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In athletes, traumatic injuries largely address the wrist and hand. Three to nine percent of all lesions caused by sports casualty pertain to these regions. Because of the high functionality of wrist and hand, the different kinds of sports can cause a broad spectrum of ligamentous or bony injuries. For further therapy, it is important to differentiate between acute traumatic and chronic lesions. Precise knowledge of hand and wrist anatomy and comprehension of the cause of the trauma is the basis column for choosing the right therapy.

Scapholunate dissociation is the most common form of carpal instability [1] (Fig. 73.1). Despite the attention given to this condition, with a large amount of publication, it has remained a therapeutic challenge especially in chronic cases. In fact many different techniques have been proposed, but they do not always give satisfactory results in all cases with a residual amount of stiffness, pain, decrease of grip strength, recurrence of SL widening and development of osteoarthritis especially in long-term follow-up [2–10].

Secondary osteoarthrosis of the wrist typically develops after intra-articular distal radius fractures with articular incongruity (step-off) of 1–2 mm or more or with an associated rupture of the scapholunate ligament. If the condition is painful and conservative measures fail, surgical treatment may be necessary. Total wrist fusion is the standard procedure but total- or hemi-wrist arthroplasty may also be used. Other motion preserving solutions are feasible, if the midcarpal joint is normal: total or partial radiocarpal fusion or a modified proximal row carpectomy, depending on the condition of the cartilage in the radioscaphoid fossa.

The management of ligament injuries of the wrist has always constituted a challenge for hand surgeons. The advent of wrist arthroscopy has facilitated the diagnosis, improved the understanding of the etiopathogenesis, and helped in the development of new therapies for these lesions with promising early to midterm results. Apart from the rare lunotriquetral ligament injuries and the complex midcarpal instability, triangular fibrocartilage complex (TFCC) injuries and scapholunate ligament (SLL) tears are the most frequently seen injuries in clinical practice. However, recent advances in the understanding of the anatomy and function of the scapholunate ligament have led to the evolution of a novel concept – the so-called scapholunate ligament complex. Triangular Fibrocartilage Complex (TFCC) Injuries Introduction According to the classification of Palmer (1989), lesions of the triangular fibrocartilage (TFCC) are divided into two basic categories, traumatic lesions (type 1) and degenerative (type 2), which are themselves divided into different subtypes depending on the location of the lesion and the presence or absence of cartilage defects. Traumatic lesions or type 1 injuries are divided into four types, of which type 1B corresponds to peripheral lesions located at the ulnar insertion of the TFCC. These lesions are the most common and best known. Recent anatomical and histological studies have shown that the ulnar part of the triangular fibrocartilage is actually located in separate complex threedimensional components, viz., the proximal part, the distal hammock/sling-like structure, and the ulnar collateral ligament (UCL) (Nakamura et al. 1996). The ulnar collateral ligament (UCL) can be thought of as being associated with the distal hammock because it shares the same function of suspension and transmission of forces on the ulnar aspect of the wrist (Nakamura et al. 1996). Both of these structures can be considered as the distal component of the ligament (TFCC) in comparison to the proximal portion of the TFCC (Fig. 1). The proximal portion of the triangular fibrocartilage (TFCC) is attached to the fovea of the ulnar head and inserts on both sides of the sigmoid notch of the distal radius by the palmar and dorsal radioulnar ligaments that stabilize the distal radioulnar joint (Nakamura andMakita 2000). Different components of these ligaments can be injured in isolation or in combination. Unlike lesions of the proximal portion of the TFCC that may cause instability of the distal radioulnar joint, the stability of the distal radioulnar joint is preserved in isolated lesions of the distal component, conventionally known as type 1B lesions according to Palmer. Many arthroscopic techniques have been proposed to suture the ligament damage to the dorsal capsule (Whipple and Geissler 1993; Zachee et al. 1993; Haugstvedt and Husby 1999; Bohringer et al. 2002; Conca *Email: cmathoulin@orange.fr Sports Injuries DOI 10.1007/978-3-642-36801-1_52-1 # Springer-Verlag Berlin Heidelberg 2014

Fractures of the radial styloid should always be suspected to be part of a progressive perilunate fracture-dislocation injury. Knowledge of the pathomechanism is therefore important in order to detect possible concomitant carpal injuries. A scapholunate ligament disruption and/or a scaphoid fracture are the most commonly associated injuries to the radial styloid fracture. However, correct diagnosis and choice of treatment remain a challenge as various combinations of intrinsic or radiocarpal ligament injuries are known to occur which may lead to late carpal instability. Knowledge of the anatomy and injury patterns is essential to avoid complications and provide optimal treatment. This chapter discusses surgical treatment of radial styloid fractures, concomitant scapholunate ligament tears, and screw fixation of concomitant scaphoid fractures.

The complex anatomical nature of the hand and wrist brings about diagnostic challenges both for the Clinician and the Radiologist when considering pathology in this region. MR is a proven, widely employed imaging modality used in the detection, assessment and follow-up of disorders of both the hand and the wrist. Optimisation of both sequences and protocols are essential in order to provide good quality images which allow high sensitivity and specificity for detection of pathology. High field strength units are usually used in hand and wrist imaging alongside dedicated extremity coils. Even then, there are numerous artefacts which may be encountered including movement, pulsation, truncation, magic angle and chemical shift. These phenomena will be discussed in this chapter in addition to a brief outline of sequences and their potential uses. Pathology relating to osseous structures, tendons, TFCC and both intrinsic and extrinsic ligaments are all readily assessed on MR imaging and the optimal planes for imaging are discussed alongside common pathologies and potential pitfalls in image interpretation. MR arthrography is also discussed with particular reference to both TFCC and intrinsic ligament pathology. Recent advances in technology, including the advent of 7T units, have led to improvements in the assessment of articular cartilage at the wrist and techniques of biological imaging, which continue to evolve.

The purpose of this chapter is to discuss wrist arthroscopy and its value in the staging and treatment of osteonecrosis of the lunate, or Kienbock’s disease. A brief review of the condition will also be included to help support wrist arthroscopy as a useful tool in the management of this difficult problem. Additional tips for use of arthroscopy in Kienbock’s disease, for both diagnostic and treatment purposes, are also discussed here. Please note that the content of this chapter largely reflects what is available in published literature, but also includes the opinions of the authors.

Fractures of the distal end of radius account for nearly 20% of all fractures seen in a routine emergency room and are commonly associated with intercarpal ligamentous injuries and other soft tissue disruptions [6]. The structure most frequently injured in distal radial fractures is the triangular fibrocartilage complex (TFCC) [15, 21, 24, 27]. In one cadaveric study where a hyperextension force was applied to cadaveric wrists until a distal radial fracture occurred, an injury to the TFCC occurred in 63% of the specimens followed by injuries to scapholunate ligament (32%) and to lunotriquetral ligament (17%) [20]. The TFCC consists of the central fibrocartilage, the dorsal and palmar distal radioulnar ligaments, the sheath of extensor carpi ulnaris tendon, the ulnar collateral ligaments, and the ulnocarpal ligaments. It works as a single unit that aids in movements, stability, and load sharing at the wrist. The central area of TFCC is avascular and called the debridement zone, whereas, the peripheral zone enjoys an extensive blood supply and is termed the repair zone [25] (Fig. 5.1).