Keywords
dorsal radiocarpal ligament - ligament tear - arthroscopic repair
Introduction
The dorsal radiocarpal ligament (DRCL) is important in carpal stability.[1]
[2] The DRCL is a dorsal capsular ligament of the wrist; it originates from the distal
radius, just ulnar and distal to Lister's tubercle, and extends to the ulnar horn
of the lunate and to the distal region of the lunotriquetral ligament (LTL), inserting
onto the tubercle of the triquetrum.[2] The dorsal intercarpal ligament (DIC) originates from the triquetrum and extends
radially to attach to the lunate, the dorsal groove of the scaphoid, and then the
trapezium.[2] The DRCL and DIC have a lateral V configuration that works like a dorsal radioscaphoid
ligament, allows normal carpal kinematics, and provides stability to the scaphoid
over the full arc of wrist motion.[2]
[3] Tears of the DRCL have been related to the development of volar intercalated segmental
instability (VISI), dorsal intercalated segmental instability (DISI) and may be involved
in the development of midcarpal instability.[1]
[3]
[4]
We have to consider the arthroscopic repair of the DRCL in isolated DRCL tears and
in cases when the associated lesions are treated, such as when the scapholunate interosseous
ligament (SLIL) is debrided and/or pinned; and in ulnar-sided pathology, like lunotriquetral
ligament tears and triangular fibrocartilage complex tears.[5] The contribution of the DRCL to the final outcome in combined repairs, however,
is difficult to isolate.
The DRCL is difficult to visualize through the standard dorsal wrist arthroscopy portals.
The torn edge of the DRCL tends to float up against the arthroscope while viewing
through the 3–4 portal but can be seen obliquely through the 1–2 and 6U portal. The
best view of the DRCL is through the volar radial portal.[6]
[7]
[8]
The purpose of the present article is to describe three cases of uncommon DRCL tear
that were treated by arthroscopic repair with good results.
Clinical Case
Case 1
A 29-year-old male patient, professional futsal player and supermarket cashier, went
to the clinic because he had a left wrist pain for 17 months. He referred a trauma
with hyperextension of the wrist while playing futsal. Upon physical examination,
he had dorsal wrist pain, radial styloid pain, and dorsal-volar carpal translation.
There was no visible deformity or neurovascular deficit. The anteroposterior (AP)
and lateral radiographs were normal. An ultrasound showed an extensor tenosynovitis
and dorsal capsule-ligament thickening. A magnetic resonance imaging (MRI) showed
a dorsal heterogeneous hyperdensity of the radiocarpal interface compatible with distension
of the DRCL, fluid in the carpus, and slight anteversion of the scaphoid and posttraumatic
ligament lability between the deep ligament structures of the carpus. An arthro-computed
tomography (CT) was requested to confirm the diagnosis, which showed the presence
of disruption of the dorsal articular capsule, involving the DRCL, without other lesions
([Fig. 1]). The patient failed a trial of splinting and activity modification. He was proposed
for arthroscopic repair.
Fig. 1 Arthro-computed tomography, case 1.
Case 2
A 33-year-old female patient, casino worker, went to the clinic because she had a
right wrist pain for 7 months, after a traffic accident. Upon physical examination,
she had dorsal wrist pain. There was no visible deformity or neurovascular deficit.
The AP and lateral radiographs were normal. She performed an MRI that showed edema
of the DRCL, possibly related to stretch. The patient failed a trial of splinting
and activity modification. She was proposed for arthroscopic repair.
Case 3
A 31-years-old male, forklift driver, went to the clinic because he had a wrist pain
for 9 months. He referred a trauma with hyperextension of the wrist. Upon physical
examination, he had radial wrist pain and dorsal-volar carpal translation. There was
no visible deformity or neurovascular deficit. The AP and lateral radiographs and
ultrasound were normal. He performed an MRI, which raised the suspicion of DRCL lesion
without another ligament injury. An arthro-CT was requested to confirm the diagnosis,
which showed a presence of disruption of the DRCL and of the scapholunate and lunotriquetral
interosseous ligaments too ([Fig. 2]). The patient failed a trial of splinting and activity modification. He was proposed
for arthroscopic repair.
Fig. 2 Arthro-computed tomography, case 3.
Surgical Technique
We used the outside-in technique described by Slutsky.[4]
[5]
[6] Under tourniquet control, the patient's arm is suspended in a traction tower, the
dorsal portals (3–4, 4–5, 6R, 6U and radial e ulnar midcarpal portals) and volar radial
portal are established. The DRCL is observed just ulnar to the 3–4 portal underneath
the lunate, and the hook probe reveals the torn edge of the ligament ([Fig. 3]). A 3-0 absorbable suture is passed through a needle that is introduced through
the 4–5 portal, running across the ligament, and the end of the suture is retrieved
with a grasper in the 3–4 portal ([Figs. 4] and [5]). After both ends of the suture are withdrawn, dorsal traction can be seen to pull
the torn edge of the DRCL up against the dorsal capsule ([Fig. 6]). The suture is passed under the extensor tendons and tied at either dorsal portal
after releasing traction. Case 1 was performed under dry arthroscopy. There was dorsal
synovitis and no other injuries. Case 2 was performed with saline infusion; there
was a lunotriquetral interosseous ligament tear Geissler II, which was addressed by
lunotriquetral pinning. Case 3 was performed with dry arthroscopy; we found a scapholunate
interosseous ligament tear Geissler II, which was repaired by arthroscopic dorsal
capsule-ligamentous repair as described by Mathoulin et al.[9]
Fig. 3 Volar radial portal, dorsal radiocarpal ligament tear view.
Fig. 4 Ongoing ligament suture.
Fig. 5 Schematic view of the DRCL suture technique.
Fig. 6 Ligament repaired.
Postoperative, Rehabilitation and Follow-up
After surgery, the patients are placed in a short arm sugar tong cast with the wrist
in neutral rotation for 6 weeks. Wrist motion with use of a removable splint for comfort
is instituted after cast removal. Gradual strengthening exercises were added after
8 to 10 weeks. At 6 months postoperatively, the patients performed their work activities
without limitation and, in case 1, sport activity at 100%. The quick Disabilities
of the Arm, Shoulder and Hand (DASH) score was 29.5 at 6 months after the surgery.
Case 2 had a minor flexion loss without impact in her daily life. The patient returned
3 years later with unrelated symptoms and had a new MRI done that showed healing of
the DRCL and no synovitis or carpal injury. Case 3 recovered full range of motion,
returned to work at 3 months after the surgery, and the quick DASH score was 22 at
4.5 months after the surgery.
Discussion
The incidence of DRCL tears is not known.[3] This can be related to the fact that it is difficult to visualize the DCRL through
the standard dorsal wrist arthroscopy portals.[3] In a study of Slutsky, 35 of the 64 patients with wrist pain had a DRCL tear and
only 5 had an isolated DRCL tear.[4] An arthroscopic staging scheme for DRCL tears has been proposed ([Table 1]), depending on whether it is a lesion isolated from the DRCL or associated with
lesions of other structures, namely the scapholunate interosseous ligament, lunotriquetral
interosseous ligament or triangular fibrocartilage complex.[3]
[5] Although the natural history of these DRCL tears is not known, in a study of Slutsky,
the patients with an isolated DRCL tears had the most duration of pain, with a median
time of 36 months, whereas the group with associated intracarpal pathology had pain
for 12 months.[4] They concluded that even though the numbers are small, it is apparent that an isolated
DRCL tear does not necessarily lead to other intracarpal ligament or triangular fibrocartilage
complex (TFCC) tears.[4] An arthroscopic repair is indicated for isolated DRCL tears because it can provide
favorable outcomes.[3]
[6]
[10] Furthermore, Elsaidi demonstrated the importance of the DCRL on scaphoid kinematics
through a series of sectioning studies, concluding that when the DRCL was divided,
a DISI deformity occurred.[11]
Table 1
|
Stage
|
Description
|
|
1
|
Isolated DRCL tear
|
|
2
|
DRCL tear with associated SLIL or LTIL (Geissler I/II) or TFCC tear or midcarpal instability
|
|
3A
|
DRCL tear with associated SLIL or LTIL (Geissler III) and/or TFCC tear
|
|
3B
|
DRCL tear with associated SLIL or LTIL (Geissler IV) and/or TFCC tear
|
|
4
|
DRCL tear with chondromalacia or widespread degenerative changes
|
Short, in cadaveric studies, detected that either a dorsal capsulotomy sectioning
the dorsal radiocarpal ligament or insertion of the pressure sensor alters the scaphoid
and lunate kinematics during dynamic wrist motion, supporting the idea that the dorsal
wrist ligament should be spared during surgical approaches to the carpus.[1]
In case 1, the isolated DRCL rupture, we obtained a good postoperative quick DASH
score, although we cannot quantify the improvement because we did not have the preoperative
score. This good result is in line with the literature.
This condition can easily be missed by the orthopedic surgeon unless there is a high
degree of suspicion and it is actively looked for before and during arthroscopy. Good
results are expected following the arthroscopic repair of an isolated DRCL tear, however
he contribution of the DRCL to the final outcome in combined repairs is difficult
to isolate. It is arguable whether the DRCL repair changes the final result when other
ligament injuries are the primary diagnosis.
