Arch Orthop Trauma Surg (2014) 134:1017–1022 DOI 10.1007/s00402-014-2002-z
Handsurgery
Two cases of pisiform bone impingement syndrome after proximal row carpectomy Sebastian Kluge · Stephan Schindele · Daniel Herren
Received: 4 March 2014 / Published online: 24 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Proximal row carpectomy (PRC) is an established surgical procedure used to treat post-traumatic osteoarthritis of the wrist with sparing of the midcarpal joint and advanced aseptic necrosis such as lunatomalacia. Proximalization of the distal carpal row following PRC may lead to secondary problems such as radiocarpal impingement. At follow-up, two of our patients complained about ulnarsided wrist pain after proximal row carpectomy. Computed tomography (CT) scans were taken for both patients with an additional magnetic resonance imaging scan for one patient. The CT scan revealed clear osteolysis consistent with a pisiform bone impingement on the ulnar styloid process in both the cases, and also on the hamate in one patient. An impingement syndrome of this nature has not previously been described and should be kept in mind when patients report ulnocarpal symptoms after PRC. Keywords Impingement · Proximal row carpectomy · Ulnocarpal · Wrist · Case report
Introduction Proximal row carpectomy (PRC) is an established surgical procedure [1] used particularly in the treatment of posttraumatic wrist arthritis [i.e. Stage II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse)] and cases of advanced aseptic necrosis of the lunate (Kienböck’s disease). The functional outcome after this type of treatment is similar to that achieved with S. Kluge (*) · S. Schindele · D. Herren Department of Hand Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland e-mail: [email protected]
partial midcarpal arthrodesis [2–6]. However, unlike with four-corner fusion surgery, the lack of the intercalated segment in PRC leads to proximalization of the distal row of the carpus and approximation of the radius and ulna. An associated radiocarpal impingement syndrome has been described, for which the recommended treatment is resection of the radial styloid process [1, 7–13]. In contrast, there are no published reports of secondary problems in the ulnocarpal compartment, except for one case of pisiform impingement after total wrist arthroplasty [14]. The purpose of this paper is to present two patients with a pisiform bone impingement syndrome after PRC.
Case presentations Over a 10-year period from 2002 to 2011, 44 PRC procedures were performed in our department. During the routine postoperative follow-up of these patients, two of them reported pain over the ulnocarpal joint following a dorsal approach PRC for a SLAC or SNAC wrist. Although both patients had no pain in flexion/extension of the wrist or in radial/ulnar deviation, stabbing pain was experienced at the palmar ulnar endpoint of the dart thrower’s motion, a position which may place pressure on the pisiform bone and increase localized grinding pain. Only one of the two patients had undergone resection of the radial styloid process during the initial operation The second patient also reported pain on dorsal radial movement of the wrist, which was considered typical of radiocarpal impingement. Patient 1 A 49-year-old filling station attendant experienced localized radiocarpal pain and swelling. He could not recall
13
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Arch Orthop Trauma Surg (2014) 134:1017–1022
Fig. 1 Anteroposterior radiograph of patient 1 showing osteolysis of the proximal pole of the pisiform bone projecting onto the ulnar styloid process
any previous trauma. Preoperative radiographs showed a Stage II SLAC wrist with sparing of the midcarpal joint. Six months after PRC, most of the symptoms subsided, but the patient reported mild and initially tolerable ulnocarpal pain. Two years post-surgery, he presented with recurrent strain-related positional radiocarpal pain and progressive ulnocarpal symptoms. The radial-sided pain resolved temporarily with steroid injection, confirming the provisional diagnosis of radiocarpal impingement, however, the ulnarsided wrist pain persisted. The plain radiograph showed a local decrease in radio-opacity of the proximal cortical margin of the pisiform, which projected onto the ulnar styloid tip (Fig. 1). Dynamic imaging revealed an approximation of the two bones, which was confirmed with a computer tomography (CT) scan. The anatomical proximity of the two bones could be clearly recognized in both coronal (Fig. 2a) and sagittal (Fig. 2b) sections. The findings were consistent with an impingement syndrome involving the two bones. Patient 2 The second patient was referred to our clinic with progressive radiocarpal pain and recurrent synovitis after an undiagnosed scaphoid fracture sustained during his youth. The diagnostic investigations showed a scaphoid nonunion, which had developed into well-defined post-traumatic radiocarpal Stage II SNAC arthritis. A CT scan ruled out involvement of the midcarpal joint. Following resection
13
Fig. 2 CT images of patient 1 showing impingement between the pisiform bone and ulnar styloid process. a Coronal and b sagittal views
of the proximal row of the carpus, intraoperative passive movement in the dorsal radial direction showed incipient radiocarpal impingement; this led to additional resection of the radial styloid process. Immediate postoperative recovery was unremarkable. At 3 months post-surgery, the patient noticed occasional ulnocarpal pain associated with position and loading of the joint, but was unable to precisely localize the pain. Clinical examination elicited stabbing pain at the level of the pisiform bone upon certain degrees of forced passive and active wrist movement in the ulnar palmar direction. The pain intensified by radial ulnar gliding of the pisiform. Anteroposterior radiographs revealed slight shadowing at the proximal tip of the pisiform bone (Fig. 3), with a subsequent CT scan showing impingement (Fig. 4). For
Arch Orthop Trauma Surg (2014) 134:1017–1022
1019
Fig. 3 Anteroposterior radiograph of patient 2 showing osteolysis of the proximal pole of the pisiform bone projecting onto the ulnar styloid process
this patient, the sagittal view also showed slight osteolysis at the distal pole of the pisiform (Fig. 5). In addition to impingement of the two bones, their anatomical proximity suggested a dynamic impaction of the pisiform bone between the hook of the hamate and the ulnar styloid process (Fig. 6). Therefore, magnetic resonance imaging was carried out and showed slight but recognizable oedematous bone marrow changes at both poles of the pisiform bone (Fig. 7); this outcome confirmed our initial diagnosis. Somewhat surprisingly, bone marrow oedema was also seen at the tip of the hamate bone (Fig. 8), giving rise to the suspicion of an additional ulnocarpal impaction. This was, however, considered to be subclinical, as there was neither ulnocarpal grinding nor pain upon forced pronation of the forearm. Additional surgical details Resection of the pisiform bone was carried out for both patients with additional resection of the radial styloid process for patient 1 only. The pisiform was approached via a palmar zigzag incision crossing the distal wrist crease. The ulnar nerve and artery were identified and protected, the flexor carpi ulnaris (FCU) tendon was split longitudinally, and the pisiform bone was resected sharply in one piece. The FCU tendon was closed with an absorbable running suture and skin closure was made with interrupted sutures. Mobility exercises were started immediately post-surgery.
Fig. 4 CT images of patient 2 showing impingement between the pisiform bone and ulnar styloid process. a Coronal and b sagittal views
Discussion Radiocarpal impingement has been described by many authors [1, 7–13] and resection of the radial styloid process is therefore performed either routinely [1, 8, 11, 12] or following intraoperative testing [9, 10, 13]. We have also observed impingement of this nature in our patients, so that the intraoperative indication for simultaneous resection of the radial styloid process is important and should be routinely checked. The two cases described here further demonstrate the possibility of ulnocarpal impingement or entrapment of the pisiform bone between the ulnar styloid process and hamate hook, which leads to persistent ulnocarpal pain after PRC. To date, no published reports of ulnocarpal pain following PRC exist; on
13
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Arch Orthop Trauma Surg (2014) 134:1017–1022
Fig. 5 CT image (in sagittal view) of patient 2 highlighting osteolysis at the distal pole of the pisiform bone
the contrary, the possibility has tended to be excluded by kinematic studies [7]. From an anatomical perspective, the pisiform bone is found in the tendon of the FCU muscle and acts as a sesamoid bone. Contraction of the muscle applies a force directed dorsally that contributes, via the pisotriquetral joint surfaces, to the maintenance or stabilization of the proximal row of the carpus [15]. Mediated by proprioceptive reflex mechanisms, this stabilization seems to protect against ligamentous injury of the proximal carpal row [15, 16]. The function of the pisiform bone after removal of the proximal row is unclear. While the FCU tendon certainly continues to exert a palmar ulnar deviation force to the wrist, the corresponding articular surface of the triquetrum is lacking, potentially leading to an altered force transmission of the pisiform onto the remnants of the wrist capsule, hamate bone or styloid process of the ulna positioned dorsally; this altered force is increased by compression forces transmitted via the FCU tendon with ulnopalmar flexion and/or a certain amount of forearm rotation. Impaction of the pisiform between the hook of the hamate and the ulnar styloid process with these movements could also theoretically explain the clinical symptoms. Resection of the pisiform bone led to full symptomatic relief for our two patients, and thus should be regarded as the treatment of choice in these specific cases of impingement. Additionally, a routine dynamic intraoperative examination under fluoroscopic control may be advisable for all cases undergoing PRC. Further clinical and/or cadaver studies should be carried out to address these issues. If pisiform
13
Fig. 6 CT reconstruction images of patient 2 showing the anatomical proximity of the pisiform bone to the ulnar styloid process and hook of the hamate. a Anteroposterior, b lateral, and c oblique views
impingement or impaction appears only in isolated cases, there is probably no need to change the recommended treatment protocol. On the other hand, standard resection of the pisiform bone during PRC needs to be considered if ulnocarpal problems are identified more often than expected in the future. In this case, a palmar approach might be advisable. As a secondary finding, the radiologic workup showed that even after PRC, ulnocarpal impaction is still possible between the ulna and the distal row of the carpus. Shortening of the ulna by osteotomy or a wafer procedure has to be considered if symptoms persist despite resection of the pisiform bone. A reliable preoperative differentiation
Arch Orthop Trauma Surg (2014) 134:1017–1022
1021
Fig. 8 MRI image (in coronal view) of patient 2 showing bone marrow oedema of the tip of the hamate bone
The primary workup of an ulnocarpal impingement after PRC requires a precise clinical examination and conventional radiographs. For our two patients, a reliable provisional diagnosis could be made even at this stage, and was further confirmed by dynamic imaging. Real-time dynamic fluoroscopy indicated possible reasons for the pain, and showed the proximity of the pisiform bone in relation to the hook of the hamate and ulnar styloid; it is recommended as a diagnostic tool prior to cross-sectional imaging. A CT scan was performed for both cases, and one patient also had an MRI, which showed slight changes due to entrapment of the pisiform between the hook of the hamate and ulnar styloid process as well as ulnocarpal impaction. An additional ulna shortening osteotomy or wafer procedure needs to be considered in cases where pain persists postoperatively. Acknowledgments The authors would like to thank M. Wilhelmi, PhD for the copy-editing of this manuscript. Fig. 7 MRI images (in coronal view) of patient 2 showing bone marrow oedema of the a distal and b proximal poles of the pisiform bone
of the two causes of pain is probably not possible when there is bone marrow oedema of both the pisiform bone and the hook of the hamate, although a trial injection may be attempted. However, the anatomical proximity of these trouble zones makes it difficult to make a clear distinction, due to diffusion of the local anesthetic.
Conflict of interest None.
References 1. Stamm TT (1944) Excision of the proximal row of the carpus. Proc R Soc Med 38:74–75 2. Cohen MS, Kozin SH (2001) Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and
13
1022 four-corner arthrodesis. J Hand Surg Am 26:94–104. doi:10.105 3/jhsu.2001.20160 3. Lukas B, Herter F, Englert A, Bäcker K (2003) The treatment of carpal collapse: proximal row carpectomy or limited midcarpal arthrodesis? A comparative study. Handchir Mikrochir Plast Chir 35:304–309. doi:10.1055/s-2003-43119 4. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS (2009) Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur 34:256–263. doi:10.1177/ 1753193408100954 5. Nakamura R, Horii E, Watanabe K, Nakao E, Kato H, Tsunoda K (1998) Proximal row carpectomy versus limited wrist arthrodesis for advanced Kienböck’s disease. J Hand Surg Br 23:741–745 6. Tomaino MM, Miller RJ, Cole I, Burton RI (1994) Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? J Hand Surg Am 19:134–142 7. Blankenhorn BD, Pfaeffle HJ, Tang P, Robertson D, Imbriglia J, Goitz RJ (2007) Carpal kinematics after proximal row carpectomy. J Hand Surg Am 32:37–46. doi:10.1016/j.jhsa.2006.10.014 8. Crabbe WA (1964) Excision of the proximal row of the carpus. J Bone Joint Surg Br 46:708–711 9. DiDonna ML, Kiefhaber TR, Stern PJ (2004) Proximal row carpectomy: study with a minimum of ten years of follow-up. J Bone Joint Surg Am 86:2359–2365
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Arch Orthop Trauma Surg (2014) 134:1017–1022 10. Imbriglia JE, Broudy AS, Hagberg WC, McKernan D (1990) Proximal row carpectomy: clinical evaluation. J Hand Surg Am 15:426–430 11. Jebson PJ, Hayes EP, Engber WD (2003) Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg Am 28:561–569. doi:10.1016/S0363-5023(03)00248-X 12. Lumsden BC, Stone A, Engber WD (2008) Treatment of advanced-stage Kienböck’s disease with proximal row carpectomy: an average 15-year follow-up. J Hand Surg Am 33:493– 502. doi:10.1016/j.jhsa.2007.12.010 13. Neviaser RJ (1983) Proximal row carpectomy for posttraumatic disorders of the carpus. J Hand Surg Am 8:301–305 14. Johnson ST, Patel A, Calfee RP, Weiss AP (2007) Pisiform impingement after total wrist arthroplasty. J Hand Surg Am 32:334–336. doi:10.1016/j.jhsa.2006.12.014 15. Garcia-Elias M (2008) The non-dissociative clunking wrist: a personal view. J Hand Surg Eur 33:698–711. doi:10.1177/ 1753193408090148 16. Hagert E, Persson JK, Werner M, Ljung BO (2009) Evidence of wrist proprioceptive reflexes elicited after stimulation of the scapholunate interosseous ligament. J Hand Surg Am 34:642– 651. doi:10.1016/j.jhsa.2008.12.001
Handsurgery
Two cases of pisiform bone impingement syndrome after proximal row carpectomy Sebastian Kluge · Stephan Schindele · Daniel Herren
Received: 4 March 2014 / Published online: 24 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Proximal row carpectomy (PRC) is an established surgical procedure used to treat post-traumatic osteoarthritis of the wrist with sparing of the midcarpal joint and advanced aseptic necrosis such as lunatomalacia. Proximalization of the distal carpal row following PRC may lead to secondary problems such as radiocarpal impingement. At follow-up, two of our patients complained about ulnarsided wrist pain after proximal row carpectomy. Computed tomography (CT) scans were taken for both patients with an additional magnetic resonance imaging scan for one patient. The CT scan revealed clear osteolysis consistent with a pisiform bone impingement on the ulnar styloid process in both the cases, and also on the hamate in one patient. An impingement syndrome of this nature has not previously been described and should be kept in mind when patients report ulnocarpal symptoms after PRC. Keywords Impingement · Proximal row carpectomy · Ulnocarpal · Wrist · Case report
Introduction Proximal row carpectomy (PRC) is an established surgical procedure [1] used particularly in the treatment of posttraumatic wrist arthritis [i.e. Stage II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse)] and cases of advanced aseptic necrosis of the lunate (Kienböck’s disease). The functional outcome after this type of treatment is similar to that achieved with S. Kluge (*) · S. Schindele · D. Herren Department of Hand Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland e-mail: [email protected]
partial midcarpal arthrodesis [2–6]. However, unlike with four-corner fusion surgery, the lack of the intercalated segment in PRC leads to proximalization of the distal row of the carpus and approximation of the radius and ulna. An associated radiocarpal impingement syndrome has been described, for which the recommended treatment is resection of the radial styloid process [1, 7–13]. In contrast, there are no published reports of secondary problems in the ulnocarpal compartment, except for one case of pisiform impingement after total wrist arthroplasty [14]. The purpose of this paper is to present two patients with a pisiform bone impingement syndrome after PRC.
Case presentations Over a 10-year period from 2002 to 2011, 44 PRC procedures were performed in our department. During the routine postoperative follow-up of these patients, two of them reported pain over the ulnocarpal joint following a dorsal approach PRC for a SLAC or SNAC wrist. Although both patients had no pain in flexion/extension of the wrist or in radial/ulnar deviation, stabbing pain was experienced at the palmar ulnar endpoint of the dart thrower’s motion, a position which may place pressure on the pisiform bone and increase localized grinding pain. Only one of the two patients had undergone resection of the radial styloid process during the initial operation The second patient also reported pain on dorsal radial movement of the wrist, which was considered typical of radiocarpal impingement. Patient 1 A 49-year-old filling station attendant experienced localized radiocarpal pain and swelling. He could not recall
13
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Arch Orthop Trauma Surg (2014) 134:1017–1022
Fig. 1 Anteroposterior radiograph of patient 1 showing osteolysis of the proximal pole of the pisiform bone projecting onto the ulnar styloid process
any previous trauma. Preoperative radiographs showed a Stage II SLAC wrist with sparing of the midcarpal joint. Six months after PRC, most of the symptoms subsided, but the patient reported mild and initially tolerable ulnocarpal pain. Two years post-surgery, he presented with recurrent strain-related positional radiocarpal pain and progressive ulnocarpal symptoms. The radial-sided pain resolved temporarily with steroid injection, confirming the provisional diagnosis of radiocarpal impingement, however, the ulnarsided wrist pain persisted. The plain radiograph showed a local decrease in radio-opacity of the proximal cortical margin of the pisiform, which projected onto the ulnar styloid tip (Fig. 1). Dynamic imaging revealed an approximation of the two bones, which was confirmed with a computer tomography (CT) scan. The anatomical proximity of the two bones could be clearly recognized in both coronal (Fig. 2a) and sagittal (Fig. 2b) sections. The findings were consistent with an impingement syndrome involving the two bones. Patient 2 The second patient was referred to our clinic with progressive radiocarpal pain and recurrent synovitis after an undiagnosed scaphoid fracture sustained during his youth. The diagnostic investigations showed a scaphoid nonunion, which had developed into well-defined post-traumatic radiocarpal Stage II SNAC arthritis. A CT scan ruled out involvement of the midcarpal joint. Following resection
13
Fig. 2 CT images of patient 1 showing impingement between the pisiform bone and ulnar styloid process. a Coronal and b sagittal views
of the proximal row of the carpus, intraoperative passive movement in the dorsal radial direction showed incipient radiocarpal impingement; this led to additional resection of the radial styloid process. Immediate postoperative recovery was unremarkable. At 3 months post-surgery, the patient noticed occasional ulnocarpal pain associated with position and loading of the joint, but was unable to precisely localize the pain. Clinical examination elicited stabbing pain at the level of the pisiform bone upon certain degrees of forced passive and active wrist movement in the ulnar palmar direction. The pain intensified by radial ulnar gliding of the pisiform. Anteroposterior radiographs revealed slight shadowing at the proximal tip of the pisiform bone (Fig. 3), with a subsequent CT scan showing impingement (Fig. 4). For
Arch Orthop Trauma Surg (2014) 134:1017–1022
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Fig. 3 Anteroposterior radiograph of patient 2 showing osteolysis of the proximal pole of the pisiform bone projecting onto the ulnar styloid process
this patient, the sagittal view also showed slight osteolysis at the distal pole of the pisiform (Fig. 5). In addition to impingement of the two bones, their anatomical proximity suggested a dynamic impaction of the pisiform bone between the hook of the hamate and the ulnar styloid process (Fig. 6). Therefore, magnetic resonance imaging was carried out and showed slight but recognizable oedematous bone marrow changes at both poles of the pisiform bone (Fig. 7); this outcome confirmed our initial diagnosis. Somewhat surprisingly, bone marrow oedema was also seen at the tip of the hamate bone (Fig. 8), giving rise to the suspicion of an additional ulnocarpal impaction. This was, however, considered to be subclinical, as there was neither ulnocarpal grinding nor pain upon forced pronation of the forearm. Additional surgical details Resection of the pisiform bone was carried out for both patients with additional resection of the radial styloid process for patient 1 only. The pisiform was approached via a palmar zigzag incision crossing the distal wrist crease. The ulnar nerve and artery were identified and protected, the flexor carpi ulnaris (FCU) tendon was split longitudinally, and the pisiform bone was resected sharply in one piece. The FCU tendon was closed with an absorbable running suture and skin closure was made with interrupted sutures. Mobility exercises were started immediately post-surgery.
Fig. 4 CT images of patient 2 showing impingement between the pisiform bone and ulnar styloid process. a Coronal and b sagittal views
Discussion Radiocarpal impingement has been described by many authors [1, 7–13] and resection of the radial styloid process is therefore performed either routinely [1, 8, 11, 12] or following intraoperative testing [9, 10, 13]. We have also observed impingement of this nature in our patients, so that the intraoperative indication for simultaneous resection of the radial styloid process is important and should be routinely checked. The two cases described here further demonstrate the possibility of ulnocarpal impingement or entrapment of the pisiform bone between the ulnar styloid process and hamate hook, which leads to persistent ulnocarpal pain after PRC. To date, no published reports of ulnocarpal pain following PRC exist; on
13
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Arch Orthop Trauma Surg (2014) 134:1017–1022
Fig. 5 CT image (in sagittal view) of patient 2 highlighting osteolysis at the distal pole of the pisiform bone
the contrary, the possibility has tended to be excluded by kinematic studies [7]. From an anatomical perspective, the pisiform bone is found in the tendon of the FCU muscle and acts as a sesamoid bone. Contraction of the muscle applies a force directed dorsally that contributes, via the pisotriquetral joint surfaces, to the maintenance or stabilization of the proximal row of the carpus [15]. Mediated by proprioceptive reflex mechanisms, this stabilization seems to protect against ligamentous injury of the proximal carpal row [15, 16]. The function of the pisiform bone after removal of the proximal row is unclear. While the FCU tendon certainly continues to exert a palmar ulnar deviation force to the wrist, the corresponding articular surface of the triquetrum is lacking, potentially leading to an altered force transmission of the pisiform onto the remnants of the wrist capsule, hamate bone or styloid process of the ulna positioned dorsally; this altered force is increased by compression forces transmitted via the FCU tendon with ulnopalmar flexion and/or a certain amount of forearm rotation. Impaction of the pisiform between the hook of the hamate and the ulnar styloid process with these movements could also theoretically explain the clinical symptoms. Resection of the pisiform bone led to full symptomatic relief for our two patients, and thus should be regarded as the treatment of choice in these specific cases of impingement. Additionally, a routine dynamic intraoperative examination under fluoroscopic control may be advisable for all cases undergoing PRC. Further clinical and/or cadaver studies should be carried out to address these issues. If pisiform
13
Fig. 6 CT reconstruction images of patient 2 showing the anatomical proximity of the pisiform bone to the ulnar styloid process and hook of the hamate. a Anteroposterior, b lateral, and c oblique views
impingement or impaction appears only in isolated cases, there is probably no need to change the recommended treatment protocol. On the other hand, standard resection of the pisiform bone during PRC needs to be considered if ulnocarpal problems are identified more often than expected in the future. In this case, a palmar approach might be advisable. As a secondary finding, the radiologic workup showed that even after PRC, ulnocarpal impaction is still possible between the ulna and the distal row of the carpus. Shortening of the ulna by osteotomy or a wafer procedure has to be considered if symptoms persist despite resection of the pisiform bone. A reliable preoperative differentiation
Arch Orthop Trauma Surg (2014) 134:1017–1022
1021
Fig. 8 MRI image (in coronal view) of patient 2 showing bone marrow oedema of the tip of the hamate bone
The primary workup of an ulnocarpal impingement after PRC requires a precise clinical examination and conventional radiographs. For our two patients, a reliable provisional diagnosis could be made even at this stage, and was further confirmed by dynamic imaging. Real-time dynamic fluoroscopy indicated possible reasons for the pain, and showed the proximity of the pisiform bone in relation to the hook of the hamate and ulnar styloid; it is recommended as a diagnostic tool prior to cross-sectional imaging. A CT scan was performed for both cases, and one patient also had an MRI, which showed slight changes due to entrapment of the pisiform between the hook of the hamate and ulnar styloid process as well as ulnocarpal impaction. An additional ulna shortening osteotomy or wafer procedure needs to be considered in cases where pain persists postoperatively. Acknowledgments The authors would like to thank M. Wilhelmi, PhD for the copy-editing of this manuscript. Fig. 7 MRI images (in coronal view) of patient 2 showing bone marrow oedema of the a distal and b proximal poles of the pisiform bone
of the two causes of pain is probably not possible when there is bone marrow oedema of both the pisiform bone and the hook of the hamate, although a trial injection may be attempted. However, the anatomical proximity of these trouble zones makes it difficult to make a clear distinction, due to diffusion of the local anesthetic.
Conflict of interest None.
References 1. Stamm TT (1944) Excision of the proximal row of the carpus. Proc R Soc Med 38:74–75 2. Cohen MS, Kozin SH (2001) Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and
13
1022 four-corner arthrodesis. J Hand Surg Am 26:94–104. doi:10.105 3/jhsu.2001.20160 3. Lukas B, Herter F, Englert A, Bäcker K (2003) The treatment of carpal collapse: proximal row carpectomy or limited midcarpal arthrodesis? A comparative study. Handchir Mikrochir Plast Chir 35:304–309. doi:10.1055/s-2003-43119 4. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS (2009) Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur 34:256–263. doi:10.1177/ 1753193408100954 5. Nakamura R, Horii E, Watanabe K, Nakao E, Kato H, Tsunoda K (1998) Proximal row carpectomy versus limited wrist arthrodesis for advanced Kienböck’s disease. J Hand Surg Br 23:741–745 6. Tomaino MM, Miller RJ, Cole I, Burton RI (1994) Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? J Hand Surg Am 19:134–142 7. Blankenhorn BD, Pfaeffle HJ, Tang P, Robertson D, Imbriglia J, Goitz RJ (2007) Carpal kinematics after proximal row carpectomy. J Hand Surg Am 32:37–46. doi:10.1016/j.jhsa.2006.10.014 8. Crabbe WA (1964) Excision of the proximal row of the carpus. J Bone Joint Surg Br 46:708–711 9. DiDonna ML, Kiefhaber TR, Stern PJ (2004) Proximal row carpectomy: study with a minimum of ten years of follow-up. J Bone Joint Surg Am 86:2359–2365
13
Arch Orthop Trauma Surg (2014) 134:1017–1022 10. Imbriglia JE, Broudy AS, Hagberg WC, McKernan D (1990) Proximal row carpectomy: clinical evaluation. J Hand Surg Am 15:426–430 11. Jebson PJ, Hayes EP, Engber WD (2003) Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg Am 28:561–569. doi:10.1016/S0363-5023(03)00248-X 12. Lumsden BC, Stone A, Engber WD (2008) Treatment of advanced-stage Kienböck’s disease with proximal row carpectomy: an average 15-year follow-up. J Hand Surg Am 33:493– 502. doi:10.1016/j.jhsa.2007.12.010 13. Neviaser RJ (1983) Proximal row carpectomy for posttraumatic disorders of the carpus. J Hand Surg Am 8:301–305 14. Johnson ST, Patel A, Calfee RP, Weiss AP (2007) Pisiform impingement after total wrist arthroplasty. J Hand Surg Am 32:334–336. doi:10.1016/j.jhsa.2006.12.014 15. Garcia-Elias M (2008) The non-dissociative clunking wrist: a personal view. J Hand Surg Eur 33:698–711. doi:10.1177/ 1753193408090148 16. Hagert E, Persson JK, Werner M, Ljung BO (2009) Evidence of wrist proprioceptive reflexes elicited after stimulation of the scapholunate interosseous ligament. J Hand Surg Am 34:642– 651. doi:10.1016/j.jhsa.2008.12.001
