Multiple carpometacarpal dislocations and an ipsilateral scapho-trapezium-trapezoid fracture-dislocation: a rare pattern of injury

We report a rare case of simultaneous dorsal dislocation of 4 ulnar carpometacarpal joints and dorsoradial dislocation of the trapezium with an associated fracture of the scaphoid tuberosity. The injuries were diagnosed early and treated successfully with closed reduction and transfixation using Kirschner wires. The functional results were excellent at 17-month follow-up.

Sagittally split fracture of trapezium associated with subluxated carpo-metacarpal joint of thumb

Trapezial fractures are uncommon, and require careful clinical and radiological assessment and treatment. Poor or inadequate treatment of displaced fractures of trapezium can lead to long-term morbidity. We report two displaced fractures of the trapezium. The clinical and radiological features are discussed. Both fractures were treated operatively and a good functional outcome was achieved.

Potential MR Signs of Recurrent Carpal Tunnel Syndrome: Initial Experience

OBJECTIVE

In nonoperated patients, the MR diagnosis of carpal tunnel syndrome (CTS) is difficult. In the postoperative patient this difficulty is compounded. Consequently, we sought to evaluate for potential MR signs of postoperative CTS.

METHODS

At 1.5 T, 41 wrists in 37 patients with previous CTS release were evaluated by two observers for 1) flexor retinacular regrowth; 2) median nerve: a) high T2 signal, b) proximal enlargement, c) fibrous fixation, d) neuroma, and e) entrapment; 3) flexor tenosynovitis; 4) mass, bursitis, accessory muscle, distal belly progression, or excessive deep fat; 5) hamate fracture; and 6) volar nerve migration. Electromyography (EMG), operative findings, and clinical follow-up were used to determine the presence of recurrent CTS.

RESULTS

Fifteen of 41 wrists had recurrent CTS. Retinacular regrowth was seen in 4/15 (27%) with and 7/26 (27%) without recurrent CTS (P=0.7). Excessive fat was seen in 1/15 (7%) with and 2/26 (8%) without CTS (P=0.19). No patient had incomplete resection of flexor retinaculum, scarring, neuroma of nerve, or tendon laceration; bursitis, accessory or distal muscle progression of muscle belly, or hamate fracture. Nerve edema with high T2 signal was seen in 4/15 (27%) with and 3/26 (12%) without CTS (P=0.16); proximal enlargement was seen in 6/15 (40%) with CTS and 2/26 (8%) without CTS (P=0.007). Also, 1 patient with recurrent disease demonstrated a mass and 1 other patient without CTS had nerve entrapment. Tenosynovitis was seen in 9/15 (60%) with and 9/26 (35%) without recurrent CTS (P=0.02). Counterintuitively, the nerve was more palmar with recurrent CTS than without (mean 6.9/8.9 mm).

CONCLUSION

Only proximal enlargement, tenosynovitis, and the rare mass may help to diagnose recurrent CTS by MR. However, there appears to be a subgroup of patients with recurrent neuropathy related to an excessively superficial median nerve.

Concurrent scaphoid fracture with scapholunate ligament rupture

Various patterns of traumatic carpal injury have been described in the literature. Although the combination of scaphoid fracture and scapholunate ligament rupture in the same injury has been reported and these lesions can no longer be considered mutually exclusive, little information is available on management methods and the long-term results of such seemingly paradoxical complex injuries. This study reviews 11 previously described cases and reports an additional two cases of concurrent scaphoid fracture with scapholunate ligament rupture. This concurrent injury has two presentations; namely perilunate fracture-dislocation, which is the most common presentation, and complex scaphoid fracture. No single mechanism of injury exists that accounts for these complex injuries. High-energy trauma was the only characteristic common to all these cases. Most cases had unsatisfactory radiographic results including scaphoid nonunion, avascular necrosis of the lunate or the proximal pole of the scaphoid and arthrotic wrist changes at an average follow-up of 11 months. Managing these difficult problems needs critical recognition and repair of both bony and ligamentous damage. Early proximal row carpectomy or four-corner midcarpal fusion is another option when these injuries preclude stable reduction and fixation.

Dorsal transscaphoid-transtriquetral perilunate dislocation in pseudarthrosis of the scaphoid

A patient reported that he sustained a minor fall on the outstretched hand in hyperextension, pronation, and in ulnar deviation. Initial radiographs suggested dorsal transscaphoid-transtriquetral perilunate dislocation. Traditionally, however, this injury is the result of a high-energy impact. A CT scan obtained after closed reduction of the dislocation revealed not only a fresh fracture of the triquetrum but also two corticalized fragments of the scaphoid. A former major fall on this hand and a normal scaphoid of the other hand made pseudarthrosis more likely than scaphoid bipartition. Arthrography revealed intact lunotriquetral and scapholunate ligaments, precluding the possibility of preexisting ligamentous instability. Pseudarthrosis of the scaphoid with a loss of scaphoid function as a mechanical tie-rod of the carpus is most likely responsible for this complex injury. This is the first clinical study that shows that single scaphoid discontinuity without preexisting ligamentous carpal instability may lead to complex perilunar dislocation in minor trauma.

MR imaging of ligaments and triangular fibrocartilage complex of the wrist

Imaging of the wrist with MR imaging can be difficult because of the small size of this joint, its complex anatomy, and its sometimes poorly understood pathologic lesions. A recent study by Hobby and coworkers of 98 patients revealed that MR imaging of the wrist influences clinicians' diagnoses and management plans in most patients. This article summarizes the current diagnostic criteria that can be useful in interpreting abnormalities of the wrist ligaments and triangular fibrocartilage complex (TFCC) of the wrist in this difficult topic in joint MR imaging.

MR imaging findings in ulnar-sided wrist impaction syndromes

Ulnar-sided wrist impaction syndromes are a common source of ulnar pain and limitation of motion. These conditions refer to a group of pathologic entities that result from repetitive or acute forced impaction between the distal ulna and ulnar carpus or distal radius and surrounding soft tissues. MR imaging allows earlier detection of the bone and soft-tissue lesions that are present in the different ulnar-sided wrist impaction syndromes and is helpful in formulating the extensive differential diagnosis in patients with ulnar wrist pain and limitation of motion.

Volar Barton's fractures with concomitant dorsal fracture in older patients

PURPOSE

To describe a variant of Barton's volar articular shearing fracture of the distal radial articular surface with a subtle concomitant fracture of the dorsal metaphyseal cortex.

METHODS

This fracture pattern was observed in 6 women and 2 men with an average age of 67 years (range, 58-76 years). All 8 patients were treated with a volar plate and screws. The dorsal metaphyseal fracture was not recognized in 5 patients and a volar buttress plating technique using an intentionally undercontoured volar plate was used. In 3 patients the dorsal fracture line was identified before surgery and the plate was contoured to fit the volar surface of the distal radius.

RESULTS

All 5 patients treated with an undercontoured plate had loss of the normal palmar tilt of the distal radius (average,-9.4 degrees; range, 0 degrees to-22 degrees ) and dorsal translation of the distal radial articular fragments. For the entire group the palmar tilt averaged-5.9 degrees (range, 0.0 degrees to-22.0 degrees ), the ulnar inclination 19 degrees (range, 10 degrees -23 degrees ), and the ulnar variance-0.9 mm (range, 0.0 to-3.0 mm). All patients attained forearm supination of 80 degrees and the average pronation was 75 degrees (range, 45 degrees -80 degrees ). According to Sarmiento's modification of the system of Gartland and Werley there were 1 excellent, 6 good, and 1 fair results. The average Patient-Rated Wrist Evaluation score was 16 (range, 0-35).

CONCLUSIONS

Some fractures with an oblique volar marginal articular fracture of the distal radius and volar radiocarpal subluxation (known as Barton's fracture) may also have a fracture through the dorsal metaphyseal cortex. Failure to identify this fracture line can lead to dorsal translation and angulation of the distal radius articular surface, particularly when an undercontoured volar plate is used for internal fixation.

Occult fracture of the trapezoid bone: a report on two cases

The authors report two cases of isolated, undisplaced, fractures of the trapezoid bone. Because of its well-protected position in the wrist, traumatic lesions of the trapezoid bone are rare. Dislocation of the trapezoid has been reported in 30 patients; fractures are seen even less frequently and usually go with dorsal displacement. To our knowledge and based on a Medline literature review, only two cases of acute and isolated, undisplaced or minimally displaced fractures of the trapezoid have been previously described. We believe that the lesion has often been missed in the past and modern diagnostic tools will make its diagnosis far more frequent.

Ultrasound treatment of nonunion of the hook of the hamate in sports activities

Two cases of nonunion of the hook of the hamate were treated with low-intensity pulsed ultrasound. The patients were baseball players and had been injured as a result of hitting repeatedly. Nonunion was detected on computed tomography (CT) and was exposed to ultrasound for 20 min a day for 4 months. In both cases pain at the hypothenar eminence disappeared, and bone union was confirmed on CT at the end of the ultrasound treatment.

Dislocation of the pisiform bone after severe crush injury to the hand

The pisiform bone dislocated in a 56-year-old worker who had a crush injury of his wrist. Open reduction and reconstruction of the ligaments resulted in proximal subluxation of the pisiform bone and post-traumatic arthritic changes. Other authors recommend that excision of the pisiform is considered to be a more appropriate method of treatment.

Wrist injuries; diagnosis with multidetector CT

The aim of the study was to assess acute-phase multidetector CT (MDCT) findings in wrist injuries. We retrieved all emergency room MDCT requests processed in the period from August 2000 to May 2003. All patients with a wrist injury who underwent MDCT initially were included. Imaging studies were evaluated in relation to injury mechanism, fracture location, and fracture type. A total of 6422 MDCT examinations were performed during this 34-month period, and 38 patients (24 male, 14 female, age range 21-73 years, mean age 40 years) met the inclusion criteria. MDCT revealed 56 fractures and 7 dislocations in 29 patients. In 9 patients (24%) MDCT findings were normal. Eleven patients (29%) underwent surgical procedures. The main injury mechanism was a fall (58%). In 33 cases the primary radiograph was available. Compared to primary radiographs, MDCT revealed 9 occult fractures, mainly in small carpal bones. In 14 cases a suspected fracture (of the scaphoid in 7 cases) was ruled out by MDCT. Due to high-quality two-dimensional reformatting, MDCT examinations were not dependent on the wrist's position in the CT gantry. In the comparison with radiography, MDCT detected occult fractures and ruled out suspected fractures, both mainly in the small carpal bones. High-quality two-dimensional reformats gave significant information about the fracture anatomy. MDCT provides fast and valuable information in assessing complex wrist fractures or when the primary radiograph is equivocal.

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.

[The mid-term results of proximal row carpectomy in the treatment of degenerative wrist joint derangements]

OBJECTIVES

We evaluated the mid-term results of proximal row carpectomy (PRC) in patients who underwent treatment for wrist joint derangements.

METHODS

Nine patients (4 men, 5 women; mean age 38 years; range 23 to 66 years) underwent PRC to relive pain in the wrist joint and to improve motion and grip strength. Indications for surgery were acute transscaphoid-perilunate fracture dislocation in one patient, formerly unreduced perilunate fracture dislocation in one patient, Kienbock's disease in four patients, and scaphoid nonunion associated with scapholunate advanced collapse (SLAC) in three patients. The duration of the symptoms ranged from eight months to 10 years. The results were assessed with the use of pre- and postoperative clinical and radiographic studies, and measurements of active and passive motion, grip strength, and pulp and key pinch strengths. The mean follow-up was 35.4 months (range 13.5 to 72 months).

RESULTS

Postoperatively, pain relief was achieved in all the patients and no complications were encountered in the early period. One patient with acute transscaphoid-perilunate fracture dislocation developed radiocapitate joint degeneration three years after surgery and underwent total wrist arthrodesis. Compared to the uninvolved side, wrist functions were found adequate with painless motion, except for passive radial deviation which exhibited a significant decrease (p<0.05). Age, sex, and the duration of symptoms did not influence postoperative results.

CONCLUSION

In selected patients with wrist joint derangement, PRC enables painless and adequate motion and grip strength for daily activities. However, radial styloidectomy seems to be necessary to prevent restriction in radial deviation.

Trans-trapezium carpo-metacarpal dislocation of the thumb

We report a case of carpo-metacarpal dislocation associated with an isolated horizontal fracture of the trapezium. It is a rare lesion which is difficult to diagnose by standard radiography, and CT may be necessary for the diagnosis and correct treatment. In our case, stable osteosynthesis was achieved by internal screw fixation, and at follow-up there was an unrestricted, painless range of motion of the thumb.

Bildgebende Verfahren am Handgelenk

Injuries of the wrist are difficult to diagnose because of the complex and narrow anatomic structures. Based on precise clinical examination, X-rays, CT, and MRI are valuable additional tools that can be used. If a fracture is suspected a CT scan is preferable. In the case of a suspected soft tissue or ligamentous injury and non-vital fragments or necrosis MRI is suitable. Other diagnostic tools are presently of minor importance for the wrist. Technical innovations allow better visualization and classification of lesions. However, exact knowledge of the tools is important.

[Functional results two years after the treatment of a delayed diagnosed scapho-capitate fracture syndrome]

The scapho-capitate syndrome (Fenton syndrome) is so rare that diagnosing is a real challenge to every clinician. Therefore, its primary treatment is not always possible. In this case we are reporting about a delayed open treatment of a Fenton syndrome ten days after the original injury. Open reduction was performed via a dorsal approach and the capitate fracture was stabilized with K-wires and the scaphoid fracture with screw fixation. After postoperative immobilization of the wrist using an external fixator for six weeks the patient was already able to work again only twelve weeks after surgery.