BRITISH SOCIETY FOR SURGERY OF THE HAND Instructional Courses in Hand Surgery

WRIST OCCUPATIONAL AND MEDICOLEGAL ASPECTS 3rd & 4th June 2016 SERIES 6, COURSE 6

INSTRUCTIONAL COURSES IN HAND SURGERY For surgeons and trainees throughout Europe. Series Six 2014 - 2016 Organising Committee: J L Hobby G Bourke D J Brown V Bhalaik F Iwuagwu P Johnston Z Naqui G D Snmith BOTA Representative PLASTA Representative

27 May 2016 Dear Speaker/Participant Welcome to the 6th meeting of the sixth series of the Instructional Courses in Hand Surgery and to the Manchester Conference Centre. All refreshments and luncheon on both days will be served in the Pioneer Room. The trade stands will be located in the Pioneer Room, where refreshments and lunch will be served throughout the two days. We would be most grateful if all participants would visit the exhibition stands, as I am sure you will appreciate that their attendance helps to support these courses. The telephone number for the BSSH registration desk is: 07582 902 630. Since the introduction of online registration for the Instructional Courses, we no longer send out the programme and other details in advance. Information about the course can be found: http://www.bssh.ac.uk/about/events/2085/ichs_66_wrist_occupational_and_medicolegal_aspects I will be present throughout the two days and if you have any queries, please do not hesitate to contact me. Yours sincerely

Angela Rausch Events & Membership Administrator

INSTRUCTIONAL COURSE IN HAND SURGERY (SIX MEETING, SIXTH SERIES) WRIST, OCCUPATIONAL AND MEDICOLEGAL ASPECTS AT THE MANCHESTER CONFERENCE CENTRE 3RD & 4TH JUNE 2016 FRIDAY 3RD JUNE 08:30

Registration and refreshments

08:55

Welcome and introduction

Jonathan Hobby

09:00 09:10 09:25 09:50 10:05

SESSION 1: EVALUATION OF THE WRIST CHAIR: JONATHAN HOBBY Structure and function of the wrist with reference to pain radiology History and examination of the wrist Arthrography, CT, ultrasound and MRI – What you can and what you can’t see Arthroscopy – How I do it and what is normal Discussion

Mo Akhavani Phil Sauve Waqar Bhatti Riccardo Luchetti Jonathan Hobby

10:15

Refreshments and trade exhibitions

12:05 12:25 12:40

SESSION 2: DISTAL RADIUS FRACTURES CHAIR: DAVID SHEWRING Radius Fractures – Classification, assessment, imaging and associated injuries Children’s radius fractures: Potential for remodelling, acceptable limits of malunion, diagnosis and management of growth arrest Non-operative treatment? How to treat extra-articular fractures: The evidence (including K-wiring) Volar locking plates – Principles, biomechanics and uses Intra-articular fractures – Decision making, treatment options and outcomes (including K-wiring) Management of distal radial malunion – Dorsal or volar, bone graft or substitute? Techniques and results DRAFT Study – Where are we now? (Discussion of cases) Treatment of ulnar fractures associated with distal radius fractures TFCC tears: Arthroscopy assessment and treatment

12:55

Lunch and trade exhibitions

10:40 10:55 11:05 11:20 11:35 11:50

15:00 15:15

SESSION 3: LIGAMENTOUS INJURIES IN THE WRIST CHAIR: LINDSAY MUIR Wrist ligament anatomy and kinematics Acute ligament injuries – Patterns and diagnosis and management, including acute scapho-lunate tear and carpal/perilunate dislocations and transcaphoid /styloid fracture dislocation Acute management of intrinsic ligament injuries Midcarpal and ulnar-sided instability: Clinical presentation, clinical tests, radiology and management – Arthroscopic, soft tissue and fusion Chronic scapho-lunate instability: Symptoms and signs, classification, natural history and treatment of pre-arthritic stages Salvage of chronic carpal instability Discussion and Faculty Cases

14:15

BREAKOUT SESSION Wrist instability for the uninitiated… A tutorial

15:30

Refreshments and trade exhibitions

13:45 14:00 14:15 14:30 14:45

Joe Dias Farhan Ali Tim Davis Vijay Bhalaik Ian McNab Jeremy Field David Shewring Jeremy Field Riccardo Luchetti

Jonathan Hobby Zaf Naqui Mathilde Gras David Hargreaves John Stanley John Stanley Lindsay Muir Dan Brown

16:00 16:15 16:30 16:45 17:00 17:15 17:30

SESSION 4: ULNAR CORNER PROBLEMS & FOREARM CHAIR: ZAF NAQUI Ulna-carpal impaction and central TFC tears: Ulnar shortening Other causes of ulnar-sided wrist pain, including pisotriquertral OA, ECU The anatomy and physiology of forearm rotation Instability of the DRUJ Complex forearm injuries – Galeazzi, Monteggia & Essex Lopresti Salvage of the stiff or painful distal radioulnar joint Discussion

18:00

Close of day

Miguel Oliveira David Warwick Vivien Lees Andrea Atzei Grey Giddins Grey Giddins Zaf Naqui

SATURDAY 4TH JUNE 08:00

Registration

08:30 08:45 09:00 09:15 09:30 09:45

SESSION 5: DISORDERS OF THE RADIAL SIDE OF THE WRIST AND SCAPHOID CHAIR: DAN BROWN Radial-sided wrist pain When is a scaphoid fractured? Acute scaphoid fractures – Plaster or fixation? Scaphoid fixation – How to do it Scaphoid non-union – Simple graft, vascularised graft and arthroscopic technique Discussion and Faculty’s Cases

10:00

Refreshments and trade exhibitions

10:30 10:50 11:10 11:30 11:50 12:00

SESSION 6: THE HAND AND BRAIN CHAIR: NICK DOWNING The doctor as an expert witness The influence of psychological factors on physical disease: Does RSI exist? Dystonia and the musician’s hand CRPS Factitious disorder: Clinical aspects Discussion

David Shewring Jonathan Hobby Katherine Butler Jonathan Hobby Tim Davis Nick Downing

12:25

Series 7 Preview

Lindsay Muir

12:30

Lunch and trade exhibitions

13:20 13:30 13:40 13:50

SESSION 7: OVERUSE? CHAIR: GILL SMITH Epicondalgia A practical guide: Disorders of the tendons: DeQuervain’s, trigger finger, peritendonitis crepitans Chronic compartment syndrome Discussion

14:45 15:00 15:15 15:30

SESSION 8: WRIST ARTHRITIS CHAIR: JONATHAN HOBBY Avascular necrosis of carpal bones Osteoarthritis of the wrist: Presentation and patterns of wrist involvement Osteoarthritis of the wrist: Treatment options, partial fusion, partial and total arthroplasty Wrist fusion: How I do it Partial fusion in the wrist options and technical tips Wrist arthroplasty: How I do it – Technical tips Discussion

15:45

Close of Meeting

14:00 14:15 14:30

Ian Trail Tim Davis Joe Dias Phil Sauve Ian McNab Dan Brown

Nick Downing Miguel Oliveira Jill Arrowsmith Gill Smith

Ian Trail Philip Johnston David Warwick Lindsay Muir Nick Downing Dan Brown Jonathan Hobby

Continued Medical Development: Friday - 7.0 points; Saturday - 7.0 points; Total - 14.0 points

Dr. Andrea Atzei

Dr. Andrea Atzei was trained in Orthopaedics & Traumatology and Plastic Reconstructive Surgery at the University of Verona, Italy. Since the very beginning of his career, his clinical practice was devoted hand & wrist surgery and reconstructive microsurgery. He attained the European Diploma in Hand Surgery (EBHS) in 1996. He had 20 years of practice at the University Hospital of Verona, where he was appointed as Consultant in the Hand Surgery Unit, Associate part-time Professor at the Post-graduate program in Orthopaedics and Plastic Surgery (1996 – 2011), Clinical Coordinator of the Master Degree in Hand Surgery (2001-2003). Dr. Atzei is involved in several Scientific Societies: Italian Society for Surgery of the Hand (SICM), as Member of the Council since 1999 and currently President of the SICM Committee on Outcome & Guidelines; International Wrist Investigators Workshop (IWIW); American Society for surgery of the Hand, International Member; International Federation of Societies for Surgery of the Hand, Member of the IFSSH Committee on Arthroscopy; European Wrist Arthroscopy Society (EWAS), EWAS President (2014-2015) and member of the Board. Chairman and Keynote speaker of several hand & wrist meetings and courses in Europe and overseas, he has authored more than 100 scientific papers and book chapters. He was awarded the Whipple Prize (2007) by the EWAS, for recognition of his contribution to the development of wrist arthroscopic surgery.

Dr Mathilde Gras

Dr Gras has studied DIU arthroscopy, hand surgery- Bichat, Paris, Pr Oberlin 1st and 2nd years and microsurgery - Bichat, Paris, Pr Oberlin. She has been the senior in Hospices Civiles de Lyon, Hand and Upper limb surgery – Professor Herzberg – 2009-2011. Dr Gras is an Associate Member of the French Society of Hand Surgery and is a member of EWAS: European Wrist Arthroscopic Surgery. Dr Gras has been involved in many publications, including Arthroscopic Treatment of Intrinsic Ligament Injuries of the Wrist. In Sports Injuries, 2nd edition, Arthroscopic management of wrist intrinsic ligament tears – Techniques in arthroscopie du membre supérieur – Cahiers d’enseignement de la SOFCOT 2013, Treatment of Avascular Necrosis of the Proximal Pole of the Scaphoid by Arthroscopic Resection and Prosthetic Hemi Replacement Arthroplasty using the Pyrocarbon Adaptative Proximal Scaphoid Implant (APSI): Long Term Functional Outcomes. Journal of Wrist Surgery Volume 1, number 2, November 2012, pages 159-164 and many more. Dr Gras is currently working on a couple of publications - Book on arthroscopic techniques and Spasticity: selective neurectomy.

Dr. Riccardo Luchetti

Rimini Hand and Upper Extremity Centre, Rimini (Italy) Dr. Riccardo Luchetti studied medicine in Modena (1972-8) and was awarded his doctorate by the Medical University of Modena (1979). His specialist training in Orthopaedic Surgery and Hand Surgery were at the University of Modena (Prof. P. Bedeschi: 1979-86). He also underwent specialist training in Clinical Neurophysiology and Electromyography at the University School of Medicine of Pavia (1981). He performed research at the Rizzoli Orthopaedic Institute of Bologna University in 1988. 1988-99 Head of assistants in Dept of Orthopaedics and Hand Surgery at the Hospital of San Marino Republic 2000-9 Contract Professor in Hand Surgery at the Clinic of Plastic and Reconstructive Surgery of Ancona University. Currently Consultant for the Pathology of the Wrist at the Department of Hand Surgery of the Clinic of Plastic and Reconstructive Surgery in the Multimedica Policlinic of Milan University. 1980 Member of the Italian Society for Hand Surgery (SICM) 1999 Chief of the Informatics Committee of SICM Past President of the European Wrist Arthroscopy Society (EWAS). Past-President of the Italian Society for the Surgery of the Hand (SICM) 2013-2015 and present President of ISSPORTH. Also a member of the Italian Society of Orthopaedic and Traumatology, Italian Society of EEG and Clinical Neurophysiology, Italian Society of Shoulder and Elbow Surgery, International Wrist Investigator Workshop, French Society for Surgery of the Hand (GEM), American Society for Surgery of the Hand (ASSH), American Academy of Orthopaedic Society (AAOS) Dr. Luchetti is the author of three books and a co-author of the Italian Textbook of Hand Surgery and over 120 scientific articles and book chapters. He is married and has a 30 year-old daughter and a 14 year-old boy.

British Society for Surgery of the Hand Instructional Courses Series Six 2014 – 2016

Meeting 6.6 Wrist, Occupational and Medicolegal Aspects (14 CME points)

Manchester Conference Centre Friday and Saturday 3rd & 4th June 2016 International Faculty Dr Andrea Atzei Dr Mathilde Gras Dr Riccardo Luchetti

Verona Paris Rimini National Faculty

Mr Mo Akhavani Mr Farhan Ali Miss Jill Arrowsmith Mr Vijay Bhalaik Dr Waqar Bhatti Mr Dan Brown Ms Katherine Butler Professor Tim Davis Professor Joe Dias Mr Nick Downing Mr Jeremy Field Mr Grey Giddins Mr David Hargreaves Mr Jonathan Hobby Mr Philip Johnston Professor Vivien Lees Mr Ian McNab Mr Lindsay Muir Mr Zaf Naqui Mr Miguel Oliveira Mr Philip Sauve Mr David Shewring Miss Gill Smith Professor John Stanley Professor Ian Trail Mr David Warwick

London Manchester Derby Wirral Manchester Liverpool London Nottingham Leicester Nottingham Cheltenham Bath Southampton Basingstoke Cambridge Manchester Oxford Manchester Manchester Guildford Portsmouth Cardiff London Wigan Wrightington Southampton

INTSRUCTIONAL COURSE IN HAND SURGERY 6.6 WRIST, OCCUPATIONAL AND MEDICOLEGAL ASPECTS AT THE MANCHESTER CONFERENCE CENTRE 3RD & 4TH JUNE 2016

DELEGATE LIST CORRECT AS OF THURSDAY 27 May 2016

Title Mr Mr Mr Miss Mr Mrs Mr Miss Dr Dr Mr Mr Dr Dr Miss Mrs Ms Mr Miss Mr Ms Dr Mr Dr Mr Mr Mr Professor Professor Ms Mr Dr Dr Mr Mr Professor

Forename Mo Anmar Farhan Katerina Dan Sara Magnus Jill Andrea EvaMaria Onur Vijay Waqar Asa Grainne Karen Anca Mark Kate Dan Katherine Paul Chris Peter Henk Jonathan Quentin Tim Joe Ella Ella Nick Gerald Jamila Ross Jeremy Grey

Surname Akhavani Al-Shawi Ali Anesti Armstrong Arnadottir Arnander Arrowsmith Atzei Baur

Town London Truro Manchester Exeter Nottingham Uppsala, Sweden London Derby Viale Murnau

Berber Bhalaik Bhatti Bolander Bourke Brandt Rosing Breahna Brewster Brown Brown Butler Ceuterick Coapes Coeman Coert Compson Cox Davis Dias Donnison Donnison Downing Duff Eriksen Fawdington Field Giddins

London Wirral Manchester Uppsala, Sweden Leeds Aalborg East Grinstead Birmingham Watford Liverpool London Brussels Middlesbrough Deinze, Belgium Utrecht London Inverness Nottingham Leicester Derby Derby Nottingham Dublin Copenhagen Birmingham Cheltenham Bath

Miss Dr Mrs Dr Miss Mr Mr Mr Ms Mrs Mr Mr Mr Mrs Mr Mr Mr Mr Miss Mr Dr

Gill Gras Greenhowe Gueffier Hamlin Hargreaves Hassan Hobby Hobby Isaacson Issa Iwuagwu Johnson Johnson Johnston Joyce Klass Kraan Langley Larkin Larsen

Liverpool Paris Dundee Bourgoin Jallieu Aberdeen Southampton Nottinghm Basingstoke Basingstoke Stoke-on-Trent Aylesbury Chelmsford Perth Stockton-on-Tees Cambridge Dublin Manchester Delft Oxford Portsmouth Aalborg

Larsen

Copenhagen

Lees Logina Luccardi Luchetti Madura Mariathas McArdle McNab Middleton Miller Milward Moon Mopuri Morritt Muir Nagrani Naqui Nicholls Oliveira Palial Pearl Phillips

Mr Miss Mr

Parneet Mahhilde Jennifer Xavier Katharine David Sami Jonathan Lotte Toni Fadi Fortune Simon Riem Phillip Kenneth Ben Gerald Clare Grahame Lotte Priess Morten Bo Vivien Laura Anna Riccardo Tomas Chrishan Ciarstan Ian Claire Clare Tim Anna Nabil Daniel Lindsay Prakash Zaf Lynne Miguel Vishal Robert SallyAnne Mark Kavita Roland

Dr Miss

Christine Sadia

Quinlan Rafiq

Manchester Riga London Rimini Manchester Sheffield Hull Oxford London Nottingham Leicester Redditch Chelmsford Chelmsford Manchester Llanelli Manchester Coventry Guildford Scunthorpe East Grinstead Newcastle Upon Tyne East Grinstead BSSH Staff Newcastle upon Tyne Cork East Grinstead

Dr Professor Dr Dr Dr Mr Mr Miss Mr Miss Miss Mr Ms Mr Mr Mr Mr Mr Mrs Mr Mr Mr Miss

Pickford Prashar Pratt

Dr Mrs Mr Mr Miss Mr Mr Mr Miss Mr Mr

Mr Mr Miss Mr Professor Mr Professor Mr Mr Mr Dr

Dimitris Helen Gjermund Ibrahim Soha Philip Ranjit David Claire Rohit TorJohannes Stray Gill Lars John Jeremy Janni Kjargaard Roshin Simon Vi Vien Ferenc Ian Ramesh David Daniel Daniel Fizan Luc

MD

Lena

Miss Dr Professor Mr Dr

Reissis Roberts Roe Roushdi Sajid Sauve Sehjal Shewring Simpson Singh Slardahl

London BSSH Staff Trondheim Derby Stoke-on-Trent Porstmouth Margate Cardiff Livingston Shrewsbury Ãlesund

Smith Solgaard Stanley Stanton Thillemann

London Copenhagen Wigan Sheffield Holstebro

Thomas Thomas Toh Toth Trail Vidyadharan Warwick Wilks Williams Younis van Overstraeten von V Palffy

Dumfries Perth Hull Barlborough Wigan Birmingham Southampton Leeds Harlow Blackburn Tournai Holstebro

INSTRUCTIONAL COURSES IN HAND SURGERY 6.6 MANCHESTER CONFERENCE CENTRE 3RD & 4TH JUNE 2016 The British Society for Surgery of the Hand would like to thank the following companies for supporting the Instructional Courses in Hand Surgery:

TRADE EXHIBITORS ACUMED LTD Huebner House, The Fairground, Weyhill, Andover, Hampshire SP11 0QN Telephone: 01264 774 450, Email: [email protected] Contact: Ms D Brown ARTHREX LTD Unit 5, 3 Smithy Wood Drive, Smithy Wood Business Park, S35 1QN, Sheffield Telephone: +44 7785 623465, [email protected] Contact: Brendon Leigh MEDARTIS LTD 17A St Christopher Way, Pride Park, Derby DE24 8JY Telephone: 01924 476 699, Fax: 01924 472 000, Email: [email protected] Contact: Ms M Widdowson

Session 1 (09:00) Mr Mo Akhavani BSSH Instructional Course 6.6 – June 2016

BSSH Instructional Course 6.6 –June 2016

Structure and Function of the Wrist with Reference to Radiology

03.06.2016

Need to cover • Anatomy • Systematic approach to reading the X-ray • Common Views

Mo Akhavani MD FRCS(Plas t) DipHandSurg EBHS Dip Cons ultant Plas tic and Hand s urgeon Royal Free Hos pital, London

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Osseous Anatomy • The osseous structures of the wrist are • The distal portions of the radius and ulna • The proximal and distal rows of carpal bones • The bases of the metacarpals

What to look for? • ABCDs rule • Alignment • Bone • Mineralisation, osteopenia • Osteophytes • Joint spaces • Fractures • Cartilage • Joint spaces • Calcifications • Distribution of any changes • Symmetry • Pattern of joint involvement • Soft Tissue • Swelling • Calcification

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

What is a standard wrist view? • PA

• Arm abducted 90° from the trunk and the forearm flexed at 90° to the arm

• Lateral • Oblique

• Additional Views: • • • • •

radial or ulnar deviation carpal tunnel carpal bridge special scaphoid views other specialised techniques Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Structure and Function of the Wrist with Reference to Radiology

PA views Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

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Session 1 (09:00) Mr Mo Akhavani BSSH Instructional Course 6.6 – June 2016

03.06.2016

PA views

On PA views comment on

• With the forearm in a pronated position, the ulnar styloid is seen in profile.

• Arcs of the wrist • Scapholunate joint space • Ulnar variance • Carpal height

• When views are taken in supination, the ulnar styloid overlaps the central portion of the distal ulna. • With the wrist in a neutral position, one-half or more of the lunate (L) should contact the distal radial articular surface. Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Normal Arcs of the wrist

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Gilula’s Arcs

• In the normal situation, on a neutral PA view

• curvilinear arcs are roughly parallel • without disruption • interosseous spaces are nearly equal in size.

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Normal Scapholunate Joint Space • Measured at the center of the scapholunate joint • 2mm or less • Remains constant even within the normal range of radial or ulnar deviation of the wrist

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Structure and Function of the Wrist with Reference to Radiology

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Session 1 (09:00) Mr Mo Akhavani BSSH Instructional Course 6.6 – June 2016

Ulnar Variance

03.06.2016

Ulnar Variance

• Ulnar variance :

• extending a line along the distal articular surface of the radius toward the ulna • measuring the distance from this line to the distal ulna

Influenced by Rotation • Pronation => ulnar positive • Supination => ulnar negative MUST use standardised films (90/90)

• Normally, the radius and ulna are almost the same length • If Ulna short: -ve variance • If Ulna long: +ve variance Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Carpal Height

On PA views comment on

• Distance between the base of the third metacarpal and the distal radial articular surface

• Arcs of the wrist • Scapholunate joint space • Ulnar variance • Carpal height

• Must be on PA radiograph of the wrist

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Lateral Views • Comment on: • Longitudinal Axes of the Radius, Lunate, and Capitate • Longitudinal Axis of the Scaphoid • Distal Radial Measurements

Lateral Views Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Structure and Function of the Wrist with Reference to Radiology

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

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Session 1 (09:00) Mr Mo Akhavani BSSH Instructional Course 6.6 – June 2016

03.06.2016

Lateral View • Look for : • The long axis of the third metacarpal should be parallel with the long axis of the radius • Ulna covered by the Radius • Pisiform projects directly over the dorsal pole of the scaphoid. Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Longitudinal Axes of the Radius, Scaphoid, Lunate, and Capitate • The axis of the radius is constructed as a line parallel to the center of the radial shaft • The axis of the lunate can be drawn through the midpoints of its proximal and distal articular surfaces • The axis of the capitate is drawn through the centers of its head and its distal articular surface • The axes of the radius, lunate, and capitate should superimpose, with 0 to 30° described as the capitolunate angle in normal patients •

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Longitudinal Axis of the Scaphoid • Line drawn through the midpoints of its proximal and distal poles • Angle formed between the long axis of the radius, the lunate, and the capitate and that of the scaphoid • (the scapholunate angle) • Ranges: 30o and 60o and • Averages 47o

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Distal Radial Measurements • 3 key measurements

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Lateral Views • Comment on:

• Palmar tilt: 11o

• Angle of intersection between a line drawn tangentially across the most distal points of the radial articular surface and a perpendicular to the midshaft of the radius

• Longitudinal Axes of the Radius, Lunate, and Capitate • Longitudinal Axis of the Scaphoid • Distal Radial Measurements

• Radial inclination: 22o • Ranges 11-30 o

• Radial length: 22mm

• distance between the tip of the radial styloid and the ulnar head articular surface

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Structure and Function of the Wrist with Reference to Radiology

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

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Session 1 (09:00) Mr Mo Akhavani BSSH Instructional Course 6.6 – June 2016

03.06.2016

Oblique View • PA position, with the hand in partial pronation • helpful in detection of

Oblique View

• scaphoid tuberosity and waist fractures • dorsal margin triquetral fractures • show the first carpometacarpal and the scaphotrapezoidal joints

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Radial and Ulnar deviation views • In radial deviation:

• The scaphoid rotates toward the palm and appears foreshortened. • The distal scaphoid is projected endon and appears as a circular density (asterisk).

• In ulnar deviation:

• The scaphoid is seen in full length.

Carpal Tunnel View

• The scaphoid rotates (its distal pole moving dorsally and toward the ulna) and appears to elongate (arrows). Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Carpal Tunnel View • Palmar soft tissues • Palmar aspects of the • • • • • •

trapezium, scaphoid tuberosity, capitate, hook of the hamate, triquetrum, entire pisiform.

Scaphoid Views Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Structure and Function of the Wrist with Reference to Radiology

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

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Session 1 (09:00) Mr Mo Akhavani BSSH Instructional Course 6.6 – June 2016

Scaphoid Views

Scaphoid Views

• 4 Keys X-rays: • • • •

03.06.2016

PA with ulnar deviation 300 ; lateral s emi-pronated oblique s emi-s upinated oblique

• Scaphoid waist fractures are best seen on an ulnar deviated angled PA view and true lateral film • Dorsal sulcal fractures are best seen on a 45° semipronated oblique view on which the fracture line runs from the dorsal apex of the ridge adjacent to the lunate • Proximal pole fractures are best seen on a 45° semi-supinated oblique view. Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

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PA in Radial and Ulnar Deviation

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Semisupinated and Semipronated Oblique View • A) Normal AP semisupinated oblique radiograph: • The hamate (H), pisiform (P), triquetrum (tq), and pisiformtriquetral joint (arrow) are specifically seen on this view when evaluating for inflammatory disease.

• B) Normal semipronated oblique radiograph: • radial aspect of the wrist, • scaphoid • radial styloid (arrow)

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Structure and Function of the Wrist with Reference to Radiology

Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

Summary • X-Rays must be standardised • Carpal alignment on standardised lateral view • Scaphoid view – PA in ulnar deviation 30o tilt • Some fractures cannot be seen on XR • Beware the other carpal bones Stru ctu re an d Fu n cti o n of the W ri st wi th Referen ce to R ad i o l o gy

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Session 1 (09:10) Mr Philip Sauve

Examination of the Wrist – Mr Philip Sauve FRCS(Tr&Orth), Consultant Trauma & Orthopaedic Surgeon Diagnosis of wrist pathology is made by obtaining a detailed history and performing a thorough clinical examination followed only then by directed imaging and, occasionally, wrist arthroscopy. Wrist pain may be due to an acute fracture or fracture non-union, articular degeneration, ligamentous injury or tendinopathy. Pain at the radial or ulnar side of the wrist can be attributed to many possible aetiologies. The intimate relationship between osseous and ligamentous structures imposes difficulties in determining the source of ulnar-sided wrist pain in particular, especially with instability as a result of ligamentous injury. This instructional lecture will outline the principles of evidence-based wrist examination with a special emphasis on provocative tests to diagnose the causes of radial and ulnar sided wrist pain.

Scaphoid Fracture Fixation, How I do it – Mr Philip Sauve FRCS(Tr&Orth), Consultant Orthopaedic Surgeon Indications for scaphoid fracture fixation include fracture displacement, delayed union or non-union and associated injuries including perilunate fracture dislocation and distal radius fracture. Fracture fixation may be performed with antegrade or retrograde screw fixation with an open or percutaneous approach. In this instructional lecture I will outline how I perform percutaneous retrograde screw fixation of a scaphoid waist fracture and open antegrade proximal pole scaphoid fracture fixation.

Session 1 (09:25) Dr Waqar Bhatti

Arthrography, CT, ultrasound and MRI – What you can and what you can’t see The aim of this presentation is to cover:

Basic MRI sequences, techniques and MR arthrography. Normal MRI anatomy of the intrinsic and extrinsic ligaments shall be covered. Examples of ligamentous pathology and the optimal imaging planes to identify pathology shall be discussed. Patterns of pathological carpal bone marrow signal and imaging assessment of ulna sided wrist sprain shall be covered.

Session 1 (09:50) Dr Riccardo Luchetti

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Arthroscopic Wrist Anatomy and Setup Nicole Badur, Riccardo Luchetti, and Andrea Atzei

Introduction Arthroscopy, first described in 1918 in a cadaver knee joint and 1962 successfully as an operative procedure [1], has equipped the orthopedic surgeon with an excellent tool to assess and treat intra-articular pathologies. After successful application on large joints, the technique has been progressively extended onto smaller sized joints as the shoulder, the hip, the ankle, the elbow and the wrist. Wrist arthroscopy was reported first in 1979 for diagnostic purposes [2]. From the late 1980s through the 1990s arthroscopy has become an important means in the armory of a hand surgeon and wrist arthroscopy the so-called golden standard for diagnosing intra-articular lesions in the wrist. Since then it has continued to evolve not only as a diagnostic, but also therapeutic tool and indications have steadily grown. Iatrogenic complications from open wrist surgery as capsular fibrosis resulting in stiffness are reduced by arthroscopic surgery [3, 4]. Wrist arthroscopy is now an established procedure for treating many intra-articular wrist pathologies with chronic wrist pain and in acute wrist trauma [5].

Electronic supplementary material: Supplementary material is available in the online version of this chapter at 10.1007/978-1-4614-1596-1_1. Videos can also be accessed at http://www.springerimages.com/ videos/978-1-4614-1595-4. N. Badur, M.D. Hand Surgery and Surgery of Peripheral Nerves, University Hospital Bern, Freiburgstrasse, Bern 3010, Switzerland e-mail: [email protected] R. Luchetti, M.D. (*) Private Activity, Rimini Hand & Rehabilitation Center, Via Pietro da Rimini 4, Rimini 47924, Italy e-mail: [email protected] A. Atzei, M.D. Fenice HSRT Hand Surgery and Rehabilitation Team, Centro di Medicina, Via Repubblica, 10/B Villorba, Treviso 31050, Italy Policlinico San Giorgio, Via Gemelli 10, Pordenone 33170, Italy e-mail: [email protected]

The wide list of indications for wrist arthroscopy is continuously growing and includes basic treatment of soft tissue pathologies as synovitis, ganglia, fibrosis, stiffness, management of triangular fibrocartilage complex (TFCC) tears, scapholunate- and lunotriquetral ligament lesions and removal of loose bodies. Osseous procedures include partial bone resections in ulnocarpal- or ulnostyloid impaction syndrome and scaphotrapeziotrapezoid (STT) or triquetrohamate (TH) arthritis [6]. The method has also gained wider acceptance in more sophisticated procedures as assisting reduction of intra-articular distal radius fractures [7–13], or scaphoid fractures [14, 15] and in posttraumatic sequelae. Arthroscopically assisted osteotomy in intra-articular distal radius malunions [16, 17], treatment of scaphoid nonunions [15] and arthroscopic arthrolysis has been described [18]. Arthroscopic decompression of the lunate for Kienböck’s disease [19], arthroscopic proximal row carpectomy [20] and arthroscopically assisted partial wrist fusions have been described [21]. Dedicated miniaturized instrumentation meeting the needs of a small joint, a thorough knowledge of wrist anatomy and the anatomic landmarks [22] as well as careful and skilled surgical technique are required to allow a safe and appropriate arthroscopic treatment of disorders in the wrist joint.

Setup and Equipment Setup Wrist arthroscopy requires standard arthroscopic equipment. An arm table, arthroscopy tower system with monitor, video recorder and printer, a scope with a camera attached, light source with fiber-optic cable, motorized shavers, radiofrequency ablators, an image intensifier and a traction system have become the standard of care. Digital systems allow data transfer to a USB stick. The intervention is frequently carried out under regional anesthesia (axillary block) or general anesthesia under sterile

W.B. Geissler (ed.), Wrist and Elbow Arthroscopy: A Practical Surgical Guide to Techniques, DOI 10.1007/978-1-4614-1596-1_1, © Springer Science+Business Media New York 2015

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Fig. 1.1 Different traction systems. Vertical traction tower designed by Whipple (Linvatec®, Largo, FL, USA). Wrist positions can be adjusted through a ball-and-socket joint. The central rod position hinders intraoperative X-ray views (a). Traction tower designed by Borelli (Micai®, Genova, Italy), allowing free dorsal and volar approach to the wrist, rotation of the wrist and easy image intensifier access with the eccentric

rod position. Vertical and horizontal position of the wrist is possible (b). Wrist tower designed by Geissler (Acumed®, Hillsboro, Oregon, USA) that can be modified allowing different angles in wrist position and vertical or horizontal traction positioning without interference with intraoperative X-ray (c)

conditions in an aseptic operation theater. Although wrist arthroscopy has also been described without exsanguination [15], the use of a pneumatic tourniquet placed at the upper arm is generally recommended. The patient is positioned supine on the operation table with the affected arm on a hand table. The arm is abducted 90° and the elbow flexed 90° allowing a vertical position of the forearm, wrist and hand. In this position the wrist is kept in neutral prono-supination. Horizontal wrist arthroscopy has been described [23, 10], however, we prefer the vertical position to maintain a neutral rotation of the wrist and 360-degree access to the wrist. Traction is usually recommended to distend the wrist and improve intra-capsular vision [1]. Vertical traction across the wrist is preferably achieved using a traction tower. The arm and forearm need to be padded with towels, preventing direct skin contact with

the metal of the tower, and are then stabilized to the tower. Different models of traction towers exist (Fig. 1.1). Vertical traction is then applied by suspending the fingers with sterile finger traps and applying counter-traction through a gearing mechanism at the tower that allows precise modulation. To visualize the radiocarpal joint, the finger traps are preferably placed on the index- and middle-finger or the index-, middle- and ring finger. Other traction devises allowing traction to all fingers are also used (Fig. 1.2). The applied traction varies between 3.5 and 7 kg in patients. For visualization of the STT joint traction can be applied by suspending only the thumb. Advantages of traction towers as the Whipple-, Borelli- or Geissler traction tower are that they provide good stability that can be crucial for certain interventions as arthroscopic assisted reduction of distal radius fractures. Further they can

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Fig. 1.2 Vertical traction is applied using Chinese finger traps at the index- and middle finger (a). Traction on all fingers, the thumb included if needed, can be applied by special traction hands (e.g., Arthrex®, Naples, FL, USA) (b) and standard suspension systems (c) [Modified

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from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

Fig. 1.3 Unconventional vertical overhead traction systems allowing rotation of the wrist and 360° access (a and b). A counter-traction band is placed around the arm proximal to the elbow. The tension can be adjusted by adding weights (c)

be sterilized. For some interventions, however, we need a free pronosupination as for arthroscopic stabilization of TFCC lesions and the stability provided by the tower can hinder. Also the central bar of some towers can interfere with the intraoperative use of an image intensifier. The fact that traction towers need to be sterilized can be a hassle if there is only one available and more wrist arthroscopies are performed within the same operating session.

If a traction tower is not available a simple traction method can be used: a shoulder traction holder can provide overhead suspension with a counter traction band around the arm proximal to the elbow. The tension can be adjusted by adding weights (Fig. 1.3). Those systems are easy to set up and allow undisturbed intra-operative X-ray access as well as more freedom of motion than a traction tower while providing less stability (Fig. 1.4).

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Equipment

Fig. 1.4 Undisturbed intra-operative X-rays access is possible by simple overhead suspension of the wrist while providing less stability

Fig. 1.5 Positioning of the patient, the surgical and anesthetic staff and the arthroscopic equipment

Anesthesia is positioned on the side of the uninvolved extremity or at the patient’s head, the surgeon on the side that is awaiting surgery, at the patient’s head. The arthroscopy tower and video monitor are placed at the patient’s feet, usually on the opposite side of the patient. An image intensifier is positioned in the operating theater so that it is not in the way of the surgeon and rolled into the operating field as needed. The assistant and scrub nurse can position themselves depending on the intervention and the surgeon’s needs which may differ in diagnostic and interventional wrist arthroscopies (Fig. 1.5).

The most important instrument is the arthroscope (Fig. 1.6). Because of the size of the joint, arthroscopes for wrist arthroscopy are smaller in diameter than traditional arthroscopes. Different diameters of the optic are used in wrist arthroscopy, ranging from 1.9 to 2.7 mm, with either a 30-degree- or less common a 70-degree-viewing-angle to meet the needs of the different articulations in the wrist. The light source cable is also smaller in diameter. The smaller the diameter of the arthroscope, the higher is the risk of bending and damaging the fiber-optic in the cannula. Short cannulas (5–8 cm) and scopes (lever arm of 100 mm) are long enough and allow easier handling and control [24]. The 2.7 or 2.4 mm optic is ideal for the exploration of the radiocarpal- and midcarpal joint as the arthroscopic vision field is bigger, but too bulky for exploration of the distal radioulnar joint (DRUJ), the scaphotrapeziotrapezoid (STT) joint and in patients with a small wrist. In those cases the use of an arthroscope with a diameter of 1.9 mm or smaller is more appropriate. A blunt trocar with a trocar sleeve is important to establish the viewing and working portals of the joints to be inspected without damaging the articular cartilage. Numerous instruments, appropriate to meet the criteria of diagnosing and treating wrist pathologies have been developed. The probe is probably the simplest but most useful diagnostic tool in wrist arthroscopy, serving as an extension of the surgeon’s finger [1]. For some interventions the use of a stronger probe as used in shoulder arthroscopy that does not bend is beneficial [16]. A variety of differently angled punches, baskets with or without the option of incorporating a suction mechanism and grasping forceps in various sizes are useful in removing loose bodies and excising pieces of soft tissue. Small arthroscopy knives with differently shaped and retrograde blades aid in excising unstable chondral portions of the carpal bones. A freer elevator, pins and a variety of small differently shaped osteotomes are useful tools in arthroscopically assisted correction of mal-united distal radius fractures [17]. Differently aggressive and sized motorized shavers and differently sized burrs ranging from 2.0 to 4.5 mm with integrated finger-controlled suction mechanism are powered instruments for debriding synovium or resecting bone, e.g., when performing a resection of the distal pole of the scaphoid for STT arthritis or a radial styloidectomy for beginning radiocarpal arthritis as in stage 1 of scaphoid nonunion advanced collapse (SNAC I). Shavers and burrs can be operated with a foot pedal or by finger control and allow continuous or oscillating cutting. Radiofrequency probes allow efficient soft tissue debridement and ligament- or capsular shrinkage [25], but because of the risk of thermal injury adequate fluid control must be carefully managed [26].

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Fig. 1.6 Wrist arthroscopy equipment

Traditionally wrist arthroscopy has been carried out with constant joint irrigation for distension and improvement of intra-articular vision [27]. Lactated Ringer’s solution is used for irrigation because it is rapidly reabsorbed from the soft tissues [8]. Electric fluid pumps that regulate fluid volume to avoid extravasation and decrease intraoperative bleeding may be used but pure gravitational force is generally sufficient for the irrigation of the wrist joint. Outflow is provided via the port of the cannula with the camera or a separate needle placed into the ulnar side of the wrist or the successively established portals. While the classic (wet) wrist arthroscopy bears the disadvantage of cumbersome extra-articular water leakage into the soft tissue and the risk of serious complications as development of compartment syndrome [7, 8, 28, 29], the wrist joint can easily be inspected without the use of water, referred to as “dry arthroscopy” [30]. Synovial villi or ruptured ligament parts do not interfere with the intra-articular vision as they do not float into the field of vision and remain at their origins. In the usual joint there is mucous fluid that does not impede vision. However, depending on the procedure to be performed, an initial washout of the joint may be useful, e.g., evacuation of hematoma in acute intra-articular distal radius fractures. Debris can be cleared by injecting 10–20 ml of saline through the side valve of the scope followed by aspirating with the shaver. The wrist joint can also be dried with small neurosurgical patties inserted with a grasper. Other helpful maneuvers to keep a clear vision in dry arthroscopy are to immerse the tip of the scope into warm water to prevent condensation (fog effect) due to temperature

differences outside and inside the wrist and to avoid closeness of the scope and motorized instruments, thus preventing splashing. The arthroscope can be cleaned by rubbing its tip carefully at the local soft tissue [30]. However, dry arthroscopy also has its limits. For example when radiofrequency ablators are used, water is necessary as milieu conductor and to prevent temperature peaks and possible joint damage. Also when using a burr the aspiration may be blocked by small cartilage and bone fragments and water facilitates the aspiration. The equipment is completed by different utensils for specified arthroscopic procedures as ligament repair, from simple needles or longer Tuohy needles [31] to more sophisticated, commercially available ligament repair kits [32].

Surgical Technique Certain rules need to be respected in order to obtain a good intra-articular vision and to avoid complications. It is very important that all external anatomic landmarks and portals must be marked after the traction to the wrist is applied but before starting the arthroscopic procedure so that the relationship of surface landmarks are not altered [28]. The following landmarks can be palpated if the wrist is not too swollen (Fig. 1.7): Osseous landmarks: • Dorsal: Lister’s tubercle, distal radial edge, dorsal ulnar head, index-, middle-, (ring-) and small metacarpals.

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Fig. 1.7 Osseous and tendinous landmarks of the wrist from dorsal (a), volar (b) and ulnar (c). RS radial styloid, L Lister’s tubercle, UH ulnar head, US ulnar styloid, P pisiform, DS distal pole of the scaphoid, APL abductor pollicis longus, ECRL extensor carpi radialis longus, ECRB extensor carpi radialis brevis, EPL extensor pollicis longus, EDC

• Radial: radial styloid process, trapezium, base of the first metacarpal. • Ulnar: ulnar styloid, triquetrum, base of the fifth metacarpal. • Volar: pisiform and distal pole of the scaphoid. Tendinous landmarks: • Dorsal: extensor carpi radialis longus (ECRL) tendon, extensor pollicis longus (EPL) tendon, extensor digitorum communis (EDC) tendon, extensor carpi ulnaris (ECU) tendon. • Radial: abductor pollicis longus (APL) tendon. • Ulnar: extensor carpi ulnaris (ECU) tendon. • Volar: flexor carpi radialis (FCR) tendon, flexor carpi ulnaris (FCU) tendon. Not all palpable surface landmarks need to be drawn onto the skin as orientation for establishing the portals, we mark the key structures as needed for each intervention (Fig. 1.8). Standard wrist arthroscopy includes the assessment of the radiocarpal- and ulnocarpal joint, the midcarpal- and STT joint and the distal radioulnar joint (DRUJ). Numerous arthroscopic dorsal and palmar approaches have been described and are routinely used. The most commonly used dorsal radiocarpal portals are named relative to the extensor compartments between which they are located. The first portal to be established in almost every wrist arthroscopy is the 3-4 radiocarpal portal. It can be identified by simple palpation of the “soft spot” just distal of the dorsal rim of the radius in a vertical line with Lister’s tubercle. Two methods of localizing the entry point for the 3-4 portal are used. The first method is called the “3 circle method” (Fig. 1.9). A circle is drawn around Lister’s tubercle.

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extensor digitorum communis, ECU extensor carpi ulnaris, FCU flexor carpi ulnaris, FCR flexor carpi radialis. The numbers 1–6 represent the extensor compartments. Volar incisions for the establishment of the VR and VM joint (black line), for the VU and V-DRUJ (red line) and for the 6-U and DF portal (blue line)

Fig. 1.8 Preoperative marking of the landmarks and dorsal portals for performing a standard wrist arthroscopy. Abbreviations are according to the previous figure

Two other circles of the same dimension are drawn just distal to the first one in a vertical line with Lister’s tubercle. The third circle is located directly over the soft spot that is the entry point of the 3-4 portal [33]. The second method is called the “rolling thumb method” (Fig. 1.10). The thumb

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Fig. 1.9 Establishment of the 3-4 portal using the “three circles technique”: a circle is drawn around the palpable Lister’s tubercle (a). Two circles of the same size are then drawn distally to the first circle. The third and most distal circle lies at the level of the 3-4 portal (b)

Fig. 1.10 Establishment of the 3-4 portal using the “rolling thumb technique”: the thumb is placed on the palpable Lister’s tubercle (a). The thumb is then rolled distally over the tubercle until the pulp of the surgeon’s thumb feels the soft spot corresponding to the 3-4 portal (b)

pulp is placed on Lister’s tubercle and is then rolled over the tubercle distally. The tip of the thumb is now exactly centered on the soft spot corresponding to the 3-4 portal. An 18- or 22-G needle is inserted at the soft depression into the radiocarpal joint, minding the normal inclination of the distal radius. Therefore the needle is pointing 20–30° proximally to parallel the articular curve of the distal radius to verify correct intra-articular placement (Fig. 1.11). Injection of a saline solution through this needle to distend the radiocarpal joint has been described. A normal uninjured wrist can contain 2–5 ml of fluid, but in the case of TFCC lesions, or lesions of the intracarpal ligaments of the proximal carpal row, up to 10–15 ml can be injected and the

adjacent joints (distal radioulnar- and midcarpal joint) are indirectly filled. As stated above our preferred method for wrist arthroscopy is the so-called dry technique. The traction often is sufficient for obtaining a quiet good intra-articular vision. After the needle has been placed correctly the skin is incised with a number 15 blade instead of using a number 11 blade as common for arthroscopy in other joints. Care must be taken to incise only the skin to prevent damage to superficial vessels, tendons, and cutaneous nerves. Depending on the portal to be established the nerves can be found in very close proximity to the portals and are at risk [34–36]. Longitudinal incisions are possible and favorable if the incision needs to be enlarged in a proximal-distal direction, for

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Fig. 1.11 Schematic lateral view of the wrist (a). External traction allows widening of the articular spaces. The arthroscope should be inserted into the radiocarpaland midcarpal joint respectively, paralleling the dorsal articular slope of the joints. Horizontal introduction of the arthroscope may damage the articular cartilage of the carpal bones (b).

Fig. 1.12 Standard procedure for establishment of an arthroscopic wrist portal (3-4 portal), right wrist. Localization of the radiocarpal joint space with a 22-G needle (a). Horizontal skin incision (b).

Spreading of the subcutaneous tissues with a blunt hemostat to the capsule (c). Piercing of the capsule with the closed tip of the hemostat (d)

example if conversion to an open intervention needs to be performed. However, we generally prefer horizontal skin incisions on the dorsal aspect of the wrist, in line with the skin lines, thus improving the esthetic appearance of the scar. A blunt hemostat is advanced through the subcutaneous tissue by carefully spreading the branches until there is contact with the joint capsule. The capsule is then pierced with the tip of the closed hemostat (Fig. 1.12). A blunt trocar is introduced through a cannula into the joint directed volar and proximal at an approximately 30° angle, aligning the cannula with the volar inclination of the distal radius. The trocar is

removed and the arthroscope is introduced through the cannula. The radial midcarpal portal can be established following the same technique, following the 10° obliquity of the first carpal row (Fig. 1.11). For establishment of the other portals we recommend to insert the needle arthroscopically controlled. Despite the revolutionary advances in wrist arthroscopy we have to remember that all indications to perform an arthroscopy should be based on a thorough clinical examination, aiming at detecting the origin of the intra-articular pathology and consequently avoiding inappropriate

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Fig. 1.13 Handling of the arthroscope. Control of minimal movements within the joint is achieved by constant finger contact to the patient’s wrist with the index finger (a) or the middle- to small finger (b)

indications that would not address the true nature of the pathology [37]. The diagnostic evaluation always starts with the exploration of the radiocarpal joint, but the evaluation of the midcarpal joint should never be neglected and is considered a part of wrist arthroscopy. Arthroscopy of the DRUJ has only recently gained interest [38, 39]. It is performed in special indications and not conducted in every wrist arthroscopy. A standardized, systematic arthroscopic examination with a routine circuit helps in visualizing all structures and not forgetting anything [4]. A few simple rules that should be followed are: • Examination of the radial side before the ulnar side. • Examination of the distal part of the articulation before the proximal part. • Examination of the volar aspect before the dorsal aspect. • Examination of the ligaments before the articular surfaces. • Simple inspection before using a probe. Rotation of the 30-degree-angle arthroscope allows the exploration of different regions of the articulation and switching the arthroscope and the instrument within the different portals can be limited. It is crucial to stabilize the arthroscope and control the small movements of the optic within the joint in order to prevent damage to the articular cartilage. Therefore the arthroscope should be held in a manner that allows constant contact to the skin of the wrist. The small optic is short enough to be grasped in a way that provides contact of the surgeon’s index finger to the patient’s wrist while larger arthroscopes need to be stabilized with the middle- and ring finger (Fig. 1.13).

Arthroscopic Portals: Approaches and Anatomy Meticulous knowledge of the anatomy is essential for performing wrist arthroscopy (Fig. 1.14) [40]. The entry portals are numerous (Fig. 1.15) and need to be adapted to the pathology and the particular anatomy in this region [1, 28, 41]. The standard arthroscopic portals have been developed on the dorsal side of the wrist and their localizations and names are in direct relation to the six extensor compartments. In the space between two extensor compartments the arthroscopic portals can be established and instruments introduced without the risk of damaging the extensor tendons. On the dorsal side of the wrist there are not many neurovascular structures that could be damaged (Fig. 1.16a–c). Volar portals have been previously reported [42, 43] but lacked popularity for a long period because they seemed to jeopardize important neurovascular structures on the volar side of the wrist (Fig. 1.16d, e). Only recently the safety of volar portals to the wrist could be shown [44–48], and it is possible to have viewing and working portals that encircle the whole wrist joint. This is called the “box concept” (Fig. 1.17) [24]. The arthroscopic exploration of the wrist is divided into three parts: proximal, volar (dorsal when using a volar portal), and distal. Then the arthroscope can be rotated to the radial and the ulnar side. We generally proceed with the arthroscopic overview from proximal to distal and from radial to ulnar (Fig. 1.18).

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Fig. 1.14 Anatomic dissection of the radiocarpal- (a) and midcarpal joint (b). The radiocarpal portals are indicated with red circles and the midcarpal portals with black circles. The proximal articular part of the radiocarpal joint is comprised by the scaphoid- and lunate fossa of the radius (R(S) and R(L)), separated by the interfosseal ridge (š) and the TFCC with its volar- and dorsal distal radioulnar ligaments (DRUL). The volar radiocarpal ligaments are from radial to ulnar the radioscaphocapitate (RSC) ligament, the long radiolunate (LRL) ligament and the short radiolunate (SRL) ligament. The volar ulnocarpal ligaments are the ulnolunate (UL) and the ulnotriquetral (UT) ligament. Ulnar and distal to the UT ligament we find the entry to the pisotriquetral joint (˚). The distal part of the radiocarpal joint is formed by the proximal articular surfaces of the scaphoid (S), the lunate (L) and the triquetrum (T). The scapholunate ligament (★) and the lunotriquetral ligament (♦) separate the carpal bones of the first carpal row, respectively. The proximal part

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of the midcarpal joint is formed by the distal articular surfaces of the scaphoid, lunate and triquetrum. The distal pole of the scaphoid and the proximal articular surfaces of the trapezium (Tz) and the trapezoid (Td) form the scaphotrapeziotrapezoid (STT) joint as a part of the midcarpal joint. The scaphoid body articulates with the capitate. The lunate, triquetrum, capitate and hamate form the 4-bone-corner. The lunate may have two distal articular facets, a major one for the capitate and a smaller one for the hamate (♯), which are separated by a longitudinal crest (). The volar midcarpal ligaments are radially the scaphocapitate (SC) ligament as the distal portion of the RSC ligament and ulnarly the capitotriquetral (CT) ligament, that is usually covered by a fibroadipose structure (◉). UH ulnar head, US ulnar styloid. [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

Fig. 1.15 Overview of the dorsal (a) and volar (b) portals used in wrist arthroscopy. Portals to the radiocarpal joint are marked in red, portals to the midcarpal joint are marked in black and portals to the DRUJ are marked in blue

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Fig. 1.16 Anatomic dissection of the wrist from dorso-radial (a), dorsal (b), dorso-ulnar (c), ulnar (d) and volar (e). (1) First compartment: containing the abductor pollicis longus (APL) tendon and the extensor pollicis brevis (EPB) tendon. (2) Second compartment: containing the extensor carpi radialis longus and -brevis (ECRL and ECRB) tendons. (3) Third compartment: containing the extensor pollicis longus (EPL) tendon. (4) Fourth compartment: containing the extensor digitorum communis (EDC) tendons and the extensor indicis proprius (EIP) tendon. (5) Fifth extensor compartment: containing the extensor digiti quinti (EDQ) tendon.

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(6) Sixth extensor compartment: containing the extensor carpi ulnaris (ECU) tendon. On the radial side of the wrist the sensitive branches of the superficial radial nerve can be visualized and on the ulnar side the terminal branches of the sensitive dorsal branch of the ulnar nerve. Entry portals to the radiocarpal joint and the midcarpal joint are marked in red or black, respectively. Entry portals to the DRUJ joint are marked in blue [a–c: Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

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Dorsal Portals of the Radiocarpal Joint Five standard dorsal portals of the radiocarpal joint are routinely used [35].

Fig. 1.17 “Box concept” of the wrist. The wrist can be thought of as a box, which can be visualized from almost every perspective. Through a combination of arthroscopic portals it is possible to have viewing and working portals that encircle the wrist. This enables the arthroscopic surgeon to see and instrument from all directions [Modified from Bain GI, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy. 2008;24:355-67. With permission from Elsevier]

Fig. 1.18 Arthroscopic tour of the radiocarpal and midcarpal joint. For the radiocarpal joint the primary viewing portal is the 3-4 portal and we proceed from radial to ulnar, proximal to distal (a). For the midcarpal

1-2 Portal The 1-2 portal is situated between the first extensor compartment, containing the abductor pollicis longus (APL) tendon and the extensor pollicis brevis (EPB) tendon, and the second extensor compartment, containing the extensor carpi radialis longus and -brevis (ECRL and ECRB) tendons. Proximally it is bordered by the distal, radial end of the radius, the radial styloid, and distally by the scaphoid. Several important structures can be found in this interval and may be endangered when establishing the 1-2 portal (Fig. 1.19). Two branches of the sensory branch of the radial nerve (SBRN) were shown in proximity with a mean of 3 mm radial and 5 mm ulnar to the portal. The radial artery was located on average 3 mm radial to the portal [34]. In a different study the mean distance of the SBRN was only 1.8 mm [36]. Partial or complete overlap of the lateral antebrachial cutaneous nerve (LABCN) with the SBRN is reported in up to 75 % [49]. We recommend to carefully entry the joint capsule close to the tendons of the first extensor compartment and just distal to the radial styloid to avoid damage to the dorsal branch of the radial artery. Inserting the optic through this portal allows exploration of the entire dorsal capsule of the radiocarpal joint and the major part of the anterior capsule with

joint the MCU portal is the main viewing portal and we proceed with the arthroscopic tour from ulnar to radial (b). Abbreviations are according to Fig. 1.14

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Fig. 1.19 Particular anatomy of the radial (a) and ulnar (b) aspect of the wrist. Branches of the sensitive branch of the radial nerve (SBRN) are moved radially by a retractor and the close relation of the dorsal branch of the radial artery to the 1-2 portal becomes evident. On the ulnar side the close relation of the two dorsal branches of the ulnar nerve (UN) to the 6-U portal and the direct foveal (DF) portal is

demonstrated. The terminal branching of the dorsal branch of the ulnar nerve (DBUN) is variable and a transverse branch of the DBUN (TBDBUN) can be found in some cases [a: Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

the extrinsic ligaments. Further the proximal pole and the body of the scaphoid, the proximal pole of the lunate, the articular surface of the radius, and the dorsal rim of the radius can be visualized. This portal is mainly used as portal for instrument placement in special surgical procedures as arthroscopic arthrolysis, resection of volar or dorsal ganglion cysts, or styloidectomy just to mention a few. • Proximal: we can observe the radial styloid and the scaphoid fossa of the radius. • Volar: we identify the radioscaphocapitate (RSC) ligament and the long radiolunate (LRL) ligament that originate from the anterior margin of the radius. • Distal: the most proximal 2/3 of the scaphoid and the proximal surface of the lunate can be visualized. • Radial: rotating the arthroscope to the radial side one is very close to the radial part of the radiolunate articulation and the vision is limited. • Ulnar: pivoting to the ulnar side the anterior margin of the radius and the radioscapholunate (RSL) ligament (ligament of Testut) can be appreciated. • Dorsal: rotating to the dorsal side we can see the entire dorsal part of the radiocarpal capsule with an oblique view of the dorsal radiocarpal ligament (DRCL).

The 3-4 portal is situated between the third extensor compartment, containing the extensor pollicis longus (EPL) tendon and the fourth extensor compartment with the common finger extensor (EDC) tendons and the extensor indicis proprius (EIP) tendon (Fig. 1.20, Video 1.1). Proximally it is boarded by the distal radius and distally by the scapholunate ligament. The entry is 1 cm proximal to Lister’s tubercle. The portal is considered safe with a low risk of damaging neurovascular structures. The mean distance of the SBRN is reported between 4.85 mm [36] and 16 mm radial to the portal [34]. The main risk is damaging the EPL tendon itself. We recommend to routinely establish this portal as the first portal for placement of the arthroscope. It is the main radiocarpal viewing portal as almost the complete radiocarpal articulation can be visualized through this portal: • Proximal: we can observe the distal radial epiphysis with the interfosseal ridge that separates the scaphoid fossa and the lunate fossa in a sagittal direction. • Volar: in the center of the field of vision we see the RSL ligament that has the aspect of a fibro-fatty villus. It is considered to be more of a neurovascular connective tissue than a true ligament [50]. De facto it is the reference point

3-4 Portal

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Fig. 1.20 Complete arthroscopic view of the radiocarpal joint through the 3-4 portal, from the radial styloid to the ulnar insertion of the TFCC in a right wrist. S scaphoid, R(S) scaphoid fossa of the radius, L lunate, R(L) lunate fossa of the radius, T triquetrum, SL (★-line) scapholunate ligament, RSC radioscaphocapitate ligament, LRL long radiolunate ligament, TS Testut (radioscapholunate) ligament, SRL short radiolunate ligament,

LT (♦-line) lunotriquetral ligament, UL ulnolunate ligament, UT ulnotriquetral ligament, V-DRUL volar distal radioulnar ligament, D-DRUL dorsal distal radioulnar ligament, @ gap between RSC and LRL ligament [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

for the exploration of the radiocarpal articulation. The volar radiocarpal ligaments are examined next. From radial to ulnar we find the stout radioscaphocapitate (RSC) ligament, arising from the radial styloid, then inserting on the waist of the scaphoid and reaching the palmar part of the capitate. Ulnar to the RSC ligament we find the long radiolunate (LRL) ligament that is wider and its fibers are orientated more obliquely. Its insertion is mainly at the lunate while some fibers proceed to the triquetrum. The short radiolunate (SRL) ligament is the most ulnar ligament. The RSC and the LRL ligaments are separated by an interligamentous gap where volar wrist ganglions usually originate. The LRL ligament forms together with the SRL ligament a reversed V that comprises the radioscapholunate ligament. At the apex of the V one will find the anterior part of the scapholunate ligament. • Distal: The articular surfaces of the scaphoid and the lunate and the scapholunate interosseous ligament (SLIL) between the two bones are visualized. It appears as an “indentation” and has a cartilage-like look [22]. The SLIL can be divided into a weak anterior part, a thin membranous proximal part and a strong dorsal part [51]. By slightly flexing and extending the wrist, the articular surfaces of the scaphoid and the lunate can be inspected more volarly and dorsally. • Radial: rotating the arthroscope radially one can explore the radial compartment of the radiocarpal articulation. We can visualize the proximal pole and the body of the scaphoid, the radiocarpal ligament, the radial styloid, and the scaphoid fossa of the radius very nicely. • Ulnar: rotating the optic to the ulnar side we can appreciate the lunate fossa of the radius and the triangular fibrocartilage

complex (TFCC). Sometimes it can be difficult to see the separation between the radial margin of the TFCC and the articular surface of the lunate fossa of the radius. A probe will help in distinguishing between articular surface and TFCC. The TFCC is arranged in a three-dimensional manner into three components: the proximal triangular ligament, the distal hammock structure, and the ulnar collateral ligament (UCL) [52]. The volar and dorsal distal radioulnar ligaments (v-DRUL and d-DRUL) are thickenings of the periphery of the TFCC. They originate from the ulnar margin of the radius and insert as the proximal component of the TFCC at the ulna fovea (pc-TFCC) while the distal hammock structure and the UCL represent the distal component of the TFCC (dc-TFCC), attaching at the ulnar styloid and the ulnocarpal capsule. If the TFCC is intact only the superficial part of the ulnar attachment of the radioulnar ligaments can be seen. In traumatic or degenerative central TFCC lesions we can see onto the exposed ulnar head and the pc-TFCC at the fovea can be visualized. The ulnocarpal ligaments consist of the ulnolunate ligament (UL), the ulnocapitate (UC) and the ulnotriquetral ligament (UT) and originate at the anterior edge of the TFCC, the v-DRUL and the ulnar styloid and insert on the lunate and the triquetrum, respectively. It is also possible to visualize the prestyloid recess, a synovial pouch that is located volar to the ulnar styloid. The meniscus homologue, a synovial tissue distal to the prestyloid recess that physiologically covers the tip of the ulnar styloid, can sometimes present as an indurated structure that can lead to impingement between the ulnar styloid and the triquetrum [53]. Next we analyze the complete articular surface of the lunate and the triquetrum as well as the lunotriquetral ligament.

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• Distal: we recognize the proximal lunate and triquetrum, separated by the lunotriquetral interosseous ligament (LTIL). • Radial: swinging the arthroscope to the radial side we can visualize the volar rim of the radius and the ulnar part of the scaphoid fossa, the RSC and the LRL ligaments as well as the dorsal capsule of the radiocarpal articulation. We can observe the dorsal surface of the lunate and the central, membranous part as well as the dorsal part of the scapholunate ligament and its distal attachment to the dorsal capsule. • Ulnar: rotating the arthroscope to the ulnar side we can observe the most ulnar part of the TFCC up to the prestyloid recess and the pisotriquetral articulation. The pisotriquetral joint is part of the wrist joint. It is a diarthrosis and is enclosed in a small capsule. The pisotriquetral joint often communicates with the radiocarpal joint through a fenestration in the capsule [54].

Fig. 1.21 Arthroscopic exploration of the ulnar compartment of the wrist from the 4-5 radiocarpal portal. Abbreviations and symbols are used according to the previous figure. ˚: entry to the pisotriquetral joint. The opening is covered by a synovial membrane (right wrist) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

4-5 Portal This portal is situated between the fourth extensor compartment containing the above-mentioned tendons and the fifth extensor compartment with the extensor digiti quinti (EDQ) tendon. It is in line with the fourth metacarpal and slightly proximal to the 3-4 portal. Proximally it is bordered by the radius and distally by the lunate. Establishing the 4-5 portal does not put any particularly relevant structures at risk except from the EDC and EDQ tendons itself, dorsal sensory nerve branches are at a mean distance of 16.13 mm (range: 9.48– 26.82 mm) [36]. The 4-5 portal has been the most frequently used portal for placement of the instruments, however, nowadays it is less frequently used than the 6-R portal. The 4-5 portal allows observation of the same structures as the 3-4 portal but with a more direct view onto the ulnar compartment of the wrist joint (Fig. 1.21). The possibility of exchanging the position of the arthroscope and the instruments with the 3-4 portal allows to accomplish surgical interventions in all parts of the radiocarpal articulation: • Proximal: in the center of the field of vision we see the radial insertion of the TFCC that merges with the lunate fossa on the radial side. • Volar: focusing on the ulnar side we encounter the LRL ligament and the SRL ligament, the UL ligament and the UT ligament.

6-R Portal The 6-R portal is localized radial to the sixth extensor compartment that contains the extensor carpi ulnaris (ECU) tendon. Its radial border is the EDQ tendon. The portal is approximately 5 mm distal to the dorsal part of the TFCC, representing the proximal border. Distally the portal is bounded by the lunotriquetral interosseous ligament. The structure most at danger in establishing this portal is the TFCC. To avoid damage of the TFCC this portal is established by the use of a needle under direct vision of the arthroscope (Videos 1.2 and 1.3). The structure second most at risk is the dorsal sensory branch of the ulnar nerve (DBUN) (Fig. 1.19b). The mean distance of the DBUN to the 6-R portal has been found to be 8.2 mm [34]. A transverse branch of the DBUN (TBDBUN) has been found in 27 % of dissected cadavers [55] with a very variable course. If present it is encountered a mean of 2 mm proximal to the 6-R portal [34] (Fig. 1.22). Together with the 3-4 portal the 6-R portal is one of the two essential portals in wrist arthroscopy as they allow to examine and access the whole radiocarpal joint. Although the 6-R portal is the main working portal, instruments and the arthroscope can easily be switched between those two portals. The 6-R portal shows the ulnocarpal compartment and is particularly useful in repairing lesions of the TFCC, the lunotriquetral ligament or lesions of the lunate and the triquetrum (Video 1.4): • Proximal: we can perfectly visualize the complete peripheral component of the TFCC up to the prestyloid recess and the opening into the pisotriquetral bursa. • Volar: the ulnolunate and ulnotriquetral ligaments (ULL and UTL), supporting the TFCC volarly, and the depression corresponding to the pisotriquetral articulation are examined. • Distal: The entire articular surface of the triquetrum and the central volar part of the LTIL can be analysed.

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Fig. 1.22 Open approach to the DRUJ after wrist arthroscopy. Note the transverse branch of the dorsal branch of the ulnar nerve (TBDBUN) crossing 3 mm proximal to the 6-R portal

• Radial: sweeping the arthroscope radially we will find the TFCC, the lunate fossa of the radius and the short radiolunate ligament. We also can explore parts of the dorsal aspect of the radiocarpal articulation (Fig. 1.23, Video 1.5). • Ulnar: rotating the arthroscope to the ulnar side it is possible to glide into the prestyloid recess and the pisotriquetral space if the opening is not covered by a thick synovial membrane as reported in 27 % [54].

6-U Portal The 6-U portal is situated ulnar to the ECU tendon. Ulnarly it is bounded by the DBUN, proximally by the TFCC and distally by the triquetrum. Damaging the terminal branches of the DBUN that divides itself inconsistently about 1.5 cm distal to this portal is the highest risk when establishing the 6-U portal. The frequent anatomical variations of the terminal branching of the DBUN are an additional risk. The mean distance of the DBUN from the 6-U portal is 8.3 mm if there is only one terminal branch and 1.9 mm if two terminal branches are present. In cases where a TBDBUN is found the mean distance is 2.5 mm proximal to the portal. In some cases the branch is crossing directly over the portal [36]. Therefore the 6-U portal has been used for a long time predominantly as an outflow portal. Some authors however have shown that respecting certain rules and keeping the possible anatomic variations of the dorsal branch of the ulnar nerve in mind, the 6-U portal can be

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Fig. 1.23 Arthroscopic view onto the dorsal aspect of the radiocarpal joint from the 6-R portal. The dorsal, distal aspect of the lunate (L) and the scapholunate ligament (★-line) can be inspected up to the attachment of the SL ligament to the dorsal capsule (§), that separates the radiocarpal joint from the midcarpal joint (right wrist) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

used advantageously in diagnostic wrist arthroscopy and in treating certain pathologies [56], especially those around the ulnocarpal complex as the visualization of the ulnocarpal compartment is excellent. • Proximal: we can see the ulnar and dorsal border of the TFCC and the prestyloid recess. • Volar: the ULL and the UTL can be inspected. • Dorsal: the dorsal ulnotriquetral ligament on the dorsal aspect of the TCFF may be visualized if not covered with synovial tissue. The ECU subsheath is a further stabilizer on the dorsal aspect of the TFCC but not visible with an intact capsule. • Distal: the triquetrum can be perfectly displayed, most notably the ulnar part as well as the depression between the triquetrum and the lunate corresponding to the lunotriquetral ligament. The lunotriquetral ligament is more difficult to detect than the scapholunate interosseous ligament and probing the ligament is the best way to localize it [57].

Volar Portals of the Radiocarpal Joint Two volar portals to the radiocarpal joint are used. Especially the dorsal capsular structures, dorsal radiocarpal ligaments and volar subregions of the scapholunate interosseous ligament as well as the lunotriquetral interosseous ligament are better visualized from a volar perspective [44, 45].

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Fig. 1.24 Establishment of the volar radial radiocarpal portal with the “in-out” technique (right wrist). The optic is introduced via a dorsal ulnar portal (4-5 or 6-R): above the proximal pole of the scaphoid (S) is visualized and below we see the scaphoid fossa of the radius (R(S)); the trocar is introduced via the 3-4 portal and advanced through the gap (@) between the radioscaphocapitate (RSC) and the long radiolunate (LRL) ligaments and advanced volarly (a). On the volar radial side of the wrist the skin incision is made at the level of the proximal wrist crease

(blue line), radial to the flexor carpi radialis (FCR) tendon, close to the radial artery (b). After the blunt tip of the trocar has been advanced volarly through the joint capsule, a trocar sleeve can be placed over the trocar from the volar side, the trocar removed from the dorsal side and the arthroscope is place into the trocar sleeve from volar (c) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

Volar Radial Portal (VR) Two ways of establishing this portal have been described and are considered safe. The first method is the so-called in-out technique, first described in cadavers (Fig. 1.24) [43]: the optic is placed in an ulnar portal (4-5 or 6-R), a blunt trocar is inserted into the 3-4 portal and pushed towards the anterior radiocarpal joint capsule. It is then pushed through the capsule between the RSC and LRL ligaments, exiting next to the flexor carpi radialis tendon where a small skin incision is made. A cannula can then be placed safely over the trocar and the arthroscope inserted from the volar side into the radiocarpal joint. The second method of establishing the volar radial portal has also been shown to be safe [44, 45]: a 1–2 cm longitudinal skin incision is made at the proximal wrist crease over the flexor carpi radialis (FCR) tendon, the tendon sheath is divided and the tendon retracted ulnarly. After identification of the radiocarpal joint space with an 18-G needle the volar capsule is penetrated with the tip of a blunt artery forceps between the RSC ligament and the LRL ligament. A blunt trocar is inserted with a cannula, the trocar removed and the arthroscope is introduced over the cannula. Structures at risk are the radial artery on the radial side and the volar cutaneous branch of the median nerve (VBMN) ulnarly (Fig. 1.16d). There is a safe zone of 3 mm in all directions with respect to the mentioned structures [47]. This portal allows visualization of the complete radiocarpal articulation, particularly the dorsal capsule, the dorsal radiocarpal ligament (DRCL), the volar aspect of the bones

of the first carpal row and the volar subregions of the intercarpal ligaments. The TFCC can also be visualized (Fig. 1.25). A good surgical indication where the volar radial portal is beneficial is arthroscopic arthrolysis in cases in which complete dorsal capsulotomy for the treatment of flexion stiffness is needed: • Proximal: the scaphoid and lunate fossae of the distal radius as well as the dorsal rim of the radius can be visualized. • Dorsal: the dorsal capsule is inspected, the established dorsal 3-4 portal can be localized and the radiolunotriquetral ligament is seen. • Distal: we can visualize the proximal pole of the scaphoid and the volar part of the SLIL. • Radial: rotating the optic to the radial side it is possible to visualize the radial styloid and the external part of the articular capsule. • Ulnar: swinging the optic to the ulnar side one can visualize the entire surface of the distal radius up to the TFCC and the prestyloid recess. It is also possible to visualize the anterior part of the lunate but the vision may be limited in cases where the radioscapholunate ligament is very voluminous.

Volar Ulnar Portal (VU) The volar ulnar portal of the radiocarpal joint has been described by Slutsky [46]. Like the volar radial portal its clinical experience is still limited. The VU portal is bounded

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Fig. 1.25 Arthroscopic exploration of the radiocarpal joint from the volar radial portal (right wrist). Abbreviations and symbols are used according to the previous figures. Exploration of the ulnar part of the radiocarpal joint and the ulnocarpal joint: the articular surface of the lunate fossa of the radius can be examined and the corresponding proximal and volar aspect of the lunate. Further the radial insertion of the TFCC, the TFCC and the volar- and especially the dorsal distal radioulnar ligaments are visualized. On the volar aspect the UL and UT ligaments can also be seen (a). With the probe in the 3-4 portal the Testut

ligament can be palpated. Especially the volar aspect of the scaphoid and the scapholunate ligament is visualized (b). The dorsal extrinsic radiolunotriquetral (RLT) ligament can be tested with a probe. The proximal aspect of the scaphoid, lunate and the scapholunate ligament are inspected (c) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

proximally by the ulnar styloid, distally by the triquetrum, ulnarly by the FCU tendon and radially by the finger flexor tendons. A 2 cm longitudinal skin incision is centered over the proximal wrist crease along the ulnar edge of the common finger flexor tendons (Fig. 1.7b). The tendons are retracted radially and the volar radiocarpal joint capsule is pierced with an 18-G needle. The capsule is then pierced with the tip of a blunt hemostat, followed by the insertion of a cannula and a blunt trocar. The trocar is removed and the arthroscope is inserted. The portal penetrates the ulnolunate ligament adjacent to the radial insertion of the TFCC. As for the establishment of the volar radial portal the volar ulnar portal can also be created with the “in-out” technique with the arthroscope in the 3-4 portal. A blunt trocar is inserted into the 6-U portal and pushed towards the anterior ulnocarpal joint capsule. It is then pushed through the capsule between the UL and UT ligaments, exiting ulnar to the flexor tendons where a small skin incision is made. Structures at risk are the flexor tendons, the ulnar artery and ulnar nerve; however, they have been generally found more than 5 mm ulnar to the trocar (Fig. 1.16d). The median nerve is protected by the flexor tendons. The volar cutaneous branch of the ulnar nerve is highly variable and its distal branch is at risk with a volar ulnar approach if present. Like the VR portal the VU portal provides a view of the dorsal articular surface of the radius and the dorsal extrinsic ligaments. Ulnar-sided structures that are more easily seen from the ulnar volar side of the wrist include the volar subregion of the LTIL, the dorsal distal radioulnar ligament, and the dorsal ulnar wrist capsule, containing the ECU subsheath

(ECUS) [46]. Like the scapholunate interosseous ligament (SLIL) the LTIL can be divided into three parts: the volar part, the central part and the dorsal part [58]. While the central part has more the structure of a thin membrane, the dorsal part of the SLIL and the volar part of the LTIL are the most important subregions contributing to stability. The VU portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament [46] and in assisting in reduction of distal radius fractures [24].

Arthroscopy of the Midcarpal Joint The midcarpal joint contributes together with the radiocarpal joint to flexion-extension and radio-ulnar deviation of the wrist (Fig. 1.14) and arthroscopy of the midcarpal joint should be routinely performed in every wrist arthroscopy. Six portals to the midcarpal joint are used in wrist arthroscopy (Figs. 1.15 and 1.16). Next to the two standard dorsal midcarpal portals, one volar midcarpal portal [47], the standard ulnar STT portal, the radial STT portal [59] and the accessory triquetro-hamate (TH) portal [60] have been described. The midcarpal joint is comprised of three proximal bones: the scaphoid, lunate and triquetrum, and four distal bones: the trapezium, trapezoid, capitate and hamate. The depth of the midcarpal joint is less than half of that of the radiocarpal joint and the joint is tighter than the radiocarpal joint. The joint space of the scapholunate and lunotriquetral articulation can be inspected directly as there are no interosseous ligaments distally. The portal most

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Fig. 1.26 Arthroscopic exploration of the midcarpal joint through the MCR portal (right wrist): below we see the concave surface of the scaphoid (S) and the lunate (L), separated by a narrow gap corresponding to the scapholunate articulation. Above the articular surface of the round head of the capitate (C) can be inspected (a). Exploration of the STT joint from the MCR portal (right wrist): the distal pole of the scaphoid (S), articulating with the trapezium (Tz) and the trapezoid

(Td) can be assessed. Note that the trapezoid is encountered more dorsally than the trapezium and only the dorsal aspect of the trapezium can be visualized through this portal (b) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

commonly used in midcarpal arthroscopy is the ulnar midcarpal (MCU) portal.

possible. As the joint is usually tight it is however not always possible to advance the arthroscope sufficiently volar to see the volar capsule and midcarpal ligaments [60]: • Proximal: we see the concave surface of the lunate and the scaphoid, separated by a physiologic cleft corresponding to the scapholunate articulation. A fibrocartilaginous meniscus can be present in the joint, mainly at the volar aspect. • Volar: when the joint is lax we can pass the arthroscope volarly enough to visualize the distal part of the RSC ligament that forms the radial limb of the arcuate ligament anterior to the capitate. • Distal: the field of vision is completely filled by the convex head of the capitate. • Radial: sweeping the arthroscope radially along the scaphoid, we can follow the complete scaphocapitate articulation area up to the STT joint distally. The trapezoid is found more dorsally than the trapezium, the two carpal bones are separated by a narrow groove corresponding to the trapeziotrapezoidal articulation. Sometimes the volar radial scaphotrapezial ligament can be seen, a strong structure that is reinforced by the FCR tendon sheath [60, 61]. • Ulnar: rotating the scope to the ulnar side we find the articulating corner of four carpal bones, forming a cross by the hamate, capitate, lunate and triquetrum. We inspect carefully the lunotriquetral joint and we can assess the distal alignment of the articulating surfaces of the two bones. A fibrocartilaginous meniscus can be present in the joint. The lunate can present with one concave, articulating

Radial Midcarpal Portal (MCR) The MCR portal is situated 1 cm distal to the 3-4 portal and in line with the radial margin of the third metacarpal. It is bounded radially by the ECRB tendon, ulnarly by the fourth extensor compartment, proximally by the concave surface of the scaphoid and distally by the proximal pole of the capitate. The radial midcarpal portal is the principle midcarpal portal as it allows visualization of the complete midcarpal joint including the STT joint. Structures at risk while establishing this portal are the extensor tendons (Fig. 1.16a–c). The SBRN is found at a mean distance of 6.65 mm [36] to 15.8 mm radial to the portal and was found in one occasion 2 mm ulnar to the portal [34]. A small transverse skin incision is made over the palpable soft spot 1 cm distal to the 3-4 portal after the entry to the joint has been triangulated with an 18-G needle. The joint capsule is pierced with a blunt hemostat, then a trocar sleeve with a blunt trocar is inserted, orientated approximately 10° proximally to parallel the dorsal midcarpal joint axis, followed by a 1.9 mm 30-degreeangle arthroscope. The complete midcarpal articulation can be visualized (Video 1.6), the distal surface of the lunate, the triquetrum and the scaphoid (Fig. 1.26a) and the proximal surface of the hamate and the capitate. Sweeping the arthroscope over the distal pole of the scaphoid, even the proximal surface of the trapezium and trapezoid can be evaluated (Fig. 1.26b) and resection of the distal pole of the scaphoid in STT arthritis is

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Fig. 1.27 Exploration of the corner of the four midcarpal bones (lunate, triquetrum, capitate and hamate) via the MCR portal. Lunate type I according to Viegas with one distal articular facet, articulating with the capitate. Note the step of the triquetrum to the lunate that is a physiological finding and not a sign for lunotriquetral instability. (◉) Fibroadipose tissue, covering the capitatotriquetral ligament (a). Lunate type II according to Viegas with a separate distal articular facet (L(H)),

articulating with the hamate (H). The facet articulating with the capitate (L(C)) is bigger. The two facets of the lunate are separated by a longitudinal crest () (b) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

only with the capitate, or two concave facets for a common articulation with the capitate and hamate. In this case we find a longitudinal ridge at the lunate, separating the two articulation fossae to the hamate and the capitate, respectively. Viegas has classified the different types of the lunate into type I, if articulating only with the capitate, and type II, if an additional facet for the hamate is present [62] (Fig. 1.27).

midcarpal joint is easier via the MCU portal (Fig. 1.28), however, the visualization of the radial aspect of the midcarpal joint is not as good as through the MCR portal, especially the exploration of the STT joint is not convenient from the MCU portal. • Proximal: the distal lunate with the lunotriquetral articulation in the center and the scapholunate articulation can be visualized (Videos 1.7 and 1.8). • Volar: one can identify the ulnar limb of the arcuate ligament, the continuation of the capitotriquetral ligament and the distal fibers of the ulnocapitate ligament. • Distal: this portal allows visualization of the proximal aspect of the capitate, the apex of the hamate, and the capitohamate interosseous ligament (CHIL). • Radial: sweeping the arthroscope radially we have a better view of the scapholunate articulation and the alignment of those two bones of the proximal carpal row can be assessed. It is also possible to visualize and test the scaphocapitate articulation with a probe inserted into the MCR portal (Video 1.9), but not the STT joint. • Ulnar: looking ulnarly we see the distal surface of the triquetrum and it is possible to analyze the articulation between the hook-shaped tip of the hamate and the triquetrum. The saddle-shaped triquetrohamate (TH) joint is held tightly by the volar triquetrohamate and triquetrocapitate ligaments [60] and it is difficult to enter the TH articulation directly except in the setting of midcarpal instability.

Ulnar Midcarpal Portal (MCU) The MCU portal is situated symmetrically to the abovementioned portal in the soft depression of the four-corner intersection of the hamate, capitate, lunate and triquetrum, on the midaxial line of the fourth metacarpal where the soft sport is easily palpable making it to the preferred portal to be established first for arthroscopy of the midcarpal joint (Fig. 1.18b). The portal is situated approximately 1–1.5 cm distal to the 4-5 portal. It is bounded radially by the EDC tendons and ulnarly by the EDQ tendon. In type I lunates the proximal border is the lunotriquetral joint and the distal border is the capitohamate articulation. In type II lunates the proximal border remains the same but the distal border is the proximal pole of the hamate. The structure most at risk is the EDQ tendon. The SBRN is remote to this portal and the branches of the DBUN are found a mean of 15.1 mm ulnar to this portal (Fig. 1.16a–c). However, aberrant branches can run closer or directly over the portal [34]. In type II lunates the exploration of the ulnar component of the

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Fig. 1.28 Arthroscopic view of the midcarpal joint through the MCU portal. The scapholunate articulation is tested with a probe (a) and is intact as the probe cannot be protruded into the articulation. The articulation of the lunate, triquetrum, capitate and hamate is inspected,

showing a lunate type Viegas II (b) [Modified from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Setup, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With permission from Elsevier]

Volar Midcarpal Portal (VM) The volar midcarpal portal has been mentioned as an accessory midcarpal portal [47], however, it lacks widespread use and we do not have any clinical experience with this portal. The topographic landmarks and skin incision are the same as for the VR portal (Figs. 1.15b and 1.16d). The volar aspect of the midcarpal joint is identified with a 22-G needle on average 11 mm (range 7–12 mm) distal to the entry to the VR portal, and the joint entered with a cannula and a blunt trocar after piercing the joint capsule with a blunt artery forceps. The portal may be useful in assessing the palmar aspects of the capitate and the hamate in cases of avascular necrosis or osteochondral fractures and the capitohamate interosseous ligament that provides stability to the transverse carpal arch [63].

over a trocar sleeve after a blunt trocar has been introduced to the joint. The STT joint can be inspected, however, the concavity of the distal pole of the scaphoid makes it difficult to explore the anterior part of this articulation. The portal is primarily utilized for instrumentation, particularly for arthroscopic resection of the distal pole of the scaphoid in STT arthritis.

Scaphotrapeziotrapezoid Portal (STT) The STT portal is found at the level of the STT joint in line with the radial margin of the index metacarpal just ulnar to the EPL tendon. The portal is bordered ulnarly by the ECRL tendon, proximally by the distal pole of the scaphoid and distally by the trapezium and the trapezoid and is localized approximately 1 cm distally to the 1-2 portal. Structures that can be jeopardized are the radial artery, the EPL tendon and small terminal branches of the SBRN (Figs. 1.16a, b and 1.19a). Establishing the portal on the ulnar side of the EPL tendon usually keeps the radial artery safe. The joint is triangulated with an 18-G needle, and confirming correct placement of the needle in the STT joint under fluoroscopy can be convenient. Then a skin incision is made and the joint capsule pierced with a blunt artery forceps. A 1.9 mm 30-degree-angled arthroscope is inserted

Radial STT Portal (STT-R) The radial STT portal is situated at the same level of the STT joint as the standard STT portal but radial to the APL tendon [59]. The radial artery is found at a mean distance of 8.8 mm radial to the portal. The terminal branches of the SBRN with individual arborization are in close vicinity of the portal and care must be taken when establishing the portal. The portal is created as described for the standard STT portal above. Together the two portals for the STT joint allow a working angle of 130° and the radial STT portal (sometimes also called volar STT portal) serves as a better working portal for removal of the distal pole of the scaphoid in STT arthritis. Triquetrohamate Portal (TH) For completeness we mention the TH portal that is an accessory portal on the ulnar aspect of the midcarpal joint. It is located between the ECU and FCU tendon and is bordered proximally by the triquetrum and distally by the base of the fifth metacarpal and the hamate. The portal has been described for an inflow or outflow cannula and can be used as an instrument portal in assessing the triquetrohamate joint and the proximal pole of the hamate [60]. However, we do not have any experience with this portal.

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Fig. 1.30 Dorsal DRUJ portals: drawing of the dorsal portals. D: distal DRUJ portal, P: proximal DRUJ portal, M: mid–DRUJ portal (preferred dorsal portal)

Fig. 1.29 Drawing of the DRUJ. LT lunotriquetral ligament, ECU extensor carpi ulnaris, 1, 2, 3: volar ulnocarpal ligaments (1: ulnotriquetral, 2: ulnocapitate, 3: ulnolunate); A: volar distal radioulnar ligament, B: dorsal distal radioulnar ligament, C: dorsal articular capsule

Arthroscopy of the DRUJ The DRUJ is the main articulation of the wrist allowing pronosupination. Arthroscopy of the DRUJ is the most recently introduced part in wrist arthroscopy and preserved for special indications. The anatomy of the DRUJ is complex. It is mostly described as a diarthrodial trochoid articulation composed of the medial articular facet of the distal radius, the radial notch and the distal end of the ulna. As the distal ulna not only articulates with the distal radius but also with the carpus by the ulnocarpal joint, arthroscopy of the DRUJ addresses the evaluation of pathologies of the DRUJ and the ulnocarpal articulation. In a normal wrist joint the TFCC with its volar and dorsal distal radioulnar ligaments, merging at the insertion at the fovea, supports the DRUJ. The volar branch of the DRUL merges also with the ulnocarpal (UC) ligaments, which also contribute stability to the ulnar side of the carpus (Fig. 1.29). In a normal wrist the DRUJ is very narrow and hard to enter and explore, therefore the 1.9 mm arthroscope should be used. Traction should be reduced to 3–5 kg for DRUJ arthroscopy [5] to reduce the tension. As for the radiocarpal joint arthroscopy fluid distension is generally not necessary for DRUJ arthroscopy. If needed we use saline to flush out the synovial liquid in intense DRUJ synovitis, then the joint is dried with suction. DRUJ arthroscopy is useful in the assessment of soft tissue disorders and the articular cartilage of the sigmoid notch or ulnar head [64].

Four portals for the DRUJ have been described, two dorsal portals [65], one volar portal (V-DRUJ) [39] and the direct foveal portal (DF) [66] (Figs. 1.15 and 1.16). The two dorsal portals, the proximal DRUJ portal (P-DRUJ) and the distal DRUJ portal (D-DRUJ) are the standard portals for exploration of the DRUJ and normally utilized for the assessment of the foveal insertion of the deep component of the distal RUL as the main stabilizer of the DRUJ or for arthrolysis of the DRUJ. However, we prefer to start the DRUJ exploration through a dorsal portal located at a midpoint between the traditional P-DRUJ and D-DRUJ portals, below the radial insertion of the TFCC, at the point where the distal profile of the ulnar head curves to parallel the sigmoid notch (Figs. 1.30 and 1.31). Through this portal we assess the surface of the ulnar head, the TFCC with its volar and dorsal distal RUL and its foveal insertion, and the sigmoid notch. As in the radiocarpal joint the dorsal und volar portals allow an omnidirectional evaluation of the DRUJ (Fig. 1.32).

Distal DRUJ Portal (D-DRUJ) This portal is located in line with and about 5–8 mm proximal to the 6-R portal just under TFCC (Fig. 1.16). With the forearm in neutral rotation the TFCC has the least tension, however, because of the shape of the ulnar head wrist supination facilitates the establishment of the dorsal DRUJ portals (Fig. 1.33). The DRUJ is bordered radially by the EDQ and EDC tendons and ulnarly by the ECU tendon. Proximally it is bounded by the ulnar head and distally by the TFCC (Fig. 1.16e). The structure that can be jeopardized is the TFCC, while the only sensory nerve in proximity to the portal is the TBDBUN that has been found at a mean distance of 17.5 mm distally to the portal (Figs. 1.18b and 1.22) [34]. In the presence of a positive ulnar variance this portal should not be used [64]. After localizing the portal with a 22-G needle, a small longitudinal skin incision is made and the

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Fig. 1.31 Establishment of our preferred dorsal DRUJ portal. The red arrow is pointing at the entry portal and its relation to the classic proximal DRUJ portal (P-DRUJ) and distal DRUJ portal (D-DRUJ) (a).

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Verification of the correct entry point with introduction of a needle (b) and introduction of a blunt trocar over a trocar sleeve (c)

Fig. 1.32 Drawing of the “box concept” of the arthroscopic portals to the DRUJ: dorsal view (a) and volar view (b). There are three dorsal and two volar portals: (♯): preferred dorsal portal; (*): preferred volar portal

dorsal capsule is pierced with a blunt artery forceps. Then a cannula with trocar is inserted, followed by a 1.9 mm 30-degree-angle arthroscope. We recommend starting the joint exploration by rotating the scope (Fig. 1.34), rather than moving its tip inside the joint. • Proximal: the whole surface of the ulnar head can be visualized. • Distal: the undersurface of the TFCC is visible. • Radial: rotating the scope radialwards the TFCC is visualized and its radial insertion at the sigmoid notch of the

radius is shown (Fig. 1.35). The DRUJ capsule attaches to the volar and dorsal distal radioulnar ligaments, and the volar capsule of the DRUJ can be seen obliquely. • Ulnar: turning the arthroscope to the ulnar side, the proximal insertion of the deep component of the distal radioulnar ligaments, merging at the ulnar fovea, can be seen. A 22-G needle, introduced from the area of the DF portal, may elevate the ligament to obtain a better vision of the ulnar part of the TFCC, inserting at the fovea (Fig. 1.36).

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Fig. 1.33 Transverse drawing of the DRUJ in neutral rotation (a) and supination (b). Due to the osseous morphology of the ulnar head it becomes evident that introduction of the scope through a dorsal portal into the DRUJ (red arrow) is easier when the wrist is fully supinated (b)

Fig. 1.34 Rotation of the scope for a better vision of the DRUJ (red arrows). The first position allows a better vision of the TFCC insertion (a); the second allows a better vision of the radial insertion of the TFCC and the sigmoid notch (b)

Proximal DRUJ Portal (P-DRUJ) The P-DRUJ portal is situated 1 cm proximal to the distal DRUJ portal. It is located at the level of the proximal soft spot of the DRUJ, corresponding to the axilla of the joint, just proximal to the sigmoid notch of the radius and the flare of the ulnar metaphysis [64]. The portal is bordered radially by the EDQ tendon and the radial sigmoid notch, ulnarly by the ECU tendon and the neck of the ulna and distally by the TFCC. The structure most at risk is the EDQ tendon. The P-DRUJ portal is a very narrow portal. If preferred the joint can then be filled with saline but the capacity of distension of this articulation is limited. A small skin incision is made and

the dorsal joint capsule is pierced with a blunt hemostat. A cannula with a blunt trocar is inserted, aiming slightly distally, then a 1.9 mm 30-degree wide-angle scope. On entry into the P-DRUJ we can first see the sigmoid notch of the radius and the articular surface of the neck of the ulna (Fig. 1.37). Systematically the following structures are inspected: • Proximal: the palmar aspect of the capsule of the DRUJ can be visualized. • Distal: the articular surface of the ulnar head can be seen on the ulnar side and the junction of the TFCC to the sigmoid notch of the radius is visible.

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Fig. 1.35 Arthroscopic exploration of the DRUJ through the D-DRUJ portal. SN sigmoid notch, UH ulnar head, (): central insertion of the TFCC, (♯): radial insertion of the volar and dorsal branches of the TFCC

Fig. 1.36 Arthroscopic view of the undersurface of the TFCC with its volar and dorsal DRUL, merging at the insertion at the fovea (blue arrows)

• Volar: the volar capsule of the DRUJ can be seen and the course of the volar radioulnar ligament. The origin of the volar ulnocarpal ligaments more distally is difficult to see. • Radial: the sigmoid notch of the radius can be inspected by rotating the arthroscope radially. • Ulnar: the articular surface of the neck of the ulna can be visualized by turning the scope to the ulnar side.

Volar Distal Radioulnar Portal (V-DRUJ) Two ways of establishing the V-DRUJ exist. The initial description of establishing the V-DRUJ portal uses the same

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Fig. 1.37 Arthroscopic exploration of the DRUJ from the P-DRUJ portal. UH ulna head, SN sigmoid notch

landmarks as those of the VU portal (Figs. 1.7b and 1.15b, e) [39]. After the skin incision is made, the common flexor tendons retracted radially and the FCU tendon with the ulnar neurovascular bundle retracted ulnarly, the joint capsule is entered approximately 5–10 mm proximal to the entry to the VU radiocarpal portal. The DRUJ joint is located with a 22-G needle and the joint capsule pierced with a blunt artery forceps followed by insertion of a cannula and a blunt trocar, then the arthroscope. Our preferred method for creating the V-DRUJ portal uses a similar technique as described above for the establishment of the volar radial radiocarpal joint (Fig. 1.38). In our experience the ulnar neurovascular bundle has never been damaged performing this technique. For the introduction of the arthroscope through the V-DRUJ portal a switching rod can be used. From a volar approach the course of the dorsal radioulnar ligament can be followed, which is not possible from the dorsal DRUJ portals, until it merges with the volar radioulnar ligament and inserts at the fovea. With the instruments placed through one of the dorsal DRUJ portals, arthroscopic procedures as the wafer partial ulnar head resection can be performed directly under the TFCC instead of through its lesion from above.

Direct Foveal Portal (DF) The direct foveal (DF) portal as described by Atzei et al. [66], is located approximately 1 cm proximal to the 6-U portal (Figs. 1.15b, 1.16e, 1.39). For establishment of the DF portal the forearm is held in full supination. That way the portal is bounded by the ulnar styloid and the ECU tendon dorsally, the flexor carpi ulnaris (FCU) tendon volarly, the ulnar head proximally and the TFCC distally. The DBUN is at risk and is usually displaced dorsally to the portal if the

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Fig. 1.38 Technical procedure to establish the volar DRUJ portal: A blunt trocar perforates the volar capsule and is pushed through the volar skin after a small skin incision is made (red circle) (a and b). The trocar is then used as a guide for the introduction of the shaver into the DRUJ, Fig. 1.39 Anatomic location of the DF portal (a). The DF portal is located 1 cm proximal to the 6-U portal and a skin incision can connect those two portals while leaving the retinaculum and capsule intact (b)

the trocar is pulled backwards and the shaver advanced into the DRUJ through the volar DRUJ portal (c and d). Handling of the arthroscope and shaver. The Surgeon should stay at the ulnar side of the wrist (e)

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forearm is held in supination (Fig. 1.16e). A 22-G needle is inserted percutaneously just underneath the TFCC to verify the correct position. Then a small longitudinal skin incision is made between the ECU and FCU tendon. Next the extensor retinaculum is exposed and split along its fibers. The DRUJ capsule is incised longitudinally to reach the distal articular surface of the ulnar head under the TFCC. When the surgeon is more experienced with establishing this portal and familiar with the anatomy, the DF portal can be created using the standard portal establishing technique without any clinically relevant disturbance to the DBUN. The DF portal is used as a dedicated working portal for fixation of the TFCC to the ulnar fovea in proximal TFCC lesions. Small shavers or curettes are used to debride the torn or avulsed ligament back to healthy tissue, debride the fovea and prepare it for suture screw or anchor insertion while the arthroscope is in the distal DRUJ portal.

Conclusion Wrist arthroscopy is a reasonable recently introduced technique but has continued to evolve rapidly. In its beginnings wrist arthroscopy was primarily used for diagnostic purposes. The introduction of smaller optics and miniaturized instruments however has allowed the development of more arthroscopically sophisticated surgical interventions. Nowadays it is impossible to ignore the impact of therapeutic wrist arthroscopy that limits the iatrogenic effect of open wrist procedures, e.g., as creating intra-articular fibrosis. It has been proved more reliable in assessing many wrist pathologies than even sophisticated MRI images. Step by step and adapting to the surgical needs, the portals for wrist arthroscopy have been developed. Starting with the four classic standard portals (3-4 radiocarpal, 4-5 radiocarpal, radial midcarpal and ulnar midcarpal), an increasingly number of new portals as well as volar portals have been established and proved to be safe. However, the learning curve takes its time and precise knowledge of the anatomy and the pathologies of the wrist is crucial in order to limit the risk of complications or true diagnostic or therapeutic failures. Earlier teaching of wrist arthroscopy has been performed under simple observing conditions. Nowadays the teaching is much more structured and numerous instructional courses are offered, allowing to study wrist arthroscopy and the handling of the arthroscope and instruments in cadavers. The European Wrist Arthroscopy Society (EWAS, www.wristarthroscopy.eu) has developed specific courses on fresh cadavers for a couple of years. Practicing on cadavers and examining the wrist joint from different portals and viewing angles helps in understanding the three-dimensional anatomy of the wrist. Once normal arthroscopic wrist anatomy is clear, pathologic problems can be more readily

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identified and treated. It is without doubt that the creativity of the surgeon and the introduction of adapted miniaturized instruments will allow for realization of precise performance and continuous development of more and more sophisticated arthroscopic techniques.

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28 22. Buterbaugh GA. Radiocarpal arthroscopy portals and normal anatomy. Hand Clin. 1994;10:567–76. 23. Huracek J, Troeger H. Wrist arthroscopy without distraction. A technique to visualise instability of the wrist after a ligamentous tear. J Bone Joint Surg Br. 2000;82:1011–2. 24. Bain GI, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy. 2008;24:355–67. 25. Lee JI, Nha KW, Lee GY, Kim BH, Kim JW, Park JW. Long-term outcomes of arthroscopic debridement and thermal shrinkage for isolated partial intercarpal ligament tears. Orthopedics. 2012;35:e1204–9. 26. Sotereanos DG, Darlis NA, Kokkalis ZT, Zanaros G, Altman GT, Miller MC. Effects of radiofrequency probe application on irrigation fluid temperature in the wrist joint. J Hand Surg Am. 2009;34:1832–7. 27. Botte MJ, Cooney WP, Linscheid RL. Arthroscopy of the wrist: anatomy and technique. J Hand Surg Am. 1989;14:313–6. 28. Geissler WB, Freeland AE, Weiss APC, Chow JC. Techniques of wrist arthroscopy. J Bone Joint Surg Am. 1999;81:1184–97. 29. Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005;21:407–16. 30. del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am. 2007;32:119–23. 31. DeAraujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy. 1996;12:699–703. 32. Geissler WB. Arthroscopic knotless peripheral ulnar-sided TFCC repair. Hand Clin. 2011;27:273–9. 33. Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131–44. French. 34. Abrams RA, Petersen M, Botte MJ. Arthroscopic portals of the wrist: an anatomic study. J Hand Surg Am. 1994;19:940–4. 35. Grechening W, Peicha G, Fellinger M, Seibert FJ, Weiglein AH. Anatomical and safety considerations in establishing portals used for wrist arthroscopy. Clin Anat. 1999;12:179–85. 36. Tryfonidis M, Charalambous CP, Jass GK, Jacob S, Hayton MJ, Stanley JK. Anatomic relation of dorsal wrist arthroscopy portals and superficial nerves: a cadaveric study. Arthroscopy. 2009;25:1387–90. 37. Atzei A, Luchetti R. Clinical approach to the painful wrist. In: Geissler WB, editor. Wrist arthroscopy. New York: Springer; 2005. p. 185–95. 38. Lawler EA, Adams BD. Arthroscopy of the distal radioulnar joint. In: Slutsky D, Nagle D, editors. Techniques in wrist and hand arthroscopy. Philadelphia: Churchill Livingstone Elsevier; 2007. p. 54–7. 39. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Up Extrem Surg. 2007;11:38–44. 40. Berger RA. Arthroscopic anatomy of the wrist and distal radioulnar joint. Hand Clin. 1999;15:393–413. 41. Whipple TL, Marotta JJ, Powell 3rd JH. Techniques of wrist arthroscopy. Arthroscopy. 1986;2:244–52. 42. Levy HJ, Glickel SZ. Arthroscopic assisted internal fixation of volar intraarticular wrist fractures. Arthroscopy. 1993;9:122–4. 43. Tham S, Coleman S, Gilpin D. An anterior portal for wrist arthroscopy. Anatomical study and case reports. J Hand Surg Br. 1999;24:445–7. 44. Abe Y, Doi K, Hattori Y, Ikeda K, Dhawan V. A benefit of the volar approach for wrist arthroscopy. Arthroscopy. 2003;19:440–5.

Session 1 (09:50) Dr Riccardo Luchetti

N. Badur et al.

45. Slutsky DJ. Wrist arthroscopy through a volar radial portal. Arthroscopy. 2002;18:624–30. 46. Slutsky DJ. The use of a volar ulnar portal in wrist arthroscopy. Arthroscopy. 2004;20:158–63. 47. Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy. Tech Hand Up Extrem Surg. 2004;8:229–38. 48. Van Meir N, Degreef I, De Smet L. The volar portal in wrist arthroscopy. Acta Orthop Belg. 2011;77:290–3. 49. Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. J Hand Surg Am. 1985;10:522–6. 50. Berger RA, Kauer JM, Landsmeer JM. Radioscapholunate ligament: a gross anatomic and histologic study of fetal and adult wrists. J Hand Surg Am. 1991;16:350–5. 51. Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg Am. 1996;21(2):170–8. 52. Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex. J Hand Surg Br. 2000;25: 479–86. 53. Zahiri H, Zahiri CA, Ravari FK. Ulnar styloid impingement syndrome. Int Orthop. 2010;34:1233–7. 54. Arya AP, Kulshreshtha R, Kakarala GK, Singh R, Compson JP. Visualisation of the pisotriquetral joint through standard portals for arthroscopy of the wrist: a clinical and anatomical study. J Bone Joint Surg Br. 2007;89:202–5. 55. Ehlinger M, Rapp E, Cognet JM, Clavert P, Bonnomet F, Kahn JL, Kempf JF. Transverse radioulnar branch of the dorsal ulnar nerve: anatomic description and arthroscopic implications from 45 cadaveric dissections. Rev Chir Orthop Reparatrice Appar Mot. 2005; 91:208–14. 56. Luchetti R, Atzei A, Rocchi L. Incidence and causes of failures in wrist arthroscopic techniques. Chir Main. 2006;25:48–53. French. 57. Lee JH, Taylor NL, Beekman RA, Rosenwasser MP. Arthroscopic wrist anatomy. In: Geissler WB, editor. Wrist arthroscopy. New York: Springer; 2005. p. 7–14. 58. Ritt MJ, Bishop AT, Berger RA, Linscheid RL, Berglund LJ, An KN. Lunotriquetral ligament properties: a comparison of three anatomic subregions. J Hand Surg Am. 1998;23:425–31. 59. Carro LP, Golano P, Fariñas O, Cerezal L, Hidalgo C. The radial portal for scaphotrapeziotrapezoid arthroscopy. Arthroscopy. 2003;19:547–53. 60. Viegas SF. Midcarpal arthroscopy: anatomy and portals. Hand Clin. 1994;10:577–87. 61. Bettinger PC, Cooney III WP, Berger RA. Arthroscopic anatomy of the wrist. Orthop Clin North Am. 1995;26:707–19. 62. Viegas SF, Wagner K, Patterson R, Peterson P. Medial (hamate) facet of the lunate. J Hand Surg Am. 1990;15:564–71. 63. Garcia-Elias M, An KN, Cooney III WP, Linscheid RL, Chao EY. Stability of the transverse carpal arch: an experimental study. J Hand Surg Am. 1989;14:277–82. 64. Whipple TL. Arthroscopy of the distal radioulnar joint. Indications, portals, and anatomy. Hand Clin. 1994;10:589–92. 65. Bowers WHWT. Arthrosopic anatomy of the wrist. In: McGinty J, editor. Operative arthroscopy. New York: Raven Press; 1991. p. 613–23. 66. Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008; 12:226–35.

Session 2 (10:40) Professor Joe Dias

Session 2 (10:55) Mr Farhan Ali

Session 2 (11:05) Professor Tim Davis

Extra-Articular Dorsally Displaced Fractures of the Distal Radius Non-Operative Treatment “The Evidence” Tim Davis, Nottingham, UK The management of dorsally displaced fractures of the distal radius remains controversial. Fracture management is not only determined by evidence from clinical observation and research, but also fear of criticism, and perhaps claims of negligence, raised by colleagues and " experts who have strong beliefs on how these fractures which should be treated, despite an absence of evidence to support their opinions. The assessment of the outcome of fractures of the distal radius should consider not only the longterm functional outcome, but also: a. the cosmetic outcome, b. the short-term disability consequent to the treatment method and, c. the cost of the treatment and management of any complications to the health purchaser. All surgeons would agree that the aim of nonoperative treatment is to achieve fracture union in “acceptable alignment”. However different surgeons have different opinions on what is “acceptable alignment”. There are suggested parameters to define an “acceptable reduction”, and these may be useful. However many fractures treated non-operatively in plaster slowly redisplace during treatment in plaster, with this process often continuing for more than 2 weeks after the original reduction. Thus achieving an acceptable reduction does not mean that the fracture will unite in acceptable alignment. One UK study found that 70% of 225 fractures treated non-operatively in plaster united with "malunion", but none of these patients required salvage surgery and satisfactory outcomes were generally achieved. Many studies have tried to correlate the functional outcome of these fractures with parameters of malunion, but the findings of these studies show no consistency. Perceptions of the impact of malunion on the functional outcome determine individual surgeons preferred treatment options for these common fractures, and their views on the acceptability of non-operative treatment in plaster at a time when internal fixation devices can effectively and relatively reliably produce union in near normal alignment.

The effect of malunion on outcome. There is no doubt that severely malunited fractures cause cosmetic deformity, but no-one has: 1. investigated how well the cosmetic outcome can be predicted by radiological measures of malunion or; 2. produced radiological limits to malunion, below which a good satisfactory cosmetic outcome can be achieved. Many studies have investigated the impact of malunion on the functional outcome. A survey of these shows no consistency in their findings. In the long term extra-articular malunion does not appear to impact on the clinical outcome as was shown by a study with a 38 year follow up which assessed outcome with PROMs (Patient Reported Outcome Measures). Kirschner wire fixation. When it is decided that a fracture should be treated non-operatively, the common choices is between closed reduction and Kirschner wire fixation and ORIF with a volar locking plate. Both will be more expensive than non-operative treatment in plaster, assuming the plaster treatment is not provided in the operating theatre. There are numerous techniques of Kirschner wire fixation of fractures of the distal radius. Two or three wires are usually utilised, with at least one being inserted obliquely through the radial styloid area and one dorsally. The Kirschner wires can be passed through both fracture fragments or through the fracture and into the proximal fragment (Kapandji technique). Kirschner wires work best in non-porotic bone but it is not without complications, particularly pin site infections. Furthermore many patients find the ends of the wires uncomfortable under the plaster which in my opinion is always needed to support Kirschner wire stabilisation of fractures. Use of Kirschner wires when compared to plaster alone probably does not speed up the recovery following the injury but will probably achieve a better cosmetic outcome by allowing the fracture to unite in better alignment. It has never been shown that Kirschner wire stabilisation produces superior functional outcome to plaster treatment and I suspect this is unlikely in view of the findings on malunion.

Session 2 (11:05) Professor Tim Davis Kirschner wire fixation has been compared with internal fixation with a volar locking plate. Some studies have shown that it results in a slower recovery of function than internal fixation, though does not delay the return to work. However it appears that any short-term benefit in terms of recovery of function provided by volar locking plates has resolved by 12 weeks, after which the outcome of these two treatment techniques appear similar. Kirschner wire stabilisation of distal radius fractures is cheaper than volar locking plate fixation, with the difference mainly due to the cost of the plate which is determined by the manufacturer. One study suggests that benefit of plate fixation would not satisfy NICE’s criteria for use in place of Kirschner wires (ICER = £31 898). References Costa ML et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ 2014;349:g4807 Handoll HH, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006080. Forward DP, Davis TR, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic posttraumatic osteoarthritis? J Bone Joint Surg Br. 2008;90:629-37. Karantana et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am. 2013;95:1737-44 Karantana et al. Cost-effectiveness of volar locking plate versus percutaneous fixation for distal radial fractures: Economic evaluation alongside a randomised clinical trial. Bone Joint J. 2015;97-B:1264-70

Session 2 (11:20) Mr Vijay Bhalaik

 VOLAR LOCKING PLATES: PRINCIPLES, BIOMECHANICS AND USES Vijay Bhalaik Consultant Hand Surgeon, Wirral Hand Service, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral, Merseyside, UK

Mr Bhalaik is a Consultant Hand Surgeon at The Wirral Hand Unit. He trained in plastic surgery in India and orthopaedic surgery in Liverpool, Pulvertaft Hand Unit, Derby and Indiana Hand Centre, USA. He runs a busy hand unit in his hospital, treating all aspects of traumatic and complex hand injuries. He has a wide range of research interests, which include regional anaesthesia, intra-articular fractures, assessment of acutely injured hands and hand fractures and teaching and training of surgeons. Abstract: Fixed angle devices have been a major development in the management of distal radius fractures. The operating surgeon should understand the principles of the workings of a volar locking plate. The talk highlights the following:         

Principles of volar locking plates. Rationale of a volar locking plate. Peg versus screw fixation. Types of plate. Anatomical considerations. Approach. Radiographic evaluation. Uses of a volar locking plate. Tips and tricks whilst using a volar locking plate.

Further reading: Volar, Intramedullary, and Percutaneous Fixation of Distal Radius Fractures. Alluri R, Longacre M, Pannell W, Stevanovic M, Ghiassi A. J Wrist Surg. 2015 Nov;4(4):292-300. Can the use of variable-angle volar locking plates compensate for suboptimal plate positioning in unstable distal radius fractures? A biomechanical study. Hart A, Collins M, Chhatwal D, Steffen T, Harvey EJ, Martineau PA. J Orthop Trauma. 2015 Jan;29(1):e1-6. Biomechanical comparison of volar locked plate constructs using smooth and threaded locking pegs. Yao J, Park MJ, Patel CS. Orthopedics. 2014 Feb;37(2):e169-73. Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius: a cadaveric study. Maschke SD, Evans PJ, Schub D, Drake R, Lawton JN. Hand (N Y). 2007 Sep;2(3):144-50. Semin Roentgenol. 2005 Jul;40(3):248-89. Radiographic evaluation of the wrist: a vanishing art. Loredo RA1, Sorge DG, Garcia G.

An anatomical study of the watershed line on the volar, distal aspect of the radius:  implications for plate placement and avoidance of tendon ruptures. Imatani J, Akita K, Yamaguchi K, Shimizu H, Kondou H, Ozaki T. J Hand Surg Am. 2012 Aug;37(8):1550-4. Distal radius anatomy applied to the treatment of wrist fractures by plate: a review of recent literature. Obert L, Loisel F, Gasse N, Lepage D. SICOT J. 2015 Jun 19;1:14. J Hand Surg Am. 2010 Apr;35(4):619-27. Rotational fluoroscopy assists in detection of intraarticular screw penetration during volar plating of the distal radius. Tweet ML1, Calfee RP, Stern PJ. Hand (N Y). 2008 Mar;3(1):55-60. Biomechanical evaluation of volar locking plates for distal radius fractures. Levin SM1, Nelson CO, Botts JD, Teplitz GA, Kwon Y, Serra-Hsu F. Jorge Orbay et al. Techniques of hand and upper extremity surgery – the extended flexor carpi radialis approach: a new perspective for distal radius fracture

Session 2 (11:35) Mr Ian McNab

BSSH IC 6.6 June 2016 Intra-articular fractures – Decision making, treatment options and outcomes (including K-wiring)  Ian McNab Introduction Management principles for intra-articular (IA) fractures in general:  Anatomical reduction of fragments: No step-offs No depression No (or only small) gaps  Stable internal fixation Can withstand early mobilization  Early motion of joint Important for hyaline cartilage healing Prevents stiffness Intra-articular Distal Radius fractures:  Variety of patients: different ages, functional demands & bone quality  Injury mechanism determines energy transferred: Spectrum of injuries & fracture characteristics  Range of treatment options: increasing complexity, cost & complications  Large but conflicting literature / evidence base about treatments & outcomes: lack of universal consensus Treatment Options • Non-operative: – Cast (or splint) • Surgical: – Percutaneous pinning – External fixation – Open reduction and internal fixation (ORIF) – Palmar or Dorsal plates or both – Combination (of above with or without bone graft substitute) – Adjuncts: • Arthroscopic assisted reduction and fixation • ± Bone graft (substitute) Evidence Base, Outcomes & Guidelines (consensus expert opinion) AAOS GUIDELINE 2009 DRAFFT 2014 ORCHID 2014 (BSSH/BOA BLUE BOOK – 2017) Intra-articular Distal Radius fractures: Guidance for decision making & treatment principles Treatment Goals: • Union & Pain-free function

Session 2 (11:35) Mr Ian McNab

• • •

“Functional” ROM - Approx. half normal flexion & extension, good Supination & Pronation Functional grip strength Restore anatomy & articular congruity (young high demand patients)

Treatment aims: restoration of “acceptable” anatomy: • Restore articular congruity “ 2 months — PRC — Arthrodesis 41

Post-Op — Slab to allow for swelling — Full POP 6 – 8/52 — K wires removed ?12/52 — Supervised physio out of splint — Sports at 4/12

42

Complications — Median n — Wound healing / infection — Compartment syndrome — Tendon rupture — CRPS — Instability — AVN – (rare even in Mayfield IV) — Arthritis

43

Outcomes — Mixed pathology — Short term outcomes better — Long term: poor Mayo, function, radiological outcomes — Kremer 2010 – loss of reduction over time — Post-traumatic arthritis (Herzberg 50% at 6 years) — Little correlation between Xray and function — Loss of ROM and Grip strength — However: 70 – 90% return to work, DASH scores of 20-30 pretty good

44

Outcomes

10  

— AVN – (rare even in Mayfield IV) — Arthritis 43

Outcomes — Mixed pathology — Short term outcomes better — Long term: poor Mayo, function, radiological outcomes — Kremer 2010 – loss of reduction over time — Post-traumatic arthritis (Herzberg 50% at 6 years) — Little correlation between Xray and function — Loss of ROM and Grip strength — However: 70 – 90% return to work, DASH scores of 20-30 pretty good

44

Outcomes

45

Prognostic factors — Controversial — Kremer 2010 : operative approach (dorsal v combined), dennervation, pre-trauma occupation significant — Kardashian 2011: delay, open, poor reduction, osteochondral defects

46

Case 1

47

Case 1

48

Case 2

49

Case-2

50

Case-3

51

Case-3

52

Summary — Devastating — Early recognition, early treatment in specialised Unit — Gold standard: ORIF — Dorsal vs Volar vs Combined vs Arthroscopic — ? Dennervate wrist

53

CIC: Palmar Perilunate — Capitate palmar to lunate — Rare (3%) — Assoc. Lunate fracture — Forced hyperflexion and supination — Highly unstable injury — Emergent closed reduction — Open repair

54

CIC: Rare Axial fracture patterns — Crush of palmar concavity of carpus — Longitudinal disruption of carpal arch

22/05/2016  

11  

— Dorsal vs Volar vs Combined vs Arthroscopic — ? Dennervate wrist 53

CIC: Palmar Perilunate — Capitate palmar to lunate — Rare (3%) — Assoc. Lunate fracture — Forced hyperflexion and supination

22/05/2016  

— Highly unstable injury — Emergent closed reduction — Open repair 54

CIC: Rare Axial fracture patterns — Crush of palmar concavity of carpus — Longitudinal disruption of carpal arch — Axial radial — Axial ulnar — Industrial accidents in developing countries — Major soft tissue issues, traumatic carpal tunnel decompression — MX: Exploded hand: skin, muscle, NV,

55

CIC: Rare Isolated Carpal Dislocations — Scaphoid — I– palmar anterolat dislocation — II – capitohamate derrangement Closed reduction successful — Isolated Trapezium - ?open reduction vs trapeziectomy — Isolated Trapezoid – ? Direct blow - fuse

12  

Session 3 (14:15) Dr Mathilde Gras

Acute management of intrinsic ligament injuries – Mathilde GRAS [email protected] chirmain.com Institut de la Main Clinique Jouvenet 6 square Jouvenet 76016 Paris

Intrinsic ligament injuries are frequent and often misdiagnosed. Scapholunate ligament (SL) tears are difficult to diagnose and lack of treatment generates chronic instability and SLAC wrist. The arthroscopy became an essential tool in the diagnosis and treatment of these lesions, especially at early stage. The encouraging results of the capsuloligamentous repair for SL chronic lesions led us to perform this technique arthroscopically in acute cases, thus avoiding the pitfalls of open surgery. This presentation expose the principle of the technic, and report the results of this technique with a minimum follow-up of one year. The dorsal capsuloligamentous repair is a simple technique that allows to link the dorsal capsular ligament complex, avoiding the systematic pinning. The triangular fibrocartilage complex (TFCC) is a fibrocartilaginous structure with two distal peripheral insertions and one foveal proximal insertion on the ulnar head. The most common injury is a tear of the dorsal peripheral and medial part of the TFCC (Palmer type 1B or EWAS Atzei 1). This type of lesion is commonly seen in young, active individuals and does not cause instability of the distal radioulnar joint (DRUJ). However, it often causes very annoying pain with any strenuous activities, especially sports (tennis, golf, fencing, basketball, etc.). Instability of DRUJ is due to foveal disinsertion (EWAS Atzei 2-3). Open repair often entails large incisions and results in stiffness, especially in pronosupination. Arthroscopy allows better visualization, analyse and repair of these lesions, resulting in less morbidity. The outcomes with this technique are very good, and most patients recover a functional and painless wrist without any loss of movement. Arthroscopy for intrinsic ligament repair is a non-invasive technic and avoids the classic stiffness after open surgery.

Session 3 (14:30) Mr David Hargreaves

16/05/16

Ulnar Sided Carpal Instability: Diagnosis and Treatment

TYPES B)Non-Dissociative

A)  Dissociative Luno-Triquetral Lig Rupture

Midcarpal Instability

David G Hargreaves Consultant Hand Surgeon Southampton University Hospitals

Luno-Triquetral Lig Rupture Mechanism of Injury 1)  Reverse Perilunate Ring

Diagnosis •  Clinical Examination –  Ballottment Test (Reagan)

–  Isolated LT Lig : No Instability –  Combined Ligs : Dynamic / Static

2)Ulno-Carpal Impaction

–  Shear Test

–  Squeeze Test (Whipple)

Diagnosis •  Radiology –  Plain films

Diagnosis •  Arthroscopy –  Radio-carpal : 4/5 or 6R portal

–  Dynamic Instability views –  Arthrogram –  MRI

–  Midcarpal:

Probe / Stress

–  Video Fluoroscopy

1

Session 3 (14:30) Mr David Hargreaves

16/05/16

Treatment

Midcarpal Instability

•  Arthroscopic Debridement •  Heterogenous group of disorders

•  Arthroscopic Capsulodesis •  Tenodesis procedures

–  –  –  – 

Ulnar Midcarpal Instability (Lichtman ‘81) Capito-Lunate Instability Pattern (CLIP) (Louis ‘84) Medial anterior midcarpal Instability (MAMI) (Schernberg ‘84) Chronic Capito-lunate instability (Johnson ‘86)

•  LT Arthrodesis •  Instabilty of Proximal Carpal Row –  (Wright - JHand Surg Am 1994)

Litchman Classification (1993)

Aetiology

•  Palmar •  Laxity : common (Park JBJS 2002) •  Instability: rare

•  Dorsal

•  Minor Trauma

•  Combined P & D •  Extrinsic (Adaptive)

•  Loss of propioceptive control •  Generalised Joint Laxity

Natural History

Diagnosis - History

•  Spontaneous improvement •  Dorsal wrist pain - vague •  Joints stiffen with age !! •  Giving way •  Approx 30% improve

•  Clunk- pron & ulnar dev

•  No evidence in Literature •  Sportsmen - ↓ performance

2

Session 3 (14:30) Mr David Hargreaves

16/05/16

Diagnosis - Examination •  Ulnar Shift Test –  Catch -up clunk –  VISI to DISI in ulnar dev –  “That’s it” test !!!

•  Exclusion of intrinsic ligament ruptures

Diagnosis- Investigations •  X rays •  MRI •  Dynamic Fluroscopy •  Arthroscopy

All Normal

Treatments •  Physiotherapy: –  Biofeedback –  General Strengthening –  Gyroscope - Spinball

Surgical Options •  Midcarpal fusion: –  Triq-Hamate :50% good (Rao ‘93)

–  4 corner fusion: ROM 45% (Goldfarb 2004)

•  No proven protocol

Surgical Options •  Volar Capsular Reefing •  Tenodesis

Thermal Capsular Shrinkage •  Denaturation of Collagen Type 1 •  Shoulder

•  66% failure (Lichtman ‘93)

–  Recurrence: 40% –  Chondrolysis

Immobilisation >6/52 Beware of Temp↑

3

Session 3 (14:30) Mr David Hargreaves

16/05/16

Discussion •  Not so rare •  Diagnosis : can be difficult •  Treatable •  Role of Arthroscopic treatments

4

Session 3 (14:45) Professor John Stanley

Chronic Scapholunate Instability Definition of chronic The term chronic is often applied when the course of the disease lasts for more than three months. Background Kinematics of the wrist row, column, axial x,y,z axes and 9 degrees of freedom Symptoms May be obscured or complicated by associated injuries Ranges from none to full monty Weakness of grasp Restriction of flexion/extension Clicking/clunking Sudden onset pain associated with sudden loss of grip Dorsal rim impaction Signs Weakness of grasp Limited range of motion Positive Kirk Watson test Catch-up clunk Tender sl interval Painful sl stress test Visible Terry Thomas sign on xray, seen on MRI and or/at arthroscopy (Dependant upon the row/column characteristics of the individual wrist) Classification Pre-arthritic _ SLAC 1,2,3,4. Arthroscopic(Geissler) 1,2,3,4. Natural History Basically unknown but minor injuries tend to be over-reacted to and generally accepted that significant instability and collapse is likely to progess through to SLAC Treatment of pre-arthritic stages

Session 3 (14:45) Professor John Stanley

The literature generally suggests the time frame for the appearance of oa in SLIL is anywhere between 3 to 30 years but 10 -15 years seems to be the most likely. Treatment ranges from conservative through ligamentoplasty, capsulodesis, bone ligament bone repair, tendon rerouting (ECRB, FCR), limited fusion, to PRC and TWF. (Dependant upon the row/column characteristics of the individual wrist)

Literature The Wrist :Diagnosis and Operative treatment William P Cooney Publisher: Philadelphia [Pa.] : Wolters Kluwer/Lippincott Williams & Wilkins Health, 2010. Scapholunate interosseous ligament injuries: a retrospective review of treatment and outcomes in 82 wrists. Rohman EM, Agel J, Putnam MD, Adams JE J Hand Surg Am. 2014 Oct;39(10):2020-6 The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. Watson HK, Ballet FL. J Hand Surg Am. 1984 May;9(3):358-65. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. Garcia-Elias M, Lluch AL, Stanley JK. J Hand Surg Am. 2006 Jan;31(1):125-34.

Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability. Talwalkar SC, Edwards AT, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. J Hand Surg Br. 2006 Feb;31(1):110-7.

Outcomes of Capitohamate Bone-Ligament-Bone Grafts for Scapholunate Injury. van Kampen RJ, Bayne CO, Moran SL, Berger RA. J Wrist Surg. 2015 Nov;4(4):230-8.

Wrist essentials: the diagnosis and management of scapholunate ligament injuries. Chim H, Moran SL. Plast Reconstr Surg. 2014 Aug;134(2):312e-322e

Session 3 (15:00) Professor John Stanley

Salvage of chronic carpal instability It is reported by Watson HK and Ballet that 5.25% wrists exhibit degenerative arthrosis on xray . The London study of skeletons from 1729 – 1861 show an incidence of 2.7% wrist OA. Chronic SLIL is either with or without arthritic changes stage 1,2,3 Treatment for the patient with Chronic SLIL and arthritis(SLAC) is SYMPTOM DRIVEN. And complicated by the patient’s expectations ie pain relief (rarely complete), range of motion (never enough), power grasp (never better than 80% 0f contralateral side), dexterity (loss of radio-ulnar and dart throwers is significant) Conservative Tea and sympathy and explanation Activity modification Tea sympathy and pills Pills and a splint Splint and injection Repeat x 2 and investigate and catalogue patients ambitions Surgical Neurectomy Styloidectomy + micropick Stage 1 SLAC 4 corner + Scaphoidectomy Stage 2 and 3 SLAC PRC Stage 1and 2 SLAC Total Wrist Fusion Wrist replacement Post surgical Management Treatment for non-union (5%) Treatment for CRPS type 1(2-4%) Treatment for removal of metalwork (5-10%)

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Wrist Instability •  •  •  • 

Anatomy Mechanics Description of instability Terminology

Row Classification

Important Anatomy •  Carpus usually described as 2 rows

Important Anatomy •  Carpus usually described as 2 rows •  Also as 3 columns (Taleisnik)

Column Classification

Important Anatomy •  Carpus usually described as 2 rows •  Also as 3 columns (Taleisnik) •  Also as a ring (Lichman)

Dan Brown

1

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Ring Classification

Important Anatomy •  Carpus usually described as 2 rows •  Also as 3 columns (Taleisnik) •  Also as a ring (Lichman)

Row Classification

Important Anatomy •  Position of the bones is controlled by

Distal Row Proximal Row

Lunate is the key!

Dan Brown

–  The shape of the bones –  Ligaments

•  The lunate always wants to extend

Scapho-Lunate Angle

2

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Scapho-Lunate Angle

Scapho-Lunate Angle

Scapho-Lunate Angle

Scapho-Lunate Angle

Scapho-Lunate Angle

Scapho-Lunate Angle

Normal 30 – 60O

Dan Brown

3

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Carpal Ligaments •  Ligaments are of 2 types –  Intrinsic –  Extrinsic

Carpal Ligaments •  Intrinsic –  Short ligaments between adjacent bones of the same row

•  Extrinsic –  Longer ligaments that connect carpal bones to the radius or to metacarpals

Intrinsic Ligaments

Intrinsic Ligaments

•  Between adjacent bones –  Scapho-lunate

Intrinsic Ligaments

Intrinsic Ligaments

•  Between adjacent bones –  Scapho-lunate –  Luno-triquetral

Dan Brown

4

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Intrinsic Ligaments •  Between adjacent bones –  Scapho-lunate –  Luno-triquetral

Intrinsic Ligaments •  Between adjacent bones –  Scapho-lunate –  Luno-triquetral

•  These ligaments allow some movement between the bones of the proximal carpal row

•  These ligaments allow some movement between the bones of the proximal carpal row •  Distal row bones are held so firmly by the metacarpals that they move as one

Intrinsic Ligaments

Extrinsic Ligaments •  Intracapsular condensations •  Volar ligaments are much the stronger –  Radial collateral –  Radio-scapho-capitate –  Radio-lunate –  Radio-scapho-lunate

Volar Extrinsic Ligaments

Mechanics •  In radial deviation, scaphoid shortens by flexing

Dan Brown

5

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

In Radial Deviation

Scaphoid must shorten

Which it does by flexing

Mechanics •  In radial deviation, scaphoid shortens by flexing •  In ulnar deviation, scaphoid lengthens by extending

In Ulnar Deviation

Dan Brown

Scaphoid must lengthen

6

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Which it does by extending

Mechanics •  Movement starts with the scaphoid •  As a result of the intrinsic ligaments this movement occurs in all 3 bones of the proximal row

Carpal Instability Carpal Instability

•  The abnormal position may be present all the time •  More commonly, the abnormal position may only be present intermittently (with certain movements of the wrist)

Carpal Instability •  Intrinsic ligament damage causes instability between bones of a single carpal row

Carpal Instability •  The distal carpal row is fixed to the metacarpals •  The proximal row “floats free” between the mid-carpal and radio-carpal joints

•  Extrinsic ligament damage causes instability between the 2 carpal rows

Dan Brown

7

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Carpal Instability •  Normally flexion and extension occur simultaneously at both the mid-carpal and radio-carpal joints •  Lack of constraints may cause the radiocarpal joint (or part of it) to flex whilst the mid-carpal joint extends (or vice-versa)

Carpal Instability •  As a result of the intrinsic ligaments movement occurs in all 3 bones of the proximal row •  With a intrinsic tear, the bones ulnar to the tear do not move with the scaphoid

Carpal Instability •  With a scapholunate tear –  scaphoid flexes: lunate & triquetrum extend

•  With a Luno-triquetral tear –  Scaphoid & lunate flex: triquetrum extends

Carpal Instability - Terminology •  Intrinsic ligament damage causes instability between bones of a single carpal row Dissociative •  Extrinsic ligament damage causes instability between the 2 carpal rows Non-dissociative

Dan Brown

Carpal Instability Terminology

Carpal Instability - Terminology •  The abnormal position may be present all the time Static •  More commonly, the abnormal position may only be present intermittently (with certain movements of the wrist) Dynamic

8

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Carpal Instability - Terminology

Carpal Instability - Terminology

•  The distal carpal row is fixed to the metacarpals •  The proximal row “floats free“ between the mid-carpal and radio-carpal joints Intercalated segment

•  Normally flexion and extension occur simultaneously at both the mid-carpal and radio-carpal joints •  Lack of constraints may cause the radiocarpal joint (or part of it) to extend whilst the mid-carpal joint flexes (or vice-versa) Intercalated segment instability

Carpal Instability - Terminology •  With a scapho-lunate tear –  scaphoid flexes: lunate & triquetrum extend

Dorsal intercalated segment instability

Intercalated Segment Instability •  Dorsal – DISI –  More common (eg scapho-lunate) –  Scahoid flexes, lunate extends –  Scapho-lunate angle increases

•  Volar – VISI •  With a lunp-triquetral tear –  Scaphoid & lunate flex: triquetrum extends

Volar intercalated segment instability

DISI

–  Less common –  Both scaphoid and lunate both flex with triquetrum extended –  Scapho-lunate angle decreases

DISI

80O

Dan Brown

9

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

•  CI

26/05/16

VISI

VISI

Classification

Classification

Carpal Instability

•  CID •  CIND

Classification •  •  •  •  • 

CID CIND CIA CIC CIL

dissociative non-dissociative adaptive complex longitudinal

dissociative non-dissociative

Classification •  •  •  •  • 

CID CIND CIA CIC CIL

dissociative non-dissociative adaptive complex longitudinal

•  All may be static or dynamic

Dan Brown

10

Session 3 (14:15) Mr Dam Brown

Wrist Instablity

26/05/16

Summary

Summary

•  The lunate wants to extend •  Ligaments stop this happening •  Damage to various ligaments allows the lunate (and its neighbours) to behave abnormally

•  Carpal instability relates to the proximal carpal row –  Relationship between individual bones dissociative –  Relationship with radius and distal row Non-dissociative

Remember •  Instability detected at examination or xray may not be the cause of the symptoms

Dan Brown

11

Session 4 (16:00) Mr Miguel Oliveira Miguel Oliveira Consultant Orthopaedic Surgeon St. Richard’s Hospital Chichester

Ulnar-sided wrist pain: Ulnar impaction syndrome and central TFC tears Ulnar shortening

Terminology Ulnar impaction syndrome Ulnocarpal impaction Ulnocarpal Abutment

vs.

Ulnar impingement syndrome

Definition of ulnar impaction syndrome A degenerative wrist condition caused by chronic compressive overloading of the ulnocarpal joint, with impaction of the ulnar head against the triangular fibrocartilage and ulnar-sided carpus

Outline of talk Risk factors for ulnar impaction syndrome Diagnosis and evaluation Central (degenerative) TFC tears Treatment - concentrating on techniques for ulnar shortening

Session 4 (16:15) Mr David Warwick

16/05/16

F  Tendon ­ 

Ulnar Corner pain

­  ­ 

F  TFCC:

ECU tendonitis ECU instability FCU tendonitis

­  ­  ­ 

F  Bone ­ 

F  Piso-triquetral joint

Hook of hamate fracture

­ 

F  Joint ­  ­ 

­ 

Mid-carpal instability Lunate-triquetrum instability

F  Distal radio-ulnar joint:

Professor David Warwick MD FRCS FRCS(Orth)

­  ­ 

European Diploma of Hand Surgery

.

­ 

Osteoarthritis Rheumatoid arthritis Instability

­  ­  ­  ­ 

www.handsurgery.co.uk

­  ­  ­ 

F History F Examination

­  ­  ­  ­  ­  ­ 

Xray Ultrasound MRI MRI arthrogram CT CT arthrogram Arthroscopy

­  ­  ­ 

Ulnar nerve compression—Guyon’s canal Cubital tunnel syndrome Cervical radiculopathy Neuroma dorsal branch of ulnar nerve DRUJ instability with secondary ulnar nerve irritation (SUN syndrome- subluxation related ulna neuropathy )

F  Vascular ­ 

Hypothenar hammer syndrome

Foveal Sign

F Investigation ­ 

Arthritis Instability Ganglion

F  4th-5th CMC OA F  Lunate—Hamate arthritis F  Nerve ­ 

TFCC perforation Ulno-carpal instability Ulno-carpal impaction Styloid-carpal impaction Synovial impingement Ulnar translation of carpus Ulno-triquetral tear ligament tear

Assessment of the ulnar corner

­ 

­ 

F  Ulno-carpal joint:

BSSH Instructional Course June 2016

Perforation Tear Crystal deposition

F 272 Wrist arthroscopy patients ­ 

95% sensitive for UT ligament injuries •  ulnar edge of palmar radioulnar ligament

­ 

87% sensitive for foveal disruptions

Tay, Tomita Berger (2007) The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity J Hand Surg (Am) 32:438-44 Tay, Berger, Parker (2010) Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 26:495-501

F Treatment

Tendonitis F Sites ­  ­ 

FCU ECU

F Causes ­  ­ 

Unaccustomed overuse Ulnar styloid metalwork

F Investigation ­  ­ 

­  ­  ­  ­ 

rest and splint NSAIDs Inject Excise

ECU Instability F Needs a pulley F Stop bowstringing ­  ­  ­ 

Extension Ulnar deviation Supination

F Must allow unrestricted pronation-supination

Xray Ultrasound

1

Session 4 (16:15) Mr David Warwick

16/05/16

• MRI Web Clinic - February 2009 Extensor Carpi Ulnaris Subsheath Injury by Mark H. Awh, M.D.

Retinaculum & ECU Subsheath

• MRI Web Clinic - February 2009 Extensor Carpi Ulnaris Subsheath Injury by Mark H. Awh, M.D.

• Pronation

Full supination

• Supination

Full pronation

Mechanism of Injury F Acute •  Sudden movement –  Tennis, double handed backhand, wrist nearest racquet

F Chronic Usually tennis, sometimes golf and rugby league Pain and swelling in ulnar corner ­  Painful clunking ­  ­ 

History F Onset of pain ­  ­ 

Sudden trauma Gradual onset

F Site of Pain Dorso-ulnar ­  Aggravated by ­ 

•  Ulnar deviation •  Supination

F Clunking or snapping on rotation

Anatomical repair

Rowland SA 1986 Acute traumatic subluxation of the ECU tendon at the wrist J Hand Surg 11A; 809-811 Eckhardt WA, Palmer AK 1981 Recurrent dislocation of ECU tendon. J Hand Surg 6A:629-631 Inoue G and Tamura Y 2001 Surgical treatment for recurrent dislocation of the ECU tendon J Hand Surg 26B. 556-559

MacLennan A et al 2008 Diagnosis and anatomical reconstruction of ECU subluxation. J Hand Surg 33A: 59-64

2

Session 4 (16:15) Mr David Warwick

16/05/16

Unstable sheath movie

Final knot

Final reconstruction movie

Fracture Hook of Hamate

3

Session 4 (16:15) Mr David Warwick

16/05/16

Stylo-carpal impaction

Stylo-carpal impaction

F Examination ­ 

painful on ulna tilt

F Treatment ­  ­  ­ 

­ 

leave excise subperiosteally reef soft issue with Bone Anchor Do not remove the foveal attachment

Ulno-carpal synovitis

Ulno-triquetral ligament tear

Foveal Sign

Tay, Tomita Berger (2007) The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity J Hand Surg (Am) 32:438-44

Tay, Berger, Parker (2010) Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 26:495-501

4

Session 4 (16:15) Mr David Warwick

16/05/16

Pisotriquetral Arthritis F Symptoms ­  ­  ­  ­ 

Palmar-ulnar pain Worse on flexion in ulnar deviation under load holding iron cutting meat

F Examination ­ 

distinguish LTIL and PTOA •  shear transversely •  shear obliquely

Tay, Berger, Parker (2010) Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 26:495-501

F Steroid injection awkward

­ 

F Investigation

F Excision

20 degrees supinated lateral ­  CT/MRI ­ 

Split FCU subperiosteal excision ­ beware motor branch! ­  ­ 

Lunate-hamate arthritis F Anatomy and pathology F Ganglion ­ 

­  ­ 

associated with ulnar nerve signs investigation MRI

F Instability ­  ­  ­ 

spontaneous predisposes to OA? Trauma

­ 

Type I lunate (30%)

­ 

Type II lunate: (70%)

•  does not articulate with hamate •  articulates with hamate.

F Rare pattern of arthritis ­ 

associated with Type II lunate

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9812 . Viegas SF, Wagner K, Patterson R et-al. Medial (hamate) facet of the lunate. J Hand Surg Am. 1990;15 (4): 564-71

5

Session 4 (16:15) Mr David Warwick

16/05/16

Lunate-Hamate arthritis F Symptoms and signs ­ 

­  ­ 

F Treatment

Ulnar-sided pain, worse on ulnar deviation. Point tenderness. Possible LT signs.

­ 

Arthroscopy •  to confirm diagnosis, exclude or confirm associated injuries, •  arthroscopic resection of proximal pole of hamate. •  Radial mid-carpal portal (scope); ulnar mid-carpal portal (burr). Remove 3mm.

Case courtesy of Dr Tim Luijkx, Radiopaedia.org, rID: 36803 Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9812 

Vascular occlusion F Constant percussion baseball mason ­ martial arts ­  ­ 

F Ischaemia of hand F Microemboli F Ulnar nerve injury F Pisotriquetral pain

Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 16724

Investigation

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 19867

Treatment F Reconstruct with reversed vein graft. F Treat associated pisiform symptoms ­  ­ 

cortisone excision

F Treat associated ulnar nerve symptoms ­ 

neurolysis

6

Session 4 (16:30) Professor Vivien Lees

THE ANATOMY AND PHYSIOLOGY OF FOREARM ROTATION (15mins in Manchester) VC Lees Introduction The elbow, forearm and wrist function as a unified structure to provide a stable, strong and highly mobile strut for positioning of the hand in space and for conducting certain load-bearing tasks. An understanding of the relevant anatomy and biomechanics is important for the surgeon assessing and treating injuries of these areas. Evolution During evolution the development of forearm rotation was important for the placement of the hand in 3-dimensional space – this came into its own in the action of brachiation with apes swinging through the tree branches. Our own DRUJ is recognisable in the great apes – the less evolved mammals have a syndesmosis for a DRUJ. The development of forearm rotation, the ability to transfer loads and the mobile wrist was probably as important as development of the opposable thumb in allowing early man to develop as a hunter-gatherer. Composite movement of forearm rotation Forearm rotation occurs between the head of the ulna on the sigmoid notch distally and the head of the radius and the radial notch of the ulna proximally. These joints - the proximal radioulnar joint (PRUJ) and distal radioulnar joint (DRUJ) – are, in functional terms, hemi-joints each supporting the movement of forearm rotation. One study we undertook showed only a 2% difference in articular areas between the PRUJ and DRUJ with the PRUJ being the fractionally greater of the two. Furthermore, if that part of the ulna which forms the hinge of the elbow joint is subtracted then the forearm bones have very similar volume with the radius being just 4% larger than the ulna.

1

Session 4 (16:30) Professor Vivien Lees

The movements of pronation and supination are a combination of rotation of the radius and translocation of the ulna. As the forearm rotates between full pronation into full supination the ulna shifts sideways by an average 9mm in a movement known as translocation. As the radius pronates around the ulna it displays a relative proximal movement and vica versa in supination. There is also relative movement of the radius distally as the elbow is extended. Axis of forearm rotation passes through the centre of the head of radius at the elbow and through the fovea of head of ulna at wrist level. This axis is not constant but changes slightly as the radial and ulna heads shift slightly on their respective articular surfaces during pronation-supination. Anatomical adaptations affecting forearm function Bone  Ulna – the ulna is the primary ‘load-bearing’ bone of the forearm and supports the distal radius as the radius rotates around the ulna. The ulna styloid represents an expansion for the attachments of a series of important stabilising ligaments. During rotation the centroid of rotation passes not through the ulna styloid but through the fovea  Radius – the radius rotates around the ulna. The most proximal part of the bone proximal to the radial tuberosity is straight and lies parallel to the axis of forearm rotation. Distal to this the radius develops an anterior curvature without which the radius could not rotate around the ulna We had made the observation that there appeared to be some difference between the range of pronation / supination with the elbow flexed compared to when it is extended. We measured this with a simple jig on human volunteers and showed clearly that there is greater range of supination with elbow flexed and greater pronation with elbow extended. Range of forearm rotation dependent on elbow position Active supination & pronation in R arm Forearm rotation

150 Supin

100

Pron

50 0 FE

45F

90F

FF

Degree of elbow flexion

Teleologically, it is an advantage to have that extra supination when putting the hand to the mouth and equally when we’re handling an object at some distance with the elbow extended we usually want our hand pronated. Joints and ligaments acting as stabilisers PRUJ –the radial head articulates with the radial notch of the ulna stabilised by the annular ligament

2

Session 4 (16:30) Professor Vivien Lees

DRUJ- the ulna seat articulates with the sigmoid notch – differential curvatures – some stability from shape though considerable variability. This joint is stabilised by the following structures in order of descending importance.  TFCC –primary stabiliser of DRUJ (including DRUL) o The TFCC is the ligamentous and the fibrocartilaginous structure that suspends the distal radius and ulnar carpus from the distal ulna. Comprises the disc proper, ulnar collateral ligament, meniscus homologue (occasionally present), volar and dorsal DRUL, ECU subsheath and the ulnolunate and ulnotriquetral ligaments. [Function is to stabilise the ulnocarpal and DRUJ transmitting load from the carpus to the ulna and facilitating complex movements of the wrist]. The TFC is the fibrocartilage plus the DRUL.  IOM – with forearm in anatomical alignment the membranous structure runs from the radius proximally to the ulna distally and is reinforced centrally by a tendinous part in the middle. A dorsal oblique accessory cord runs at right angles to the rest (phylogenetically represents degenerate FPL). The IOM is one of the stabilisers of the radius on the ulna and also acts to transmit load as well as presenting an expanded surface from which certain muscles can take origin.  The Distal Oblique Bundle of the IOM is not always present but appears to be an effective stabiliser where it exists  ECU subsheath (technically is included as part of the TFCC although is often considered separately in descriptions)  Pronator quadratus contributes to transverse stability and ECU with its subsheath stabilises the head of ulna during forearm rotation.  DRUJ capsule

Muscles Supination  Biceps (musculocutaneous nerve) with elbow in flexion  Supinator (radial nerve) with elbow extended Pronation  Pronator teres (median nerve) with elbow extended  Pronator quadratus (anterior interosseous nerve)

Skin Because the radius rotates around the ulna the skin envelope around the radial side might be expected to be subject to more deformation and shearing strains than the ulna side. We had previously observed that scars on the radial side are usually of worse quality and tend to stretch compared to those on the ulna side. We measured deformation of marked-circles to show that the skin envelope does deform more on the radial side. Subluxation-related ulna neuropathy (SUN syndrome) Studies have been undertaken on the impact of instability of the distal radius on the ulna head in respect of ulna nerve function. A clinical study has shown up to 38% patients with unstable DRUJ have transient pins and needles in the ulna nerve

3

Session 4 (16:30) Professor Vivien Lees

territory ulna typically related to the position of forearm rotation. MRI imaging has been undertaken on a group of such patients showing kinking of the ulna nerve in the region of the ulna head/Guyon’s canal suggesting a possible cause for the observed clinical picture. Proprioception There is a concentration of proprioceptive nerve fibres on the outer layer of the ulnar part of the wrist ligament complexes. It is thought that these probably play an important part in initiating the protective musculotendinous reflexes that protect the osseo-ligamentous structures. In this sense the wrist ligaments act as a sense organ that are important part of the reflex governing coordinated muscle contraction to prevent damage to the joints. The forearm/DRUJ as a load-bearing mechanism. A cadaveric biomechanical model has been used to demonstrate the DRUJ is actually a load-bearing joint with maximum load transmission occurring in mid-supination. Further, using strain gauges bonded to the forearm bones it was possible to demonstrate a reciprocal relationship of load-bearing with an increase in load passing down the radius matched by a decrease in that down the ulna and vica versa. Axial loading of the model produced increase in pressure profiles across the joint as illustrated here. Disruption of the linked chain by removal of the ulna head (Darrach procedure) defunctions the system with all the load then passing down the radius. Ulna 9

Radius

8

Force (kg)

7 6 5 4 3 2 1 0 Pmax P60

P30 Neutral S30

S60 Smax

Position of forearm

4

Session 4 (16:30) Professor Vivien Lees

Ulna Radius

8 7

Force (kg)

6 5 4 3 2 1 0 Pmax

P60

P30 Neutral S30

S60

Smax

Position of forearm

Later studies showed that both DRUJ and PRUJ have reproducible and similar force profiles for load transmission and contact areas. Again, this reinforces the understanding we have of the two joints working in a co-ordinated manner to transmit load through the forearm.

Co-ordinated model In summary, our concept of forearm rotation incorporates the load-bearing functions that are so important to normal activity. The anatomical structures of the forearm show a number of adaptations that facilitate rotation not least of which is to provide both mobility and stability. More recent work has modified our understanding of what happens in the system when load is applied. Traditionally applied forces were thought simply to transmit down the radius or to pass from radius to ulna in a unidirectional fashion via the IOM. Our current understanding is that the osseoligamentous structures act more like a linked chain with forces passing in a much more dynamic way in either direction depending on the conditions at the time.

Bibliography

5

Session 4 (16:30) Professor Vivien Lees

Birkbeck DP, Failla JM, Hoshaw SJ, Fyhrie DP & Schaffler M. The interosseous membrane affects load distribution in the forearm. J Hand Surg(Am) 1997; 22A:975980. Brink PR & Hannemann PF. Distal oblique bundle reinforcement for treatment of DRUJ instability. J Wrist Surg 2015 4(3): 221-8. Canham CD, Schreck MJ, Maqsoodi N, Doolittle M, Olles M & Elfar JC. A nondestructive, reproducible method of measuring joint reaction force at the distal radioulnar joint. J Hand Surg (Am) 40(6) : 1138-44. Cartmill M & Milton K. The lorisiform wrist joint and the evolution of ‘brachiating’ adaptations in the hominoidea. Am J Phys Anthrop 1974; 47: 249. Drewniany JJ & Palmer AK. Injuries to the distal radioulnar joint. Orthop Clin North Am 1986; 17:451-459. Gray’s Anatomy 39th Edition 2004, Churchill Livingstone, Edinburgh – Sections on Biomechanics of the wrist joint, Anatomy of wrist ligaments and Forearm Rotation Greybe D, Boland MR, Wu T, Mithraratne K. Examining the influence of distal radius orientation on distal radioulnar joint contact using a finite element model. Int J Numer Method Biomed Eng 2016, 10.1002/cnmm.2766(EPub ahead of print) Hagert E, Garcia-Elias M, Forsgren S & Ljung BO. Immunohistochemical analysis of wrist ligament innervation in relation to their structural composition. Journal of Hand Surgery; 2007 : 32: 30-6. Hotchkiss RN, An KN, Sowa DT, Basta S & Weiland AJ. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg(Am) 1989: 14: 256-261. Kane PM, Vopat BG, Got C, Mansuripur K, Akelman E. The effect of supination and pronation on wrist range of motion. J Hand Surg(Am) 2014:3(3): 187-91. King GJ, McMurtry RY, Rubenstein JD & Gertzbein SD. Kinematics of the distal radioulnar joint. J Hand Surg(Am) 1986; 11: 798-804. Lees VC & Scheker LR. The radiological demonstration of dynamic ulnar impingement. J Hand Surg(Br): 1997; 22B: 448-450. Manson TT, Pfaeffle HJ, Herndon JH, Tomaino MM & Fischer KJ. Forearm rotation alters interosseous ligament strain distribution. J Hand Surg(Am) 2000; 25A: 10581063. Morrey BF. Anatomy of the elbow joint. In: Morrey BF (ed) The elbow and its disorders, 2nd ed, Philadelphia, WB Saunders, 1993: 16-52. Nakamura T, Yabe Y & Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg(Br); 1996: 21B: 581-586.

6

Session 4 (16:30) Professor Vivien Lees

Nakamura T, Yabe y Horiuchi Y & Yamazaki N. In vivo motion analysis of forearm rotation utilizing magnetic resonance imaging. Clinical Biomechanics 1999; 14: 315320. Nakamura T, Matsumura N, Iwamoto T, Sato K, Toyama Y. Arthroscopy of the distal radioulnar joint. Handchir Mikrochic Plast Chir 2014; 46(5): 295-9. Palmer AK. The distal radioulnar joint. Anatomy, biomechanics, and triangular fibrocartilage complex abnormalities. Hand Clinics 1987; 3: 31-40. Ray RD, Johnson RJ & Jameson RM. Rotation of the forearm: An experimental study of pronation and supination. J Bone Joint Surg 1951; 33A: 993-996. Salter N & Darcus HD. The amplitude of forearm and of humeral rotation. J Anat 1953; 87: 407-418. Shaaban H, Giakis G, Bolton M, Williams R, Scheker LR & Lees VC. The distal radioulnar joint as a load-bearing mechanism – a biomechanical study. J Hand Surg(Am); 2004: 57A: 45-49. Shaaban H, Giakis G, Bolton M, Williams R, Wicks P, Scheker LR & Lees VC. The load-bearing characteristics of the forearm: Pattern of axial and bending force transmitted through ulna and radius. J Hand Surg(Br) 2006; 31B: 274-279. Shaaban H, Giakis G, Bolton M, Williams R, Wicks P, Scheker LR & Lees VC. Contact area inside the distal radioulnar joint: Effect of axial loading and position of the forearm. Clinical Biomechanics 2007; 22; 313-318. Skahen JR, Palmer AK, Werner FW & Fortino MD. Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg(Am); 1997: 22: 981985. Weiss APC & Hastings H. The anatomy of the proximal radioulnar joint. J Shoulder Elbow Surg 1992: 1: 193-199. Werner FW & An K-N. Biomechanics of the elbow and forearm. Hand Clinics 1994; 18 (3): 357-372. Vivien Lees May 2016

7

Session 4 (16:45) Dr Andrea Atzei

Session 4 (17:00) Mr Grey Giddins

Complex forearm injuries - Galeazzi, Monteggia & Essex Lopresti Introduction Potentially complex Uncommon Biomechanics The “ring” of the forearm; a ring has to break/deform is at least two places Is DRUJ instability following injury all or nothing or a continuum? – a continuum (so what?) The joints cannot hold the bones to length but restoration of bone anatomy can largely stabilize the joints Presentation High(ish) energy injury Pain, swelling, deformity and stiffness – much easier to miss in children Rarely neurovascular deficit Investigations Radiographs – siting may be crucial especially in children (consider elbow, forearm and wrist) If the ring is broken in one place find the other Repeat the radiographs as necessary – they are your responsibility Rarely CT or MRI Treatment Surgical Reduction and stabilization of the bone(s) Children – often plastic deformity that will settle with manipulation and POP. If not then typically closed reduction and nailing Adults – ORIF and assess stability and ROM. K wire stabilization of the unstable joint is uncommon Post-operative care Children - Immobilization in POP c. 4 weeks and mobilize Adults - Immobilization in POP c. 7-10 days and mobilize Outcomes Typically very good with clinically insignificant DRUJ (?PRUJ) instability

Late reconstruction Monteggia/Galleazzi Weeks to a few months Correct the long bone anatomy and reduce and stabilize the PRUJ/DRUJ Years PRUJ - Aim to do nothing DRUJ – reconstruction may be possible but try to avoid ablation procedures (Darrach’s, S-K procedure) except in the elderly

Session 4 (17:00) Mr Grey Giddins

Essex-Lopresti If the radial and ulnar heads are intact reconstruction may be possible. Often one has been excised: Replacement and possible soft-tissue stabilization IOM reconstruction – unproven One bone forearm

Session 4 (17:15) Mr Grey Giddins

Salvage of the stiff or painful distal radio-ulnar joint Introduction Common A stiff DRUJ may not be very symptomatic Biomechanics Stiff – Functional ROM – 450 supination and pronation (900 arc) Loss of supination less well tolerated than loss of pronation Causes Stiffness Mechanical – arthritis, dislocation/subluxation, fracture mal-union, soft tissue tightness, spasticity Pain Pain – Peripheral – arthritis, dislocation/subluxation, instability, TFCC tear, fracture malunion, neuropathy, CRPS Central – CRPS Presentation Pain or stiffness Systemic disease Local injury Instability Neuropathy Examination Inspection – scar, prominent ulnar head, systemic disease Palpation – synovitis, tenderness Stability – clinical testing, mechanical testing Movement – set position, active vs passive, end points Tendon function – esp EDM, ECU Sensibility – SSBUN ELBOW ………. Investigations Radiographs - ? grip views CT scan – alignment, anatomy MRI scan – synovitis, TFCC, ECU USS – ECU Treatment Non-operative Analgesia, activity modification, therapy, splint, steroid injection

Session 4 (17:15) Mr Grey Giddins

Operative Stiff – Good anatomy – soft tissue release (assuming pain controlled), ulnar shortening, DRUJ stabilization Bad anatomy – Darrach’s, S-K procedure, ulnar head replacement, total DRUJ replacement Painful – Good anatomy – why, why, why??? Synovectomy, TFCC repair/debridement, ECU stabilization, SSBUN surgery, shortening osteotomy, Feldon wafer, DRUJ stabilization Bad anatomy – Darrach’s, S-K procedure, ulnar head replacement, total DRUJ replacement

Session 5 (08:30) Professor Ian Trail

Radial Sided Wrist Pain

I A Trail Wrightington 2016

Chronic

Scaphoid non-union Scapholunate injury Osteoarthritis incld radial styloid STT 1st CMC Tendon pathology de Quervains peritendonitis crepitans

Uncommon Neuroma superficial branch radial nerve EPL rupture

26/05/2016

Differential Diagnosis Acute Scaphoid fracture Scapho-lunate injury Radial styloid fracture Other base of thumb fracture

Chronic

Scaphoid non-union Scapholunate injury Osteoarthritis incld radial styloid STT 1st CMC Tendon pathology de Quervains peritendonitis crepitans

Radial Styloid Fracture “Chauffeurs Fracture”

Acute calcification FCR / ECRL / ECRB rupture

1

Session 5 (08:30) Professor Ian Trail

Can occur in isolation or in combination with other injuries

26/05/2016

Incidence reduced with the advent of CT scanners and the decline in the number of chauffeurs

Fixation with wires (k) or screw

Bennett’s fracture (1882) Intra-articular fracture dislocation Small fragment held by oblique lig. Large fragment (metacarpal) subluxes

Differential Diagnosis Acute Scaphoid fracture Scapho-lunate injury Radial styloid fracture Other base of thumb fracture

Rolando fracture (1910) Comminuted intra-articular fracture T or Y

2

Session 5 (08:30) Professor Ian Trail

To wire CMC

26/05/2016

No clear advantage to either !

or fix fracture ?

Do they develop secondary OA?

Aye

Nay

Kjaer-Peterson et al (1992) Cannon et al(1986) Livesley (1990)

Chronic

Scaphoid non-union Scapholunate injury Osteoarthritis incld radial styloid STT 1st CMC Tendon pathology de Quervains peritendonitis crepitans

Griffiths et al (1974)

Cadaveric & Xray Studies Peritrapezial 35% O > o + 83% cadavers

Bathia et al (1996)

3

Session 5 (08:30) Professor Ian Trail

Related to long standing scapho-lunate lig. injury

26/05/2016

Localised discomfort Watsons manoeuvre FCR tendonitis

Weinzig & Watson (2001)

Treatment

Excision of trapezium

Conservative

Excision of distal scaphoid

Operative

Trapezial replacement Arthrodesis STT joint

Good results Posn of fusion

pain movement (50%)

Mid-carpal collapse

radio-scaphoid arthritis < 50% radial styloidectomy Non-union ?

4

-

+

Session 5 (08:30) Professor Ian Trail

26/05/2016

Interpose slip of FCR Capito-lunate fusion Dorsal capsulodesis

Entrapment of the Superficial Branch Radial Nerve

Localised discomfort Tinels

+ve

Loss of sensation

Wartenbergs Syndrome (1932) Spontaneous Iatrogenic

Treatment Conservative Surgical

Hypersensitivity

5

Session 5 (08:30) Professor Ian Trail

26/05/2016

Release 86% successful Excision unpredictable

Thank You

Acute (OED) “Coming sharply to a crisis”

Chronic “lingering, lasting, constant”

6

Session 5 (08:45) Professor Tim Davis

Factitious Disorders and Injuries Professor T.R.C. Davis Hand Surgeons will from time to time encounter, both in their NHS Clinics and Medico-Legal Practices, people who either feign or create disease for secondary benefit. Such people are not always readily identified, even by experienced Hand Surgeons. It is not always easy to classify these patients but, in general, those who: 





consciously fabricate symptoms, signs and disabilities for financial gain in personal injury litigation are classed as malingerers; consciously fabricate symptoms and signs of disease for other secondary gain (entry into the sick role, alteration of family dynamics, etc) are classified as suffering with factitious injuries or disorders; have suffered a definite injury, though exaggerate the ongoing symptoms, are guilty of “exaggeration”.

People with factitious disorders or injuries have created disease and can present to a Hand Surgeon in many ways. Common presentations are:  

 

swelling of the whole of the arm due to the application of a tourniquet; localised swelling on the back of the hand (Secretan’s Disease) due to constantly knocking it against a hard surface; a persistent wound which will not heal; abnormal hand postures.

People from all walks of life can present with factitious injuries though health professionals are over represented, as are women. Their “problem” may develop spontaneously but frequently develops after an injury (which is usually trivial), an operation or a labour dispute which the treating doctor may be totally unaware of. These patients often present to the Hand Surgeon many months after the original “injury”. Factors in the history which should alert the Surgeon to a possible factitious injury include:    

an apparently trivial injury; a lengthy delay from the injury until seeking medical advice; significant delay from the time of injury to the onset of the disability; previous consultations with other doctors, none of whom had been able to make a diagnosis despite numerous investigations which are all normal.

It is amazing how many doctors never consider the possibility that the patient may be creating the problem and many of these patients are labelled as suffering with chronic regional pain syndrome and are referred to Pain Clinics for treatment. Many will agree to undergo painful treatments, such as Guanethedine blocks (Munchausen’s syndrome), though others will claim unexpected adverse reactions to the treatment, such that that it is conveniently discontinued. Despite the apparent disastrous predicament of the “patients”, they often appear calm and relatively indifferent to their apparent marked disability. The clinical examination must be thorough and not only record what is present, but also what is not present. For example, someone who is not using their hand at all should have atrophy of the soft tissues of the fingers, shallow finger prints and joint creases and no callosities or ingrained dirt. The management of these people is difficult. It is absolutely vital that careful Clinic notes are kept, in case the “patient” makes a complaint against your diagnosis and management. If one challenges the “patient” regarding the causation of their symptoms and signs, one should have a witness present. Referrals to psychiatric outpatients or a Psychologist can be offered but such requests are often rejected. In the first instance my personal practice is to reassure the “patient” that there is nothing seriously wrong and that they will get better. I also ask questions which let them know that I know what is going on, without actually accusing them of fabricating their disease. If I am convinced of the situation, then I perform no further investigations and withdraw all treatment. Communication with other treating doctors, particularly the Pain Clinic, is vital. Should other treating doctors dispute your opinion, and continue with treatments of their own, then useful treatment is impossible. In a case of Secretan’s Disease or a wound which will not heal, one can temporarily place the hand, wrist and forearm in a plaster to demonstrate that the swelling/wound will resolve if the patient is unable to perpetuate the signs by continuing to knock the back of the hand or tamper with the wound. The long term outcome for these patients is unpredictable with some re-presenting to other Hospitals, possibly with other presentations of factitious injury/disease, at later dates.

Session 5 (09:00) Professor Joe Dias

The acute scaphoid fracture- Cast or Fixation Professor Joe Dias AToMS, Leicester, United Kingdom There are many challenges in the clinical decision making for acute scaphoid fractures. The major decision points are the diagnosis of the injury, the treatment and the controversy on early fixation, the optimal treatment of non-union, this section will cover some clinical questions. Incidence The reported incidence of scaphoid fractures varies widely depending on the age of subjects studied and how the population was defined. Our data on 530 acute scaphoid fractures over a 3-year period gave a scaphoid fracture incidence of 14.7 fractures per 100,000. Men between 15-19 years had the highest rate of 95 fractures per 100,000. In women, the highest rate of 20 fractures per 100,000 was observed in 10-14 year olds. We estimate the annual UK scaphoid fracture burden at 9,545. Based on our figures we would expect 47,610 acute scaphoid fractures each year in the USA and 74,704 in the European Union. Larsen et al.19921 report an incidence of 22 per 100,000 per year, which is similar to our rate in the UK. The rate reported in Scotland was double at 29 per 100,000. The incidence of scaphoid fractures in an urban population in Norway, was 43 per 100,000 per year. Studies on military personel quote rates significantly higher than in the UK of 121 per 100,000 but this reflects the age and gender specific incidence. So the burden of scaphoid fractures with the early impact of non-union and wrist OA is very high. This section will address questions to help manage acute scaphoid fractures. If a scaphoid fracture non-union is left untreated the wrist becomes arthritic, usually within 5 years and after 10 years all will have arthritis on radiographs. This affects patients at a very young age2. That is why treating this fracture correctly in the first instance is so important. Diagnosis The first question is how to avoid missing a fracture. For every 100 patients presenting to the emergency department with pain on the radial side of the wrist after a fall on the outstretched hand and in who a clear fracture is not immediately apparent on radiographs only 3 will have a scaphoid fracture3. Young ladies are less likely to have a fracture and could have a minor capsule-ligamentous stretch causing pain and older folk could tweak of an arthritic joint in the wrist or thumb during the fall. But young men, especially if the mechanism of injury is substantial, are likely to have a scaphoid fracture. Our clinical clue is the swelling of the wrist. Marked swelling should alert you of the possibility of a more complex and transcarpal injury- so be aware. If you are uncertain you can resolve this with a CT or MR scan and there are pros and cons for each. The MRI is sensitive but less specific than a CT scan. The most important step in management of this large group of patients however is a good explanation given to the patient. If a fracture is not seen on adequate radiographs it is likely to be either incomplete or undisplaced with a very

1

Session 5 (09:00) Professor Joe Dias

high chance of union in any case. However, bear in mind that the CT has a false negative rate. Cast or Fix Once a fracture is identified we need to decide whether to fix it or treat it in a cast for 6 weeks or so. The cast we use in the UK is different from that used in the USA. We use a below elbow cast and leave the thumb free. This immobilises the scaphoid by preventing radiocarpal and midcarpal movement with the thumb contributing very little to the movement of the scaphoid. Importantly this cast allows hand use and permits early return to many occupations. In fractures treated in this manner most (9/10) will unite. The 1/10 with a clear gap confirmed as ununited on a CT scan are identified in at 6 weeks and fixed4. The success rate of this method of management- “the Aggressive non-operative method”, is very high and almost as good as after immediate fixation of all scaphoid fractures. The alternative is to fix a scaphoid fracture but benefits of early return to work are short lived and improvement in union rate is slight. The patient is exposed to avoidable risks. We looked at the rate of scaphoid fixation and provided funnel plots all hospitals in England. The x-axis is the population served and the y-axis is the rate/1000 population of acute scaphoid fractures fixed. These plots show the rate increased each year over three years. This trend of increased fixation of scaphoid fractures was based on “experts” recommending it rather than evidence as the literature showed almost no advantage of one method over the other. This increase was driven by the mushrooming of implants to fix the scaphoid, on the recommendation of eminent surgeons that fixing the scaphoid was better, and surgeons instinctive preference for the surgical alternative. The decision to fix the broken scaphoid is not an automatic one. If you fix the scaphoid the usual pathway is to protect the wrist for around a fortnight and then slowly recover function, light activity first. Return to contact sport would only be after the bone has healed, a process that will take around at least 3 months. On the other hand the patient will be exposed to technical problems in 10-20% of cases and around 5 % of fractures will still not join. Patients are exposed to the uncommon surgical risks of infection, damage to nerves, etc. so the decision to fix is a clinical judgement. We do not know whether immediately fixing a scaphoid is better than treating it a cast. The UK National NIHR funded SWIFFT study comparing fixation to casts in 438 patients with scaphoid waist fractures has now recruited over 420 patients. We intend to follow these patients up for five years. We will finish recruitment next month and will report the year after on the early one-year outcome. In 2023 we will report on the five-year outcome. For now you need to use your judgement in each case but be aware that the jury is out on whether we should fix the scaphoid immediately. If you do decide to fix the broken scaphoid then you can do it from the front or the back. This is again a judgment call. The palmar approach is easy in lax jointed patient(6) and those with a large scaphoid. Fractures located in the middle and distal thirds are easy to fix from the palmar approach. The palmar approach protects the main weight bearing cartilage of the scaphoid and if the screw is left protruding distally, this is in the front and unlikely to cause significant articular cartilage damage. The scaphoid flexes under load moving the prominent screw away from the scapho-trapezium articular surface. On the other hand the dorsal approach allows central position of the implant which improves the rate of bone union, proximal scaphoid fractures are easier to fix, and the technique is 2

Session 5 (09:00) Professor Joe Dias

simple. But this approach breaches weight-bearing cartilage and any prominence of the screw will irreversibly damage the cartilage in the radioscaphoid joint. We choose between these two approaches. In our practice most fractures are fixed from the palmar approach but fractures in the proximal third, in stiff individuals or in scaphoids with a hypoplastic distal pole we prefer the dorsal approach5. Displacement We know that displaced fractures do worse, but which displaced fractures and how much worse? Displacement is defined by the step, gap or the angle between the proximal and distal scaphoid. It is traditional to use either 2 mms or 1 mm as a threshold to define scaphoid displacement and Greg Bain showed us how to define scaphoid angulation. We know that the union rate is poorer if the fracture is displaced and that displacement can be clarified on a CT scan6. However the rate of union if treated in a cast is reduced to 85% so displacement does not hamper union in most cases. There is better logic to subject a patient to surgery in a displaced fracture. The NIHR SWIFFT study will address displacement as well so we will be able to understand the impact of displacement. The consequence of the fracture healing in a displaced position is malunion, but we do not clearly know what to tell our patients that they will experience if the scaphoid heals in a slight non-anatomcal position. Proximal pole fractures Proximal fractures change the ball game7. There is a stronger case for fixation if the fracture is proximal-defined as involving the proximal 20%. The relative risk of non-union in proximal pole scaphoid fractures compared to fractures of the waist of the scaphoid is 7.5. However, 2/3 of these fractures will unite in a cast. So the judgment on whether to fix is easier but still not clearly in favor of fixation. There is no evidence for this judgement at present. Patient factors Two patient factors modify how we manage scaphoid fractures. Both have a significant effect on the scaphoid: smoking and laxity. Smoking delays union after a fracture or nonunion so if the fracture in a smoker is also proximal the odds of failure of union are high. Fixing in such a scenario may improve the odds for the patient. The same judgement shift can occur in displaced fractures. Patients must know the impact of smoking on union and that the risk of failure may not be altered just because we have stabilised the fracture with a headless screw. Laxity is the second factor. Here even when the wrist is immobilised the act of pinching will cause greater movement between the proximal and distal parts of the fractured scaphoid. We have two alternatives: to either immobilise the thumb to defunction it by putting the thumb tip away from the index so the patient cannot pinch for the initial 4 week at least; or alternatively fix the scaphoid, allowing us to mitigate the effects of laxity. Union The final judgement we need to make as surgeons is whether the fracture has united. This is usually done at 6 weeks regardless of the initial management. If the state of union is in doubt get a CT scan. This may show a nonunion but mostly confirms partial union and even if there is only 10% bone bridging, this will consolidate in time. Patients must be informed that whatever we do we are not making the injured wrist normal. 1/5 will continue to have some pain even if the fracture has united and 7% will go on and develop arthritis in the fullness of time.

3

Session 5 (09:00) Professor Joe Dias

Outcome 20% patients had some pain and tenderness 1.7-2.6 years after a healed scaphoid fracture but grip strength and wrist movement were nearly normal. They felt the persistent symptoms were attributable to damage to the articular cartilage at the time of the injury8. Another study9 assessed 229 acute scaphoid fractures which had united with non-operative treatment at seven years and found that 11% experienced persistent symptoms, including pain at rest (3%), restricted range of motion (6%), pain with wrist motion (10%) and weakness of grip (11%). This study noticed osteoarthritis in 5% of wrists after a fracture of the scaphoid. Yet another study 10 found marked painful radiocarpal osteoarthritis in only 1/47 patients who had a healed fracture over 31 years before; although the rate of osteoarthritis was 7% the rest were asymptomatic. In summary the jury is out whether immediate fixation is better than cast treatment. Using a CT scan we can confirm a fracture early and assess the state and magnitude of union at 6 weeks. Conclusion The approach to undisplaced scaphoid fractures was best summarized by Ibrahim et al. :, “we recommend a policy of “aggressive conservative” management of scaphoid waist fractures with initial treatment in a cast. The patient should be encouraged to return to normal activity as early as possible. Concerns regarding the status of union after 6 weeks of treatment should be addressed with a CT scan and if doubt remains, the patient should be offered surgery. Ultimately, the choice of treatment will be dictated by the patient’s preferences and where early hand function is important to livelihood or lifestyle, surgery may be offered early having informed the patient of the attendant risks.”11 References 1. Larsen CF, Brondum V, Skov O. Epidemiology of scaphoid fractures in Odense, Denmark. Acta Orthop Scand 1992;63:216-8. 2. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid nonunion. J Bone Joint Surg Am 1984;66:504-9. 3. DaCruz DJ, Bodiwala GG, Finlay DB. The suspected fracture of the scaphoid: a rational approach to diagnosis. Injury 1988;19:149-52. 4. Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Should acute scaphoid fractures be fixed? A randomized controlled trial. J Bone Joint Surg Am 2005;87:2160-8. 5. Slade JF, III, Jaskwhich D. Percutaneous fixation of scaphoid fractures. Hand Clin 2001;17:553-74. 6. Singh HP, Taub N, Dias JJ. Non-surgical treatment of Displaced Scaphoid waist fractures: meta-analyses of comparative studies. Journal of Bone & Joint Surgery, British Volume 2012;94:137-. 7. Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol 2013;38:888-97. 8. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br 1989;71:307-10.

4

Session 5 (09:00) Professor Joe Dias

9. Lindström G, Nyström A. Incidence of post-traumatic arthrosis after primary healing of scaphoid fractures: a clinical and radiological study. J Hand Surg Br 1990;15:11-3. 10. Duppe H, Johnell O, Lundborg G, Karlsson M, Redlund-Johnell I. Long-term results of fracture of the scaphoid. A follow-up study of more than thirty years. J Bone Joint Surg Am 1994;76:249-52. 11. Ibrahim T, Qureshi A, Sutton AJ, Dias JJ. Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials. J Hand Surg Am 2011;36:1759-68.e1.

5

Session 5 (09:15) Mr Philip Sauve

Management of Scaphoid Nonunion Nicholas D. Riley, Ian S. H. McNab

Scaphoid Nonunion No

Is the patient symptomatic? Principles of Treatment of Scaphoid Nonunion Debride the nonunion where possible to bleeding bone Restore the bony anatomy Ensure the fixation provides stability

Yes

Consider non-operative treatment Continued observation, analgesia, splintage Warn the patient of the risk that SNAC may develop in 5-10 years

If nonoperative treatment fails Yes

Is there scaphoid nonunion advanced collapse? No Yes

Counsel to stop before treatment

Does the patient smoke? No

CT Scan to assess bony deformity (such as humpback), bone loss and presence of cysts Consider MRI with gadolinium enhancement if dysvascularity is suspected. Proximal Pole

No1

Is the proximal pole reconstructable?

Distal Pole

AVN?

Is the distal pole fragmented?

Yes

1

Yes ✝✝Autologous proximal pole arthroplasty

Waist

*Pedicled VBG + ORIF (dorsal approach)

No

No

✝Pedicled VBG + ORIF ⍑Non-vascularised graft (volar approach) + ORIF (volar approach)

⍑Non-vascularised graft + ORIF (volar approach)

Discharge d

Yes

No

No

**Free VBG + ORIF

**Free VBG + ORIF

No

Consider distal pole excision

If there is scaphoid nonunion advanced collapse

Regular clinical and X-ray checks +/- CT scan to assess for union. Has the scaphoid united? Yes

Yes

No

✝Pedicled VBG + ORIF ✝Pedicled VBG + ORIF (volar approach) (volar approach)

Regular clinical and X-ray checks +/- CT scan to assess for union. Has the scaphoid united? No

No

No

No

Salvage - SNAC Nonoperative Treatment Observation, Analgesia, Splintage, Injections

Nonoperative treatment failure. Investigate with plain radiographs +/- arthroscopy or MRI to assess articular surfaces

Stylo-scaphoid arthritis

Radioscaphoid arthritis

Midcarpal arthritis

Yes

Total wrist arthrodesis

Pancarpal arthritis Is the individual high functioning? Denervation & styloidectomy

PRC or 4-corner fusion2

4-corner fusion

No

Total wrist arthroplasty

Management of Scaphoid Nonunion Nicholas D. Riley, Ian S. H. McNab Notes VBG = vascularised bone graft SNAC = scaphoid nonunion advanced collapse PRC = proximal row carpectomy * our preferred option is the distal radius vascularised graft popularised by Zaidemburg ✝ our preferred option is the distal radius vascularised graft popularised by Kuhlmann ⍑ our preferred option is cortico-cancellous iliac crest bone graft ** our preferred option is the free vascularised medial femoral condyle graft ✝✝ our preferred option is the costochondral autologous flap 1 - We feel that the preferred option for a proximal pole nonunion, regardless of whether it is avascular or not, is a vascularised graft. Ramamurthy et al. demonstrated a 32% union rate for proximal pole nonunions using a non-vascularised graft. Robbins et al. showed a 53% union rate using non-vascularised iliac crest graft. Chang et al. demonstrated a 68% union rate and Spiteri et al. a 96% union rate with Zaidemburg vascularised grafting. 2 - If the capitate head is not involved in the degenerative process, the choice of whether to offer a PRC or a four-corner fusion is complex. Both operations provide 85% of patients with good or better pain relief. Range of motion is 75-80o with either procedure, but around ten degrees less with 4-corner fusion, strength is reliably around 80% of the contralateral side with both procedures. The complication rate is higher with four-corner fusion. We, therefore, offer a fourcorner fusion to those below 35 years of age and high demand patients in their 40s or 50s and consider a PRC for everyone else.

References Chang MA, Bishop AT, Moran SL, Shin AY (2006). The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. Journal of Hand Surgery, 31A: 387-396. Ramamurtny C, Cutler L, Nuttall D, Simison AJM, Trail IA, Stanley KJ (2007). The factors affecting outcome after nonvascular bone grafting and internal fixation for nonunion of the scaphoid. Journal of Bone and Joint Surgery (Br), 89B: 627-632. Kuhlmann JN, Mimoun M, Boabighi A, Baux S (1987). Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid. Journal of Hand Surgery, 12B: 203-212. Larsen AN, Bishop AT, Shin A (2007).Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis. Techniques in Hand and Upper Extremity Surgery. 11(4):246-58. Logan JS, Warwick D (2015). The treatment of arthritis of the wrist. The Bone and Joint Journal, 97B: 1303-1308. Sandow M (2001). Costo-Osteochondral grafts in the wrist. Techniques in Hand and Upper Extremity Surgery. 5(3):165-172. Spiteri M, Whalley H, McNab I (2015). Fifteen year experience of successful reconstruction of scaphoid fracture nonunion with distal radius vascularised bone grafts. Presentation at BSSH Autumn Scientific Meeting. Strauch RJ (2011). Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Arthritis - Update on Evaluation and Treatment. Journal of Hand Surgery, 36A:729-735. Zaidemberg C, Siebert JW, Angrigiani C (1991). A new vascularized bone graft for scaphoid nonunion. Journal of Hand Surgery, 16A: 474-478.

Session 6 (10:30) Mr David Shewring

Session 6 (10:50) Mr Jonathan Hobby

BSSH Instructional Course 6.6; Session 6, the hand and brain. Jonathan Hobby. Work Related Upper Limb Pain: Does RSI Exist? Australian Epidemic 1980 Reports of Repetitive Strain Injury, Heralded as a new industrial disease Early treatment to avoid “crippling disease” Treatments ineffective RSI and Australia Telecom 34% of all telephonists working for Australia Telecom (1981-85) Inversely related to keystroke rate 1987 Loss of Court Case. 1988 Compensation laws changed by Labour Government Sequence of Events Speculative Diagnosis, Attributed to Occupation, Panel of Experts, Compensation, Epidemic of Disability Miner’s Nystagmus First Described 1890, Attributed to Safety Lamps 1907 Expert Panel recognised disorder, 1908 437 cases, 1938 Over 10,000 cases Telegraphist’s Cramp Osler 1900, 1908 Panel Recognised Disorder, 1912 60% of some companies workforce Repetitive Strain Injury Umbrella Diagnosis, No specific clinical features, No evidence of “injury” No evidence that repeated use causes damage Clear evidence of pyschosocial factors, Conventional treatments ineffective Litigation => secondary gain, Epidemics Specific Conditions Epicondylitis, De Quervain’s disease, Carpal Tunnel Syndrome, Trapezio-metacarpal OA Impingement/Rotator Cuff disease, Tenosynovitis, Cervical Radiculopathy Clearly defined symptoms, Consistent findings on clinical examination Recognisable histopathology, Response to physical treatment Neck and/or arm pain in 9% of males and 12% of females. (Hadler NM: J Hand Surg (1985) 10A:451). Musculo-skeletal pain is a part of life, not all physical symptoms are due to physical disease What is RSI? “RSI is not a disease, but a label used to describe a complex phenomenon with social, psychological and economic facets in which claims for compensation for injury at work occur in epidemics” (Brahams D. Lancet 1993: 342:1168) Regional Pain Syndrome Work Related Upper Limb Pain - Helliwell Br J Rheumatol (1996) 35:1195 Non-specific Upper Limb Pain Disorder - Harrington J Occup Med (1998) 55:264

Session 6 (11:10) Ms Katherine Butler

Dystonia and the musician’s hand Task specific focal hand dystonia – musicians’ and writing dystonia. Dystonia is a movement disorder characterised by abnormal postures. Task specific dystonia is one form of dystonia, where dystonia occurs during the performance of a specific, usually highly skilled task, such as playing a musical instrument (musicians’ dystonia) or writing (writing dystonia). Though uncommon, task specific dystonia can be very disabling, especially for professional musicians. The pathophysiology and aetiology of TSD is still poorly understood, but it is thought likely to be related to functional sensorimotor system alterations caused by repetitive practice of a highly skilled movement. There is evidence for both sensory and motor dysfunction in TSD, as well as a wider cognitive context including attentional focus during performance, anxiety and perfectionism. If TSD is viewed as a corruption or dysfunction of specific motor skill learning, there is face validity in considering rehabilitative ‘re-training’ techniques. The focus of this talk is rehabilitative therapies that aim to re-shape sensory and motor representations in the brain in order to regain control of the affected movement. Specific rehabilitative techniques that will be discussed include: sensory re-education, sensory motor retuning, mirror treatment and slow down exercise treatment.

Session 6 (11:30) Mr Jonathan Hobby

Complex Regional Pain Syndrome spontaneous and evoked regional pain, usually beginning in a distal extremity, that is disproportionate in magnitude or duration to the typical course of pain after similar tissue trauma CRPS is distinguished from other chronic pain conditions by the presence of signs indicating prominent autonomic and inflammatory changes in the region of pain. Patients present with a limb displaying extreme hyperalgesia and allodynia (normally non-painful stimuli such as touch or cold are experienced as painful); obvious changes to skin color, skin temperature, and sweating relative to the unaffected side; edema and altered patterns of hair, skin, or nail growth in the affected region; reduced strength; tremors; and dystonia. Altered body perception and proprioception may also be present, reflected in reduced limb positioning accuracy, delays in recognizing limb laterality, abnormal referred sensations and tactile perception, and altered subjective mental representations of the affected limb First recognized as a distinct pain condition during the American civil war Reflex Sympathetic Dystrophy, Causalgia, Sudek’s Atrophy CRPS is subdivided into type I and type II on the absence or presence of nerve injury Usually precipitated by trauma including surgery. Commoner in the upper limb 3-4 x more common in women, peaks in 5th – 7th decade Leading cause is fracture (40%), incidence 3-8%. Role of psychological factors controversial International Association for the Study of Pain clinical diagnostic criteria for CRPS • Continuing pain, which is disproportionate to any inciting event • Must report at least one symptom in three of the four following categories*: ––Sensory: Reports of hyperalgesia and/or allodynia ––Vasomotor: temperature asymmetry and/or skin color changes or asymmetry ––Sudomotor/edema: edema and/or sweating changes and/or sweating asymmetry ––Motor/trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nails, skin) • Must display at least one sign in two or more of the following categories*: ––Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch or deep somatic pressure, or joint movement) ––Vasomotor: temperature asymmetry and/or skin color changes and/or asymmetry ––Sudomotor/edema: edema and/or sweating changes and/or sweating asymmetry ––Motor/trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nails, skin)

Session 6 (11:30) Mr Jonathan Hobby

Incidence United States, Type 1 reported as 5.46 per 100 000 person years and type 2. 0.82 per 100 000 person years, respectively. Netherlands reported an incidence of CRPS type I and type II combined of 26.2 cases per 100 000 person years Spontaneous resolution in 70 – 80% of cases. Poor evidence for benefit from medical management. Summary of treatments for complex regional pain syndrome (CRPS) and RCT evidence Standard treatments Multidisciplinary treatment Physical and occupational therapy Oral corticosteroids (for acute CRPS) Anticonvulsants Analgesic antidepressants Transdermal lidocaine Opioids Sympathetic nervous system blocks Spinal cord stimulation Pain focused psychological therapy

None Positive Positive Equivocal None None None Negative Positive None

Uncommon treatments Graded motor imagery or mirror therapy Calcitonin Vitamin C (prevention after injury) Topical dimethylsulfoxide (DMSO) Oral N-acetylcysteine Bisphosphonates Subanesthetic intravenous ketamine

Positive Positive Positive (controversy single centre) Positive Positive Positive (multiple studies) Positive (multiple studies)

References S Bruehl. Complex regional pain syndrome BMJ 2015;350:h2730 C Bass. Complex regional pain syndrome medicalises limb pain. BMJ 2014;348:g2631

Session 6 (11:50) Professor Tim Davis

Session 7 (13:20) Mr Nick Downing

Overuse?  

“Epicondylalgia”  

Nick  Downing  

“Epicondylalgia”   Cause  of  lateral,  medial  (or  posterior)  elbow   pain      Peak  35-­‐55  age  group    Annual  incidence  4-­‐7/1000    Prevalence  1-­‐3%      Lateral>>medial  (X7)  

Consultant  Hand  Surgeon   University  Hospital   No?ngham  

Tennis  elbow   Golfer’s  elbow   Shooter’s  elbow   Archer’s  elbow   Lateral  (medial)  epicondyli