The Modern History of the Wrist

The history of the wrist dates back to the times of Destot,[1] [2] who first described fractures of the scaphoid; Fisk,[3] who demonstrated carpal instability in association with displaced scaphoid fractures; Gilford et al[4] who entertained an explanation of wrist function in face of wrist fractures, and many other early investigators.[5] [6] [7] [8] [9] [10] [11] The concept of wrist instability evolved further with definition of perilunate instability by Mayfield and coworkers[12] [13] and an understanding of perilunate injuries with both dorsal and volar carpal displacements.[3] [4] [14] [15] [16] [17] But it was the publication of the article “Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics” in 1972 from the Mayo Clinic by Linscheid and associates[18] that stimulated a very keen and enduring interest in the wrist. These investigators introduced the new and defining terms dorsal intercalated carpal instability (DISI) and volar intercalated instability (VISI) as pathologic disorders that define scapholunate instability (DISI) and lunotriquetral instability (VISI) as well as a host of complex or combined problems of instability of the wrist. The follow-up publications in the Journal of Hand Surgery in 1983 by Linscheid and coauthors,[19] and nearly 10 years later in 1992,[20] further defined the basic concepts, diagnosis, and treatment of wrist instability.

At the Mayo Clinic, I had the privilege of early participation in both clinical and basic science research related to carpal instability. At our institution and in other investigational centers, radial side wrist pain with weakness and instability was recognized as not uncommon clinical presentations, especially acute and chronic scapholunate instability.[19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] Other conditions related to wrist instability included displaced scaphoid fractured, posttrapezectomy secondary instability, and instability associated with malunited fractures of the distal radius. Ulnar side wrist instability and midcarpal instability, which are most commonly associated with extrinsic ligament and lunotriquetral ligament tears and rheumatoid arthritis were studied later.[30] [31] [32] Within our biomechanical and anatomy laboratories, hand and research fellows from the United States, Great Britain, Europe, Korea, Sweden, Taiwan, and Japan became keen to understand the anatomic and mechanical reasons for loss of wrist function associated with presentations of carpal stability.[28] [33] [34] [35] [36] [37] [38] [39] The importance of the proximal and dorsal, distal scapholunate ligaments, extrinsic dorsal and volar capsular ligaments, and patterns of ligament stretch or disruption became appreciated as the underlying pathology of carpal instability. Anatomic studies by several investigators demonstrated the importance of a coupled or linked intra- and extracarpal ligament system and the importance of rebalancing the wrist by including repair or reconstruction of both intrinsic and extrinsic ligaments of the wrist.[9] [18] [22] [24] [30] [40] [41] [42] [43] [44] [45] With the analysis of fetal specimens, Berger et al[5] and Lewis[46] helped us understand the basic subcomponents of ligament anatomy and function and to advance understanding of adult conditions of carpal instability. Vascularity of the wrist was investigated, including both the global blood supply as well as the isolated external and internal vascular supply to carpal bones and the triangular fibrocartilage (TFC).[47] [48] [49] [50] Functional anatomy of the wrist was investigated in Europe with important contributions to carpal instability by several investigators.[51] [52] [53] Extrinsic associations such as malunion of Colles fracture and ulnar variance (ulna-minus variance) were shown to contribute to primary carpal instability such as scapholunate disassociation and late or secondary carpal instability.[27] [33] [45] [54]

At our institution, weekly hand conferences and wrist meetings provided access to a wide variety of wrist pathology and both national and international visitors interested in concepts of carpal instability and other wrist pathology were in attendance. It often was “standing room only.” What evolved from this interest were triennial wrist conferences ([Fig. 1]) initially presented by Mayo Division of Hand Surgery and then later in association with the American Society for Surgery of the Hand (ASSH). A list of “who's who” in hand and wrist surgery provided talent on a reoccurring basis with faculty and students equally participating in didactic lectures and hands-on anatomy and surgical reconstructive procedures in hand models and cadaveric specimens. Under the auspices of Dr. Linscheid and Dr. Dobyns, both national and international clinical visitors and hand fellows populated the clinical and research activities at the Mayo Clinic. Hand surgeon fellowship training became a unique contribution with highly sought after hand fellowships at our institution and others with, in particular, a high level of involvement of international hand fellows (Ian Trail, Michael Haydon, Frederick Schuind, Akio Minami, Damien Ireland, Michael Sauerbier, Marc Garcia-Elias, Guillaime Herzberg, Emikio Horii, Yasao Ueba, Monroe Beppu, and many others). It was an exciting time for those interested in the wrist and in the pursuit of understanding carpal instability and other pathologic conditions involving the wrist.

Figure 1 Mayo Wrist Course, October 1978. First meeting. Facility, front row: Christof Meuli, James Dobyns, Alfred Swanson, Robert Carroll, Ronald Linscheid, Roger Johnson; second row: William Cooney, Robert Beckenbaugh, John Kauer, Andrew Palmer, Edward Weber, Robert Volz, Julio Taleisnik (not shown upper left, Jack Mayfield).

Comparative anatomy and morphology of the wrist of humans and animals led to further understanding of wrist development and associated pathology. Visits by Mary Marske led us to the introduction to Lewis, Leakey, O'Connor, Napier, and others who demonstrated the prehensile function of the hand and importance of an opposable thumb, the freed distal radioulnar joint (from syndesmosis to well-developed synovial joint), the triangular disk and pisotriquetral articulation, and role of the bifacetlunate.[46] [55] [56] [57] [58] [59] [60] [61] Broadened bone support of the capitate and scapho-trapezio-trapizoidal joint was reflective of the increasing forces along the thumb ray associated with prehensile pinch and power grasp and “for the rapid, forceful, flexion, supination, and ulna deviation needed for the maneuvering and wielding of tools.”[56] Interestingly, features on the ulnar side of the wrist compatible with activities involving strong power grip were present at least 60,000 years ago. The evolving concepts of differences between power grip and prehensile grasp were so well demonstrated in tool making (holding a large stone in one hand and positioning the other for striking with a hammer stone) have progressed to explain the extensive excursion of the thumb metacarpal, strong intrinsic muscles, and comparative increased carpal support of the radial and ulnar rays of the wrist.

Studies on wrist biomechanics of the wrist at several academic centers, including the studies on the forces across the carpal bones and ligaments at the Mayo Clinic, have improved our understanding of the functional demands on the wrist.[36] [41] [43] [44] [62] [63] [64] [65] [66] [67] [68] Excessive stress can lead to local arthrosis, such as at the scaphotrapezial joint or collapse of carpal bones, such as Kienbock disease.[66] [69] [70] [71] [72] Division of forces between the distal radius and distal ulna[64] [67] [73] and the role of positive ulna variance has allowed surgeons to provide corrective procedures to treat or prevent arthritis of the wrist. Malunion of fractures of the scaphoid, capitate, and distal radius were studied with respect to force transmission, and corrective osteotomy procedures to rebalance the wrist and prevent secondary carpal instability were developed and studied in our research laboratories by fellows from Taiwan, Japan, Sweden, France, Portugal, Norway, and Germany. Pressure-sensitive film (Fuji film) and pressure-sensitive rubber sensors to directly measure forces in both the radiocarpal and distal radioulnar joints and resultant differential force transmission were implanted.[34] [36] [41] [74] Pressure magnitude and location of loads were measured with varying wrist motion.[64] [67] [75] Wrist simulators[62] [67] [76] [77] were developed with spring loaded tendons to reproduce physiologic loads across the wrist and then combined with anatomic lesions (ligament disruptions or fractures) to better understand the basic pathophysiology. Load cells were used to measure differences in load between the radius and ulna, and effect of positive ulna variance, dorsal angulation of the distal radius, opening and closing osteotomy of the distal radius, and resection of the distal ulna.[71] Patterson and colleague performed three-dimensional (3D) reconstruction of the wrist and showed the percentage of loading of individual carpal bones.[78] Advanced biomechanical engineering modeling at Mayo using a “rigid body spring model” provided a database of force transmission through the normal wrist which has been used in development of prosthetic replacement of the distal radius, the study of proximal carpal row carpectomy, and total wrist replacement.[75] Studies of motion of the wrist have been extended from the original works of de Lange et al, Savelberg et al, Youm et al, and others from biplanar X-ray techniques, light emitting diodes, fluoroscopy, and stereoscopic roentgenography to 3D motion assessments.[68] [79] [80] Motion related to the scapholunate, lunotriquetral, and midcarpal joint using newer methods of high speed video data acquisition systems resulted in the ability to track static 3D motion of individual carpal bones along with global motions of the wrist. At my institution, four conditions related to abnormal carpal kinematics were studied: (1) unstable scaphoid fractures, (2) scapholunate disassociation, (3) lunotriquetral disassociation, and (4) intercarpal fusions. Today, using the three-space electromagnetic sensor tracking systems, measurements are performed on cadavers and patients to provide accurate measures of wrist flexion-extension, radioulnar deviation, and global wrist motion associated with specific diseases and injuries of the wrist, including most recently out-of-plane motions referred to as “dart throwers motion” of the wrist.[38] [81] [82] [83] These studies performed in real time provide great insight into the 3D interaction of assessing carpal kinematics.

Applied to the distal radial ulna joint, kinematic studies[52] [64] [84] [85] [86] [87] [88] [89] have helped define what Hagert describes as the forearm axis of rotation that is distinct from carpal motion (pronation-supination).[73] The “ulna carpal” joint was thus defined with variations in anatomic shape, function, and force transmission related to differences in ulna length or variance[64] [73] [88] [90] and the important role of the TFC was established as the prime stabilizer of the distal radial ulnar joint.[87] The role of TFC as a gliding surface extension of the distal radius and cushion for force transmission across the ulna carpus was established and the importance of the deep and superficial insertion of the TFC on the distal ulna contributed to the understanding of both degenerative and posttraumatic tears leading to painful wrist and to a host of new treatment modalities (arthroscopic and open treatment of radial and ulna sided injuries as well as the role of ulna shortening procedure and ligament reconstructions).[91] [92] [93] [94]

Clinical and basic research on the wrist evolved in 1980 to the development of a Wrist Investigators Workshop. ([Fig. 2]) The first meeting was held in conjunction with an ASSH-sponsored Mayo Wrist course. Dr. James Dobyns, Dr. Lou Gilula, and I served as the chairpersons. There were always lively discussions on current topics of wrist instability ([Fig. 3]) and biomechanical principles affecting the wrist ([Fig. 4]). Subsequently, an international flavor was added and there have been meetings of the International Wrist Investigators' Workshop (IWIW) annually since 1987. Most meetings have been in association with the ASSH (1999 to the present) with alternative workshops in Newport Beach, California; Rochester, Minnesota; and Asheville, North Carolina (Lou Gilula, personal communication).[95] International meetings were held in Paris, France (host: Phillipe Saffar); Helsinki, Finland (host: Marty Vastamaki), and Vancouver, Canada (host: James Roth), along with study group gatherings in association with the International Foundation of Societies for Surgery of the Hand. One of the founders of the IWIW, James Dobyns, passed away this past year (July 14, 2011), leaving wrist surgery without one of its gurus, but an individual who remains as a gifted spirit for all of us and to the Listserv of the ASSH in which the title “Yoda Doc” appropriately was applied. Other workshops of the wrist included an arthroscopy study group at Bowman Gray School of Medicine hosted by Gary Poehling and Andrew Kolman in 1986. Wrist arthroscopy sprung forth from that experience as Terry Whipple and Jim Roth, who among others, navigated the attendees through all aspects of the wrist.[83] [96]

Figure 2 International Wrist Investigators Workshop, Mayo Foundation House, October 2001. First row, second from left is Cochairman James Dobyns and front row fourth from the left is Cochairman Lou Gilula gathered with workshop participants.

Figure 3 Mayo Wrist Course meeting, October 1990. Dr. James Dobyns (left) discussing find points of wrist pathology with former hand fellow, Dr. Andrew Palmer (center), and orthopedic resident, Dr. Damien Ireland (right).

Figure 4 Mayo Wrist Course, October 1990. Dr. Ronald Linschied (left) clarifying wrist biomechanics with innovator Dr. John Agee (right).

Clinical advances in management of disease, disorders, and trauma to the wrist have been dramatic in the modern history of the wrist. These have included volar plate fixation of distal radius fractures,[26] [97] corrective osteotomy of malunion of the distal radius,[98] [99] early open treatment of scaphoid fractures with cannulated screws,[100] vascular bone grafting of scaphoid nonunions and Kienbock disease,[49] [50] [70] and open and arthroscopic treatment of soft tissue injuries and TFC tears.[101] [102] [103] [104] Limited surgical approaches were developed to the radiocarpal and distal radioulnar joint and for denervation procedures of the wrist.[105] [106] [107] In congenital and developmental disorders in children, distraction lengthening for correction of radial aplasia evolved as well as for treatment of early and late Madelung's deformity. Vickers visited our medical center to demonstrate in a surgical case the physeal bar across the distal radius and dorsal radioulnar band (Vicker's ligament).[108] At the Mayo Clinic as visiting professor, Buck-Gramcko demonstrated denervation procedures of the wrist[106] and Flatt rebalancing the extensor tendons in rheumatoid arthritis of the wrist. Ligament reconstruction of the distal radioulnar joint evolved from works of Hui and Linscheid[85] and Adams and Berger.[109] Clinical evaluation of the wrist advanced with 3D imaging (computed tomography and magnetic resonance imaging of the wrist) alone or in association with arthrography.[95] [110] In treatment of scaphoid fractures, the work of Slade[100] is well recognized in development of percutaneous (arthroscopic aided) treatment of scaphoid fractures and that of Slutsky, Nagle, and many others related to advanced arthroscopic techniques including new dorsal and volar arthroscopy portals of the wrist.[93] [111] More complex injuries of the wrist that include displaced scaphoid fractures (wrist fractures and dislocations) still require open surgical methods of treatment, and despite advances in technique, remain a serious challenge to surgeons to gain effective patient outcomes.[35] Clinical measures were developed to assess outcomes of the wrist surgical treatment as well as clinician methods to score results of reconstructive procedures.[26]

On the soft tissue side of wrist instability, progress has been made in the treatment of acute and chronic scapholunate instability by ligament reconstruction or intercarpal fusion.[23] [112] [113] [114] Clinical assessments as described by Watson and Ballet[72] and Dobyns et al[27] have contributed to provide a key to diagnosis and treatment of carpal instability. When the clinical assessment is combined with abnormal radiographic appearance of the scapholunate or lunotriquetral intervals, operative intervention to repair the ligament has been beneficial.[42] [114] [115] Arthroscopy of the wrist has allowed identification of lesser interosseous ligament injuries with a classification related to anatomic finding and clinical importance. Watson is correctly credited for calling attention to stages of carpal instability from predynamic, dynamic to static, fixed instability, as well as credit for the natural history of progression to scapholunate advanced collapse when not identified and treated.[72] For chronic cases of scapholunate instability, the work of several investigators have proven valuable in providing external ligament support (tenodesis and capsulodesis) to prevent the scaphoid from returning to an unstable position of flexion.[23] [112] Newer methods of combined ligament reconstruction with dorsal capsulodesis appears to provide better outcomes than earlier capsule-only reconstructions.[115] In late cases with fixed carpal malalignment, intercarpal arthrodesis has been recommended and the new techniques to achieve solid fusions are of value. Similar ligament-based reconstructions of the lunotriquetral joint have also been designed in recent years and have proven superior to limited fusions of the wrist.[31]

All of the advances in the recent history of the wrist can be found in recent text books and monographs.[26] [97] [103] [113] [116] [117] Many additional references, too numerous to include, can be found in these text related to diagnosis and treatment of disorders of the wrist. From a historical standpoint, it is of interest, to note, that despite improvements in care of the wrist, many salvage procedures continue to be recommended such as proximal row carpectomy and limited wrist fusion and that despite success in the hip, knee, and foot, the upper extremity continues to be a difficult challenge in joint arthroplasty. Replacement of the wrist, after a turbulent time with large resection arthroplasties, may have success with resurfacing arthroplasty and distal ulna replacement appears to be beneficial. However, long-term successes must be demonstrated. Although interest in disorders of the wrist, in particular, carpal instability, started in Great Britain and then in France and the United States, there are now many international endeavors to study by basic research and clinical studies disorders of the wrist. A journal devoted to the wrist is, therefore, a very needed and, one would expect, rewarding endeavor. The increasing number of presentation related to the wrist at national and international meetings is reason alone to have a medical journal devoted to this unique area of anatomy and biomechanical function.

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