539
Short report letters
Symptomatic bilateral bipartite lunate: a case report Dear Sir, A 72-year-old man presented with a 10-year history of vague pain in both wrists that had increased over the preceding year. He had worked as a day labourer on construction sites and recalled no history of injury. Physical examination showed mild swelling on the dorsal aspect of the right wrist and tenderness over the radial styloid process, but no tenderness in the left wrist. The limitation of motion was more severe in the right wrist. The ranges of motion were reduced as
follows: right wrist flexion 40°, extension 50°, radial deviation 10°, and ulnar deviation 30; and left wrist flexion 70°, extension 60°, radial deviation 20°, and ulnar deviation 40°. Supination and pronation were normal. The grip strengths were 127 N on the right and 216 N on the left. Radiographs of both wrists showed a lunate in two pieces. There is gross carpal collapse with widening of scapholunate joints and flexed scaphoids. The arthritic change at the radioscaphoid joint and osteophytes around the radial styloid were observed only in the right wrist (Figure 1). Computed tomography scans of both wrists showed the lunates divided into two well corticated pieces with smooth margins. On the right
Figure 1. (A) Posteroanterior radiograph of the right wrist showed osteoarthritis of radioscaphoid joint, widening of the scapholunate joint space, and proximal migration of capitate. (B) Lateral radiograph showed subluxated dorsal part of lunate and swollen soft tissue.
the dorsal part of the lunate had displaced dorsally with proximal migration of the capitate (Figure 2). In view of the patient’s symptoms the dorsum of the right wrist was explored. There was tenosynovitis and severe attrition of the middle and ring finger extensor tendons in the fourth compartment owing to prominence of the dorsal part of the lunate, which was excised along with a radial styloidectomy. This helped the patient’s symptoms. Subsequent radiographs showed no further deterioration at 1 year follow up. Only three cases of congenital bipartite lunate have previously been reported in the English literature (Akahane et al., 2002; Drez and Romero, 1978; Loh et al., 2011). All were asymptomatic and found incidentally after trauma. Our case is unique because it caused pain. In addition, our patient is the oldest reported to date with congenital bipartite lunate and had been exposed to heavy labour for a long time. Congenital bipartite lunate could proceed to the pattern of osteoarthritis of radioscaphoid joint, subluxation of lunate and proximal migration of capitate without major trauma.
Figure 2. Computed tomography image of right wrist showed the smooth and well corticated margin of both lunate parts in the sagittal plane. The dorsal part of the lunate was displaced dorsally.
Downloaded from jhs.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on September 27, 2015
540
The Journal of Hand Surgery (Eur) 40(5)
Conflict of interests None declared.
Ethical approval details The patient was informed that the case would be submitted for publication and gave his consent.
References Akahane M, Ono H, Sada M, Saitoh M. Bilateral bipartite lunate: a case report. J Hand Surg Am. 2002, 27: 355–9. Drez D Jr, Romero JR 3rd. Congenital bipartite carpal lunate. A case report. Am J Sports Med. 1978, 6: 405–8. Loh BW, Harvey J, Ek ET. Congenital bipartite lunate presenting as a misdiagnosed lunate fracture: a case report. J Med Case Rep. 2011, 14: 102.
C. H. Lee and K. H. Lee Department of Orthopaedic Surgery, Kepco Medical Center, and Hanyang University College of Medicine, Seoul, Korea. Corresponding author: [email protected]
© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413508513 available online at http://jhs.sagepub.com
Changes in the area of the volar scapholunate interosseous ligament at different positions of the wrist Dear Sir, Partial or complete tears of the scapholunate interosseous ligament (SLIL) are frequently observed after wrist injury and may lead to wrist pain and kinematic changes in the carpus. A fall onto an outstretched hand in hyperextension is the predominant mechanism for SLIL injuries (Mayfield, 1980). In addition, rotation of the forearm may be another important causative factor of SLIL injuries. Recent investigation suggests that the volar part of the SLIL is thinner and more elastic than the dorsal part of the SLIL (Berger et al., 1999). Therefore, we investigated changes in the area of the volar SLIL during wrist full extension and forearm rotation in vivo. Twelve healthy adult volunteers were recruited for this study, and their right wrists were studied. The volunteers were divided into two groups of six: in one group, computer tomography (CT) images were acquired at wrist full extension, and in the other group, CT images were obtained at forearm extreme
pronation or supination. In the wrists of both groups, the neutral position was included as the control baseline wrist position. We used data from the CT scans to reconstruct 3-dimensional images using analytic software (Mimics 10.0; Materalise, Leuven, Belgium). We defined the volar region of the SLIL according to their known bone insertions and marked the origin and insertion on the surfaces of the bone reconstructions (Nagao et al., 2005) (Figure 1). We then measured the area of volar SLIL using analytic software (ImageJ 1.42; National Institutes of Health, Maryland, USA). We analyzed the changes in area using repeated-measure one-way analysis of variance followed by post-hoc paired t-tests. From the neutral position to full extension, areas (X ± SD) of the volar SLIL increased from 30.6 ± 3.0 to 39.8 ± 4.5 mm2, and the change was statistically significant (p = 0.001). Areas of the volar SLIL increased from 31.1 ± 3.5 to 33.9 ± 4.9 mm2, when the wrist moved from the neutral position to forearm extreme pronation, and the increase was also statistically significantly (p = 0.007). No significant difference in the average areas of the volar SLIL were found at forearm extreme supination (31.7 ± 3.6 mm2) compared with those in neutral position (31.1 ± 3.5 mm2) (p = 0.131). Using in vivo noninvasive 3-dimensional bone reconstruction to study joint motion has become increasingly popular. Many carpal injuries occur when the hands are outstretched to support body weight, and wrists are usually at positions of full extension. The study by Lee et al. (2010) indicated a mean elongation in loaded extension of 48.4% for the palmar component of the SLIL using in vivo magnetic resonance image scanning and image reconstruction. Our data showed that mean percentage increases of the extending areas of the volar SLIL in full extension and forearm extreme pronation were 30.1% and 9%, respectively. Our findings suggest that the volar part of the SLIL was highly strained in two positions. Furthermore, our findings suggest that wrist full extension may have a more important influence on the areas of volar SLIL than forearm rotation. However, based on our findings, we are unable to speculate whether the volar region of SLIL is more easily disrupted or injured earlier after hand trauma, because less extendable ligaments do not necessarily disrupt more easily. Ultimately, the damage incurred depends on the strengths of different regions of the SLIL, loading speed, and structural properties, such as the elastic modulus of these regions. We acknowledge the limitations of our study. One limitation was the small sample size, creating the potential for type II (false negative) errors for detecting changes in the extending area at the forearm
Downloaded from jhs.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on September 27, 2015
Short report letters
Symptomatic bilateral bipartite lunate: a case report Dear Sir, A 72-year-old man presented with a 10-year history of vague pain in both wrists that had increased over the preceding year. He had worked as a day labourer on construction sites and recalled no history of injury. Physical examination showed mild swelling on the dorsal aspect of the right wrist and tenderness over the radial styloid process, but no tenderness in the left wrist. The limitation of motion was more severe in the right wrist. The ranges of motion were reduced as
follows: right wrist flexion 40°, extension 50°, radial deviation 10°, and ulnar deviation 30; and left wrist flexion 70°, extension 60°, radial deviation 20°, and ulnar deviation 40°. Supination and pronation were normal. The grip strengths were 127 N on the right and 216 N on the left. Radiographs of both wrists showed a lunate in two pieces. There is gross carpal collapse with widening of scapholunate joints and flexed scaphoids. The arthritic change at the radioscaphoid joint and osteophytes around the radial styloid were observed only in the right wrist (Figure 1). Computed tomography scans of both wrists showed the lunates divided into two well corticated pieces with smooth margins. On the right
Figure 1. (A) Posteroanterior radiograph of the right wrist showed osteoarthritis of radioscaphoid joint, widening of the scapholunate joint space, and proximal migration of capitate. (B) Lateral radiograph showed subluxated dorsal part of lunate and swollen soft tissue.
the dorsal part of the lunate had displaced dorsally with proximal migration of the capitate (Figure 2). In view of the patient’s symptoms the dorsum of the right wrist was explored. There was tenosynovitis and severe attrition of the middle and ring finger extensor tendons in the fourth compartment owing to prominence of the dorsal part of the lunate, which was excised along with a radial styloidectomy. This helped the patient’s symptoms. Subsequent radiographs showed no further deterioration at 1 year follow up. Only three cases of congenital bipartite lunate have previously been reported in the English literature (Akahane et al., 2002; Drez and Romero, 1978; Loh et al., 2011). All were asymptomatic and found incidentally after trauma. Our case is unique because it caused pain. In addition, our patient is the oldest reported to date with congenital bipartite lunate and had been exposed to heavy labour for a long time. Congenital bipartite lunate could proceed to the pattern of osteoarthritis of radioscaphoid joint, subluxation of lunate and proximal migration of capitate without major trauma.
Figure 2. Computed tomography image of right wrist showed the smooth and well corticated margin of both lunate parts in the sagittal plane. The dorsal part of the lunate was displaced dorsally.
Downloaded from jhs.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on September 27, 2015
540
The Journal of Hand Surgery (Eur) 40(5)
Conflict of interests None declared.
Ethical approval details The patient was informed that the case would be submitted for publication and gave his consent.
References Akahane M, Ono H, Sada M, Saitoh M. Bilateral bipartite lunate: a case report. J Hand Surg Am. 2002, 27: 355–9. Drez D Jr, Romero JR 3rd. Congenital bipartite carpal lunate. A case report. Am J Sports Med. 1978, 6: 405–8. Loh BW, Harvey J, Ek ET. Congenital bipartite lunate presenting as a misdiagnosed lunate fracture: a case report. J Med Case Rep. 2011, 14: 102.
C. H. Lee and K. H. Lee Department of Orthopaedic Surgery, Kepco Medical Center, and Hanyang University College of Medicine, Seoul, Korea. Corresponding author: [email protected]
© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413508513 available online at http://jhs.sagepub.com
Changes in the area of the volar scapholunate interosseous ligament at different positions of the wrist Dear Sir, Partial or complete tears of the scapholunate interosseous ligament (SLIL) are frequently observed after wrist injury and may lead to wrist pain and kinematic changes in the carpus. A fall onto an outstretched hand in hyperextension is the predominant mechanism for SLIL injuries (Mayfield, 1980). In addition, rotation of the forearm may be another important causative factor of SLIL injuries. Recent investigation suggests that the volar part of the SLIL is thinner and more elastic than the dorsal part of the SLIL (Berger et al., 1999). Therefore, we investigated changes in the area of the volar SLIL during wrist full extension and forearm rotation in vivo. Twelve healthy adult volunteers were recruited for this study, and their right wrists were studied. The volunteers were divided into two groups of six: in one group, computer tomography (CT) images were acquired at wrist full extension, and in the other group, CT images were obtained at forearm extreme
pronation or supination. In the wrists of both groups, the neutral position was included as the control baseline wrist position. We used data from the CT scans to reconstruct 3-dimensional images using analytic software (Mimics 10.0; Materalise, Leuven, Belgium). We defined the volar region of the SLIL according to their known bone insertions and marked the origin and insertion on the surfaces of the bone reconstructions (Nagao et al., 2005) (Figure 1). We then measured the area of volar SLIL using analytic software (ImageJ 1.42; National Institutes of Health, Maryland, USA). We analyzed the changes in area using repeated-measure one-way analysis of variance followed by post-hoc paired t-tests. From the neutral position to full extension, areas (X ± SD) of the volar SLIL increased from 30.6 ± 3.0 to 39.8 ± 4.5 mm2, and the change was statistically significant (p = 0.001). Areas of the volar SLIL increased from 31.1 ± 3.5 to 33.9 ± 4.9 mm2, when the wrist moved from the neutral position to forearm extreme pronation, and the increase was also statistically significantly (p = 0.007). No significant difference in the average areas of the volar SLIL were found at forearm extreme supination (31.7 ± 3.6 mm2) compared with those in neutral position (31.1 ± 3.5 mm2) (p = 0.131). Using in vivo noninvasive 3-dimensional bone reconstruction to study joint motion has become increasingly popular. Many carpal injuries occur when the hands are outstretched to support body weight, and wrists are usually at positions of full extension. The study by Lee et al. (2010) indicated a mean elongation in loaded extension of 48.4% for the palmar component of the SLIL using in vivo magnetic resonance image scanning and image reconstruction. Our data showed that mean percentage increases of the extending areas of the volar SLIL in full extension and forearm extreme pronation were 30.1% and 9%, respectively. Our findings suggest that the volar part of the SLIL was highly strained in two positions. Furthermore, our findings suggest that wrist full extension may have a more important influence on the areas of volar SLIL than forearm rotation. However, based on our findings, we are unable to speculate whether the volar region of SLIL is more easily disrupted or injured earlier after hand trauma, because less extendable ligaments do not necessarily disrupt more easily. Ultimately, the damage incurred depends on the strengths of different regions of the SLIL, loading speed, and structural properties, such as the elastic modulus of these regions. We acknowledge the limitations of our study. One limitation was the small sample size, creating the potential for type II (false negative) errors for detecting changes in the extending area at the forearm
Downloaded from jhs.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on September 27, 2015
