Loisel Francois, Orr Steven, Ross Mark, Couzens Greg, Leo Andrew J, Wolfe Scott
Besançon Teaching Hospital, Besançon, France.
New York University Langone Health, New York, NY.
J Hand Surg Am. 2022 Mar;47(3):285.e1-285.e11. doi: 10.1016/j.jhsa.2021.04.024. Epub 2021 Jun 25.
We report 8 cases of acute or subacute unilateral nondissociative carpal instability (CIND) in the context of nondisplaced scaphoid fractures.
Eight patients from 3 centers developed abnormal volar intercalated segment instability (VISI) or dorsal intercalated segment instability (DISI) following the diagnosis of a nondisplaced scaphoid fracture. An operative inspection in each patient confirmed intact scapholunate and lunotriquetral interosseous ligaments. We outline the demographic characteristics of our patient cohort, radiologic and operative findings of CIND-DISI and CIND-VISI, and the outcomes of acute and delayed treatment.
Two patients were diagnosed with CIND-DISI and 6 with CIND-VISI associated with ipsilateral nondisplaced scaphoid fractures. The average time from injury to diagnosis of CIND was 11 weeks, and the mean clinical and radiographic follow-up was 18 months. Rapid healing of the scaphoid fractures was achieved in all patients (4 open reduction internal fixation, 4 cast). All patients underwent surgery to improve proximal carpal row alignment: in 3 of the 4 patients who were diagnosed and treated surgically within 12 weeks of injury, the radiolunate angle (RLA) was successfully restored. A contracture release and ligament repair or reconstruction with tendon graft 12 or more weeks following injury was unsuccessful in restoring proximal row alignment in all 4 patients. Two patients in the delayed treatment group required secondary surgery for partial fusion.
Based on the arthroscopic, imaging, and operative findings, we propose that the ligamentous restraints to CIND-VISI are dorsal at the radiocarpal joint and volar at the midcarpal joint. Conversely, the ligamentous restraints to CIND-DISI are dorsal at the midcarpal joint and volar at both the radiocarpal and midcarpal joints. In our series, a delayed diagnosis and late reconstructive surgery were associated with no improvement in RLA. We recommend early recognition of traumatic CIND and prompt treatment of injured ligaments prior to the development of a fixed deformity.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
我们报告8例在无移位舟骨骨折情况下发生的急性或亚急性单侧非分离性腕骨不稳定（CIND）病例。
来自3个中心的8例患者在诊断为无移位舟骨骨折后出现了异常的掌侧插入节段不稳定（VISI）或背侧插入节段不稳定（DISI）。对每位患者进行的手术检查证实舟月和月三角骨间韧带完整。我们概述了患者队列的人口统计学特征、CIND-DISI和CIND-VISI的放射学及手术结果，以及急性和延迟治疗的结果。
2例患者诊断为CIND-DISI，6例为CIND-VISI，均与同侧无移位舟骨骨折相关。从受伤到诊断为CIND的平均时间为11周，平均临床和影像学随访时间为18个月。所有患者的舟骨骨折均实现快速愈合（4例行切开复位内固定，4例行石膏固定）。所有患者均接受手术以改善近端腕骨排的对线：在受伤后12周内接受诊断和手术治疗的4例患者中，有3例成功恢复了桡月角（RLA）。受伤12周或更长时间后进行挛缩松解及韧带修复或肌腱移植重建均未能成功恢复所有4例患者的近端排对线。延迟治疗组的2例患者需要二次手术进行部分融合。
基于关节镜、影像学和手术结果，我们提出对CIND-VISI的韧带限制在桡腕关节处为背侧，在腕中关节处为掌侧。相反，对CIND-DISI的韧带限制在腕中关节处为背侧，在桡腕关节和腕中关节处均为掌侧。在我们的系列研究中，延迟诊断和晚期重建手术与RLA无改善相关。我们建议早期识别创伤性CIND，并在固定畸形形成之前及时治疗受损韧带。
研究类型/证据水平：治疗性研究V。
