosseous ative injuries on the ulnar side of the wrist. It is ligament that fixes both bones into a single mechan- conceivable that not only does ulnar positive variance ical unit and determines the position of the lunate result in degenerative changes, but also predisposes to throughout wrist range of motion. lunotriquetral injury with axial loading. 198 LUNOTRIQUETRAL INJURIES ⅐ BUTTERFIELD ET AL dynamic instability,12 but has been observed to allow slightly abnormal intercarpal motions.5,13 Additional sectioning of the palmar lunotriquetral ligaments re- sulted in dynamic volar intercalated segment instabil- ity (VISI),12,13 thus these ligaments were determined to be important for proper rotation of the carpal bones on radial or ulnar deviation. Still further sectioning of the dorsal radiocarpal ligaments (dorsal radiotrique-
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