Reliability and validity of carpal alignment measurements in evaluating deformities of scaphoid fractures

Evaluation of Normal Ranges of Wrist Radiologic Indexes in Jordanian Population

Background

The wrist is a complex joint that plays a role in several everyday tasks. Various radiological indices have been created to assess the alignment and structure of the wrist using standard X-ray images. Nevertheless, these indicators may differ based on variables such as age, gender, ethnicity, handedness, and wrist position. This research aimed to assess the radiological indices of the wrist in a group of healthy people from Jordan and investigate the impact of age and gender on these indices.

Methods

We obtained data from a sample of 385 patients who presented at our hospital with minor non-specific wrist pain and satisfied the specified criteria for inclusion. We conducted measurements of radial inclination, radial height, volar tilt, ulnar variance, and carpal height ratio using both anteroposterior and lateral views of the wrist. We used linear regression and independent sample t-test to examine the correlation between age, gender, and radiological indicators. The reliability of the measurements was assessed using the intraclass correlation coefficient (ICC).

Results

Our study revealed a negative correlation between age and carpal height ratio (r = -0.13, p = 0.03). However, no significant gender differences were seen in any of the radiological indices (p > 0.05). Our findings indicate that ulnar variance had the greatest level of reliability across observers, with an intra-observer intraclass correlation coefficient (ICC) of 0.95 and an inter-observer ICC of 0.8. Conversely, volar tilt exhibited the lowest inter-observer reliability, with an ICC of 0.1.Our results provide a valuable point of reference for the wrist morphology and alignment in the Jordanian population. Our suggestion is that the carpal height ratio might indicate alterations in the wrist joint due to aging, whereas ulnar variation may serve as a dependable indicator of wrist alignment. We suggest doing more research to investigate the biological and anatomical factors behind these results and to compare them with other demographic groups.

Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?

The aim of this retrospective study was to assess the relation between carpal malalignment correction and radiological union rates in surgery for scaphoid nonunions. A total of 59 scaphoid waist fracture nonunions treated with open reduction and palmar tricortical autograft were divided according to their pre- and postoperative scapholunate (SL) and radiolunate (RL) angles. We found that carpal malalignment failed to correct in 32 of 59 (54.2%) patients despite meticulous surgical technique and placement of an appropriately sized wedge-shaped graft. In total, 43 (72.9%) fractures united at a mean of 4.47 months (range 3-11). Of the 27 fractures with postoperative SL and RL angles within the normal range, 21 united, whereas 22 of the 32 remaining fractures that failed to achieve postoperative angles within the normal range went on to union. The postoperative SL and RL angles were not related to union. Our findings suggest that in scaphoid fracture nonunion surgery, carpal malalignment may not be corrected in a substantial proportion of patients, but such correction may not be essential for bony union. Our findings also show that there is no marked collapse of the scaphoid graft in the early postoperative period.

LEVEL OF EVIDENCE

IV.

Subchondral Radial and Ulnar K-Wire Positioning With Cancellous Bone Graft Shortens Union Time in Scaphoid Waist Nonunion

BACKGROUND

Bone grafting in patients with scaphoid waist nonunion can present several technical challenges. In this study, we aimed to present a modified surgical technique for scaphoid waist nonunion, which consisted of subchondral radial and ulnar K-wires positions with cancellous bone graft, and to compare the clinical outcome of this modified technique with the conventional method.

METHODS

We retrospectively reviewed 72 patients with scaphoid waist nonunion who had been surgically treated between January 2011 and December 2020. Of these, 34 patients were treated with the modified method and 38 with the conventional method. Debridement of the nonunion site was performed using a curette, rongeur, and microburr. Two or 3 K-wires were inserted along the cancellous portion of the scaphoid in the conventional method. In the modified method, 2 K-wires were inserted along the ulnar and radial subchondral portion of the scaphoid to increase the space for bone grafting in the cancellous portion of the scaphoid. The autologous cancellous bone grafted in both the methods. Demographic, radiological, and clinical outcomes were reviewed and compared between the groups.

RESULTS

There were no significant differences in demographics and characteristics of nonunion between the 2 groups of patients. The modified method group showed significantly shorter union time than the conventional method group (conventional group: 13.0 ± 1.3 weeks, modified group: 11.4 ± 1.1 weeks; P < 0.001). The bony union rate was 97.1% for the modified method and 89.5% for the conventional method. Satisfactory clinical outcomes (excellent and good Mayo wrist scores) were achieved in 27 cases (81.8%) using the modified method and 22 cases (64.7%) using the conventional method.

CONCLUSION

Subchondral radial and ulnar K-wire positioning with cancellous bone graft (modified method) can improve the union time with satisfactory clinical outcomes in the treatment of scaphoid waist nonunion.

Comparison of corticocancellous bone graft from the anterolateral metaphysis of the distal radius versus iliac crest for the treatment of unstable scaphoid nonunion with humpback deformity

BACKGROUND

Corticocancellous bone grafting from the iliac crest is acceptable treatment for unstable scaphoid nonunion with a viable proximal pole. However, harvesting graft from the iliac crest is associated with donor site morbidity and the requirement of general anesthesia. Thus, bone grafting from the anterolateral metaphysis of the distal radius (DR) can be a treatment option. However, no study has compared the clinical effect between the two grafting techniques.

METHODS

From 2014 to 2019, patients with unstable scaphoid nonunion with humpback deformity underwent corticocancellous bone grafting from the anterolateral metaphysis of the DR (group DR) or iliac crest (group IC). Humpback deformity was determined by evaluating the scapholunate angle (SLA) ≥ 60°, intrascaphoid angle (ISA) ≥ 45°, and radiolunate angle (RLA) ≥ 15° from preoperative radiographs and computed tomography scans. The SLA, ISA, and RLA served to gauge carpal alignment. The operative time, grip strength, active range of motion (ROM), the Modified Mayo Wrist score (MMWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score were assessed postoperatively.

RESULTS

Thirty-eight patients qualified for the study (group DR, 15; group IC, 23). Union rates did not differ by patient subset (group DR, 100%; group IC, 95.7%; P = .827), and grip strength, ROM, MWS, and DASH score were similar between groups at the last follow-up. The operative time (minutes) was significantly shorter in group DR (median, 98; quartiles, 80, 114) than in group IC (median, 125; quartiles, 105, 150, P < .001). The ISA, RLA, and SLA improved postoperatively in both groups (P < 0.001). The degree of restoring carpal alignment, as evaluated by SLA, showed superior correction capability in group DR (median, 25.3% quartiles, 21.1, 35.3, P < 0.05). Donor site complications were not significantly different between the groups.

CONCLUSIONS

Corticocancellous bone graft from the anterolateral metaphysis of the DR for unstable scaphoid nonunion is associated with a shorter operation time and comparable results with that from the iliac crest in regard to union, restoration of carpal alignment, and wrist function.

LEVEL OF EVIDENCE

Level III.

Comparison of computer-aided and manual measurements in the evaluation of carpal alignment

The purpose of this study was to compare computer-aided analysis and different methods of manual measurements in the evaluation of carpal alignment. The radioscaphoid, radiolunate, radiocapitate and radiometacarpal angles were measured on cone-beam computed tomography (CT) scans of 30 healthy wrists by automated software (Disior Ltd.) and by hand surgeons using lateral radiographs reconstructed from the CT data. Hand surgeons were either given (n = 6) or not given (n = 7) prior instructions on how to perform the measurements. Inter- and intra-observer reliability of manual measurements ranged from good to excellent (intra-class correlation coefficients [ICC] 0.77-0.99), being highest in specialists with standardized methods and in reconstructed radiographs with bone overlap digitally removed. Computer-aided software provided excellent intra-observer reliability (ICC 0.94-1.00) consistently and values that were highly comparable (mean difference range 1°-7°) with the manual measurements made in optimal settings. Computer-aided software provides an accurate and repeatable method to measure carpal alignment in CT scans, minimizing observational errors.

Intercarpal Angles on Hand Versus Wrist Films: Are Hand Radiographs Sufficient for Assessing Intercarpal Angles?

PURPOSE

Carpal angles traditionally are measured on the lateral projection of a standard wrist series; however, this often necessitates obtaining additional radiographic views resulting in additional radiation exposure and increased cost. We aimed to determine whether carpal angles could be measured accurately on a standard series of hand radiographs when compared to wrist radiographs.

METHODS

Carpal indices were measured on lateral wrist and hand radiographs of 40 patients by three orthopedic upper extremity surgeons. Inclusion criteria were no metabolic disease, no hardware, no fractures, radiographic positioning of the wrist in flexion/extension <20°, minimum 3 cm of distal radius visible, and acceptable scaphopisocapitate relationship (defined as the volar cortex of the pisiform lying between the volar cortices of the distal pole of the scaphoid and capitate). Angles measured included radioscaphoid (RSA), radiolunate (RLA), scapholunate (SLA), capitolunate (CLA), and radiocapitate (RCA). Measurements on wrist versus hand radiographs were compared for each patient. Interclass correlation coefficients (ICCs) were computed to assess interrater and intrarater agreement.

RESULTS

Interrater agreement for hand and wrist radiographs were (respectively): SLA 0.746 and 0.763, RLA 0.918 and 0.933, RCA 0.738 and 0.538, CLA 0.825 and 0.650, RSA 0.778 and 0.829. Interrater agreement was superior in favor of hand radiographs for the RCA (0.738 [0.605-0.840] vs 0.538 [0.358-0.700]) and CLA (0.825 [0.728-0.896] vs 0.650 [0.492-0.781]), but not the SLA, RLA, or RSA. Two of the three raters had excellent intrarater agreement for all hand radiograph measures (ICC range, 0.907-0.995). The mean difference in measured angles on hand versus wrist radiographs was <5° for all angles.

CONCLUSIONS

Carpal angles may be measured reliably on hand radiographs with an acceptable scaphopisocapitate relationship and wrist flexion/extension of <20°.

CLINICAL RELEVANCE

By mitigating the need to obtain additional radiographic views, surgeons may be able to reduce the cost and radiation exposure to their patients.

Arthroscopic versus open cancellous bone grafting for scaphoid delayed/nonunion in adults (SCOPE-OUT): study protocol for a randomized clinical trial

BACKGROUND

Scaphoid non-union results in pain and decreased hand function. Untreated, almost all cases develop degenerative changes. Despite advances in surgical techniques, the treatment is challenging and often results in a long period with a supportive bandage until the union is established. Open, corticocancellous (CC) or cancellous (C) graft reconstruction and internal fixation are often preferred. Arthroscopic assisted reconstruction with C chips and internal fixation provides minimal trauma to the ligament structures, joint capsule, and extrinsic vascularization with similar union rates. Correction of deformity after operative treatment is debated with some studies favouring CC, and others found no difference. No studies have compared time to union and functional outcomes in arthroscopic vs. open C graft reconstruction. We hypothesize that arthroscopic assisted C chips graft reconstruction of scaphoid delayed/non-union provides faster time to union, by at least a mean 3 weeks difference.

METHODS

Single site, prospective, observer-blinded randomized controlled trial. Eighty-eight patients aged 18-68 years with scaphoid delayed/non-union will be randomized, 1:1, to either open iliac crest C graft reconstruction or arthroscopic assisted distal radius C chips graft reconstruction. Patients are stratified for smoking habits, proximal pole involvement and displacement of > / < 2 mm. The primary outcome is time to union, measured with repeated CT scans at 2-week intervals from 6 to 16 weeks postoperatively. Secondary outcomes are Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH), visual analogue scale (VAS), donor site morbidity, union rate, restoration of scaphoid deformity, range of motion, key-pinch, grip strength, EQ5D-5L, patient satisfaction, complications and revision surgery.

DISCUSSION

The results of this study will contribute to the treatment algorithm of scaphoid delayed/non-union and assist hand surgeons and patients in making treatment decisions. Eventually, improving time to union will benefit patients in earlier return to normal daily activity and reduce society costs by shortening sick leave.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05574582. Date first registered: September 30, 2022. Items from the WHO trial registry are found within the protocol.

Scaphoid Malunion: Incidence, Predictors, and Outcomes

Background  Scaphoid malunion is rarely reported. Previous literature has attributed loss of carpal height and degenerative changes to scaphoid malunion, but the percentage of asymptomatic malunions remains unknown. Purpose  The authors of this study aim to define predictors of malunion and outcomes associated with scaphoid malunion. Methods  Institutional board review was obtained prior to evaluating medical records of patients 18 years and older who were treated for scaphoid fractures and/or nonunion between 2000 and 2020. The following data were collected for each patient: age, gender, fracture location, surgical technique, time to union, and whether malunion resulted. Malunion was defined using a lateral intrascaphoid angle (LISA) >45 degrees and height-to-length ratio (HLR) >60. Pain scores, range of motion (ROM), and secondary surgery were also evaluated. Results  Overall, 355 scaphoid injuries, including 196 acute fractures and 159 nonunions, were evaluated in this analysis. Of these, 55 scaphoids (15%) met the definition of malunion. Of these patients, 23% were female. The mean age at the time of injury was 29 years. Nonunion cases were more likely than acute cases to be associated with malunion. Proximal pole fractures were more likely to associated with malunion than waist fractures. When controlling for nonunion and fracture location, malunited scaphoids were not associated with any significant difference in pain score, ROM, or secondary surgery, compared with nonmalunion cases. A total of 10 patients (3.3%) without malunion and 2 patients (3.6%) with malunion went on to a secondary surgery. Final extension/flexion was 67/67 degrees and 56/59 degrees in nonmalunion and malunion groups, respectively, but these differences were not significant. Conclusion  Compared with scaphoid injuries that do not result in malunion, scaphoid injuries that heal into malunion have similar outcomes. While scaphoid malunion in a single case or series may be associated with poor outcomes, this study suggests that scaphoid malunions do not have worse functional outcomes. Level of Evidence  This is a Level IV study.

Arthroscopy-assisted bone grafting for the treatment of SNAC stage I without radial styloidectomy

To report the clinical and radiological outcomes of arthroscopic bone grafting and percutaneous K-wire fixation without radial styloidectomy in patients with scaphoid nonunion advanced collapse (SNAC). We retrospectively analyzed the records of 15 patients with SNAC who were treated with arthroscopic bone grafting and percutaneous K-wire fixation and subsequently followed up for a minimum of 1 year between November 2009 and March 2018. The clinical outcomes were evaluated by comparing the range of motion (ROM), grip strength, the modified Mayo Wrist Score, and visual analog scale (VAS) scores for pain, all of which were measured preoperatively and at the last follow-up. The radiologic outcomes were evaluated by comparing the scapholunate (SL) and radiolunate (RL) angles preoperatively and at the last follow-up. All 15 cases of nonunion were resolved. The average radiologic union time was 9.7 ± 1.2 weeks. The average VAS score increased from 5.7 ± 2.3 (range, 2 - 10) preoperatively to 1.3 ± 1.3 (range, 0 - 3) at the last follow-up (P < .05). The average modified Mayo wrist score increased from 58.3 ± 14.0 preoperatively to 80.0 ± 9.2 at the last follow-up (P < .05). The mean ROM of the wrist improved, but there was no statistical significance. At the last follow-up, the mean flexion and radial deviation on the affected side were significantly decreased, and the mean extension on the affected side was significantly improved compared to the normal side (P < .05). The mean preoperative SL and RL angles were 66 ± 11.9° and 7.2 ± 6.8°, respectively, and were decreased to 50.4 ± 7.5° and 6.4 ± 5.2°, respectively, at the last follow-up. The mean SL angle was significantly corrected (P = .01). Arthroscopic bone grafting and percutaneous Kerschner (K)-wire fixation without radial styloidectomy are considered to be very effective methods for correcting scaphoid deformities to treat SNAC stage I. However, caution may be needed during the surgery to prevent reductions in flexion and the radial deviation of the wrist.

Plate fixation in challenging traumatic carpal scaphoid lesions

BACKGROUND

Complex fractures of the carpal scaphoid with poles fragmentation, edges comminution, bone loss and non-union of fractures previously treated by screw fixation remain challenging for hand surgeons. The authors present the indications, advantages and results of scaphoid plating, underlining the importance of correct plate positioning well shaped onto the bone.

MATERIALS AND METHODS

The study includes 11 patients presenting acute fracture with distal pole fragmentation, acute fracture with comminution and non-union after prior failure of screw fixation. All patients were treated with volar locked plate fixation, adding a cortical bone graft in cases of non-union.

RESULTS

Bone consolidation was achieved in all cases; excellent outcomes in fracture healing and relevant improvement in symptoms and functions were obtained in non-union group that are consistent with the literature. Only one patient underwent early further surgery (first row carpectomy) with poor results.

CONCLUSION

The treatment of the selected scaphoid lesions with volar locked plate is a surely efficient technique. The plate can be easily adjusted to the shape of the scaphoid and can achieve an adequate correction of bone deformity and high degree of stability both in non-union and fractures.

Clinical and Patient-Reported Outcomes After Hybrid Russe Procedure for Scaphoid Nonunion

Background: Hybrid Russe technique for the treatment of scaphoid nonunion with humpback deformity has been described with a reported 100% union rate. We sought to evaluate the reproducibility of this technique. Methods: We completed a retrospective chart review of patients with a scaphoid waist nonunion and humpback deformity treated with the hybrid Russe technique from 2015 to 2019 with a minimum of 3-month follow-up. Twenty patients with 21 nonunions were included (mean follow-up: 7.0 months). Scapholunate angle was the primary outcome measure. Secondary outcomes included: intrascaphoid angle, radiolunate angle, pain on the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Other variables included: time to computed tomography (CT) union, range of motion, and complications. Descriptive statistics were presented. Pre- and postoperative angles, VAS, and QuickDASH scores were evaluated with Wilcoxon signed rank tests. Results: The mean scapholunate angle improved -17.6° ± 6.4°. The mean intrascaphoid angle improved 28.2° ± 6.3°. The mean radiolunate angle improved 12.8° ± 8.8°. Of the 21 scaphoids, 20 (95%) demonstrated union on a CT scan. One patient was diagnosed with a nonunion. In total, 90% of patients noted symmetric range of motion compared with the contralateral side. The mean VAS pain score improved 6 ± 3 points. The mean QuickDASH score improved 10 ± 8 points. Complications (aside from nonunion) included 1 patient with persistent wrist pain that resolved with removal of hardware. Conclusions: The hybrid Russe technique for the treatment of scaphoid nonunions with humpback deformity demonstrates a 95% union rate. This technique is effective, reproducible, and may serve as an alternative to techniques that include structural grafts from distant sites.

Structural Versus Nonstructural Bone Grafting for the Treatment of Unstable Scaphoid Waist Nonunion Without Avascular Necrosis: A Randomized Clinical Trial

PURPOSE

We evaluated the impact of structural versus nonstructural bone grafting on the time to union, scaphoid deformity correction, and clinical outcomes in adults with unstable scaphoid waist nonunion without avascular necrosis. We hypothesized that nonstructural grafting would provide earlier time to union, restoration of scaphoid anatomy, and equivalent clinical outcomes compared with structural grafting.

METHODS

We prospectively randomized 98 patients to undergo open reduction, iliac crest bone grafting with either corticocancellous (CC group) or cancellous bone only (C-only), and internal fixation using a Herbert screw. The lateral intrascaphoid angle (LISA) and scaphoid height length ratio (HLR) were measured on wrist computed tomography scans along the scaphoid longitudinal axis before surgery and an average of 84 weeks afterward. Pain, range of motion, grip strength, and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were measured before surgery and an average 84 weeks afterward.

RESULTS

The trajectory of scaphoid union showed a higher union rate of the C-only group at 12, 14, and 16 weeks after surgery. However, at 24 weeks after surgery, there was no difference between the groups, The union rate was 94% in patients treated with C-only and 90% with CC grafting. In patients with preoperative LISA less than 70° and/or HLR less than 0.80 (n = 53), there were no differences between the CC and C-only grafting techniques for radiographic and clinical outcomes, QuickDASH scores, and malunion rate. In patients who had preoperative LISA greater than 70° and/or HLR greater than 0.80 (n = 45), radiographic outcome measures, range of motion, and QuickDASH scores were significantly better in the CC than in the C-only group. Scaphoid malunion was observed in 9 of 22 of C-only patients (41%) and 4 of 23 of CC patients (18%).

CONCLUSIONS

The severity of the scaphoid deformity may be a factor in determining the best graft type, because this may affect the rate of successful deformity correction. Corticocancellous grafting in patients who had a high degree of scaphoid deformity provided consistent deformity correction and superior QuickDASH scores. Otherwise, C-only grafting provides earlier time to union and equivalent clinical and radiographic outcomes compared with CC grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures

Background  Scaphoid fracture accounts for approximately 15% of acute wrist fractures. Clinical examination and plain X-rays are commonly used to diagnose the fracture, but this approach may miss up to 16% of fractures in the absence of clear-cut lucent lines on plain radiographs. As such, additional imaging may be required. It is not clear which imaging modality is the best. The goal of this study is to summarize the current literature on scaphoid fractures to evaluate the sensitivity, specificity, and accuracy of four different imaging modalities. Case Description  A systematic-review and meta-analysis was performed. The search term "scaphoid fracture" was used and all prospective articles investigating magnetic resonance imaging (MRI), computed tomography (CT), bone scintigraphy, and ultrasound were included. In total, 2,808 abstracts were reviewed. Of these, 42 articles investigating 51 different diagnostic tools in 2,507 patients were included. Literature Review  The mean age was 34.1 ± 5.7 years, and the overall incidence of scaphoid fractures missed on X-ray and diagnosed on advanced imaging was 21.8%. MRI had the highest sensitivity and specificity for diagnosing scaphoid fractures, which were 94.2 and 97.7%, respectively, followed by CT scan with a sensitivity and specificity at 81.5 and 96.0%, respectively. The sensitivity and specificity of ultrasound were 81.5 and 77.4%, respectively. Significant differences between MRI, bone scintigraphy, CT, and ultrasound were identified. Clinical Relevance  MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound. Level of Evidence  This is a Level II systematic review.

Multiplanar reformation computed tomography for carpal malalignment

Correct interpretation of scaphoid axial length and carpal malalignment is difficult owing to the complex geometry of the scaphoid. Traditional measurements, such as the scapholunate angle and radiolunate angle, have shown limited reproducibility. To improve the assessment of these measurements, we used multiplanar reformation computed tomography with added average intensity projection. Four measurements for scaphoid morphology and carpal alignment were independently measured by four observers on computed tomography scans of 39 consecutive patients who were treated conservatively for scaphoid fracture. Fleiss's kappa for categorical results showed substantial agreement for the measurements of the scapholunate and radiolunate angles. Intraclass correlation coefficients were significant for measurements of the axial length, scapholunate angle and radiolunate angle. Our results suggest that multiplanar reformation computed tomography with added average intensity projection is a reliable technique for assessment of scaphoid morphology and carpal alignment. Level of evidence: II.

The Management of the Healed Scaphoid Malunion: What to Do?

Successful bone union is only a portion of scaphoid fracture management. Malunion is possible and can alter wrist kinematics, potentially causing wrist pain and accelerated degeneration. Evaluation of scaphoid malunion begins with adequate imaging and understanding of deformity. Treatment includes nonoperative management, reconstruction, or salvage options. Correction of malunion can be obtained with an osteotomy and the use of structural graft to recreate anatomy and restore normal carpal motion. Clinical improvement of symptomatic scaphoid malunion can be reliably obtained with reconstruction, although the natural history and role for intervention in asymptomatic malunions remains unclear.

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy

INTRODUCTION

Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT.

MATERIALS AND METHODS

The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm² within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist.

RESULTS

A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used.

CONCLUSIONS

Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Importance of Computed Tomography in Determining Displacement in Scaphoid Fractures

Background  Displaced scaphoid fractures have a relatively high rate of nonunion. Detection of displacement is vital in limiting the risk of nonunion when treating scaphoid fractures. Questions/Purpose  We evaluated the ability to diagnose displacement on radiographs and computed tomography (CT), hypothesizing that displacement is underestimated in assessing scaphoid fracture by radiograph compared with CT. Materials and Methods  Thirty-five preoperative radiographs and CT scans of acute scaphoid fractures were evaluated by two blinded observers. Displacement and angular deformity were measured, and the fracture was judged as displaced or nondisplaced. Scapholunate, radiolunate, and intrascaphoid angles were measured. Radiograph and CT measurements between nondisplaced and displaced fractures were compared. Intraobserver reliability was measured. Results   Reader 1 identified 12 fractures as nondisplaced on radiograph, but displaced on CT (34%). Reader 2 identified 9 fractures as nondisplaced on radiograph, but displaced on CT (26%). For displaced fractures, the mean intrascaphoid angle was over three times greater when measured on CT than on radiograph (56 vs. 16 degrees). Scapholunate angle >65 degrees and radiolunate angle >16 degrees were significantly associated with displacement on CT. Interobserver reliability for diagnosing displacement was perfect on CT but less reliable on radiograph. Conclusion  Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement. These results underscore the importance of CT scan in determining displacement and angular deformity when evaluating scaphoid fractures, as it may alter the decision on treatment and surgical approach to the fracture. We recommend considering CT scan to evaluate all scaphoid fractures. Level of Evidence  Level III.

Stabilization of scaphoid type B2 fractures with one or two headless compression screws

INTRODUCTION

Fractures of the scaphoid account for the most commonly injured carpal bone. Minimally displaced fractures of the waist will heal in 85-90% when using a below elbow cast. However, fractures with displacement have a higher risk for nonunion. Therefore, open reduction and fixation with headless compression screws (HCS) have become the preferred method of treatment. The aim of this study was to compare the radiological and clinical outcome of unstable scaphoid B2 type fractures, stabilized using one or two headless compression screws.

PATIENTS AND METHODS

A total of 47 unstable scaphoid B2 type fractures were included in this retrospective follow-up study. Twelve patients were not accessable and three refused to attend follow-up checks. Therefore, a total of 32 patients were included in this study with a mean follow-up interval of 43 (12-81) months. Twenty-two patients were treated using one HCS and ten with two HCS. Clinical assessment included range of motion (ROM), pain according to the visual analogue scale (VAS), grip strength, Disability of the Arm, Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien Wrist Score. The follow-up study on each patient included a CT-Scan of the wrist which was analyzed for union, osteoarthritis, dorsiflexed intercalated segment instability and humpback deformity.

RESULTS

Radiologically, 29/32 (91%) of the scaphoid B2 type fractures showed union, 10/10 (100%) in the two HCS group and 19/22 (86%) in the one HCS group (p < 0.05). No significant differences could be found in respect to ROM, grip strength, VAS and scores between the groups. Screw removal was necessary in two patients in the two HCS group and one in the one HCS group.

CONCLUSION

The unstable B2 type fractures of the scaphoid, when using two HCS without bone grafting is a safe method, shows a significantly higher union rate and equal clinical outcome compared to stabilization using only one HCS.

Is there a trend in CT scanning scaphoid nonunions for deformity assessment?-A systematic review

PURPOSE

The effect of scaphoid nonunion deformity on wrist function is uncertain due to the lack of reliable imaging tools. Advanced three-dimensional (3-D) computed tomography (CT)-based imaging techniques may improve deformity assessment by using a mirrored image of the contralateral intact wrist as anatomic reference. The implementation of such techniques depends on the extent to which conventional CT is currently used in standard practice. The purpose of this systematic review of medical literature was to analyze the trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally.

MATERIALS AND METHODS

Using Medline and Embase databases, two independent reviewers searched for original full-length clinical articles describing series with at least five patients focusing on reconstructive surgery of scaphoid nonunions with bone grafting and/or fixation, from the years 2000-2015. We excluded reports focusing on only nonunions suspected for avascular necrosis and/or treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging. For data analysis, we evaluated the use of CT scans and distinguished between uni- and bilateral, and pre- and postoperative scans.

RESULTS

Seventy-seven articles were included of which 16 were published between 2000 and 2005, 19 between 2006 and 2010, and 42 between 2011 and 2015. For these consecutive intervals, the rates of articles describing the use of pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively. Hereof, only two (3%) articles described the use of bilateral CT scans.

CONCLUSION

There is an evident trend in performing unilateral CT scans before and after reconstructive surgery of a scaphoid nonunion. To improve assessment of scaphoid nonunion deformity using 3-D CT-based imaging techniques, we recommend scanning the contralateral wrist as well.

Dorsal intercalated segmental instability associated with malunion of a reconstructed scaphoid

We analysed scaphoid deformity as a result of surgical treatment of scaphoid fracture nonunion and assessed the deformity associated with a dorsal intercalated segmental instability pattern of carpal malalignment. A total of 45 patients who were treated for scaphoid fracture nonunion were included in the study. The height-to-length ratio of the scaphoid was measured on computed tomographic images and used to assess scaphoid deformity. Carpal malalignment was quantified based on the radio-lunate angle. A correlation analysis between the height-to-length ratio and the radio-lunate angle was performed. Dorsal intercalated segmental instability was defined as a radio-lunate angle >15°, and a receiver operating curve analysis was used to calculate the cutoff height-to-length ratio that can be accompanied with dorsal intercalated segmental instability. Extension of the lunate increases in proportion to the flexion deformity of the scaphoid; dorsal intercalated segmental instability can occur if the height-to-length ratio of the scaphoid is >0.73.

LEVEL OF EVIDENCE

IV.

Rotational stability in screw-fixed scaphoid fractures compared to plate-fixed scaphoid fractures

BACKGROUND

The literature describes the treatment of scaphoid fractures comparing the volar and dorsal approaches, the advantages and disadvantages of percutaneous screw fixation, as well as the treatment of scaphoid nonunions using different types of cancellous or corticocancellous bone grafts. Yet, to date no studies are available comparing the outcome of rotational stability in screw-fixed scaphoid fractures to angular stable systems. The purpose of this study is to provide reliable data about rotational stability in stabilised scaphoid fractures and to gain information about the rigidity and the stability of the different types of fixation.

METHODS

Three groups of different stabilisation methods on standardised scaphoid B2 fractures were tested for rotational stability. Stabilisation was achieved using one or two cannulated compression screws (CCS) or angular stable plating. We performed ten repetitive cycles up to 10°, 20° and 30° rotation, measuring the maximum torque and the average dissipated work at angle level.

RESULTS

Our study showed that rotational stability using a two CCS fixation is significantly (p < 0.05) higher than single CCS fixation. Using the angular stable plate system was also superior to the single CCS (p < 0.05). There was, however, no significant difference between two CCS fixation and angular stable plate fixation.

CONCLUSION

Even though indications of using screws or plate systems might be different and plate osteosynthesis may be preferable in treatment of dislocated or comminuted fractures as well as for nonunions, our study showed a better rotational stability by choosing more than just one screw for osteosynthesis. Angular stable plating of scaphoid fractures also provides more rotational stability than single CCS fixation. The authors therefore hypothesise higher union rates in scaphoid fractures using more stable fixation systems.

Hybrid Russe Procedure for Scaphoid Waist Fracture Nonunion With Deformity

PURPOSE

To assess the results of a hybrid Russe procedure using a corticocancellous strut, cancellous autologous nonvascularized bone graft, and cannulated headless compression screw to reduce the deformity reliably from a collapsed scaphoid nonunion, provide osteoinductive stimulus, and stabilize the fracture for predictable union.

METHODS

A hybrid Russe procedure was performed for scaphoid waist fracture nonunions with humpback deformity and no evidence of avascular necrosis. A volar distal radius autologous bone graft was harvested and a strut of cortical bone was fashioned and placed into the nonunion site to restore length and alignment. We packed cancellous bone graft in the remainder of the nonunion site and fixed the scaphoid was with a headless compression screw. Union was determined by radiographs or computed tomography, and intrascaphoid, scapholunate, and radiolunate angles were calculated on final radiographs. We recorded wrist range of motion, grip strength, pinch strength, pain, and complications.

RESULTS

Fourteen male and 3 female patients (average age, 32 years; range, 16-78 years), with a mean follow-up of 32 months, were examined clinically and radiographically. All 17 scaphoids united with a mean time for union of 3.6 months. The mean postoperative intrascaphoid angle was significantly reduced from 65° preoperatively to 35° postoperatively. The mean radiolunate angle was significantly improved from 20° from neutral (lunate tilted dorsally) preoperatively to 0° postoperatively. The scapholunate angle also demonstrated significant improvement from 70° preoperatively to 56° postoperatively. Grip strength improved from 70% of the contralateral hand to 89% after the procedure. All patients were satisfied with the functional outcome and no donor site morbidity or hardware issues were identified.

CONCLUSIONS

This straightforward hybrid Russe technique predictably restored radiolunate, scapholunate, and intrascaphoid angles with a 100% union incidence. The technique provides excellent functional results in patients with a challenging clinical problem, and we recommend it for scaphoid fracture waist nonunions with dorsal intercalated segment instability deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Determining scaphoid waist fracture union by conventional radiographic examination: an analysis of reliability and validity

INTRODUCTION

Conventional radiographic imaging is the first imaging tool of choice in scaphoid fractures. The majority of undisplaced scaphoid waist fractures unite after 6 weeks of cast immobilization. We hypothesized that conventional radiographic imaging at 6 weeks after injury can both accurately and reliably predict union in undisplaced scaphoid waist fractures.

MATERIALS AND METHODS

Fleiss' kappa statistics were used concerning the opinions of four observers reviewing 47 sets of good-quality scaphoid radiographs of undisplaced scaphoid waist fractures. As reference standard for union, radiographs were taken at a minimum of 6 months after injury to determine validity.

RESULTS

Overall agreement was defined as moderate. (κ = 0.583) "No consolidation" (κ = 0.816), "full consolidation" (κ = 0.517) and "partial consolidation" (κ = 0.390) were defined as good, moderate and fair agreement, respectively. The average sensitivity and specificity of diagnosing scaphoid waist fracture union on standard scaphoid radiographs were 0.65 and 0.67, respectively. The positive predictive value for diagnosing union was 0.93 and the negative predictive value was 0.22.

CONCLUSIONS

Conventional radiographic imaging is accurate and moderately reliable in diagnosing union, and reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6 weeks follow-up.