0363-5465/103/3131-1038$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 31, No.

6 2003 American Orthopaedic Society for Sports Medicine

Clinical Sports Medicine Update

Athletic Injuries of the Wrist and Hand

Part I: Traumatic Injuries of the Wrist
Arthur C. Rettig,* MD From the Methodist Sports Medicine Center, Indianapolis, Indiana

Hand and wrist injuries in sports are some of the most common injuries reported. This review discusses briefly the causes of hand and wrist injuries in sports and discusses pertinent biomechanical findings regarding the range of motion required in different sports activities. The bulk of the review discusses specific traumatic and overuse injuries to the hand and wrist commonly seen in the athlete. Emphasis is placed on problematic traumatic injuries such as carpal scaphoid fractures and hook of the hamate fractures, as well as ligament injuries to the wrist with regard to diagnosis, treatment, and return to athletic competition. 2003 American Orthopaedic Society for Sports Medicine

Hand and wrist injuries are common occurrences in all sports. A review of the literature reveals that 3% to 9% of all athletic injuries involve the hand and wrist.10, 27, 55, 82 Hand and wrist injuries may be divided into two major classifications, traumatic and overuse. Traumatic injuries include fractures, dislocations, and ligament tears often seen in contact/collision sports; stress and overuse conditions are seen in gymnastics, racquet sports, and golf. The majority of injuries in a primary care setting are soft tissue injuries (sprains, strains, and contusions). In tertiary referral centers, fractures of the hand and wrist are more common. In a 10-year study of all injuries at the Olympic Training Center (Colorado Springs, Colorado), 8.7% (729 of 8311 total injuries) involved the wrist and hand. The majority of these injuries were sprains and contusions (64%).82 In collision sports, such as football, hand and wrist injuries account for 15% of all injuries. These data are based on a study presented by the National Athletic Trainers Association (unpublished data, 1986) of high school injuries and the incidents recorded on an NFL team (A. Rettig, unpublished data, 1989 to 1993). The incidence of wrist problems is much higher in sports such as gymnastics, ranging from 46% to 87% of participants.19 Many injuries are sport-specific, such as stress fractures of the hook of the hamate in golf, tennis, and baseball; Guyons canal syndrome (cyclists palsy) in cycling; distal physeal injuries in gymnastics; and ulnar wrist pain in racquet sports.

BIOMECHANICS OF THE WRIST IN SPORTS

The wrist functions to position the hand in space for gripping and grasping activities. This is accomplished mechanically by a unique and complex arrangement of bony and ligamentous structures. Using electrogoniometric studies, Ryu et al.90 have shown that most daily activities can be performed with 40 of wrist extension, 40 of flexion, and a 40 arc of radial and ulnar deviation. Wrist range of motion required for performance in various sports has been calculated by using the triaxial electrogoniometric technique. Free throw shooting in basketball requires an average of 50 of extension (range, 40 to 56) and 70 of flexion (range, 48 to 84) for an arc of 120 in the shooting hand. The nondominant wrist required only an arc of 32 of flexion/extension and 16 of radial-ulnar deviation in the activity. This has implications when considering certain motion-limiting reconstructive procedures in the wrist of a basketball player. Pappas et al.76 studied wrist range of motion in baseball pitchers, including the cocking, acceleration, deceleration, and recovery phases of throwing. During the cocking phase, the wrist extends from neutral to 32 of extension, followed by rapid flexion over 94 during the 105 msec of the acceleration phase. Wrist flexion is important in the throwing athlete. The golf swing in right-handed golfers has also been studied and reveals that an arc of 103 of flexion/extension is required in the right wrist as opposed to 71 in the left (J. Y. Ryu, unpublished data, 1990). It is noteworthy that 45 of radial-ulnar excursion is required in both wrists. Advanced players use less flexion/extension on the left, but more on the right, than those with high handicaps.
1038

* Address correspondence and reprint requests to Arthur C. Rettig, MD, Methodist Sports Medicine Center, 201 Pennsylvania Parkway, Suite 200, Indianapolis, IN 46280-1381. No financial benefit was bestowed on the author or institution in the creation of this work.

Vol. 31, No. 6, 2003

Wrist and Hand Injuries in Athletes

1039

These studies have implications for wrist splinting as there is great variability between sports and positions regarding the ability of athletes to participate with limited wrist motion.

TRAUMATIC INJURIES
Carpal Scaphoid Fractures The most common, and also the most problematic, fracture in the wrist of athletes is that of the carpal scaphoid. It accounts for 70% of all carpal fractures and is most prevalent in the 15- to 30-year-old population.81 The scaphoid bone has an irregular shape, and 80% of the surface is covered by articular cartilage.65 Blood supply to the scaphoid has been well documented by Panagis et al.,75 who have shown that dorsal vessels supply 70% to 80% of vascularity, the majority of which enters at the dorsal ridge of the scaphoid (Fig. 1). Because of the vascular anatomy, proximal pole fractures have a worse prognosis for healing than more distal injuries. The biomechanics of the scaphoid fracture have been well defined by Weber and Chao,107 who reproduced the fracture in the laboratory in wrists in more than 90 of dorsiflexion and more than 10 of radial deviation and with more than 400 kg of force. Distal radius fractures occur with less dorsiflexion and with less load.107 The diagnosis of acute scaphoid fracture is sometimes difficult because initial plain radiographs frequently do not show the fracture. Any contact-sport athlete who has radial wrist pain should be considered to have a scaphoid fracture until proven otherwise. Physical examination in the acute setting reveals tenderness in the anatomic

Figure 1. A cleared specimen showing the internal vascularity of the scaphoid. The vessels in the dorsal and volar scapholunate ligaments do not penetrate the bone. 1, dorsal scaphoid branch of the radial artery; 2, volar scaphoid branch. (Reprinted with permission from Rettig AC: Management of acute scaphoid fractures. Hand Clin 16: 381395, 2000.)

snuffbox, decreased range of motion, swelling, and pain with dorsiflexion. In cases of clinical suspicion of scaphoid fracture that are not shown radiographically, other imaging studies are indicated. My colleagues and I prefer to obtain MRI studies to determine the presence or absence of a fracture. Other studies such as bone scan and CT39 are helpful, but bear in mind that false-negative studies have been reported91 (Fig. 2). Scaphoid fractures are classified by location, stability, and time from injury.5, 89, 97 Most acute fractures in the athlete are midthird and minimally displaced, although unstable and midthird proximal pole fractures are not uncommon. The goal of treatment of acute scaphoid fracture is to obtain union. Natural history studies of untreated scaphoid fractures demonstrate that fracture nonunion and progressive radial carpal arthrosis ensue, with severity increasing with time from injury.61, 87 Kerluke and McCabe51 noted that these studies are retrospective and that a true prospective study has not been done. Treatment of acute scaphoid fracture in the athlete depends on location and stability of the fracture, sport and position, and desires of the athlete and his or her family. Options include 1) cast treatment with no sports participation until healed, 2) cast treatment plus use of a playing cast/splint in sports where applicable, and 3) internal fixation of the fracture with return to play as symptoms permit. Cooney et al.23 have shown that 90% to 100% of midthird fractures will heal with cast treatment if treatment is started in the first 3 weeks after injury. The average healing time in these cases is 8 to 10 weeks. Application of a Muenster-type or long arm cast for 4 weeks, followed by a short arm cast, is the traditional method of treatment.56, 96 The athlete must be prepared to miss a minimum of 3 months of sports participation with this treatment. An alternative to casting is the use of a short arm thumb spica splint during nonathletic activities and a playing cast to allow participation in sports where this is allowed, such as football and soccer. Reister et al.85 and Rettig et al.83 reported a 90% union rate using this method. Redondo and Rehak (unpublished data, 1996) more recently compared union rates with traditional casting and no participation, versus casting plus playing cast. They noted an increased nonunion rate in the playing cast group and that 39% of athletes with a playing cast required surgery to obtain union, versus 15% in the cast-only group. The third treatment option is to proceed with open reduction and internal fixation of the fracture. Some authors agree that open reduction and internal fixation is indicated for unstable fractures and proximal pole fractures.45, 80, 83 Treatment of minimally displaced or nondisplaced midthird fractures is more controversial. This type of fracture is amenable to limited incision (mini-open) internal fixation or percutaneous internal fixation. Inoue and Shionoya49 compared cast treatment with mini-open internal fixation in workers and noted that time to work averaged 10.2 weeks in the cast group and 5.8 weeks in the internal fixation group, with nearly 100% union in both groups.

1040

Rettig

American Journal of Sports Medicine

Figure 2. A high school football player sustained a hyperextension injury to his right wrist. Examination revealed anatomic snuffbox tenderness and swelling, although plain radiographs were read as negative. Because of a high suspicion for scaphoid fracture, a CT scan was obtained. A and B, the scan was read as negative; C, an MRI showed the fracture. (Reprinted with permission from Rettig AC: Management of acute scaphoid fractures. Hand Clin 16: 381395, 2000.) Return to sports after use of an open Russe89 approach was found to be 5.8 weeks,80 versus 4.4 weeks with a limited incision approach (Rettig and Puckett, unpublished data, 1995). Use of a cannulated Herbert-Whipple 3.0 synthetic compression screw with threaded washer and, more recently, percutaneous fixation by Acutrak screw (Acumed, LLC, Hillsboro, Oregon) (J. Slade, unpublished data, 2003) have been advocated. Although internal fixation of acute scaphoid fractures is still controversial, it has become more accepted as the standard of treatment for this difficult problem. Scaphoid fractures with delayed or no union are frequently seen in athletes because the initial injury is often ignored. Frequently, a football player is seen at seasons end with a painful wrist and an established nonunion. Symptomatic nonunion fractures should undergo bone grafting and internal fixation, but return to play must be delayed until healing occurs. The standard procedure consists of an iliac crest bone graft. More recently, vascularized bone graft from the distal radius has been shown to result in accelerated healing.110 Use of electrical stimulation to aid in healing is controversial.37 Controversy also exists regarding the treatment of asymptomatic nonunion of these fractures. On the basis of previously noted natural history studies, some physicians advocate bone grafting and internal fixation. Participation in sports at a high level with nonunion of scaphoid fractures has been shown by Shields (unpublished data, 1982); the option of treatment must be discussed with the athlete and his or her family. Hook of the Hamate Fractures Fractures of the body of the hamate may occur from trauma and usually occur in combination with fractures of

Figure 3. Volar view of the carpus showing the hook of the hamate, just distal to the pisiform. (Reprinted with permission from Walsh JJ 4th, Bishop AT: Diagnosis and management of hamate hook fractures. Hand Clin 16: 397 403, 2000.) the base of the fourth and fifth metacarpals. Fractures of the hook of the hamate are more common in athletes (Fig. 3). The incidence of hook of the hamate fractures is 2% to 4% of all carpal fractures.11, 13, 18, 67, 107 The mechanism of injury is thought to be caused by abutment of the hook on an object or by a shearing force applied by the flexor tendon of the small and ring fingers.95, 107 The injury usually occurs in athletes who participate in baseball, golf, and racquet sports because of the position of the implement in the hand (Fig. 4). Fracture anatomy has been studied; of note is a watershed area that may explain the high incidence of nonunion post fractures (Fig. 5).32, 75, 101 Hook of the hamate fracture must be suspected in ath-

Vol. 31, No. 6, 2003

Wrist and Hand Injuries in Athletes

1041

Figure 5. Hook of hamate vascularity. Percentage of hooks of the hamate with vascular foramina at radial base (RB), radial hook tip (RH), ulnar hook tip (UH), and ulnar proximal base (UPB). (Reprinted with permission from Walsh JJ IV, Bishop AT: Diagnosis and management of hamate hook fractures. Hand Clin 16: 397 403, 2000.) athletes usually have insidious onset of fracture, although a single traumatic event may be recalled. Physical findings of these fractures include tenderness in the lunate or at the radial carpal area, decreased range of motion, and decreased grip strength. Plain radiographs may be negative in the early stages, and MRI is needed for a definitive diagnosis. The condition is usually associated with an ulnar negative variance on posteroanterior radiographs. Treatment of Kienbocks disease is complex and de pends on the stage of the disease.4 In stage 0 to 2A of the disease, where there is minimal carpal collapse, jointleveling procedures (such as radial shortening) is compatible with return to sports. Intercarpal arthrodesis or proximal row carpectomy should be reserved for salvage cases and will result in significant limitation of wrist motion.4 Pisiform Fractures The pisiform bone may be injured from a direct blow and it can undergo chondral changes from overuse, leading to pisotriquetral arthrosis. This is frequently seen in athletes who participate in racquet sports.74 Diagnosis may be made by injection of lidocaine at the pisotriquetral articulation. In cases of pisotriquetral fractures, excision of the pisiform may be indicated, with return to sports in 6 to 8 weeks.44, 74

Figure 4. Location of the hook of the hamate (H) relative to a bat end in the nondominant left hand of a right-handed hitter. (Reprinted with permission from Walsh JJ IV, Bishop AT: Diagnosis and management of hamate hook fractures. Hand Clin 16: 397 403, 2000.)

letes participating in racquet sports, golf, or baseball who are seen with ulnar wrist pain. Examination reveals tenderness over the hook of the hamate, which lies on a line between the pisiform and second metacarpal head. Plain radiographs usually do not reveal the fracture; carpal tunnel and supinated oblique views should be obtained. Diagnosis is confirmed by CT scan and bone scan.30 Treatment of hook of the hamate fractures in athletes varies from casting to open reduction and internal fixation to excision. Bishop and Beckenbaugh11 reported 21 cases of this fracture, 17 were treated by excision, 3 underwent open reduction and internal fixation, and 1 had casting. Although two of three fractures that were treated with open reduction and internal fixation healed, many authors recommend excision, which has an average return to sport of 7 to 10 weeks.35, 43, 77, 95

LIGAMENT INJURIES OF THE WRIST

Stability of the wrist depends on the geometry of the individual carpal bones and the ligamentous interconnections that control movement of one bone on another. The most common instabilities involve injury to the intrinsic ligaments of the wrist, mainly those that connect the scaphoid and lunate, and lunate and triquetrum bones. A less common type of instability (midcarpal instability) results from injury or attenuation of the ligaments connecting the proximal and distal carpal rows. The scaphoid exerts a flexion moment on the proximal

Lunate Fractures Acute fracture of the lunate is rare; however, athletes may be seen with Kienbocks disease or avascular necrosis of the lunate, presumably due to repetitive trauma. Such

1042

Rettig

American Journal of Sports Medicine

row and the triquetrum exerts an extension moment. The lunate is held in neutral alignment by the scapholunate and lunotriquetral ligaments. If one of these ligaments is disrupted, abnormal carpal alignment and mechanics result. The disruption may be partial or complete, with the former resulting in dynamic carpal instability, which can be demonstrated in stress radiographic views or cine studies, and the latter resulting in static deformity, in which resting radiographs reveal the abnormalities.

SCAPHOLUNATE INJURIES
Scapholunate injuries, the most common type of wrist ligament injury, results from excessive wrist extension and ulnar deviation with intercarpal supination, such as a fall on a pronated hand.63 Injury to the scapholunate ligament may be partial or complete, depending on the force involved. The injury is common in collision and contact sports or any activity where a fall may occur. After scapholunate ligament disruption, the scaphoid assumes a flexed position and the lunate and triquetrum extend, producing a dorsal intercalated segment instability pattern.28, 60 Wrist motion and load-bearing capacity may be compromised after such an injury, and pain occurs secondary to abnormal cartilage loading (shear) and synovitis. Over time, progressive arthrosis may ensue after scapholunate dissociation, with advanced collapse. The diagnosis of the scapholunate ligament injury in the acute setting depends on obtaining an accurate history (the inciting incident is usually a fall or injury from jamming into another athlete), precise physical examination, and appropriate imaging studies. In acute injuries, there is usually significant swelling, decreased range of motion, and tenderness, most marked in the scapholunate area and on the dorsal aspect of the wrist. The scaphoid shift test (Watsons sign104) is performed by applying a dorsal load to the distal pole of the scaphoid as the wrist is moved from an ulnar to radial deviation. Reproduction of pain and hearing a pop constitutes a positive test (Fig. 6). This test frequently is not possible to perform in the acute setting because of inflammation and pain; it is more reliable in chronic cases. The examination findings should always be compared with the opposite wrist as many athletes have a physiologically positive scaphoid shift test. Imaging studies may be positive in acute and complete injuries, demonstrating a gap of more than 2 to 3 mm on the posteroanterior views and an increased scapholunate angle on the lateral radiograph. Stress views, such as a clenched fist view and supinated view in ulnar deviation, are helpful. All radiographs must be compared with those of the uninjured wrist. Additional imaging studies such as arthrography or MRI may be obtained but have variable sensitivity and specificity regarding intercarpal ligament tears.53, 66, 86, 92, 93 Although complete scapholunate tears can usually be diagnosed by these studies, incomplete tears present a more difficult problem. Wrist arthroscopy is now the standard method of diagnosing intercarpal ligament injuries. Treatment of acute and complete scapholunate ligament

Figure 6. The scaphoid shift test is designed to evaluate scapholunate ligament integrity. The wrist is taken from ulnar to radial deviation with the examiners thumb applying palmar pressure to the distal pole of the scaphoid. This pressure opposes the normal scaphoid flexion that occurs in radial deviation of the wrist. When devoid of the ligamentous attachment to the lunate, the proximal pole of the scaphoid can be subluxated out of the elliptical fossa of the distal radius. Reproduction of pain in the context of pathologic scaphoid motion is diagnostic of scapholunate ligament insufficiency. (Reprinted with permission from Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 17: 533552, 1998.)

injuries involves arthroscopy of the wrist to confirm the diagnosis and open repair of the scapholunate ligament with or without augmentation. Nathan and Blatt68 described a dorsal capsulodesis as augmentation (Fig. 7), but this results in some decrease in palmar flexion, which is undesirable in many athletes. Berger (unpublished data, 2003) has recently proposed using a portion of the dorsal intercarpal ligament, which runs from the triquetrum to the distal scaphoid, for repair of this injury. The ligament is detached from the triquetrum and attached to the lunate by a suture anchor to augment the repair. Theoretically, this results in more normal range of motion. It is important for the athlete to have a stable, pain-free wrist with near-normal range of motion and grip strength after repair. In scapholunate ligament injuries that are not complete, arthroscopic evaluation with percutaneous pin fixation has been advocated.109 More recently, Geisler and Savoie (unpublished data, 2003) have described thermal shrinkage of partial tears with or without pin fixation. Long-term results of this procedure are not available yet. Scapholunate ligament injuries are commonly chronic problems. Treatment of these cases is much more challenging. Primary repair may be performed up to 6 to 9 months after injury in certain situations. Berger (unpublished data, 2003) has described a bone-ligament-bone reconstruction for chronic cases using capitate-hamate bone plugs, similar to patellar tendon grafts for ACL reconstruction. Results of this procedure and others are somewhat unpredictable, but promising. In more chronic cases, where anatomic reduction cannot

Vol. 31, No. 6, 2003

Wrist and Hand Injuries in Athletes

1043

Figure 7. Capsulodesis as augmentation for complete scapholunate ligament injury. A, intraoperative photograph depicting scapholunate ligament disruption in which the ligament has avulsed off the lunate; B, after Kirshner wire stabilization of the reduced scapholunate relationship, the ligament has been repaired; C, diagram depicts a dorsal capsulodesis, securing the dorsal wrist capsule to the distal pole of the scaphoid. (Reprinted with permission from Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 17: 533552, 1998.) be obtained, a partial wrist arthrodesis such as a scaphocapitate or scapho-trapezio-trapezoid fusion7 may be performed, although this results in approximately 35% decreased range of motion, which is compatible with adequate performance in many sports. If arthrosis is present, a salvage procedure such as proximal row carpectomy41, 47, 48, 70 or scapholunate dissociation with advanced collapse wrist reconstruction may be indicated.7, 105 a dorsally directed force over the pisiform (triquetrum) and a palmar-directed force on the lunate, which produces a click and reproduces the patients pain (Fig. 8). In diagnosis of lunotriquetral injuries, plain radiographs are usually normal, although occasionally a stepoff may be noted along the proximal carpal row. Wrist arthrography has a variable sensitivity,53, 66 and it has

LUNOTRIQUETRAL INJURIES
Lunotriquetral injuries are usually the result of a sudden axial load with wrist extension and radial deviation with intercarpal pronation as opposed to supination, as in the scapholunate tears. These tears are much less common than scapholunate injuries (approximately 1:698), and the lunotriquetral ligament is much thinner than the scapholunate ligament. Although complete scapholunate disruption frequently leads to static dorsal intercalated segment instability deformity, lunotriquetral tears are rarely seen as a volar intercalated segment instability pattern because of the presence of secondary stabilizers.100, 103 Dorsal and volar extrinsic ulnar carpal and volar carpal ligaments help maintain the resting orientation of the triquetrum and lunate. The athlete with a lunotriquetral injury usually gives a history of a fall on an outstretched hand and resultant ulnarsided wrist pain, weakness, giving way, and a click sound with loading.28 Examination reveals tenderness over the lunotriquetral ligament and includes provocative tests such as a lunotriquetral shear test.54 This test involves applying

Figure 8. Depiction of the provocative lunotriquetral shear test used to detect lunotriquetral ligament insufficiency. Dorsal pressure is applied to the lunate, with corresponding palmar pressure on the triquetrum. This creates a shear vector on the lunotriquetral joint. A painful click with instability is diagnostic of lunotriquetral dissociation. (Reprinted with permission from Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 17: 533552, 1998.)

1044

Rettig

American Journal of Sports Medicine

been shown in cadaveric studies that 20% of asymptomatic persons between 20 and 60 years of age have a positive arthrogram.16 Magnetic resonance imaging is unpredictable as the ligament is quite small and the signal is difficult to interpret.86, 92, 94 If symptoms persist after immobilization, wrist arthroscopy remains the most definitive diagnostic tool. Lunotriquetral injuries, as opposed to scapholunate tears, usually do not lead to progressive arthrosis. In acute lunotriquetral injuries, immobilization is the initial treatment of choice and may lead to ligament healing in 80% of cases.22 In cases of persistent symptoms that do not respond to activity modification or nonsteroidal antiinflammatory drugs with or without steroid injection, surgical options vary from simple arthroscopic lunotriquetral ligament debridement88, 108 to lunotriquetral arthrodesiswhich has a significant nonunion rate64, 69 and results in 20% to 30% loss of range of motion52, 69to ulnarshortening osteotomy. Ulnocarpal forces are significantly reduced (20% to 4% with 2 mm of shortening)59, 69 after ulnar shortening and tension on the ulnar carpal ligament complex is increased, thus aiding in stabilization of the lunotriquetral joint. Also, return to sports after arthroscopic debridement is 6 to 8 weeks, whereas ulnar shortening may require 3 to 6 months.

Figure 9. Ulnar support splint for midcarpal instability provides dorsal pressure on the pisiform and volar pressure on the distal ulna. Athletic tape secures the splint and applies additional support.

MIDCARPAL INSTABILITY
Midcarpal instability is a form of carpal instability nondissociative, which means that the relationship within each carpal row is intact and the lesion occurs between the carpal rows.106 The lesion is thought to be caused by attenuation of the ulnar V ligament connecting the capitate with the distal carpal row to the triquetrum of the proximal row. Patients with this instability have ulnar wrist pain, and there is a painful clunk sound with ulnar deviation. Normally, the proximal carpal row moves from a flexed position in radial deviation to an extended position in ulnar deviation in a smooth transition. In midcarpal instability, the proximal row stays flexed until late in ulnar deviation and then snaps audibly into dorsiflexion, a situation known as the catch-up clunk.15, 58 On physical examination, a sulcus may be noted in the dorsal ulnar border of the wrist and a catch-up clunk may be demonstrated by simply having the athlete actively deviate the wrist ulnarly. The clunk is neutralized by applying dorsal-directed pressure over the pisiform and ulnar carpus. This maneuver helps confirm the diagnosis. The condition is frequently bilateral and the opposite wrist must be tested. Plain radiographs may demonstrate a volar intercalated segment instability pattern because of the palmar-flexed proximal row. Cinefluoroscopic examination of the wrist is the most helpful tool in confirming the diagnosis. Treatment of midcarpal instability is controversial. Frequently, athletes with midcarpal instability will respond to activity modifications, splinting, nonsteroidal antiinflammatory drugs, and will be able to return to sport. The use of a splint that supports the volar ulnar carpus

(Fig. 9) may be helpful for participation in some sports, especially racquet sports. If the athlete cannot participate and continues to be symptomatic, surgical options are unpredictable. A recent development involves the use of thermal shrinkage or modification of the V ligament arthroscopically. This is an attractive option, although longterm results are unknown. Reconstruction and midcarpal arthrodesis are last-resort procedures that are of questionable benefit to the athlete.

DISLOCATION OF THE CARPUS

Perilunate dislocation or volar lunate dislocation of the wrist results from excessive radiocarpal hyperextension and ulnar deviation plus intercarpal supination.34, 36, 50 Mayfield62 has described various stages of progressive injury; the previously discussed scapholunate dissociation is stage I. Perilunate dislocation results from disruption of the scapholunate and lunotriquetral ligaments, plus radial collateral ligament failure, and by rupture of the capitolunate capsule (Fig. 10). Perilunate dislocation should be suspected after trauma in collision sports when significant swelling and significant decreased range of motion are observed. Minor swelling and deformity may not be that noticeable. The examiner should check neurocirculatory function as carpal tunnel syndrome with compression of the median nerve is frequently a complication of the injury. The diagnosis is readily made on a true lateral radiograph in which the capitate is dorsally displaced on the lunate. In volar lunate dislocation, the lunate is displaced volarly into the carpal tunnel. Treatment of perilunate/volar lunate dislocations range from closed reduction with percutaneous pinning1, 6, 20, 40, 42, 79 to open reduction, repair, and internal fixation using a dorsal or dorsal and volar combined approach. The standard surgical approach of perilunate/volar lunate dislocations is open reduction and repair of ligament structures and pin fixation stabilizing the scapholunate and lunotriquetral articulations. If there is

Vol. 31, No. 6, 2003

Wrist and Hand Injuries in Athletes

1045

Figure 10. The four stages of progressive perilunate instability resulting from sequential disruption of key ligament structures in the vulnerable perilunar zone. Stage I is characterized by scapholunate dissociation, stages II and III by perilunate dislocation, and stage IV by complete destabilization with volar dislocation of the lunate. (Reprinted with permission from Melone CP Jr, Murphy MS, Raskin KB: Perilunate injuries. Repair by dual dorsal and volar approaches. Hand Clin 16: 439 448, 2000.) median nerve compromise, dorsal and volar approach with decompression of the nerve and repair of the volar capsule structures is desirable. Raab et al.79 reviewed 10 cases of perilunate dislocation in the National Football League, 6 of which were treated by closed reduction and percutaneous pin fixation. Nine of the 10 athletes returned to play, and 5 returned during the same season as injury, between 3 and 8 weeks after the injury. In certain cases, percutaneous pin fixation after closed reduction is a viable option in the athlete, although long-term results are questionable.

relatively avascular, and the dorsal and palmar radioulnar ligaments, which are more vascular and are stabilizing structures of the distal radioulnar joint (Figs. 11 and 12). The volar ulnar carpal ligaments extend from the periphery of the triangular fibrocartilage complex and ulnar styloid to the lunate and triquetrum. The triangular fibrocartilage complex is completed by the ulnar extensor muscle subsheath and the ulnar collateral ligament.14 The axially loaded forearm bears 82% of the load through the radius and 18% through the triangular fibrocartilage complex and ulna.72 The thickness of the triangular fibrocartilage complex varies inversely with a positive ulnar variance, and it has been shown that increased positive ulnar variance results in increased load-bearing through the ulnar axis.72 Injuries to the triangular fibrocartilage complex are more common in the wrist with ulnar positive variance. The diagnosis of triangular fibrocartilage complex injury depends on a careful history of injury and whether a single traumatic event is implicated or there is an insidious onset. Triangular fibrocartilage complex injury must be differentiated from other causes of ulnar wrist pain such as lunotriquetral injuries (described earlier), ulnar extensor muscle tendinitis or subluxation, chondral lesions of the distal radioulnar joint, ulnar flexor muscle tendinitis/pisotriquetral compression syndrome, and ulnar carpal impingement. Palmer and Werner72 have classified triangular fibrocartilage complex tears into trau-

DISTAL RADIOULNAR JOINT AND TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES

Distal radioulnar joint and triangular fibrocartilage complex injuries are common in athletes and may be the result of acute trauma, traumatic injury such as a fall or overuse, or repetitive trauma such as results from participation in racquet sports. The triangular fibrocartilage complex is generally regarded as the primary stabilizer of the distal radioulnar joint.73 The triangular fibrocartilage complex is divided into a central articular disc portion, which is

Figure 11. End-on view of the distal radius (R) and triangular fibrocartilage complex (TFC) after india ink injection. The radioulnar ligaments and peripheral 15% to 20% of the articular disc are well vascularized. No vessels have been identified in the central area of the articular disc. (Reprinted with permission from Dailey SW, Palmer AK: The role of arthroscopy in the evaluation and treatment of triangular fibrocartilage complex injuries in athletes. Hand Clin 16: 461 476, 2000.)

1046

Rettig

American Journal of Sports Medicine

Figure 12. The triangular fibrocartilage complex: triangular fibrocartilage, dorsal and palmar radioulnar ligaments, and the ulnar carpal ligaments. (Reprinted with permission from Nicolaidis SC, Hildreth DH, Lichtman DM: Acute injuries of the distal radioulnar joint. Hand Clin 16: 449 459, 2000.) matic and degenerative. Traumatic tears, usually noted in young athletes, may be central or peripheral, and peripheral tears may result in distal radioulnar joint instability. Acute traumatic events involve axial load-bearing with rotational stress, usually due to a fall on the outstretched hand. Acute injuries may be superimposed on chronic repetitive traumatic events. Triangular fibrocartilage complex injury and ulnar wrist pain are common in gymnasts, racquet players, hockey (from impact with the boards in slap shots, resulting in hypersupination), golf, boxing, waterskiing (from traction injury), and pole vaulting.73 Diagnosis of triangular fibrocartilage complex injuries should be made initially on the basis of physical examination. Triangular fibrocartilage complex tenderness is best localized by palpating the hollow between the pisiform and ulnar styloid on the ulnar border of the wrist. Dorsal peripheral tears may be elicited by the supination lift test, in which the patient is asked to lift the examination table with the palm flat on the underside of the table.19 Eliciting ulnar pain or weakness when attempting to lift ones self off the examining table also raises suspicion of triangular fibrocartilage complex injury. Distal radioulnar joint instability may be partial or complete, as classified by Bruckner et al.17 Having the athlete place both palms on the examining table and forcibly pressing the palms on the table elicits the piano key sign. Exaggerated dorsal-palmar translation, compared with the opposite side, indicates distal radioulnar joint instability. Degenerative changes in the distal radioulnar joint may be elicited by a grind test, in which the ulna and radius are compressed and the forearm is rotated. Imaging studies are helpful but may not be diagnostic for triangular fibrocartilage complex injuries. Plain radiographs should include a zero rotation posteroanterior view to evaluate the ulnar variance. In cases of acute injury, one must look for ulnar styloid base fractures, widening of the distal radioulnar joint space on AP view (compared with the opposite side), and dislocation/subluxation on the lateral view, although these findings are usually absent.

Triangular fibrocartilage complex tears may be assessed by the tricompartment wrist arthrogram. Levinsohn et al.57 showed that a three-compartment arthrogram is more sensitive in diagnosing triangular fibrocartilage complex tears than the single-compartment study. High-resolution MRI and MRI arthrogram are more commonly used to make the diagnosis.2, 3, 12, 21, 25, 57 In the experience of my colleagues and I, there is a high false-negative rate with the MRI. We reviewed 20 cases of arthroscopically proven triangular fibrocartilage complex tears and only 8 of the 20 MRIs were positive (Rettig and Marcheschi, unpublished data, 2001). To assess distal radioulnar joint instability, actual CT scans in neutral and pronation and supination are recommended.29, 31 In cases where initial imaging studies are negative but symptoms persist in spite of rest and splinting, wrist arthroscopy is recommended. Arthroscopy has the advantage of being both therapeutic as well as diagnostic. Arthroscopy of the radiocarpal, midcarpal, and distal radioulnar joint may yield a diagnosis of chondral lesions of the distal radioulnar joint as well as triangular fibrocartilage complex tears and instability. The trampoline test involves probing the triangular fibrocartilage complex to assess the tension.46 If normal bounce is not present, a peripheral triangular fibrocartilage complex tear may exist. The physician treating high-level athletes elite high school, collegiate, or professional athletesmay consider a more aggressive approach to the patient with suspected triangular fibrocartilage complex/distal radioulnar joint injury. If distal radioulnar joint instability is demonstrated, early intervention with arthroscopy and peripheral triangular fibrocartilage complex repair is indicated. If the distal radioulnar joint is stable and symptoms are present for 2 to 3 weeks, arthroscopy is also indicated. In stable distal radioulnar joint injuries with type 1A triangular fibrocartilage complex tears (traumatic tears of the central articular disc), debridement of the centrum has been well documented as the treatment of choice.71, 78, 84, 99 Postoperatively, patients with debrided central lesions are splinted for 1 week and range of motion is begun. Golf or tennis athletes may begin light-activity ball contact at 3 weeks and are typically able to return to restricted sports activity in 4 to 6 weeks. There have been 90% good-toexcellent results with debridement of the centrum reported by Bednar and Osterman.8 For type 1B lesions (peripheral triangular fibrocartilage complex tears at the ulnar insertion), a more aggressive approach, as opposed to immobilization, is recommended for athletes. Arthroscopic repair may be performed by one of several techniques.9, 24, 38, 102 Postoperatively, the repair is protected in a Muenster cast for 6 weeks, followed by active range of motion. Strengthening is begun at 8 weeks and return to sport occurs in 3 to 4 months. More than 90% good-to-excellent results have been reported with this treatment.9, 24, 26 In degenerative triangular fibrocartilage complex lesions or acute or chronic injuries, the ulnar variance must be carefully assessed. In neutral and positive variance, the option of ulnar shortening, either by a Feldon wafer resection33 or formal ulnar shortening with plate fixation,

Vol. 31, No. 6, 2003

Wrist and Hand Injuries in Athletes

1047

Figure 13. A, 1B triangular fibrocartilage complex repair with two 2 0 PDS sutures; one is tight and one is loose. B, completion of a 1B1 triangular fibrocartilage complex repair with 2 0 sutures; both are tight. (Reprinted with permission from Dailey SW, Palmer AK: The role of arthroscopy in the evaluation and treatment of triangular fibrocartilage complex injuries in athletes. Hand Clin 16: 461 476, 2000.) should be discussed with the athlete. The Feldon wafer technique is indicated in cases of an ulnar variance of less than 3 mm and may be performed open or arthroscopically.33 In cases with more than 3-mm positive variance, a formal open ulnar shortening with 3.5 compression plate fixation is indicated, accompanied by wrist arthroscopy. Midcarpal arthroscopy should be performed in all cases to evaluate the proximal pole of the hamate for possible chondral lesions, which are seen in athletes with type 2 lunate bones in which a facet on the lunate articulates with the hamate (Fig. 13). REFERENCES
1. Adkison JW, Chapman MW: Treatment of acute lunate and perilunate dislocations. Clin Orthop 164: 199 207, 1982 2. af Ekenstam F, Hagert CG: Anatomical studies on the geometry and stability of the distal radioulnar joint. Scand J Plast Reconstr Surg 19: 1725, 1985 3. Alexander AH: Bilateral traumatic dislocation of the distal radioulnar joint, ulnar dorsal: Case report and review of the literature. Clin Orthop 129: 238 244, 1977 4. Allan CH, Joshi A, Lichtman DM: Keinbocks disease: Diagnosis and treatment. J Am Acad Orthop Surg 9: 128 136, 2001

5. Amadio PC, Taleisnik J: Fractures of the carpal bones, in Green DP (ed): Operative Hand Surgery. Third edition. New York, Churchill Livingstone, 1993 6. Apergis E, Maris J, Theodoratos G, et al: Perilunate dislocations and fracture-dislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand (Suppl) 275: 5559, 1997 7. Ashmead D IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg 19A: 741750, 1994 8. Bednar JM, Osterman AL: The role of arthroscopy in the treatment of traumatic triangular fibrocartilage injuries. Hand Clin 10: 605 614, 1994 9. Bednar MS, Arnoczky SP, Weiland AJ: The microvasculature of the triangular fibrocartilage complex: Its clinical significance. J Hand Surg 16A: 11011105, 1991 10. Bergfeld JA, Weiker GG, Andrish JT, et al: Soft playing splint for protection of significant hand and wrist injuries in sports. Am J Sports Med 10: 293296, 1982 11. Bishop AT, Beckenbaugh RD: Fracture of the hamate hook. J Hand Surg 13A: 135139, 1988 12. Bock GW, Cohen MS, Resnick D: Fracture-dislocation of the elbow with inferior radioulnar dislocation: A variant of the Essex-Lopresti injury. Skeletal Radiol 21: 315317, 1992 13. Bowen TL: Injuries of the hamate bone. Hand 5: 235238, 1973 14. Bowers WH: The distal radioulnar joint, in Green DP (ed): Operative Hand Surgery. Second edition. New York, Churchill Livingstone, 1988, pp 939 989 15. Brown DE, Lichtman DM: Midcarpal instability. Hand Clin 3: 135140, 1987 16. Brown JA, Janzen DL, Adler BD, et al: Arthrography of the contralateral, asymptomatic wrist in patients with unilateral wrist pain. Can Assoc Radiol J 45: 292296, 1994 17. Bruckner JD, Alexander AH, Lichtman DM: Acute dislocations of the distal radioulnar joint. J Bone Joint Surg 77A: 958 968, 1995 18. Bryan RS, Dobyns JH: Fractures of the carpal bones other than lunate and navicular. Clin Orthop 149: 107111, 1980 19. Buterbaugh GA, Brown TR, Horn PC: Ulnar-sided wrist pain in athletes. Clin Sports Med 17: 567583, 1998 20. Campbell RD Jr, Thompson TC, Lance EM, et al: Indications for open reduction of lunate and perilunate dislocation of the carpal bones. J Bone Joint Surg 47A: 915937, 1965 21. Chidgey LK, Dell PC, Bittar E, et al: Tear patterns and collagen arrangement in the triangular fibrocartilage. J Hand Surg 15A: 826, 1990 22. Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 17: 533552, 1998 23. Cooney WP III, Dobyns JH, Linscheid RL: Nonunion of the scaphoid: Analysis of the results from bone grafting. J Hand Surg 5A: 343354, 1980 24. Corso SJ, Savoie FH, Geissler WB, et al: Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: A multicenter study. Arthroscopy 13: 78 84, 1997 25. Dameron TB Jr: Traumatic dislocation of the distal radioulnar joint. Clin Orthop 83: 55 63, 1972 26. De Araujo W, Poehling GG, Kuzma GR: New Tuohy needle technique for triangular fibrocartilage complex repair: Preliminary studies. Arthroscopy 12: 699 703, 1996 27. DeHaven KE, Lintner DM: Athletic injuries: Comparison by age, sport, and gender. Am J Sports Med 14: 218 224, 1986 28. Dobyns JH, Linscheid RL, Chao EYS, et al: Traumatic instability of the wrist. Instr Course Lect 24: 182199, 1975 29. Edwards GS Jr, Jupiter JB: Radial head fractures with acute distal radioulnar dislocation: Essex-Lopresti revisited. Clin Orthop 234: 61 69, 1988 30. Egawa M, Asai T: Fracture of the hook of the hamate: Report of six cases and the suitability of computerized tomography. J Hand Surg 8A: 393 398, 1983 31. Essex-Lopresti P: Fractures of the radial head with distal radioulnar joint dislocation. J Bone Joint Surg 33B: 244, 1951 32. Failla JM: Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion. J Hand Surg 18A: 10751079, 1993 33. Feldon P, Terrono AL, Belsky MR: Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg 17A: 731737, 1992 34. Fisk GR: Carpal instability and the fractured scaphoid. Ann R Coll Surg Engl 46: 6376, 1970 35. Foucher G, Schuind F, Merle M, et al: Fractures of the hook of the hamate. J Hand Surg 10B: 205210, 1985 36. Frykman G: Fractures of the distal radius including sequelashoulderhand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand (Suppl) 108: 1967 37. Frykman GK, Taleisnik J, Peters G, et al: Treatment of nonunited scaphoid fractures by pulsed electromagnetic field and cast. J Hand Surg 11A: 344 349, 1986

1048

Rettig

American Journal of Sports Medicine

77. Parker RD, Berkowitz MS, Brahms MA, et al: Hook of the hamate fractures in athletes. Am J Sports Med 14: 517523, 1986 78. Pederzini L, Luchetti R, Soragni O, et al: Evaluation of the triangular fibrocartilage complex tears by arthroscopy, arthrography, and magnetic resonance imaging. Arthroscopy 8: 191197, 1992 79. Raab DJ, Fischer DA, Quick DC: Lunate and perilunate dislocations in professional football players. A five-year retrospective analysis. Am J Sports Med 22: 841 845, 1994 80. Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med 24: 182186, 1996 81. Rettig AC, Patel DV: Epidemiology of elbow, forearm, and wrist injuries in the athlete. Clin Sports Med 14: 289 297, 1995 82. Rettig AC, Ryan RO, Stone JA: Epidemiology of hand injuries in sports, in Strickland JW, Rettig AC (eds): Hand Injuries in Athletes. Philadelphia, WB Saunders, 1992, pp 37 44 83. Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management of midthird scaphoid fractures in the athlete. Am J Sports Med 22: 711714, 1994 84. Rettig ME, Raskin KB, Melone CP Jr: Clinical applications of MR imaging in hand and wrist surgery. Magn Reson Imaging Clin N Am 3: 361368, 1995 85. Riester JN, Baker BE, Mosher JF, et al: A review of scaphoid fracture healing in competitive athletes. Am J Sports Med 13: 159 161, 1985 86. Rominger MB, Bernreuter WK, Kenney PJ, et al: MR imaging of anatomy and tears of wrist ligaments. Radiographics 13: 12331246, 1993 87. Ruby LK, Stinson J, Belsky MR: The natural history of scaphoid non-union: A review of fifty-five cases. J Bone Joint Surg 67A: 428 432, 1985 88. Ruch DS, Poehling GG: Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist. J Hand Surg 21A: 412 417, 1996 89. Russe O: Fracture of the carpal navicular. Diagnosis, non-operative treat ment, and operative treatment. J Bone Joint Surg 42A: 759 768, 1960 90. Ryu JY, Cooney WP III, Askew JL, et al: Functional range of motion of the wrist joint. J Hand Surg 16: 409 419, 1991 91. Sanders WE: Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg 13A: 182187, 1988 92. Schweitzer ME, Brahme SK, Hodler J, et al: Chronic wrist pain: Spinecho and short tau inversion recovery MR imaging and conventional and MR arthrography. Radiology 182: 205211, 1992 93. Smith DK: Scapholunate interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrist. Radiology 192: 217221, 1994 94. Smith DK, Snearly WN: Lunotriquetral interosseous ligament of the wrist: MR appearances in asymptomatic volunteers and arthrographically normal wrists. Radiology 191: 199 202, 1994 95. Stark HH, Jobe FW, Boyes JH, et al: Fracture of the hook of the hamate in athletes. J Bone Joint Surg 59A: 575582, 1977 96. Stewart MJ: Fractures of the carpal navicular (scaphoid). A report of 436 cases. J Bone Joint Surg 36A: 998 1006, 1954 97. Totterman SM, Miller RJ: MR imaging of the triangular fibrocartilage complex. Magn Reson Imaging Clin N Am 3: 213228, 1995 98. Trumble TE, Bour CJ, Smith RJ, et al: Kinematics of the ulnar carpus related to the volar intercalated segment instability pattern. J Hand Surg 15A: 384 392, 1990 99. Trumble TE, Bour CJ, Smith RJ, et al: Intercarpal arthrodesis for static and dynamic palmar intercalated segment instability. J Hand Surg 13A: 396 402, 1988 100. Van Demark RE, Parke WW: Avascular necrosis of the hamate: A case report with reference to the hamate blood supply. J Hand Surg 17A: 1086 1090, 1992 101. Vender MI, Watson HK: Acquired Madelung-like deformity in a gymnast. J Hand Surg 13A: 19 21, 1988 102. Viegas SF, Patterson RM, Peterson PD, et al: Ulnar-sided perilunate instability: An anatomic and biomechanic study. J Hand Surg 15A: 268 278, 1990 103. Watson HK, Ashmead D IV, Makhlouf MV: Examination of the scaphoid. J Hand Surg 13A: 657 660, 1998 104. Watson HK, Ballet FL: The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg 9A: 358 365, 1984 105. Watson HK, Black DM: Instabilities of the wrist. Hand Clin 3: 103111, 1987 106. Watson HK, Rogers WD: Nonunion of the hook of the hamate: An argument for bone grafting the nonunion. J Hand Surg 14A: 486 490, 1989 107. Weber ER, Chao EY: An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg 3A: 142148, 1978 108. Whipple TL: The role of arthroscopy in the treatment of wrist injuries in the athlete. Clin Sports Med 17: 623 634, 1998 109. Williams J: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg 59B: 408 410, 1977 110. Zaidernberg C, Siebert JW, Angrigiana C: A new vascularized bone graft for scaphoid nonunion. J Hand Surg 16: 474 478, 1991

38. Gan BS, Richards RS, Roth JH: Arthroscopic treatment of triangular fibrocartilage tears. Orthop Clin North Am 26: 721729, 1995 39. Ganel A, Engel J, Oster Z, et al: Bone scanning in the assessment of fractures of the scaphoid. J Hand Surg 4A: 540 543, 1979 40. Gilford WW, Bolton RM, Lambrinudi C: The mechanism of the wrist joint with special reference to fractures of the scaphoid. Guys Hospital Report 92: 5259, 1943 41. Green DP: Proximal row carpectomy. Hand Clin 3: 163168, 1987 42. Green DP, OBrien ET: Open reduction of carpal dislocations: Indications and operative techniques. J Hand Surg 3A: 250 265, 1978 43. Gupta A, Risitano G, Crawford R, et al: Fractures of the hook of the hamate. Injury 20: 284 286, 1989 44. Helal B: Racquet players pisiform. Hand 10: 8790, 1978 45. Herbert TJ, Fisher WE, Leicester AW: The Herbert bone screw: A ten year perspective. J Hand Surg 17B: 415 419, 1992 46. Hermansdorfer JD, Kleinman WB: Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg 16A: 340 346, 1991 47. Imbriglia JE, Broudy AS, Hagberg WC, et al: Proximal row carpectomy: Clinical evaluation. J Hand Surg 15A: 426 430, 1990 48. Inglis AE, Jones EC: Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg 59A: 460 463, 1977 49. Inoue G, Shionoya K: Herbert screw fixation by limited access for acute fractures of the scaphoid. J Bone Joint Surg 79B: 418 421, 1997 50. Johnson RP: The acutely injured wrist and its residuals. Clin Orthop 149: 33 44, 1980 51. Kerluke L, McCabe SJ: Nonunion of the scaphoid: A critical analysis of recent natural history studies. J Hand Surg 18A: 13, 1993 52. Kirschenbaum D, Coyle MP, Leddy JP: Chronic lunotriquetral instability: Diagnosis and treatment. J Hand Surg 18A: 11071112, 1993 53. Kirschenbaum D, Sieler S, Solonick D, et al: Arthrography of the wrist: Assessment of the integrity of the ligaments in young asymptomatic adults. J Bone Joint Surg 77A: 12071209, 1995 54. Kleinman WB: The luno-triquetral shuck test. Am Soc Surg Hand Corr News: 51, 1985 55. Krahl H, Michaelis U, Pieper HG, et al: Stimulation of bone growth through sports: A radiologic investigation of the upper extremities in professional tennis players. Am J Sports Med 22: 751757, 1994 56. Kuschner SH, Lane CS, Brien WW, et al: Scaphoid fractures and scaphoid nonunion. Diagnosis and treatment. Orthop Rev 23: 861 871, 1994 57. Levinsohn EM, Rosen ID, Palmer AK: Wrist arthrography: Value of the three-compartment injection method. Radiology 179: 231239, 1991 58. Lichtman DM, Schneider JR, Swafford AR, et al: Ulnar midcarpal instability clinical and laboratory analysis. J Hand Surg 6A: 515523, 1981 59. Linscheid RL: Ulnar lengthening and shortening. Hand Clin 3: 69 79, 1987 60. Linscheid RL, Dobyns JH, Beabout JW, et al: Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg 54A: 16121632, 1972 61. Mack GR, Bosse MJ, Gelberman RH, et al: The natural history of scaphoid non-union. J Bone Joint Surg 66A: 504 509, 1984 62. Mayfield JK: Mechanism of carpal injuries. Clin Orthop 149: 4554, 1980 63. Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg 5A: 226 241, 1980 64. McAuliffe JA, Dell PC, Jaffe R: Complications of intercarpal arthrodesis. J Hand Surg 18A: 11211128, 1993 65. McClain EJ, Boyes JH: Missed fractures of the greater multangular. J Bone Joint Surg 48A: 15251528, 1966 66. Metz VM, Mann FA, Gilula LA: Lack of correlation between site of wrist pain and location of noncommunicating defects shown by three-compartment wrist arthrography. AJR Am J Roentgenol 160: 1239 1243, 1993 67. Murray PM, Cooney WP: Golf-induced injuries of the wrist. Clin Sports Med 15: 85109, 1996 68. Nathan R, Blatt G: Rotary subluxation of the scaphoid. Revisited. Hand Clin 16: 417 431, 2000 69. Nelson DL, Manske PR, Pruitt DL, et al: Lunotriquetral arthrodesis. J Hand Surg 18A: 11131120, 1993 70. Neviaser RJ: Proximal row carpectomy for posttraumatic disorders of the carpus. J Hand Surg 8A: 301305, 1983 71. Palmer AK: Triangular fibrocartilage disorders: Injury patterns and treatment. Arthroscopy 6: 125132, 1990 72. Palmer AK, Werner FW: Biomechanics of the distal radioulnar joint. Clin Orthop 187: 26 35, 1984 73. Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist: Anatomy and function. J Hand Surg 6A: 153162, 1981 74. Palmieri TJ: Pisiform area pain treatment by pisiform excision. J Hand Surg 7A: 477 480, 1982 75. Panagis JS, Gelberman RH, Taleisnik J, et al: The arterial anatomy of the human carpus. Part II: The intraosseous vascularity. J Hand Surg 8A: 375382, 1983 76. Pappas AM, Morgan WJ, Schulz LA, et al: Wrist kinematics during pitching. A preliminary report. Am J Sports Med 23: 312315, 1995