J Korean Orthop Assoc JKOA Journal of the Korean Orthopaedic Association 1226-2102 2005-8918 The Korean Orthopaedic Association 10.4055/jkoa.2011.46.4.294 Original Article Intercarpal Ligament Injuries Associated with Distal Radius Fractures: Relation with the Radiographic Findings and Arthroscopic Treatment Kim Jong-Pil M.D. Park Young-Ho M.D. Department of Orthopaedic Surgery, Dankook University School of Medicine, Cheonan, Korea. Correspondence to: Jong-Pil Kim, M.D., Ph.D. Department of Orthopedic Surgery, Dankook University School of Medicine, 359, Manghyangro, Dongnam-gu, Cheonan 330-715, Korea. TEL: +82-41-550-3919, FAX: +82-41-550-3094, kimjp@dankook.ac.kr 08 2011 31 08 2011 46 4 294 302 07 11 2010 07 03 2011 Copyright © 2011 by The Korean Orthopaedic Association 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

 Purpose

The purpose of this study was to analyze the relationship between intercarpal ligament injuries associated with distal radius fracture and the fracture patterns and radiologic parameters, and to report on the clinical results of arthroscopic treatment for these injuries.

 Materials and Methods

Fifty-two patients who underwent arthroscopic surgery for intercarpal ligaments injuries associated with distal radius fracture and who had a minimum 1 year follow-up were enrolled. There were 44 patients who sustained scapholunate interosseous ligament injury (SLIL) and 30 patients who sustained lunotriquetral interosseous ligament (LTIL) injury. Among them, 22 patients had both SLIL and LTIL injuries. The carpal ligament injuries were graded according to the Geissler classification and they treated with arthroscopic debridement only for a grade I and II injury and arthroscopic reduction and percutaneous pinning for a grade III and IV injury. The patients were divided into two groups and we assessed the functional and radiological outcomes: Group 1 consisted of the patients with a grade I and II injury and group 2 consisted of the patients with a grade III and IV injury.

 Results

The preoperative mean radial inclination of group 2 with lunotriquetal interosseous ligament injury was 15.1±9.9°, which was significantly different from 20.4±5.1° of group 1, and the extra-articular type injury was more common in group 2 (p<0.05). On the follow-up radiographs, the mean scapholunate interval measured 2.1±0.5 mm in group 1 and 1.7±0.5 mm in group 2, which was significantly different (p<0.05).

 Conclusion

The grade of LTIL injury combined with distal radius fractures is associated with the loss of radial inclination and the extra-articular fracture type at the time of initial presentation. Complete tears of the SLIL can be stabilized with arthroscopic reduction and percutaneous pinning.

 scapholunate interosseous ligament lunotriquetral interosseous ligament distal radius fracture arthroscopic reduction percutaneous pinning Forward DP Lindau TR Melsom DS Intercarpal ligament injuries associated with fractures of the distal part of the radius J Bone Joint Surg Am 2007 89 2334 2340 Lindau T Hagberg L Adlercreutz C Jonsson K Aspenberg P Distal radioulnar instability is an independent worsening factor in distal radial fractures Clin Orthop Relat Res 2000 376 229 235 Wiesler ER Chloros GD Mahirogullari M Kuzma GR Arthroscopic management of distal radius fractures J Hand Surg Am 2006 31 1516 1526 Lindau T Arner M Hagberg L Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients J Hand Surg Br 1997 22 638 643 Geissler WB Freeland AE Savoie FH McIntyre LW Whipple TL Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius J Bone Joint Surg Am 1996 78 357 365 Earp BE Waters PM Wyzykowski RJ Arthroscopic treatment of partial scapholunate ligament tears in children with chronic wrist pain J Bone Joint Surg Am 2006 88 2448 2455 Geissler WB Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin 2005 21 407 416 Walsh JJ Berger RA Cooney WP Current status of scapholunate interosseous ligament injuries J Am Acad Orthop Surg 2002 10 32 42 Müler M Nazarian S Koch P Classification of AO des fractures 1987 Berlin Springer-Verlag 106 115 Cooney WP Bussey R Dobyns JH Linscheid RL Difficult wrist fractures. Perilunate fracture-dislocations of the wrist Clin Orthop Relat Res 1987 214 136 147 Cautilli GP Wehbé MA Scapho-lunate distance and cortical ring sign J Hand Surg Am 1991 16 501 503 Ruch DS Vallee J Poehling GG Smith BP Kuzma GR Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures Arthroscopy 2004 20 225 230 Mayfield JK Johnson RP Kilcoyne RK Carpal dislocations: pathomechanics and progressive perilunar instability J Hand Surg Am 1980 5 226 241 Reagan DS Linscheid RL Dobyns JH Lunotriquetral sprains J Hand Surg Am 1984 9 502 514 Viegas SF Patterson RM Peterson PD Ulnar-sided perilunate instability: an anatomic and biomechanic study J Hand Surg Am 1990 15 268 278 Brown IW Volar intercalary carpal instability following a seemingly innocent wrist fracture J Hand Surg Br 1987 12 54 56 Kim BS Ahn JH Choy WS Kim HY Park JG Scapholunate dissociation associated with distal radius fracture J Korean Orthop Assoc 2004 39 265 270 Doi K Hattori Y Otsuka K Abe Y Yamamoto H Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation J Bone Joint Surg Am 1999 81 1093 1110 Kim JP Yu HJ Management of comminuted intra-articular fractures of the distal radius: arthroscopically assisted reduction and pin fixation supplemented with external fixation J Korean Orthop Assoc 2009 44 233 239 Mudgal C Hastings H Scapho-lunate diastasis in fractures of the distal radius. Pathomechanics and treatment options J Hand Surg Br 1993 18 725 729 Richards RS Bennett JD Roth JH Milne K Jr Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures J Hand Surg Am 1997 22 772 776 Ruch DS Poehling GG Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist J Hand Surg Am 1996 21 412 417 Budoff JE Treatment of acute lunate and perilunate dislocations J Hand Surg Am 2008 33 1424 1432 Park MJ Ahn JH Arthroscopically assisted reduction and percutaneous fixation of dorsal perilunate dislocations and fracture-dislocations Arthroscopy 2005 21 1153 Weil WM Slade JF 3rd Trumble TE Open and arthroscopic treatment of perilunate injuries Clin Orthop Relat Res 2006 445 120 132 Ritter MR Chang DS Ruch DS The role of arthroscopy in the treatment of lunotriquetral ligament injuries Hand Clin 1999 15 445 454 viii Kirschenbaum D Coyle MP Leddy JP Chronic lunotriquetral instability: diagnosis and treatment J Hand Surg Am 1993 18 1107 1112 Park MJ Radiographic observation of the scaphoid shift test J Bone Joint Surg Br 2003 85 358 362

(A) Preoperative radiographs of a 30-year-old man showed an AO type C2 distal radius fracture of his wrist. (B) Midcarpal view showed a grade III scapholunte interosseous ligament injury according to the Geissler classification system.5) (C) The scapholunate joint was fixated with a K-wire under arthroscopic control. (D) Twenty-four month follow-up radiograph showed normal carpal alignment without carpal dissociation, and (E) which was demonstrated by second-look midcarpal arthroscopy. Sc, scaphoid; Lu, lunate; Cp, capitate.

(A) Preoperative radiographs of a 37-year-old man showed an AO type A3 distal radius fracture of his wrist. (B) Midcarpal view showed a grade III lunotriquetral interosseous ligament injury according to the Geissler classification. (C) The lunotriquetral interosseous ligament injury was treated with trans-lunotriquetral K-wire fixation after debridement under arthroscopy. (D) Fifteen month follow-up radiograph and (E) second-look arthroscopy showed normal carpal alignment without instability. Tq, triquetrum; Lu, lunate.

(A) Preopeative radiographs of a 42-year-old woman showed an AO type A3 distal radius fracture of her wrist. (B) The scapholunate interosseous ligament was considered as grade II injury. (C) Eighteen month follow-up radiograph after arthroscopic debridement without pinning showed static carpal instability with a 2.8 mm scapholunate gap. Sc, scaphoid; Lu, lunate.

Prevalence of Intercarpal Ligaments and TFCC Injuries Associated with Distal Radius Fractures

TFCC, triangular fibrocartilage complex.

Arthroscopic Classification of the Intercarpal Ligament Injuries

From Geissler et al.5)

Artrhoscopic Grades of Scapholunate and Lunotriquetral Interosseous Ligament Injuries

SLIL, scapholunate interosseous ligament; LTIL, lunotriquetral interosseous ligament.

Radiographic Variables at Initial Presentation

Radiographic Measurements at the Last Follow-up