[Wrist arthrodesis: alternative to resection of the proximal carpal bones?]

The results of a series of 36 post-traumatic radio-carpal arthrodeses were compared with those of the series of resection of the first row of carpal bones reported during the round table. The advantages and disadvantages of both procedures were discussed. Arthrodesis results in: 1) loss of grip strength in all cases, averaging 41%; 2) persistent pain in 78% of cases; 3) impairment of function resulting from blocking of the wrist. After the procedure, average time off work is 15 months, level of permanent disability was 30%, and 20% of patients returned to their previous jobs. These figures could be used as arguments against arthrodesis. However, they must be taken in context: final arthrodesis, usually performed on manual workers, is often chosen when resection of the first row of carpal bones would obviously be insufficient, for example, when severe arthritis of the head of the capitate is present.

Coronal fracture of the body of the hamate: case reports

Coronal fracture of the body of the hamate with associated dorsal subluxation of the bases of the fourth and fifth metacarpals is rare. Two cases of this injury with and without disruption of the dorsal carpometacarpal ligaments treated with open reduction and internal fixation are reported. Oblique roentgenographic views with the hand pronated 30 degrees from the true lateral were helpful in the assessment of the fracture.

[Diagnosis of carpal bone fractures]

The diagnosis of carpal bone fractures has been facilitated by new radiological projections and by the advent of modern imaging methods. Fractures of the scaphoid bone still account for 75% of carpal fractures with their complications (pseudarthrosis, malunion) and their sequelae of arthrosis. However, the frequency of other fractures appears to be increasing due to a better knowledge of their mechanism and to the possibilities of the new imaging methods.

Treatment of ununited fractures of the carpal scaphoid by iliac bone grafts and Herbert screw fixation

Internal fixation with a Herbert screw was used to treat 70 ununited fractures of the carpal scaphoid. Bone grafts were utilised in all cases of nonunion (56) and in 10 out of 14 with delayed union. The results were assessed at a mean time of 13 months. Definite radiographic union was achieved in 90% of patients after a mean period of postoperative immobilisation of 5.4 weeks. Although the rate of union was basically the same as in Russe's series, the final functional results were better than those obtained by using his technique. The use of an image intensifier is essential to avoid technical problems.

Scaphoid fractures and wrist pain--time for new thinking

As with the practice of all medicine, an early accurate diagnosis is essential. The same applies after injury. The diagnosis should be made at the earliest opportunity--this should be done as soon as an appropriate expert is able to examine the patient, assess adequate radiographs and, where necessary, order special investigations such as a bone scan. By this means, distal radial fractures, injuries of the radioulna joint, dislocated lunates, Bennett's fractures, dorsal capsular wrist sprains, avulsion fractures etc. can be managed accordingly. Those patients in whom clinical examination, plain radiographs and/or bone scans show minor injuries can be advised about pain relief whilst staying active either at work or in the home using a light supportive removable bandage or splint. Where doubt remains and whilst keeping the patient comfortable, a bone scan may be requested. Its availability together with updated clinical and, if necessary, radiological assessment, will define a further group of patients who can be advised definitively either about active treatment or a return to normal activity. Only a few wrists will continue to defy definitive diagnosis requiring the continuance of expert advice and investigation. When a scaphoid fracture is diagnosed, its site, degree of displacement and any associated instability should determine the degree of intervention and the length of time required in plaster. This again gives the patient more information about the long-term future than many have had hitherto. The patient's individual requirements may be taken into account; some are happy to tolerate 2-3 months in plaster whilst others want the early function which an uncomplicated operation might offer.(ABSTRACT TRUNCATED AT 250 WORDS)

Fractures of the body of the hamate

Eight cases of fracture of the body of the hamate are presented, with descriptions of the injury and management. This fracture may be considerably more common than indicated by standard texts and previous published reports.

A rare combination of fractures of the upper extremities: a diagnostic problem

The rare case is reported of fractures concurrently of the bilateral proximal radius and the right proximal carpal row. Initial radiographs of the patient showed only fractures in the bilateral proximal radius and the right triquetral bone. In addition, the bone scan showed focal increased uptake in the right scaphoid bone and lunate bone as well, suggesting fractures. Fractures of the entire right proximal row were confirmed by computer tomography. The patient received functional treatment for the elbows and had a scaphoid plaster-of-Paris cast for the wrist. This resulted in a complete recovery after one year.

Trans-radial styloid, trans-scaphoid, trans-triquetral perilunate dislocation

A rare case of trans-radial styloid, trans-scaphoid, trans-triquetral perilunate dislocation is described. The injury was treated by reduction and internal fixation using a Herbert screw and Kirschner wire. A good functional result was achieved. A review of the literature illustrates that early surgery is recommended. Alternative surgical approaches are discussed.

[Case report of an isolated fracture-dislocation of the trapezium]

Conservative management in case of a rarely observed fracture dislocation of the trapezium is reported: pertinent extension of the thumb in plaster of Paris (POP) for more than six weeks effected consolidation and healing of the unstable fracture.

Technique for diagnosis of scaphoid fractures

Fracture of the scaphoid bone accounts for 60 percent of all carpal injuries. Early diagnosis of a scaphoid fracture is extremely important. Missing the fracture may lead to disability due to potential avascular necrosis or non-union of the fragments. The presence of a scaphoid fracture may be determined with greater certainty by using a multiple angle scaphoid series detailed by the author.

Pathologic fractures: a complication of microparticulate synovitis

We report seven cases of pathologic fracture in adult patients that were seen an average of 5 years (range from 33 to 114 months) after silicone wrist (three) and trapezial (four) arthroplasty. All patients had initially done well after their operation. At return, all had radiographic evidence of generalized implant and intramedullary bone destruction, the latter always including endosteal scalloping and widening from cortical resorption. These radiographic changes may be less striking than the discrete osteolytic lesions seen after degeneration of carpal implants. Our patients represent examples of pathologic fracture as the end stage of untreated microparticulate synovitis, a consequence of prosthetic wear. Our experience suggests that careful and continuous follow-up justified after insertion of stemmed silicone implants, and that patients should be informed of the potential late complications of this procedure, including pathologic fracture.

[A new classification of distal radius fractures and corresponding treatment methods]

Based on previously published reports on fractures of the distal radius and on the analysis of 400 fresh fractures treated in two accident hospitals affiliated with our university hospital, we propose a new classification as shown in Table 2. This new classification includes a type of combined Chauffeur-Barton fracture which has never been described before. Each type of fracture of the distal radius requires a specific treatment as shown in Fig. 1.

One case of rotational subluxation of the carpal scaphoid

The authors describe one case of perilunate dislocation. After reduction of the dislocation, there was a residual rotational subluxation of the scaphoid due to dorsal tearing of the scapho-triquetral and radio-scaphoid ligaments. The subluxation results in post-traumatic dorsal instability of the carpus. The authors report their clinical experience and conclude that clinical and radiographic diagnosis is not always easy and treatment, which is always surgical, must aim at joint stabilization and ligament reconstruction.

[Fractures of the scaphoid bone in soldiers]

The conservative treatment and results obtained in the treatment of 30 scaphoid bone fractures in soldiers aging from 18 to 22 years are reported. The immobilization was performed after acute posttraumatic edema, the latest 4 days after injury, first using the plaster splint and then the "plaster gloves." The immobilization lasted two months. The complete healing was achieved in 29 injured and pseudoarthrosis occurred in one case only.

Nonunion of a carpal scaphoid fracture in a child

We report a case of a nonunion of a carpal scaphoid in a child treated successfully by cast immobilization. Contrary to the general opinion that nonunion of the scaphoid bone should be treated operatively, even in children, we showed that healing can be obtained by nonoperative treatment methods.

Treatment of nonunions of the scaphoid with the Ender compression blade plate system

A relatively high failure rate is associated with bone grafting with or without screw fixation in scaphoid nonunions. Complicating factors include avascular necrosis, cystic degeneration, and osseous size discrepancy or compromise. The Ender blade plate is suitable for adding stability in these cases, in spite of the necessity for late removal and the possibility of articular impingement. Twenty patients were treated with this technique. Nine of these patients had had previous unsuccessful attempts at nonunion repair. Nineteen had satisfactory results, but one had a persistent nonunion. The use of the Ender blade plate system is applicable for treatment of these difficult cases that are not ideally suited to compression screw fixation.

Diagnostic value of ultrasound in scaphoid fractures

Diagnostic ultrasound was used in 103 patients with a clinically suspected fracture of the scaphoid bone in order to achieve an early diagnosis. There were 48 women and 55 men aged 10-75 years (mean 31.4 years) tested with ultrasound. Of the patients, 72 were tested within 3 days after injury the remainder between 4 and 42 days. Fracture was confirmed radiologically in 27. We found that the ultrasound test, applied with a frequency of 1 MHz and intensity of 0.5 W/cm2 and 2.0 W/cm2 for 30s, had a sensitivity of 37 per cent and a specificity of 61 per cent. We thus conclude that ultrasound is not suitable for early diagnosis of scaphoid fracture.

[Pseudarthrosis of the capitate bone with special reference to ligamentous stabilization]

Non-union of the capitate is rare. So far, six cases of non-union have been reported. The authors add a new case report, involving a 29-year old tobacco worker with a typical history. The length of the capitate was restored by corticocancellous bone grafting. The mechanism by which non-union occurs is discussed, showing that the uninjured palmar V ligament in the wrist is responsible.

Computed analyses of the pathomechanics of scaphoid waist nonunions

The computed tomography scans of both the injured and the normal wrists of nine patients with a scaphoid nonunion of 5 to 120 months' duration were used to create three-dimensional computer models. When the computer images of the normal and the contralateral fractured scaphoids were superimposed, it was possible to calculate the volume of bone that was lost as a result of the injury and its failure to heal, as well as the angular relationship of the fracture components to one another. The amount of the scaphoid bone that was lost varied from 6% to 15% of bone volume and did not show a linear correlation with the duration of the nonunion. The configuration of the missing bone was consistent and exhibited a prismatic shape whose base is quadrilateral and faces palmarly. The proximal scaphoid fracture component is extended, radially deviated, and supinated in relation to its distal fracture component. The consistent fracture deformity and the configuration of the bony defect in the scaphoid waist nonunions should be helpful in the understanding and treatment of the condition.