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REVIEW ARTICLE
Ligamentous Sports Injuries of the Hand and Wrist William B. Geissler, MD and Jared L. Burkett, MD
Abstract: Athletic injuries of the hand and wrist continue to increase as athletes get bigger, faster, and the weekend warrior continues to be active throughout his or her lifespan. The management of hand and wrist injuries in these athletes depends on the sport, position, timing during the season the injury occurs, and how many years the athlete has left to play in competition. In the past, these injuries were thought to be trivial; but if not ideally managed, complications can occur which may keep the skilled athlete or the weekend warrior out for a prolonged period of time. This article concentrates on common athletic injuries of the hand and wrist. Key Words: sports medicine, wrist, hand
(Sports Med Arthrosc Rev 2014;22:39–44)
SPORTS INJURIES OF THE HAND AND WRIST The incidence of athletic injuries continues to increase for a number of reasons. First, high school and collegiate athletes continue to increase their power, speed, and size as compared with the past resulting in higher velocity and energy injuries. In addition, (the weekend warrior) athletic injuries continue to increase as the population continues to participate in athletic activities throughout their entire lifespan. Previously, when one thought of athletic pathology, injuries to the knee and shoulder were usually first to come to mind. However, athletic injuries to the wrist and hand are quite common both in younger and older athletes. In the past, these types of injuries to the upper extremity were thought to be trivial. Yet, if they are not ideally managed, complications occur which can keep the skilled athlete or weekend warrior out for a prolonged period of time. Although metacarpal and phalangeal fractures are the most common injuries, this article concentrates on common ligamentous injuries of the hand and wrist in the athlete. Football, gymnastics, wrestling, and basketball are the sports with the highest risk of hand injuries. There is a tremendous amount of pressure to return elite athletes back to competition. The management of hand and wrist injuries in these players depends on the sport, the position the athlete plays, and particularly the timing of the season. The timing not only depends on the current year, but also how it may affect the athlete to return to competition the following year. Further factors are to consider the years left to play, if the player is in his first or last year in competition, and of course the injury itself. From the Department of Orthopaedic Surgery and Rehabilitation, Division of Hand and Upper Extremity Surgery, University of Mississippi Health Care, Jackson, MS. Disclosure: W.B.G. is a consultant for Accumed and Arthrex and receives royalties. The remaining author declares no conflict of interest. Reprints: William B. Geisler, MD, Department of Orthopaedic Surgery and Rehabilitation, Division of Hand and Upper Extremity Surgery, University of Mississippi Health Care, 2500 North State Street, Jackson, MS 39216. Copyright r 2014 by Lippincott Williams & Wilkins
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Risk of scarring after surgery may be decreased in the collegiate athlete compared with the traditional patient. Usually, these athletes are under close supervision of athletic trainers and physical therapy staff, and the collegiate athlete may have access to physical therapy twice a day compared with the traditional patient that may receive therapy 3 times a week. This easy access to unlimited physical therapy allows the option of more extensive repairs, such as plate stabilization of phalangeal fractures, with a decreased risk of adhesions compared with traditional patients with limited access to physical therapy.
Proximal Interphalangeal (PIP) Dorsal Dislocations Proximal interphalangeal dorsal dislocations are the most common ligamentous injuries to the hand. Type I are hyperextension injuries to the volar plate and are considered stable. Type II is a dorsal dislocation and reduced stable. Type III are fracture dislocations. A stable fracture is considered when 40% of the articular surface is involved. PIP dorsal dislocations are usually reduced by the athletic trainer or the athlete himself. It is strongly recommended that every dislocation needs an x-ray. Chronic PIP dorsal dislocations are relatively common as the athlete does not seek radiographic management. A fracture dislocation of the PIP joint can be a difficult injury to treat in the acute situation, but even more so with a delayed presentation. In acute PIP fracture dislocations, the PIP joint is approached through a volar approach. The A-3 pulley is excised, and the fracture site is identified as the flexor tendons are retracted. The tendons are retracted either radially or laterally to best visualize the fracture fragment. It is helpful to provisionally reduce the joint and pin the middle phalanx reduced to the proximal phalanx in a reduced position. Then the volar fragment can be anatomically reduced at the base of the proximal phalanx and stabilized with mini fragment screws. In delayed presentations, there is chronic bone loss of the articular surface to the volar aspect to the base of the middle phalanx. Osteochondral transfer of a graft from the distal aspect of the hamate is an excellent option to treat this difficult problem as described by Hastings and Carroll.1 In this technique, a standard volar approach is made to the PIP joint. The flexor tendons are retracted and the volar aspect of the PIP joint is exposed. Longitudinal incisions are made along the radial and ulnar aspects of the volar plate and the volar plate is released distally off its insertion from the middle phalanx. The radial and ulnar collateral ligaments are released distally and the PIP joint is hyperextended in a shotgun approach. The defect in the volar aspect of the base of the middle phalanx is identified and a bed is prepared for the osteochondral transfer. The articulation of the hamate to the fourth and fifth metacarpals is identified under fluoroscopy. An incision
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is made and the joint is exposed. An osteochondral graft is harvested. This requires great care to not fragment the osteochondral graft. Curved osteotomes are used proximally to help elevate up the graft and the articular surface of the base of the ring and small metacarpals are carefully protected as the graft is harvested. The key is to take a larger size bone graft than is required. This graft can then be trimmed to ideally fit the base to the middle phalanx. The goal is to restore the concave shape to the base of the middle phalanx to restore stability. To do this, the osteochondral graft is placed proximally to restore the normal arch or curve to the base of the middle phalanx (Fig. 1). The fragment is stabilized with mini fragment screws. The volar plate is then reattached distally.
Triangular Fibrocartilage Complex (TFCC) Ulnar-sided wrist pain is common in athletes. Frequently, the cause of this pain may be an injury to the TFCC. The TFCC is a complex soft-tissue support system that stabilizes the ulnar side of the wrist. It acts as an extension of the articular surface of the radius to support the proximal carpal row and also to stabilize the distal radial ulnar joint. Palmer2 classically described the components of the TFCC as being composed of the fibrocartilage articular disk, the volar and dorsal radioulnar ligaments, the meniscus homologue, and the floor of the extensor carpi ulnaris tendon sheath. The central disk is wedge shaped in the coronal section and radially inserts on the articular surface of the radius by merging with the hyaline cartilage of the sigmoid notch in the lunate facet. The central portion of the articular disk has an oblique wave pattern for strength, compression, and tension. The ulnar aspect of the articular disk has 2 main bundles. One bundle is directed to the ulnar styloid and the second bundle to the fovea. The proximal limbs of the palmar and dorsal radioulnar ligaments conjoin and insert into the fovea just medial to the pole of the distal ulna. These structures are referred to as the ligamentum subcruentum or the deep portion of the radioulnar ligament. The distal superficial portions of the volar and dorsal radioulnar ligaments insert directly into the base of the ulnar styloid and are independent of the function of the ligamentum subcruentum insertion.
FIGURE 1. Shotgun approach of the proximal phalanx with a hamate graft. The hamate graft is provisionally stabilized to restore the concave contour to the base of the middle phalanx.
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The articular disk is an axial load bearing structure as defined by Palmer.2 In the static state, 82% of the axial compressive load of power grasp was transmitted from the forearm through the radial carpal joint. Approximately 18% is supported by the articular disk in the ulna. Dorsally, the TFCC has attachments to the ulnar carpus and to the sheath of the extensor carpi ulnaris. This is a common area for peripheral detachment of the articular disk. The last component of the TFCC is the meniscus homologue. This is a controversial structure in regards to its function and existence, as it is composed of loose connective tissue instead of the dense collagen of the rest of the TFCC.3 The arterial blood supply of the TFCC has been thoroughly studied. Thiru et al4 evaluated 12 cadaveric specimens with latex injections and determined that there are 3 main arterial supplies of the TFCC. They documented a complex of vessels filled with latex dye in the peripheral 15% to 20% of the articular disk. This is significant regarding procedures for arthroscopic repair of peripheral tears to the articular disk. In 1989, Palmer2 proposed a classification system for tears of the TFCC that are divided into injuries in 2 basic categories: traumatic class I, and degenerative class II. Injury to the TFCC commonly occurs with extension and pronation of the axial load of the carpus. The most common mechanism occurs with a fall on the outstretched hand. Peripheral tears of the articular disk are common athletic injuries which involve rapid twisting of the wrist, such as ulnar-sided loading activities of racket sports and golf. Symptoms of peripheral tears of the TFCC include deep infused aching along the ulnar side of the wrist. Patients complain of pain with firm gripping. The patient may complain of clicking sensation with pronation and supination. They frequently complain of pain while attempting to twist lids off jars or twisting a doorknob. The patient may also complain of generalized weakness to the wrist. Patients with ulnar peripheral tears to the articular disk frequently complain of pain at the prestyloid recess. This pain may be accentuated by hyper pronation or supination of the wrist. The pain may be further aggravated by passive anterior and posterior translation of the ulna in relation to the radius with the wrist in pronation and supination. When a large ulnar peripheral tear is present, dorsal subluxation of the ulnar head in relation to the radius may be seen particularly with the opposite wrist when both wrists are compared in pronation and flexion. The surgical indications for a peripheral ulnar-sided tear are when pain is not relieved by conservative management for at least 3 months. An additional indication is symptomatic distal radial ulnar joint instability not relieved by immobilization. There have been several arthroscopic techniques for repair of peripheral tears of the TFCC described in the literature.5–8 Recently, Geissler et al9 described his technique of an all-arthroscopic knotless repair of the articular disk back down to bone. In this technique, the arthroscope is placed in the 3 to 4 portal, and a standard 6-R portal is made. An accessory 6-R portal is made approximately 1 to 1.5 cm distal to the 6-R portal. The location of this portal is identified by an 18-G needle with the wrist flexed in a traction tower so the needle hits the center of the fovea to the distal ulna. A suture lasso (Arthrex, Naples, FL) is inserted through the accessory 6-R r
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FIGURE 2. Photograph showing the suture lasso (Arthrex, Naples, FL) about to be inserted through the accessory 6-R portal.
portal and perforates the articular disk (Fig. 2). A 2.0 fiber wire stick (Arthrex) is inserted through the lasso into the joint and then retrieved with a crochet hook inserted through the 6-R portal. The suture lasso is then backed out of the articular disk and reinserted through the disk leaving a loop of suture (Fig. 3). This loop of suture is then retrieved with a crochet hook out the 6-R portal. In this manner, a horizontal mattress stitch is then placed through the articular disk and both suture limbs are out the 6-R portal. A cannula is then inserted through the accessory 6-R portal. The 2 suture limbs are retrieved back out through the cannula. The cannula is then placed against the bone of the distal ulna. The suture limbs are teased out of the slot of the cannula and the distal ulna is drilled. The suture limbs are then brought back through the slot and loaded into a mini PushLock anchor (Arthrex) (Fig. 4). The anchor is then inserted into the previously drilled drill hole repairing the articular disk back down to bone. The suture limbs are then cut with a small upbiter inserted through the 6-R portal. This provides an all-arthroscopic knotless repair of the articular disk back down to bone. It has been the author’s experience that these patients hurt far less as compared with traditional mechanisms of repair due to lack of irritation from suture knots. Postoperatively, return to play is restricted for 3 months, and no splint is required once return to play is allowed. Radial-sided tears of the TFCC from the sigmoid notch represent a Palmer I-D type injury. These injuries are less common than peripheral or central tears, but present with similar symptoms. Nonoperative treatment is performed initially with a trial of immobilization, and occasionally physical therapy may be utilized.10 Surgical indications are similar to previously mentioned peripheral tears. Work by Bednar et al11 and Chidgey12 demonstrates the poor blood supply to the radial origin of the disk, and suggests that tears in this area are not be amenable to repair. This has led to some debate as to whether these injuries should be repaired or debrided. Despite these findings, several studies and repair techniques have shown clinical improvement and healing following repair of these injuries.5,10,13–15 It is possible this healing could result from inciting a vascular response from the abrasion of the sigmoid notch of the radius during the repair.10 r
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FIGURE 3. The lasso has been reintroduced through the articular disk to create a horizontal mattress suture for repair back to the fovea of the ulna with a knotless technique.
During surgery, the origin of the articular disk from the sigmoid notch should be evaluated. If a tear is present adjacent to the radial attachment, but the volar and dorsal
FIGURE 4. The sutures are loaded into a knotless anchor (Arthrex, Naples, FL) to be inserted into the base of the ulna with an all-arthroscopic knotless technique.
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radioulnar ligaments are found to be intact, the tear is classified as a Palmer I-A, and should be debrided. If the volar and dorsal radioulnar ligaments are found to be involved, with loss of tension of the disk, then this is consistent with a Palmer I-D tear. These tears may involve the attachment of the disk only, or there may be an associated avulsion fracture fragment. If an avulsion fracture is present, this should be reduced arthroscopically and either pinned using 0.045 Kirshner wires or fixed using a headless cannulated screw if the size of the fragment permits, with care taken not to penetrate the distal radioulnar joint.10 Utilizing a technique described by Geissler and Short,10 and similar to the one previously described by Sagerman and Short,14 a stable repair is able to be achieved. A 3 to 4 viewing portal is first placed, and under direct visualization a needle is placed percutaneously to determine the ideal location, for the 6-R and 6-U portals. After this, an arthroscopic burr is placed through the 6-R portal, and the sigmoid notch is abraded to bone, being careful not to remove too much bone.10 After preparation of the notch, a cannula is placed through the 6-U portal, and a 0.062 Kirschner wire is used to drill 3 evenly spaced holes in the sigmoid notch. These holes are placed from volar to dorsal in the notch, and exit through the radial aspect of the distal radius. Two sets of double-armed, long meniscus repair needles with nonabsorbable suture are required, and are passed through the 6-U portal. The first pass of the needle should be through the disk and the most volar drill hole in the sigmoid notch, and then advanced through the skin. An arthroscopic probe or grasper can be placed through the 6-R portal to stabilize and evert the edge of the disk, assisting in passage of the needle. The second arm of the meniscus repair needle is then passed through the disk and the central drill hole, creating a horizontal mattress suture. This process is then repeated, with the second set of meniscus repair needles being passed through the central and then the most dorsal drill holes working volar to dorsal. A small skin incision is then made over the sutures and dissection is taken down to bone. Before tying the sutures, care must be taken to ensure that no soft tissue is interposed between the suture and bone.10 Postoperatively, digital range-of-motion exercise are started immediately, and return to play is restricted for 3 months. No splint is required once return to play is allowed.
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The scapholunate ligament complex involves both intrinsic and extrinsic ligament components. The intrinsic portion of the SLIL includes the palmar, fibromembranous, and dorsal portions. Berger and Landsmeer16 have shown that the dorsal portion appears to be the primary biomechanical functional portion to the interosseous ligament. It is composed of stout transverse fibers to resist rotation. The volar portion of the interosseous ligament is composed of long oblique fibers to allow rotation in the sagittal plane. The central fibromembranous portion of the ligament is frequently perforated in older individuals. The SLIL has been shown to stretch and eventually tear. Mayfield17 has shown that the elongation to failure may be up to 225% of its length. In an isolated injury to the SLIL itself, radiographic widening on plain or stress radiographs may not be seen. However, combined injury to both intrinsic and extrinsic ligaments may result in scapholunate diastasis. A spectrum of injury to the SLIL can be seen. This is readily identifiable arthroscopically and may be managed according to the severity of the injury and chronicity.18 The crucial key to arthroscopic management of carpal instability is recognition of what is normal and what is abnormal. Both the radiocarpal and midcarpal spaces should be evaluated arthroscopically when carpal instability is suspected. As noted before, a spectrum of injury to the SLIL is seen as it starts to stretch and eventually tear. The appearance of the carpal bones converts to the normal concave to convex appearance. The torn SLIL hangs down and blocks visualization with the arthroscope in the radial carpal space. As the severity of the injury increases, the degree of rotation between the scaphoid and lunate increases and it is best to evaluate with the arthroscope in the midcarpal space. Geissler et al18 devised an arthroscopic classification of carpal instability and suggested management of acute injuries to the SLIL (Table 1). In Geissler grade I injuries, these usually resolve with temporary immobilization. In TABLE 1. Geissler Arthroscopic Classification of Carpal Instability
Grades I
Wrist Instability Hyperextension injuries to the wrist are common athletic injuries. This can lead to injuries to the intrinsic and extrinsic ligaments of the wrist resulting in carpal instability. The majority of acute wrist sprains with normal radiograph findings resolve after temporary immobilization. The method of choice to further evaluate an athlete who does not improve continues to be controversial. Tricompartmental wrist arthrography historically has been the gold standard for potential interosseous ligament tears. Recently, magnetic resonance imaging arthrograms have improved the sensitivity and detection of complete and partial tears to the interosseous ligament. However, wrist arthroscopy is the true gold standard to simultaneously detect and treat injuries of the lunotriquetral and scapholunate interosseous ligaments (SLIL). Particularly, a partial tear of the SLIL that continues to be symptomatic is difficult to detect on imaging studies alone, but is readily identifiable arthroscopically.
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II
III
IV
Description Attenuation/hemorrhage of interosseous ligament as seen from the radiocarpal joint. No incongruency of carpal alignment in the midcarpal space Attenuation/hemorrhage of interosseous ligament as seen from the radiocarpal joint. Incongruency/step-off as seen from midcarpal space. A slight gap (less than width of a probe) between carpals may be present Incongruency/step-off of carpal alignment is seen in both the radiocarpal and midcarpal spaces. The probe may be passed through the gap between carpals Incongruency/step-off of carpal alignment is seen in both the radiocarpal and midcarpal spaces. Gross instability with manipulation is noted. A 2.7mm arthroscope may be passed through the gap between carpals
r
Management Immobilization
Arthroscopic reduction and pinning
Arthroscopic/open reduction and pinning Open reduction and repair
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Geissler II and III injuries, these may be readily reduced arthroscopically and stabilized with Kirschner wires or potentially temporary screw fixation. In Geissler grade IV injuries, this is a complete tear of the interosseous ligament which is best repaired through an open approach. In Geissler grade II and III injuries, in an acute situation, the scapholunate interosseous interval is arthroscopically reduced and stabilized. If Kirschner wires are to be utilized, they are initially placed under fluoroscopic control into the scaphoid aiming toward the lunate. The wrist is then suspended back into traction with the arthroscope in the midcarpal space. Joysticks may be placed in the scaphoid and lunate to help control rotation. The scapholunate interval is best visualized with the arthroscope in the ulnar midcarpal portal to judge anatomic restoration of rotation. After the carpal interval has been anatomically reduced, the pins are driven across the scapholunate interval. Frequently, fat droplets may be seen exiting the scapholunate interval as the Kirschner wires are being driven across. The wires are left protruding from the skin and the wrist is immobilized in a below elbow cast. The patient must be evaluated every 2 weeks. The K-wires will be removed in approximately 8 weeks and the wrist is immobilized an additional 4 weeks. Digital range-ofmotion exercises are initiated immediately, and rangeof-motion and grip strengthening exercises are started at the 3-month interval. Patients with an acute grade IV injury to the SLIL are felt to be best reduced through a small dorsal incision to obtain primary repair of the SLIL. Following repair of the ligament, a SLIC screw (Acumed, Hillsboro, OR) is placed across the scapholunate interval. This screw freely rotates at its midsection and also toggles at its midsection. The screw allows compression at the scapholunate interval while the ligament heals. The screw allows early range of motion as compared with protruding Kirschner wires. The screw may be removed following healing of the SLIL. The use of the screw may also be used in Geissler grade II and III injuries in acute interosseous ligament injuries and is currently being evaluated. Isolated lunotriquetral interosseous ligament (LTIL) injuries, although less common than SLIL injuries, can be a source of ulnar-sided wrist pain, and should be evaluated for during a thorough wrist exam. Pain can be elicited with palpation over the lunotriquetral joint, and ulnar deviation and pronation with load can produce a painful click or snap if a LTIL injury is present.19–21 Other useful provocative tests include the LT ballottement test, Kleinman shear test, and the lunotriquetral compression test.22–24 The LTIL is C-shaped, and includes a true ligamentous portion in the dorsal and palmar aspects along with a proximal fibrocartilaginous or membranous portion that provides little stability. The palmar aspect is thicker and stronger, and is responsible for transmitting the extension moment of the triquetrum as it engages the hamate through the lunate.20,25 The dorsal aspect of this ligament has been found to be most important for rotational constraint.25 Shin et al19 in their series of 57 patients found the most common mechanisms of injury were either from a fall, a twisting injury, or a sports-related injury. Mayfield26 described a 4-stage progressive perilunar instability, from radial to ulnar, resulting from loading in extension, ulnar deviation, and intercarpal supination. An injury to the lunotriquetral ligament, which occurs in stage III, through this mechanism would have multiple associated injuries. r
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Reagan and colleagues proposed that loading an extended and radially deviated wrist would result in the reverse order of injury proposed by Mayfield and colleagues.21,22,26 Murray et al27 recently through biomechanical testing described a 3-stage mechanism of the reverse perilunate ligamentous injury of the wrist. Stage 1 involves an isolated disruption of the LTIL, whereas stage 2 includes disruption of the ulnolunate, ulnotriquetral, ulnocapitate, dorsal scaphotriquetral, and radiotriquetral ligaments.27 LTIL injuries can be classified as either static (VISI) or dynamic. Dynamic instabilities present with normal radiographs and only exhibit instability with positional changes or load. Although a complete tear of the LTIL may be present, this is not enough in itself to create a static or fixed deformity, and secondary constraints must also be injured to result in a static deformity.22 Horii et al20 found that sectioning of the dorsal radiotriquetral and dorsal scaphotriquetral ligaments in addition to the LTIL resulted in the creation of a static deformity. Initial treatment of both acute and chronic stable injuries should be performed with a period of immobilization, which will be curative in the majority of patients.21 Reevaluation should be performed at 4 to 6 weeks, and if symptoms have not improved significantly at that time, arthroscopy is performed. Arthroscopy of the radiocarpal and midcarpal joints allows both diagnosis, with grading based on the Geissler classification, and treatment of these injuries. Multiple surgical treatment options for these injuries have been described, including debridement, pinning, ulnar-shortening osteotomy, lunotriquetral ligament repair, reconstruction, and arthrodesis. In their series Shin and colleagues found that patients who underwent ligament repair or reconstruction achieved better results compared with the arthrodesis group, which had a high (40.9%) rate of nonunion.25 The preferred method of treatment is based on the arthroscopic findings and the Geissler classification. Geissler grades II, III, and IV injuries are treated with arthroscopic-assisted reduction and stabilization with a percutaneously placed SLIC screw (Fig. 5). Chronic lunotriquetral ligament injuries that result from positive ulnar variance, leading to impaction of the ulna on the triquetrum, are treated with debridement followed by an ulnarshortening osteotomy. These patients commonly are found to have an associated degenerative tear of the TFCC which is managed arthroscopically at the time of surgery. In the athlete with a painful wrist sprain and normal radiographs, an initial trial of immobilization is implemented. The patient will then be reevaluated, and if still symptomatic then arthroscopic surgery will be performed at 4 to 6 weeks with repair if indicated. At this time, if the repair is achieved with a SLIC screw or is reinforced by placement of a SLIC screw, the athlete will be allowed to return to play in 1 to 2 weeks with a removable wrist splint for additional protection. Patients treated with an ulnarshortening osteotomy, for ulnar impaction, will be allowed to return to play when radiographic healing of the osteotomy site is present.
CONCLUSIONS Athletic injuries to the wrist and hand have become quite common, both in younger and older athletes, and continue to increase as athletes get bigger and the (weekend warrior) continues to be active throughout his or her www.sportsmedarthro.com
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FIGURE 5. Fluoroscopic radiograph showing the SLIC screw across the lunotriquetral interval and anatomic reduction of the scaphoid arthroscopically with an Acutrak screw (Acumed, Hillsboro, OR).
lifespan. The key is to ideally manage these injuries, to allow athletes and (weekend warriors) to return to competition as soon and as safely as possible.
REFERENCES 1. Hastings H II, Carroll C IV. Treatment of closed articular fractures of the metacarpophalangeal and proximal interphalangeal joints. Hand Clin. 1988;4:503–527. 2. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am. 1989;14:594–606. 3. Moritomo H, Kataoka T. Anatomy of the ulnocarpal compartment. In: del Pinal F, Mathoulin C, Nakamura T, eds. Arthroscopic Management of Ulnar Sided Wrist Pain. Verlag: Springer; 2012:1–14. 4. Thiru RG, Ferlic DC, Clayton MI, et al. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg Am. 1986;11:258–263. 5. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg Am. 1997;22:57–65. 6. De Araujo W, Poehling G, Kuzma G. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy. 1996;12:699–703.
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7. Corso S, Savoie F, Geissler W, et al. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study. Arthroscopy. 1997;13:78–84. 8. Estrella EP, Hung LK, Ho PC, et al. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy. 2007; 23:729–737. 9. Geissler WB. Arthroscopic management of peripheral ulnar tears of the triangular fibrocartilage complex. In: Slutsky DJ, ed. Principles and Practice of Wrist Surgery. Philadelphia, PA: Saunders Elsevier; 2010:205–212. 10. Geissler WB, Short WH. Repair of peripheral radial TFCC tears. In: Geissler WB, ed. Wrist Arthroscopy. New York: Springer; 2005:42–49. 11. Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: its clinical significance. J Hand Surgery Am. 1991;16:1101–1105. 12. Chidgey LK. Histologic anatomy of the triangular fibrocartilage. Hand Clin. 1991;7:249–262. 13. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg. 1994;19:143–154. 14. Sagerman SD, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy. 1996;12:339–342. 15. Jantea CL, Baltzer A, Ruther W. Arthroscopic repair of radial sided lesion of the triangular fibrocartilage complex. Hand Clin. 1995;11:31–36. 16. Berger RA, Landsmeer JMF. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. J Hand Surg Am. 1990;15:847–854. 17. Mayfield JK. Wrist ligamentous anatomy and pathogenesis of carpal instability. Orthop Clin North Am. 1984;15: 209–216. 18. Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal softtissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78: 357–365. 19. Shin AY, Weinstein LP, Berger RA, et al. Treatment of Isolated Injuries of the Lunotriquetral Ligament. J Bone Joint Surgery Br. 2001;83 B:1023–1028. 20. Horii E, Garcia Elias M, An KN, et al. A kinematic study of luno-triquetral dissociations. J Hand Surg. 1991;16A:355–362. 21. Butterfield WL, Joshi AB, Lichtman D. Lunotriquetral injuries. J Am Soc Surg Hand. 2002;2:195–203. 22. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg. 1984;9A:502–514. 23. Kleinman WB. Diagnostic exams for ligamentous injuries. American Society for Surgery of the Hand, Correspondence Club Newsletter. 1985;51. 24. Beckenbaugh RD. Accurate evaluation and management of the painful wrist following injury. Orthop Clin. 1984;15: 289–306. 25. Ritt MJPF, Bishop AT, Berger RA, et al. Lunotriquetral ligament properties: a comparison of three anatomic subregions. J Hand Surg. 1998;23A:425–431. 26. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5:226–241. 27. Murray PM, Palmer CG, Shin AY. The mechanism of ulnarsided perilunate instability of the wrist: a cadaveric study and 6 clinical cases. J Hand Surg Am. 2012;37:721–728.
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