Carpal Fractures Research Articles

Radiographic and arthroscopic features of third carpal bone slab fractures and their impact on racing performance following arthroscopic repair in a population of racing Thoroughbreds in the UK.

Slab fractures of the third carpal bone (C3) are a common injury of Thoroughbred racehorses. Results of arthroscopically guided repair have not been reported since the initial description of the technique in 1986. Additionally, fracture details and racing outcomes in a population of Thoroughbreds racing under UK jurisdiction have not previously been described. To report the frequency distribution of C3 slab fractures and to determine the impact on racing performance following arthroscopically guided repair in a population of Thoroughbred racehorses. Retrospective case series. Case records of Thoroughbred racehorses undergoing arthroscopically guided repair of C3 slab fractures at Newmarket Equine Hospital between 2006 and 2015 were retrieved. Radiographs and arthroscopic studies were reviewed. The effect of demography and fracture morphology on racing outcome was evaluated. C3 slab fractures occurred most commonly through the radial facet in a frontal plane (45/71 63.4%). Comminution was identified during arthroscopy in 42/71 (59.2%) fractures and occurred most frequently at the palmar margin of the fracture. Forty-one out of 65 horses (63.1%) raced at least once post-operatively. Females were less likely to return to racing compared to males (P<0.001). Horses that had raced before injury were more likely (OR 4.4, 95% CI 1.4-13.5, P=0.01) to race after injury compared to horses that were unraced at the time of injury. After injury horses had a small but significant reduction in racing performance. The series is a preselected population of Thoroughbred racehorses which referring veterinary surgeons considered potential candidates for surgical repair. Fracture configurations can be identified radiographically but is not a reliable predictor of comminution or other intra-articular lesions. Arthroscopy not only directs repair but also identifies and facilitates management of concurrent lesions. The results reported should assist in formulating appropriate prognoses for Thoroughbred horses racing in the UK.

Comparison of SCAphoid fracture osteosynthesis by MAGnesium-based headless Herbert screws with titanium Herbert screws: protocol for the randomized controlled SCAMAG clinical trial

BackgroundScaphoid fractures are the most common carpal fractures. They often need to be treated by surgery, where the use of a compression screw is the globally accepted gold standard. Surgeons may choose between different implant materials including titanium alloys, which remain in the body or are removed after healing. An alternative are biodegradable magnesium-based implants. Properties of magnesium alloys include high stability, osteoconductivity, potential reduction of infections and few artifacts in magnetic resonance imaging (MRI). The aim of this trial is to demonstrate non-inferiority of magnesium-based compression screws compared with titanium Herbert screws for scaphoid fractures.MethodsThe trial is designed as a multicenter, blinded observer, randomized controlled parallel two-group post market trial. Approximately 190 patients will be randomized (1:1) with stratification by center either to titanium or magnesium-based compression screws. Follow-up is 1 year per patient. Surgical procedures and aftercare will be performed according to the German treatment guideline for scaphoid fractures. The first primary endpoint is the patient-rated wrist evaluation (PRWE) score after 6 months. The second primary endpoint is a composite safety endpoint including bone union until 6 months, no adverse device effect (ADE) during surgery or wound healing and no serious ADE or reoperation within 1 year. The third primary endpoint is the difference in change MRI artifacts over time. Non-inferiority will be investigated for primary endpoints 1 (t-test confidence interval) and 2 (Wilson’s score interval) using both the full analysis set (FAS) and the per protocol population at the one-sided 2.5% test-level. Superiority of magnesium over titanium screws will be established using the FAS at the two-sided 5% test-level (Welch test) only if non-inferiority has been established for both primary endpoints. Secondary endpoints include quality of life.DiscussionThis study will inform care providers whether biodegradable magnesium-based implants are non-inferior to standard titanium Herbert screws for the treatment of scaphoid fractures in terms of wrist function and safety. Furthermore, superiority of magnesium-based implants may be demonstrated using MRI, which is used as surrogate endpoint for screw degradation.Trial registrationDRKS, DRKS00013368. Registered Dec 04, 2017.

Epidemiology of hand fractures at a tertiary care setting in Saudi Arabia.

Objectives:To examine the epidemiology of hand fractures including common bones affected, causes, interventions, outcomes, and complications.Methods:This retrospective records-based study included patients who were admitted to King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, with traumatic metacarpal or phalangeal fractures between January 2016 and September 2017. Carpal fractures, wrist fractures, and all pathological fractures were excluded.Results:A total of 82 patients (90.2% of them men with an average age of 27.6±13.4 years) with 101 fractures were included. The fifth (25.5%) and first (24.5%) rays were the most commonly affected ones. The fifth finger (27.8%) and first metacarpal (28.9%) were the most commonly affected finger and metacarpal bone. Approximately 32.7% of the fractures were open fractures. The most frequent causes of hand fractures included falls (40.5%), road traffic accidents (20.3%), crushing injuries (9.5%), and machinery injuries (9.5%). Approximately 90.1% of the patients underwent operative interventions including open reduction (50.5%) and closed reduction (34.3%). The majority of fractures (79.2%) healed, and only 14.7% of fractures developed complications.Conclusion:In this study of hand fractures, patients were predominantly males and the main causes of fractures were falls and road traffic accidents.

Trapezium fracture: a common clinical mimic of scaphoid fracture.

Fractures of the trapezium are rarely diagnosed on plain radiographs after acute wrist trauma. High-resolution cross-sectional imaging identifies fractures of the trapezium as the most common radiographically occult carpal bone fracture. We review the fracture frequency, mechanisms and patterns of trapezium fractures. Cone beam CT was performed in patients with suspected radiographically occult radiocarpal fracture following acute injury. The frequency of carpal bone fractures was assessed and compared. Ninety-three radiographically occult wrist fractures were identified in 166 patients with acute trauma and negative radiographs. The trapezium was the most frequently fractured carpal bone, making up 20.4% of wrist fractures. Seventy-nine percent of trapezium fractures involved the volar ridge. The scaphoid was the clinically suspected fractured bone at initial assessment in 84% of patients with trapezium fractures. Fractures of the trapezium in acute wrist trauma are much more common than described in the literature. If initial radiographs are negative, a fracture of the trapezium is more likely to be present than one of the scaphoid, despite high levels of clinical suspicion for scaphoid injuries. Awareness of the types and mechanisms of trapezium fracture is important. Cross-sectional imaging should be considered in all cases of post-traumatic wrist pain with negative radiographs.

The relationship between obesity and fractures

There has been very limited analysis of the relationship between obesity and fractures in the orthopaedic literature. It has been established for some years that underweight individuals are at greater risk of proximal femoral fractures but recently there has been interest in the susceptibility of obese post-menopausal females to fracture. We have undertaken an analysis of 4886 adult patients who presented with a fracture and had their BMI assessed. Analysis has confirmed the relationship between underweight individuals and proximal femoral fractures but there is also a negative association between obesity and clavicle fractures in males and females and with calcaneal fractures in females. There is a positive relationship between obesity and proximal humeral, finger phalangeal and ankle fractures in males and with humeral diaphyseal, carpal and ankle fractures in females. There was no relationship found between open or multiple fractures and obesity.

Hand and Wrist Injuries in Tennis Players.

The purpose of this article is to review common hand and wrist injuries experienced by tennis players. A myriad of different wrist pathologies can be seen in tennis players ranging from metacarpal and carpal stress fractures to triangular fibrocartilage injuries and ulnar impaction. These vary depending upon the nature of the player, stroke mechanics, and time point within the season. A broad differential should guide work-up and management of wrist pain in tennis players.

Lag screw fixation of an ulnar carpal bone fracture in a dog

A two-year-old, entire male saluki presented with right forelimb lameness of acute onset six weeks previously, associated with a transverse minimally displaced ulnar carpal bone fracture. A palmarolateral approach was...

Temporal changes in synovial fluid composition and elastoviscous lubrication in the equine carpal fracture model.

The objective of this study was to examine temporal variations in synovial fluid composition and lubrication following articular fracture. Post-traumatic osteoarthritis (PTOA) was induced by creating an osteochondral fracture in the middle carpal joint of four horses while the contralateral limb served as a sham-operated control. Horses were exercised on a high-speed treadmill, and synovial fluid was collected pre-operatively and at serial timepoints until 75 days post-operatively. Lubricin and hyaluronic acid (HA) concentrations were measured using sandwich ELISAs, and the molecular weight distribution of HA was analyzed via gel electrophoresis. Synovial fluid viscosity and cartilage friction coefficients across all modes of lubrication were measured on days 0, 19, 33, and 61 using a commercial rheometer and a custom tribometer, respectively. HA concentrations were significantly decreased post-operatively, and high molecular weight HA (>6.1MDa) did not recover to pre-operative values by the study termination at day 75. Lubricin concentrations increased after surgery to a greater extent in the OA as compared to sham-operated limbs. Viscosity was significantly reduced after surgery. While boundary and elastoviscous mode friction coefficients did not vary, the transition number, representing the shift between these modes, was lower. Although more pronounced in the OA limbs, similar derangements in HA, HA molecular weight distribution, viscosity, and transition number were observed in the sham-operated limbs, which may be explained by synovial fluid washout during arthroscopy. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Return to racing after surgical management of third carpal bone slab fractures in thoroughbred and standardbred racehorses.

To determine the prognosis for racing of horses surgically treated for slab fractures of the third carpal bone (C3). Retrospective case study. Horses (n = 125) surgically treated for C3 slab fractures. Medical records of horses surgically treated for dorsal or sagittal C3 fractures were reviewed for age, sex, breed, limb, fracture type, degree of cartilage damage, and surgical treatment. Radiographs were evaluated to determine fracture depth, width, and displacement. Osteophytes, C3 lysis, and fragmentation were scored. Racing performance was obtained from online databases. Univariable and multivariable analyses were used to determine associations between independent variables and outcomes. Fifty-four (43%) horses raced postoperatively. Among thoroughbreds, 35% (30/86) with dorsal fractures and 63% (17/27) with sagittal fractures raced postoperatively. Among standardbreds, 77% (10/13) with dorsal fractures and 0% (0/2) with sagittal fractures raced postoperatively. Fracture displacement, C3 lysis, and cartilage damage affected the likelihood of racing postoperatively. Placement of 3.5-mm screws vs 4.5-mm screws and the placement of fewer screws were associated with improved likelihood of racing. The prognosis for postoperative racing of thoroughbreds with dorsal C3 fractures was less favorable than that previously reported. Concurrent joint pathology, such as cartilage damage at time of surgery, affected the ability of the horse to race postoperatively. Although internal fixation of C3 slab fractures is required to restore joint congruity, return to racing should be expected in only 42% of thoroughbreds and 67% of standardbreds.

Heritability estimates of fractures in Japanese Thoroughbred racehorses using a non-linear model.

Thoroughbred racehorses are produced by mating small numbers of Arabian stallions and native British mares, and have been improved by selection of horseracing performance for about 300years. While these improvements led to good performance as racehorses, they exposed horses to numerous medical disorders, aggravated by extensive exercise. Fractures are frequent medical disorders in Thoroughbred racehorses. In this study, fracture heritability was estimated using 3,927 Japanese Thoroughbred racehorses to elucidate the risk of racehorse fractures. The heritability estimates of all examined fractures were low (h2 =0.06), while those of fractures in carpal bone and carpus (carpal bone plus distal radius) were moderate (h2 =0.37, 0.24, respectively). Fracture occurrence age for carpal bone and distal radius was both 3.3years old and was younger than that for other fractures. These results indicated that a larger proportion of the variation in the studied population was due to genetic factors for carpal fractures than for other fractures, while the fractures at other bones were largely affected by environmental factors, correlated with the athlete period (number year in racing). These findings contribute to develop a management plan for suppressing racehorse fractures and improving horseracing safety.

Return to sport following scaphoid fractures: A systematic review and meta-analysis.

BACKGROUNDScaphoid fracture is the most commonly fractured carpal bone in the athletic patient, accounting for over 85% of all sport-related carpal bone fractures, and is particularly common in sports involving high impact injuries to the wrist. The management of such injuries comprises both conservative and surgical techniques, as guided by fracture location and type. Athletes demonstrate a unique challenge with regards to the management of scaphoid fractures due to their requirement to return to sport, as soon as able.AIMTo review systemically all studies recording return to sport following scaphoid fractures, to collate information on return rates to sport (RRS) and mean return times (RTS) to sport and to determine differences in sporting outcome for the various treatment methods.METHODSA systematic search of MEDLINE, EMBASE, CINAHAL, Cochrane, Google Scholar, Physiotherapy Evidence Database, SPORTDiscus, Web of Science and Scopus was performed in August 2018 using the keywords “scaphoid”, “fracture”, “acute”, “carpal”, “athletes”, “sports”, “non-operative”, “conservative”, “operative” and “return to sport”. All studies that recorded RRS and RTS following scaphoid fractures were included. RTS was recorded as the length of time from commencement of either primary conservative management or primary surgical procedure to return to sport.RESULTSEleven studies were included: Two randomised controlled trials, six retrospective cohort studies and three case series. Seven studies reported on conservative management (n = 77), and eight studies reported on surgical management (n = 83). For conservative management, RRS was 90% (69/77), and the mean RTS was 9.6 wk. Three studies allowed to return to sport in cast [RRS 89% (25/28); RTS 1.9 wk], and four studies required completion of cast treatment prior to returning to sport [RRS 90% (44/49); RTS 13.9 wk]. Four studies recorded fracture union data: Union rate 85% (47/55); mean time to union 14.0 wk. For surgical management, RRS was 98% (81/83), and RTS was 7.3 wk. Three studies reported on Percutaneous Screw Fixation [RRS 97% (32/33); RTS 6.5 wk], and five studies reported on Open Reduction Internal Fixation [RRS 98% (49/50); RTS 7.9 wk]. Six studies recorded fracture union data: Union rate 97% (69/71); mean time to union 9.8 wk. On meta-analysis, RRS (RR = 1.09; 95% confidence interval (CI): 1.00-1.18; P < 0.045), RTS (MD 2.3 wk; 95%CI: 0.79-3.87; P < 0.002), union rates (RR = 1.14; 95%CI: 1.01-1.28; P < 0.030) and mean times to union (MD 4.2 wk; 95%CI: 3.94-4.36; P < 0.001) were all significantly better for the surgical cohort compared to the conservative cohort.CONCLUSIONSurgical management of scaphoid fractures can provide significantly improved RRS and RTS to sport compared to conservative management. Both treatments, however, remain acceptable options, and athletes should be fully informed of the benefits and risks of both prior to deciding treatment plans. Immediate return to sport in a cast should be avoided due to the significant risk of non-union.

Operative Management for Pediatric and Adolescent Scaphoid Nonunions: A Meta-analysis.

Scaphoid fractures in the pediatric population represent ∼3% of all hand and carpal fractures. Cast immobilization has been shown to yield excellent results in the acute phase, however some patients develop nonunions. Currently, there is no consensus regarding the best surgical treatment after development of a pediatric/adolescent scaphoid nonunion. A comprehensive literature review was performed utilizing Medline, Ovid, and Embase databases to compare surgical techniques for adolescent scaphoid nonunions on the basis of union rates, functional outcomes, and operative complications. Our initial search returned 2110 publications. Inclusion criteria consisted of a scaphoid fracture with >3 months of no clinical or radiographic improvement after cast immobilization and age less than 18 years. Ultimately, 11 studies met our criteria and were included in the final analysis. A total of 176 surgically treated pediatric/adolescent scaphoid nonunions were identified from the 11 studies, including 157 nonvascularized bone graft procedures and 19 nongrafted rigid fixation procedures. Patients treated with a nongrafted method achieved union with a total random effects model revealing a union rate of 94.6%, whereas the grafted cohort had a union rate of 94.8%. Functional outcomes including range of motion and grip strength were significantly improved in both cohorts. Patients managed operatively with bone graft had 4 complications, in contrast those without bone grafting did not report complications (P=0.9). Surgical treatment of pediatric/adolescent scaphoid fracture nonunions produce excellent union rates and functional outcomes after surgical intervention, using both grafted and nongrafted techniques. Future prospective studies are needed to assess if the outcomes of a specific technique are more favorable, as well as to determine if differences exist based on fracture location. Level III. This study is a meta-analysis of studies containing level of evidence of III or greater.

Management of osteoarthritis of the wrist and hand

Osteoarthritis of the wrist and hand can cause significant functional impairment and disability. Its management is as much an art as it is science, as one has to consider increasing patient expectations, functional demands, pain relief and preserving motion. A sound knowledge of the wrist and hand anatomy, biomechanics, appreciation of the specific location and grade of wrist and hand joints arthritis and various treatment options and their pros and cons is important to successfully manage patients with this condition. Wrist osteoarthritis can be idiopathic, however more commonly it is secondary to distal radius and/or carpal fractures and ligamentous injuries. A small proportion still can occur due to avascular necrosis of carpus or congenital and developmental causes. Osteoarthritis of the hand is often idiopathic with a high familial tendency, especially in younger patients but can be secondary to other causes such as trauma, gout and ligamentous laxity. Once the non-surgical management options such as analgesia, activity modifications, steroid injections and splints have been exhausted, then there are various surgical options available for wrist and hand osteoarthritis. These are tailored to the exact location of arthritis and patient factors. For the wrist, these include anterior and posterior interosseous nerve neurectomy, arthroscopic debridement, selective bony excisions, wrist arthroplasty and focal or total fusion. Whilst for finger osteoarthritis, surgical options include arthroplasty and arthrodesis. This article aims to describe the pathology of wrist and hand arthritis and various treatment options available.

A virtual pathway reduced the need for physical review in patients with a suspected scaphoid fracture

Objectives: Suspected scaphoid fractures are a common reason for referral from the emergency department to fracture clinics. Few patients actually have a fracture. Cross sectional imaging has the potential to improve early diagnosis and reduce unneccessary immobilisation. The aim of this audit was to investigate the effectiveness of a virtual pathway, incorporating early magnetic resonance imaging (MRI) scan, for suspected scaphoid fractures. The secondary aim was to investigate whether the accuracy of other clinical signs, such as anatomical snuffbox pain on wrist ulnar deviation, was sufficient to reduce the number of patients requiring a MRI scan. Methods: A prospective audit was undertaken of 123 patients in an emergency department and associated minor injuries unit. These patients were managed with an early MRI scan. Where no significant injury was found, they were discharged after a phone call from a virtual fracture clinic nurse. Results: There were 16 (13%) true scaphoid fractures. MRI scanning showed other injuries including significant soft tissue injuries (13%), other carpal fractures (17%) and fractures of the distal radius (19.5%). The number of clinical appointments required was 0.42 per patient. Eighty patients did not have any face-to-face review. Other clinical examination techniques, such as anatomical snuff box pain on ulnar deviation of the wrist were not sufficiently sensitive or specific to reduce the need for MRI scanning or review. Conclusions: A virtual fracture clinic pathway and early MRI scanning reduced face-to-face reviews and unneccesary immobilisation. Clinical examination techniques are not sufficiently sensitive to reduce the need for scanning.

Markers for oxidative stress in the synovial fluid of Thoroughbred horses with carpal bone fracture.

ABSTRACTArthritis is thought to cause oxidative stress in synovial fluid in humans, but there have been few reports in horses. To evaluate oxidative stress in synovial fluid in horses, this study used 19 horses with unilateral fracture of the carpal joint bone. Synovial fluid was collected from the carpal joint on the fracture (arthritis group) and contralateral (control group) sides. Diacron-reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) were then measured, and the oxidative stress index (OSI) was calculated. d-ROMs and OSI of the arthritis group were significantly higher than the control group. BAP of the arthritis group was significantly lower than the control group. Thus, this study revealed that oxidative stress develops in the synovial fluid of horses during arthritis.

Fracture Risk After Initiation of Use of Canagliflozin: A Cohort Study.

Sodium-glucose cotransporter-2 inhibitors promote glycosuria, resulting in possible effects on calcium, phosphate, and vitamin D homeostasis. Canagliflozin is associated with decreased bone mineral density and a potential increased risk for fracture. To estimate risk for nonvertebral fracture among new users of canagliflozin compared with a glucagon-like peptide-1 (GLP-1) agonist. Population-based new-user cohort study. Two U.S. commercial health care databases providing data on more than 70 million patients from March 2013 to October 2015. Persons with type 2 diabetes who initiated use of canagliflozin were propensity score-matched in a 1:1 ratio to those initiating use of a GLP-1 agonist. The primary outcome was a composite end point of humerus, forearm, pelvis, or hip fracture requiring intervention. Secondary outcomes included fractures at other sites. A fixed-effects meta-analysis that pooled results from the 2 databases provided an overall hazard ratio (HR). 79964 patients initiating use of canagliflozin were identified and matched to 79964 patients initiating use of a GLP-1 agonist. Mean age was 55 years, 48% were female, average baseline hemoglobin A1c level was 8.7%, and 27% were prescribed insulin. The rate of the primary outcome was similar for canagliflozin (2.2 events per 1000 person-years) and GLP-1 agonists (2.3 events per 1000 person-years), with an overall HR of 0.98 (95% CI, 0.75 to 1.26). Risk for pelvic, hip, humerus, radius, ulna, carpal, metacarpal, metatarsal, or ankle fracture was also similar for canagliflozin (14.5 events per 1000 person-years) and GLP-1 agonists (16.1 events per 1000 person-years) (overall HR, 0.92 [CI, 0.83 to 1.02]). Unmeasured confounding, measurement error, and low fracture rate. In this study of middle-aged patients with type 2 diabetes and relatively low fracture risk, canagliflozin was not associated with increased risk for fracture compared with GLP-1 agonists. Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics.

Pseudarthrosis of the Carpal Scaphoid Treated with Non-Vascularized Corticocancellous Bone Graft

Objectives: To carry out an epidemiological study and to assess the evolutionary profile of patients with scaphoid non-union treated by anterior non-vascularized corticocancellous bone graft.&#x0D; Introduction: The non-union is a serious complication of carpal scaphoid fractures. Untreated, it leads to instability and osteoarthritis of the carp. The most used technique is that of Matti-Russe employing a corticocancellous graft.&#x0D; Materials and methods: We report in this retrospective study the experience of the department of Orthopaedic Surgery &amp; Traumatology II, Mohamed V Military Hospital, Rabat, in the treatment of non-unions of the carpal scaphoid by anterior non-vascularized corticocancellous graft in nine cases collected between January 2012 and March 2016. We identified six cases of stage IIA and three cases of stage IIB. All our patients were operated by the Matti-Russian technique followed by an immobilization by plaster cast cuff on three months.&#x0D; Results: All our patients achieved a union within an average of three months. The Mayo Wrist score was excellent in 66.6% of cases. Our results were very satisfying in 90% of cases, satisfying in 10%.&#x0D; Conclusion: The treatment of non-unions of the carpal scaphoid without necrosis or osteoarthritis, using anterior non-vascularized bone graft remains the most widely used technique. The presence of initial instability is a factor of poor prognosis, its correction reduces the risk of arthritis.

Fractures du carpe chez l’enfant à l’exception du scaphoïde isolé

Carpal fractures in children and adolescents are common. However, most of them occur in the scaphoid and other carpal fractures are rare in this age group. The aim of this study is to report the outcome in a larger series and to identify risk factors for an unfavourable outcome. Patients below the age of 16 years presenting to one of the 3 participating centers with a wrist fracture involving at least one carpal bone other than the scaphoid between 2000 and 2015 were included. Open injuries and isolated scaphoid fractures were excluded. Thirty-three patients with a mean age of 13.1 years (8.5–15.6) sustained uncommon wrist fractures in 35 hands. Twenty-five wrists had just one fractured bone, affecting the trapezium (8), capitatum (6), triquetrum (4), hamatum (3), trapezoideum (2) and pisiform (2). Ten wrists had multiple carpal fractures, affecting the scaphoid (9), capitatum (7), lunate (4), pisiform (3), trapezium (2), triquetrum (2), hamatum (2). Seven patients had associated fractures of the distal forearm and 5 had metacarpal fractures. Retrospective multicentre study. Twenty-six hands had a spica cast immobilization only and 9 were treated surgically. Two dislocated capitate fractures had an open reduction, one with K-wire immobilization, the other with an external fixator due to multiple CMC luxations and a distal forearm fracture. Two perilunar fracture dislocations had open reduction and K-wires. Three trapezium fractures and two hands with multiple carpal fractures had closed reductions and K-wires. A radiological union of all fractures was documented within 7 weeks. All patients returned to full, unlimited activity. Four patients complained of mild pain under maximum load at work or at sports. Three of them had sustained comminuted trapezium fractures, the other combined capitatum and scaphoid fractures. Two patients had early degenerative changes at the last X-ray follow-up, both after closed reduction and immobilization of comminuted trapezium fractures with K-wires. All carpal fractures united reliably, irrespective to their mode of treatment. Persistent pain in daily activities or early degenerative changes were found in trapezium fractures only. Similar results were found after open reduction and internal fixation of capitate fractures with only one patient with little pain at maximum load. Non-dislocated carpal fractures in children have a particularly favorable course and heal reliably. Dislocated trapezium fractures predispose to persistent pain and early degenerative changes.

Surgical Strategy for Scaphoid Nonunion Treatment.

Scaphoid fracture is the most common carpal fracture. Nonunion rate has been reported around 10 to 15% of scaphoid fractures. Risk factors for scaphoid nonunion are known as location, displacement, poor vascularity, time to treatment etc. The goals of surgical treatment for scaphoid nonunion are to achieve bony union, to correct carpal deformities and also to prevent progressive carpal instability and arthritis. Scaphoid nonunion can cause scaphoid nonunion advanced collapse (SNAC) which is a pattern of progressive degenerative radiocarpal and midcarpal arthritis secondary to posttraumatic pathomechanics of the scapholunate joint. Achieving bony union is essential to prevent carpal collapse or arthritis. To improve bony union, many surgical procedures including various forms of bone grafting have been developed and attempted. However, there is a controversy about which procedure is the most effective. In this review, we provide an overview of surgical treatment methods for scaphoid nonunion and discuss proper surgical strategies for scaphoid nonunion which requires surgical management.

Occult capitate fracture through a bone island \u2013 SPECT/CT arthrography imaging

BackgroundSingle photon emission tomography/computed tomography (SPECT/CT) combines the strengths of bone scintigraphy and CT and serve as an important alternative to magnetic resonance (MR) imaging in carpal trauma patients if conventional x-rays are equivocal.Case presentationIn a young patient with pain 4 days after carpal trauma conventional x-rays were negative for fracture and MR showed only bone bruise. SPECT/CT arthrography one month later revealed intensive uptake in the capitate bone corresponding to a fracture through a bone island on the CT part of the study.ConclusionSPECT/CT combines the sensitivity of bone scintigraphy and specificity of (diagnostic) CT and might serve as an important second line imaging modality for the detection of occult carpal fracture.