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Scientific Articles   |    
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.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
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.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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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, “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”.(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, “that these injuries be considered when distal radial fractures are treated acutely and when there are residual symptoms after fracture-healing has occurred.”

    Dr Weiss’ 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 literature’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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