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The most common cause of an arthritically damaged distal radioulnar joint is a malunion of a distal radius fracture. Therapeutically, ulnar head resection, hemiresection-interposition-technique, Kapandji-Sauvé procedure and implantation of an ulnar head prosthesis have been described. None of these procedures is able to restore the complete function of the joint. Therefore, anatomical reconstruction of the joint in acute or secondary correction osteotomy for malunited fractures of the distal radius should be performed to avoid the development of the arthrosis. Numerous clinical studies have demonstrated a similar reduction of the clinical symptoms for all procedures. Therefore, classification of the different procedures has to consider the number of complications. Biomechanically, partial resection of the distal ulna will destabilize the distal radioulnar context and clinically may lead to painful radioulnar and/or dorsopalmar instability of the distal ulnar stump. Biomechanically and clinically, this complication, next to secondary extensor tendon ruptures, has to be expected far more often following complete resection of the ulnar head than in the alternative procedures. We do not see any remaining indication for complete resection of the ulnar head. Clinical results and the occurrence of painful instability of the distal ulnar stump have been reported almost identically for the hemiresection-interposition technique and the Kapandji Sauvé procedure. Therefore, both procedures appear to be equally suitable for the treatment of painful arthrosis of the distal radioulnar joint. In patients with a preexisting instability of the distal radioulnar joint, or a major deformity of the radius or the ulna, we prefer to perform the hemiresection-interposition-technique. In these conditions we consider the remaining contact of the triangular fibrocartilage complex with the distal end of the ulna a biomechanical advantage to reduce the risk of secondary instability. Biomechanically as well as clinically, replacement of the ulnar head using a prosthesis has been shown to either avoid or solve the problem of instability. We therefore consider ulnar head replacement the treatment of choice in secondary painful instability following resection procedures at the distal end of the ulna. Primary ulnar head replacement should be considered in special indications until long-term follow-up results are available.

Introduction: The indication and treatment of malunited fractures of the distal radius in the growing skeleton differ from those for adults. The literature results are scarce. In this study we examined the results of surgical correction following fractures of the distal radius in infants., Materials and Methods: Seven infant patients with malaligned fractures of the distal radius that demonstrated significant functional deficit and poor prognosis for spontaneous recovery were treated with surgical correction. Two of them were treated because of growth disturbance from post-traumatic closure of the distal radial physis., Results: All seven osteotomies healed with acceptable radiologic alignment. After an average follow-up period of 3 years and 1 month (range 10 months to 8 years and 4 months), patients had an average range of wrist motion (ROM) of 131 deg in extension and flexion (93% of the contralateral side, 130% of presurgical situation); 65 deg in ulnar and radial deviation (94% of the contralateral side, 122% of presurgical situation); and 177 deg in pronation and supination of the forearm (97% of the contralateral side, 115% of presurgical situation). The average grip strength of 71.4 kPa was nearly equal to the other side with 72.8 kPa. The average postoperative angulation of the distal radius was 12 (range 10-17) deg, the radial inclination 20 (range 12-30) deg, and the ulnar variance was -0.6 (range -3 to +2) mm. According to the Fernandez point score system as well as the scale of Fernandez, there were five excellent results and two good results. The patients described low disability on the DASH scores, with a median of 4 (range 0-41) points., Conclusions: Surgical correction for malunited fractures of the distal radius provides good and excellent radiological and functional results in the growing skeleton. It should be considered immediately if there is poor remodeling capacity and disabling loss of function.

Purpose: Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid., Method and Material: 37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically., Results: The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain., Conclusion: Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

Objective: In literature the diagnostic value of MRI for detecting lesions of the carpal ligaments and the TFCC is judged controversially. The aim of the following study is to determine the diagnostic accuracy of direct MR arthrography for depicting and staging of intraarticular lesions of the wrist., Material and Methods: One day before undergoing arthroscopy, 125 patients suffering from wrist pain were examined with direct MR arthrography in a prospective and blinded study. A mixture of contrast medium (iodine-containing contrast medium and gadopentetate in relation 200 : 1) was injected into both radiocarpal and midcarpal joints. The following sequences were acquired on a 1.5T scanner: coronal T1-weighted SE, coronal fat-saturated T1-weighted SE, coronal T1-/T2*-DESS-3D, and sagittal T2*-weighted MEDIC. MRI results were compared with arthroscopic findings using statistical analysis (SEN = sensitivity, SPE = specificity, PPV = positive predictive value, NPV = negative predictive value, ACC = accuracy)., Results: In comparison to arthroscopy as the accepted diagnostic gold standard, the following results were found for MR arthrography. Detection of TFCC lesions: SEN 97.1 %, SPE 96.4 %, PPV 97.1 %, NPV 96.4 %, ACC 96.8 %. Detection of complete tears of the scapholunate ligament: SEN 91.7 %, SPE 100 %, PPV 100 %, NPV 99.1%, ACC 99.2%. Detection of partial tears: SEN 62.5 %, SPE 100 %, PPV 100 %, NPV 94.8 %, ACC 95.2 %. Detection of cartilage defects: SEN 84.2 %, SPE 96.2 %, PPV 80 %, NPV 97.1 %, ACC 94.4 %. In total, only three lesions of the lunotriquetral ligament were present., Conclusion: Direct MR arthrographic imaging is well suited for detecting intraarticular lesions of the wrist. The presented diagnostic results of MR arthrography are superior to the results of unenhanced MRI reported in the literature. Direct MR arthrography as a reliable diagnostic tool is strongly recommended if lesions of the scapholunate ligament and the triangular fibrocartilage complex are suspected. In contrast, an attitude of caution must be adopted in diagnosing lesions of the articular cartilage of the wrist.

Despite the important observations that have been made concerning biomechanics and function of the wrist joint in recent years, the surgeon is still confronted with a huge number of delayed posttraumatic disorders of this joint. In the past, total wrist fusion was the leading salvage procedure, whereas today several salvage procedures are available to solve these problems. Partial wrist fusions are supposed to stabilize the carpus, immobilize destroyed articulating surfaces while allowing motion in the unharmed parts of the wrist. Acknowledging pathobiomechanical laws, they have been used for a growing number of indications with a large benefit. The patients profit of better functional results than can be observed in patients with total arthrodesis of the wrist. Furthermore, partial wrist fusion provides a more stable situation and the absence of pain for a longer period of time. However, further studies evaluating the clinical outcome of these salvage procedures are necessary and to be expected in the near future.

Between December 1994 and December 1996, 26 patients with a scapholunate ligament injury (three with SLD 1. degrees, 16 with SLD 2. degrees and 7 with SLD 3. degrees ) underwent an operation for dorsal capsulodesis in the Klinik für Handchirurgie, Bad Neustadt/Saale. Mean follow-up was 24 months (16 to 37 months). Follow-up criteria were range of motion, grip strength, pain relief, and X-ray findings. Clinical outcome was evaluated using a personal questionnaire, the DASH- and a modified Cooney-Score. Although significant reduction of joint mobility compared to the opposite site was found in all cases (E/F 32 %, U/R 19 %), the reduction of pain was 30 %. Grip-strength was not altered. Thus, 86 % of the patients were satisfied with the result obtained. On X-ray, the scapholunate angle was raised in the SLD 3. degrees -group by 12 degrees postoperatively; in the group with dynamic instability, X-ray findings were normal. Overall, 19 % (5/26) needed further operations due to persistent pain.

Malunion of forearm fractures located in the distal third will remodel satisfactorily providing the child is less than twelve years of age. Complete correction of gross deformity cannot be anticipated in diaphysial fractures when the child is over five years of age. Malunion of fractures of the forearm in children can lead to permanent functional disability with limitation of forearm rotation. In the case of functional disability, there is an indication for corrective osteotomy at the age over twelve in malunion of a fracture located in the distal third and already after age five in gross deformity of fractures to the midshaft of the forearm.

Significant progress has been made in the understanding of carpal kinematics and posttraumatic disorders of the wrist. The importance of stabilization of the scaphoid is well known. More and more ligament injuries of the proximal carpal row have been diagnosed in cases of severe arthrotic changes. Long-standing scaphoid nounion or scapholunate ligament injuries can lead to progressive carpal collapse due to a break of the continuity of the proximal carpal row. SLAC-wrist (scapholunate advanced collapse) and SNAC-wrist (scaphoid nonunion advanced collapse) after missed fusion of scaphoid fractures should be differentiated. Severity of degenerative changes is classified into three stages. Salvage procedures preserving wrist mobility, like midcarpal fusion, are preferable to total wrist fusion because of the functional benefit. With complete excision of the scaphoid and fusion of the midcarpal joint, all arthritic joint surfaces are eliminated and motion is preserved in the radiolunate joint which is usually spared of degenerative changes.

Unlabelled: Arthrosis of the distal radioulnar joint (DRUJ) is a common problem following fractures of the distal radius. The treatment options include the hemiresection-interposition technique (Bowers procedure) or Kapandji-Sauvé procedure. In a retrospective study, we assessed the results of the Bowers procedure., Material and Methods: From 1992 to 1997, 24 patients were treated by the hemiresection-interposition technique (Bowers procedure) for arthrosis of the DRUJ following fracture of the distal radius. The average follow-up time was 30.5 (9 to 55) months., Results: The average preoperative pronation was 67 degrees, the supination 45 degrees. Postoperatively, we found a pronation of 80 degrees and a supination of 62 degrees. Grip-strength compared to the opposite site could be improved from 38 to 57% postoperatively. Pain was reduced markedly in 78% of the patients. However, ten patients developed a postoperative instability of the distal ulna. In only two patients did painful instability necessitate revision procedures., Conclusion: The hemiresection-interposition technique is a salvage procedure for the destroyed DRUJ, leading to good clinical results in most patients. Painful instability of the distal ulna and remaining functional deficits can be the reasons for failure. Therefore, adequate primary reduction of fractures of the distal radius or secondary reconstruction of the anatomy is necessary to prevent secondary arthrosis of the DRUJ.

Lesions of the TFCC may have degenerative or post-traumatic causes. Distal radioulnar joint as well as the ulnocarpal joint can be affected. Patients present with ulnar-sided wrist pain especially in forearm rotation. Therapy depends on the degree of lesions and additional pathology. Wrist arthroscopy offers a certain diagnostic tool. In addition, adequate therapy can be realized. After failed arthroscopic therapy, ulnar shortening osteotomy reduces ulnar load significantly.

Background: One of the most common injuries in orthopaedics is the distal radius fracture. Malunion may lead to pain, limited motion, and loss of grip strength. Presently there is no consensus concerning the indications for corrective surgery after malunion. Studies concerning the biomechanics of the wrist in cases of malunited radius fracture can be helpful., Method: Analysis of the literature of the last ten years., Results: In laboratory studies, malalignment of the radius caused alterations of the distal radioulnar joint (anatomically: reduction of the radioulnar contact area, disruption of the deep portion of the dorsal radioulnar ligament, tightness of the triangular fibrocartilage complex; functionally: limited forearm pronation and supination). Further alterations have been found concerning the carpal kinematics, the force transmission through the wrist, the pressure distribution on the articular surface of the radius and the median nerve., Conclusion: Attempts should be made to obtain an anatomic reduction of all acute distal radius fractures. Posttraumatic disability of the wrist following malunion in radius fractures should accordingly be treated by a corrective osteotomy of the radius at the original fracture site.

The ulnar head represents a keystone for normal forearm function. A complex system of soft tissues stabilizes the radius and the ulnocarpal joint against the ulnar head which is an essential part of the distal radioulnar joint as well as the ulnocarpal joint. Injuries around the ulnar head can destabilize these joints leading to loss of congruity and secondary arthrosis. The different injury patterns can result in axial or transverse instability. Axial instability primarily affects ulnocarpal function, transverse instability the function of the distal radioulnar joint. The injury pattern determines the degree of bony and soft tissue lesions that will clinically present in a variety ranging from acute dislocation to chronic instability of the ulnar head. An early and exact diagnosis of the injured structures with their anatomical reconstruction is necessary to avoid secondary arthrosis that will result in functional impairment of the distal radioulnar and ulnocarpal joints.

Longstanding unstable scaphoid nonunions inevitably lead to carpal collapse and symptomatic secondary arthrotic changes, ruling out reconstructive procedures to the scaphoid itself. Partial mediocarpal fusion, however, can preserve some wrist motion and markedly reduce or even eliminate wrist pain. By correcting the malalignment of the lunate and capitate, carpal height is restored. By excision of the scaphoid, its destroyed articular surfaces are removed. In 26 of 31 patients undergoing mediocarpal fusion, complete or at least significant reduction of wrist pain was observed. Average grip strength increased by 23%, whereas wrist mobility decreased by 33 to 40% with a relatively short follow-up of 14 months. Total wrist fusion remains the last line of defense.

Lacerations of arteries and nerves not only result in motor and sensory deficiencies. Trophic changes occur as well, more frequently after nerve injuries than after vascular injuries. The major progress in their treatment consists in primary repair of the injured structures in order to keep their loss of function as brief and as minimal as possible. Although the results after nerve laceration are still far from being ideal, there are strong indications that an improvement can be obtained with this treatment strategy. Alternatives to primary repair are discussed.