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Corresponding author: David S. Ruch, MD, Department of Orthopaedic Surgery, Division of Hand Surgery, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27710.
The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF.
Methods
A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain.
Results
One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°–68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°–87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°–87°) to 78.5° (range, 71°–107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups.
Conclusions
Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF.
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Disclosures for this Article
Editors
Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose.
Authors
All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.
Planners
Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.
Learning Objectives
Upon completion of this CME activity, the reader will understand:
•
The impact of scapholunate ligament injuries on patients with distal radius fractures.
•
The evaluation of scapholunate ligament injuries in association with distal radius fractures.
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The prevalence of scapholunate ligament injuries in the setting of a distal radius fracture.
Deadline: Each examination purchased in 2021 must be completed by January 31, 2022, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
To date, no clear consensus exists on how to treat an SL ligament injury associated with a DRF. The surgeon may elect to perform concomitant repair or reconstruction of SL ligament injury at the time of DRF fixation, treat the ligament injury at a later time, or elect to treat it nonsurgically. Lans et al
suggested there were no differences in functional long-term outcomes among patients with SL diastasis associated with a DRF. To address the question of whether SL ligament injury repair or reconstruction was required, we compared functional longer-term outcomes in 2 cohorts of intra-articular DRF: one without radiographic evidence of an SL ligament injury and another with radiographically identifiable SL ligament injury who did not undergo repair or reconstructive surgery. Our hypothesis was that there are no significant differences in outcomes between these patients after treatment of their intra-articular DRF.
Materials and Methods
We performed an institutional review board–approved retrospective analysis of a cohort of patients from a single institution’s DRF registry from January 1, 2006, through January 1, 2019. Clinical and demographic information was queried from the DRF registry database and confirmed through electronic medical records. We adhered to Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines throughout the study.
Patients included in the study were 18 years of age or older, with an intra-articular DRF that did not undergo concomitant SL ligament injury repair or reconstruction. Clinical and demographic information were collected. Radiographic parameters were measured and recorded at baseline in the ipsilateral wrist prior to injury if historic data was available, or the contralateral wrist at the time of injury; following closed reduction, but prior to surgical DRF treatment; and at final follow-up. The minimum follow-up was 12 months.
Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH),
Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
Scores were collected by hand surgeons, physical therapists, and occupational therapists 2 weeks following surgical and nonsurgical treatments and at time of final follow-up. The QuickDASH scores were measured on a scale of 0 to 100, and the mGAF scores were measured on a scale of 0 to 90 (higher scores indicate increased patient-reported disability for QuickDASH and decreased disability for mGAF)
Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
and the VAS pain was measured on a scale of 0 to 10. The mGAF scale is commonly used to assess a patient’s global function and changes in psychopathology.
Radiographic parameters used for DRFs were those set forth by the American Academy of Orthopedic Surgeons (AAOS) for palmar tilt and radial inclination.
Inadequate imaging was defined as lack of baseline radiographs or lateral radiographs that did not have proper alignment (defined as lateral radiographs with radius-to-long finger metacarpal >20° or inadequate scaphoid and lunate overlap).
The SL angles and intervals (gaps) were measured at 3 different time points: baseline in the ipsilateral wrist prior to injury if historic data was available (Fig. 1), or the contralateral wrist at the time of injury, following closed reduction, but prior to surgical DRF treatment (Fig. 2), and at final clinical follow-up (Fig. 3). The SL angles were measured on lateral radiographs by first drawing the lunate line perpendicular to the tangent of the 2 distal poles. A second scaphoid line was drawn parallel to a tangent to the palmar proximal and distal margins. The SL angles were measured between the 2 lines and reported in degrees.
The SL gaps were measured on posteroanterior radiographs as the distance between the midpoint of the proximal margins of the scaphoid and the lunate carpal bones, and reported in millimeters.
Radiographic evaluations were performed by K.M.K. and C.S.K., with discrepancies evaluated by the senior author, D.S.R.
Figure 1A Lateral radiograph of the contralateral left wrist of a 79-year-old woman at the time of her intra-articular DRF. Patient was stratified into cohort 2 following injury (SL angle ≥ 70°). B SL angle measured 52°.
Figure 2A Lateral radiograph of the right wrist of a 79-year-old woman following closed reduction of her intra-articular DRF but prior to surgical intervention. Patient was stratified into cohort 2 following injury (SL angle ≥70°). B SL angle measured 73°.
Figure 3A Lateral radiograph of the right wrist of a 79-year-old woman following open reduction internal fixation with volar locking plate and screws of her intra-articular DRF at final follow-up. Final follow-up was 24 months. Patient was stratified into cohort 2 following injury (SL angle ≥ 70°). B SL angle measured 93°.
Patients were excluded if they were younger than 18 years, sustained an extra-articular fracture, underwent repair or reconstruction of an SL ligament injury, demonstrated inadequate radiographs at any of the measured time points, did not complete outcomes scores, or were lost to follow-up prior to 12 months. Additional exclusion criteria included open fractures, perilunate injuries, fracture-dislocations, ipsilateral soft tissue injury or concurrent fractures, and SL angles 70° or greater prior to injury.
Patients were stratified into 2 cohorts based on SL angle measurements (<70° or ≥70°) after closed reduction, but prior to surgical treatment of their DRF. The SL gaps were included, but not used for stratification because they have demonstrated inconsistent predictability for diagnosis of SL ligament injury.
One cohort consisted of patients who had no radiographic evidence consistent with SL ligament injury. The other cohort consisted of patients who had radiographic evidence consistent with SL ligament injury despite reduction of the radius.
Descriptive statistics were tabulated for all study variables. Medians, interquartile ranges, minimums, and maximums were reported for the outcomes of interest based on the nonparametric distribution of study data assessed using the Shapiro-Wilk test. Patient outcomes were compared between SL angles less than 70° and SL angles 70° or greater with a minimum follow-up of 12 months (n = 192). A subgroup analysis was performed to compare outcome variables between the cohorts in patients with a minimum follow-up of 24 months (n = 100). These cohorts were analyzed using Mann-Whitney U tests for continuous variables. The SL angles and gaps were compared within each cohort at different time intervals to evaluate SL ligament injury progression (baseline versus closed reduction, closed reduction versus final follow-up). The QuickDASH, mGAF, and VAS pain scores were compared within each cohort at different time intervals to evaluate outcomes concurrently with SL ligament injury progression (initial 2-week follow-up versus final follow-up) using Wilcoxon signed-rank tests for paired nonparametric continuous variables. Post hoc power analyses were performed to confirm appropriate sample sizes for statistical comparisons. For sample size groups of 110 patients and 82 patients with a minimum 12-month follow-up, the study power was 0.99 for outcomes between cohorts (Mann-Whitney U tests) and for outcomes within cohorts (Wilcoxon signed-rank tests). For sample size groups of 59 patients and 41 patients with a minimum 24-month follow-up, the study power was 0.85 for outcomes between cohorts (Mann-Whitney U tests) and 0.99 for outcomes within cohorts (Wilcoxon signed-rank tests), greater than the 0.80 required to accept the null hypothesis. All statistical tests were 2-tailed, with the threshold for statistical significance set at a α value of 0.05.
Results
Demographics
One hundred ninety-two patients met the eligibility criteria from an estimated cohort of approximately 1,950 DRF patients over a 13-year study period. One hundred eighty-four underwent surgical interventions and 8 underwent nonsurgical interventions. Nonsurgical treatment included cast immobilization alone with a median duration of 6 weeks (range, 4–6 weeks). With the exception of 1 long-arm cast, all casts were short-arm. Demographic characteristics are listed in Table 1.
Table 1Demographics of DRF patients With SL Angles < 70° and SL Angles ≥ 70°
Of these 192 patients, cohort 1 contained 110 patients (57%) and cohort 2 contained 82 patients (43%). Median SL angles and SL gaps at each time point and in each cohort can be found in Table 2. There were no statistically significant differences between either cohort for baseline SL angle measurements. Patients with SL angles less than 70° did not have statistically significant changes in median SL angles or SL gaps from baseline to closed reduction. Patients with SL angles 70° or greater had statistically significant increases in median SL angles and SL gaps from baseline to closed reduction (58°–74.5° and 1.6–2.4 mm). Patients with SL angles 70° or greater also had significant increases in median SL angles and gaps from closed reduction to final follow-up (74.5°–78.5° and 1.6–2.4 mm). At a minimum of 24-month follow-up, patients with SL angles 70° or greater (n = 41) compared with SL angles less than 70° (n = 59) still had significant increases in median SL angles and SL gaps from baseline to closed reduction (58°–76° and 1.8–2.4 mm) (Table 3).
Table 2Outcomes of DRF Patients With SL Angles < 70° and SL Angles ≥ 70°
Initial FUs were within 2 wk of surgical and nonsurgical treatments; cohorts were analyzed using Mann-Whitney U tests (power = 0.99) for nonparametric continuous variables median (IQR) or (range); All statistical tests were 2-tailed, with the threshold for statistical significance set at an α value of 0.05.
Outcome
Time Interval
SL Angles < 70° (n = 110)
SL Angles ≥ 70° (n = 82)
P Value
SL angle, °, median (range)
Baseline
57 (38–69)
58 (40–69)
.799
Closed reduction
58 (42–68)
74.5 (70–87)
<.001
Final FU
58.9 (40–69)
78.5 (71–107)
<.001
SL interval, mm, median (range)
Baseline
1.9 (0.5–2)
1.6 (0.7–3)
.775
Closed reduction
1.7 (0.4–3.2)
2.4 (0.3–4.5)
<.001
Final FU
1.7 (0.3–3.1)
2.4 (1–5.1)
<.001
VAS pain score, median (IQR)
Initial FU
4 (2–7)
5 (4–7)
.060
Final FU
1 (0–4)
2 (1–4)
.232
QuickDASH disability score, median (IQR)
Initial FU
68 (50–82)
64 (50–80)
.562
Final FU
43 (21–75)
40 (20–68)
.547
mGAF score, median (IQR)
Initial FU
30 (13–50)
38 (20–51)
.353
Final FU
50 (21–80)
50 (23–85)
.904
Final FU, mo, median (range)
24 (12–47)
28 (12–48)
.999
FU, follow-up; IQR, interquartile range.
∗ Initial FUs were within 2 wk of surgical and nonsurgical treatments; cohorts were analyzed using Mann-Whitney U tests (power = 0.99) for nonparametric continuous variables median (IQR) or (range); All statistical tests were 2-tailed, with the threshold for statistical significance set at an α value of 0.05.
Initial FUs were within 2 wk of surgical and nonsurgical treatments; cohorts were analyzed using Mann-Whitney U tests (power = 0.85) for nonparametric continuous variables median (IQR) or (range); All statistical tests were 2-tailed, with the threshold for statistical significance set at an α value of 0.05.
Outcome
Time Interval
SL Angles < 70° (n = 59)
SL Angles ≥ 70° (n = 41)
P Value
SL angle, °, median (range)
Baseline
59 (38–65)
58 (42–65)
.508
Closed reduction
59 (42–68)
76 (70–85)
<.001
Final FU
60 (40–68)
79 (72–105)
<.001
SL interval, mm, median (range)
Baseline
1.7 (0.6–3)
1.8 (0.8–3)
.503
Closed reduction
1.6 (0.6–2.9)
2.4 (1.5–4.5)
<.001
Final FU
1.7 (1–2)
2.5 (2–3)
<.001
VAS pain score, median (IQR)
Initial FU
4 (2–7)
5 (4–7)
.042
Final FU
1 (0–4)
3 (1–5)
.068
QuickDASH disability score, median (IQR)
Initial FU
72 (50–84)
68 (54–84)
.869
Final FU
39 (19–79)
43 (21–75)
.991
mGAF score, median (IQR)
Initial FU
30 (18–55)
35 (20–58)
.656
Final FU
50 (20–80)
55 (20–89)
.970
Final follow-up, months, median (range)
30 (24–47)
30 (24–48)
.999
FU, follow-up; IQR, interquartile range.
∗ Initial FUs were within 2 wk of surgical and nonsurgical treatments; cohorts were analyzed using Mann-Whitney U tests (power = 0.85) for nonparametric continuous variables median (IQR) or (range); All statistical tests were 2-tailed, with the threshold for statistical significance set at an α value of 0.05.
There were no statistically significant differences between the 2 cohorts for QuickDASH scores, mGAF scores, and VAS pain scores at initial 2-week follow-ups and final follow-ups (Table 2). Both cohorts (SL angle < 70° and SL angle ≥ 70°) demonstrated improvements in median QuickDASH scores (both P < .05), mGAF scores (both P < .05), and VAS pain scores (both P < .05) from initial follow-up to final follow-up, respectively.
At a minimum of 24-month follow-up, there were no statistically significant differences between cohorts for QuickDASH scores, mGAF scores at initial 2-week follow-ups and final follow-ups (SL angle <70° [n = 59]; SL angle ≥70° [n = 41]). Patients with SL angles 70° or greater had significantly greater VAS pain scores at initial follow-up than patients with SL angles less than 70°. At final follow-up, there was no significant difference between VAS pain scores in the 2 cohorts (Table 3). Similarly, both cohorts (SL angle < 70° and SL angle ≥ 70°) demonstrated improvements in median QuickDASH scores (both P < .05), mGAF scores (both P < .05) and VAS pain scores (both P < .05) from initial follow-up to final follow-up, respectively.
Complications
Twenty-four patients with SL angles less than 70° and 17 patients with SL angles 70° or greater reported a complication. Tenosynovitis was the most common complication associated with volar plate application. Trigger finger developed in 2 patients as a result of volar plating impinging upon flexor tendons. Patients with tenosynovitis and trigger finger underwent subsequent hardware removal with resolution of symptoms (Table 4).
Table 4Complications of DRF Patients With SL Angles < 70° and SL Angles ≥ 70°
We found no significant differences in patient reported outcomes (QuickDASH, mGAF, and VAS pain) at both 12 and 24 months between patients with radiographic evidence of SL ligament injury treated without repair or reconstruction and patients without radiographic evidence of SL ligament injury following treatment of an intra-articular DRF. This confirms our hypothesis and provides preliminary evidence showing similar patient-reported outcomes in both cohorts at initial follow-up and final follow-up evaluations.
Concomitant soft tissue injuries are common in intra-articular DRFs.
A previous study revealed that 68% to 98% of intra-articular DRFs had soft tissue injuries of the wrist including the triangular fibrocartilage complex (43%–78%) and SL ligament (32%–54%). In addition, these soft tissue injuries were most commonly identified in intra-articular DRFs.
Out of 192 patients in our series with intra-articular DRFs, 43% patients (n = 82) were identified to have a radiographically evident SL ligament injury, similar to the incidence reported arthroscopically. Although arthroscopy is the gold standard in the diagnosis of SL ligament injury,
The main purpose of this study was to determine whether the presence of an associated radiographically apparent SL ligament injury affected patient-reported outcome measures following treatment of an intra-articular DRF at a minimum of 12-month follow-up. Although there has been evidence that concomitant ulnar-sided injuries do not affect outcomes after DRF fixation alone, there has been a paucity of evidence regarding SL ligament injury.
Ulnar-sided injuries that have undergone nonsurgical treatment with distal radius rehabilitation protocols have been shown to have no differences in patient outcomes including DASH scores, range of motion, and pain.
We sought to identify radiographic evidence of SL ligament injuries and evaluate patient-reported outcomes in those not treated at the time of DRF fixation.
attempted to answer this question. They examined 51 patients arthroscopically at the time of DRF fixation and found 32 of 51 patients with partial SL ligament injuries and 10 of 51 patients with complete SL ligament tear.
Arthroscopy identified patients with earlier stages of SL injury (stages I–III) as well as SL instability with a combined SL ligament tear and secondary restraint injury (stages IV–V), but the study was underpowered to draw any meaningful conclusions because only 9 patients with complete SL ligament injury underwent long-term follow-up.
Whereas we have observed similar findings, we sought to identify patients with combined SL ligament tears and secondary restraint injuries indicative of advanced stages of injury (stages IV–V). With our study’s larger sample size, we found patients without radiographically evident SL ligament injuries and those with radiographically evident SL ligament injuries had no differences in patient-reported outcomes in QuickDASH, VAS, and mGAF scores at a minimum of 1- and 2-year’ follow-ups. This supports the notion that SL repair or reconstruction at the time of DRF may not be necessary. Longer follow-up and outcome data are necessary because instability and progression to scapholunate advanced collapse (SLAC) may occur over many years.
Higher-energy intra-articular DRFs may result in acute scaphoid instability owing to injury of both the SL ligament and the secondary restraints.
Patients with SL angles 70° or greater demonstrate advanced stages of injury (stages IV–V), assumed to be associated with attenuation or injury to the secondary stabilizers of the wrist. These injuries necessitate restoration of radial inclination and palmar tilt to prevent further carpal instability, and presumably would be most at risk for progression to a symptomatic injury or SLAC, although this is controversial.
Our study did not attempt to capture all SL ligament injuries, but only those advanced stages (stages IV–V). Thus, although radiographs are not sensitive for capturing all SL ligament injuries, radiographs are specific for capturing patients with scaphoid instability.
Twenty-four patients had baseline ipsilateral radiographs available performed within 4 years of the DRF that were comparable with contralateral radiographs at the time of injury (Fig. 1). This was an effort to identify those patients who may have had preexisting SL ligament injuries and established a baseline for comparison. From our limited observations, SL measurements and stability may appear similar on bilateral radiographs, although further study is necessary. The SL angles were also obtained in postreduction radiographs and at the time of final follow-up. This demonstrates the progression of SL ligament injury over time and gives objective evidence regarding radiographic progression. Our study revealed that patients with a radiographic evidence of SL ligament injury had a greater SL angle at final follow-up (74.5°–78.5° from closed reduction to final follow-up). Whereas this is significant and may be an indication of progression of carpal instability, the progression is limited and may also be related to interobserver and intraobserver variability or error.
Regardless, this is an interesting finding given that outcomes scores improved (Table 2, Table 3). Future study should include long-term radiographic and outcome scores to assess any symptomatic progression of injury.
An obvious limitation of our study was the lack of arthroscopy in the diagnosis of SL ligament injuries. The purpose of this study was not to capture all SL ligament injuries, but to identify radiographic SL ligament injuries and those with carpal instability patterns indicating more severe injury. The rationale was that lateral radiographs are more readily available, demonstrate interobserver and intraobserver reliability, and SL ligament injuries defined by the SL angle indicated patients more at risk for symptomatic progression of carpal instability.
Other limitations of our study relate to the retrospective analysis and disproportionate sizes of comparative cohorts, with fewer patients in the SL ligament injury cohort (n = 82 versus n = 110).
In addition, patients were not evaluated by fracture pattern or degree of comminution. More severely comminuted or higher-energy fractures are theoretically associated with higher QuickDASH scores, lower mGAF scores, and higher VAS pain scores, and radial styloid fractures more likely associated with SL injury.
Both cohorts had QuickDASH scores at final follow-up greater than 30, which have previously been reported to reflect a high degree of patient-reported disability.
Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): operative technique and outcome assessment.
Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH).
Our median minimum change of 24 indicates clinically meaningful changes on follow-up. Although we found no differences between outcomes, patients may have had relatively poor outcomes in general given the intra-articular nature of the injury. Extra-articular fractures were excluded owing to lower risks of SL ligament injury.
One potential bias of this paper originates from exclusion of patients who underwent concomitant SL ligament injury repair or reconstruction, but only 1 patient underwent SL ligament injury repair at the time DRF treatment and this individual was excluded. This patient presented with an SL angle of 86° and gap of 2.2 mm and subsequently underwent Kirschner wire fixation with a dorsal capsulodesis. Repair or reconstruction of SL ligament injuries is not commonly performed for intra-articular DRFs at our institution, thus minimizing selection bias. Future studies should include longer follow-up of these patients with radiographically evident SL ligament injuries to determine whether outcome scores change over time because our patients only had 24 months of follow-up. Radiographic long-term follow-up should also be completed to evaluate for progression of arthritis and evidence of SLAC.
Overall, we found no significant differences in patient-reported outcomes (QuickDASH, mGAF, and VAS pain) between patients with radiographic evidence of SL ligament injuries without repair or reconstruction and patients without radiographic evidence of SL ligament injuries following treatment of an intra-articular DRF at 12 and 24 months. This supports the thought that repair of SL ligament injury at the time of distal radius fixation may not be necessary.
Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): operative technique and outcome assessment.
Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH).
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