Upper Extremity Care in an Aging Population Hand and Upper Extremity Center of Northeast Wisconsin, Ltd. Symposium February 24, 2012 1 2 Objectives Wrist Injuries/Pain by Jon J. Cherney, M.D. Anatomy History/Evaluation Late effects Complexities 3 4 Wrist Fractures Fractures of the Distal Radius 5 6 1
Anatomy Angular alignment Radial inclination - 20 degrees Volar tilt - 12 degrees Radial length, +/- 2 mm Essentials of Hand Surgery 2002 Anatomy Ulnar head anatomy Largely covered by articular cartilage Cylindrical shape Ulnar styloid Dorsal and volar radioulnar ligaments insert at base Ulnar Groove Dorsal to ulnar styloid Extensor carpi ulnaris resides in groove 7 8 Ligamentous Anatomy Ligamentous Anatomy Volar ligament complex ASSH Original Artwork 9 Dorsal ligament complex Dorsal radiocarpal ligament (radius->triquetrum) Dorsal intercarpal ligament (triquetrum->distal scaphoid) Triangular fibrocartilage complex (TFCC) Volar and dorsal radioulnar ligaments Articular disc 10 ASSH Original Artwork Demographics Mechanism of Injury Incidence ~15% of all extremity fractures Most common upper extremity fracture Age range Low energy fractures More common Two peak age ranges 6-12 years > 60 years (female predominance)» Pathologic/osteopenia High energy fractures Young adults (MVA) Working males (fall from height) 11 Low energy Fall from standing height Extension mechanism Primary mechanism (90%) Land on palm with extended wrist Tension failure through volar cortex Fracture propagates to dorsal cortex which fails in compression Flexion mechanism Less common Fall on flexed wrist Dorsal cortex fails in tension Essentials of Hand Surgery 2002 12 2
Evaluation Clinical examination Motor and sensory evaluation of median, ulnar and superficial radial nerves Consider acute carpal tunnel syndrome for severely displaced fractures Evaluate for open fracture Evaluate vascular status Assess compromise of soft tissues due to severe deformity Evaluation Radiographic evaluation Standard AP and lateral radiographs Oblique radiographs Evaluate for nondisplaced fractures not visualized on the AP and lateral views 20 degree lateral- evaluate lunate facet Computerized tomography with coronal and sagittal reconstructions to evaluate articular surface if needed 13 14 Principles of Treatment Goals For given severity of fracture, the general functional outcome correlates with maintenance/restoration of normal distal radial morphology Physiologic age significant factor in the above Digital stiffness correlates with poor functional outcome Principles of Treatment Radiographic Goals Intra-articular step-off(b) /gap(a) Restoration of articular congruity <= 2 mm Significant (>2 mm) stepoff ->radiographic evidence of post-traumatic arthritis (Knirk and Jupiter, JBJS 1986) Radial length(c) within 2 mm of normal Dorsal tilt, neutral to no more than 10 º Note capitolunate angle Essentials of Hand Surgery 2002 A B C 15 16 Principles of Treatment Distal radioulnar joint (DRUJ) Congruity Stability Radiographic-? Reduced on true lateral Clinical assessment Treatment Recommendations Must be individualized Physiologic age Individual needs Medical co-morbidities Primary decision non-operative vs. operative treatment 17 18 3
Specific Treatment Recommendations Non-displaced fractures Immobilization Short arm cast Well-molded thermoplastic splint or bivalve splint Off-the-shelf splint Follow up 7 to 10 days after initiation of treatment to check for displacement 19 Specific Treatment Recommendations Non-displaced fractures? early active range of motion at 4 weeks Reliable patient Wean/discontinue immobilization after 6 weeks Occupational therapy occasionally necessary Risk of EPL rupture Rare Occurs late (beyond 6 weeks) 20 Specific Treatment Recommendations Specific Treatment Recommendations Displaced fractures Attempt closed reduction Hematoma block +/- IV sedation Initial splint or cast Plaster or fiberglass Long arm or short arm Position of rotation: arguments for pronation, neutral and supination exist 21 Displaced fractures Post reduction radiographs Remain acceptable Follow up at 6 weeks» Removable splint/ instruct in gentle ROM Follow up at 8 weeks - evaluate need for therapy 6 months to maximum range of motion and strength Up to 1 year maximum subjective improvement Are unacceptable identified at 0, 1, 2, or 3 weeks Usually recommend change to operative treatment May consider re-reduction in first one to two weeks 22 Operative Treatment Options Closed reduction and percutaneous pinning (CR/PP) External fixation (ExFix) Arthroscopically assisted reduction Open reduction internal fixation (ORIF) Dorsal approach/ plate Volar approach/ plate Fragment specific fixation Combination of above Bone graft/ bone graft substitute 23 Operative Treatment Closed reduction and percutaneous pinning (CR/PP) Indications Isolated radial styloid fracture Minimal comminution Intrafocal vs. extrafocal pinning Intrafocal- pins placed in fracture site and act like buttress pins Extrafocal- pins used to pin fragment(s) to proximal unfractured metaphysis Oscillating driver Requires supplemental casting Pins removed in office @ 6 weeks Rehab similar to closed treatment 24 4
Operative Treatment External fixation (ExFix) Indications Displaced fractures Comminution Able to achieve satisfactory reduction via closed or percutaneous means Stabilize fracture via ligamentotaxis May be supplemented with percutaneous pinning or limited internal fixation Fixator may be used as a neutralization device Must be supplemented with percutaneous pinning or limited internal fixation Operative Treatment Arthroscopically assisted articular reduction May be used to evaluate/ manipulate articular surface in conjunction with Percutaneous Pinning with or without External Fixation Limited open procedures Best done within the first few weeks 25 26 Operative Treatment Volar buttress plate Uses plate to support fractures of volar margin of distal radius Relies on solid screw fixation at uninvolved radial shaft Primarily indicated for partial articular fractures of the volar rim (volar Barton) Screw fixation at the metaphysis is optional and not always reliable Volar approach through the FCR sheath (Henry approach) Consider concomitant carpal tunnel release Operative Treatment Fragment specific fixation Generally excellent stability allowing early range of motion Learning curve Somewhat steep Technique somewhat tedious 27 28 Associated Ulnar Fractures Ulnar styloid Usually requires no specific treatment Basilar ulnar styloid fracture may contain peripheral ulnar attachment of the TFCC Resultant distal radioulnar joint instability Requires fixation (screw, pin, tension band) if displaced Nonunion occasionally source of persistent ulnar pain Ulnar head/neck Nondisplaced fractures may be managed in a closed fashion Displaced or unstable fractures may require 29 ORIF Aftercare for Surgical Treatment Immediate range of motion of digits/elbow/shoulder; +/- forearm Within 10 days (if stable) - thermoplastic removable splint Except percutaneous pinning and ex-fix Supervised (OT) range of motion of wrist and forearm Remove for hygiene Follow up within 10 days to repeat x-rays By four weeks, begin to wean from splint 30 5
Aftercare for Surgical Treatment At six weeks, early strengthening and discontinue splint Full activity at 10 to 12 weeks, including weight-bearing If unstable or external fixation, then above is delayed for six weeks Complications Stiffness - digits/wrist/forearm Carpal tunnel syndrome CRPS Infection Symptomatic hardware Hardware failure Pain Post-traumatic arthritis Malunion Non-union 31 Courtesy of John G. Seiler, MD 32 Fractures and Dislocations of the Carpus Scaphoid Fractures 60-80% of carpal fractures Waist fractures Requires twice the force needed to cause a distal radius fracture Common in Athletes Males Motor vehicle accidents 33 34 Examination Imaging Wrist swelling Tender snuff box Tender dorsal scaphoid Tender scaphoid tubercle Courtesy of Mark E. Baratz, MD 35 Non-displaced fractures frequently missed on initial radiographs Scaphoid normally rests in 45 o of flexion relative to the radius Result: a fracture may not be visible if it rests in a plane oblique to beam of radiograph Courtesy of Mark E. Baratz, MD 36 6
Scaphoid Oblique Occult scaphoid fracture Posteroanterior (PA) view with wrist in ulnar deviation and the beam angled 20 o distal to proximal Will often show fractures not seen on PA or lateral view 37 Courtesy of Mark E. Baratz, MD PA view Scaphoid Oblique 38 Other imaging tools Bone scan Sensitive, not specific CT scan Take in plane of scaphoid Sensitive, defines comminution and angulation of the fractured scaphoid Excellent to assess healing MR Sensitive, defines vascularity of proximal pole Non-operative treatment with cast Wrist position (Jupiter et al. AAOS ICL #50, 2001) Palmar flexion and radial deviation Reduces the gap, but may lead to collapse Ulnar deviation Helps reduction; may cause distraction Neutral position: just right. 39 40 Consider long arm cast for 6 weeks followed by short arm cast until healed for: Patient Smoker Poor compliance Fracture All proximal pole Waist fracture at risk Comminution Oblique Fracture separation 41 Duration of immobilization Distal pole: 4 to 6 wks Waist fracture: 6 to 8 weeks Proximal pole: 6 weeks to 4 months 42 7
Some surgeons consider surgical treatment for the at risk fracture to avoid the morbidity of prolonged immobilization. Some surgeons consider surgery for all fractures to minimize the duration of immobilization Surgical Treatment for Scaphoid Fractures Questions to answer Is it fresh? Is it displaced? Is there arthritis? 43 44 Techniques Wrist dislocations with fracture Percutaneous or limited open Open reduction & fixation Vascularized bone grafts 45 46 Courtesy of Mark E. Baratz, MD Priorities Median nerve Skin Associated carpal injuries Initial Treatment Attempt closed reduction Yes when there is nerve compromise or gross deformity of the wrist Open surgical reduction Required for most wrist dislocations and fracture dislocations 47 48 8
Surgical Approach Dorsal Combined Pre-reduction Courtesy of Mark E. Baratz, MD Post-reduction; no smile on PA, scaphoid broken, can t draw line on lateral Support for both. Either can be done in the absence of acute carpal tunnel syndrome 49 50 Post-operative Care Cast for 8 weeks Splint for 4 weeks; allow intermittent motion out of splint Pins out at 12 weeks Courtesy of Mark E. Baratz, MD 51 52 Expected Outcome Scaphoid heals Carpal position maintained Wrist stiffness Midcarpal arthritis (about 50%) Note restoration of smile, rhomboidshaped lunate Courtesy of Mark E. Baratz, MD 53 54 9
Scapholunate Ligament Injuries In 1984, Watson and Ballet described the inexorable degenerative nature of SL injury and coined the term SLAC wrist Scaphoid palmar flexes-shifts forces to the dorsum of the radius SLAC Courtesy of Leon S. Benson, MD Courtesy of Leon S. Benson, MD 55 56 Lunate dorsiflexes- Capitate flexes and incongruous midcarpal joint SLAC Open SL Repair with Capsulodesis and Pinning Indications Acute injury - less than 3mo T.R. Courtesy of Leon S. Benson, MD Courtesy of Leon S. Benson, MD 57 58 ACUTE TEARS Repair +/- Internal fixation +/- Capsular reinforcement SALVAGE 59 60 10
Treatment of SLAC Wrist Treatment of SLAC Wrist Excise the scaphoid and allow the lunate to articulate with the radius; need to stabilize the lunate, so fuse it to the capitate Proximal Row Carpectomy-Allows the Capitate to articulate with the radius Courtesy of Leon S. Benson, MD Courtesy of Leon S. Benson, MD 61 62 Wrist Arthritis WRIST ARTHRITIS Radiocarpal Intercarpal arthritis Sequela of trauma Distal radius fractures Scaphoid fractures Intercarpal radiocarpal dislocation Scapholunate advanced collapse (SLAC) wrist Scaphoid Trapezium Trapezoid arthritis Primary osteoarthritis uncommon 63 64 Scapholunate Advanced Collapse (SLAC) Wrist Scapholunate Advanced Collapse (SLAC) Wrist Progressive condition Begins with incompetence of the scapholunate interosseous ligament Follows a predictable radiographic pattern Radioscaphoid arthritis followed by capitolunate arthritis 65 66 11
Scapholunate Advanced Collapse (SLAC) Wrist Symptoms Activity related pain Loss of motion Dorsoradial wrist pain Clinical findings Dorsoradial tenderness Scaphoid shift test Scapholunate Advanced Collapse (SLAC) Wrist SLAC wrist with scapholunate widening and radioscaphoid arthritis 67 68 Scapholunate Advanced Collapse (SLAC) Wrist Non-operative treatment Wrist splints NSAIDs Activity modification Injections Scapholunate Advanced Collapse (SLAC) Wrist Surgical options SLAC wrist reconstruction Scaphoid excision with capitate-lunatehamate-triquetrum fusion (4 corner fusion) Proximal row carpectomy Wrist arthrodesis Wrist arthroplasty 69 70 SLAC Wrist Reconstruction SLAC Wrist Reconstruction Scaphoid excision with fusion of capitate-lunate-hamate-triquetrum Post-operative radiographs 71 72 12
Proximal Row Carpectomy Proximal Row Carpectomy Indications Radiocarpal arthrosis Arthrosis with deformity or malalignment of proximal carpus Kienböck s disease Chronic scapholunate dissociation Failed silicone implants Scaphoid nonunion Requirements Normal articular surface of proximal pole of capitate and lunate fossa of the distal radius Preservation of radioscaphocapitate ligament 73 Excision of scaphoid, lunate, and triquetrum with preservation of the radioscaphocapitate ligament (arrow) 74 Wrist Arthrodesis Wrist Arthrodesis Indications Post-traumatic arthrosis Failed previous limited wrist fusion Failed arthroplasty Paralysis Reconstruction Tumor Infection Spastic hemiplegia Rheumatoid arthritis Specialized plate used for wrist arthrodesis 75 76 Scaphoid Nonunion with Wrist Arthritis Wrist Arthrodesis Pre-operative radiographs of patient with scaphoid nonunion Intraoperative view Wrist fusion with dorsal plate 77 78 13
Wrist Arthrodesis Scaphoid Trapezium Trapezoid Arthritis Post-operative radiographs 79 80 Scaphoid Trapezium Trapezoid Arthritis Clinical findings Radial sided wrist / hand pain Activity related Non-operative treatment Wrist splints NSAIDs Activity modification Injections Scaphoid Trapezium Trapezoid Arthritis Surgical indications Pain refractory to nonoperative treatment Advanced arthritis Surgical options Scaphotrapeziotrapezoid (STT) arthrodesis Trapezium excision, interposition arthroplasty 81 82 Goals Triangular Fibrocartilage Tears To discuss the anatomy of the TFCC complex To review the assessment of patients who may have a TFCC tear To review the types of TFCC tears To discuss treatment alternatives for TFCC tears 83 84 14
Anatomy TFCC Vascularity of TFCC Components Articular disc (triangular fibrocartilage[tfc]) Volar radial ulnar ligament Dorsal radial ulnar ligament Meniscal homologue Ulnolunate ligament Ulnotriquetral ligament Subsheath of extensor carpi ulnaris (ECU) 85 Peripheral margins well-vascularized Central articular disc and radial attachment are avascular Courtesy of Michael S. Bednar, MD 86 Function of components of TFCC Articular disc (TFC) Transmits load between ulnar carpus and ulnar head Normally ~ 20% carpal load Volar RUL Stabilizes DRUJ Tightens in supination Resists volar subluxation of ulna (relative to radius) Dorsal RUL Stabilizes DRUJ Tightens in pronation Resists dorsal subluxation of ulna (relative to radius) 87 Function of components of TFCC Volar ulnocarpal ligaments and ECU subsheath Stabilize ulnar carpus relative to ulna Resists carpal supination relative to ulna 88 Injuries to the TFCC Classification possible by Structure involved Articular disc most common Acute direct injury versus attritional tear Presentation acute, subacute, or chronic Primary injury to TFCC or secondary (e.g.- secondary to malunion of distal radius fracture) 89 Injuries to the TFCC Mechanisms for acute injury Fall extension, axial load, pronation Forced rotation relative to forearm machinery Associated with distal radius fracture Chronic injuries Repetitive loading of wrist in ulnar deviation Attritional Progressive wearing of TFC, ulnar carpus, ulnar head More likely with positive ulnar variance 90 15
Clinical presentation Frequently presentation is weeks to months after injury Common presenting symptoms: Ulnar-sided wrist pain Pain increased with rotational activities and/or ulnar deviation activities Pain when lifting or carrying in supinated position Ulnar swelling or prominence of ulnar head Ulnar-sided wrist click 91 Clinical Presentation Examination Negative exam radial aspect of wrist (unless concomitant radial pathology) Lunotriquetral shuck/ tenderness negative (unless LT also involved) Mild ulnar swelling +/- ECU tenderness Reproduction of pain with manual pressure in soft spot bordered by ECU FCU Ulnar styloid Triquetrum 92 Clinical presentation Examination Ulnar impaction sign Forced ulnar deviation of wrist by examiner in attempt to produce contact between lunate and ulnar head/tfcc Ulnar grind Evaluate stability of DRUJ Neutral Pronation Supination Compare to asymptomatic side Piano key sign indicative of dorsal DRUJ subluxation Imaging for TFCC Tears Plain radiographs 90/ 90 PA view Neutral forearm rotation Shoulder abducted at 90 Elbow flexed 90 Palm flat on cassette True lateral view Evaluate for dorsal subluxation of ulna 93 94 Imaging for TFCC Tears Plain radiographs Determine ulnar variance (=A- B) Radiographic measure of relative length of ulnar head (B) relative to ulnar margin of lunate facet of distal radius(a) Evaluate lunate for cystic changes at proximal ulnar aspect Bottom Left Image: Top Right Image: Essentials of Hand Surgery 2002 95 Imaging for TFCC tears MRI Ability to evaluate/visualize TFCC varies Depends upon technique Magnet strength Use of wrist coil Sequences utilized Depends upon experience of radiologist interpreting study May be greatly enhanced with use of pre-mri arthrogram (gadolinium) of RC joint Bony signal changes (edema) may be seen at proximal ulnar aspect of lunate with impaction syndrome 96 16
Imaging for TFCC tears CT scan may be combined with arthrography to better demonstrate site of TFCC tear May be utilized to demonstrate DRUJ subluxation Image abnormal and normal wrists simultaneously in pronation, neutral, and supination Bone scan not frequently utilized May show increased uptake in face of 97 impaction syndrome General Treatment Pathway History and Physical Examination Diagnostic Imaging Non Surgical Treatment Immobilization NSAID OT for modalities Corticosteroid injection Surgical Treatment Usually reserved for patients with symptomatic TFCC tears that are confirmed by diagnostic imaging & are refractory to non-surgical treatment 98 Diagnosis DRUJ instability after subluxation or dislocation Indicative of significant injury to V and/or D RUL and DRUJ capsule Acute dislocation may be amenable to treatment with: Reduction Immobilization in long arm cast in position of maximum stability x 6 weeks 99 Diagnosis DRUJ instability/subluxation/dislocation Late instability/ subluxation If no DRUJ arthritis Usually will require open reconstruction/stabilization of DRUJ Requires use of tendon graft Challenging problem DRUJ arthritis ->salvage procedure Darrach procedure Sauve-Kapandji procedure 100 Diagnosis TFCC tear History consistent with ulnar-sided wrist pain Exam consistent with TFCC tear/pathology Confirmatory imaging studies Asymptomatic TFCC perforation ~ 30% incidence beyond third decade Increases with advancing age Radiographic findings must be correlated with clinical symptoms and examination 101 Traumatic Attritional TFCC Tears 102 17
TFCC Tear Peripheral: May be repairable 103 104 Central: TFCC Tear Debride +/- ulnar recession 105 106 WAFER 107 108 18
Ulnar Shortening Osteotomy 109 110 Causation THANK YOU Fracture easy SLAC? 111 112 References Lauder, Anthony J., M.D., Hanel, Douglas P., M.D., Trumble, Thomas E., M.D.: The Ulnar Shortening Osteotomy, Wrist and Elbow Reconstruction and Arthroscopy, 2006, ASSH, p. 96. Waitayawinyu, Thanapong, M.D., Lauder, Anthony J., M.D., Trumble, Thomas E., M.D.: Arthroscopic Repair of the Triangular Fibrocartilage Complex (TFCC), Wrist and Elbow Reconstruction and Arthroscopy, 2006, ASSH, pp. 62 & 67. Nagle, Daniel J., M.D.: Degenerative Triangular Fibrocartilage Complex Tears; Ulnar Abutment Syndrome, Wrist and Elbow Reconstruction and Arthroscopy, 2006, ASSH, p. 53. Williams, Craig S., M.D.: Triangular Fibrocartilage Tears, Crucial Elements in Hand Surgery, ASSH, edited by John Gray Seiler,III,M.D. 113 References Williams, Craig S., M.D.: Fracture of the Distal Radius, Crucial Elements in Hand Surgery, ASSH, edited by John Gray Seiler,III,M.D. Baratz, Mark E., M.D.: Fracture and Dislocations of the Carpus, Crucial Elements in Hand Surgery, ASSH, edited by John Gray Seiler, III, M.D. Lee, Donald H., M.D.: Arthritis of the Wrist, Crucial Elements in Hand Surgery, ASSH, edited by John Gray Seiler, III, M.D. Ruch, David S., M.D.: Chronic Intercarpal Instability, Crucial Elements in Hand Surgery, ASSH, edited by John Gray Seiler,III,M.D. 114 19