So, I was supposed to talk about carpal injuries that are associated with distal radius fractures. And we're going to focus a lot on intercarpal ligament injuries. So, you know, this is sort of the case that causes the problem for me in the practice and the one that we're going to talk about a little bit today. And that's the, you know, 50-year-old female. She's at a wedding. She falls dancing to the song, Shout. I didn't make that up. And then here's her x-ray. And you can see the interarticular distal radius fracture. She's got dorsal tilt. But then we've got that wide SL interspace and the flex scaphoid. So, you say, all right, what are we going to do with that? So, we're going to go through a little bit of evidence and what there is out there and then talk about what I would do, which is just one opinion. So, the prevalence of carpal pathology has been documented, I think, fairly well in multiple series. And what all the series have shown us is that the incidence or prevalence of carpal pathology with distal radius fracture is quite high, probably 68 to 98%. And we also know that those numbers are based on a mix of high-grade and low-grade injuries to multiple structures, including cartilage, ligaments, and the TFCC. So, looking at a couple of the classic studies, Geisler in 96 looked at 60 people. And basically, each one of these studies is based on saying, I'm going to take a series of distal radius fractures, put an arthroscope in every one of them, and just document what I see. And so, in this series of young folks, he found nine complete SL tears and quite a few incomplete, a lot of LT injuries, TFCC tears. And then each of these studies has tried to look at risk factors for predicting who's going to have this carpal injury. And they're not consistent, as I'm going to show you. But what Geisler found was he said the fractured lunate facet was a risk factor. He felt that the comminution in that radial styloid going into the joint, as you saw from Rob's talk, was associated with SL ligament injuries. And then those with at least three millimeters of gap between the scaphoid and lunate all ended up having complete tears in his series. Lindau, same study design, 50 more fractures. In this case, almost everybody had something they could call abnormal within the carpus. And the only thing that they could identify, though, as a predictive factor was ulnar styloid fracture being associated with TFCC injury, which I think makes common sense to a lot of us. Now, Forward did another study, same sort of design, focusing a little bit more on the SL ligament. And they just noted that out of 50 fractures, they had 20% with a high-grade SL injury. And the factors that they found as predictive of SL injury were that increased ulnar variance over two millimeters at the time of injury, so more displaced. And then those intraarticular fractures, which I think we all agree also are kind of the red flag for what's going on in the carpus. So how do you make the diagnosis? You know, there's multiple options. Actually, I didn't include on this slide physical exam. And I think it's better than you think. The next time you have one of those radius fractures, if you carefully palpate along the radius, I know they hurt there. But then you very carefully go out over the carpus and just press over the scaphoid or over SL or LT, you'll start to pick out people that have isolated pain there. It is reasonable. Imaging, multiple options shown here. None are perfect, but you can get more aggressive as you want. I think if you're really worried about it and you're not sure because we know some of these carpal ligament injuries, you have to treat early if you're going to treat them. I'm going to think about direct examination, whether arthroscopic or just a small dorsal arthrotomy. Again, I don't think there's any harm or lost pride in saying, you know what, I just need to make a small one-inch incision or two-inch on the back of the wrist and look at the SL ligament if I'm not sure. I'd rather do that and sleep at night than not know. A few caveats here in terms of making the diagnosis. Remember, some people just have a wide SL interval normally. Check the other side, especially young females. Sometimes it's an old injury. You know, you get the person with the distal radius, they say, my wrist never hurt before, but guess what? You know, you're not sure. It doesn't look grossly arthritic on the x-ray. If it's arthritic, you can know the answer. Other times I might stick a scope in and I had at least one patient who we would have bet the SL ligament was acute. But when you looked with the arthroscope, as you can see with the picture on the second to the bottom right, there was full thickness cartilage where in the scaphoid, you go, you know what? That predated things. And then finally, think about gout. Ask people about it. It's been well documented that gout causes SL incompetence. And a lot of times if you look in there and see the deposition consistent with gout, in my experience, even if the SL ligament just finally gave way with that injury, the tissue has been eaten up and it's not very amenable to direct repair. Okay, so how about now? We know these happen at a high incidence. So what happens over time? And I think there's been some very nice studies. So FORWARD did the first one in 2007, which was kind of a short follow-up. So here they are. They've documented 10 people with fairly high-grade SL injuries. They didn't treat them. They just documented it. So what happened over time? So at 14 months, you saw that the people with higher-grade SL injuries had a bit more pain in terms of being more frequently painful. They didn't report very much more severe pain. Range of motion wasn't different. Grip wasn't different. Maybe they had a bit more SL dissociation by x-ray. But this was early. So you think later on they might get more arthritic. But at least now, at that time, they said, well, the natural history and clinical importance of these intercarpal ligament injuries with these fractures is not known. And their conclusion was that it may not be necessary to treat all of them. Reasonable conclusion. Now this was a really nice study. Just came out this year, I suppose, in JHS. And this was the group looking at, again, untreated SL injuries. Now we're 13 years out. So we've got nine pretty high-grade, grade 3. Admittedly, these are not grade 4 where everything's gone. 17 partials and 12 without SL injuries. And when they looked at it, there was a very slight decrease in grip with the complete or what they called a complete SL injury. No range of motion changes. No difference in the dash. Really no difference in pain. So their conclusion was that there was no evidence that untreated SL ligament injuries up to grade 3 with distal radius fracture negatively impacted any of the subjective or objective outcomes long-term. Pretty good data. And then there was one other study. And I don't know if Dave is going to talk about this as well with TFCC things. But there was a similar same group looking at long-term TFCC documented injuries not treated. And at 13 years, they only had one patient that had come back out of 43 needing some sort of really secondary procedure to stabilize the DRUJ. And now a lot of them had a little bit of laxity on their physical exam. But there was very slight changes in patient-rated outcomes or grip strength. So their conclusion there was that untreated TFCC injuries with distal radius fracture do not diminish the long-term outcomes. So the literature suggests a high incidence of these injuries. But I think a lot of them are kind of mixed or low-grade injuries that really don't require us to treat them. So this is sort of my summary now, this level 0 evidence. I can't say level 5 unless I was Dr. Orbe. So I'm going to say no expert opinion. But this is what I do with the evidence. First of all, I do not go searching for the occult injury in the distal radius with the carpus because I think that they're low-grade. You don't have to treat them. Let's not go find them. I know they're there. Second, if you think I didn't talk about scaphoid fractures. But if you have a non-displaced radius and scaphoid, I don't think that means you need to jump to fix both. You can still immobilize it. They both can heal. If you have a carpal injury that requires surgery or a distal radius that requires surgery and you know the other is present, I usually fix both. I'm a little bit more aggressive. I'm already giving an anesthesia. I'm already there. So complete SL tear and a distal radius, I'm going to obviously treat both. Now for SL ligament injuries, I personally like to just do it all through a dorsal approach. Because to fix the SL ligament, I have to make an open dorsal incision for suture anchors and such for the dorsal SL. There's nothing wrong with putting a vulvar plate on and then doing that. I just like to keep it in one incision. That's purely my opinion. My last few points here. In older patients, I don't know what to do exactly. I've had a few with operative distal radiuses, and they clearly tore their SL. And they're 70. And they've got arthritis in the fingers and the thumb. And I think, I'm going to immobilize them for how long after I try to repair or pin the carpus? And I get a little nauseated. So most of the time in the older group, even if I'm treating the radius, I may leave the intercarpal ligament injury and just say, you know, you've got it. I don't think you're going to get arthritis too much over time. But it's a point that I don't have an answer for. For the older styloids, I only fix them if the DRUJ is unstable after fixing the radius. And I will tell you that at least in my experience, I don't know what your guys' experience is. But when I fix the ulnar styloid in that situation, invariably, the DRUJ is stable. And I'm not putting pins in between the radius and ulna. And I will admit, this is sort of my disclaimer. I have not done any acute TFCC repairs with distal radius fracture. And it's another one. Maybe it's seen me, and I haven't seen it. But I fix the styloid or move on. And then finally, I don't know if these natural history reports, I think they're true. I don't know if it's that the carpal injuries with a distal radius fracture are actually different than just the isolated carpal injury. Because we know that you get slack wrists and these other problems in isolation. So I wonder if the difference is because we are immobilizing when you have a distal radius fracture with this. Maybe there's more bleeding in the wrist with the distal radius fracture. Or maybe some of this energy from the injury is going through the radius, and so it's producing a little different carpal injury. I don't have the answer. Just some thoughts. So finally, here's our lady with the SL ligament injury. There's my dorsal plates and the pin fixation for the carpus. Again, just the way that I like to do it. And then this is just sort of the one other variant. Younger female, construction worker, tough lady. Fractures her radius. Things don't look quite right. And on the lateral, I think you can see a lunate that looks pretty extended, even though that's not a perfect lateral. It's kind of oblique with a flexed scaphoid. We opened her up dorsally. You can see that dorsal fracture through the lunate facet, kind of going into the sigmoid notch. SL, you have an opening in the membranous portion, at least. There's some dorsal scarring. But the thing was is there was proximal wear in the scaphoid. So to me, that becomes, I no longer worry about any of that. Fix the distal radius, ignore the carpus, and she got back to work. But thank you very much, guys, and we'll turn it over to you.

carpal injuries

distal radius fractures

intercarpal ligament injuries

diagnostic methods

treatment options