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Textbook Reading – Orthropaedic Review 870.~884.

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1 Textbook Reading – Orthropaedic Review 870.~884.

2 Physical examination and radiographic evaluations of the Wrist
870. 關於”Watson test” (A)Also call the scaphoid shift test (B)It is the test to evaluate scaphoid stability and periscaphoid synovitis (C)With the patient’s wrist initially in radial deviation and slightly flexion (D)The scaphoid thus is pushed dorsally out of the radial fossa

3 871. With ulnar deviation of the wrist, the following motion occurs in the carpal bones
(A)dorsiflexion of the triquetrum (B)dorsal flexion of the scaphoid (C)dorsalrotation of the scaphoid (D)Dorsal change in lunate positioning

4 872. About the scapholunate angle
(A)The true lateral view can measure the scapholunate angle (B)The angle formed by the intersection of the two lines, long axis of the lunate and scaphoid, is the scapholunate angle (C)Normal values range from degree (D)An angle greater than 60 degree should be considered scapholunate dissociation or rotary subluxation of scaphoid

5 873. List the radiographic signs of scapholunate dissociation
(A)Foreshortened scaphoid- when the scaphoid is volar flexed, as in scapholunate dissociation, it appears shorter on the AP view (B)Signet ring sign- on the AP view, represents an axial view of volar flexed scaphoid (C)Lack of parallelism between the articular surfaces of the scaphoid and lunate (D)Increased capitolunate angle

6 Scapholunate Instability
most common and most significant ligament injury of wrist Risk factors: ulna minus configuration slope of radial articular surface lunotriquetral coalition

7 spectrum of injury: (increasing severity)
Dynamic scapholunate instability - no radiographic evidence of malalignment is present (ie dynamic deformity);  - diagnosis is established by dorsal S-L tenderness and positive shift test;   Rotatory subluxation of scaphoid: Scapholunate dissociation (SLD): - scapholunate ligament tear may lead to rotational dislocation of scaphoid allowing proximal pole to displace posteriorly & distal pole to displace anteriorly; - scaphoid inherently tends to palmar flex because of its oblique position and the loading applied thru (STT) joint; - because scaphoid lacks  proximal of ligament, it will rotate around radiocaptitate ligament leading to dorsal rotary subluxation of the proximal pole; 4. Dorsal intercalated segment instability: (DISI) 5. Scapholunate advanced collapse:

8 mechanism of injury mechanism is similar to that of scaphoid fracture and stress loading of extended carpus, except it is usually in ulnar rather than radial deviation; a severe hyperextension injury of the wrist, there is tear of scapholunate interosseous ligament further loading causes tear of - radiocapitate ligaments; - radiotriquetral ligaments; - dorsal radiocarpal ligaments; - lunate follows triquetrium into extension & DISI deformity results

9 Radiopraphic findings
Clenched fist AP – ulnar deviation view 1. scapholunate interval > 2-3 mm as compared to the opposite side (Terry Thomas sign); 2. Cortical ring sign: produced by cortex of distal pole of palmar flexed scaphoid and cortical outline of the distal pole of scaphoid; 3. scaphoid is foreshortened:distance between scaphoid ring & proximal pole is < 7 mm

10 4. negative ulnar variance(4.2-2.3mm)
5. axial scaphoid shift sign: - normally a smooth arc can be outlined around the scaphoid, lunate, and the triquetrum; - scapholunate injury, the arc will be broken as the scaphoid migrates proximally; - this finding may be useful in the presence of scapholunate injury which occurs in the presence of a distal radius fracture

11 Lateral view: Scapholunate angle formed by intersection of longitudinal axes of scaphoid & lunate avg deg & ranges from deg;  - in SLD, scaphoid is palmar-flexed with prox migration of capitate; - angle > deg suggests SLD capitolunate angle of > deg is strongly suggestive of SLD

12 3. normally it should be possible to draw straight line thru longitudinal axis of radius, lunate, & capitate - in SLD lunate and triquetrum are displaced ulnarly; - when lunate lies plamar to capitate but faces dorsally, collapse pattern is referred to as DISI

13 De Quervain’s Disease 874. De Quervain’s Disease
(A)病灶位於第一個dorsal wrist compartment; 內含abductor pollicis longus and extensor pollicis brevis (B)好發於女性 (C)Finklestein’s test 可用來診斷 (D)類固醇注射為治療首選 (E)症狀包含手腕疼痛而且會影響拇指活動

14 De Quervain’s Disease Stenosing tenosynovitis of APL & EPB tendons (first compartment) at the styloid process of the radius; Inflammation causes thickening & stenosis of synovial sheath of first compartment & pain when tendon movement; most common in women between 30 and 50 years; pain over radial styloid process (sometimes forearm & thumb);

15 PE Swelling & palpable thickening of fibrous sheath;
Sharp tenderness over styloid process of radius Finkelstein's test: pt makes fist over thumb, and ulnarly deviating wrist

16 Treatment Non Operative Treatment: Thumb spica splint
Steroid injection: A recent study concluded that injecting this compartment can provide complete relief of symptoms.  If the symptoms persist after injection, then the injection can be repeated (30% of cases require reinjection after one year).  If 2-3 injections over a 3-5 week period fail to give relief, then surgical management becomes appropriate. Surgical Treatment

17 Carpal Instability 875. About the dorsal intercalated segment instability(DISI)and volar intercalated segment instability(VISI) deformity (A)DISI occurs when scapholunate ligament disruption results in volar flexion of the scaphoid and dorsal angulation of the lunate (B)VISI signifies a lunotriquental ligament disruption (C)VISI stands for volar intercalated segmental instability (D)VISI results in volar angulation of the lunate compared with a normally aligned scaphoid

18 876. 關於Carpal injuries的敘述 (A) DISI (dorsal intercalated segment instability) 為Abnormal flexion of the lunate and scaphoid with +30 degrees volar tilt (B) VISI(volar intercalated segment instability)為 abnormal dorsiflexion of the lunate with a vertical scaphoid(scapholuate angle> 80 degrees) (C) Scapholunate interosseous ligament tear時, X-rays可能呈現”scaphoid ring sign”, 或scapholuante gap > 3 mm (D) A PA view a clenched fist 可scapholuate gap 更加open, 可用來診斷incomplete ligament tear 或 dynamic instability

19 Dorsal Intercalated Segment Instability: (DISI)
Lunate will tend to flex when loss of ulnar ligamentous support from the triquetrum; Lunate extends when there is loss of radial ligamentous stability; DISI may arise as a result of: scaphoid frx; scapho-lunate dissociation; perilunate dislocation (esp trans-scaphoid perilunate dislocation); end result may be Scapholunate Advanced Collapse wrist

20 Radiographic Analysis
On lateral x-rays, when lunate slips into statically dorsiflexed position > 10 deg, condition is defned as DISI; similarly, when lunate lies palmar to capitate but faces dorsally, collapse pattern is also consistent when dorsiflexion instability; DISI deformity is also present when the scapholunate angle is greater than 70 deg

21 Volar Intercalated Segment Instability: (VISI)
Consists of volar flexion of the lunate relative to the longitudinal axis of the radius and capitate, when the wrist rests in a neutral position; Lunate will tend to flex when there is loss of ulnar support from the triquetrum; Result from disruption of radial carpal ligaments on ulnar side of wrist & is characterized by scapholunate angle < 30 deg; Volar flexion instability pattern is usually associated with triquetrolunate or triquetral-hamate instability;

22 Distal Radioulnar Joint
877. 關於遠端橈尺骨關節不穩定或關節炎(Instability or arthritis of the DRUJ) (A) 不穩定最常見的原因是遠端橈骨骨折, 而大多數的ulnar styloid 骨折則不會造成不穩定 (B) 不穩定時考慮韌帶重建手術(ligament reconstruction), 但若是有明顯的關節炎就不適合韌帶重建 (C) 年輕人外傷性DRUJ arthritis 建議可以進行Sauve-Kapandji procedure, 保持握力 (D) 穩定的關節炎(stable arthritic joint)的病患可進行modified Darrach procedure (切除尺骨頭並修補關節囊) (E) 若是關節炎合併不穩定, 可以考慮進行 ulnar hemiresection with tendon interposition

23 878. Distal radioulnar joint(DRUJ)
(A) Ulnar styloid fracture 是由於附著於styloid tip的ulnar collateral ligament 所造成的avulsion fracture; 若無明顯的instability, 通常不需surgical repair (B)正常wrist pronation時, distal radioulnar capsuloligament變緊,防止ulnar head dorsal migration. 可利用" piano key sign" 來診斷DRUJ instability (C) Distal radius fracture with > 25度 dorsal angulation and > 5 mm shortening 可能有high incidence of TFCC injuires (D) Dorsal DRUJ dislocation 是指volar translation of radiocarpal unit and dorsal subluxation of ulna (E) 治療 Acute instability可使用六週的long arm cast in supination for dorsal dislocation 或 in pronation for volar dislocation 固定

24 Triangular Fibrocartilage Complex (TFCC)
879. About the injuries of Triangular Fibrocartilage Complex(TFCC) (A)The lunotriquetral ligament is commonly injured along with the TFCC. These two structures are the most likely soft tissue elements of the ulnar wrist to cause pain (B)The TFCC is prone to degenerative tears that are directly proportional to age of the patient. (C)An ulnar-plus variance patients, the ulna pushes into the underside of the TFCC, causing degenerative changes and ulnar-sided wrist pain (D)TFCC has a rich vascular supply. Tears located in the peripheral portion have a high propensity to heal if treated by debridement and /or repair

25 880. 關於三角纖維軟骨綜合體 (Triangular Fibrocartilage Complex)的敘述
(A)其組成大部分是第二型膠原(Type I collagen), 及小部分的第一型所組成 (B)尺骨側的周圍是血液供應最好的部位,受傷癒合的潛力也最好 (C)它的掌側(volar wall)是由ulnar triquetral and ulnar lunate ligaments 所組成, 兩者合稱ulnar carpal ligament complex (D)可以幫助力量由腕骨傳遞到尺骨, 在neutral ulnar variance 的人有20 %的力量經由TFCC傳遞到尺骨 (E)力量經由TFCC傳遞的比例和ulnar variance 有關. 在supination 時, 相對比較negative ulnar variance, 力量較少經由TFCC傳遞

26 881. 關於外傷性三角纖維軟骨綜合體受傷(traumatic triangular fibrocartilage complex injury)的敘述
(A)分為第一型主要是外傷引起; 第二型主要是和positive ulnar variance 相關的退化造成 (B)Type IA是中央的破裂(central tears without instability), 中央無血管區可用關節鏡清創,但若周圍2 mm被破壞可能會影響遠端尺骨關節的穩定性 (C)Type ID是在sigmoid notch有破裂,和遠端橈骨骨折有關或其內固定有關 (D)疾病的治療與預後和破裂的位置有關,除了修補TFCC外,還要開放復位內固定或切除骨碎片

27 882. 關於退化型三角纖維軟骨綜合體受傷(degenerative triangular fibrocartilage complex injury)的敘述
(A)有軟骨軟化症(chondromalacia)但還沒有穿孔(perforation)是 Type IIB (B)Type IIE是有廣泛性的關節炎變化,合併近排腕骨掌伸不穩定 (volar intercalated segmental instability) (C)Type IIA由於還沒有穿孔,所以只需要尺骨縮短術 (ulnar shortening)即可 (D)Type IIC 若不是positive ulnar variance 的話,只需要進行關節鏡清創手術即可 (E)Type IIE若有月三角骨間關節不穩定(lunotriquetral instability)時, 可先做尺骨縮短術 (ulnar shortening), 若還不穩定, 則考慮將該關節經皮固定 (percutaneous pinning)

28 883. 關於退化型三角纖維軟骨綜合體受傷(degenerative triangular fibrocartilage complex injury)的治療
(A)Type IIA由於雖還未達穿孔(perforation)的程度, 手術治療不需關節鏡清創,直接做Ulnar shortening (B)Type IC在作關節鏡時很容易直接看到pisotriquetral joint, 可以直接關節鏡修補TFCC或open repair (C)Type IIC手術時可進行尺骨縮短術或Wafer procedure,前者可能造成未癒合;後者會加速遠端橈尺骨關節關節炎 (D)Type I injury的預後和受傷時間有關,若在受傷三個月內直接修補的話,其握力及活動度可恢復80% (E)尺骨縮短術只要超過2.5mm就可以減少ulnocarpal load,並可增加ulnocarpal ligament 的張力,進而穩定lunotriquetral joint

29 884. 關於 Triangular Fibrocartilage Complex injury
(A)Type IA的治療,經常以arthroscopic debridement I 為主 (B)Chronic type IB一般診斷困難,關節鏡檢查TFCC會喪失正常的tension (C)Type IC關節鏡檢查可呈現loss of tension in the ulnar extrinsic ligament,和容易看見pisotriquetral joint (D)Distal radius fracture經常合併type ID lesion (E)Subacute injuries(3 months to 1 year)仍然可以direct repair,但是regain less strength and ROM (F)Ulnar shortening 因減少load distributed to the distal ulna, 對chronic TFCC injury有幫助

30 Triangular Fibrocartilage Complex (TFCC)

31 Palmer classification
Class 1: Traumatic A - Central perforation B - Ulnar avulsion with or without distal ulnar fracture C - Distal avulsion D - Radial avulsion with or without sigmoid notch fracture Class 2: Degenerative A - TFCC wear B - TFCC wear with lunate and/or ulnar chondromalacia C - TFCC perforation with lunate and/or ulnar chondromalacia D - TFCC perforation with lunate and/or ulnar chondromalacia and LT ligament perforation E - TFCC perforation with lunate and/or ulnar chondromalacia, LT ligament perforation, and ulnocarpal arthritis

32 Treatment Treatment of traumatic central tears (Palmer class 1A)
→Debridement Treatment of traumatic ulnar-side tears (Palmer class 1B) with outside-in technique → Debride the synovitis and the edges of the tear. Treatment of ulnar extrinsic ligament tears (Palmer class 1C) → Perform a mini open or arthroscopic repair using zone-specific cannulas. Treatment of traumatic radial side tears (Palmer class 1D) → Debride as with a Palmer class 1A tear, or mini open repair

33 Treatment of degenerative tears (Palmer classes 2A and 2B)
→ Gently debride. If the patient is ulnar positive and symptomatic, use open ulnar shortening. Treatment of degenerative tears (Palmer class 2C/2D) → Gently debride in patients who are ulnar neutral or ulnar negative. For patients who are ulnar positive, consider the arthroscopic wafer procedure. Treatment of degenerative tears (Palmer class 2E) → Degenerative tears have an unpredictable response to arthroscopic debridement. These tears usually require a salvage operation. Address the DRUJ and LT joint. A limited ulnar head excision can be performed. The Sauve-Kapandji procedure involves radioulnar joint arthrodesis and proximal ulnar pseudoarthrosis. The Darrach procedure is a resection of the distal end of the ulna.


35 (885)關於Triangular fibrocartilage complex 的anatomy和biomechanism
(A)TFCC的解剖構造包含triangular fibrocartilage和supporting ligaments TFCC is composed of the triangular fibrocartilage and its supporting lagments

36 (885)關於Triangular fibrocartilage complex 的anatomy和biomechanism
(B)Triangular fibrocartilage的構造meniscus,但有高比例的typeII collagen TFCC is a meniscu-like structure with a high proportion of type II collagen

37 (885)關於Triangular fibrocartilage complex 的anatomy和biomechanism
(C)Theulnar periphery of the TFCC has the richest blood supply and the best potential for healing 1. a fibrocartilaginous rim, meniscal homolog 2. The structure has a distinct blood supply (figure 10 p359)

38 (885)關於Triangular fibrocartilage complex 的anatomy和biomechanism
(D)in neutral ulna variance 大約有20% loading經過TFCC傳到distal ulna. 1. Fig in campbell’s 2. With positive ulnar variance, the load across the TFCC is increased, with a resultant thinning of its central disk 3. A relative positive variance in pronation and a relative negative variance in supination

39 (885)關於Triangular fibrocartilage complex 的anatomy和biomechanism
(E) In positive ulna variance, loading 經過TFCC會增加,而central disc厚度會漸少

40 (885)關於Triangular fibrocartilage complex 的anatomy和biomechanism
In pronation, radius會proximal migration而致relative positive variance,而增加loading transfer to distal ulna

41 (886)關於遠單橈骨骨折瘉合不良的敘述 Criteria for treating distal radius nonunions with a corrective osteotomy with tricortical bone graft include: A loss of radial height of greater than 4 to 5mm A loss of >=10 degrees in radial inclination A reversal of the palmar tilt to 25degrees or dorsal angulation to 15degrees

42 (886)關於遠單橈骨骨折瘉合不良的敘述 Contraindication to corrective osteotom includes the development of significant traumatic arthritis

43 (886)關於遠單橈骨骨折瘉合不良的敘述 (A)若radial height loss大於4-5mm或radial inclination loss大於10度,則要進行切骨矯正手術(corrective osteotomy) (B)若dorsal angulation大於15度或palmar tilting大於25度時,建議corrective osteotomy (C)若有明顯的外傷性關節炎,則不建議corrective osteotomy Figure 1 p353 OKU

44 (886)關於遠單橈骨骨折瘉合不良的敘述 (D)若發生complex regional pain syndrome時,可以考慮藥物治療,如Gabapentin,amitriptyline 1. after trauma or surgery without nerve injury 2. reflex sympathetic dystrophy 3.triad of pain, vasomotor changes and trophic changes 4. treatment: pharmacology: TCA, sympathetic blockade; nerve blocks.. Rockwood 8th

45 (887)Distal radius fracture

46 (A) radial styloid fracture常與scapho-lunate injuries有關
1. Fractures of the scaphoid are second only to fractures of the distal radius among fractures of the upper extremity 2. The mechanism of fracture is usually considered to be bending with compression dorsally and tension on the palmar surface, owing to forced dorsiflexion of the wrist. 3. Most patients with fractures of the lunate have a history of a hyperextension injury, such as a fall on the outstretched hand.

47 Scaphoid 68.2% Triquetrum 18.3% Trapezium 4.3% Lunate 3.9% Capitate 1.9% Hamate 1.7% Pisiform 1.3% Trapezoid 0.4%

48 887

49 (B)Initial management for a complex injury 須包含stabilization of forearm rotationsufficient fracture stability to allow finger intrinsic and extrinsic tendon motion

50 (C)將wrist joint 固定在>25 degree of wrist flexion or >30 degrees of wrist extension 可能造成carpal tunnel pressure的增加 1. Palmar flexion of an uninjured wrist to 60 degrees has been shown to cause a significant elevation of pressure in the carpal tunnel. 2. the wrist at greater than 30 degrees of palmar flexion places the patient at an increased risk of an acute carpal tunnel syndrome

51 887 (D)Distal radioulnar stabilization 與TFCC,ulnar radial articulation及extrinsic soft tissue supports有關. Pronator quadrates因scarification導致tightening可能限制supination功能

52 887 (E)使用long arm cast 做復位後之固定時,需強調維持在supination之位置;目的在減少brachioradialis 對於distal fracture fragment之拉力.同時,並能使pronator quadratus維持在最大長度,及穩定DRUJ皆有助於supination功能恢復

53 (888)Arthroscopic surgery in distal radial fracture
The strength, range of motion, and radiographic appearance were significantly better in patients in the arthroscoically assisted group OKU 8th P351 or Campbells 4th p4007

54 (888)Arthroscopic surgery in distal radial fracture
(A)約有50%會合並有soft tissue injuries,包括luntriquetral ligament, scapholunate ligament及TFCC (B)相較於conventional open reduction and internal fixation, arthroscopically assited reduction 可能得到較accurate reduction with minimal capsular and soft tissue scarring及improving the overall results

55 (889)Surgical management in distal radius fracture
(A)外固定的使用,以limited open approach為佳,可避免soft tissue injury, eccentric pin placement及open section bone defect的發生 (B)使用外固定的好處: resist compression, apply a buttress effect及provide loading shearing (C)一般而言,dorsal approach 使用於clear visualization of intra-articular fracture,而volar approach 較適用extra-articular fractutre (D)由於multiangulated titaniumplate有較顯著的soft tissue,包括tendon rupture;目前觀念認為,使用distal radius的titanium plates應該再次手術

56 (890)Scaphoid fractures and Nonunion
1. Figure 6 OKU 8th p356 2.vascularized via a dorsal branch of the radial artery, which perforates the distal third of the dorsal cortex of the scaphoid 3.The more proximal a scaphoid fracture, the more likely is delayed healing or nonunion and osteonecrosis

57 (890)Scaphoid fractures and Nonunion
(A)舟狀骨的血液供應大多來自dorsal branch of radial artery穿過舟狀骨的遠端1/3來支配 (B)未癒合常常是近舟狀骨extension,遠端則會flexion,呈現humpback deformity (C)沒有位移的舟狀骨骨折未癒合,可以考慮保守性治療,以石膏固定,並考慮電刺激或超音波治療 (D)未癒合或壞死的機率和骨折部位有關,越近端骨折發生機率越高 (E)骨壞死可以進行free vascularized bone graft 成功率和症狀的持續時間無關

58 (891)Scaphoid fracture Displaced, unstable scaphoid fracture
=>1mm displacement, lunocapitate angulation >=15 degrees,scapholunate amgi;atopm>=45degrees Compbells 4th

59 (891)Scaphoid fracture (A)Pain in the snuffbox 以及swelling about the radial side of the wrist,需懷疑有scaphoid fracture, 立即casting or splinting治療;7-10天後再行追蹤檢查,不可當做一般sprain injury 看待 (B)少於1mm的displacement或15degrees的angulation,視為nondisplaced fracture;可使用long arm cast with thumb spica extension固定治療.在無內固定的情況下,若單以short arm cast做為固定,則會因為無法控制torsional moments而可能發生secondary displacement

60 (891)Scaphoid fracture (C)即便是使用了compression screw fixation,術後仍需splint or cast support for 6-12weeks (D)當治療nonunion or malunion,需注意humpback deformity 的correction;除了要有adequate debridement外,還須採取T or winged graft,以便同時達到wedge open及inlay grafting的目的

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