The Wrist: Anatomical and Pathophysiological Approach to Diagnosis and Treatment

280 Pages·1987·59.38 MB·English

by  Dr. Gontran Sennwald (auth.)

Gontran Sennwald
TheWrist
Anatomical and Pathophysiologica1
Approach to Diagnosis and Treatment
Forewords by
1.-1. Comtet and G. Segmüller
Adapted for the English edition by
R.G. McCormack
With 343 Figures
Illustrations and Diagrams by the Author
Springer-Verlag
Berlin Heidelberg NewYork
London Paris Tokyo
Dr. GONTRAN SENNWALD
Kantonsspital
Klinik für Orthopädische Chirurgie
CH-9007 St. Gallen
Adapted for the English edition by:
ROllERT G. MCCORMACK, M.D.
310-1076 West 14th Ave.
Vancouver
British Columbia
Canada V6H-IP3
Translated from the French by:
DAVID LE VAY
Dewhurst Lodge
Wadhurst
Sussex TN5 6QB
Great Britain
Original French edition
Ventite radius-carpc
Cl Springer-Verlag Berlin Heidelberg 1987
ISBN-13: 978-3-642-71624-9 e-ISBN-13: 978-3-642-71622-5
001: 10.1007/978-3-642-71622-5
Library of Con8re5S Cataloging·in-Publication Data. Sennwald. Gontran. 1943- The wrist.
Translation of: L'entite radius-carpc. Indudes bibliographies and index. 1. Wrist. 2. Wrist ~
Diseascs. 3. Wrist Surgery. l. Title. [DNLM: I. Wrist. 2. Wrist Injuries.
WE830 S478LJ RD559.S47131987 611'.574 86-33911
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Cl Springer· Verlag Beriin Heidelberg 1987
Softoover reprint ofthe hardcovcr 1st edition 1987
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2124/3130-543210
Love and friendship form the foundations of this book.
Thanks to the constant and acrive support of my wi/e, I have
been ab/e 10 comp/ele it; rhanks to the well-founded and
stimuloting advice of Dr. Segmüller, the ideas conrained in il
have come to full fruition; fts precision I owe ro my friend
Wolfram Fischer, marhematician and information techn%gist.
My profound rhanks
Foreword
In thc space of ooly a few years, reconstructive surgery of the
skeleton of the hand has become a foeus of attention. Thc reason
for this has been the advent of principles and techniques of
stable internal fixation, tbc unparaJleled advantages of which
are particularly evident in the treatment of the complex, multi
structural lesions so typical of injuries of the hand, and also
in procedures such as replantation or revascularisatioß.
What a striking contrast on the other hand is to be seen
in the slow and painful progress made in Dur understanding
of the biomechanics of the radiocarpal joint! This is most elo
quently ilIustrated by the embryonie state of prosthetic surgery
of the wrist, compared with the sophisticatcd advances made
in hip and knee surgery. Yet it is undeniable that painful condi
tions involving dysfunctions of the wrist are increasing in
number and affect young people in particular; this should spur
us on to seek more effective therapeutic solutions.
The very complexity of the carpus has been a subject of
theoretical interest. Still, it was not until 1943 that our knowl
edge of the wrist acquired a c1inical dimension: Gilford, Bolton
and Lambrinudi formulated the notion of a joint consisting of
a chain of intercalated small bones. They determined the axes
of each bone and were thus able to define instability of the
carpus in terms of deviations from these axes. Ever since, c1ini
cians and anatomists have been increasingly successful in their
efforts to gain a better understanding of the principles of mobil
ity as weil as of stability of the carpus.
These endeavours constitute the basis of this stimulating
monograph by G. Sennwald, who has amply succeeded in setting
forth a unified concept of the anatomy, function and pathology
of the carpus. Dr. Senn wald both presents a critical analysis
of the body of literature published on this subject around the
world and at the same time, examines with equal thoroughness
a large group ofpatients treated in the unit for hand surgery at the
Kantonsspital, SI. Gall, Switzerland. From this body of data, he
formulates a theory ofthe global function ofthe radiocarpaljoint,
which also constitutes a rationale for proposals of patient care.
Not only does this volume represent a benchmark for the progress
made in surgery of the hand; it also underscores the paramount
position this fie1d ofsurgery has come to occupy in modern recon
structive surgery. There can be no doubt that this book will earn
the respect it deserves from c1inicians and future researchers alike.
G. SEGMÜLLER
VI
Foreword
This is a book that is original and personal in content and style.
It provides amine of information and ideas to consider: a de
scription ofthe carpalligaments cJarified by a functional classifi
cation, a new concept of carpal stability, ingenious hypotheses
on pathogenesis of certain traumatic disorders, and analyses of
results of tested operative techniques.
Tedious, purely morphological description of the difTerent
carpal ligaments is replaced by c1assification ioto restraining,
stabilizing and guiding ligaments. Thc presence of restraining
ligaments is related to the existence of the distal carpal row
monolith. Failure of thc stabilizing ligaments accounts for dis
placements, and even dislocations. Failure of the guiding liga
ments is responsible for malalignment.
The author's concept of carpal stability rejects the notion
of a "central column", which is hardly admissible in the virtual
absence of an efTective luno-capitate ligament. How could it
be otherwise, when at its very centre there is a point of such
weakness that every perilunate dislocation disrupts this column 1
At last, the lunate has been accorded its proper place as
the keystone of the carpal edifice. Finnly buttressed against the
radius, it supports its two lateral partners. And, as the scaphoid
is too loosely attached to the distal monolith to coordinate the
mobility of the two carpal rows, with all respect to Gilford,
this coordinating function can only be ascribed to the distal
V ligament.
We are then presented with the consequences of hyperexten
sion injuries: the ligamentous tears (or the alternative fractures)
originate at one side of the lunate and progress around the bone
in direction one or the other. The author explains how to read
the radiographs in order to identify the signs of these tears or
fracture: disjunction, arthrographic leakage, or final disalign
ment or dislocation, until ultimately the lunate loses its radial
attachments.
Fractures of the distal ends of the two foreann bones and
fractures of the carpus are not merely bony lesions. The author
shows how they fall within the setting of alesion of the radio
carpal entity, where the ligamentous injuries worsen the progno
sis. This applies especially to pseudarthroses of the scaphoid,
when they are associated with instability requiring Iigamento
plasties and pins to secure fixation of the site and correction
of disalignment. Nevertheless, taking all categories together,
these pseudarthroses unite in 85% of cases.
Vll
The author is clearly not in favour of the use of Silastic,
whether for pseudarthroses of the scaphoid or for Kienböck's
disease. It is true that, despite encapsulation, the implant never
acquires ligamentous attachments, and can be maintained in po
sition only by some form of intracarpal arthrodesis. In this field,
although the outright condemnation of scapho-lunate arthrode
sis is possibly debatable, the review of the different methods
of fusion between the carpal bones provides an excellent basis
for discussion.
In the chapters on surgical technique, the author gives an
account of his own experience with precision and sincerity, and
this section is one to be readily resorted to before undertaking
a particular operation. However, younger surgeons should resist
the temptation to bypass the first part of the book, however
arduous it may seem, for quality of surgical procedure and the
proper choice of indications are to be achieved by global under
standing of the radio-carpal entity.
At the end of the work the author, in his direct, personal
and sometimes nonconformist style, addresses himself directly
to his readers. Perhaps I may be allowed to reply on their behalf.
Persuaded by your concepts, we shall adopt your proposals for
standardization of the clinical and radiological approach to ra
dio-carpallesions. "Treatment will continue to develop, thanks
to the elaboration of a common language as the basis for pro
gress and research". We congratulate and thank Dr. Sennwald
for this youthful and stimulating book.
J.-J. COMTET
VIII
Preface
Is it really necessary to add yet another book to the already
very long catalogue of medicalliterature? Aware of the responsi
bilities that this implies, and thoroughly absorbed in my hospital
activities, I needed streng motivation to write this monograph
on the carpus. By means of this modest work it is my earnest
hope to bring to colleagues who, though interested, but possibly
overworked or out of touch, a digest of my experience, my read
ing and my own research and studies on a fascinating but diffi
eult subject; to make it more accessible to them.
I also hope to stimulate research workers to abolish all my
question-marks by devoting themselves to new studies, with their
inventive and scientific spirit, and evermore-refined modern
techniques. I hope to assist surgeons anxious to make a precise
diagnosis, and to thereby choose the appropriate treatment
methods; and I hope to contribute to the eradication of certain
popular but erroneous ideas that are harmful to the rehabilita
tion of patients.
To satisfy these ambitions, I have attempted to extract the
gist of what the best authors and researchers have supplied us
with so far, and also of what I have learned from c1inical and
operative experience, the dissecting-room and the analytical
study of results obtained. In reviewing the c1assical anatomy I
have striven to simplify the facts without loss of accuracy, with
the overriding aim of being essentiaJly practical and therefore
usefuL This has sometimes led me to entirely new concepts. The
statistical study complies with the modern scientific spirit, but al
so with the desire to comfort all those who talk about "medical
flair", weil realizing that this boils down to a fine brew of anatorn
ical knowledge, technical competence and c1inical experience.
If our approach to the carpus, in that it is difTerent and
novel, manages to stimulate the mi nd and arouse contradiction,
then my task will not have bcen in vain; progress may come
through confrontation which leads to revision of one's opinions
and, sometimes, to an opening of new pathways.
It is in this spirit that I set out here a new concept of the
stability of the carpus; agiobai radiological approach to the
injured wrist; a broadening of the spectrum of treatment of
pseudarthrosis of the scaphoid, necessitated by ligamentous in
stability; and a new c1assification of, and new ideas concerning,
fracture of the distal radius, so common and yet so misunder
stood, especially as regards its c1inical and anatomical conse
quences, those of the associated radio-carpalligamentous lesions
in particular.
IX
I acknowledge the assistence of Dr. David Le Vay in the
primary translation and the Springer Verlag for their coopera
tion for the success of the English edition. Again I thank Rohert
McCormack. M.D .• F.R.C.S., Vancouver (Canada), who added
bis skill to make this English edition possible.
Thus, whether the reader be a trainee or an experienced sur
geon. or perhaps a research worker, I helieve that he or she
will find something to ponder. It is with optimism that I entrust
the reader with the fruits of my reflections.
G. SENNWALD
x
Contents
Introduction
History 5
The Carpus 5
The Concept of Stability 8
The Radius and the Radio-carpal Joint 9
References ....... ... . 11
CHAPTER I
Anatomical Approach 13
A. Sony Anatomy 13
B. Ligamentous Anatomy 15
Nomenclature 15
Classification . _ . . 16
1. Articular Ligamenlous System 16
Interosseous Group . . 17
The Palmar V Group 17
The Ulnocarpal Complex 18
The Dorsal V Group 18
Systematic Analysis . . 19
2. Extra-articular Ligamentous System 27
Extensor Retinaculum . . . . 27
Flexor Retinaculum . . . . . 31
3. Anatomical Study: Conclusions 33
C. Kinematics . . . . . . . . . . 34
1. Analysis of the Mobility of the Proximal Row
in the Frontal Plane 34
Ulnar Deviation 34
Radial Deviation 35
Neutral Position 37
2. Analysis in the Sagittal Plane 37
D. Functional Ligamentous Anatomy 39
.. Restraining " Ligaments 39
"Stabilizing" Ligaments 39
"Guiding" Ligaments 40
Conclusion ..... 40
E. The Concepts of StabiJity 40
History ...... 40
Discussion . . . . . 41
Ligamentous Anatomy 41
Xl