At the end of this lecture you will be able to:- Describe the anatomy of the ligaments stabilising the wrist, DRUJ and the MCP joints Assess confidently the stability of these joints and identify the anatomy of the lesions Identify and provide a management plan for patients with ligament injuries and their post-op rehabilitation.

1. Ligament Injuries
of hand and wrist
Mr Vaikunthan Rajaratnam
Senior Consultant Hand Surgeon
vaikunthan@gmail.com www.handsurgerymanual.com
NuwaraEliya Workshop SL19 21 Dec 2019 - Webinar

2. Learning Outcomes
• Describe the anatomy of the ligaments stabilising the wrist, DRUJ and
the MCP joints
• Assess confidently the stability of these joints and identify the
anatomy of the lesions
• Identify and provide a management plan for patients with ligament
injuries and their post op rehabilitation.

3. Scapholunate Ligament Injuries
space of Poirier

5. Anatomy and Epidemiology
• three structurally distinct parts: volar;
membranous;and dorsal (strongest)-
• 2 mm to 3 mm in thickness and is in the range of 2 mm
to 5 mm in length.
• commonly injured ligament - 5% of wrist sprains
• Phases
• 1.occult
• 2.dynamic SL dissociation (gap)
• 3. carpal collapse
• 4.SLAC wrist
EFORT Open Rev 2017;2:382–393.

6. Clinical Examination and Assessment
• positive Watson’s shift test
• Xrays (dynamic instability)
• SL gap of > 3 mm
• SL angle of > 60°.
• MRI discontinuity with increased
signal intensity or a complete
absence of the SL ligament
• Arthroscopy – Geissler classification

7. Xray Plain and
Clenched fist
Signet Ring Sign
Terry Thomas Sign

8. Classification
Geissler’s classification Arthroscopic
Classification of the dorsal scapholunate (SL) ligament injury, according to Andersson-
Garcia-Elias. Type 1: lateral avulsion (42% of all SL injuries); type 2: medial avulsion (16%);
type 3: mid-substance rupture (20%); type 4: partial rupture plus elongation (22%).

9. Carpal instability
• malfunction carpal row (intracarpal ligaments: SL,
lunotriquetral (LT)
• abnormal carpal kinetics (altered stress with the inability to
bear functional loads)
• Scaphoid - volar flexion, Lunate forced- dorsal extension
• Static instability - dorsal intercalated segment instability (DISI)
• SLAC - degenerative arthritis of the wrist

10. Non-surgical treatment
• Splint
• Proprioceptive
• Neuromuscular training
• Physiotherapeutic treatment regimens

11. 5 questions decisions making
• 1) Is the dorsal SLL intact?
• 2) Does the dorsal SLL have sufficient tissue to be repaired?
• 3) Is the scaphoid posture normal?
• 4) Is any carpal malalignment reducible?
• 5) Is the cartilage on the radiocarpal and mid-carpal surfaces
normal?
Garcia-Elias

12. Treatment of scapholunate (SL) ligament (SLL) injury

13. Surgical treatment
• Acute - within four to six weeks with suture
repair or re-insertion and pinning
• Sub Acute ( < 4 months) - Direct open repair
with ligament sutures, osteosutures, or bony
fixation with bone anchors supplemented by
Kirschner-wire fixation and/or capsulodesis
• Chronic - dynamic instability, which is still
reducible, can be treated with ligament
reconstruction.
• Symptomatic static irreducible SLD - STT
fusion, SL fusion, RSL fusion and distal
scaphoidectomy,
The three-ligament tenodesis (S, scaphoid; L, lunate; RTq, dorsal radiotriquetral ligament; FCR, flexor carpi radialis

18. Dorsal capsulodesis - Berger technique.

19. Stage 2 SLAC Wrist

20. Proximal row carpectomy and four-corner fusion

21. DRUJ and TFCC

22. 22yo female, right handed
Staff nurse
• Injured right wrist while lifting
patient in June 2019
• Ulnar sided wrist pain
• Transient improvement after
H&L and rest (cast)
On examination
• DRUJ unstable
• volar ulnar wrist swelling
• Tender

23. DRUJ grossly unstable
Radiocarpal joint arthroscopy:
Torn radial and foveal TFCC insertion, with dorsal and volar DRUL
detached
Synovitis ++

24. Approach to DRUJ/TFCC

25. Preparation and insertion of Pushlock
suture anchor to radial attachment

26. Foveal repair

27. Must all TFCC tear
be treated?
traumatic TFCC tears with distal radius fractures
do not affect the long-term functional results
further diagnostic tests and treatment of TFCC
tears in stable distal radius fractures may be
unnecessary

28. TFCC Tear is common
• distal radius fractures associated with a high incidence of TFCC tear.
• The majority of these tears do not heal
• TFCC associated with clinical instability
• Majority asymptomatic no functional dysfunction
• Repair of TFCC is not necessary for all cases

29. Open or not?
• no scientific evidence to suggest superiority of one technique over the
other, albeit some surgeons and authors may express a strong
personal view.

30. a primary open repair of the TFCC should be considered when patients present with instability during intra-
operative DRUJ ballottement test after distal radius fixation, in the absence of an ulnar styloid fracture or when
the ulnar fracture fragment is too small to be fixed.

33. MCP Anatomy
• Proper UCL
• Accessory UCL