Carpal Fractures Research Articles

Volar Locking Plate Fixation for Scaphoid Fractures: Surgical Technique

Scaphoid fractures are the most encountered carpal fracture. Unstable fractures with substantial comminution or bone loss, as well as scaphoid nonunions, may benefit from fixation using volar locking plates. This article presents a surgical technique for open reduction and internal fixation of scaphoid fractures using a volar locking plate and a non-vascularized autogenous cancellous bone graft from the distal radius.

The Conservative and Operative Treatment of Carpal Fractures.

Carpal fractures (incidence: 30-60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones. This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV). The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2-4 weeks) than with conservative treatment (6-8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobilization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available evidence is limited to expert consensus. Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.

Transradial Trans-Scaphoid Transcapitate Transtriquetral Perilunate Dislocation of the Wrist

Abstract Perilunate dislocation is a severe complex injury associated with carpal bone fracture. The most common pattern is trans-scaphoid perilunate dislocation. A transradial, trans-scaphoid, transcapitate, and transtriquetral perilunate dislocation pattern, an extremely rare complex injury of the wrist joint, may be the first reported case of a combination of three carpal bone fractures and radial styloid fracture associated with perilunate dislocation.

In vivo non-contact regions of proximal scaphoid in six extreme wrist positions

IntroductionFractures of the scaphoid are the most common carpal injuries, account for 80-90% of all carpal fractures. 5-15% nonunion of scaphoid fractures were reported even with adequate primary treatment, which probably progresses to osteoarthritic changes several decades later. Researches regarding to scaphoid physiological characteristic in vitro and in vivo and kinds of trials in clinical practice are being kept on going, which contribute much to our clinical practice. With the advancing wrist arthroscopy, 3D-print patient-specific drill guide, and intraoperative fluoroscopic guidance, dorsal approach (mini-invasive and percutaneous technique) is being popular, through which we can implant the screw in good coincidence with biomechanics and with less disturbing tenuous blood supply of the scaphoid. Investigating the noncontact area of the dorsal proximal scaphoid in different wrist positions can facilitate preoperatively estimating insert point of the screw.Materials and methodsEight volunteers were recruited to accept CT scans in six extreme wrist positions. The images of DICOM mode were imput into the Mimics analytical system, the segmented scaphoid, lunate and radius were exported in mode of ASCII STL and were opened in the software of Geomagic studio. We created four planes based on anatomic markers on the surface of the radius and scaphoid to confine the proximal scaphoid to form the so-called non-contact regions. We measured and compared the areas in six targeted positions.ResultsAmidst six extreme wrist positions, area of the non-contact region in extreme dorsal extension (59.81 ± 26.46 mm2) was significantly the smallest, and it in extreme palmar flexion significantly was largest (170.51 ± 30.44 mm2). The non-contact regions increased in order of dorsal extension, supination, ulnar deviation, radial deviation, pronation and palmar flexion. As for two-group comparison, the non-contact region showed significantly larger (p < 0.05) in palmar flexion than the others except for in pronation individually, and in radial deviation (p < 0.05) than in dorsal extension.ConclusionsSufficient space was available for the screw started from the dorsal approach despite the wrist positions.

PANORAMIC REVIEW OF ACUTE SCAPHOID FRACTURES: DESCRIPTION, EPIDEMIOLOGY, ETIOLOGY, PRESENTATION, DIAGNOSIS, TREATMENT AND PROGNOSIS

Introduction: Scaphoid fractures are the most common fractures of the carpal bone and commonly occur in young males. Inadequate treatment of these fractures commonly leads to pseudarthrosis, resulting in pain and significant disability. Tenderness to palpation and/or pain with axial loading of the thumb should be managed as if it were a scaphoid fracture until proven otherwise. Objective: to detail current information related to scaphoid fractures, description, epidemiology, etiology, presentation, diagnosis, treatment and prognosis. Methodology: a total of 37 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 20 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: fracture, scaphoid, carpal bones, trauma, surgery. Results: Scaphoid fractures account for 2% to 7% of all fractures and 60% to 70% of carpal bone fractures. They are infrequent in children with approximately 3% of all pediatric hand and wrist fractures. Non-displaced fractures have high healing rates with cast treatment. Radiographs may miss fractures up to 25% of the time. Physical therapy is important in both operative and nonoperative treatment. Conclusions: Knowledge of the clinical presentation, diagnosis and treatment of scaphoid fractures is of utmost importance, because sometimes this type of fracture can go undetected on radiographs, which can lead to complications such as pseudarthrosis. The diagnosis of scaphoid fractures is sometimes complicated, so when there is clinical suspicion, appropriate complementary examinations should be performed to better determine the pathological condition, as is the case of computed tomography. Conservative or surgical management will depend on the type of fracture. Smoking cessation is recommended to improve fracture healing and physiotherapy both after surgical and non-surgical treatment. KEY WORDS: fracture, scaphoid, carpal bones, trauma, surgery.

Review of extraosseous and intraosseous blood supply of the carpal bones

The blood supply of the carpal bones has been updated and described with new dissection, vascular filling and imaging techniques. It is very important to know the vascular anatomy of the carpal bones in order to predict vascular insufficiency and associated avascular necrosis that may occur as a result of any injury such as fracture. This article reviews the extraosseous and intraosseous vascular supply of the carpal bones. The carpal bones are supplied by three vascular arches formed by the radial, ulnar and anterior interosseous arteries on the dorsal and palmar sides of the wrist. These contribute to the dorsal and palmar carpal vascular systems, which consist of transverse arteries connected by longitudinal anastomoses. The scaphoid and capitate have a high risk of avascular necrosis, while the trapezium, triquetrum, pisiform and 80% of the lunate have a lower risk. With the development of new imaging techniques, new information is added to the literature. With the increase in three-dimensional studies, intraosseous vascularity and its correlation with carpal bone fractures and its relationship with avascular necrosis will be revealed more clearly.

Spontaneous union of neglected proximal pole scaphoid fracture: A case report

Scaphoid fractures are the most common carpal bone fractures and usually occur due to trauma, typically a fall on an outstretched hand. The scaphoid bone is integral to wrist biomechanics, linking the proximal carpal row to the distal row. Neglected scaphoid fractures can lead to significant long-term complications, with degenerative changes likely to occur. The most common consequence of a neglected scaphoid fracture is known as scaphoid non-union advanced collapse, which typically begins within five years following the injury. It is widely accepted that scaphoid fractures, in general, should be treated to avoid long-term complications. Many surgeons aggressively treat proximal pole fractures with surgical fixation due to the high risk of avascular necrosis. Although some surgeons may consider a period of immobilization, none would argue against the need for treatment of proximal pole fractures, either through immobilization or surgical fixation. In this case, we present an instance of spontaneous union of a neglected proximal pole fracture non-union in a mature adult. This report aims to provide awareness of the possible spontaneous union of neglected proximal pole scaphoid fracture. It also challenges the call for acute aggressive surgical intervention in such fractures. Radiographs and magnetic resonance imaging scan images before and after union are presented, along with a review of the available literature.

Anaesthesia-related morbidity associated with recumbent, low-field magnetic resonance imaging of horses

ABSTRACT Case history: Medical records from 2009 to 2021 from a private equine referral hospital in Rochester, NH, USA were analysed for cases that underwent general anaesthesia for low-field MRI of the distal limb. These were used to determine peri-anaesthetic morbidity and mortality. Clinical findings and outcome: Two hundred and forty-three anaesthetic episodes were recorded in horses undergoing low-field MRI. The peri-anaesthetic complication rate prior to discharge was 6.2% (15/243). No patients experienced a fatal complication. Ninety two of the 243 patients had multiple sites imaged, 90/243 received pre-anaesthetic dantrolene, 134/243 received intra-anaesthetic dobutamine, and 15/243 were positioned in dorsal recumbency. Complications included: abdominal discomfort (“colic”; 9/243), myopathy (4/243), hyphaema (1/243) and carpal fracture (1/243). At the time of discharge, 14/15 complications had resolved. Of 135 horses for which data were available 55 became hypotensive during the procedure (lowest mean arterial pressure < 65 mmHg). Median body weight was 553 (min 363, max 771) kg. Horses were anaesthetised for a median of 150 (min 45, max 210) minutes. There was no evidence of an association between higher body weight (p = 0.051) or longer duration of anaesthesia (p = 0.421) and development of an anaesthetic complication. For categorical variables (dantrolene administration pre-anaesthesia, dobutamine administration during anaesthesia, hypotension (mean < 65 mmHg) during anaesthesia, dorsal vs. lateral recumbency, and imaging of single vs. multiple sites), the 95% CI for the OR included 1, indicating a lack of effect of the variable on the odds of complication. Clinical relevance: The cases included in this series suggest that low-field MRI under general anaesthesia is a viable option for diagnostic imaging in otherwise healthy horses. Complications occur, but most resolve before discharge.

Clinical Features and Classification of Proximal Carpal Fracture Dislocation Through the Radiocarpal Joint.

Background: The most common types of wrist dislocation are trans-scaphoid lunate dislocation (TLD) and trans-scaphoid perilunate dislocation, in which the lunate and proximal scaphoid are dislocated through the midcarpal joint. There is another rare type of dislocation in which the proximal carpi are dislocated through the radiocarpal joint. The purpose of this study is to examine the clinical features of this type of dislocation. Methods: Six cases of the proximal carpal fracture dislocation via the radiocarpal joint were retrospectively reviewed. All patients underwent open reduction and internal fixation with the ligament reconstruction. A Mayo wrist score was assigned to each patient based on the assessment of pain, functional status, range of motion and grip strength at the last follow-up. Clinical subjective evaluation of function and pain was assessed using the patient-rated wrist evaluation (PRWE) method. Results: All patients were male and injured with a median age of 33.5 years. The median follow-up period was 10 months. There were three types of dislocations: Scaphoid fracture dislocation, TLD and scaphoid-lunate dislocation. All patients had satisfactory results with an average PRWE of 7.2 ± 4.7. The preoperative VAS was 6.7 ± 1.0 and the postoperative VAS was 0.7 ± 0.7 (p < 0.01). Postoperative grip strength accounted for 89.2% ± 9.8% of the contralateral side; the Mayo wrist score averaged 90.0 ± 6.5, with four patients obtaining excellent and two good results. Conclusions: Fracture dislocation of the proximal carpal bones through the radiocarpal joint is an independent type of wrist dislocation that tends to occur in young men with high-energy impact. The wrist is most often injured in a pronation hyperextension position. If treatment is timely and appropriate, the prognosis is quite good. Level of Evidence: Level IV (Therapeutic).

Evaluation of the Effect of Ununion Percentage of Scaphoid on Stress and Displacement of Fragment Part of Scaphoid in Various Degrees of Wrist Extension with and without External Force

Abstract Background Scaphoid fractures are almost two-thirds of different kinds of carpal fractures. Surgeons usually have challenges in deciding if the wrist should be mobilized or immobilized for the patients with different percentiles of partial union of scaphoid. This study's aim was to investigate different percentiles of union (25–50–75) in waist and proximal pole of scaphoid fracture to find the union percentile which can tolerate normal daily activities to help surgeons in taking appropriate decisions in this regard. Method A model of wrist joint was developed in this study based on computed tomography scan images of wrist joint. Various percentage of union in waist and proximal poles of scaphoid with and without internal fixation were tested in this study. The stress applied on scaphoid and displacement of fragment parts were evaluated in Abaqus software during motion of wrist from neutral to 40 degrees of extension. Results Although Von Mises stress of scaphoid bone increased following use of external force, the difference was significant for conditions 3 and 6 (75% of union in middle and distal parts). The stress applied on scaphoid increased depends on conditions (ununion percentage of bone). Moreover, its stress depends on the angle of wrist extension. Use of internal fixation screw decreased stress of scaphoid in most of conditions. Conclusion The stress developed in scaphoid depends on the nonunion percentage of scaphoid and the amount of motion of wrist joint. It is better to use external fixation screw especially for conditions 3 and 6 (75% of union in middle and distal parts) to decrease the displacement of fragment parts and to decrease the stress applied on scaphoid in wrist extension. Type of Study and Level of Evidence Case study, level of evidence: III.

Radiofrequency Ablation of Palmar Digital Branches of Ulnar Nerve in a Patient with Ulnar Neuropathy

Ulnar Tunnel Syndrome (UTS) is ulnar neuropathy at the wrist or hand typically caused by ganglion cysts, lipomas, wrist or hand compression, carpal bone fractures, carpal tunnel syndrome, or anything else that can impinge on the nerve. The symptoms of UTS can be uncomfortable and debilitating, with numbness and tingling of the 4th and 5th digits being the most common. Weakness of the ulnar portion of the hand can lead to decreased grip strength. UTS is typically managed with conservative treatment including anti-inflammatory oral medications, splinting, physical therapy, activity modification, acupuncture, and stretching. Second line treatment includes corticosteroid injections, although these have shown to have little efficacy. Surgery is also an option but may lead to iatrogenic ramifications. Radiofrequency ablation (RFA) is a treatment modality used for chronic pain, which utilizes heat to target nociceptive fibers. Traditionally, RFA is used in treating cervical and lumbar radiculopathy, but it is less studied in peripheral nerve areas. This case report examines a patient who had clinically significant pain relief after RFA to the palmar digital branches of the ulnar nerve. The patient was 63-year-old male who presented with left ulnar neuropathy that had been ongoing for 3 years. Despite conservative management, his symptoms of pain, paresthesia, and weakness persisted. The patient then elected to have a left cubital tunnel release at the elbow with anterior subcutaneous transposition. The surgery provided relief for three months but then led to worsening contractures and pain in the 4th and 5th digits of the left hand. Due to persistent symptoms after conservative management and surgical intervention, he was referred to interventional pain clinic. A decision was made to trial a digital nerve block of the left medial and lateral digital palmar nerves. Following the nerve block, the patient reported 100% improvement in pain and increased range of motion and function. Four weeks later, the patient returned for a radiofrequency ablation of the same nerves. In the week following the procedure, the patient reported that the pain in the little finger was entirely resolved. While radiofrequency ablation has become increasingly popular for the treatment of chronic back pain, its use in peripheral nerve pain has been limited to case reports and few randomized control trials. This case report highlights the successful use of radiofrequency ablation in the treatment of little finger pain and ulnar neuropathy by targeting the median and lateral branches of the palmar digital nerve.

Anesthesia Type and Short-Term Outcomes in Open Treatment of Hand Fractures.

The hand is one of the most commonly fractured parts of the body. Many of these injuries are treated operatively. This study compares short-term outcomes between general anesthesia and other forms of anesthesia in the open treatment of hand fractures. Procedures related to the open treatment of carpal, metacarpal, and phalangeal fractures from the years 2005-2017 were queried from the National Surgical Quality Improvement Program (NSQIP) database. Outcome measures included 30-day reoperation rate, length of stay (LOS), minor complications, and major complications. Chi-squared tests were used to identify significant demographics and comorbidities. Significant variables were included in a logistic regression model. A total of 5,907 patients were included, of which 4,547 (77%) received general anesthesia, and 1,360 (23%) received local anesthesia, regional anesthesia, sedation, or monitored anesthesia care. Patients treated with general anesthesia were younger and more likely to be male. Operative time was longer with general anesthesia (65.0 vs. 59.8minutes, P<0.01). Anesthesia technique had no statistically significant association with thirty-day rate of reoperation, minor complications, or major complications (P=0.32, 0.91, and 0.07, respectively). General anesthesia had greater odds for LOS exceeding the 75th percentile (OR 2.05, P<0.01). In the open treatment of hand fractures, short-term complication rates are similar between general anesthesia and other forms of anesthesia, but extended LOS is more likely with general anesthesia. When practical, surgeons can consider local anesthesia, regional anesthesia, sedation, and monitored anesthesia as reasonably safe alternatives to general anesthesia.

Delayed union of a pediatric lunate fracture in the United Kingdom: a case report and a review of current concepts of non-scaphoid pediatric carpal fractures.

Pediatric carpal fractures are rare and often difficult to detect. This paper reviews the current literature on pediatric non-scaphoid carpal fractures, with a case report of a lunate fracture associated with a distal radius and ulnar styloid fracture, managed nonoperatively in a 12-year-old boy. There is lack of consensus regarding the management of these fractures due to the low number of reported cases. A frequent lack of long-term follow-up limits our understanding of the outcomes, but good outcomes have been reported for both nonoperative and operative management. This case report brings attention to the current time period for the definition of delayed union in pediatric carpal fractures, and emphasizes the need for prolonged follow-up for the detection of delayed complications leading to functional impairment.

Application of Artificial Intelligence and Machine Learning in Diagnosing Scaphoid Fractures: A Systematic Review.

The integration of artificial intelligence (AI) in healthcare has sparked interest in its potential to revolutionize medical diagnostics. This systematic review explores the application of AI and machine learning (ML) techniques in diagnosing scaphoid fractures, which account for a significant percentage of carpal bone fractures and have important implications for wrist function. Scaphoid fractures, common in young and active individuals, require an early and accurate diagnosis for effective treatment. AI has the potential to automate and improve the accuracy of scaphoid fracture detection on radiography, aiding in early diagnosis and reducing unnecessary clinical examinations. This systematic review discusses the methods used to identify relevant studies, including search criteria and quality assessment tools, and presents the results of the selected studies. The findings indicate that AI-driven methods can improve diagnostic accuracy, reducing the risk of missed fractures and complications. AI assistance can also alleviate the workload of medical professionals, improving diagnostic efficiency and reducing observer fatigue. However, challenges such as algorithm limitations and the need for continuous refinement must be addressed to ensure reliable fracture identification. This review underscores the clinical significance of AI-assisted diagnostics, especially in cases where fractures may be subtle or occult. It emphasizes the importance of integrating AI into medical education and training and calls for robust data collection and collaboration between AI developers and medical practitioners. Future research should focus on larger datasets, algorithm improvement, cost-effectiveness assessment, and international partnerships to fully harness the potential of AI in diagnosing scaphoid fractures.

Zoledronic Acid Accelerates Bone Healing in Carpal Navicular Fracture via Silencing Long Non-coding RNA Growth Arrest Specificity 5 to Modulate MicroRNA-29a-3p Expression.

Carpal navicular fractures are the most common carpal fractures. This study intends to explore the specific mechanism of Zoledronic Acid (ZA) in carpal navicular fracture healing via long non-coding RNA (lncRNA) growth arrest specificity 5 (GAS5) to mediate microRNA (miR)-29a-3p.A fractured rat model was constructed. Two weeks later, a subcutaneous injection of systemic ZA was implemented, and an injection of plasmid vectors interfered with GAS5 or miR-29a-3p expression was performed on the fracture site. Osteocalcin (OCN) and bone morphogenetic protein-2 (BMP-2) were determined, as well as serum levels of alkaline phosphatase (ALP), osteopontin (OPN) and osteoprotegerin (OPG) and bone mineral density. MC3T3-E1 cells were transfected with plasmid vectors interfering with GAS5 or miR-29a-3p, and cell proliferation and apoptosis were analyzed. GAS5 and miR-29a-3p expression in fractured rats was tested, together with their binding relationship.ZA promoted OCN and BMP-2 expression, increased bone mineral density and serum levels of ALP, OPN and OPG in fractured rats. GAS5 was upregulated and miR-29a-3p was down-regulated in fractured rats. Downregulation of GAS5 or upregulation of miR-29a-3p further promoted bone healing in fractured rats. GAS5 targets miR-29a-3p, and down-regulation of miR-29a-3p can reverse the effect of down-regulation of GAS5 on bone healing in fractured rats. ZA promoted the proliferation of MC3T3-E1 cells and inhibited apoptosis by regulating the GAS5/miR-29a-3p axis.ZA regulates miR-29a-3p expression by down-regulating GAS5 to promote carpal navicular fracture healing, promote MC3T3-E1 cell proliferation, and inhibit cell apoptosis.

Arthroscopic Volar Capsuloligamentous Reattachment and Reinforcement to Bone.

Background: Injuries of the volar ligaments of the wrist are not uncommon, but their arthroscopic treatment presents a significant challenge. The objective of this paper is to introduce a technique for reattaching (in acute injuries) or reinforcing (in chronic injuries) various volar wrist ligaments to the bone, using standard wrist arthroscopic dorsal and volar portals. Methods: There are three common steps for all the arthroscopic volar capsuloligamentous reattachments or reinforcements Step 1 - Volar Portal Establishment: volar radial, volar ulnar and volar central portals are used depending on which structure needs to be reattached or reinforced. Step 2 - Anchor Placement: the anchor is positioned at the site where the ligament has been detached. Step 3 - Capsuloligamentous Suture and Knotting: a knot pusher is introduced inside the joint from the dorsal portal and advanced inside the volar portal where the threads of the anchor are located. The knot pusher is loaded with the threads and retrieved to the dorsal portal. A 16G Abbocath, loaded with a loop is used to pierce the volar ligaments. The loop of the Abbocath is captured from the dorsal portal and loaded with the threads. Both threads are taken to the volar portal and knotted after releasing the traction. This way the knot is placed out of the wrist and the ligaments are reattached or reinforced to the bone. Result: This technique has been used to reinforce and reattach the scapholunate and lunotriquetral ligaments and to reattach the radiocarpal ligaments and the Poirier space. Since this procedure has been performed in various conditions and in conjunction with other ligament treatments (such as perilunate injuries, carpal bone fractures, distal radius fractures, and reinforcement or reattachment of the dorsal portions of intrinsic ligaments), specific results are not presented. Conclusions: The described technique enables the reattachment and reinforcement of most volar ligaments to the bone using standard wrist arthroscopic portals. It can be performed in conjunction with the treatment of the dorsal portion of intrinsic ligaments or other wrist injuries.

Effectiveness of occupational therapy interventions on function and occupational performance among adults with conditions of the hand, wrist, and forearm: A systematic review and meta-analysis.

This systematic review and meta-analysis examines the effectiveness of occupational therapy interventions for adults with conservatively managed conditions of the hand, wrist, and forearm. Searches were carried out in CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, MEDLINE (OVID), EMBASE, and PubMed. Grey literature was searched for via Google Scholar. A systematic literature search was undertaken for randomised studies that examined occupational therapy interventions for treatment of hand, wrist, and forearm conditions. The primary outcome was function, with secondary outcomes of occupational performance, satisfaction with occupational performance, pain, and quality of life. Meta-analyses were completed, and GRADE was used to determine the certainty of evidence. Twelve studies with 1429 participants were identified. Interventions included combinations of occupation-based intervention, assistive device provision, education, orthosis provision, and exercise programmes for arthritis, carpal tunnel syndrome, and fracture and tendon injuries of the hand, wrist, and forearm. Occupational therapy resulted in an improvement of function (REM, SMD -0.27, 95% CI -0.00 to -0.53, I2 = 69%, low certainty evidence) (p = 0.05), occupational performance (REM, SMD 0.83, 95% CI 1.61-0.06, I2 = 91%, low certainty evidence) (p = 0.04), satisfaction with occupational performance (REM, SMD 0.74, 95% CI 1.42-0.05, I2 = 89%, low certainty evidence) (p = 0.03), and pain reduction (FEM, MD -1.35, 95% CI -0.84 to -1.86, I2 = 0%, moderate certainty evidence) (p < 0.00001). Further high-quality research is recommended to determine the effects of occupational therapy interventions on specific upper limb conditions, inclusive of a broader range of clinical and patient reported outcome measures.

Carpal fractures: epidemiology, classification and treatment of 6542 fractures from the Swedish Fracture Registry.

This study describes the age and sex distribution, trauma mechanism, treatment and influence of patient-reported outcomes of 6542 carpal fractures from the Swedish Fracture Registry (SFR). The most commonly fractured carpal bone was the scaphoid (60%), followed by the triquetrum (25%), hamate (5%) and trapezium (4%). The mean age at injury was 41 years, and 69% of patients were male. The age and sex distribution of carpal fractures differed substantially between the different carpal bones. Men were more likely to sustain a carpal fracture after high-energy trauma and were more likely to be treated surgically. Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury.Level of evidence: IV.

MDCT evaluation of distal radius fractures and their association with carpal and distal ulnar fractures.

The purpose of this study was to evaluate the characteristics of distal radius fractures (DRFs) in patients undergoing multi-detector computed tomography (MDCT) and their association with carpal and distal ulnar fractures. This retrospective study analyzed 120 patients, who underwent MDCT for evaluation of DRFs. Two radiologists independently evaluated the data for various fracture characteristics and for associated carpal and distal ulnar fractures. Out of 120 DRFs, 74 were complete articular, 40 were partial articular and only 6 were extra-articular. Displacement was present in 99 fractures and intra-articular step off was present in 73 fractures. A total of 81 carpal bone fractures were identified in 46 (38.3%) patients, with more than one carpal bone fracture in 21 patients. Distal ulnar fractures were detected in 79 patients (65.8%), out of which 67 involved the ulnar styloid. DRFs with intra-articular step off were more frequently associated with carpal bone fracture (p value: 0.021), while displaced DRFs were more frequently associated with distal ulnar fracture (p value <0.001). Interobserver agreement for detection of carpal bone fractures (κ = 0.807) and distal ulnar fractures (κ = 0.923) was excellent. Majority of DRFs in patients referred for MDCT were complete articular with high incidence of displacement and intra-articular step off. Associated carpal bone and distal ulna fractures were not uncommon.

Scaphoid and Carpal Bone Fracture: The Difficult Cases and Approach to Management.

Scaphoid and carpal bone fractures are challenging injuries to manage and have significant functional implications. Prompt diagnosis is important and relies on systematic evaluation via history, examination, and imaging. Cross-sectional imaging is often helpful for diagnosis and treatment planning. Treatment for nondisplaced fractures is often closed but these injuries typically require prolonged immobilization and may still result in nonunion or avascular necrosis. Displaced carpal bone fractures, and those associated with carpal instability, typically require open reduction internal fixation.