Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial

Immobilisation of the thumb is widely believed to be important in the management of fractures of the carpal scaphoid. To assess the need for this, we randomly allocated 392 fresh fractures for treatment by either a forearm gauntlet (Colles') cast, leaving the thumb free, or by a conventional 'scaphoid' plaster incorporating the thumb as far as its interphalangeal joint. In the 292 fractures which were followed for six months, the incidence of nonunion was independent of the type of cast used.

The natural history of suspected scaphoid fractures

Clinically suspected scaphoid fractures are common injuries. The authors prospectively followed up, by serial radiography and bone scanning, 23 patients who had a history of trauma to the carpus and associated localized tenderness to the anatomic "snuff box": in 15 patients the radiographs and bone scans were negative; in 5 the radiograph was equivocal and the bone scan positive. The authors concluded that patients with clinically suspected scaphoid fractures and negative radiographs can be treated symptomatically without immobilization in a cast. Patients with equivocal radiographs should be assumed to have a fractured scaphoid and treated accordingly.

Fractures of the carpal scaphoid. A critical study of the standard splint

The effect of the position of splintage on displacement of fractures of the waist of the scaphoid was studied during operations and in cadavers. We found that these fractures were best splinted in neutral or slight palmar flexion with no ulnar deviation. Providing the wrist was not ulnar deviated, the position of the thumb had no effect on displacement.

[Indications for percutaneous screw fixation of scaphoid fractures]

A total of 198 patients with scaphoid fracture who were treated by percutaneous screw fixation were reexamined after a mean postoperative time of 82 months. Sound radiological union and clinical healing were found in 89% of the recent fractures, 81.8% of fractures with delayed or nonunion and in 42.8% with sclerotic nonunion. Based on our experience, good results can be anticipated if the fracture is anatomically reduced and the screw correctly placed. In cases of carpal collapse, sclerotic nonunion, and or a very small proximal fragment, an open fixation method should be used.

Simulated scaphoid proximal pole fracture

Five fresh cadaver upper extremities were studied with use of a static positioning frame, pressure-sensitive film, a microcomputer-based videodigitizing system, and a Sun station image analysis system to assess the load bearing characteristics of the scaphoid in the proximal carpal joint. Specimens were studied in their normal condition, after a proximal pole osteotomy of the scaphoid, and after resection of the proximal pole of the scaphoid. The amount of contact area born through the scaphoid fossa was essentially the same whether the scaphoid was intact, or after a simulated scaphoid fracture of its proximal pole, or after resection of the proximal pole. The scaphoid contact area and pressure, although overall relatively constant, was redistributed after osteotomy, resulting in increased contact area under the distal fragment and no change or a slight decrease in the contact area under the proximal fragment of the scaphoid. After resection of the proximal fragment, all scaphoid contact area and pressure was born by the distal scaphoid fragment. The contact area and pressure characteristics of the lunate remained unchanged in all conditions compared with the normal condition. There were no significant changes in the locations of the centroids of the scaphoid segments and the lunate in any of the conditions tested.

Magnetic resonance imaging to assess vascularity of scaphoid nonunions

The unreliability of current methods of assessing of bone vascularity is well documented, precluding any prospective analysis of its influence on bone healing. In hopes of accurately predicting scaphoid vascularity, magnetic resonance imaging was used prospectively in patients with radiographic evidence of nonunion. Magnetic resonance imaging scans were compared to plain radiographs, tomograms, and the operative impressions of the surgeon. The diagnostic accuracy of each test was determined by a pathologist's interpretation of histological sections. Ten of thirteen surgical specimens were available for analysis. The magnetic resonance imaging scan accurately predicted scaphoid viability in all ten cases (three viable, seven avascular). This compared with diagnostic errors in six of ten plain radiographs, one of seven tomographs, and two of ten surgical assessments. Magnetic resonance imaging can accurately predict the vascularity of the ununited scaphoid. With further follow-up of these patients, the capability of the avascular scaphoid to heal will become evident. Definitive preoperative determination of the healing potential of scaphoid nonunions may then be possible, thereby aiding the surgeon's choice of the appropriate surgical procedure.

Analysis of scaphoid fracture displacement by three-dimensional computed tomography

Scaphoid fracture displacement was studied in twenty-five patients using three-dimensional computed tomography. Fracture displacement was more readily detected and distinct in three-dimensional computed tomography images than in plain radiography. Two different types of offset of the distal fragment with respect to the proximal fragment are described on three dimensional computed tomography; volar type and dorsal type. In the volar type, the distal fragment overhung in the volar direction relative to the proximal fragment and was frequently accompanied by humpback deformity and axial rotation. In the dorsal type, the distal fragment slipped dorsal on the proximal fragment and was commonly accompanied by humpback deformity. The volar type had a transverse or vertical fracture line on both the volar and dorsal surfaces of the scaphoid, while the dorsal type had a horizontal fracture line. The volar type was frequently found when the fracture was distal, whereas the dorsal type was noted more frequently for proximally located fracture.

Positional dislocation of the pisiform

Positional dislocation of the pisiform repeatedly occurred in the right wrist of a 19-year-old man following a motorcycle accident. The pisiform repeatedly dislocated distal to the triquetrum when the wrist was extended to 45 degrees or more, and the pisiform was reduced to proper joint congruity after wrist flexion of 55 degrees or more. The patient had a background of generalized joint laxity. Resection of the pisiform resulted in a pain-free, fully functional wrist.

A new vascularized bone graft for scaphoid nonunion

Nonunion and avascular necrosis after scaphoid fractures continue to be problem sequelae because of unrecognized injuries, inadequate immobilization techniques, or insufficient treatment time. Screw fixation and inlay bone grafting techniques remain the options of choice, with successful union reported in approximately 90% of patients. However, prolonged immobilization with plaster up to 4 to 6 months is required with conventional techniques. With the use of standard latex injection techniques with vascular filling of vessels to less than 0.1 mm diameter in ten fresh cadaver dissections, we discovered a consistent vascularized bone graft source from the distal dorsoradial radius. We have used this vascularized bone graft source with good results in eleven patients with long-standing nonunion of the scaphoid. It is technically easy and seemingly offers the advantages of a decreased period of immobilization and a higher union rate.

Palmar lunate transtriquetral fracture dislocation

A palmar lunate transtriquetral fracture dislocation with a concomitant radial styloid avulsion fracture has not been described before in the literature. This injury represents an interesting variation of stage IV perilunar instability. Treatment was complicated by persistent scapholunate dissociation (rotary subluxation of the scaphoid) after attempted closed reduction and percutaneous pinning. At open reduction, the proximal half of the triquetrum, which had been dislocated palmarward with the lunate and which had been thought to be reduced after our attempted closed reduction was indeed returned to its normal position. However, it was rotated 180 degrees on its transverse axis. Restoration of the normal scapholunate interval was not possible until the triquetral fracture was reduced.

[Rupture of the tendon of the m. flexor pollicis longus--a rare complication after surgery on the scaphoid bone]

Tendon ruptures in the hand without previous direct trauma are rare. Two cases are reported on with attrition of the flexor pollicis longus tendon. The first tendon rupture was along a dislocated cortico-cancellous bone graft following a Matti-Russe procedure; the second was by attrition over the screw of an AO-plate following internal fixation in scaphoid nonunion. Immediate tendon repair by interposition of a short tendon graft or by transposition of the superficialis flexor tendon of the ring finger is the treatment of choice. Further tendon ruptures can arise if surgical intervention is delayed.

A forty-three-year follow-up of a vitallium scaphoid arthroplasty

Over the years various treatment options for scaphoid nonunions have been proposed. We present as a historical note the long-term follow-up of one such treatment, the insertion of a vitallium scaphoid.

Nonunion of a pathologic juvenile scaphoid fracture after osteomyelitis

A patient with osteomyelitis of the scaphoid in childhood resulting in a pathologic fracture with nonunion is presented. This ununited fracture of the scaphoid was successfully grafted eight years later with a satisfactory outcome.

The use of totally de-proteinized heterologous bone graft in non-union of the scaphoid

In an attempt to avoid the complications associated with taking autologous bone graft for use in the treatment of non-union of the scaphoid, a clinical trial of the use of totally de-proteinized heterologous bone graft has been carried out. Ten patients with established non-union of the scaphoid were treated with internal fixation and grafting using one such commercially available material, Pyrost. The clinical and radiological results in eight patients about one year later are reported. The operative use of this material proved difficult because of its poor mechanical properties and it is not recommended as a substitute for the patient's own bone.

Scaphoid non-union with D.I.S.I. deformity. A survey of clinical cases with special reference to ligamentous injury

To clarify whether or not scapho-lunate ligamentous injury is common in scaphoid non-union with D.I.S.I. deformity and whether ligamentous repair is required to treat scaphoid non-union with D.I.S.I. deformity, roentgenographic, arthrographic and arthroscopic findings were analysed and compared to those of scaphoid non-union without D.I.S.I. deformity. The carpal alignment of scaphoid non-union with D.I.S.I. deformity treated by reduction and anterior wedge grafting without ligamentous repair was also studied. No significant difference in the scapho-lunate gap was present between 26 patients with D.I.S.I. deformity and 20 without. No statistically significant difference was detected in the incidence of arthrographically-proved scapho-lunate ligamentous tears between the two groups. Arthroscopic examination carried out in 22 patients did not detect massive ligamentous injury, and carpal alignment was satisfactory in most patients who underwent anterior wedge grafting. These results show that ligamentous injury rarely causes D.I.S.I. deformity in scaphoid non-union, and anterior wedge grafting alone is sufficient to correct D.I.S.I. deformity in most cases.

A personal technique for treatment of scaphoid non-union

We describe a personal technique for the treatment of scaphoid non-union, consisting of styloidectomy of the radius associated with axial perforation of the scaphoid, emptying of the bone, filling it again by cancellous bone taken from the styloid and securing it with a peg obtained from the cortex of the same styloid. 52 patients out of 77 operated on with this technique were reviewed. Results are shown and seem to be better than those found in literature.

Pisiform fractures

Fractures of the pisiform are often missed due to improper radiographic evaluation and a tendency to focus on other, more obvious injuries. Delayed diagnosis may result in disabling sequelae. A high index of clinical suspicion and appropriate radiographic examination will establish the correct diagnosis. Ten patients with pisiform fracture are presented. The anatomy, mechanism of injury, clinical presentation, radiographic features, and evaluation of this injury are discussed.

[Osteosynthesis in hand bone fractures in children]

At 12 preparations of the upper extremities of still-born fetuses has been studied microcirculatory channel of long bones of a hand. Clinical confirmation of the experimental results is based on the analysis of data obtained in process of treatment of 54 children with instable fractures of phalanges and metacarpal bones. An arterial channel of long bones of a hand is formed by the branches of finger arteries and vessels of the surrounding tissues. Epiphysis, metaphysis and growth cartilage have common circulatory system. The types of phalanx epiphysiolysis determine the terms of the open reposition realization. Comparison of morphological data and clinical observations demonstrated that the optimal methods of fixation of instable fractures of long bones of a hand are as follows: diafixation by means of wires, intramedullary osteosynthesis and perosseous compressive-distractive osteosynthesis.

[Fracture and dislocation fracture of the os pisiforme]

Four cases of pisiform fracture are presented. In one case the largest fragment of the pisiform bone with the articular surface was dislocated. After open reduction, osteosynthesis with K-wires was performed. Two patients had an isolated fracture without fragment dislocation. They had their lower arms immobilized with a plaster of Paris cast for 4 weeks. In the fourth case the fracture of the pisiform bone was associated with an intraarticular distal radial fracture and wrist dislocation. The typical traumatic cause of pisiform fracture is a fall onto the outstretched hand. Immobilization for 4 weeks results in functional recovery. In cases with dislocation of the pisotriquetral joint open reduction and osteosynthesis are necessary. Excision of the pisiform bone is not indicated in a fresh injury.