Carpal Ligament Injuries and Instability. FESSH Instructional Course Book 2023

Preface
Contributors
Section I: Anatomy and Biomechanics
1. Anatomy and Histology of Wrist Ligaments
1.1 Wrist Ligaments: Overview of Anatomy and Histology
1.1.1 Anatomy Overview
1.1.2 Histology Overview
1.2 Extrinsic Ligaments
1.2.1 Anatomy
1.2.2 Volar Radiocarpal Ligaments
1.2.3 Volar Ulnocarpal Ligaments
1.2.4 Dorsal Radiocarpal Ligament
1.3 Intrinsic Ligaments
1.3.1 Anatomy
1.3.2 Midcarpal Ligaments
1.3.3 Intercarpal Ligaments
References
2. Biomechanics of the Wrist
2.1 Introduction
2.2 Functions of the Wrist
2.2.1 Optimum Position for Finger Function/ Arthrodesis
2.2.2 Functional Range of Movement
2.2.3 Dart-Throwing Motion
2.3 Basic Functional Anatomy of the Wrist
2.3.1 Osteology
2.3.2 Ligaments
2.4 Wrist Stability
2.4.1 Trabecular Patterns
2.4.2 Pressure and Forces Across Wrist
2.4.3 General Aspects and the Importance of Locking
2.4.4 Locking of the Midcarpal Joint
2.4.5 Locking Mechanisms in the Radiocarpal Joint
2.4.6 Isolated Joints
2.5 Carpal Movement
2.5.1 Historical Perspective
2.5.2 Wrist Movement
2.6 Hydromechanics of the Wrist
2.7 Conclusions and Future Developments
References
3. Role of Muscles in Wrist Stabilization and Clinical Implications
3.1 Introduction
3.2 Interosseous Ligament–Competent Wrist (Normal Wrist)
3.2.1 Kinetic Effect of the Axial Loading on the Carpal Bones Alignment: How Does a Normal Carpus Adapt to the Axial Loading to Avoid Any Collapse?
3.2.2 Kinetic Effect on the Carpal Bones Alignment of the Isometric Muscle Loading
3.3 Scapholunate Joint Ligament–Deficient Wrist
3.3.1 Kinetic Effect of the Axial Loading: How Does an SLL-Incompetent Carpus Adapt to the Axial Loading?
3.3.2 Muscle Control of the Carpal Bones Alignment When the SLL Is Incompetent
3.4 Lunotriquetral Joint Ligaments (LTqL) Deficient Wrist
3.4.1 Kinetic Effect of the Axial Loading on the Carpal Bones Alignment: How Does a Deficient LTqL Carpus Adapt to the Axial Loading?
3.4.2 Muscle Control of the Carpal Bones Alignment When the LTqj Ligaments Are Incompetent
3.5 Volar Nondissociative Proximal Carpal Row Dysfunction Secondary to the Midcarpal and Dorsal Radiocarpal Ligaments Incompetence
3.5.1 Normal Wrist Proximal Carpal Row Kinematics During Wrist Inclinations
3.5.2 Proximal Carpal Row Kinematics During Wrist Radial/Ulnar Inclination When the Radial MC Ligaments Are Incompetent
3.5.3 Muscular Control of the Volar Proximal Carpal Row Dyskinesia
References
4. Ligament Injury and Carpal Instability
4.1 Introduction
4.2 Ligament Tears
4.3 Biomechanical Studies
4.4 Carpal Instability
4.5 Conclusions
References
5. Surgical Approaches to the Carpus
5.1 Introduction
5.2 Dorsal Approach
5.2.1 Skin and Subcutaneous
5.2.2 Retinaculum
5.2.3 Capsule
5.2.4 Exposure
5.2.5 Modifications
5.2.6 Closure
5.3 Volar Approach
5.3.1 Skin Incision and Subcutaneous Tissue
5.3.2 Retinaculum
5.3.3 Capsule
5.3.4 Modifications
5.3.5 Closure
5.4 Volar Approach to the Scaphoid
5.4.1 Skin Incision and Subcutaneous Tissue
5.4.2 Deeper Dissection
5.4.3 Capsulotomy
5.4.4 Closure
5.5 Dorsal Approach to the Scaphoid
5.5.1 Skin Incision
5.5.2 Retinaculum
5.5.3 Capsule
5.5.4 Exposure
5.5.5 Closure
References
Section II: Assessment of the Wrist
6. Physical Examination of the Wrist.
6.1 Medical History
6.2 Inspection
6.3 Palpation
6.4 Range of Motion
6.5 Specific Tests
6.5.1 Scapholunate Dysfunction
6.5.2 Lunotriquetral Instability
6.5.3 Midcarpal Instability
6.6 Other Specific Tests
6.6.1 Hamate Hook Pull Test
References
7. Arthroscopic Examination of the Wrist
7.1 Introduction
7.2 Arthroscopic Portals and General Joint Exploration
7.2.1 Radiocarpal Joint
7.2.2 Midcarpal Joint
7.3 Scapholunate
7.3.1 Generalities and Normal Arthroscopic Anatomy
7.3.2 Arthroscopic Pathological Exploration
7.3.3 Arthroscopic Classifications
7.4 Lunotriquetral
7.4.1 Generalities and Normal Arthroscopic Anatomy
7.4.2 Specific Pathological Evaluation
7.4.3 Arthroscopic Classifications
7.5 Extrinsic Ligaments
7.5.1 Generalities and Normal Arthroscopic Anatomy
7.5.2 Specific Pathological Evaluation and Arthroscopic Classification
7.6 Conclusions
References
8. Imaging of the Wrist.
8.1 Imaging Techniques
8.1.1 Conventional Radiographs
8.1.2 Fluoroscopy
8.1.3 Ultrasound
8.1.4 Computed Tomography
8.1.5 Magnetic Resonance Imaging
8.2 Imaging in Carpal Instability Dissociative
8.2.1 Scapholunate Dissociation
8.2.2 Lunotriquetral Dissociation
8.3 Imaging in Carpal Instability Nondissociative
8.3.1 Extrinsic Ligaments
8.4 Conclusions
References
Section III: Scapholunate Injury and Instability
9. Scapholunate Ligament Injury Etiology and Classification
9.1 Introduction
9.2 Natural History of Scapholunate Dysfunction
9.3 Scapholunate Ligament Injury Pathomechanics
9.3.1 Injury Mechanisms
9.3.2 Associated Injuries to SLL Tears
9.4 Scapholunate Ligament Injury Classifications
9.4.1 Scapholunate Ligament Injury Classifications
9.4.2 Stages of Scapholunate Joint Dysfunction
9.5 Conclusion
References
10. The “4R” Algorithm of Treatment
10.1 Introduction
10.2 Defining the Type and Stage of Injury Through the Arthroscopic Exploration
10.2.1 Gap Between the Bones
10.2.2 Acute vs Chronic
10.2.3 Quality of the Ligament
10.2.4 Dorsal Displacement of the Scaphoid
10.2.5 Reducibility
10.2.6 Combined Injuries
10.2.7 Degenerative Changes
10.3 Organizing the Treatments: The 4R
10.3.1 Repair
10.3.2 Reinforcement
10.3.3 Reconstruction
10.3.4 Resection
10.4 Conclusion
References
11. Acute “R”epair: Open Treatment
11.1 Introduction
11.2 Clinical Signs
11.3 Instrumental Diagnostics
11.4 Arthroscopy
11.5 Traditional Surgical Technique
11.5.1 Advantages and Limits of the Traditional Technique
11.6 Preferred Method
11.7 Discussion
References
12. Acute “R”epair: Arthroscopic Treatment
12.1 Introduction
12.2 Indications
12.3 Technique
12.4 Scapholunate Dorsal Capsuloligament Reattachment
12.4.1 Step 1: Insertion of the Anchor and Ligamentous Suture
12.4.2 Step 2: Dorsal Capsulodesis (Dorsal Capsular Reinforcement)
12.5 Scapholunate Volar Capsuloligament Reattachment
12.5.1 Step 1: Volar Portal Establishment
12.5.2 Step 2: Anchor Placement
12.5.3 Step 3: Capsuloligamentous Suture and Knotting
12.6 Postoperative Period
12.7 Discussion
12.8 Conclusions
References
13. Chronic “R”einforcement (Capsulodesis): Open Treatment of Chronic
13.1 Introduction and Historical Perspective 120
13.1.1 Scapholunate Injury Overview
13.1.2 Overview of Open Surgical Techniques and Indications
13.2 Capsulodesis: Literature Review and Surgical Considerations
13.3 Author’s Preferred Technique; The Dorsal Intercarpal Ligament Capsulodesis
13.3.1 Approach
13.3.2 Scapholunate Reduction
13.3.3 Dorsal Intercarpal Ligament Fixation
13.4 Essential Rehabilitation Points
13.5 Conclusion
References
14. Chronic “R”einforcement (Capsulodesis): Arthroscopic Scapholunate Repair
14.1 Introduction
14.2 Indications
14.3 Surgical Technique
14.3.1 Classic Arthroscopic Repair
14.4 Results
14.4.1 Classic Arthroscopic Repair
14.4.2 Arthroscopic Scapholunate Capsulodesis
14.5 Discussion
14.6 Conclusion
References
15. Chronic “R”econstruction (Ligamentoplasties): Open Treatment
15.1 Introduction
15.2 Ligamentoplasties
15.2.1 The Brunelli Procedure
15.2.2 The Three-Ligament Tenodesis (3LT)
15.2.3 Volar Scapholunate Ligament Reconstruction
15.2.4 The 360 Tenodesis (SLITT)
15.3 The Author’s Preferred Technique and Pitfalls
15.4 Conclusion
References
16. Chronic “R”econstruction (Ligamentoplasties): Arthroscopic Treatment
16.1 Introduction and Historical Perspective 139
16.2 Literature Review and Different Surgical Techniques
16.3 Indications and Contraindications for Surgery
16.4 Authors’ Preferred Technique
16.5 Patient Preparation and Positioning
16.6 Exploration of Radiocarpal Joint and Midcarpal Joint
16.7 Taking-Down of Intra-Articular Fibrosis
16.8 Identification of Scaphoid and Lunate Bone Tunnel Sites
16.9 Correction of DISI Deformity
16.10 Preparation of Lunate Bone Tunnel
16.11 Preparation of Scaphoid Bone Tunnel
16.12 Passing the Palmaris Longus Tendon Graft Through the Scaphoid and Lunate Bone Tunnel
16.13 Assessment Through Midcarpal Joint Arthroscopy and Scapholunate Interval Reduction with Palmaris Longus Tendon Graft
16.14 Closure and Postoperative Care
16.15 Clinical Outcome
16.16 Tips and Tricks
16.17 Conclusion
References
17. Chronic “R”esection (Palliative): Open Salvage Surgery after SL Degeneration
17.1 Introduction
17.1.1 Carpal Collapse—SLAC Pattern
17.2 Indication for Treatment
17.3 Operative Procedures
17.3.1 Denervation
17.3.2 Proximal Row Carpectomy (PRC)
17.3.3 Four-Corner Fusion
17.4 Results
17.5 Conclusion
References
18. Chronic “R”esection (Palliative): Arthroscopic Salvage Surgery after
18.1 Introduction
18.2 Styloidectomy
18.2.1 Tips and Tricks
18.3 Radiocarpal Interposition
18.3.1 Tips and Tricks
18.4 Scaphocapitate Arthrodesis
18.4.1 Tips and Tricks
18.5 Partial Arthrodesis
18.5.1 Radioscapholunate Arthrodesis
18.5.2 Intracarpal Arthrodesis
18.6 First-Row Carpal Bone Resection
18.6.1 Tips and Tricks
18.7 Total Arthrodesis under Arthroscopy (SLAC 4)
18.8 Authors’ Preferred Technique
18.9 Conclusion
References
Section IV: Lunotriquetral Injury and Instability
19. Isolated Lunotriquetral Interosseous Ligament Ruptures
19.1 Introduction
19.2 Definition of the Key Concepts
19.3 LTIL Rupture in Carpal Dislocations
19.3.1 Consequences of LTIL Rupture
19.4 Prevalence of Wrist Pain
19.4.1 Prevalence of LTIL Variations
19.4.2 The Association of LTIL Variations and Discomfort and Incapability
19.5 Diagnosis and Treatment of LTIL Variations as the Cause of Wrist Pain
19.6 Potential Harms Associated with the Concept of LTIL Variations as a Cause of Wrist Pain
References
20. Acute Management: Open Treatment of LT Injury and Instability
20.1 Introduction and Historical Perspective
20.2 Surgical Anatomy
20.3 Indications and Contraindications for Surgery
20.4 Literature Review and Different Surgical Techniques
20.4.1 Debridement
20.4.2 Direct Ligament Repair
20.4.3 Ligament Reconstruction
20.4.4 Arthrodesis
20.4.5 Augmentation
20.5 Authors’ Preferred Technique/Tips and Tricks
20.5.1 Acute Lunotriquetral Ligament Repair vs Reconstruction with Distally Based Extensor Carpi Ulnaris Strip
20.5.2 Tips and Tricks
20.6 Essential Rehabilitation Points
20.7 Conclusion
References
21. Chronic Injury Management of the LT Joint: Open Treatment
21.5 Classification
21.6 Surgical Treatment
21.6.1 Soft Tissue Procedures
21.6.2 Lunotriquetral Fusion
21.6.3 Radiolunate (RL) and Radioscapholunate (RSL) Fusion
21.6.4 Total Wrist Fusion
21.6.5 Wrist Denervation
21.7 Literature Review
21.7.1 Soft Tissue Procedures
21.7.2 Lunotriquetral Fusion
21.7.3 Salvage Procedures
21.8 Authors’ Preferred Technique
21.8.1 Ligament Reconstruction
21.8.2 Postoperative Treatment
21.8.3 Tips and Tricks
21.8.4 Lunotriquetral Fusion
21.8.5 RL/RSL Fusion
21.8.6 Midcarpal and Total Wrist Fusion
21.8.7 Wrist Denervation
21.9 Conclusion
References
22. Acute and Chronic Management of LT Ligament Injury: Arthroscopic
22.1 Introduction
22.2 Acute Injury
22.3 Acute Management
22.4 Subacute Management
22.5 Chronic Management
22.5.1 Ligament Reconstruction
22.5.2 Arthrodesis
References
23. LT Ligament Injury (Disorders) and Instability Associated to Ulnocarpal
23.1 Ulnocarpal Abutment Syndrome
23.2 Lunotriquetral Ligament (LT) Injury
23.3 Symptom of the LT Ligament Injury with the Ulnocarpal Abutment Syndrome
23.4 Diagnosis of the LT Injury with Ulnocarpal Abutment Syndrome
23.5 Treatments
23.5.1 Conservative Treatment
23.5.2 Surgical Treatment
References
Section V: Extrinsic Ligament Injuries
24. Perilunate Injuries
24.1 Introduction
24.2 Classification
24.3 Assessment and Investigations
24.4 Treatment
24.4.1 Perilunate Dislocations
24.4.2 Perilunate Fracture Dislocations
24.4.3 Postoperative Care
24.5 Clinical Results
24.6 Conclusion
References
25. Perilunate Injuries Non-Dislocated
25.1 Introduction
25.2 Acute PLIND Cases
25.3 Chronic PLIND Cases
25.4 Discussion
References
26. Axial Carpal Dislocations and Fracture Dislocations
26.1 Introduction
26.1.1 Mechanism of Injury
26.1.2 Historical Perspective and Classification
26.2 Indications and Contraindications for Surgery
26.3 Literature Review and Different Surgical Treatment
26.4 Essential Rehabilitation Points
26.5 Conclusion
References
27. Classification and Treatment of Nondissociative Proximal Row Instability
27.1 Introduction and Historical Perspective
27.2 Kinematic Dysfunction of the Unstable Proximal Row
27.3 Classification of Proximal Row Instability
27.4 Clinical Presentation of Proximal Row Instability
27.4.1 Physical Examination
27.4.2 Advanced Investigations
27.5 Options of Treatment for Proximal Row Instability.
27.5.1 Treatment of Volar Proximal Row Instability (V-PRI)
27.5.2 Treatment of Dorsal Proximal Row Instability (D-PRI)
27.5.3 Treatment of Combined Proximal Row Instability (C-PRI)
27.6 Conclusions
References
Section VI: Other Injuries
28. Ligament Injuries Associated to Distal Radius Fractures
28.1 Introduction
28.2 Indications for Arthroscopy
28.2.1 The Arthroscopic Procedure—“Dry” or Wet?
28.2.2 The Arthroscopic Procedure—Arthroscopic Assessment
28.2.3 Triangular Fibrocartilage Complex (TFCC) Injuries
28.2.4 Intercarpal Ligament Injuries
28.2.5 Scapholunate (SL) Ligament Injuries
28.2.6 Lunotriquetral (LT) Ligament Injuries
28.2.7 Chondral Lesions
28.3 Outcomes
28.4 Conclusion
References
29. Pisotriquetral Instability
29.1 Introduction
29.2 The Underwater Part of the Iceberg: Three Components
29.2.1 The Whole Territory of the Ulnar Side
29.2.2 Biomechanics: Need of New Biomechanical Considerations
29.2.3 Grades of Instability
29.3 Anatomy
29.4 Symptoms
29.5 Physical Examination
29.6 Imaging Studies
29.7 Pathology and Classification
29.8 Treatment
29.9 Surgical Technique
29.10 Postoperative
29.11 Discussion
29.12 Conclusion
References
Index

An up-to-date, instructional resource on open and arthroscopic management of wrist injuries

Major advances have been made in the field of wrist surgery, including the use of arthroscopy and better rehabilitation protocols. In addition, understanding of proprioception has changed conservative management, often preventing surgery. Nevertheless, the assessment and management of a myriad of wrist dysfunctions remains daunting, due in part to complicated anatomy and mechanics and a lack of high-quality prospective clinical studies. Carpal Ligament Injuries and Instability: FESSH Instructional Course Book 2023 edited by renowned hand surgeons Fernando Corella, Carlos Heras-Palou, and Riccardo Luchetti covers the investigation, diagnosis, staging, and management of ligament injuries and the latest open and arthroscopic techniques to treat carpal instabilities.

The first two sections lay a solid foundation, with eight chapters encompassing anatomy and biomechanics, clinical and arthroscopic examination of the wrist, and imaging. Section three includes 10 chapters on scapholunate injury and instability, with discussion of open and arthroscopic repair, reinforcement, reconstruction, and resection techniques. Section four features five chapters on lunotriquetral injury and instability, including acute and chronic open and arthroscopic injury management. Section five includes four chapters on extrinsic ligament injuries, from perilunate injuries to staging and treatment of nondissociative proximal row instability. The book concludes with a final section comprising two chapters on other types of injuries.

• An impressive group of renowned global experts describe new treatment algorithms and surgical techniques
• Clinical pearls throughout the text provide guidance on preventing complications and improving outcomes
• A wealth of high-quality operative photos, imaging scans, illustrations, and videos enhance understanding of impacted anatomy and techniques

This resource provides trainees, surgeons, and therapists with current thinking and up-to-date evidence-based treatment for wrist ligament injuries and carpal instabilities, with the goal of improved patient outcomes.

This book includes complimentary access to a digital copy on https://medone.thieme.com.