Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Lana Kang, MD, and Andrew J. Weiland, MD*,
Hospital for Special Surgery, New York, NY
Posted November 2007
While our understanding of intercarpal injuries of the wrist
has improved, the methods of treating these injuries remain variable and
controversial. We are thus left with treatment options that, while more effective
than in the past, are certainly not "curative."
Arthroscopy of the wrist has provided a new and different
window into the wrist joint. Indeed, an increasing number of investigative
studies in peer-reviewed orthopaedic journals have confirmed that arthroscopy of
the wrist is an accurate diagnostic tool. These studies have shown that, in comparison
with other imaging modalities, arthroscopy provides both improved visualization
and improved diagnosis of intercarpal ligamentous injuries1-3.
But in our enthusiasm to embrace wrist arthroscopy and other
new techniques, perhaps we tend to lose sight of the fundamental questions that
should be asked when doing such research. In this regard, the nature and focus
of the study, "Intercarpal Ligament Injuries Associated with Fractures of the
Distal Part of the Radius," are similar to those of its predecessors. The
authors imply that their overall goal is to determine the incidence and natural
history of intercarpal injury. However, the design and result of the study do
not achieve this goal. The readers are left with no better understanding of the
prevalence or natural history of intercarpal injuries; in addition, questions
of fundamental importance remain: Which intercarpal injuries are truly the ones
of interest—those that are purely ligamentous, or those associated with distal
radial fractures? Which intercarpal injuries are clinically more common and
problem-causing?
What this study does achieve is a descriptive correlation
between the findings on physical examination and radiographs and the intraoperative
arthroscopic findings with regard to distal radial fracture in fifty-one
patients. One novel finding was that radiographic ulnar variance of >2 mm at
the time of injury was significantly correlated with grade-3 scapholunate
ligament tears (p = 0.01). The utility of this finding is that it suggests that
ulnar variance can be used as a radiographic marker for intercarpal ligament
injuries in the presence of a distal radial fracture. Another important finding
was that, when compared with extraarticular fracture, intraarticular fracture
was associated with a twofold increased rate of scapholunate dissociation. It
would be useful to know the correlation between the degree of scapholunate
dissociation and the degree of fracture displacement for specific intra-articular
fracture patterns, such as T-type and radial styloid fractures, because these
fracture types reflect a sagittal line of transmission of energy into the
carpus1 in healthy bone but dissipate energy into a pattern of
extensive comminution in osteopenic bone.
The results of this study and similar published studies
suggest that arthroscopy should be incorporated more frequently into the
treatment algorithm for distal radial fractures. Before adopting this suggestion
into practice, however, we need to consider the following: several long-term
outcome studies of patients with distal radial fractures show little
correlation between functional outcome and radiographic progression of
posttraumatic arthritis4,5. This finding suggests that
arthroscopically-assisted treatment of intra-articular fractures may not have
as great a positive impact in the treatment of distal radial fractures as we
originally hoped, especially when compared with other technical factors, such
as method of fixation and surgical approach. Secondly, it is important to
consider that, although intercarpal ligamentous injury is very common after
distal radial fractures1,2, the degree to which it is clinically
relevant remains unclear, especially when compared with problems such as malunion,
ulnar impaction, deformity, and arthrofibrosis. Finally, the important clinical
problem typically encountered is not the triangular fibrocartilage complex tear
or scapholunate injury that occurs with a distal radial fracture. Rather, it is
the triangular fibrocartilage complex or scapholunate-related wrist pain in the absence of fracture—especially the injury that remains unaddressed and
untreated for months or years after a "sprain" or a fall—for which the prevalence,
natural history, prognosis, and response to surgical treatment remain undefined.
Consideration of these facts should not imply that the
published literature on the effectiveness of wrist arthroscopy has not been
informative or that hand surgeons should abandon evaluating the role of arthroscopy
in providing quantifiable improvement in the diagnosis and management of many
challenging conditions of the wrist. Since its advent over a decade ago, wrist
arthroscopy has certainly played an invaluable role in our ability to detect intercarpal
injuries when they do occur with distal radial fractures. But it has not been
shown that our newfound ability to diagnose these injuries under these
circumstances has led to significant changes in functional outcome. This
suggests that injuries that occur in association with carpal or distal radial
fractures are clinically distinct from those that occur without fracture, and it
also suggests that most injuries that occur in association with distal radial
fracture will heal spontaneously.
*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.
References
1. 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.
2. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000;376:229-35.
3. 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.
4. Chen NC, Jupiter JB. Management of distal radial fractures. J Bone Joint Surg Am. 2007;89:2051-62.
5. Goldfarb CA, Rudzki JR, Catalano LW, Hughes M, Borrelli J Jr. Fifteen-year outcome of displaced intra-articular fractures of the distal radius. J Hand Surg [Am].2006;31:633-9.
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