Deviation Of Wrist Research Articles

Outcome of tendon transfer for radial nerve palsy using Flexor Carpi Radialis combination (Brands transfer)

Introduction–Loss of radial nerve function leads to severe weakness of grip and tendon transfer is considered the standard treatment. However; there is continuing debate as to the best combination of tendon transfers in such patients. The aim of this study is to present the results of Flexor carpi radialis (FCR) combination of triple tendon transfer for radial nerve palsy. Material and methodsIt is a retrospective study conducted over 15 years. 58 patients of with irreversible radial nerve paralysis were included. Brands transfer was performed in all cases. The ranges of movement of the wrist, fingers and thumb were evaluated pre-operatively and postoperatively using Bincaz scale. ResultsTotal 58 patients were included in the study, 47 were male and 11 female patients with mean age of 35.27 years. Causes of radial nerve palsy were comminuted open humeral fracture (n = 42), penetrating injuries (n = 13) and brachial plexus palsy (n = 3). Mean duration of palsy was 9.37 months (range = 9–12 months). The mean post-operative follow-up was 10 (range = 2–15) years. On evaluation with the Bincaz score, 6 patients had excellent results, 49 patients had good results, and 3 patients had poor results. There were 3 complications in 5 patients, including radial deviation of wrist, inadequate abduction of thumb and restricted wrist flexion. 55 patients (94.82%) were able to return to their normal daily work after ∼8 weeks. Conclusions - Tendon transfer is a standard procedure for radial nerve palsy but potential advantage of one method over the other has not been demonstrated. Brand’s transfer results in an acceptable restoration of hand function.

Incidence of De Quervain’s Tenosynovitis in Computer Operators

Background: De Quervain’s tenosynovitis is an inflammatory disease in which the pain is felt over the radial border of the wrist especially in the thumb with the ulnar deviation of the wrist. The objective of the study was to find out the incidence of De Quervain’s tenosynovitis in regular computer operators. Materials and Methods: Each participating person among the 147 regular computer operators was examined for the Finkelstein’s Test in order to diagnose the De Quervain’s tenosynovitis. Along with this a wrist pain questionnaire was asked to be filled in order to check the prevalence of wrist pain in regular computer operators. Results: Among 147 regular computer operators there were 74 (50.3%) males and 73 (49.7%) females with a mean age of 22.44 ± 1.81 years. Among 147 participating regular computer operators 99 (67.3%) showed the Finkelstein’s test positive whereas 48 (32.7%) showed the pain in Finkelstein’s test as being negative. Conclusion: It is concluded that the incidence of De Quervains Tenosynovitis among the regular computer operators on the basis of Finkelstien Test was quite high.

Musculoskeletal Disorders Symptoms among Taiwanese Bakery Workers.

In this study, the Nordic Musculoskeletal Questionnaire (NMQ) was administered to a valid sample of 81 Taiwanese bakery workers to explore their discomfort or symptoms of work-related musculoskeletal disorders and identify the risk factors. Wrist postures were also examined during 3 typical dough operations (kneading, rolling, and rounding) by using an electrogoniometer. The prevalence of musculoskeletal discomfort in any part of the body in the past year among the respondents was 93.0%, with the highest prevalence of 66.3% and 51.8% in the hands/wrists (right and left), followed by the prevalence of 50.6% and 45.8% in the shoulders (right and left) and the lower back (48.2%), respectively. The results also revealed that during the 3 dough processing operations, the workers’ wrist movements in specific operations were close to the recommended limits suggested in previous studies, especially the ulnar deviation and palm flexion of the right wrist during dough kneading and the radial deviation of the left wrist during dough rolling and rounding. The study findings can be used to explain why the bakers self-report a high proportion of wrist and shoulder disorders and can also serve as a reference for task rearrangement and redesign.

Assessment of Muscular Activity and Postural Load During Coffee Harvesting Activities – A Case Study

Objective: The goal of this case study was to analyze and evaluate the posture, force and repetitive movement risks associated with manual coffee harvesting activities. Materials and Methods: A self-discomfort report was administered to 28 participants, of whom 4 volunteered for an evaluation of postural load on muscular activity using electromyography and electrogoniometry. Eight upper limb muscles and the kinematics of the wrist and upper arm of the dominant arm were assessed. Results: The results of the self-discomfort report showed a greater demand, from the harvester’s perception, in areas such as the back, lower back, knees and feet during a period of one week of work. The outcomes of the muscular activity assessment showed that the extensor carpi ulnaris (ECR) was the muscle with the highest demand during the assessment. The dynamic activity of the muscle exceeded 20% of the maximum voluntary contraction (MVC), which classifies coffee harvesting as a threatening activity. The postural load on the body segments revealed that wrist deviation was critical due to an abnormal range of the wrists during the activity. Conclusions: It is necessary to improve the working conditions of the coffee harvesters.

A rare developmental anomaly of the upper limb: Case of ulnar dimelia

Ulnar dimelia is a rare developmental anomaly, which is characterized by the duplication of ulna, absence of radius, and polydactyly. We report a case of a 5-year-old male child who was referred to our care with an extension deformity of the right elbow, loss of pronation and supination of the forearm, and flexion deformity with radial deviation of the ipsilateral wrist. Initially, we aimed to provide flexion of the elbow to improve his elbow function. The flexion was restricted to

Is Radial Deviation of Wrist Related With Median Nerve Swelling in Patients With Rheumatoid Arthritis? A Radiographic, Ultrasonographic, and Electroneuromyographic Study.

This study aims to investigate whether or not radial deviation developing after wrist involvement of rheumatoid arthritis (RA) is a cause of median nerve swelling. The study included 51 RA patients (12 males, 39 females; mean age 50.9±8.9 years; range, 18 to 65 years) without carpal tunnel syndrome (CTS) detected by electroneuromyography. Duruöz hand index, visual analog scale, and painDETECT questionnaire were performed in clinical assessment. Radiographic measurements including radial inclination (RI) angle were performed. Using ultrasonography, the median nerve cross-sectional areas (CSAs) were measured from the four levels of the distal one third of the forearm, radioulnar joint, pisiform bone, and hook of hamate, while the ulnar nerve CSAs were measured from the pisiform bone. The study was completed with 102 hands of 51 patients. A negative correlation was found between the RI and the median CSAs measured from the radioulnar joint (R=-0.49; p=0.00), the pisiform bone (R= -0.45; p=0.00), and hook of hamate (R= -0.60, p=0.00). When the hands were divided into three groups according to the ranges of RI specified in the literature, the median nerve CSA was found to be significantly higher in the group with low RI at these levels (p<0.001). In patients with RA without CTS, the increase in the median nerve CSAs may be associated with radiographic measures such as radial deviation.

Morphological and positional changes of the carpal arch and median nerve associated with wrist deviations

BackgroundCarpal tunnel and median nerve dynamically change with wrist motion. The purpose of this study was to investigate the morphological changes and positional migration of the carpal arch and median nerve, as well as nerve-arch positional relationship associated with wrist deviation in healthy volunteers. MethodsTwenty asymptomatic male volunteers performed wrist motion from neutral to deviated positions combining flexion-extension and radioulnar deviation. Ultrasound images of the carpal arch and median nerve at the distal carpal tunnel were collected during wrist motion. Morphological and positional parameters of the carpal arch and median nerve were derived from the ultrasound images. FindingsCarpal arch height, area, and palmar bowing of the transverse carpal ligament (TCL) increased with flexion related wrist motion and decreased with extension related motion (P < 0.05). Arch width increased with radial flexion and decreased with extension and ulnar extension (P < 0.05). Median nerve circularity increased with flexion and radial flexion but decreased with extension, ulnar extension, and ulnar deviation (P < 0.05). Nerve centroid displaced ulnarly with radial deviation, radial flexion, and radial extension and displaced radially with ulnar deviation, ulnar flexion, and ulnar extension (P < 0.05). Nerve centroid displaced in the dorsal direction with flexion and radial flexion, but in the palmar direction with extension (P < 0.05). Nerve-TCL distance increased with flexion related motion and decreased with extension relation motion (P < 0.05). InterpretationThe current study advances our understanding the effect of wrist motion on the carpal tunnel and its contents, which has implications for pathomorphological and pathokinematic changes associated with wrist disorders.

Development of the Ergonomic Wrist Posture Range for Indonesian in Typing Activity Using Electromyograph

Carpal Tunnel Syndrome (CTS) is one of the most common neuropathies which occurs due to repetitive activity of hand using non-neutral wrist posture whether in flexion, extension, or ulnar and radial. Even though this posture may be inevitable, however it should be confined in maximum range. Thus, this is very significant to develop the allowable of maximum deviation of wrist. Objective of this study is to determine the maximum range of wrist postures in such four motions with evaluating the muscle contraction at wrist. A case study applied is to type a manuscript using computer. Experimental study was conducted by using electromyograph to identify Maximum Voluntary Contraction (MVC) on Flexor Digitorum Superficialis (FDS) and Abductor Pollicis Brevis (APB). Ten healthy university students (5 females, 5 males) were participated with age between 20 to 23 years old. The statistical analysis was conducted to test the hypothesis. Result of this study shows that the suggested maximum wrist posture range is not greater than 30˚ extension, 20˚ flexion, 20˚ ulnar, and 20˚ radial, although the neutral posture of 0˚ was highly suggested. This guideline is proven to be valid for both male and female.

Factors Associated With Reoperation After Silicone Metacarpophalangeal Joint Arthroplasty in Patients With Inflammatory Arthritis.

Background: Silicone metacarpophalangeal (MCP) joint arthroplasty has a high revision rate. It has been suggested that the preoperative degree of ulnar drift and radial wrist deviation influences the durability of MCP silicone arthroplasties. The goal of this study was to evaluate what factors are associated with reoperation after silicone MCP arthroplasty. Materials and Methods: We retrospectively evaluated all adult patients who underwent MCP silicone arthroplasty between 2002 and 2016 at one institutional system for inflammatory arthritis. After manual chart review, we included 73 patients who underwent 252 arthroplasties. Fingers treated included 66 index, 67 long, 60 ring, and 59 small fingers. Results: The overall reoperation rate was 9.1% (N = 23). Indications for reoperation were implant breakage (n = 11), instability (n = 4), soft tissue complications (n = 4), infections (n = 3), and stiffness (n = 1). There was a trend that patients who underwent single-digit arthroplasty had higher rates of revision (19% vs 3.5%, P = .067). Radiographic follow-up demonstrated joint incongruency in 50% of cases, bone erosion in 58% of cases, and implant breakage in 19% of cases. There was a trend toward higher rates of revision in patients without preoperative MCP joint subluxation (19% vs 6.7%, P = .065) The 1-, 5-, and 10-year implant survival rates were 96%, 92%, and 70%, respectively. Revision surgery occurred at <14 months in 15 patients (65%) and after 5 years in 8 (35%) patients. Conclusions: Revision surgery after silicone MCP arthroplasty appears to be bimodal. Patients with greater hand function preoperatively may be at higher risk of revision surgery.

Ulnar Wrist Deviation in Children With Obstetric Brachial Plexus Palsy: A Descriptive Study of Clinical and Radiological Findings of Impaired Ulnar Growth and Associated Incongruence of the Distal Radioulnar Joint.

Backround: Some children with obstetric brachial plexus palsy (OBPP) present later on with an ulnarly deviated wrist. The aim of this study was to present a retrospective analysis of a subgroup of OBPP children with ulnarly deviated wrists and to describe their morphologic wrist deformity in terms of clinical and radiological appearance. Methods: We present a retrospective analysis of the records of 27 children with an ulnarly deviated wrist as a consequence of OBPP. Radiographs of the affected wrist were performed when the ulnar deformity became clinically manifest and merited investigation, at a mean age of 15 (range: 6.5-27) years. Available clinical and radiological data were analyzed and categorized. Results: The ulnar-deviated position was associated with impaired active and passive pronosupination in all patients. Fifteen fixed supination deformities and 3 anterior radial head dislocations were noted clinically. Plain radiographs were completed in 24 patients and could be analyzed in 18, showing variations in ulnar variance (7 neutral, 7 ulna minus, and 4 ulna plus) along with 6 subluxations of the distal radioulnar joint (DRUJ). Of the patients treated surgically (n = 7), only the 2 patients treated with wrist fusion had an actual improvement in ulnar wrist deformity. Conclusion: Radiologically visible ulnar head hypoplasia, overgrowth of the distal ulna, or a shortened ulnar diaphysis and an incongruent DRUJ were present in all examined OBPP patients with a clinically evident ulnarly deviated wrists. The radiological findings highlight the morphologic adaptation behind this clinical condition and could allow further investigation into suitable treatment strategies.

Application of multiple‐response optimization methods for the ergonomic evaluation of carpet weaving knife

AbstractThe aim of this study is to evaluate several weaving knife configurations in response to multiple criteria’s for optimum design. Nine different knife combinations were tested over ten female weavers in a field experiment. Three levels of blade width and angular orientations were taken as the independent variables. Output response about goniometry and electromyography were taken as dependent variables. Multivariate analysis was carried out to estimate the effect of independent variables on output responses. To tackle the difficulty of knife selection with several output responses, three multicriteria optimization approaches have been compared. Multivariate analysis of variance results showed that the effect of both blade width and angle were significant at wrist angles. Also, the magnitude of effect size on both blade width and the angle was highest for the wrist angles. Despite the same weighing criteria, a slight difference was evident between the ranks from optimization methods. The higher blade widths and smaller angular orientations should be recommended for reduction of wrist deviation and muscle activity during weaving. The best possible combination of knife evaluated using multicriteria optimization was 25 mm × 100°.

Combined radius addition osteotomy and ulnar shortening to correct extra-articular distal radius fracture malunion with severe radial deviation and ulnar plus.

Malunion can occur in 11 to 28% of Distal Radius Fractures and can result in radius shortening and ulnar plus with wrist deviation, pain and disability. We aimed to report particular cases of extra-articular distal radius fracture malunion with severe radial deviation and ulnar plus treated by corrective osteotomy of distal radius with bone graft associated to ulnar procedure. One of these patients was firstly operated with ulna subtraction osteotomy synthesized with plate and in a second stage with distal radius corrective addition osteotomy with homologous bone graft, plate and external fixator. Two other cases were treated in a single-step byradius addition osteotomy and caput ulnae Darrach resection. These three patients were followed-up from 2 to 12 years, successfully observing the maintenance of anatomical correction and recovery of ROM and strength with good pain relief and return to daily activities. After Darrach procedure external-fixation wasn’t needed and pronation-supination was better. Darrach procedure can solve ulna plus and improve ROM in pronation-supination with a quicker healing, avoiding the risk of ulnar non-union. Darrach’s procedure associated to addition corrective osteotomy of distal radius can be a valid treatment for distal radius severe malunion, in patients with low-moderate functional demand. In conclusion, the surgeon should choose the right corrective treatment after the complete evaluation of the patient and his functional needs. (www.actabiomedica.it)

Effect of assistive devices on hand and arm posture during activities of daily living

Assistive devices (ADs) are products designed to overcome the grip strength and mobility difficulties produced by ageing and different pathologies. Nevertheless, little is known about the postural effect of such devices. This work aims to quantify this effect on the entire upper limb. Ten healthy right-handed subjects performed 13 activities of daily living (ADL) with normal products and 22 ADs and both arm (shoulder, elbow and wrist) and hand (grasp types and contacts) postures were analysed. ADs were found to affect upper limb postures in ADL, reducing the use of precision grasps in the right hand by 31.9% and increasing palm contact by 26% and 29.1% in right and left hands, respectively. Nevertheless, they were also found to increase shoulder flexion, elbow pronation and wrist deviation, which may be a drawback in some pathologies. Results may help in the selection of a suitable AD for enhancing ADL performance depending on the patient's limitations due to a particular pathology.

Evaluation of forearm and wrist posture in a dental hygienist's occupational activities

The aim of this study was to evaluate the risk of exposure of 210 dental hygienists to forearms and wrists overloading. The study was based on a Rapid Entire Body Assessment (REBA) questionnaire. The results showed that 42.4% and 43.35% of respondents adopted a strenuous working posture of the right and left forearm, respectively. Strenuous inclination of the right and left wrist was reported by 37.1% and 43.8% of respondents, respectively. Additional twisting and lateral deviation of wrists was reported by 83.8% and 84.3% of respondents for the right and left wrist respectively. The results confirm the premise that dental hygienists are at a high risk of overloading their forearms and wrists. Therefore, there is an urgent need to implement preventive measures and to carry out periodic check-ups.

Morphological Changes of the Median Nerve Within the Carpal Tunnel During Various Finger and Wrist Positions: An Analysis of Intensive and Nonintensive Electronic Device Users

To investigate the effects of static hand postures during various finger and wrist positions on morphological changes of the median nerve within the carpal tunnel in intensive and nonintensive electronic device users. Forty-eight university students, equally divided into intensive and nonintensive users (≥5 h/d and <5 h/d of electronic device usage, respectively), were randomly selected after questionnaire responses and evaluated clinically and by ultrasonography. Intensive users reported more wrist/hand pain with a high severity score than nonintensive users. They also had larger median nerve cross-sectional areas, flattening ratios, and perimeters than nonintensive users, and showed less median nerve deformation under various finger and wrist positions. Compared with the neutral wrist position with all fingers extended for both intensive and nonintensive users, the cross-sectional areas decreased under finger flexion and grip, as well as wrist extension-flexion and radial-ulnar deviation. Overall, the average median nerve size of the dominant hand was much larger than that of the nondominant hand, especially for intensive users. Wrist deviation from neutral can lead to more pronounced deformation of the median nerve than finger flexion for both intensive and nonintensive users. To minimize compression on the median nerve, it is important to keep the wrist as near to the neutral position as possible during computer-related work and avoid keeping the thumb and fingers in a static flexed position when using mobile devices, especially for single-hand use. On the basis of this observational study, intensive users had enlarged and flattened median nerves as well as decreased nerve deformation during hand motions compared with nonintensive users. As overuse of electronic devices may adversely affect the median nerve, caution may be warranted.

Use of Varied Definitions of Repetition with the Distal Upper Extremity Tool (DUET)

Defining what constitutes a repetition in performance of a task involving exertions of the upper extremity can be difficult due to highly varied activities. In this paper, we examine three different definitions of repetition with the use of the Distal Upper Extremity Tool (DUET). These definitions include Grips Alone (manipulation of an object by the hands), Reps Alone (wrist deviations), and Grips + Reps (manipulations plus deviations). Validation of the DUET tool was performed against an existing cross-sectional epidemiology study for all three definitions. The log of the DUET Cumulative Damage (CD) measure demonstrated strong and consistent associations with five separate distal upper extremity outcomes using each of these definitions of repetition when controlled for covariates including site, gender, age, and BMI (with significant odds ratios ranging from 1.20 – 2.10). Results suggest that DUET may allow for flexibility in the definition of “repetition” and still successfully identify hazardous jobs.

Spectrum of Joint Deformities in Children with Juvenile Idiopathic Arthritis.

To determine the frequency and types of joint deformities in children with juvenile idiopathic arthritis and their association with clinical parameters and rheumatoid factor. Cross-sectional study. Rheumatology Outpatient Clinic, the Children's Hospital and the Institute of Child Health, Lahore, from September 2014 to February 2015. All patients of both genders of less than 16 years of age, who fulfilled the International League of Association for Rheumatology (ILAR) criteria for Juvenile Idiopathic Arthritis (JIA), were enrolled in this study. Their demographic data, duration of disease at the time of presentation, types of JIA, various joint deformities and rheumatoid factor (RF) were documented. Statistical analysis of data was done on SPSS version 16. Chi-square test was applied to determine the association of clinical deformity with age of patients, disease duration at presentation, types of JIA and RF. Out of 70 patients enrolled during the study period, 51.4% were boys with mean age at presentation being 9.44 ±3.89 years (2-7 years) and median duration of disease being 24 months (interquartile range 42 months). Forty patients (57.1%) had joint deformities. Most common joints involved were hand (50%), wrist (50%), and knee (35.7%). The common types of joint deformities were boutonniere deformity (28.6%), ulnar deviation of wrist (28.6%), fixed flexion deformity of wrist (22.9%), and knee (31.4%). The most common type of JIA was polyarthritis RF negative with or without deformity. There was a strong association of deformities with older age of patients at presentation (p=0.036), longer duration of disease at presentation (p=0.028), polyarthritis (RF seronegative / seropositive) (p=0.013), and seropositivity (p=0.04). More than 50% patients with JIA have joint deformities. Joint deformities are more likely to be seen in children with long-standing disease, those with polyarthritis JIA and seropositive patients.

Defining the upper extremity range of motion for safe automobile driving

BackgroundThere are no guidelines for return to driving following upper extremity injury. A greater comprehension of the role of the upper extremity in driving is required to assist clinicians in their fitness-to-drive assessments. This research aims to assist clinicians by analyzing the motion at the upper extremity in safe automobile driving. MethodsThirty-six participants were recruited to the Monash University Accident Research Centre's driving simulator. They were tested in a realistic driving simulation using highway scenarios and traffic hazards. An OptiTrack™ motion tracking system recorded participants' upper limb movements. FindingsThe following ranges of motion were recorded (left and right arm mean whole numbers): The shoulder flexed from 14 to 54°, abducted to 18°and adducted to 9°. Shoulder rotation ranged from 6° external to 32° internal rotation. Elbow flexion ranged from 35° to 72°. Pronation reached 77° and supination to 24°. Wrist flexion reached 34° and extension reached 23°. The wrist deviated to 17°radially and 38° ulnar. To avoid simulated hazards, the steering wheel revolved 57.2° (SD 19.2). The key movements in hazard avoidance are shoulder flexion, shoulder rotation, forearm rotation and wrist deviation. InterpretationShoulder flexion, internal rotation and forearm rotation have been shown to be key upper extremity movements in safe driving. Clinicians can refer to the ranges of motion recorded in this investigation, or the driving task at hand in their fitness-to-drive assessments. The ability to revolve the steering wheel 100° exceeds the 95th percentile of the steering wheel revolution angle required to avoid simulated traffic hazards.

Three-dimensional kinematics of the lunate, hamate, capitate and triquetrum with type 1 or 2 lunate morphology.

The purpose of this study was to investigate the differences in three-dimensional carpal kinematics between type 1 and 2 lunates. We studied 15 instances of wrist flexion to extension (nine type 1, six type 2), 13 of radial to ulnar deviation (seven type 1, six type 2), and 12 of dart-throwing motion (six each of type 1 and 2) in 25 normal participants based on imaging with computerized tomography. Mean proximal translation of the distal articular midpoint of the triquetrum relative to type 2 lunates during wrist radioulnar deviation was 2.9 mm (standard deviation (SD) 0.7), which was significantly greater than for type 1 lunates, 1.6 mm (SD 0.6). The hamate contacted the lunate in ulnar deviation and ulnar flexion of wrists with type 2 lunates but not with type 1. We conclude that the four-corner kinematics of the wrist joint are different between type 1 and 2 lunates.

Fracture luxation trans-scapho rétrolunaire dorsale bilatérale – à propos de deux cas

Trans-scaphoid perilunate fracture–dislocations represent a rare injury. These are responsible of one of the most devastating damages of the carpus. These injuries may be easily overlooked or misdiagnosed which deteriorate its prognosis. The aim of this study is to present two unique cases of this injury, comparision to the reported cases and discuss the prognosis factors and treatment options. The first case is a 21-year-old male labourer injured secondary to a motor-cycle accident. Urgent open reduction and stabilization of both wrists was done. Currently, the wrist is stable with functional range of motion and bony union at 18 months. The second case is a 30-year-old male farmer, who presented a polytrauma of after a fall. The patient was referred to our department twelve days after the trauma. Open reduction was first done with a fixation of the carpus and stabilization of the scaphoid were performed using Kirschner wires with ligamentous repair for both wrists. Functional outcomes were satisfactory despite non-union of the scaphoid on one side at two year follow-up. Perilunate dislocations are devastating high-energy wrist injuries. These injuries combine bony avulsions, ligament disruption and fractures in different forms. The present concept of the mechanism of dorsal perilunate dislocation in literature is a fall on outstretched hand with ulnar deviation and supination of the wrist. Dislocation in this region requires rapid realignment, as untreated, it will lead to serious secondary damage. Diagnosis can be difficult as it was missed in our patient, it is frequently the case due to other associated injuries or inadequate interpretation of radiographs of the wrist. Treatment options include closed reduction and cast immobilization, closed reduction and percutaneous pinning, and open reduction. We have performed an open reduction through a dorsal approach with repair of the damaged ligaments and stabilization with K-wires of the carpus and the scaphoid fracture with good functional results for both patients. Early open reduction and restoration of carpal anatomy and repair of damaged ligaments are emphasized in order to restore the complex anatomic inter-carpal anatomy. Non-union rate of the scaphoid was relatively higher in the series treated by closed reduction. These are high velocity injuries and are often missed. Early diagnosis of this entity is essential to prevent complication, through clinical examination and careful evaluation of the radiographs. When detected and treated early patient can have a satisfactory functional outcome.