PROCEEDINGS

Symposium on the wrist joint

On November 29 and 30, 1980, a symposium on the wrist joint was held at the American Hospital, Paris, under the direction of Professor R. Tubiana.

A session on functional anatomy was moderated by Professor J. M. F. LANDSMEER. J. M. G. KAUER stressed the importance of individual carpal bone morphology in providing wrist stability. R. L. LiNSCHEID reviewed the pathomechanics of carpal instability. Carpal collapse is caused by compressive muscular forces across the wrist and may be represented by vector forces of known magnitude, points of application, and direction . These forces have a range of approximately 200 to 800 kg. J . NORBERT KUHLMANN stated that radio and ulnocarpal ligaments form slings that oppose forces present in the wrist that normally result in a tendency of the carpus to sublux palmar- and ulnarwards. J. TALEISNIK reviewed two types of medial column carpal instability: triquetro­lunate, resulting in static palmar intercalated segmental instability (PIS!) collapse patterns, and triquetroha­mate, leading to dynamic forms of dorsal intercalated segmental instability and PISI collapse patterns. O. GAGEY and F. MAZAS presented a study of muscles controlling wrist movements. The extensor carpi ul­naris is an ulnar deviator; the abductor pollicis longus is a carpal stabilizer. No single muscle can produce pure wrist dorsiflexion, but rather a combination of dor­siflexion and radial or ulnar deviation. K. BAcKHousE arrived at similar conclusions . He believes that flexor and extensor carpi ulnaris provide ulnar deviation and form an ulnar "splint" to the wrist. A similar function is provided on the radial side by the extensor carpi radialis longus and the flexor carpi radialis. R. TUBIANA reviewed the significance of the transverse palmar arch. Its most important function is to establish a balance between the stronger digital flexors and the relatively weak extensors. SCHERNBERG presented a radiological assessment of the carpus based on a study of 130 normal wrists. J. NORBERT KUHLMANN reported a study of the carpal arteries of 50 cadaver wrists. Based on this study, he proposed two techniques for the creation of vascularized corticocancellous bone grafts: one based on the palmar carpal artery and the second on the pisiform supplied by a dorsoulnar carpal artery pedicle.

A second session was chaired by Professor R. TUBIANA. R. L. LINSCHEID reviewed the biomechani-

528 THE JOURNAL OF HAND SURGERY

cal principles of the surgical procedures designed to stabilize the wrist . Collapsed ununited scaphoid frac­tures require overcorrection of the angulatory deformity and replacement of lost palmar scaphoid height by bone grafting. Scapholunate dissociation and lunotriquetral injuries may be treated by ligament repair and/or re­construction by intracarpal arthrodesis. Proximal-row carpectomies are useful in some patients with scapho­lunate dissociation. Distal radioulnar subluxations may be treated by capsular imbrication or procedures de­signed to tether the ulnar head during pronation (dor­sal subluxation) or supination (palmar subluxation). G . ASENCIO, F. BONNEY, and Y. ALLIEU presented a study of ligamentous lesions produced in cadaver wrists. Progressive dorsiflexion, ulnar deviation, and carpal supination lead to initial scapholunate dissocia­tion and result in retrolunar carpal dislocation. Dorsi­flexion and radial deviation may produce transscaphoid perilunate dislocations. Palmar flexion, carpal supina­tion, and radial deviation cause dorsal triquetrohamate and triquetrocapitate ligamentous rupture and result in midcarpal subluxation. Y. ALLIEU stressed the early treatment of carpal ligament ruptures. Ulnar tears may heal with plaster immobilization alone, with the wrist in slight palmar flexion. Scapholunate dissociations may be treated by manipulation and percutaneous pin­ning. If this is unsuccessful he recommended open re­duction from a dorsal approach and internal fixation. G. FISK reported his successful experience in the treatment of nonunions of the scaphoid by radial styloidectomy and the insertion of a palmar wedge graft cut from the excised styloid.

Two final sessions were held, one on wrist ar­throdesis and one on wrist arthroplasties. D. BucK­GRAMCKO reported 93 arthrodeses performed between 1966 and 1979. Two techniques were utilized: iliac bone grafting with or without pin fixation (14 cases) and compression plating with supplementary bone grafting (67 cases) or without grafting (12 cases). K. BACKHOUSE discussed the use of wrist arthrodesis in rheumatoid patients, an indication restricted to a very small proportion of his cases. H. K. WATSON reviewed his experience with the use of limited wrist arthrodesis and presented examples of trapezio-trapezoid-meta­carpal fusions and arthrodesis between scaphoid, tra­pezium, and trapezoid, between capitate and lunate, between capitate, lunate, and scaphoid (or capitate and

Vol. 7, No.5 September 1982

hamate), and between radius, scaphoid, and lunate. B. HELAL discussed the usefulness of the Day compres­sion staple in arthrodesis of the rheumatoid wrist. B. HELAL and Y. ALLIEU presented three patients with primary avascular necrosis of the capitate. The final session on wrist arthroplasties included a discussion on proximal row carpectomies, performed by Y. GERARD in 24 patients, with 19 good or excellent results. R. TUBIANA showed the indication and technique for the

Proceedings 529

use of scapholunate implants and H. C. MEULI pre­sented his experience using his total joint replacement. The final paper was a report on the "CARDAN" ar­throplasty of the trapeziometacarpal joint, by A. KAPANDJI. This device is manufactured in high­performance silicone and has two hinges, each per­pendicular to the other. It is not cemented, but placed between the trapezium and the first metacarpal.