Scaphoid Research Articles

Investigation of Computed Tomographic Scan Concurrent Criterion Validity in Doubtful Scaphoid Fracture of the Wrist

Rapid diagnosis of scaphoid bone fracture in the wrist is important so that appropriate treatment can be started. If a fracture is clinically suspected without being visible on radiography, further investigation has to be conducted to reveal a fracture or to rule it out. The objective of this study was to investigate the validity of computed tomographic (CT) scanning and bone scintigraphy compared with the clinical fracture rate during follow-up of 1 year for examining patients with a suspected scaphoid fracture. Bone scintigraphy and CT scanning were performed in 29 patients with persistent clinical suspicion of a scaphoid bone fracture 5 to 10 days after trauma. The sensitivity, specificity, and positive and negative predictive values of the CT scan were 100%. The sensitivity, specificity, and positive and negative predictive values of bone scintigraphy were 78%, 90%, 78%, and 90%, respectively. Seven patients showed a fracture on both CT scanning and bone scintigraphy. Eighteen patients showed no fracture on both CT scanning and bone scintigraphy. A false-positive bone scintigram showed up in two patients and a false-negative bone scintigram in another two patients. CT scanning is a rapid, simple, valid method for demonstrating or ruling out a scaphoid fracture and is superior to bone scintigraphy.

MRI diagnosis of fracture of the scaphoid bone: Impact of a new practice where the images are read by radiographers 1

Rationale and objectives To investigate whether magnetic resonance imaging (MRI) radiographers are able to evaluate MRI examinations with regard to scaphoid fractures to save patients unnecessary immobilization and clinical and radiographic examinations, and to reduce the costs for the hospital as well as society in general. Materials and methods Over a 1-year period 224 consecutive patients with a suspected clinical scaphoid fracture but negative radiography were referred for MRI and examined within 11 hours. The MR images were primarily evaluated by the MRI radiographer on duty. Other fractures and bone edema were not reported because these were not part of the work-up protocol agreed upon by the radiology and the orthopedic departments. The following weekday a final report was provided by a radiologist. For the economical analysis the official price-list for Danish hospital service was used. Results The MRI radiographers reported 43 scaphoid fractures, whereas the radiologist ultimately diagnosed only 36 scaphoid fractures (16.1% of patients) (sensitivity, 100%; specificity, 96.3%). Six of the seven false-positive fractures occurred in patients with edema of the scaphoid. The seventh false-positive was a fracture of the capitate. The hospital saved at least €20,000 and the social care system €70.000. Conclusion It is possible to provide an acute MRI service to patients with clinically suspected fracture of the scaphoid and a normal plain radiograph. The MR images can be primarily read by sufficiently trained MR radiographers. This new work-up protocol reduces the cost for society.

The morphological and morphometric features of the scaphoid

This cadaveric study used 200 scaphoid bones (100 left and 100 right) to assess 24 morphological and 11 morphometric parameters. At least one morphometric feature was absent in all scaphoids, though the tubercle and the dorsal sulcus were present in all instances. There were significant differences in the circumferences of the waist and the base of the tubercle, the width of the main sulcus and the secondary height of the tubercle between left and right scaphoids. Detailed knowledge of anatomy and correlations between the anatomical features may help better understanding of clinical problems.

Clinical significance of scaphoid ring sign in Lichtman X ray staging of Kienb(o)ck's disease

目的 阐明Lichtman ⅢB期中舟骨环形征的临床意义.方法对17例Lichtman Ⅲ期腕月骨无菌性坏死的术前X线平片,分别测量其腕高、腕高比值及桡舟角;以判断Lichtman ⅢB期腕关节是否较ⅢA期进一步塌陷及舟骨是否进一步掌屈.同时,在5侧新鲜腕关节标本上观察稳定腕舟骨的韧带的走行、起点和止点. 结果在Lichtman ⅢA期、ⅢB期,腕高和腕高比值的测量值两者差异无显著意义(P ＜ 0.05),而桡舟角的测量值ⅢB期较ⅢA期明显增大(P ＜ 0.05).解剖发现,舟骨近极对腕舟骨起稳定作用的3条韧带为桡舟头韧带、长桡月韧带及舟月骨间韧带.结论舟骨环形征是舟骨旋转半脱位的X线片表现,代表舟骨的近极向背侧移位,在治疗时应注意矫正。

The radiological analysis of osteonecrosis in rare positions

目的 探讨SARS恢复期患者罕见部位骨坏死影像学表现及原因.方法采用平片、0.5 T MR机,对2003年6～8月间复查的41例SARS恢复期患者四肢骨骼进行检查,分析影像学检查结果及其与应用激素的相关性;检查距最初使用激素的平均时间为88.2 d(67～106 d);平均激素(甲基泼尼松龙)最大用量392(320～480) mg;平均持续用药时间为47.2 (30～70)d.结果 MRI显示5例罕见部位骨坏死病变共累及11个部位.3例双侧肱骨头坏死,其中1例合并右侧坐骨坏死; 1例右侧腕舟骨坏死;1例双侧跟骨坏死合并右侧距骨坏死.主要MRI表现为各部位的不规则异常信号病灶.平片仅显示1例右侧坐骨坏死.结论 SARS恢复期患者骨坏死早期发现需做MR扫描,而且是多部位扫描,激素用量、时间及患者对激素的敏感性和个体差异是骨坏死的重要原因。

Interfragmentary compression across a simulated scaphoid fracture—analysis of 3 screws

Purpose To measure the interfragmentary compression generated across a simulated fracture in cadaveric scaphoids by 3 different headless compression screws. Methods A transverse osteotomy was made through the waist of each scaphoid and a load cell to measure compression was interposed between the fragments, which were then fixed internally retrograde with either an Acutrak Standard (n = 10), Acutrak Mini (n = 12), or Bold (n = 10) screw. The surgeon was blinded to the measured compression, which was recorded during screw insertion and for the following 5 minutes. As a measure of scaphoid bone quality the modulus of elasticity of the trabecular bone of each specimen was then calculated from uniaxial compression tests. Results The mean interfragmentary compression generated by the Acutrak Standard screw was significantly greater and more consistent than the Bold screw or the Acutrak Mini screw. The compression achieved by the Acutrak Standard screw was also more consistent than that obtained by either the Bold or the Acutrak Mini screws as reflected by the lower standard deviation. The mean modulus of elasticity of the scaphoid trabecular bone was similar for each screw group. Conclusions The interfragmentary compression generated by the Acutrak Standard screw was significantly greater and more consistent than that generated by either the Bold or Acutrak Mini screws. The compression generated by the Acutrak Standard and Mini screws was significantly better sustained over time than that generated by the Bold screw; however, these differences were small and may not be clinically important. The optimal compression required to promote scaphoid fracture union remains unknown and clinical trials are needed to further evaluate the outcome from using these devices.

Non-union fractures of the scaphoid and carpal bones in children: surgical treatment

Carpal bone fractures in children are rare. This study reports a series of 16 cases: 12 fractures of the scaphoid (11 non-union), two of the trapezium, one (non-union) of the hamatum, and one of the triquetrum. Only three of these fractures (triquetrum, trapezium and hamatum) were seen at an early stage. The non-union cases involving the scaphoid and hamatum were treated by bone graft. The scaphoid fracture seen early and the triquetrum fracture were treated orthopaedically. One trapezium fracture was treated by osteosynthesis with wires, and the other (seen at the defective callus stage) was not treated because of a total absence of symptomatology. All fractures or non-union cases consolidated. After a minimum follow-up of 1 year, all patients except one have regained strength and mobility comparable to that of the contralateral limb, with a near total absence of pain. Only the patient with an articular fracture of the trapezium has lost 30% of strength compared with the uninjured limb.

Non-union fractures of the scaphoid and carpal bones in children: surgical treatment

Non-union fractures of the scaphoid and carpal bones in children: surgical treatment

Bone grafting the scaphoid nonunionA systematic review of 147 publications including 5 246 cases of scaphoid nonunion

In order to elucidate the history of scaphoid nonunion and to evaluate whether or not the problem has been solved, we have reviewed the literature from 1928 to 2003 for union rates, postoperative immobilization periods and complications of the different scaphoid bone grafting procedures. The outcomes of 5 246 scaphoid nonunions were evaluated in three treatment groups. In the first group involving nonvascularized bone grafting without internal fixation, we found a union rate of 80% (95% CI: 78-82) after an average immobilization period of 15 weeks. In the second group involving nonvascularized bone grafting with internal fixation, the figures were 84% (CI: 82-85) and 7 weeks, respectively. In the last group involving vascularized bone grafting with or without internal fixation, the figures were 91% (CI: 87-94) and 10 weeks, respectively. We found no prospective randomized studies comparing different operative treatments of scaphoid nonunion. We conclude that there still is a need for improvement in the treatment of scaphoid nonunion.

Preiser’s disease: identification of two patterns

Purpose: A large series of patients with Preiser’s disease was reviewed to compare 2 potentially different categories of this disorder: complete versus partial vascular impairment of the scaphoid bone as determined by magnetic resonance imaging (MRI). Methods: Nineteen patients with Preiser’s disease were identified retrospectively from 2 institutions. Using MRI criteria, 2 disease patterns were identified: diffuse necrosis and/or ischemia of the scaphoid (type 1 disease, 11 cases) and segmental vascular impairment of the scaphoid (type 2 disease, 8 cases). Risk factors for osteonecrosis, treatment methods, and serial radiographs were reviewed in all cases. Sixteen patients were examined for the purpose of this study at an average follow-up of 25 months. Results: MRI signal changes of necrosis and/or ischemia involved 100% of the scaphoid in type 1 cases and on average approximately 42% in type 2 cases (range, 33% to 66%). In type 1 cases, regardless of the treatment used, the scaphoid typically fragmented and collapsed. In type 2 cases, scaphoid architecture was altered minimally after similar treatment methods. A history of wrist trauma was significantly more common in type 2 cases, and the results of treatment were generally better in this group of patients (mean Mayo modified wrist scores, 86 vs 58 points). Conclusions: This study supports the concept of 2 patterns of scaphoid involvement in Preiser’s disease. Type 1 cases are characterized by MRI signal changes of necrosis and/or ischemia involving the entire scaphoid bone. Patients in this group have a propensity for scaphoid deterioration. Type 2 cases have MRI signal changes involving only part of the scaphoid. These patients commonly report a history of wrist trauma, show fewer tendencies toward scaphoid fragmentation, and may have a more favorable clinical outcome.

Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis

Purpose: The treatment of scaphoid nonunion with degenerative arthritis poses a clinical problem that is particularly challenging in cases of associated dorsal intercalated segmental instability collapse, radiocarpal and intercarpal degenerative changes, and poor scaphoid bone quality. The purpose of this study was to report our clinical experience performing a distal scaphoid resection for symptomatic scaphoid nonunion in patients with either radioscaphoid or intercarpal arthritis who have had multiple surgeries. Methods: Nine patients with recalcitrant scaphoid nonunion and associated degenerative arthritis treated by resection of the distal scaphoid fragment were evaluated both clinically and radiographically. Eight patients were male and one patient was female; the average follow-up period was 28.6 months (range, 12–52 mo). Results: Seven patients reported pain with daily use and the remaining 2 patients reported mild pain with light work before surgery, whereas after surgery 4 of the 9 patients had no wrist pain and the remaining 5 patients had only mild pain with strenuous activity. The wrist range of motion improved from 70° (51.4% of the opposite wrist) to 140° (94% of the opposite wrist) and grip strength improved from 18 kg (40% of the opposite wrist) to 30 kg (77% of the opposite wrist). Clinical results were excellent in 6 patients and good in 3 patients based on a modified Mayo wrist-scoring chart. Radiographically neither additional degeneration nor progress of degenerative changes was noted after surgery in 8 patients. Newly developed degenerative arthritis occurred at the proximal scapholunate capitate articulation in the remaining patient who has a type II lunate, which had a facet (medial facet) articulation with the hamate. Conclusions: The results of this study showed that distal scaphoid resection produces a satisfactory clinical outcome, requires only a short period of immobilization, and should be considered one of the surgical options for long-standing scaphoid nonunion with either radioscaphoid or intercarpal degenerative arthritis. Nevertheless care must be taken in performing this procedure on patients whose preoperative radiograph show a type II lunate.

Scaphoid Osteochondroma-A Case Report

Tumors of the scaphoid bone are very rare and their treatment has not been well established. A 9-year-old child presenting with progressive enlargement and deviation of the wrist was found to have osteochondroma of the scaphoid. It was treated by total scaphoidectomy and arthroplasty was accomplished with the tendon of flexor carpi radialis. The tendon strip was coiled along the K-wire across the scaphoid cavity. In the subsequent follow-up of 4.5 years, the result was satisfactory in terms of growth, deformity correction as well as functional recovery although there was the decrease of the carpal height ratio. It is concluded that the modified Anchovy procedure can be applied to this situitation in the children.

Scaphoid nonunion: correction of deformity with bone graft and internal fixation

The scaphoid is the most commonly fractured bone in the carpus. Although greater than 90% of scaphoid fractures unite with cast immobilization, failure to heal remains a clinical reality, particularly when the fracture is displaced or associated with intracarpal instability [1–3]. Dabezies [4] reported a 55% incidence of nonunion and a 50% rate of proximal pole avascular necrosis (AVN) in scaphoid fractures with greater than 1 mm of displacement. Cooney and colleagues [2] noted a nonunion rate of 46% for 13 displaced scaphoid fractures. Scaphoid nonunion has been associated with progressive symptomatic radiocarpal and midcarpal arthrosis [5–7]. This arthrosis is the sequela of altered wrist kinematics [3,8,9]. The alteration of wrist kinematics reflects not only motion through the nonunion site, but also the apex-dorsal malalignment of the scaphoid (the so-called humpback deformity) with associated dorsal angulation of the lunate and alteration in carpal height [10,11]. Although scaphoid deformity and its adverse effects on kinematics were recognized early on by Fisk [12], for many years the standard treatment of symptomatic scaphoid nonunion was based on gaining union without an attempt to correct the deformity of the scaphoid. It has been recognized, however, that some patients with residual bony deformity of the healed scaphoid may continue to have pain and functional limitations [13–15]. As a result of a greater appreciation of carpal kinematics, many authors now believe that the approach to a scaphoid nonunion should consist of realigning the scaphoid anatomy and gaining union. Scaphoid deformity Posttraumatic scaphoid deformity is complex but predictable. Displaced scaphoid fragments lie in a so-called humpback configuration with flexion of the distal fragment. The dorsal intercalary pattern of carpal instability (DISI) follows [16]. With the use of three-dimensional reconstructions of computed tomography images, the three-dimensional orientation of a fractured scaphoid has been represented more clearly. Belsole and coworkers [17] looked at a series of scaphoid nonunions and performed a detailed three-dimensional CT evaluation comparing the fractured and contralateral scaphoids. They found that the proximal scaphoid fracture component is extended, radially deviated, and supinated in relation to the distal fracture component. They also identified that the volume and configuration of missing bone is consistent. The amount of the scaphoid bone that was lost varied from 6% to 15% of bone volume. The bony defect is prismatic with a quadrilateral base facing palmarly.

Scaphoid anatomy and mechanics: Update and review

This review has been an attempt to collate previous research on scaphoid anatomy, load mechanics and kinematics into one article so that the reader can assimilate the information in a convenient way. The scaphoid is a unique carpal bone in shape and function. It has a three-dimensionally oblique orientation and performs a unique function as a mechanical link between the distal and proximal carpal rows on the radial aspect. The load mechanics of the scaphoid play an important role in wrist function and kinematics. Studies of the normal biomechanics of the proximal wrist joint have determined that the scaphoid and lunate bones have separate, distinct areas of contact on the distal radius surface. Kinematics of the scaphoid can be viewed either from proximal or distal. From a proximal view, during radial/ulnar deviation of the wrist, the scaphoid exhibits both a flexion/extension and radial/ulnar deviation motion. Distally, kinematic studies revealed that the scaphoid-trapezoid motion during wrist extension is the same as in wrist radial deviation and the scaphoid-trapezoid motion in wrist flexion is the same as in wrist ulnar deviation. Knowledge of the anatomy of the dorsal carpal ligaments has also provided a wealth of information on their role in carpal motion. The lateral V construct of the DRC (Dorsal Radiocarpal), DIC (Dorsal Intercarpal), and dorsal component of the SLIO (Scapho-lunate interosseous) ligament delivers indirect dorsal stability, yet allows relative free motion of the scaphoid. Injuries that involve the scaphoid can be ligamentous or can involve fracture of the scaphoid with or without ligamentous injury. Because of its complex anatomy, treating scaphoid fractures and nonunions can be challenging and difficult to detect true displacement patterns from plain X-ray films due to the overlapping of the other carpal bones. Degenerative arthritis of the STT (scapho-trapezium-trapezoid) joint is the second most common site of degenerative changes in the wrist. Plain radiographs can be used to measure TT (trapezium-trapezoid) inclination, which has been shown to be correlated with degenerative changes in the STT joint. Research in our lab has demonstrated that wrists with a higher TT inclination had a higher incidence of degenerative changes. This new perspective taking into account anatomy, mechanics and kinematics begins to offer a more global view of how form and function are related and what part the scaphoid plays in carpal function and stability.

Die Zylinderfrästechnik (Surgical Diamond Initiative - SDI) für Therapie der Kahnbeinpseudarthrose

The treatment of the scaphoid pseudarthrosis is up to now a special challenge. The operative treatment has to beware the integrity of the scaphoid bone and its ligamentous structures. Gold standard is the debridement of the pseudarthrosis and then implantation of a autograft from the iliac crest and compression screw. The operation is however very sophisticated, invasive and with high risk. The technique described here includes dowelling of the pseudarthrosis, implantation of a cylindric autograft without screw stabilisation. Preliminary results in 7 patients demonstrate a minimal-invasive technique with less risk and satisfying results up to now. Subsequent investigations with more patients are planned for the future.

Scaphoid (navicular) fractures of the wrist in children: attention to the impacted buckle fracture.

We retrospectively analyzed the radiographic findings in 76 patients with proven scaphoid (navicular) fractures. The purpose of the study was to determine the incidence of the impacted buckle fracture of the scaphoid bone in children. Fourteen of the 76 patients (17%) demonstrated such a fracture, and all of the fractures occurred in the middle or distal third of the scaphoid bone. The mean age of this group of patients was 13.7 years, as compared to the mean age of 15.6 years in the patients with overt transverse fractures. One out of 14 of the patients with a buckle fracture was female. None developed complicating aseptic necrosis. The fractures were most clearly visualized on AP and oblique views of the wrist, and all cases demonstrated edematous thickening of the soft tissues and/or navicular fat pad obliteration adjacent to the scaphoid bone. The use of comparative views was extremely helpful in the detection of this fracture.

Diagnostik der Skaphoidpseudarthrose - Bedeutung der kontrastmittelunterstützten Extremitäten-MRT

Eine schnelle und ökonomisch sinnvolle diagnostische Strategie der Skaphoidpseudarthrose ist aufgrund des besonderen Krankheitsbildes und der prognostischen Bedeutung erforderlich. Neben der Anamnese und dem klinischen Verlauf gestattet die Röntgenaufnahme in 2 Ebenen und die „Quartettaufnahme” in nahezu allen Fällen die Diagnosesicherung der Skaphoidpseudarthrose. Häufig gelingt hier bereits die Definition des Krankheitsstadiums. Beim Vorliegen eines Stadium III b bzw. IV ist eine weitere Bildgebende Diagnostik aufgrund des vorgegebenen Therapieregimes nicht mehr notwendig. Bei Stadium I bis III a sollte nach der Nativdiagnostik die KM-unterstützte Extremitäten-MRT zur Vitalitätsbeurteilung der Skaphoidpole erfolgen, da die weitere Therapie von der Vitalität der Skaphoidpole abhängig ist.

Microsurgical reconstruction of the scaphoid and lunate bones with small, free vascularized iliac crest bone grafts

The primary surgical goal in repairing a scaphoid nonunion, particularly one associated with avascular fragments, or reconstructing the lunate is to prevent progressive carpal collapse. In patients with persistent nonunion of the scaphoid and progressive aseptic necrosis of the lunate bone, reconstruction can be managed with a small microvascular iliac crest bone transfer. This retrospective study reports on the anatomical fundamentals, the operative procedure (particularly the harvesting of the bone flap and microsurgery), the assessment of the viability of the bone graft and the postoperative results in 80 out of a total of 210 patients on whom the surgery had been performed. From 1985 until 1998, 210 carpal bone reconstructions (134 scaphoid bones and 76 lunate bones) were performed using small, free vascularized iliac crest bone grafts. Of these, 80 patients were preoperatively evaluated and postoperatively followed up clinically and by means of conventional radiography and magnetic resonance imaging (MRI). The total rate of viability and bony union was 91.2%. This means a bone flap loss-rate and, consequently, a progressive arthrosis/necrosis/persistent nonunion of 8.8%. The patients who had vital reconstructed carpal bones did not report pain, but motion and grip strength were decreased as compared with the uninvolved side. This procedure offers stability and vascularity to treat avascular scaphoid nonunion and has proved beneficial in achieving union in avascular scaphoid pseudoarthrosis and lunate necrosis. It can be considered to be the definitive alternative technique. The high rate of union and the absence of progressive carpal arthrosis are the best evidence for the vascularity of the bone graft.

Sonography of the scapholunate ligament in four cadaveric wrists: correlation with MR arthrography and anatomy.

The objective of our study was to sonographically characterize the dorsal aspect of the scapholunate ligament in cadaveric wrists using arthrography, MR arthrography, and anatomic correlation as the gold standard. The dorsal aspect of the scapholunate ligament in four cadaveric wrists was evaluated on sonography without knowledge of the findings from standard arthrography, MR arthrography, and anatomic sectioning. The sonographic findings were compared with the findings from other modalities. The criteria for an abnormal scapholunate ligament included an abnormal contrast communication between the radiocarpal and midcarpal joints on arthrography and a discontinuity of the dorsal aspect of the scapholunate ligament that was documented both on MR arthrography and at anatomic sectioning. Arthrography, MR arthrography, and anatomic sectioning showed the dorsal aspect of the scapholunate ligament to be normal in one specimen and abnormal in three specimens. On sonography, the normal scapholunate ligament was hyperechoic between the scaphoid and lunate bones. In the three cases of abnormality, a normal scapholunate ligament was not visualized, and an abnormal hypoechogenicity was present. The dorsal aspect of the scapholunate ligament can be depicted on sonography; abnormality is present in patients in whom the normally hyperechoic fibrillar ligament is hypoechoic or absent.

Composite implant of native bovine bone morphogenetic protein (BMP) and biocoral in the treatment of scaphoid nonunions--a preliminary study.

Bone morphogenetic protein (BMP) has been shown to induce bone formation and union in long bone defects and nonunions. We report a preliminary study of a composite implant consisting of a biocoral frame, carrier collagen and bovine BMP in the treatment of scaphoid nonunions. Two proximal and eight waist area scaphoid nonunions were treated using BMP/coral implant combined with either the Matti-Russe procedure (2 cases) or an interpositional bone graft fixed with screws or compression fixation pins (8 cases). In two cases only a one piece BMP/coral implant was used as an interpositional graft and in other cases interpositional autograft was used with granular BMP/coral implant placed between the fragments and the graft. Only two wrists resulted in complete union. These preliminary results suggest that composite implant of BMP, as used in the present study, may not solve the problems encountered in the treatment of scaphoid nonunions. Poor vascular conditions in scaphoid may not provide enough mandatory osteogenic cells for BMP to function properly. In avascular conditions coral does not resorb edequately and implants may also work as a sequester between the bone graft and the scaphoid bone and therefore actually inhibit the healing process.