JBJS | Intracarpal Soft-Tissue Lesions Associated with an Intra-Articular Fracture of the Distal End of the Radius*

The Journal of Bone & Joint Surgery, Volume 78, Issue 3

Articles | March 01, 1996

Intracarpal Soft-Tissue Lesions Associated with an Intra-Articular Fracture of the Distal End of the Radius*

WILLIAM B. GEISSLER, M.D.†; ALAN E. FREELAND, M.D.†; FELIX H. SAVOIE, M.D.‡, JACKSON, MISSISSIPPI; LEWIS W. McINTYRE, M.D.§; TERRY L. WHIPPLE, M.D.§, RICHMOND, VIRGINIA

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Investigation performed at the Department of Orthopaedic Surgery, University of Mississippi Medical Center, and River Oaks Hospital, Jackson, and Orthopaedic Research of Virginia, Richmond

The Journal of Bone & Joint Surgery. 1996; 78:357-65

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Abstract

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The result after a fracture of the distal end of the radius may be influenced by the pattern of injury, any associated soft-tissue trauma, and the specific method of treatment^{2,5,6,9,13,14,17,18,27-31}. The relationship of the restoration of the skeletal and articular anatomy after a fracture to the ultimate result has been well documented^{1,4,7,10,15,16,26,32,33}. The prevalence of associated injury of the supporting soft-tissue structures within the wrist has been less thoroughly investigated. Some authors have suggested a casual relationship between the result and injury of the intracarpal ligaments or the triangular fibrocartilage complex even with successful restoration of the skeletal and articular anatomy of the fractured radius^8,22. The purpose of the present study was to investigate the occurrence and severity of soft-tissue lesions within the wrist in conjunction with displaced intra-articular fractures of the distal end of the radius.

*One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund or foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. No funds were received in support of this study.

†Department of Orthopaedics, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.

‡Mississippi Sports Medicine and Orthopaedic Center, 1325 East Fortification Street, Jackson, Mississippi 39216.

§1800 Glenside Drive, Richmond, Virginia 23229.

†Department of Orthopaedics, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.

‡Mississippi Sports Medicine and Orthopaedic Center, 1325 East Fortification Street, Jackson, Mississippi 39216.

§1800 Glenside Drive, Richmond, Virginia 23229.

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Figs. 1-A, 1-B, and 1-C: Illustrations of the AO/ASIF classification system for fractures of the distal end of the radius. Fig. 1-A: Classification of extra-articular fractures (type A). (Reprinted, with permission, from: Fernandez, D. L., and Geissler, W. B.: Treatment of displaced articular fractures of the radius. J. Hand Surg., 16A: 376—377, 1991.)

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Classification of simple intra-articular fractures (type B). (Reprinted, with permission, from: Fernandez, D. L., and Geissler, W. B.: Treatment of displaced articular fractures of the radius. J. Hand Surg., 16A: 376—377, 1991.)

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Classification of complex intra-articular fractures (type C). (Reprinted, with permission, from: Fernandez, D. L., and Geissler, W. B.: Treatment of displaced articular fractures of the radius. J. Hand Surg., 16A: 376—377, 1991.)

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Arthroscopic view of the normal concave appearance between the carpal bones as seen from the radiocarpal space (arrow). There are no separations or step-offs. L = lunate and T = triquetrum.

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Arthroscopic view of a grade-II tear of an interosseous ligament, showing loss of the normal congruent appearance of the carpal bones. There is a step-off between the scaphoid (S) on the left and the lunate (L) on the right, as seen from the mid-carpal space (arrows).

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Arthroscopic view of a grade-III tear of an interosseous ligament. There is a gap between the scaphoid (S) and the lunate (L), as seen from the mid-carpal space (arrows). A similar gap between the carpal bones is seen from the radiocarpal space, and a probe can be passed between the carpal bones.

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Arthroscopic view of a grade-IV tear of an interosseous ligament. There is a larger separation between the carpal bones, as seen from the mid-carpal space (arrows). A 2.7-millimeter arthroscope can pass between the carpal bones from the mid-carpal space to the radiocarpal space L = lunate and S = scaphoid.

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TABLE I DATA ON THE PATIENTS

*See Table II for descriptions of the grades.†As measured on the posteroanterior radiograph.‡As measured on the lateral radiograph with use of the tangential method.§The tear had an attached avulsed fragment of bone.

Case	Fracture Type²⁴	Tear			Size of Fragment of Ulnar Styloid Proc. (mm)	Scapholunate Gap†	Lateral Scapholunate Angle‡
Scapholunate Lig.* (Grade)	Lunotriquetral Lig.* (Grade)	Triangular Fibrocartilage²⁵(Type)
1	B1.1	—	—	—	—	2	50
2	B1.1	—	—	—	—	2	45
3	B1.2	II	—	—	—	2	50
4	B1.2	IV	—	—	—	6	75
5	B1.2	—	—	B	—	2	45
6	B1.2	—	—	B	—	1	50
7	B1.3	—	—	D§	2	3	50
8	B2.1	—	—	—	2	2	50
9	B2.2	II	—	B	3	2	50
10	B3.2	—	—	—	2	2	45
11	B3.3	II	II	—	—	2	55
12	B3.3	—	—	D	—	3	50
13	C1.2	—	—	A	4	1	55
14	C1.2	—	III	—	—	2	50
15	C1.2	—	—	B	5	2	45
16	C1.2	II	—	B	2	2	50
17	C1.2	II	—	—	—	2	50
18	C1.2	II	—	—	—	3	50
19	C1.2	—	—	B	—	2	50
20	C1.2	II	—	D	—	3	50
21	C1.2	—	III	D	4	2	45
22	C1.3	—	—	—	1	1	45
23	C1.3	II	—	—	—	3	50
24	C1.3	III	—	B	2	3	50
25	C1.3	III	—	—	—	4	60
26	C2.1	—	—	B	1	2	55
27	C2.2	III	—	—	—	4	50
28	C2.2	—	—	A	—	2	50
29	C2.2	—	—	—	—	1	50
30	C2.2	IV	—	A	—	5	80
31	C2.2	—	—	—	—	2	55
32	C2.2	—	—	B	2	1	50
33	C2.2	—	—	A	—	2	50
34	C2.2	—	III	B	—	2	50
35	C2.2	—	—	—	2	3	45
36	C2.2	—	—	—	1	1	50
37	C2.3	—	—	—	—	3	50
38	C3.1	III	—	D§	1	5	55
39	C3.1	—	—	B	2	3	45
40	C3.1	—	—	—	—	3	50
41	C3.1	—	—	—	—	2	50
42	C3.1	—	—	—	—	2	50
43	C3.1	—	—	—	—	1	50
44	C3.1	III	—	A	—	4	60
45	C3.1	III	—	—	—	4	55
46	C3.1	—	—	—	—	2	50
47	C3.1	II	—	—	—	2	50
48	C3.1	—	—	—	—	3	50
49	C3.1	—	III	—	—	2	45
50	C3.1	—	III	—	7	2	50
51	C3.1	—	—	B	2	2	55
52	C3.1	—	—	—	—	1	50
53	C3.1	II	III	—	—	2	50
54	C3.1	—	III	B	2	1	45
55	C3.1	III	II	—	3	3	55
56	C3.2	—	—	—	4	2	50
57	C3.2	—	—	—	3	3	50
58	C3.2	—	—	D§	2	1	50
59	C3.2	—	—	D§	2	2	45
60	C3.2	—	—	A	2	1	55

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TABLE I DATA ON THE PATIENTS

Case	Fracture Type²⁴	Tear			Size of Fragment of Ulnar Styloid Proc. (mm)	Scapholunate Gap†	Lateral Scapholunate Angle‡
Scapholunate Lig.* (Grade)	Lunotriquetral Lig.* (Grade)	Triangular Fibrocartilage²⁵(Type)
1	B1.1	—	—	—	—	2	50
2	B1.1	—	—	—	—	2	45
3	B1.2	II	—	—	—	2	50
4	B1.2	IV	—	—	—	6	75
5	B1.2	—	—	B	—	2	45
6	B1.2	—	—	B	—	1	50
7	B1.3	—	—	D§	2	3	50
8	B2.1	—	—	—	2	2	50
9	B2.2	II	—	B	3	2	50
10	B3.2	—	—	—	2	2	45
11	B3.3	II	II	—	—	2	55
12	B3.3	—	—	D	—	3	50
13	C1.2	—	—	A	4	1	55
14	C1.2	—	III	—	—	2	50
15	C1.2	—	—	B	5	2	45
16	C1.2	II	—	B	2	2	50
17	C1.2	II	—	—	—	2	50
18	C1.2	II	—	—	—	3	50
19	C1.2	—	—	B	—	2	50
20	C1.2	II	—	D	—	3	50
21	C1.2	—	III	D	4	2	45
22	C1.3	—	—	—	1	1	45
23	C1.3	II	—	—	—	3	50
24	C1.3	III	—	B	2	3	50
25	C1.3	III	—	—	—	4	60
26	C2.1	—	—	B	1	2	55
27	C2.2	III	—	—	—	4	50
28	C2.2	—	—	A	—	2	50
29	C2.2	—	—	—	—	1	50
30	C2.2	IV	—	A	—	5	80
31	C2.2	—	—	—	—	2	55
32	C2.2	—	—	B	2	1	50
33	C2.2	—	—	A	—	2	50
34	C2.2	—	III	B	—	2	50
35	C2.2	—	—	—	2	3	45
36	C2.2	—	—	—	1	1	50
37	C2.3	—	—	—	—	3	50
38	C3.1	III	—	D§	1	5	55
39	C3.1	—	—	B	2	3	45
40	C3.1	—	—	—	—	3	50
41	C3.1	—	—	—	—	2	50
42	C3.1	—	—	—	—	2	50
43	C3.1	—	—	—	—	1	50
44	C3.1	III	—	A	—	4	60
45	C3.1	III	—	—	—	4	55
46	C3.1	—	—	—	—	2	50
47	C3.1	II	—	—	—	2	50
48	C3.1	—	—	—	—	3	50
49	C3.1	—	III	—	—	2	45
50	C3.1	—	III	—	7	2	50
51	C3.1	—	—	B	2	2	55
52	C3.1	—	—	—	—	1	50
53	C3.1	II	III	—	—	2	50
54	C3.1	—	III	B	2	1	45
55	C3.1	III	II	—	3	3	55
56	C3.2	—	—	—	4	2	50
57	C3.2	—	—	—	3	3	50
58	C3.2	—	—	D§	2	1	50
59	C3.2	—	—	D§	2	2	45
60	C3.2	—	—	A	2	1	55

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TABLE II ARTHROSCOPIC CLASSIFICATION OF TEARS OF THE INTRACARPAL LIGAMENTS

Grade	Description
I	Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space. No incongruency of carpal alignment in mid-carpal space.

II	Attentuation or hemorrhage of interosseous ligament as seen from radiocarpal space. Incongruency or step-off of carpal space. There may be slight gap (less than width of probe) between carpal bones.

III	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. Probe may be passed through gap between carpal bones.

IV	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. There is gross instability with manipulation. 2.7-millimeter arthroscope may be passed through gap between carpal bones.

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TABLE II ARTHROSCOPIC CLASSIFICATION OF TEARS OF THE INTRACARPAL LIGAMENTS

Grade	Description
I	Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space. No incongruency of carpal alignment in mid-carpal space.

II	Attentuation or hemorrhage of interosseous ligament as seen from radiocarpal space. Incongruency or step-off of carpal space. There may be slight gap (less than width of probe) between carpal bones.

III	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. Probe may be passed through gap between carpal bones.

IV	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. There is gross instability with manipulation. 2.7-millimeter arthroscope may be passed through gap between carpal bones.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

We designed a multicenter study to investigate the occurrence of injury of the carpal ligaments and triangular fibrocartilage complex with displaced intra-articular fractures of the distal end of the radius. Four of us (W. B. G., A. E. F., F. H. S., and T. L. W.), orthopaedic surgeons who are experienced in arthroscopy of the wrist, contributed to the study from three centers. Sixty consecutive patients who had had a failed manipulative reduction of a displaced fracture, as defined by persistent displacement of the articular surface of two millimeters or more, formed the basis of this study. Excluded from the study were patients who had radiographic evidence of injury of intracarpal ligaments after manipulative reduction but for whom arthroscopically assisted articular manipulation was not necessary as the reduction of the fracture was thought to be anatomical.

The thirty-eight male and twenty-two female patients had an average age of thirty-two years (range, seventeen to forty-eight years). The mechanism of injury was a motor-vehicle accident for forty-two patients, a fall from a height for eight, and a fall from a standing position for ten.

The fractures were classified according to the Association for the Study of Internal Fixation (AO/ASIF) classification of fractures of the distal end of the radius²⁴ (Figs. 1-A, 1-B, and 1-C). This system provides information regarding the displacement of the fracture; the amount of articular, metaphyseal, and diaphyseal comminution; and associated lesions of the distal end of the ulna. Type A indicates an extra-articular fracture; type B, a simple intra-articular fracture; and type C, a complex intra-articular fracture.

Each type is in turn divided into three subtypes depending on the specific configuration of the fracture, and these subtypes can be broken down further into three categories depending on the displacement and comminution of the fracture (Figs. 1-A, 1-B, and 1-C). According to this classification, a cuneiform articular fracture of the distal end of the radius is a type-B1 fracture (Fig. 1-B). Seven patients had a type-B1 fracture. Of these seven fractures, two were of the radial styloid process (type B1.1), four were a comminuted fracture of the radial styloid process (type B1.2), and one was a shearing fracture of the lunate facet (type B1.3). A type-B2 fracture involves the dorsal margin of the radius (a Barton fracture). Two patients had a type-B2 fracture: one fracture was a simple dorsal shearing fracture (type B2.1), and the other was a dorsal marginal shearing fracture in conjunction with a fracture of the radial styloid process (type B2.2). A type-B3 fracture involves the volar margin of the distal end of the radius (a volar Barton fracture). Three patients had a type-B3 fracture. Of these three fractures, one involved the entire distal metaphysis with extension into the sigmoid notch (type B3.2), and two were comminuted volar marginal fractures (type B3.3) (Table I).

An intra-articular fracture of the distal end of the radius involving two articular fragments and no metaphyseal comminution is classified as type C1 (Fig. 1-C). Thirteen patients had a type-C1 fracture; nine of the fractures were type C1.2, which consists of a fracture of the radial styloid process and a dorso-ulnar fragment, and four were type C1.3, which represents a T-fracture in the sagittal plane. A type-C2 fracture has a simple intra-articular component but also has metaphyseal comminution. Twelve patients had a type-C2 fracture. Of these twelve, one had a type-C2.1 fracture (a Colles fracture with metaphyseal comminution affecting the distal radio-ulnar joint), ten had a type-C2.2 fracture (a T-fracture in the sagittal plane with metaphyseal comminution), and one had a type-C2.3 fracture (a T-fracture in the frontal plane with metaphyseal comminution). Comminuted intra-articular fractures of the distal end of the radius are classified as type-C3. Twenty-three patients had a type-C3 fracture, with eighteen type-C3.1 fractures (volar and dorsal medial fragments in conjunction with a radial styloid fragment—a so-called four-part fracture) and five type-C3.2 fractures (a four-part fracture with metaphyseal comminution) (Table I).

The operation was performed three to seventeen days (average, six days) after the injury. A compressive elastic bandage is wrapped around the forearm to retard extravasation of fluid into the muscle compartments during arthroscopy of the wrist. The wrist is suspended in a traction tower, and ten pounds (4.5 kilograms) of traction is applied through finger traps to the index and long fingers. An inflow cannula is inserted through a portal located ulnar to the extensor carpi ulnaris tendon (the 6U portal), and the joint is distended³⁴. A 20-gauge needle is inserted between the extensor pollicis longus tendon and the extensor digitorum communis tendons (the 3/4 portal). The needle should pass easily into the joint without impinging on either the carpal bones or the distal end of the radius. This ensures that the arthroscopic cannula will not be inserted into a carpal bone or the fractured radius. The skin is then lanced over the 3/4 portal by pulling the skin against the tip of a number-11 scalpel blade, and a hemostat is used to dissect down to the joint capsule to prevent injury of the cutaneous nerves and dorsal veins. A blunt arthroscopic cannula is inserted through the portal, and the joint is lavaged to clear it of hematoma and fracture debris. A small-joint arthroscope (2.7 millimeters long) is inserted through the cannula in the 3/4 portal. An additional portal is created between the extensor digitorum communis tendons and the extensor digiti minimi tendon (the 4/5 portal). A small-joint shaver (2.9 millimeters wide) placed through this portal helps to clear the joint of remaining hematoma in order to provide a good view of the site of the fracture. Loose fragments of bone and cartilage are removed with a mini-grasper. Extravasation of fluid through the fracture fragments and capsular rents that causes troublesome soft-tissue swelling may be minimized by allowing the irrigation fluid to exit through either the arthroscopic cannula or a separate outflow portal.

Although the focus of this study is not on the actual treatment of these fractures, it is important to provide a brief description of the technique of treatment. In most patients, the fracture was treated with manipulative reduction and percutaneous fixation alone. In some patients, it was treated with a limited extensile operative procedure. The initial reduction of the fracture involves the radial styloid process, which is then stabilized to the distal aspect of the diaphysis with 0.045-inch (1.14-millimeter) smooth Kirschner wires placed percutaneously. Placement of these wires into the dorsal aspect of the styloid process and through a soft-tissue protector sleeve minimizes the risk of injury of branches of the radial sensory nerve as well as the radial artery. The radial styloid fragment provides a landmark for subsequent realignment of the remaining displaced articular fracture fragments. Displaced articular fragments of the dorsal aspect of the lunate facet can be elevated and reduced under arthroscopic guidance. A small fragment can be elevated by means of a trocar inserted through the 4/5 portal directly underneath the fragment. If the fragment is large or if it cannot be disimpacted with the trocar, a 0.11-inch (2.79-millimeter) Kirschner wire is placed percutaneously into the fragment approximately two centimeters proximal to the surface of the joint. The Kirschner wire can then be used as a joystick to elevate and reduce the fragment as it is viewed arthroscopically. Once restored to its anatomical position, the fragment can be stabilized with 0.045-inch (1.14-millimeter) smooth Kirschner wires introduced through the styloid process horizontally and dorsally and directly entering the subchondral bone of the lunate facet fragment. The reduction of the articular fracture fragments is confirmed with use of both fluoroscopic and arthroscopic guidance.

The unstable articular marginal fractures were stabilized with a plate in five patients who had a volar or dorsal Barton fracture (one fracture was type B2.1, one was type B2.2, one was type B3.2, and two were type B3.3) and in eight patients who had a large displaced volar medial fragment (all fractures were type C3.1). These patients had a combination of a limited open and arthroscopically assisted reduction. The accuracy of the reduction of the marginal (Barton) fracture fragments was confirmed by realignment of the metaphyseal fracture lines. The forearm was then suspended in traction, and the articular reduction was viewed arthroscopically and could be adjusted as necessary. For the treatment of the type-C3.1 fractures, which involve four main fragments, the radial styloid process was anatomically reduced as previously described. This was followed by a volar approach between the flexor tendons and the ulnar neurovascular bundle, which exposed the displaced volar ulnar fragment. After stabilization of this fragment with a 2.7 or 3.5-millimeter buttress plate, the forearm was suspended, and the dorsal fragments were elevated and pinned while viewed arthroscopically. Fourteen patients who had extensive metaphyseal comminution or osteopenic bone (one who had a type-B2.2 fracture, one who had a type-C2.1, six who had a type-C2.2, one who had a type-C2.3, and five who had a type-C3.2) had an external fixator applied. Ten patients had supplemental cancellous bone-grafting as a metaphyseal defect was present after the articular surface was reduced.

After reduction and stabilization of the articular fracture fragments, the intra-articular soft-tissue structures are systematically inspected. The long radiolunate, radioscaphocapitate, radioscapholunate, and scapholunate interosseous ligaments are most easily seen with the arthroscope in the 3/4 portal¹¹. A probe may be inserted through the 4/5 portal in order to palpate each of these ligaments and to clear any fibrin debris that may be obscuring the view. Even though they may be injured, the extrinsic ligaments appear taut because of the continuous traction applied to the wrist. The ulnocarpal and lunotriquetral interosseous ligaments and the triangular fibrocartilage complex are best seen with the arthroscope in the 4/5 portal. The triangular fibrocartilage complex is carefully palpated with a probe to detect any laxity or tears that may not be readily visualized.

The mid-carpal space is also evaluated by placement of the arthroscope approximately one centimeter distal to the 3/4 portal, in line with the radial border of the long finger in the radial mid-carpal space. The inflow cannula is initially left in the radiocarpal space after the arthroscope has been placed in the mid-carpal space to determine if the irrigation fluid communicates with the mid-carpal space, which suggests a possible tear of an interosseous ligament. After this, the inflow is transferred to the arthroscopic cannula, and a needle for the outflow of irrigation fluid is placed in the ulnar mid-carpal portal located one centimeter distal to the 4/5 portal in line with the metacarpal of the ring finger. Injury of the interosseous ligaments between the carpal bones of the proximal carpal row is determined by observing separation of the bones from each other or incongruity of their distal articular surfaces, or both.

A classification system was developed to standardize the arthroscopic observation of injury of the intracarpal ligaments (Table II). With a grade-I lesion, attenuation or hemorrhage of an interosseous ligament is seen with the arthroscope placed in the radiocarpal space. The interosseous ligament bulges and the normal smooth concave appearance between the carpal bones (Fig. 2) becomes convex. There is no incongruency between the carpal bones with the arthroscope in the mid-carpal space. With a grade-II lesion, attenuation or hemorrhage of the interosseous ligament is again seen with the arthroscope in the radiocarpal space. However, there is an incongruency between the carpal bones when they are viewed from the mid-carpal space (Fig. 3). With a grade-III lesion, a separation between the carpal bones is evident from both the radiocarpal and the mid-carpal space (Fig. 4). A small-joint probe passes through the gap between the carpal bones. A 2.7-millimeter arthroscope cannot pass through even when the gap is stressed. With a grade-IV lesion, the gap between the carpal bones is wider, and a 2.7-millimeter arthroscope can be passed through this gap (Fig. 5).

Lesions of the triangular fibrocartilage complex were classified according to the system of Palmer²⁵. In this classification, lesions that are thought to be the result of a traumatic injury are considered to be class I. The class-I lesions are subdivided into those having a central perforation (type A), a peripheral tear (type B), a tear distal to the articular disk (type C), or a tear of the triangular fibrocartilage from the sigmoid notch of the radius (type D).

The scapholunate gap, measured in millimeters on the posteroanterior radiograph, and the lateral scapholunate angle, measured in degrees with use of the tangential method on the lateral radiograph, were determined preoperatively. With the tangential method, a line is drawn tangential to the palmar outline of the scaphoid and another is drawn perpendicular to a line connecting the poles of the lunate. The size of any associated ulnar styloid fragment was recorded (Table I).

Results

Introduction | Materials and Methods | Results | Discussion | References

A partial or complete tear of an intracarpal ligament or of the triangular fibrocartilage complex was observed during the arthroscopic examination in forty-one (68 per cent) of the sixty wrists. Twenty-six patients had a tear of the triangular fibrocartilage complex in association with the fracture (Table I). A peripheral ulnar-sided tear (Palmer²⁵ type B), with or without an associated fracture of the ulnar styloid process, was observed in thirteen patients. Hemorrhagic synovitis at the site of the tear, consistent with an acute injury, was noted in all thirteen patients. A peripheral radial-sided tear (Palmer²⁵ type D), with or without a fragment of bone from the radius, was seen in seven patients, and a central perforation of the triangular fibrocartilage complex (Palmer²⁵ type A) was noted in six. Four of the seven peripheral radial tears had an attached avulsed fragment of bone, consistent with an acute injury.

Twenty-five patients had a fracture of the ulnar styloid process. Sixteen of them had a lesion in the triangular fibrocartilage complex. Peripheral tears predominated in this group, with fourteen of the sixteen wrists having a type-B (ulnar) or type-D (radial) tear.

A lesion of the scapholunate interosseous ligament was observed in nineteen patients (Table I): ten had a grade-II (partial) tear, seven had a grade-III (complete) tear, and two had a grade-IV tear (Table II). Of the ten wrists with a grade-II lesion, seven had a two-millimeter scapholunate gap, as measured on the posteroanterior radiograph, and three had a three-millimeter gap. The average lateral scapholunate angle in the wrists with a grade-II lesion was 51 degrees (range, 50 to 55 degrees). The scapholunate gap measured three millimeters in two of the wrists with a grade-III lesion, four millimeters in four, and five millimeters in one. The average lateral scapholunate angle was 55 degrees (range, 50 to 60 degrees) in these wrists. The scapholunate gap was five millimeters in one of the wrists with a grade-IV lesion and six millimeters in the other, and the lateral scapholunate angle was 80 and 75 degrees, respectively. In both of the wrists with a grade-IV lesion, the volar radioscaphocapitate ligament was thought to be attenuated when stressed with an arthroscopic probe.

Nine patients had a tear of the lunotriquetral interosseous ligament (Table I). The tear was complete (grade III) in seven patients and partial (grade II) in two.

Thirteen patients had two concurrent soft-tissue injuries. Seven patients had a combined injury of the triangular fibrocartilage complex and the scapholunate interosseous ligament, three had tears of the triangular fibrocartilage complex and the lunotriquetral interosseous ligament, and three had tears of the scapholunate and lunotriquetral interosseous ligaments.

Thirteen of the nineteen wrists with a lesion of the scapholunate interosseous ligament had an associated type-C1.2, C1.3, or C3.1 fracture. Six of the seven complete tears of the lunotriquetral interosseous ligament and eleven of the twenty-six tears of the triangular fibrocartilage complex were associated with a type-C1.2 or C3.1 fracture. Of the four wrists with a type-B1.2 comminuted fracture of the radial styloid process, two had a lesion of the scapholunate interosseous ligament (one was a grade-II tear and the other was a grade-IV tear).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The purpose of this paper was not to advocate the use of arthroscopy of the wrist in the treatment of fractures of the distal end of the radius. Rather, we found arthroscopy to be a valuable and sensitive adjunct with which to determine the prevalence and severity of intracarpal soft-tissue lesions that were not detectable on standard radiographs of wrists with such fractures¹⁹.

While arthroscopy is useful for the observation of soft-tissue intracarpal lesions, including those of the intrinsic interosseous ligaments and the triangular fibrocartilage complex, it is difficult to evaluate damage to the volar extrinsic ligaments, including the radioscaphocapitate and long radiolunate ligaments, with an arthroscope. Because of the traction applied to the wrist to allow entry of the arthroscope, these ligaments may appear taut when palpated with a probe even when there is an injury. It is frequently difficult to discern if hemorrhage noted at the base of the volar aspect of the capsule, where it originates from the radius, is a result of injury of the wrist capsule or of the fracture. The volar ligaments of the wrist may also tear more proximally than can be appreciated arthroscopically. Data were not kept on the radioscapholunate ligament because of the controversy regarding its role as a neurovascular structure rather than as a ligament³. For these reasons, we confined our study to the evaluation of the intrinsic interosseous ligaments and the triangular fibrocartilage complex, as arthroscopic assessment of the radiocarpal and mid-carpal spaces is very sensitive and objective for these structures.

It must be asked whether these intracarpal lesions were definitely acute or whether they might have been degenerative and thus had been present before the fracture of the distal end of the radius. Wright et al., in a study of sixty-two wrists from cadavera of individuals who were an average of seventy-eight years old (range, forty-six to ninety-nine years) at the time of death, found a lesion of the scapholunate ligament in eighteen wrists (twelve lesions were incomplete), a lunotriquetral tear in twenty wrists (eight lesions were incomplete), and a tear of the triangular fibrocartilage complex in thirty-three wrists (eleven lesions were central and twenty-one were vertical radial)³⁵. Mikic noted perforations of the triangular fibrocartilage complex in 53 per cent (twenty-six) of the forty-nine patients in his study who were more than sixty years old²¹. While it is difficult to determine arthroscopically if an observed lesion of an interosseous ligament is acute, on the average our patients were relatively young, compared with those in the studies by Wright et al. and by Mikic, and thus were at a lower risk for degenerative changes. In addition, the arthroscopic appearances of acute and chronic tears of the triangular fibrocartilage complex differ in that an acute central or radial tear is seen as a linear dorsal volar tear, with the edges sharply defined, as opposed to a more chronic lesion, which characteristically appears as a circular defect with ill-defined and frayed edges. The presenting finding of acute peripheral tears is hemorrhagic synovitis along the ulnar periphery of the particular disk or an osseous avulsion from the sigmoid notch of the radius²⁵.

We found the triangular fibrocartilage complex to be the most frequently torn structure in our series, with twenty-six of sixty wrists affected. This observation was similar to that in an arthrographic study performed by Fontes et al., who also found that the triangular fibrocartilage complex was the most frequently torn carpal soft-tissue structure; it was torn in 66 per cent of fifty-eight patients who had a fracture of the distal end of the radius⁸. These authors performed systematic operative arthrography on fifty-eight wrists with an intra-articular or extra-articular fracture of the distal end of the radius in patients who had an average age of less than fifty years. They believed that such a population was at a low risk for degenerative tears. A comparable arthrographic study by Mohanti and Kar revealed an injury of the triangular fibrocartilage in 45 per cent of sixty patients who had a fracture of the distal end of the radius²². Forty-eight of the patients were more than forty years old. The authors concluded that a tear of the triangular fibrocartilage complex is more common in the presence of radio-ulnar diastasis and also in association with a fracture of the ulnar styloid process. Our data were consistent with the results of that study²².

Hixon et al. used arthrograms of the wrist to investigate prospectively the prevalence of acute ligamentous injuries associated with fractures of the distal end of the radius in twenty-two patients with twenty-two Colles fractures¹². The arthrograms were considered positive for eighteen patients, and they suggested a variety of isolated and combined ligamentous defects. Radiographic evidence of carpal instability on standard radiographs correlated with the arthrographic findings in nine of the twenty-two patients. Follow-up examination revealed that no late ligamentous abnormalities had developed in the patients who had positive findings on the arthrograms and negative findings on the standard radiographs. Standard radiographs were most helpful in the diagnosis of tears of the scapholunate interosseous ligament and were least helpful in the diagnosis of tears of the lunotriquetral ligament and the triangular fibrocartilage complex.

Intracarpal ligamentous tears and some fractures of the distal end of the radius may be the result of a similar mechanism of injury. Mudgal and Jones described ten fractures of the distal end of the radius associated with scapholunate diastasis as detected on plain radiographs²³. All patients had a four-part fracture according to the classification system of Melone²⁰. Mudgal and Jones postulated that, as the lunate is driven proximally, a shearing stress is imposed on the scapholunate interosseous ligament, resulting in either attenuation or rupture. Most of the intracarpal soft-tissue lesions in our study occurred in patients who had a type-C1.2, C1.3, or C3.1 fracture of the lunate facet. Fontes et al. found that tears of the scapholunate interosseous ligament were frequently associated with a fracture of the radial styloid process or with an intra-articular fracture⁸. Similarly, in our study, two of the four patients who had a comminuted fracture of the radial styloid process (type B1.2) had a lesion of the scapholunate interosseous ligament.

In conclusion, in this study, tears of the carpal interosseous ligaments and the triangular fibrocartilage complex occurred in a high percentage of our patients who had a displaced intra-articular fracture of the distal end of the radius. Partial or complete tears of the ligaments of the wrist that are not detectable on standard radiographs may be the reason that some patients continue to have symptoms despite an anatomically healed fracture. Consequentially, the possibility of a soft-tissue injury in association with a fracture of the distal end of the radius should always be considered.

References

Introduction | Materials and Methods | Results | Discussion | References

Axelrod, T. S., and |and |McMurtry, R. Y.: Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J. Hand Surg.,15A: 1-11, 1990.15A1 1990

Bacorn, R. W., and |and |Kurtzke, J. F.: Colles' fracture. A study of two thousand cases from the New York State Workmen's Compensation Board. J. Bone and Joint Surg.,35-A: 643-658, July 1953.35-A643 1953

Berger, R. A.; Kauer, J. M.; and |and |Landsmeer, J. M.: Radioscapholunate ligament: a gross anatomic and histologic study of fetal and adult wrists. J. Hand Surg.,16A: 350-355, 1991.16A350 1991

Bradway, J. K.; Amadio, P. C.; and |and |Cooney, W. P.: Open reduction and internal fixation of displaced, comminuted intra-articular fracture of the distal end of the radius. J. Bone and Joint Surg.,71-A: 839-847, July 1989.71-A839 1989

Cooney, W. P.: Management of Colles' fractures [editorial]. J. Hand Surg.,14-B: 137-139, 1989.14-B137 1989

Cooney, W. P., III; Dobyns, J. H.; and |and |Linscheid, R. L.: Complications of Colles' fractures. J. Bone and Joint Surg.,62-A: 613-619, June 1980.62-A613 1980

Fernandez, D. L., and |and |Geissler, W. B.: Treatment of displaced articular fractures of the radius. J. Hand Surg.,16A: 375-384, 1991.16A375 1991

Fontes, D.; Lenoble, E.; De Somer, B.; and |and |Benoit, J.: Lésions ligamentaires associées aux fractures distales du radius. A propos de cinquante-huit arthrographies peropératoires. Ann. chir. main,11: 119-125, 1992.11119 1992 [CrossRef]

Gartland, J. J., Jr., and |and |Werley, C. W.: Evaluation of healed Colles' fractures. J. Bone and Joint Surg.,33-A: 895-907, Oct. 1951.33-A895 1951

Geissler, W. B., and |and |Fernandez, D. L.: Percutaneous and limited open reduction of the articular surface of the distal radius. J. Orthop. Trauma,5: 255-264, 1991.5255 1991 [PubMed][CrossRef]

Geissler, W. B., and |and |Savoie, F. H.: Arthroscopic techniques of the wrist. Medi-guide Orthop.,11: 1-8, 1992.111 1992

Hixon, M. L.; Walker, C. W.; Fitzrandolph, R. L.; and |and |McAndrew, M. P.: Acute ligament tears of the wrist associated with Colles' fracture. Orthop. Trans.,14: 164-165, 1990.14164 1990

Hollingsworth, R., and |and |Morris, J.: The importance of the ulnar side of the wrist in fractures of the distal end of the radius. Injury,7: 263-266, 1976.7263 1976 [PubMed][CrossRef]

Jenkins, N. H.; Jones, D. G.; Johnson, S. R.; and |and |Mintowt-Czyz, W. J.: External fixation of Colles' fractures. An anatomical study. J. Bone and Joint Surg.,69-B(2): 207-211, 1987.69-B(2)207 1987

Knirk, J. L., and |and |Jupiter, J. B.: Intra-articular fractures of the distal end of the radius in young adults. J. Bone and Joint Surg.,68-A: 647-659, June 1986.68-A647 1986

Lidström, A.: Fractures of the distal end of the radius. A clinical and statistical study of end results. Acta Orthop. Scandinavica,Supplementum 41: 1959.Supplementum 41 1959

McCarroll, H. R., Jr.: Nerve injuries associated with wrist trauma. Orthop. Clin. North America,15: 279-287, 1984.15279 1984

McMurtry, R. Y., and Jupiter, J. B.: Fractures of the distal radius. In Skeletal Trauma. Fractures, Dislocations, Ligamentous Injuries, edited by B. D. Browner, J. B. Jupiter, A. M. Levine, and P. G. Trafton. Vol. 1, p. 1063. Philadelphia, W. B. Saunders, 1992.

Meade, T. D.; Schneider, L. H.; and |and |Cherry, K.: Radiographic analysis of selective ligament sectioning at the carpal scaphoid. A cadaver study. J. Hand Surg.,15A: 855-862, 1990.15A855 1990

Melone, C. P., Jr.: Articular fractures of the distal radius. Orthop. Clin. North America,15: 217-236, 1984.15217 1984

Mikic, Z. D.: Age changes in the triangular fibrocartilage of the wrist joint. J. Anat.,126: 367-384, 1978.126367 1978 [PubMed]

Mohanti, R. C., and |and |Kar, N.: Study of triangular fibrocartilage of the wrist joint in Colles' fracture. Injury,11: 321-324, 1980.11321 1980 [PubMed][CrossRef]

Mudgal, C. S., and |and |Jones, W. A.: Scapho-lunate diastasis. A component of fractures of the distal radius. J. Hand Surg.,15-B: 503-505, 1990.15-B503 1990

Müller, M. E.; Nazarian, S.; Koch, P.; and Schatzker, J.: The Comprehensive Classification of Fractures of Long Bones, pp. 106-115. New York, Springer, 1990.

Palmer, A. K.: Triangular fibrocartilage complex lesions: a classification. J. Hand Surg.,14A: 594-606, 1989.14A594 1989

Porter, M., and |and |Stockley, I.: Fractures of the distal radius. Immediate and end results in relation to radiologic parameters. Clin. Orthop.,220: 241-252, 1987.220241 1987 [PubMed]

Sarmiento, A.; Pratt, G. W.; Berry, N. C.; and |and |Sinclair, W. F.: Colles' fractures. Functional bracing in supination. J. Bone and Joint Surg.,57-A: 311-317, April 1975.57-A311 1975

Short, W. H.; Palmer, A. K.; Werner, F. W.; and |and |Murphy, D. J.: A biomechanical study of distal radial fractures. J. Hand Surg.,12A: 529-534, 1987.12A529 1987

Stein, A. H., Jr., and |and |Katz, S. F.: Stabilization of comminuted fractures of the distal inch of the radius: percutaneous pinning. Clin. Orthop.,108: 174-181, 1975.108174 1975 [PubMed][CrossRef]

Stewart, H. D.; Innes, A. R.; and |and |Burke, F. D.: The hand complications of Colles' fractures. J. Hand Surg.,10-B: 103-106, 1985.10-B103 1985

Stewart, H. D.; Innes, A. R.; and |and |Burke, F. D.: Factors affecting the outcome of Colles' fracture: an anatomical and functional study. Injury,16: 289-295, 1985.16289 1985 [PubMed][CrossRef]

Szabo, R. M., and |and |Weber, S. C.: Comminuted intraarticular fractures of the distal radius. Clin. Orthop.,230: 39-48, 1988.23039 1988 [PubMed]

Weber, S. C., and |and |Szabo, R. M.: Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques. J. Hand Surg.,11A: 157-163, 1986.11A157 1986

Whipple, T. L.; Marotta, J. J.; and |and |Powell, J. H., III: Techniques of wrist arthroscopy. Arthroscopy,2: 244-252, 1986.2244 1986 [PubMed][CrossRef]

Wright, T. W.; Del Charco, M.; and |and |Wheeler, D.: Incidence of ligament lesions and associated degenerative changes in the elderly wrist. J. Hand Surg.,19A: 313-318, 1994.19A313 1994

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Arthroscopic view of the normal concave appearance between the carpal bones as seen from the radiocarpal space (arrow). There are no separations or step-offs. L = lunate and T = triquetrum.

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TABLE I DATA ON THE PATIENTS

Case	Fracture Type²⁴	Tear			Size of Fragment of Ulnar Styloid Proc. (mm)	Scapholunate Gap†	Lateral Scapholunate Angle‡
Scapholunate Lig.* (Grade)	Lunotriquetral Lig.* (Grade)	Triangular Fibrocartilage²⁵(Type)
1	B1.1	—	—	—	—	2	50
2	B1.1	—	—	—	—	2	45
3	B1.2	II	—	—	—	2	50
4	B1.2	IV	—	—	—	6	75
5	B1.2	—	—	B	—	2	45
6	B1.2	—	—	B	—	1	50
7	B1.3	—	—	D§	2	3	50
8	B2.1	—	—	—	2	2	50
9	B2.2	II	—	B	3	2	50
10	B3.2	—	—	—	2	2	45
11	B3.3	II	II	—	—	2	55
12	B3.3	—	—	D	—	3	50
13	C1.2	—	—	A	4	1	55
14	C1.2	—	III	—	—	2	50
15	C1.2	—	—	B	5	2	45
16	C1.2	II	—	B	2	2	50
17	C1.2	II	—	—	—	2	50
18	C1.2	II	—	—	—	3	50
19	C1.2	—	—	B	—	2	50
20	C1.2	II	—	D	—	3	50
21	C1.2	—	III	D	4	2	45
22	C1.3	—	—	—	1	1	45
23	C1.3	II	—	—	—	3	50
24	C1.3	III	—	B	2	3	50
25	C1.3	III	—	—	—	4	60
26	C2.1	—	—	B	1	2	55
27	C2.2	III	—	—	—	4	50
28	C2.2	—	—	A	—	2	50
29	C2.2	—	—	—	—	1	50
30	C2.2	IV	—	A	—	5	80
31	C2.2	—	—	—	—	2	55
32	C2.2	—	—	B	2	1	50
33	C2.2	—	—	A	—	2	50
34	C2.2	—	III	B	—	2	50
35	C2.2	—	—	—	2	3	45
36	C2.2	—	—	—	1	1	50
37	C2.3	—	—	—	—	3	50
38	C3.1	III	—	D§	1	5	55
39	C3.1	—	—	B	2	3	45
40	C3.1	—	—	—	—	3	50
41	C3.1	—	—	—	—	2	50
42	C3.1	—	—	—	—	2	50
43	C3.1	—	—	—	—	1	50
44	C3.1	III	—	A	—	4	60
45	C3.1	III	—	—	—	4	55
46	C3.1	—	—	—	—	2	50
47	C3.1	II	—	—	—	2	50
48	C3.1	—	—	—	—	3	50
49	C3.1	—	III	—	—	2	45
50	C3.1	—	III	—	7	2	50
51	C3.1	—	—	B	2	2	55
52	C3.1	—	—	—	—	1	50
53	C3.1	II	III	—	—	2	50
54	C3.1	—	III	B	2	1	45
55	C3.1	III	II	—	3	3	55
56	C3.2	—	—	—	4	2	50
57	C3.2	—	—	—	3	3	50
58	C3.2	—	—	D§	2	1	50
59	C3.2	—	—	D§	2	2	45
60	C3.2	—	—	A	2	1	55

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TABLE I DATA ON THE PATIENTS

Case	Fracture Type²⁴	Tear			Size of Fragment of Ulnar Styloid Proc. (mm)	Scapholunate Gap†	Lateral Scapholunate Angle‡
Scapholunate Lig.* (Grade)	Lunotriquetral Lig.* (Grade)	Triangular Fibrocartilage²⁵(Type)
1	B1.1	—	—	—	—	2	50
2	B1.1	—	—	—	—	2	45
3	B1.2	II	—	—	—	2	50
4	B1.2	IV	—	—	—	6	75
5	B1.2	—	—	B	—	2	45
6	B1.2	—	—	B	—	1	50
7	B1.3	—	—	D§	2	3	50
8	B2.1	—	—	—	2	2	50
9	B2.2	II	—	B	3	2	50
10	B3.2	—	—	—	2	2	45
11	B3.3	II	II	—	—	2	55
12	B3.3	—	—	D	—	3	50
13	C1.2	—	—	A	4	1	55
14	C1.2	—	III	—	—	2	50
15	C1.2	—	—	B	5	2	45
16	C1.2	II	—	B	2	2	50
17	C1.2	II	—	—	—	2	50
18	C1.2	II	—	—	—	3	50
19	C1.2	—	—	B	—	2	50
20	C1.2	II	—	D	—	3	50
21	C1.2	—	III	D	4	2	45
22	C1.3	—	—	—	1	1	45
23	C1.3	II	—	—	—	3	50
24	C1.3	III	—	B	2	3	50
25	C1.3	III	—	—	—	4	60
26	C2.1	—	—	B	1	2	55
27	C2.2	III	—	—	—	4	50
28	C2.2	—	—	A	—	2	50
29	C2.2	—	—	—	—	1	50
30	C2.2	IV	—	A	—	5	80
31	C2.2	—	—	—	—	2	55
32	C2.2	—	—	B	2	1	50
33	C2.2	—	—	A	—	2	50
34	C2.2	—	III	B	—	2	50
35	C2.2	—	—	—	2	3	45
36	C2.2	—	—	—	1	1	50
37	C2.3	—	—	—	—	3	50
38	C3.1	III	—	D§	1	5	55
39	C3.1	—	—	B	2	3	45
40	C3.1	—	—	—	—	3	50
41	C3.1	—	—	—	—	2	50
42	C3.1	—	—	—	—	2	50
43	C3.1	—	—	—	—	1	50
44	C3.1	III	—	A	—	4	60
45	C3.1	III	—	—	—	4	55
46	C3.1	—	—	—	—	2	50
47	C3.1	II	—	—	—	2	50
48	C3.1	—	—	—	—	3	50
49	C3.1	—	III	—	—	2	45
50	C3.1	—	III	—	7	2	50
51	C3.1	—	—	B	2	2	55
52	C3.1	—	—	—	—	1	50
53	C3.1	II	III	—	—	2	50
54	C3.1	—	III	B	2	1	45
55	C3.1	III	II	—	3	3	55
56	C3.2	—	—	—	4	2	50
57	C3.2	—	—	—	3	3	50
58	C3.2	—	—	D§	2	1	50
59	C3.2	—	—	D§	2	2	45
60	C3.2	—	—	A	2	1	55

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TABLE II ARTHROSCOPIC CLASSIFICATION OF TEARS OF THE INTRACARPAL LIGAMENTS

Grade	Description
I	Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space. No incongruency of carpal alignment in mid-carpal space.

II	Attentuation or hemorrhage of interosseous ligament as seen from radiocarpal space. Incongruency or step-off of carpal space. There may be slight gap (less than width of probe) between carpal bones.

III	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. Probe may be passed through gap between carpal bones.

IV	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. There is gross instability with manipulation. 2.7-millimeter arthroscope may be passed through gap between carpal bones.

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TABLE II ARTHROSCOPIC CLASSIFICATION OF TEARS OF THE INTRACARPAL LIGAMENTS

Grade	Description
I	Attenuation or hemorrhage of interosseous ligament as seen from radiocarpal space. No incongruency of carpal alignment in mid-carpal space.

II	Attentuation or hemorrhage of interosseous ligament as seen from radiocarpal space. Incongruency or step-off of carpal space. There may be slight gap (less than width of probe) between carpal bones.

III	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. Probe may be passed through gap between carpal bones.

IV	Incongruency or step-off of carpal alignment as seen from both radiocarpal and mid-carpal space. There is gross instability with manipulation. 2.7-millimeter arthroscope may be passed through gap between carpal bones.