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.
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Ligament injuries of hand and wrist
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.
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
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%).
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
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
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.