Well, the early literature, you know, starting back in the 80s, there's a lot of papers to show you that treating these nonoperatively leads to a bad outcome, so nobody would recommend that anymore. This is, you know, Guillaume wrote a paper in 93, which is now a classic paper, and 16 to 25 percent of these injuries are initially missed. This is, when I saw this man at seven months, really hard to reduce. I mean, I agree with Jesse, I still try and fix them rather than do an immediate salvage procedure if I can, but in this case I had to put in a radiolunocapitate pin to maintain the carpal alignment, and as I put the scaphoid screw in, the proximal pole started splitting on me, so I stopped and left it a little bit proud, left in this guide wire to make it easier to remove it. At four months when I took it out, you can see he's already got mid-carpal osteoarthritis, you know, so that's the consequence of missing these. You can still reduce them, get them to heal, but they certainly are not going to have a good long-term outlook. This is someone who walked in with wrist pain, and, you know, the radiologists say they have wrist arthritis. Well, we don't get wrist arthritis, we get perilunate arthritis, and the vast majority of cases, sometimes SCT, unless they've got an inflammatory arthritis, so this guy has obvious mid-carpal arthritis, but look, the radial carpal joint is well-preserved, there's no DZ deformity, so that's what happens, untreated long-term in natural history, and Guillaume wrote a review paper more recently that said basically there's lots of ways to skin the cat, and you can get a good outcome with multiple approaches, so this is now what I was trained to do as a resident and a fellow, and certainly at Harbor, this is what they do all the time, and Max is here, he can tell you that, he's probably done this case with me. So, you go VOLR, a lot of the reasons why you go VOLR are because median nerve symptoms, it's not carpal tunnel syndrome, it's a median nerve contusion, so although you want to decompress it, you'll tell the patient it's going to be four to five months before they get improvement, it's not going to get better the same day, otherwise they think you've done something wrong, but you see, this is the space of PARA, there's no capsule attachments, I don't think you need to repair it at all, but we all do it, if we're going VOLR, we all put a few sutures in, so this is to decompress the median nerve, you go VOLR, and then you go dorsal, and using KURs as joysticks, you want to reduce it, and remember that part of that is you have to take the scaphoid, and you have to supinate it to close that gap, if you take a tile clip and put them together, you won't always close the gap, which is very frustrating, and then, although we always talk about repairing the LT ligament, usually there's nothing to repair, it's just shredded, and I don't think I've ever felt good about replacing a ligament with a 20 fiber wire suture, so then you're trying to pin it, make sure it's collinear, and by convention, we'll hold them still for 8 weeks, move them and remove the pins at 12 weeks, and as Jesse said, they get soupy, they get loose, you have to put them subcutaneous, I hate using them. Now there is some literature that shows that a combined approach leads to worse outcomes, some of that might be bias built into it, because you tend to go vulnerable if there's a meaty nerve problem or irreducible dislocation, so it might not be a consequence of doing the double approach, but just the fact it's a more severe injury cohort, but the dorsal approach has sort of now been popularized since the last decade, and I think that's what I see more often, so we try and repair the ligaments, and if you have a trans scaphoid, that's easier than a perilunate injury per se. So this is a case where I did the dorsal approach, you can see it's a typical dorsal perilunate dislocation, and sometimes when you try and reduce these in the emergency room, the lunate which was in the lunate faucet now gets pushed vulnerably, so it doesn't get reduced, it just goes back and forth depending on where the capitate head is. So that was treated with the scaphoid screw and pinning, so this was a case I did probably 10 years ago, but there's been some very interesting stuff since then, of course the paper that Jesse alluded to where they used temporary screw fixation and they took the two cohorts, a very small series, so you can't get statistical significance, but they treated one group with screws, moved them at three weeks, didn't lock up the mid-carpal row, and then took out the screws, and then they compared them with intercarpal K wires, treated at three months with pins and immobilization, and then they moved, and at the follow-up they basically got a smattering of good, middle, and poor outcomes, so there was no real difference, but the point is that you can get by with mobilizing them early without deterioration of the results, so it's an option, and I agree with him, I prefer early motion rather than 12 weeks in a splinter cast. Transdiabloid perilunate, they're actually pretty common in my experience, not rare, which the literature suggests, so this is a case where I used Jesse's technique on steroids, I put screws in everything that I could have put a screw in, but there was also capsule revulsion here that required repair, so this was a severe injury, but I started early motion, took out the K wires, and then came back and took these out later on, but there's been some exciting stuff coming out of Asia, especially Taiwan, TC Wong, actually he's in Hong Kong I believe, he's PC's friend, he started saying, well, maybe we can go back and do percutaneous approaches, because when we first tried them, the results were horrible, nobody would say you should treat scapholunate ligament tears with percutaneous pinning alone, but that's what they're doing and going back and doing it, so they had 21 young patients, the immediate percutaneous screw fixation of the scaphoid, so right away the mid-corpal row is fine, and then multiple K wire fixation, and they had a good union rate, they had four failures, which you're going to see in every paper I quote, everybody's got a smattering of failures, that's I think the injury, not the treatment that determines that, and they did have one DZ, and two with mid-corpal OA, this is another one that came out recently also, 24 patients percutaneous screw, I love this idea, it's just one capital lunate pin, and that's now exactly what I do all the time, it's easy to manage, and it's basically doing the same thing, it's letting in my opinion, the volar arcuate ligament to heal, so you don't have to pin the LT joint per se, you just have to mobilize the ulnar side of the carpus in some way, so I started to do that, and same thing, they got 18 of the fractures to heal, but that meant six of them didn't, and they had some poor outcomes as well. So this is the case where I did it basically entirely percutaneous, I won't do the peri-lunate injuries percutaneous, but I will do the trans-scaphoid percutaneous, because if you can get the screw in the scaphoid, that's a done deal, and then the capital lunate pin, and move them early, I mean I move them in a week after this, I don't wait 12 weeks, but I take out the pin at 8-12 weeks. So now, exciting area, Guillaume and Bo are both going to talk about arthroscopic procedures, which is sort of our interest, you certainly don't need to stick a scope in them, and if you do, have a good breakfast, as Mike Hayton says, and take Valium before, because if I'm not having a good day, I don't go anywhere near the scope, these are so hard to see, it takes you about 45 minutes to just clear the field, you can use rapid fluid irrigation, you can try doing it dry, but there's constant bleeding from the bones, so just getting to visualize the debris that takes the longest part of the case, and in this case, Dr. Lee out of Korea, or Park I should say, with Dr. Kim and colleagues, treated with arthroscopic scaphoid screws insertion, and then KY the carpus, and at 31 months, they had reasonable dash scores, but look at this, 9 poor outcomes, and that's the injury speaking, not the method of treatment. So this is one of my early attempts, so this was irreducible, and so I made a small mid-carpal portal, and put a freer elevator in, and after I bent two freer elevators, I put a Holman retractor in, that's how hard this was to reduce, and then levered it, and this is what I did the first night, rather than operating on them, and then I did it semi-electively, a radiolunate pin to hold it in place, and then I've used targeting K-wires to try and line up the scaphoid, so this is what they look like. Here we have the partial ligament tear, even though there was a scaphoid fracture, you can still tear the ligament. The radial scaphocapitate is usually torn, sometimes the short radiolunate or long radiolunate is as well. Arcuate ligament tear, you can see it, there's not much to do about it other than just notice it, but you can see I'm going back and forth with using fluid and no fluid, and you have, as Jesse said, these chondral fractures all over, and this is like the traqueatum, this is why they get mid-carpal arthritis, you can see that, there's really not much you can do about it, you can't drill it because it's already exposed bleeding bone. This is the scaphoid fracture site, I'm looking through a scaphoid trapezial portal, that's the capitate, and I'm basically between the two fragments, so this is now trying to line this up and put a screw across it. I don't do that anymore, I find sometimes with this it's too hard and I do a mini-open, so I do much of it arthroscopic, but I combine it with mini-open as well, and then I locked them up with screws as well. It was a bit disconcerting when I looked at it after, I could see screw threads, and this is because the bone's not well aligned, there's some carminution, and so then I went ahead and used PC's trick of mid-carpal arthroscopy, or mid-carpal percutaneous bone grafting, and went on from there. So these are different ways of treating it, you can use the scope as an adjunct to treatment, but it's not the operation. Transradial styloid fractures, I've seen about four or five of them now, and as time's gone on I've become more comfortable with this mini-open and arthroscopic combination, so I'll try and treat part of it arthroscopically and percutaneously, and the rest allows me to use a smaller incision, so I think less carpal injury from just the exposure, because the normal exposure is quite big. So here's the scapholunea diastasis, and I wouldn't recommend treating that with percutaneous pins alone. This is now looking at the radial styloid fracture, it's much easier to do it without fluid, like Paco Del Panale has shown us, and you have the scope in the 6R portal usually, so it's stable, and you're looking across the joint, you put K-wires in this radial styloid fracture and treat it like it's an undisplaced radial styloid fracture, you can then reduce it, and put percutaneous screws across it if you choose, or leave the K-wires in, so it's dealer's choice. But then once you've done that, then it's an open procedure for the scapholunate ligament repair in my hands, and that's where I'm at right now. Let's see, and so that's a healed fracture, and I put a scapholunate screw in, and the motion's not bad, I mean it's the left wrist here. You can see he has loss extension and loss flexion. At 5 months, when I take that out, he still, he opens up, so I don't know if that's going to be a problem long term, but that's the same problem we have with scapholunate ligament repairs in general. As soon as we take out the K-wires, they go away. One more, a few more slides, and then we can talk. So Guillaume's going to tell us about this. This is something, you know, when you look at a wrist, and the hair on the back, your neck stands up because you go, you know, like this, it looks like just a minor fracture, but why am I so nervous about it? Well, because they're so swollen, and because you're worried that there's something else, and when you start to see these little flecks of bone, Guillaume's going to show us that those are significant problems, and in his hands, he goes to arthroscopy, but I think you should do a CT scan, and if you see chondral injuries, then you should not treat it closed. This was done by my colleagues at Harbor, and I grabbed the slides because I recognized what it was. It was an unrecognized, non-displaced perilunate injury, which they treated with K-wire fixation, and look at this. At 3 months, he's got a VZ deformity, and you notice there's no LT pin, no mid-carpal pin, so they treated it as a fracture on the radial side, and missed the fact that it was a perilunate injury. So, this is one slide on my experience with one of these, only to show you how I approach the transcapoid perilunate in general. So, they had these avulsion fractures everywhere, one off the hamate. This is from the 3-4 portal, looking at the radial styloid fracture, and the radial scapho-capitates avulsed as well. So, same approach of a percutaneous K-wire fixation, followed by percutaneous screw fixation. Now, in the mid-carpal portal, you can see the complete scapholunate ligament tear, and don't get me wrong, this is after an hour of washing it out before I got this kind of visual vision, so this is the hamate fracture as well. So, you certainly don't need to scope these, but it helped me in this regard, just to know what kind of surgical approach I needed after, where I needed to make my incisions. And so, what I then wound up doing was, I connected the mid-carpal and the 3-4 radial carpal portal, so it's a mini-arthrotomy, not the big ligament-sparing one. I lifted up the capsule, gave me access to the scapholunate ligament, and repaired that with suture anchors, and put in a scapholunate screw, and then I was able to get to the hamate through the same incision. So, small incision, but I think I'm just respecting the soft tissues, rather than making it worse with a big capsule approach. So, that's what arthroscopy helps us with, making smaller mini-incisions to accomplish the same. And then, locked up the two joints with the screw. Now, this is at 12 weeks, this is a 75-year-old lady. This is before I took the screws out, and I mean, I think this is better than some of my younger patients, so age doesn't determine my treatment. I'll treat these arthroscopically as well, and I've had some good experience with early motion with these patients. What about immediate salvage procedures? Well, there's not a lot of literature on it, but there is some, and there's a few papers on immediate proximal carpectomies. A little bit dangerous because, you know, the capitate heads often destroyed, like Jesse showed us, so you don't, once you got a bad PRC, there's not a lot of options except a fusion. There's one I found on someone who found an extruded fragment and reduced it and got it to heal, and another one doing an immediate four-corner fusion. So, these are some of the options with the fractures that I think that are too bad to treat with fixation. So, this is my experience with a man who came in with a horrible wrist injury after a motorcycle accident, and you'll see just the abrasions all along his forearm from the road rash. I couldn't find the proximal pole. I just didn't know where it was on the x-ray, and this was unfortunately middle of the night, so it wasn't pre-planned, and I didn't have any special implants, but you can just see the soft tissue injury, markedly swollen hand, ulnar laceration. So, now I'm doing the dorsal approach, and capitate, proximal, distal scaphoid, no proximal scaphoid. It's just not there. So, it was on the ulnar side of the wrist. It was extruded completely, and I thought that fixing that and getting it to heal was not the right treatment because he still had scaphoid instability, which I could not do anything about. So, I went ahead with an immediate salvage procedure, and all I had available was K-wires. So, it took a while to make sure that the mid-carpal joint was well aligned, and you can use K-wires for this fusion. You don't have to use a circular plate. If you'll notice this, when these peri-luteate injuries go all the way to the ulnar side, he had an unstable DREJ, so I fixed the styloid too, and at a two-year follow-up, he's got almost no wrist flexion. He doesn't have much pain. He's got a nicely remodeled carpus, but it's certainly not a normal wrist, and I didn't take out the distal scaphoid for worry of making him even more unstable, so it wasn't a problem, and we've got a few minutes for questions, and then we'll bring Guillaume up here. Yes, sir? How much time did the ER reduction handling and hanging and traps for 10 to 15 minutes or 10 hours? Failed in my hands every single time. Your experience? I think it's good to reduce it. If you don't have median nerve symptoms, I just get them put on the OR slate in that first week. I'm not going in the middle of the night. If they have median nerve symptoms, I worried about the medical-legal problem, and then that's why, in this case, I did take them to the OR and reduced it, but then I planned it and did it arthroscopically a few days later when I had all the equipment I wanted, so I wasn't panicked into doing it that night, but I thought it needed a reduction.

wrist injuries

treatment options

perilunate injuries

trans-scaphoid injuries

early motion