Triquetral-lunate arthritis secondary to synostosis

Triquetral-lunate arthritis secondary to synostosis Until recently the problem of painful, symptomatic arthritis of the wrist secondary to congenitally incomplete separation of carpal bones has been infrequently recognized. Five patients with either excessive stress loadii or trauma had eight symptomatic wrists with congenitally incomplete separation of the triquetral-lunate johtt. Three of these patients had bilateral symptoms. Sii of the wrists had been treated by a limited wrist arthrodesis of the triquetral-lunate joint resulting in asymptomatic wrists and improved range of motion. It appears that patients with thii congenital condition poorly tolerate stress loading or trauma secondary to deficient intra-articular cartilage formation resulting in a clinical and anatomic state similar to degenerative arthritis. We suggest a liiited wrist arthrodesis as definitive treatment for symptomatic congenitally incomplete separation of the triquetral-lunate joint, with possible application in incomplete separation of the other intercarpal joints. (J HANDSuac 1989;14A:95-102.)

Stewart C. Gross, MD, H. Kirk Watson, MD, James W. Strickland, MD, Andrew K. Palmer, MD, and Laurence H. Brenner, MD, Hartford and New Haven, Conn.

A symptomatic

complete congenital fusion of carpal bones is well documented in the literature. la Most commonly involved are the lunate and the triquetrum.3-5.’ Symptomatic incomplete synostosis of the scaphoid and trapezium has only recently been described.’ This incomplete coalition was thought to be the cause of pain and tenderness in the region of the scaphoid. More recently, a case of symptomatic incomplete coalition of the Uiquetral-lunate joint successfully treated by triquetral-lunate fusion was presented.” However, no mention was made of the contralateral wrist. Patients with incomplete synostosis who apply heavy load activities to their wrists may be a new subset of that patient population with wrist pain of unknown cause. In addition, traumatic incidents may be poorly tolerated by patients with congenital changes of the carpal skeleton. This article reports on such a group of patients with painful wrists. Eight wrists in five patients Combined Hand Service: Hartford Hospital, University of Connecticut, Newington Children’s Hospital, Hart-

From the Connecticut

ford, Conn.; Yale University~New Haven, Conn.; University of Massachusetts, Worcester, Mass.; Indiana University School of Medicine, St. Vincent Hospital, Indianapolis, Ind; and the Upstate Medical Center, Syracuse, N. Y. Received for publication May 16, 1988.

Dec. 30, 1987; accepted

in revised form

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: CT 06106.

H. Kirk Watson, MD, 85 Seymour

St., Hartford,

were evaluated separately by the three senior authors, resulting in the use of varying diagnostic modalities but all similarly treated with arthrodesis between the lunate and triquetrum. The severity and duration of pain warranted surgical intervention in six of the eight wrists, with the other two wrists remaining symptomatic to lesser degrees. Relief was achieved by limited wrist arthrodesis of the involved triquetral-lunate joint. Case reports Case 1. A 21-year-old right-handed white female college student had pain and swelling develop in the middotsum and dorso-radial area of her left wrist one day after strenuous weight lifting associated with collegiate rowing. The pain was aggravated by minimal activity. The wrist was treated with anti-inflammatory agents and splinting resulting in minimal relief. Physical examination revealed a tenosynovitis of the first dorsal compartment and a less tenderness in the middorsal area of the wrist. Grip strength of the right hand was 60 pounds compared with 40 pounds of the left. Radiographs showed a slight narrowing between the lunate and triquetrum with cyst formation on the opposing side of the most proximal border of that joint (Fig. 1). The remainder of the carpus appeared normal. Treatment consisted of a local injection of a cortisone and lidocaine preparation, which was successful in relieving the de Quervain’s symptoms, but the middorsal painful area persisted and was reinjected. A wrist arthrogram demonstrated extravasation of dye from the proximal to midcarpal rows in the intracarpal area between the lunate and triquetrum. Approximately 4 months after the initial symptoms, a triquetral-lunate arthrodesis was done. Intra-operative in-

THE JOURNAL OF HAND SURGERY

95

96

Grosset al.

The Journal of HAND SlJRGERY

Fig. 1. Preoperative x-ray films of the left wrist (case 1) demonstrate narrowing in the proximal

triquetral-lunate articular surface, where the in utero separation has failed to form a complete and normal joint.

Fig. 2. Preoperative x-ray film of the right wrist (case 1) demonstrates proximal triquetral-luante joint narrowing almost identical to the left wrist.

spection revealed incomplete fusion with narrowing and marked cartilage attrition. The limited arthrodesis resulted in significant relief of preoperative symptoms. With an asymptomatic left wrist, the patient then admitted to similar symptoms ‘of her right wrist. Radiographic evaluation showed a similar arthritic pattern (Figs. 2 and 3) for which she had a limited wrist arthrodesis of the right triquetral-lunate joint using the distal radius as a donor graft site (Fig. 4). Both joints showed good union (Fig. 5). She had relief of her preoperative pain and adequate preservation of motion with 40 degrees of right wrist extension, 55 degrees of flexion, and 55 degrees of left wrist extension, and 75 degrees flexion. Case 2. A 33-year-old right-handed black man complained of pain and loss of strength in his left wrist that had been present since 1977. He related this pain to both his sandblasting occupation and to playing the guitar. There was no known isolated traumatic event. He was treated unsuccessfully with steroid injections for what was thought to be dorsal wrist tendon&is. Physical examination revealed point tenderness over the triquetral-lunate joint of the left wrist. There was no detectable wrist instability. Wrist extension measured 55 degrees, flexion 65 degrees, with 15 degrees and 35 degrees of radial and ulnar deviation, respectively. Pronation and supination were within normal limits and grip strength averaged 45 pounds for the left wrist and 90 pounds for the right wrist. Radiographs showed incomplete separation of the joint space with narrowing and degenerative cystic changes of the

Vol. 14A, No. 1 Janu ary 1989

Triquetral-lunate

arthritis

97

Fig. 3. Close-up view of the incomplete separation area of the proximal right triquetral-Iunate joint demonstrates the bony impingement and lack of adequate cartilaginous space.

left triquetral-lunate joint (Fig. 6, A). A motion study revealed no motion between the two carpal bones. Conservative treatment for 9 months included splinting, antiinflammatory medication, steroid injections, and temporary total work disability, which were all unsuccessful. At operation, the narrowed triquetral-lunate joint was found to contain a minimal quantity of cartilage, which was quite thin. There was no evidence of synovitis or other degenerative changes. Iliac bone graft was used for arthrodesis of the triquetral-lunate joint after a trough was created between these carpal bones. After operation the wrist was immobilized in plaster for 14 weeks and then placed in a wrist immobilizer. Follow-up radiographs demonstrated persistent pseudoarthrosis. The fibrous stability, however, enabled a return to full-time work, with the exception of sandblasting and the enjoyment of playing the guitar without symptoms. Postoperative range of motion included 50 degrees of extension, 35 degrees flexion, 5 degrees radial deviation, and 15 degrees of ulnar deviation of the left wrist and no tenderness over the fusion site. Subsequent radiographs of the right wrist revealed isolated degnerative changes of the triquetral-lunate joint (Fig. 6, B). Clinically, this wrist was mildly symptomatic and was treated by conservative measures. Case 3. A 3%year-old right-handed white female school teacher was seen initially with a 4- to 5-years history of pain on the ulnar side of the right wrist. The wrist had become particularly painful in the preceding several months and was aggravated by playing tennis. In addition, it became difficult

Fig. 4. Solid bony fusion is present 6 weeks after arthrode sis of the right triquetral-lunate joint. The pins were removed at the time of this x-ray film.

98

Gross et al.

The Journal of HAND SURGERY

Fig. 5. The left wrist at 13 months after arthrodesis and the right wrist at 6 months after arthrodesis, with a normal carpal configuration and solid arthrodesis of the triquetral-lunate joints on both sides.

Fig. 6. A-B, Bilateral incomplete separation of the triquetral-lunate joint produces a standard appearance and leads to symptomatic synovitis and bony impingement, with reactive bone problems in the area of incomplete separation.

Vol. 14A, No. 1 January 1989

for the patient to carry her 9-week-old baby. The history included a number of falls on the right wrist while ice skating. At the time of initial examination, everyday nonstressful activities caused considerable discomfort to the involved wrist. She denied any particular swelling and had no neurologic symptoms. On physical examination, tenderness over the triquetrallunate joint was found. The range of motion in the involved right wrist was 55 degrees extension and 80 degrees flexion compared with 65 degrees extension and 80 degrees flexion on the apparently uninvolved side. Radial deviation was 5 degrees and ulnar deviation 35 degrees bilaterally. Pronation and supination were equal and full. Radiographs of the right wrist demonstrated narrowing of the triquetral-lunate joint, with some cystic periarticular changes of the lunate (Fig. 7). Comparative views of the asymptomatic left wrist (Fig. 8) revealed similar changes of that triquetral-lunate joint. At operation there was marked narrowing of the triquetral-lunate joint with accompanying thin cartilage of both surfaces. The fusion was incomplete. After a fusion of the right triquetral-lunate joint, the patient denied pain in the right wrist and had an excellent range of motion, with 60 degrees extension and 75 degrees flexion. There was 10 degrees radial deviation and 30 degrees ulnar deviation. Ten months after operation, grip strength in both wrists was 40 pounds.

Triquetral-lunate

arthritis

99

Fig. 7. Typical loss of cartilaginous space, sclerosis, and cystic changes at the area of incomplete separation are demonstrated (case 3).

Discussion The carpus is the most common location of synostosis. Every possible carpal combination has been described, as well as its association with skeletal anomalies and congenital syndromes. Although any pair of adjacent carpal centers may exhibit fusion, those on the ulnar side of the wrist and the same carpal row are the most commonly involved.4 Overall, the triquetrum and lunate are the most commonly fused carpal bones, with the capitate and hamate being the most frequently fused bones of the distal carpal row.3-s Sandifort2 first identified this anomaly but provided no descriptive details. The frequency of triquetral-lunate fusion is one per one thousand for persons of European descent and American Indians and sixteen per one thousand among blacks, with a female predominance of approximately two to one. The mode of inheritance for this fusion appears to be multifactorial4 In a study of Nigerians, the fusion was bilateral in 61.5% of individuals, right sided in 17.4%, and left sided in 21.1%. Incomplete synostosis probably results from a failure of separation rather than a fusing of ossification centers.‘* 2 Between the fifth and tenth weeks of intrauterine life, the upper extremity limb bud develops. A gelatinous-like substance within the cartilaginous anlage normally appears at the site of the future joint space. Programmed cellular death at these locations

results in cleft formation progressing to joint development and eventually to individual carpal structures. It is probable that failure of cleft formation or incomplete separation results in future carpal fusions.’ The degree of cellular death results in the type of synostosis that develops somewhere between complete synostosis or complete joint development. Fractures across the fused joint have been reported by Cockshott,2 although no actual description of the traumatic cause was given, and it may be that this diagnosis was deduced based solely on the radiographs. This conclusion was alluded to by Zielinski and Gunther7 in their description of a 22-year-old woman with wrist pain, no history of trauma, and radiographic evidence of an incomplete synostosis across the right scaphoid and trapezium. There was no treatment because of the mild degree of pain. In the article by Cockshott though, his radiographs of “fractures” are similar to ours, and may, indeed represent the identical entity, including his noting the “establishment of nonunion with sclerosis, cyst formation, and pseudoarthrosis.“’ In 1952, Minnaar classified lunate triquetral synostosis from an anatomic standpoint.” We believe that the clinical presentation of these patients can also be thought of as part of a spectrum. At one end are patients

The Journal of HAND SURGERY

Fig. 8. Comparison is made of both wrists (case 3). The bilateral involvement portends future problems in the asymptomatic left wrist.

with complete carpal synostosis. These are usually incidental radiographic findings and because there is no movement between the bones there are no symptoms. Incomplete carpal synostosis results in a cleft between two bones devoid of complete cartilage formation. Inadequate cartilage, regardless of the cause, results in loss of bony cortex, osteophyte formation, and cyst development that produces a clinical presentation similar to that of degenerative arthritis. It is our contention that this lack of cartilage between incompletely separated bones results in symptoms consistent with degenerative arthritis whether or not heavy stress or trauma are part of the history. This appears to be the pathologic change that produces the pain and dysfunction with which these patients arc seen initially. The joint affected by incomplete synostosis differs from the joint destroyed by degenerative arthritis. Degenerative joint disease may result in varying forms of joint destruction from bilateral articular cartilage erosion or ebumation with or without the formation of new bone at the articular margins. Small islands of new cartilage ossify and project above the cortical surface of the articulating bone, usually at the bony margins to produce another characteristic pattern of destructive joint disease, osteophytes, or bony spurs (Fig. 9, A).

Rarely is a joint only partially destroyed by osteoarthritis, which is in direct contrast to the joint affected by incomplete synostosis. It is our experience that the incomplete separation usually involves the proximal portion of the joint, with thinned cartilaginous surface with the appearance of bone protruding into the cartilage area and near the middle of the joint without joint narrowing. The distal portion of the joint appears grossly and radiographically normal (Fig. 9, B) (Fig. lO).The reason for this appearance is incomplete joint development proximally (Fig. 9, C). This is a different appearance than one sees with degenerative joint changes. Patients’ complaints of wrist pain localized to the triquetral-lunate joint are probably caused by incomplete synostosis of this carpal joint. When evaluating these wrists, radiographs are mandatory to rule out other bony articular processes, which also can present with wrist pain and localized tenderness. Fractures of carpal bones, degenerative osteoarthritis, or perilunate dislocations or subluxations may present similarly. When evaluating a congenitally acquired condition like synostosis, the contralateral wrist should be examined and radiographs taken inasmuch as it is not uncommon for the asymptomatic wrist to be similarly affected. Ar-

Vol. 14A, No. 1 January 1989

Fig. 9. (A), This joint space illustrates narrowing and osteophyte formation, with loss of cartilage that is consistent with degenerative or traumatic arthritis. (B), A normal appearing distal joint space with normal cartilage in combination with the abnormal bone intrusion proximally into the cartilage area, typical of incomplete joint development. (C), Incomplete joint formation and complete failure of development of any joint proximally.

thrograms, motion studies, intracarpal analgesia, or systemic or local anti-inflammatory agents appear to offer little relief or information in this congenital condition. Tomographs of the triquetral-lunate joint may be of some diagnostic value if plain radiographs can not illustrate an abnormal joint space. Limited wrist arthrodesis is indicated in those patients whose symptoms require a change in either their lifestyle or work habits. At this time nonoperative treatment does not appear to provide the long-term relief required to allow these patients to return to full activities. Our patient population was quite young, with many years of future productivity. This debilitating anomaly is certainly an indication for limited arthrod-

Triquetral-lunate

arthritis

101

Fig. 10. Posteroanterior radiograph of mild form of incomplete joint development of the lunate-triquetral joint.

esis in these younger patients but also in the older patient population who are handicapped by a painful, weak wrist.

Conclusion Incomplete bony spearation of the triquetrum and lunate causing pain and ultimate wrist dysfunction probably occurs more commonly than the literature indicates. This is not a degenerative arthritis but a special appearance of incomplete separation of two carpal bones with a clinical presentation similar to the more common degenerative or traumatic arthritis. We theorize that patients such as the ones presented in this article represent one end of the spectrum of congenitally fused carpal bones, where separation is almost complete and wrist dysfunction results from the combination of

The Journal of HAND SURGERY

Gross et al.

insufficient cartilage and heavy stress loading. Complete fusion of these carpal bones is usually identified as an incidental finding in an asymptomatic wrist. Suggested treatment for incomplete carpal separation is limited arthrodesis”” of the involved joint, using local cancellous bone graft from the distal radius.” This infrequent cause of wrist pain should be suspected when the symptoms are localized to the triquetral-lunate area and the unusual radiographic configuration is present. Special thanks to Richard M. Linburg, MD, for his contribution to the text. REFERENCES McCredie J. Congenitalfusion of bones: radiology, embryology, and pathogenesis.Clin Radio11975;26:47-51. Cockshott WP. Carpal fusions. Am J Roentgen011963; 89:1260-71. O’Rahilly R. A survey of carpal and tarsal anomalies. J Bone Joint Surg 1953;351\:626-42. Garn SM, Frisancho AR, Pozanski AK, Schweitzer J, McCann MB. Analysis of triquetral-lunate fusion. Am J Phys Anthropol

5. Waugh RL, Sullivan RF. Anomalies of the caxpus with

particular attention to the scaphoid (navicular). J Bone Joint Surg 1950;32A:682-6. 6. McGoey PF. Fracture-dislocation of a fused triangular and lunate (congenital). J Bone Joint Surg 1943;25A: 928-9. 7. Zielinski CJ, Gunther SF. Congenital fusion of the scaphoid and trapezium-case report. J HAND SURG 1981; 6:220-2. 8. Watson HK, Hempton RF. Limited wrist arthrodesis. Part I: The triscaphoid joint. J HAND SURG 1980;5:320-7. 9. Watson HK, Goodman ML, Johnson TR. Limited wrist arthrodesis. Part II: Intercarpal and radial carpal combinations. J HAND SURG 1981;6:223-33. 10. Simmons BP, McKenzie WD. Symptomatic carpal coalition. J HAND SURG 1985;10:190-3. 11. McGrath MH, Watson HK. Late results with local bone graft donor sites in hand surgery. J HAND SURG 1981; 6:234-7. 12. Minnaar AB, deV. Congenital fusion of the lunate and triquetral bones in the South African Banto. J Bone Joint

Surg 1952;34B:45-8.

1971;34:431-3.

Diagnosis and treatment of injury to the second and third carpometacarpal joints We describe the diagnosis, treatment, and follow-up of a group of 13 patients with hand pain traced to pathologic conditions of the second or third carpometacarpal joints. Missed diagnosis was universal. With suspicion raised by history of injury or repeated stress and point tenderness on examination, diagnosis was confirmed by complete pain relief after injection of 1% lidocaine locally. In management of patients with occult pain in the hand, attention should be directed to the second or third carpometacarpal joints. Arthrodesis with use of an inverted triangular graft from the base of the metacarpal provides predictable and lasting relief. (J HAND SURG 1989;14A:102-7.)

Robert E. Carroll, MD, and Eric Carlson, MD, New York, N.Y.

From the Department of Orthopaedic Surgery, Columbia-presbyterian Medical Center, New York, N.Y. Received for publication Dec. 15, 1987; accepted in revised form Jan. 30, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert E. Carroll, MD, Department of Orthopaedic Surgery, Columbia-Presbyterian Medical Center, 161 Fort Washington Ave., New York, NY 10032.

102

THE

JOURNALOF

HAND

SURGERY

A

cute injury to the second or third carpometacarpal (CMC) area of the hand can result in sprain, fracture, or dislocation. As described by Bunnell,’ reduction is necessary to restore muscle balance and proper mechanics in the hand. Other authors,2-5 have noted that unreduced CMC dislocations do not always produce serious disability. Green and Rowland,6 Eaton and Dray,’ Imbriglia,* and O’Brien’ have all written that normal anatomic alignment should be restored