Ellstein et al. TheHAND

11. Clendenning WE, Brecher G, Van Scott EJ: Mycosisfungoides: Relationship to malignant cutaneous re-ticulosis and the S6zary syndrome. Arch Dermatol89:785-92, 1964

12. Ishii Y, Yamanaka N, Ogawa K, et al: Nasal T celllymphoma as a type of so-called "lethal midline granu-loma." Cancer 50:2336-44, 1982

13. Watanabe S, Shimosato Y, Shimoyana M, et al: Adult Tcell lymphoma with hypergammaglobulinemia. Cancer46:2472-83, 1980

14. Colby TV, Carrington CB: Pulmonary lymphoma simu-lating lymphomatoid granulomatosis. Am J Surg Pathol6:19-32, 1982

15. Gramatzki M, Dolan MF, Fauci AS, et al: Immunologiccharacterization of a helper T-cell lymphoma. Blood59:702-8, 1982

16. Pandolfi F, DeRossi G, Semenzato G, et al:nologic evaluation of T chromic lymphocytecells: Correlations among phenotype, functional i~tivities and morphology. Blood 59:688-95, 1982 ii

17. Jaffe ES, Cossman J, Fisher RI: Immunologic, patlogic and clinical analysis of peripheral T cell ly~phomas. Blood 58(suppl 1):551, 1981 ~-

18. Evans HL: Extranodal small lymphocytic proliferati4A clinicopathologic and immunocytochemical stud~Cancer 49:84-96, 1982

19. Karcher DS, Perry D J, Hurwitz MA, Derrick-HooksT cell lymphoma occurring in the oropharynx. Ca~50:1155-9, 1982

20. Kung PC, Berger CL, Goldstein G, et al: Cutaneous~cell lymphoma: Characterization by monoclonalbodies. Blood 57:261-6, 1981

Midcarpal instability caused by malunitedfractures of the distal radius

Thirteen patients with malunited fractures c~f the distal radius developed symptoms of pain andinstability of the midcarpal joint. In six cases, a recurrent voluntary midcarpal subluxation wasalso present during ulnar deviation. These symptoms were first noticed several weeks, and at

times several months, after all immobilization for the treatment of the original fracture had beendiscontinued. We believe that the loss of the normal palmar tilt of the distal articular surface ofthe radius prepositions the carpus in a dorsal collapse alignment, which enables this instability todevelop. Although the instability is localized to the midcarpus, it is treated best, in our opinion,by a.corrective osteotomy of the distal radius. In nine patients, osteotomies resulted in relief of

preoperative symptoms and correction of midcarpal instability. In one patient, osteotomy of theradius was deemed unnecessary because the loss of palmar tilt of the radius was minimal. Insteadthe midcarpal (triquetrohamate) joint was stabilized by ligament reconstruction. Only transient

correction was obtained, with later recurrence of the voluntary midcarpal subluxation. (J HANDSURG 9A:350-57, 1984.)

Julio Taleisnik, M.D., and H. Kirk Watson, M.D., Orange, Calif., and Farmington, Conn.i)

This article describes a dynamic form of carpal insta: :iii

bility that may develop as a complication of malunions !~:.i

of fractures of the distal radius without involvement of i’!!the radiocarpal joint (Frykman’s types-I, II, V, andVI). I° The instability is localized to the midcarpal areaand is treated best by a corrective osteotomy of the i~ildistal radius, which is designed to restore alignment to

the radio-luno-capitate link.

Methods and material

Normal radiographic radiocarpal alignment, inan evaluation of the relationship of the distal radiuswith the ulnar head and the carpus, the following ra-

Complications caused by fractures of the

distal radius and their treatment are numerous.1-2z Thepotential for dorsal subluxation of the carpus to accom-pany fractures of the distal radius has been recognizedfor many years.2Z Associated disruptions of intracarpalalignment, however, have rarely been mentioned.6, 7, z4

From the University of California, Irvine, Calif., and the Universityof Connecticut, Farmington, Conn.

Received for publication March 3, 1983; accepted in revised formJuly 7, 1983.

Reprint requests: Julio Taleisnik, M.D., 1201 W. LaVeta No. 501,Orange, CA 92668.

350 THE JOURNAL OF HAND SURGERY

9A. No. 31984 Midcarpal instability caused by malunited fractures 351

Fig. 2. Lateral view of normal wrist in ulnar deviation. Thelunate: is dorsiftexed (A) and shifts in the palmar direction (B)..Axes of capitate and radius are colinear.

Normal radiographic measurements: (A) Palmar tilt,inclination or angulation, and (C) radial length.

Fig. 3. The only patient in this series with radiocarpal jointinvolvement.

diographic views are useful: routine lateral, posteroan-tenor (PA), and lateral projection obtained with the_wrist in ulnar deviation.

In the routine lateral and PA views, three radio-graphic measurements are significant8’ ~: palmar tilt,radial[ inclination or deviation, and radial length. Pal-mar tilt (Fig. 1, A) is determined by the angle betweenthe pi[ane of the distal articular surface of the radius, asseen on lateral radiographs, and a line perpendicular tothe long axis of the shaft of the radius. When this angleis 90", the tilt is 0°. Palmar tilt is identified with a plussign and dorsal tilt with a minus sign. Normally; thepalmar tilt averages + 11° in most series, although itmay Ibe as low as -7° or as high as +28°.8" 2~-30 Radialinclir.,,ation or angulation (Fig. 1, B) is represented the angle between a line tangential to the distal articularsurface of the radius as seen in PA radiographs and aperpendicular line to the shaft of the radius. It averages22° in most series but it may be as low as 12° or as highas 30°.-~5-3° Radial length (Fig. 1, C) is expressed the distance in millimeters between two parallel lines

The352 Taleisnik and Watson HAND

Fig. 4. Patient with recurrent midcarpal subluxation. A, In ulnar deviation, a "snap" is heard andcan be palpated at the midcarpal joint level (arrow). B, Lateral view in ulnar deviation. There islunate dorsiflexion without lunate palmar shift. Axes of radius and capitate are parallel but notcolinear. C, Postoperative lateral view in ulnar deviation. The palmar tilt is improved. Axes ofcapitate and radius remain colinear as lunate dorsiflexes.

that are perpendicular to the central axis of the radius,the first traced at the tip of the radial styloid and thesecond tangential to the head (not the styloid process)of the distal ulna as seen in PA radiographs; it averages-:9 mm.29

The lateral view with the wrist in full ulnar deviationshows the lunate dorsiflexed and a radio-luno-capitatealignment reminiscent of a dorsal carpal instability pat.-tern, a precollapse configuration (Fig. 2). As it dot-.siflexes, the lunate sinks or translates in a palmar direc..tion, a movement made possible by the normal palmartilt of the articula.r surface of the radius. This palmarshift of the lunate allows the longitudinal axes of radiusand capitate to remain colinear.

Clinical material. The 13 patients in this study weregrouped into two categories. Six patients had a recur-.rent dynamic midcarpal subluxation and seven had apainful midcarpal synovitis without ~dynamic subluxa-tion. All had sustained fractures of the distal radius;

with one exception (Fig. 3), the radiocarpal-jointnever involved (Frykman’s types I, II, V, and VI).!All fractures had healed with the distal fragment!dorsal angulation and with varying degrees ofshortening and loss of inclination of the distalsurface of the radius. Seven of the 13male and six were female. The average ageyears, the youngest being 15 years and the oldesttient being 54 years of age. The dominant wristinvolved in four cases and the nondominantnine. The mechanism of injury was a forcedion applied to the wrist, most frequently during falls On

the outstretched extremity. Four patientsinjuries as a consequence of a vehicularonset of midcarpal pain and synovitis with orsubluxation was gradual and. was first noticed atseveral weeks, after the healing of the Colles’find cessation of immobilization. In two patients, thesesymptoms were not noticed until several months

9A, No. 31984

Midcarpa,! instability caused by malunited fractures 353

5. Dynamic midcarpal subluxation in patient with mini-loss of palmar tilt. A, Injured wrist; B, normal wrist.

frz:~::ure had healed. The exact time that elapsednot be determined, but in all cases patients re-a period of satisfactory function after the frac-

had healed and before the onset of progressive3ility. In all cases, there was tenderness to palpa-at the lunocapitate and triquetrohamate joints. In

six patients in the group with subluxationscould reproduce a painful, audible, and

snap by bringing their hands into ulnar devia-

; the forearm pronated (Fig. 4, A). The abnor-carpal motion was clinically localized at the

. joint level. This subluxation was simi-described by Lichtman et al. 31 in their pa-

with ulnar midcarpai instability. The range ofof the wrist was modified in proportion to theof the dorsal angulation of the radius. In allloss of palmar flexion was greater than that of

although, overall, the available motion fell1 ;Within a functional range. Eight patients exhibited

of full pronation and supination. Gripwas seriously weakened, averaging only

of normal.lateral and PA radiographs showed a mal-

a fracture of the distal radius in all patients.’ one had an extension of the fracture into the radio-

joint (Fig. 3) with minimal loss of radiocarpal,. Palmar tilt averaged -23°, radial inclination

radial length 4.1 ram, compared with + 14°,and 11.2 mm in the uninjured side. Clearly, the

Fig. 6. Recurrent dynamic midcarpal instability in patientwith intra-.articular extension of fractured radius (see Fig. 3).A, Lateral radiograph in neutral deviation of the wrist.Lunocapitate axis is colinear and is parallel but dorsal toradius axis. B, Same patient, in ulnar deviation, shows typi-cal collapse alignment. Capitate is dorsal to radius. Lunate isdorsiflexeff’but has not shifted in a palmar direction. Differ-ence in appearance of distal radius is due to slight rotationalchange between these two radiographs.

major architectural change was the severe reversal ofthe normal palmar tilt. In one patient, loss of palmar tiltwas minimal (+ °) (Fig. 5), while t wo patients showedrather severe deformities (46° and 50°), In most cases(Fig. 6), the palmar tilt oscillated between -10° and-30°. Only two patients developed a negative radiallength whereby the ulnar head was actually distal to thetip of the radial styloid. In both patients, the loss oflength was -12 mm. If these two patients areexcluded, the average radial length in the remainingpatients was 7.7 mm or 68.75% of normal. Radial in-clination was least involved in this group of patients.Routine lateral radiographs of the wrists of the six pa-tients i~t the group with subluxations showed colinearlunate and capitate axes along a plane that was parallelbut dorsal to the main axis of the shaft of the radius(Fig. 6, A). Lateral radiographs were also obtained withthe wrist in ulnar deviation after the patient had actively

354 Taleisnik and Watso~

Fig. 7. Patient with voluntary dynamic midca~pal subluxation. A, Preoperative radiographs; B,appearance after osteotomy, bone graft, and internal fixation; C, final radiographs; D, preoperativecollapse alignment in ulnar deviation; E, postoperative alignment in ulnar deviation restored tonormal.

subluxed the carpus (Fig. 6, B). In this position, thelunate was seen to dorsiflex as it did in the uninjuredwrist but with a marked reduction of normal palmartranslation. Consequently, the longitudinal axis of thecapitate was displaced dorsal to the main axis of the

radius. It was in this position that these patients experi-

enced the painful subluxation at the midcarpal jointlevel.

Only three patients in the subluxation group agreed

to surgical correction. One was treated by a ligament

~,No. 3Midcarpal instability caused by malunited fractures 355

ap agreed

ion at the triquetrohamate level, a treatmentto restore midcarpal stability. We believed

procedure was indicated because the toss of. tilt was too small to warrant an osteotomy of the(Fig. 5). After a period of relief of instability,

dynamic midcarpal collapse pattern re-although the disabling preoperative pain was

relieved. The other two patients were treated byive osteotomy of the distal radius with corn-

relief of their preoperative disabling complaints,of the subluxation "jolt," and restora-

normal carpal mechanics in cineradiographicOf the two, one patient (Fig. 4) improved hisive tilt from -12° to + 11° (compared with

f ÷ ~ .-.-~: in the normal side); there was some residualradial inclination and radial length. The secondimproved all three parameters, but particularly

from - 19° to +7° (compared with + 12°

uninjured side) (Fig. 7). Radiolunate ~itate relationships returned to normal in both

restoration of lunate dorsiflexion and pal-during ulnar deviation (Figs. 4 and 7).

patients in the group with synovitis under-corrective osteotomies. Before operation, the~i i. ~ for this second group averaged -31 ° and theiz~ciination averaged 19.8°. The postoperativewere +1.42° and 19.7°, respectively. All pa-

of preoperative pain on loading; wrist, disappearance of synovitis, and correction

midcarpal subluxation. All retumed tooccupations.

of the literature

of fractures of the distal radius. Com-that arise from fractures of the distal radius

!:their t.reatment are numerous. Only 2.9% of 2132as with Colles’ fractures were judged by physi-

i:of .the Workmen’s Compensation Board of theState Department of Labor to have no per-

disability. 1 Malunions are among the most fre-complications. Carpal instabilities caused by

, are rarely mentioned as a cause ofMalunion of Colles’ fractures may result inof one or more of three normal radiographic

palmar fllt, radial inclination, and radial(Fig. 1). It is generally agreed1, 5, ~r, 30 that

on results in improved functional re-~. A poor anatomic result, however, may be accom-

by an excellent functional recovery.4, 23, 2~, 32

was attributed by Gartland and Werley~ to the¯ ¯ innate ability of the wrist joint to overcome and

for residual bony deformity .... " Thereagreement, however, as to which of the three

Fig. 8. Dorsal radiocarpal instability. A, Hand dorsiflexionrestores alignment between angulated distal radius and car-pus. B, When the hand is not dorsiflexed, instability becomesapparent at the radiocarpal level; midcarpal joint remainsstable.

anatomic parameters is more important in the preserva-tion of satisfactory function.4, xl, 14, 16. 25, 33-35 Dowlingand Sawyers concluded that no single anatomic charac-teristic seemed to be associated with either a good or apoor result. Even with a combination of all threeanatomic variables, no connection was found except inthe extremely good or poor results. We believe, how_-.ever, that changes in the normal palmar tilt of the distalradi~us will result in disturbance of radiocarpal function,while abnormal radial inclination and length values willmo:~t likely interfere with the function of the distalradiioulnar joint and result in painftii or limited forearm~

rotation. Fernandez~ found that deformities of theradius became symptomatic if the angulation of thedistal articular surface of the radius was greater than 25to 3.0 degrees in either the sagittal or the frontal planesand when there was significant radioulnar length dis-crepancy of 6 mm or more, particularly in young, man-ually active patients. In some of our own patients,however, a relatively small change in palmar tilt pro-duced midcarpal changes, a situation that, we believe,is peculiar to this syndrome (Fig. 5). In effect, it sug-gests that in patients with a preexisting potential formidcarpal instability, particularly if young, active, orvigorous, only a small change in radiocarpal alignmentmay be required to precipitate a clinical, symptomatic

356 Taleisnik and Watson

midcarpal collapse. In series of Fernandez,9 pain wasreferred to either the radiocarpal or the radioulnarjoints. There was no specific mention of mid.carpalpain, tenderness, synovitis, or instability.

Midearpal instability. References to primary mid-carpal instability are intermittently found in the lit-erature.36-’~9 Recently, Lichtman et al.31 presertted aclinical and laboratory analysis of ulnar midcarpal in-stability. The usual initial complaint in their patientswas a painful wrist click that could be reproduced inulnar deviation with axial compression of the wrist andwith the forearm in pronation. This was a dynamic typeof instability: routine radiographs were normal, but

cinefluoroscopy revealed a sudden dissociation that re-sulted in a dorsiflexion collapse deformity?S..~9 Theradiocarpal relationship was not disturbed.

Malunion of fractures of the distal radius andmidearpal instability. In their encyclopedic discussionof wrist injuries presented to the Twenty-eighth FrenchCongress of Surgery of 1919, Jeanne and Mouclaet23listed "dorsal luxation of the capitate" as a possiblecomplication of malunited fractures of the distal radius.Subsequent references to intracarpal problems associ-ated with Colles’ type fractures have been rare. In 1972Linscheid et al. 24 described loss of carpal alignment ofproximal or distal carpal rows (specifically a dorsittex-ion instability pattern) after fractures that caused a re-versal of the normal tilt of the distal articular surface ofthe radius in a dorsal and radial direction. "Interc~ccpalcollapse deformity" was included by Dobyns andLinscheid7 among intermediate and late complicationsof Colles’ fractures. In a review of 565 fractures of thedistal radius that were seen at the Mayo Clinic, Cooneyet al.6 found five patients with associated intracarpalinjuries, four of whom required operative reconstruc-tion of the scapholunate ligament. They did not reportany patients with midcarpal instabilities.

Conclusions

We believe that our patients represent a link betweenmalunions of fractures of the distal radius and dynamicmedial (ulnar) midcarpal instabilities. We believe thatit is the abnormal dorsal tilt caused by the malunion thatleads to the midcarpal instability. In all cases of mal-union with dorsal tilt, carpal alignment is most stable,but least functional, when the hand is dorsiflexedenough to line up with the displaced distal fragment ofthe radius (Fig. 8, A). Most frequently, realignment the hand from this more stable dorsiflexion attitude to aneutral alignment with the forearm is accomplishedthrough partial palmar flexion at the radiolunate lew~l(Fig. 8, B). Lunate and capitate remain colinear andshift together along the now abnormal, dorsal slope of

The Jo~HAND

the distal radius to. a position that is dorsalforearm. These patients may develop astability that is referred to the radiocarpal jointapparent to them from the time the immobilizationthe treatment of the Colles’ fracture is discontinuefl~contrast, our patients realigned their hands withforearms by palmar flexion at the lunocapitate(Figs. 4, B, 5, A, 6 B, and 7, D) and devel~bility gradually after the fracture healed as thepal joint was stressed during loading of the wrist.nate dorsiflexion and capitate alignment dorsalshaft of the radius create an unstable, true zig-zagformity. In some patients, the progression of instalwas enough to allow them to sublux actively :hecarpal joint in ulnar deviation. We believe thatpatients represent a small, select group amongwith Colles’ fractures. They are younger, moreand vigorous, and they present a predisposingmidcarpal instability. The loss of the normaland the repetitive loading of their wrists may leadmechanical synovitis at the capitolunate articulationto a gradual relaxation of midcarpal support,the wrist to develop a dynamic form of dorsality during active ulnar deviation. Itin reality, the midcarpal instability resulted fromsame injury that caused the fracture initially andfrom the repetitive loading of the malalignedThat this instability was not caused by the originaljury is shown by the fact that these patients diddevelop symptoms until several weeks or monththe fractures had healed, that these symptomsworse with time and were eventually disabling, andall those who received corrective osteotomies werelieved of the disability, although the m]-dcarpalitself was never treated. Conversely, further co~tion is provided by the only-patient whosejoint was stabilized without correction of thedial deformity but who .promptly experienced therence of midcarpal instability.

Summary

The 13 patients in this study had complaints ofand swelling at the midcarpal level. In six ofpatients, a painful snap of the wrist was alsoand could be reproduced in ulnar deviation. Inpatients, disability was due to the reversal of thepalmar tilt of the distal radius.

Corrective osteotomy of the distal radius wasformed in nine patients and was successful in relievin~i

preoperativ~ pain and instability. In one¯ had a minimal loss of palmar radial tilt, an attempt at

midcarpal (triquetrohamate) stabilization helped to de-crease her preoperative pain but did not correct the

The Journal 9A, No. 3~ID1984 Midcarpal instability caused by tnalunited fractures 357

dorsal tornptomaticpal joint

)bilization continued.tds with:apitate

s thehe wrist.dorsal toe zig-zagof instabilizely the mid.~

ve that theamong thosemore active.ing potentialal palmar tilt ¯aay lead to

"ticulation or~rt, allowingrsal instabil-argueded from theally and not :

:nedoriginal

rots didnonths after)ms

rig,ies were re-carpal joint;r confirma-

led the recur-

ints of painix of these

lso noticeda. In thesethe normal

S was

n relieving

atientattempt at

lped to de-

for recurrent midcarpal subluxation noticed in

deviation.

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