The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 11

Scientific Articles | November 01, 2007

Intercarpal Ligament Injuries Associated with Fractures of the Distal Part of the Radius

Daren P. Forward, FRCS¹; Tommy R. Lindau, MD, PhD¹; David S. Melsom, FRCS¹

¹ Pulvertaft Hand Centre, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, United Kingdom. E-mail address for D.P. Forward: daren.forward@virgin.net

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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Investigation performed at the Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, United Kingdom, and the Hand Unit, Lund University Hospital, Lund, Sweden

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Nov 01;89(11):2334-2340. doi: 10.2106/JBJS.F.01537

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Abstract

Background: Soft-tissue injuries of the wrist are often not recognized in patients with distal radial fractures, yet scapholunate injuries have been reported to occur in association with as many as 54% of distal radial fractures. The true prevalence and natural history of intercarpal ligament injury are not known.

Methods: This prospective observational study assessed the prevalence and one-year outcome of intercarpal ligament injuries in non-osteoporotic patients with displaced fractures of the distal part of the radius. The study group consisted of fifty-one patients (twenty-seven women and twenty-four men) with a median age of forty-one years (range, twenty to fifty-seven years). Patients underwent standard fracture treatment and, in addition, wrist arthroscopy was performed to identify associated carpal injuries. No ligamentous injuries were treated. Patients were reviewed at one year and underwent physical and radiographic evaluation. Patients were analyzed according to the status of the scapholunate ligament at the time of the injury and were graded with use of a modification of the Geissler classification system: Group I consisted of ten patients with a grade-3 scapholunate ligament injury, and Group II consisted of forty-one patients with a grade-0, 1, or 2 injury.

Results: Patients with an increase in ulnar variance of >2 mm at the time of the injury had a fourfold increase in the risk of sustaining a grade-3 scapholunate ligament injury (p = 0.01). Radiographically, at one year, patients in Group I (grade-3 injuries) had a greater amount of static and dynamic scapholunate dissociation and a significantly greater increase in the scapholunate angle in comparison with the uninjured wrist (p = 0.006) than did those in Group II. Intra-articular fractures were associated with a twofold increase in the prevalence of scapholunate dissociation as seen radiographically at one year. The prevalence of subjective pain on examination was significantly greater in Group I than in Group II (p = 0.009). There were no significant differences between the two groups with respect to objective outcome according to range of motion and hand grip and tip pinch strengths. Lunotriquetral injuries were uncommon and did not correlate with the scapholunate injuries, fracture grade, or configuration.

Conclusions: Grade-3 scapholunate ligament tears can be associated with ulnar positive variance at the time of initial presentation of a distal radial fracture and can be associated with more scapholunate joint pain at one year. These injuries could lead to scapholunate dissociation at the time of follow-up, particularly in patients with intraarticular fractures.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

The prevalence of ligamentous injury associated with displaced fractures of the distal part of the radius has been shown to be as high as 98%, with twenty-seven (54%) of fifty fractures in one study being associated with a tear of the scapholunate ligament¹. The diagnosis of intercarpal ligamentous injury on plain radiographs can be difficult in the absence of gross deformity^2,3, and even the use of arthrograms, ultrasound, and magnetic resonance imaging may fail to demonstrate lesions^4-6, suggesting that direct visualization with use of arthroscopy is the most accurate method^1,4.

As these ligamentous injuries may lead to carpal instability, it may be easier to treat them at the time of the initial presentation, and doing so has been shown to lead to improved outcomes^7-9. However, the natural history and clinical importance of intercarpal ligament injuries associated with fractures of the distal part of the radius are not known. It may not be necessary to treat all lesions as previously recommended¹⁰, but persistent symptoms and instability resulting from these injuries may be a confounding factor in the outcome of treatment of distal radial fractures. We assessed the prevalence and one-year outcome of intercarpal ligamentous injuries associated with non-osteoporotic displaced fractures of the distal part of the radius.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

The present prospective observational study was performed in the hand unit of a university hospital. All patients provided informed consent for entry into the study, but institutional review board approval was not required at the institution.

All men between the ages of twenty and fifty-nine years and all women between the ages of twenty and forty-nine years who were seen in the unit with a displaced fracture of the distal part of the radius were invited to take part in the study as these age-groups have no clinical osteoporosis according to current available information in the literature^11,12. The fracture was regarded as displaced if the joint surface was tilted dorsally beyond neutral¹³. Open fractures, osteoporotic fractures (those in patients with a history of endocrine disease or alcohol abuse), and bilateral fractures were the only ones excluded from the present study.

Fifty-one consecutive patients who met the inclusion criteria underwent treatment of a distal radial fracture in accordance with local guidelines during an eighteen-month period and also were evaluated with wrist arthroscopy by the senior author (T.R.L.) at the time of surgery. The study group included twenty-four men and twenty-seven women with a median age of forty-one years (range, twenty to fifty-seven years). The dominant wrist was injured in twenty-one patients. In forty patients, the fracture was caused by a more severe trauma than a fall at ground level. More than half the fractures were intra-articular and/or comminuted (Table I). No significant differences were identified between the groups with respect to age, gender, hand dominance, treatment, or follow-up. Three patients subsequently were lost to follow-up.

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TABLE I Baseline Characteristics of All Patients

	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)
Age*(yr)	43	40
Gender (M/F) (no. of patients)	3/7	21/20
Duration of follow-up*(mo)	14	14
Scapholunate grade (no. of patients)
0	—	7
1	—	11
2	—	23
3	10	—
4	—	—

The values are given as the mean.

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TABLE I Baseline Characteristics of All Patients

	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)
Age*(yr)	43	40
Gender (M/F) (no. of patients)	3/7	21/20
Duration of follow-up*(mo)	14	14
Scapholunate grade (no. of patients)
0	—	7
1	—	11
2	—	23
3	10	—
4	—	—

The values are given as the mean.

After the initial arthroscopic assessment, all fractures were treated by the senior surgeon (T.R.L.) with use of closed reduction (twenty-one fractures), arthroscopic-assisted reduction (seventeen fractures, six of which also had external fixation), external fixation (five fractures), or open reduction and internal fixation (eight fractures). Wrist arthroscopy was performed, as described by Whipple et al.¹⁴, after a median of three days (range, one to fifteen days). The examination followed a standardized protocol. Under direct vision, the carpal ligaments were probed with a hook in order to fully define any tear and the extent of the tear was graded according to a modification of the Geissler classification system¹ (Table II), such that a partial tear was defined not only by the presence of bleeding but also by loss of continuity of the ligament (Figs. 1-A, 1-B, and 1-C). A grade-3 injury also had a diastasis and step-off of the midcarpal joint (Table II, Fig. 1-C). Fractures without intercarpal injuries were classified as grade 0. The appearance of the triangular fibrocartilage complex was also noted. None of the ligamentous tears were treated.

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TABLE II Modified Geissler Grading System for Scapholunate Ligament Injury¹

Grade	Radiocarpal Ligament Appearance	Midcarpal Diastasis (mm)	Step-off (mm)
1	Hematoma or distension	0	0
2	Hematoma or distension and/or partial tear	0 to 1	<2
3	Partial or complete tear	1 to 2	<2
4	Complete tear	>2	>2

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TABLE II Modified Geissler Grading System for Scapholunate Ligament Injury¹

Grade	Radiocarpal Ligament Appearance	Midcarpal Diastasis (mm)	Step-off (mm)
1	Hematoma or distension	0	0
2	Hematoma or distension and/or partial tear	0 to 1	<2
3	Partial or complete tear	1 to 2	<2
4	Complete tear	>2	>2

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Fig. 1-A: Figs. 1-A,1-B, and1-C Arthroscopic images. By combining the radiocarpal appearance with the midcarpal measurement, the injury can be graded as described in Table II. Lun = Lunate, Scaph = scaphoid, and Cap = capitate. Fig. 1-A Radiocarpal view showing an acute scapholunate tear.

Follow-up was performed after a median of twelve months (range, eleven to twenty-seven months) by two investigators (including one of us [T.R.L.]) without reference to patient documentation. Through the passage of time, both investigators were considered to be blind to the initial arthroscopic and radiographic findings, although both had been involved in the initial treatment. Follow-up evaluation included an interview, a physical examination with stability testing, and a radiographic examination of both wrists. Standard lateral and posteroanterior radiographs, along with additional posteroanterior radiographs made with ulnar and radial deviation with a clenched fist, were made. At the time of the follow-up evaluation, both the fractured wrist and the contralateral wrist were examined. Fracture characteristics were recorded with use of well-documented methods, including the use of the central reference point for ulnar variance, which is considered to be most accurate in trauma radiographs¹⁵.

The primary outcome measures were hand grip strength and range of motion at one year. Grip strength was assessed with use of a Jamar Dynamometer (J.A. Preston, Jackson, Michigan). The maximum strength of three attempts was recorded. The handles were set at 6 cm unless this distance was uncomfortable for the subject, in which case the distance was altered to the most comfortable setting for the individual. Pain at rest and on examination with the Watson shift test was assessed with use of a visual analog scale, with 0 representing no pain and 10 representing the worst possible pain. The Watson shift test was performed by applying constant pressure from the examiner's thumb on the palmar aspect of the distal pole of the scaphoid during wrist ulnar and radial deviation. Range of motion was assessed with a goniometer. Wrist flexion and extension were measured with the goniometer positioned on the ulnar aspect of the dorsum of the wrist in pronation and aligned along the third metacarpal. Radial and ulnar deviation were assessed with the wrist in pronation on a flat surface with the elbow flexed. Measurements were made along the line of the third metacarpal and the radius. Pronation and supination were assessed with the elbow flexed to 90° and held at the side with the wrist in neutral rotation initially. Values were summated to give a range-of-motion value.

Secondary outcome measures included the Sarmiento modification of the Gartland and Werley score¹⁶. This demerit score consists of subjective, objective, and radiographic sections as well as a section dealing with complications, with higher values representing a worse outcome. The Disabilities of the Arm, Shoulder and Hand (DASH) outcome score was not validated in Sweden at the time of this study, and consequently no separate subjective outcome measurement was included. Instead, we relied on the subjective section of the Gartland and Werley score.

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Fig. 1-B: Radiocarpal view showing normal findings.

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Fig. 1-C: Midcarpal view used for the assessment of step-off (the thickness of the probe represents a 1-mm step-off).

Data Analysis

Patients were analyzed in two groups according to their modified Geissler grading: Group I comprised ten patients with a grade-3 or 4 ligamentous injury, and Group II comprised forty-one patients with a grade-0, 1, or 2 ligamentous injury. This division was chosen because it was expected that the higher grades would be infrequent and because grades 3 and 4 include complete ligamentous tears whereas grades 0, 1, and 2 do not. Statistical testing was performed with the Fisher exact test, the Mann-Whitney U test, the chi-square test, and the t test, with the level of significance set at p < 0.05.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

Subjective Outcome

There was a significantly greater prevalence of pain at the scapholunate joint on examination with the Watson shift test in Group I (scapholunate grade 3), with five of ten patients reporting pain on examination, as compared with Group II (scapholunate grade 0, 1, or 2), with four of forty-one patients reporting pain on examination (p = 0.009) (Table III). Selfreported pain from the wrist in general was not significantly different between the two groups (p = 0.06), although four of the ten patients in Group I reported pain. Despite this finding, the subjective rating section of the Gartland and Werley score was significantly worse in Group II (p = 0.039). However, with the numbers studied, the overall Gartland and Werley score did not differ between the groups (p = 0.172).

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TABLE III Subjective Outcome Measures One Year Following Injury

	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)	P Value
Subjective pain (yes/no) (no. of patients)	4/6	5/36	0.06‡
Pain on examination (yes/no) (no. of patients)	5/5	4/37	0.009‡§
Visual analog scale for pain*†
At rest	0.4 (-0.1 to 0.9)	1.1 (0.6 to 1.6)	0.215#
Under load	3.0 (0.8 to 5.2)	4.2 (3.4 to 5.1)	0.223#
Gartland and Werley*
Subjective rating	2.1 (1.4 to 2.8)	2.7 (2.5 to 3.0)	0.039§#
Overall score	3.6 (1.3 to 5.9)	5.1 (4.2 to 6.1)	0.172#
Gartland and Werley grade (no. of patients)			0.294‡
Excellent	4	8
Good	5	30
Fair	1	3
Poor	0	0

The values are given as the mean, with the 95% confidence interval in parentheses.On the visual analog scale for pain, 0 represents no pain and 10 represents the worst possible pain at rest or under load.Fisher exact test.Significant.T test.

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TABLE III Subjective Outcome Measures One Year Following Injury

	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)	P Value
Subjective pain (yes/no) (no. of patients)	4/6	5/36	0.06‡
Pain on examination (yes/no) (no. of patients)	5/5	4/37	0.009‡§
Visual analog scale for pain*†
At rest	0.4 (-0.1 to 0.9)	1.1 (0.6 to 1.6)	0.215#
Under load	3.0 (0.8 to 5.2)	4.2 (3.4 to 5.1)	0.223#
Gartland and Werley*
Subjective rating	2.1 (1.4 to 2.8)	2.7 (2.5 to 3.0)	0.039§#
Overall score	3.6 (1.3 to 5.9)	5.1 (4.2 to 6.1)	0.172#
Gartland and Werley grade (no. of patients)			0.294‡
Excellent	4	8
Good	5	30
Fair	1	3
Poor	0	0

Objective Outcome

The primary outcomes of range of motion, hand grip strength, and tip pinch strength (all represented as a percentage of the value for the uninjured side) did not differ significantly between the two groups, with the numbers available (p = 0.467) (Table IV).

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TABLE IV Objective Outcome Measures One Year Following Injury

	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)*	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)*	P Value‡
Scapholunate angle (deg)	54 (45 to 64)†	52 (49 to 55)	0.510
Scapholunate angle difference (deg)	8.9 (4 to 14)†	2.5 (1 to 4)	0.006§
Range of motion (percentage of contralateral wrist)	93% (87% to 99%)	91% (89% to 93%)	0.467
Hand grip strength (percentage of contralateral wrist)	79% (69% to 89%)	79% (72% to 86%)	0.998
Tip pinch strength (percentage of contralateral wrist)	93% (87% to 98%)	91% (85% to 97%)	0.766

The values are given as the mean, with the 95% confidence interval in parentheses.One outlying scapholunate angle value of 110° with a scapholunate angle difference of 35 excluded.T test.Significant.

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TABLE IV Objective Outcome Measures One Year Following Injury

	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)*	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)*	P Value‡
Scapholunate angle (deg)	54 (45 to 64)†	52 (49 to 55)	0.510
Scapholunate angle difference (deg)	8.9 (4 to 14)†	2.5 (1 to 4)	0.006§
Range of motion (percentage of contralateral wrist)	93% (87% to 99%)	91% (89% to 93%)	0.467
Hand grip strength (percentage of contralateral wrist)	79% (69% to 89%)	79% (72% to 86%)	0.998
Tip pinch strength (percentage of contralateral wrist)	93% (87% to 98%)	91% (85% to 97%)	0.766

Radiographic Findings at Initial Presentation

The only radiographic fracture parameter that was associated with the scapholunate injury grade was the relative increase in ulnar variance of >2 mm in the fractured wrist as compared with the value on the uninjured side. Six of nine wrists with a complete (grade-3) scapholunate injury had a relative increase in ulnar variance, as compared with only nine of thirty-five wrists with a grade-0, 1, or 2 injury (p = 0.01). Absolute values of ulnar variance in the fractured wrist were not significant (p = 0.11), nor was the amount of ulnar variance after reduction (p > 0.05 for both the absolute and the relative postreduction value).

The relative risk of a grade-3 scapholunate injury in patients with a displaced fracture of the distal part of the radius with an increase in ulnar variance of >2 mm at the time of the injury as compared with those without such an increase in ulnar variance was 3.9 (95% confidence interval, 1.1 to 13.3). This finding had a sensitivity of 67% and specificity of 74% for predicting severe (grade-3) scapholunate injury, with a negative predictive value of 90% and a positive predictive value of 40%.

With the numbers available, fracture pattern as defined by dorsal angulation, radial deviation, or radial length was not significantly associated with intercarpal ligament injury (p > 0.05).

Radiographic Findings at One-Year Follow-up Evaluation

Radiographic evidence of scapholunate dissociation was significantly greater in Group I (grade-3 scapholunate injury), with a greater proportion of dynamic and static dissociation being identified (p = 0.006, Fisher exact test) (Table V). The relative difference in the scapholunate angle between the injured and the uninjured wrist (calculated by subtracting the scapholunate angle in the uninjured wrist from that in the injured wrist as measured on the lateral radiograph) was significantly greater in Group I than in Group II (p = 0.006). One outlying value for the scapholunate angle (110°) in a patient in Group I was excluded from the analysis.

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TABLE V Radiographic Evidence of Scapholunate Dissociation at One Year*

Scapholunate Dissociation	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)
None	4	36
Dynamic dissociation	4	4
Static dissociation	2	1

A greater proportion of dynamic and static dissociation was identified in Group I than in Group II (p = 0.006, Fischer exact test).

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TABLE V Radiographic Evidence of Scapholunate Dissociation at One Year*

Scapholunate Dissociation	Group I (Grade-3 or 4 Scapholunate Injury) (N = 10)	Group II (Grade-0, 1, or 2 Scapholunate Injury) (N = 41)
None	4	36
Dynamic dissociation	4	4
Static dissociation	2	1

A greater proportion of dynamic and static dissociation was identified in Group I than in Group II (p = 0.006, Fischer exact test).

In comparison with extra-articular fractures, intra-articular fractures demonstrated a twofold increase in the rate of scapholunate dissociation as seen radiographically at the time of follow-up, with scapholunate dissociation being seen in association with nine of thirty-five intra-articular fractures as compared with two of sixteen extra-articular fractures (relative risk 1.93; 95% confidence interval, 0.5 to 7.2), although this difference was not significant, with the numbers available.

Lunotriquetral and Triangular Fibrocartilage Complex Injuries

Injuries to the lunotriquetral ligament were rare in this series. Of the fifty-one lunotriquetral ligaments that were evaluated, three were classified as grade 3, twelve were classified as grade 1 or 2, and thirty-six were classified as grade 0. It was not possible to draw any further conclusions from the data. There was a greater proportion of more severe triangular fibrocartilage complex injuries in Group I, although this difference was not significant, with the numbers available (p = 0.687).

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

The present study demonstrated that an increase of >2 mm in ulnar positive variance at the time of distal radial fracture in a young adult was associated with a fourfold increase in the risk of scapholunate ligament injury. The study also demonstrated that grade-3 scapholunate injuries are associated with greater scapholunate joint pain and signs of radiographic dissociation at one year following a fracture.

The observation that an increase of >2 mm in ulnar positive variance relative to the value for the contralateral wrist at the time of presentation was predictive of severe scapholunate ligament injury has clinical relevance as a suspicion of intercarpal ligament injury can be raised at the time of initial assessment. In the present study, such an increase in ulnar positive variance had a 40% positive predictive value, meaning that two-fifths of patients with this finding will have a grade-3 scapholunate injury. In addition, such displacement recently was shown to be a significant predictor of fracture instability¹⁷, and consequently the clinician should be aware of this finding when treating these fractures. In a previous study of 118 distal radial fractures that were also evaluated arthroscopically at the time of treatment, Richards et al. failed to demonstrate an association between ulnar variance and scapholunate ligament injury¹⁸. They assessed the absolute value, which we also found to be unrelated to injury, but they did not assess the relative value.

Intra-articular fractures are more frequent than extra-articular fractures in non-osteoporotic patients¹⁹, probably because of greater transmission of energy to the joint at the time of fracture, involving not only the surrounding fractured radius but also the intercarpal joints. Richards et al. found that 21% of intra-articular fractures were associated with a scapholunate ligament injury¹⁸, as compared with the rate of 17% (six of thirty-five) in the present study. The increased risk of having radiographic evidence of scapholunate dissociation at one year after an intra-articular fracture is therefore not surprising and presumably represents the result of energy transmission through the carpus at the time of injury.

One additional consideration is that the identified lesion of the scapholunate ligament may actually be a marker for further intercarpal ligament injury in accordance with the Mayfield theory of carpal injury, such that the identified scapholunate ligament injury is the initial part of the spectrum of trans-styloid perilunate dislocation injuries. A full fracture-dislocation would be clearly recognized as having a significant impact on outcome^20,21. We failed to demonstrate a significant rate of lunotriquetral injury that would have supported such a theory, but previous reports have shown a diversity of ligamentous injuries associated with the fracture^1,18,20. Furthermore, this theory may be an important explanation for the unsatisfactory outcomes seen in studies comparing different options for the treatment of dislocated radial fractures²² as most of those studies have not investigated the extent and influence of associated injuries to the cartilage, the triangular fibrocartilage complex, or the intercarpal ligaments.

Clearly, our initial radiographs were not standardized as usually would be the case in the research setting and as was the case for comparison with the contralateral wrist at the time of follow-up. Nevertheless, the correlation that we found between increased ulnar variance at the time of presentation and scapholunate ligament injury is understandable as one can conceive of the distal part of the ulna driving into the carpus as the radius displaces proximally at the time of the fracture. Mudgal and Jones described AO C-type fractures that were associated with scapholunate injuries and postulated a similar mode of ligamentous failure, with shearing across the scapholunate ligament due to the lunate being driven into the radius²³. The lack of standardization of trauma radiographs, in our view, makes our observation more applicable to routine clinical practice, where radiographs are rarely if ever made in the standardized position for comparison with the contralateral side.

The present study demonstrated an increase in scapholunate joint pain and an increase in the amount of dissociation as seen radiographically at one year after grade-3 scapholunate injuries, although overall subjective function as assessed with the modified Gartland and Werley score was not significantly impaired (Table III). The outcome associated with these injuries without specific treatment has not been reported previously, as investigations of scapholunate injuries have included treatment of any injury observed¹⁸. The scapholunate joint pain may have been due to persistent synovitis caused by abnormal movement between the scaphoid and the lunate but at a low level such that a functional deficit was not apparent. The clinical picture may still be evolving such that a functional problem may become apparent in the future, not only with the risk of development of the dissociation as shown here radiographically but also with the later development of additional carpal instability as hypothesized by Short et al.²⁴. Subsequently, there is a risk of development of a scapholunate advanced collapse (SLAC) with secondary osteoarthritis. Additional longitudinal studies are needed to confirm the final outcome after such injuries.

One point of concern that arises from these observations is that if these lesions are common, and demonstrably painful, then why have major problems not been observed anecdotally in clinical practice? The most obvious explanation is that fractures of the distal part of the radius often leave some residual pain as the final outcome, which may be due to the fracture or may be part of an incompletely understood condition. We have demonstrated that a series of wrist stress radiographs can show both dynamic dissociations (not visible on a standard posteroanterior radiograph) and static dissociations (visible on a standard radiograph). We speculate that, in the past, treatment usually included a prolonged period of immobilization, such as in a plaster cast, which may have adequately treated some, or even most, of these carpal ligament injuries. However, with the current move toward internal fixation and early mobilization, these intercarpal ligament injuries may not heal, thereby causing clinical instability and pain. This may be why fractures do not consistently demonstrate better outcomes following open reduction and internal fixation as compared with indirect reduction techniques, which still necessitate prolonged periods of immobilization²⁵. In order to improve our understanding of residual pain after these fractures, we have to improve both the clinical examination and radiographic investigations and, possibly, use wrist arthroscopy more frequently.

Previously it was demonstrated that the prevalence of scapholunate ligament injuries increases with age. Wright et al., in a cadaver study, demonstrated a 29% prevalence of degenerative scapholunate tears in the forty-six to seventy-eight-year-old age-range²⁰. Richards et al. also suggested false-positive identification of scapholunate lesions due to confusion of acute injuries with age-related degenerative tears¹⁸. This was unlikely in the present study because the mean age and the age-range were considerably lower than those in the study by Richards et al. and therefore the prevalence of degenerative tears would be expected to be low. Furthermore, the arthroscopic findings were clearly those of acute injuries with fresh hematoma and avulsed ligamentous insertions (Fig. 1-A).

Despite the finding of more scapholunate ligament injuries in Group I, the subjective rating section of the Gartland and Werley score was significantly worse in Group II (p = 0.039) (Table III). This finding may be explained by the greater proportion of intra-articular fractures in Group II, which are generally considered to have a worse outcome than extra-articular injuries²⁶.

In conclusion, the present study demonstrated two important risk factors for scapholunate ligament injury and subsequent radiographic evidence of scapholunate dissociation in association with displaced non-osteoporotic fractures of the distal part of the radius: (1) increased ulnar variance at the time of the injury and (2) intra-articular fracture. Furthermore, grade-3 scapholunate injuries were found to be associated with increased scapholunate joint pain and increased radiographic evidence of dissociation at the time of the one-year follow-up. These findings may represent an important confounding factor in distal radial fracture outcome studies, particularly those assessing plate fixation combined with early mobilization. We recommend that these injuries be considered when distal radial fractures are treated acutely and when there are residual symptoms after fracture-healing has occurred. Additional comparative studies should be directed at establishing the optimum treatment of carpal ligament injuries in this setting. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: C. Adlercreutz, Consultant Radiologist, Department of Radiology, Lund University Hospital, Lund, Sweden gave invaluable help with the radiographic assessment.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients. J Hand Surg [Br]. 1997;22: 638-43.22638 1997 [PubMed][CrossRef]

Biyani A, Sharma JC. An unusual pattern of radiocarpal injury: brief report. J Bone Joint Surg Br. 1989;71: 139.71139 1989 [PubMed]

Bellinghausen HW, Gilula LA, Young LV, Weeks PM. Post-traumatic palmar carpal subluxation. Report of two cases. J Bone Joint Surg Am. 1983;65: 998-1006.65998 1983 [PubMed]

Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg Am. 1996;78: 348-56.78348 1996 [PubMed]

Dao KD, Solomon DJ, Shin AY, Puckett ML. The efficacy of ultrasound in the evaluation of dynamic scapholunate ligamentous instability. J Bone Joint Surg Am. 2004;86: 1473-8.861473 2004 [PubMed]

Gilula LA. Imaging and evaluation: carpus and distal radius. In: Manske PR, editor. Hand surgery update. Englewood, Colorado: American Society for Surgery of the Hand; 1994. p 7.1-7.15.7.1 1994

Whipple TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin. 1995;11: 37-40.1137 1995 [PubMed]

Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78: 357-65.78357 1996

Peicha G, Seibert F, Fellinger M, Grechenig W. Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures. Knee Surg Sports Traumatol Arthrosc. 1999;7: 327-33.7327 1999 [PubMed][CrossRef]

Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005;21: 407-16.21407 2005 [PubMed][CrossRef]

Poole KE, Compston JE. Osteoporosis and its management. BMJ. 2006;333: 1251-6.3331251 2006 [PubMed][CrossRef]

Gass M, Dawson-Hughes B. Preventing osteoporosis-related fractures: an overview. Am J Med. 2006;119(4 Suppl 1): S3-S11.119S3 2006 [PubMed][CrossRef]

Metz VM, Gilula LA. Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am. 1993;24: 217-28.24217 1993

Whipple TL, Marotta JJ, Powell JH 3rd. Techniques of wrist arthroscopy. Arthroscopy. 1986;2: 244-52.2244 1986 [PubMed][CrossRef]

Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin. 2005;21: 279-88.21279 2005 [PubMed][CrossRef]

Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles' fractures. Functional bracing in supination. J Bone Joint Surg Am. 1975;57: 311-7.57311 1975

Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88: 1944-51.881944 2006 [CrossRef]

Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg [Am]. 1997;22: 772-6.22772 1997 [PubMed][CrossRef]

Lindau TR, Aspenberg P, Arner M, Redlundh-Johnell I, Hagberg L. Fractures of the distal forearm in young adults. An epidemiologic description of 341 patients. Acta Orthop Scand. 1999;70: 124-8.70124 1999 [CrossRef]

Wright TW, Del Charco M, Wheeler D. Incidence of ligament lesions and associated degenerative changes in the elderly wrist. J Hand Surg [Am]. 1994;19: 313-8.19313 1994 [PubMed][CrossRef]

Mayfield JK, Johnson RP, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec. 1976;186: 417-28.186417 1976 [PubMed][CrossRef]

Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(3): CD003209.CD003209 2003

Mudgal CS, Jones WA. Scapho-lunate diastasis: a component of fractures of the distal radius. J Hand Surg [Br]. 1990;15: 503-5.15503 1990

Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: Part II. J Hand Surg [Am]. 2005;30: 24-34.3024 2005 [PubMed][CrossRef]

Kreder HJ, Hanel DP, Agel J, McKee M, Schemitsch EH, Trumble TE, Stephen D. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87: 829-36.87829 2005 [PubMed][CrossRef]

Jupiter JB, Fernandez DL. Complications following distal radial fractures. Instr Course Lect. 2002;51: 203-19.51203 2002 [PubMed]

Topics

fracture ; radius ; wrist ; ligament injury ; carpal instability ; scapholunate ligament

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Daren P. Forward, FRCS

Posted on November 21, 2007

Dr. Forward et al. respond to Dr. Weiss

Pulvertaft Hand Centre, Derby, UK

We thank Dr Weiss for his interest in our article. We feel that the abstract does accurately reflect the data presented in the article and supports the stated conclusion that, â€œGrade-3 scapholunate ligament tears can be associated with ulnar positive variance at the time of initial presentation of a distal radial fracture and can be associated with more scapholunate joint pain at one year. These injuries could lead to scapholunate dissociation at the time of follow-up, particularly in patients with intraarticular fracturesâ€.(1)

The abstract was deliberately ambivalent as to the strength of our assertions reflecting the fact that the data are based on 51 patients, and that while some of the parameters examined in the two groups were significantly different, this was not universally the case. The lack of significant difference in objective data was given equal emphasis in the abstract as the presence of a significant difference in pain on examination.

At no point in the abstract or article do we recommend aggressive treatment of these injuries;instead we recommended, â€œthat these injuries be considered when distal radial fractures are treated acutely and when there are residual symptoms after fracture-healing has occurred.â€

Dr Weissâ€™ suggestion that one could conclude that an untreated grade III scapholunate ligament tear actually improves the prognosis as assessed by the Gartland and Werley subjective score following these injuries is interesting and is one we take seriously.

We take the view that these injuries may be a strong confounding factor in the outcome of distal radius fractures and could, in part, explain the literatureâ€™s failure to show a correlation between functional outcome and radiographic parameters, a point raised by Drs Kang and Weiland in their commentary published with the electronic version of the article at www.jbjs.org. Apparently similar radiographic results may or may not have unrecognized carpal ligament injuries that our data would suggest will have an impact on assessable outcome. This may have been particularly true since the predictive parameter we have identified, ulnar variance difference on presentation, will not have been recognized when post reduction parameters are compared.

Overall, we feel that the inclusion of a statement reflecting worse subjective function on the Gartland and Werley score in Group II would have been entirely reasonable, but we also feel that its absence is unlikely to mislead those physicians who fail to read the full article. The pragmatic explanation for its absence was an attempt by us to meet the word limit for the abstract, having included in the abstract what we felt were the more important balancing data of an absence of difference in objective outcome between the two groups.

Reference:

1. Forward DP, Lindau TR, Melsom DS. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg Am. 2007;89:2334-2340.

Carl B. Weiss, M.D.

Posted on November 15, 2007

Intercarpal Ligament Injuries Associated with Fractures of the Distal Part of the Radius

Orthomemphis, Memphis, TN

To The Editor:

I enjoyed reading "Intercarpal Ligament Injuries Associated with Fractures of the Distal Part of the Radius" by Forward, et al.(1). However, after reading the full text of the article, I feel that the abstract was somewhat misleading. We all know that many physicians simply read the abstracts of many articles; it is therefore important that these abstracts be free from bias, and that they not require the whole article to be read in order to obtain a clear picture of the findings.

The statement I take issue with in the abstract is: "The prevalence of subjective pain on examination was significantly greater in Group I than in Group II(p=0.009)." This statement ignores the conclusion presented in the discussion section of the article, "...the subjective rating...was significantly worse in Group II(p=0.039)." Leaving this out of the abstract might give support to the conclusion that every grade III ligament injury should be treated aggressively in this patient population, while including it would show that the study results were actually less clear-cut. Although stated, it was not emphasized that objective outcomes were not different between the two groups.

It is possible to conclude from the data that having an untreated grade III scapholunate ligament tear actually improves your prognosis concerning subjective results as measured by the Gartland and Werley score. Maybe a ligament tear allows the carpus to better conform to a post traumatic distal radius, and fixing the ligament would actually lead to more pain and degenerative arthritis in this patient population. It might be easy to ignore "pain on examination", as this arguably occurs only in the doctor's office.

While abstracts are only abstracts, they must try not to present data that may support conclusions that are not as strongly supported in the body of the article.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

Reference:

1. Forward DP, Lindau TR, Melsom DS. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg Am. 2007;89:2334-2340.

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Daren P. Forward, Tommy R. Lindau, David S. Melsom; Intercarpal Ligament Injuries Associated with Fractures of the Distal Part of the Radius. The Journal of Bone & Joint Surgery. 2007 Nov;89(11):2334-2340.

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