The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures

Surgical Treatment of Scaphoid Fractures: Recommendations for Management

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

Arthroscopic surgery for scaphoid nonunion: a 10-year systematic literature review

The purpose of the study was to investigate whether arthroscopic treatment of carpal scaphoid nonunions by osteosynthesis with bone grafting represents a successful surgical technique. This systematic literature review, conducted following the PRISMA guidelines, explores the past 10 years of clinical studies concerning the arthroscopic treatment of scaphoid nonunions. The most relevant keywords were used to search the databases, and the Downs and Black 27-item checklist has been used as quality assessment tool. Twelve papers that meet the premised eligibility criteria have been identified. These studies demonstrate the efficacy of this surgical solution, achieving a postoperative union rate of 96% in the average time of 13.5 weeks. Regardless of the method of synthesis and the origin of the graft used, excellent results were obtained. Patients who underwent this procedure reported a pain reduction of almost 80% compared to the preoperative level, improvement in grip strength close to 40%, and recovery in wrist function during daily activities. Arthroscopy has numerous advantages compared to the open approach. These are technically recognized by the surgeon and by the patient. Some disadvantages include a longer intraoperative time and considerable significant technical difficulty. Arthroscopic treatment of scaphoid nonunion by osteosynthesis with bone graft achieves a 96% union rate of the treated scaphoid with satisfying clinical results.

Comparison of Two Different Percutaneous Screw Fixations for Treating Herbert B2-Type Acute Scaphoid Fractures

OBJECTIVE

Scaphoid fracture was the most common carpal fracture and the most challenging. The purpose of this study was to investigate and compare the clinical effects of closed reduction and percutaneous cannulated screw internal fixation under fluoroscopy and arthroscopy-assisted percutaneous cannulated screw internal fixation in the treatment of Herbert B2-type of acute scaphoid fractures.

METHODS

A retrospective controlled study was conducted on 29 patients with Herbert B2-type acute scaphoid fracture with a displacement of >1 mm admitted to our hospital from January 2017 to June 2021. Patients were divided into two groups, 11 patients were treated with closed reduction percutaneous cannulated screw internal fixation under fluoroscopy and 18 patients were treated with percutaneous cannulated screw internal fixation assisted by arthroscopy. The operative time, intraoperative fluoroscopy times, fracture healing time, complications, and postoperative wrist function score of the two groups were compared.

RESULTS

All patients were followed up for 6-18 months (mean follow-up duration: 10.38 ± 2.69 months). The respective operation times in the arthroscopy group and fluoroscopy group was 51.50 ± 6.69 min and 56.73 ± 11.48 min, respectively (p > 0.05). The number of fluoroscopies performed in the arthroscopy group was (6.83 ± 1.30), which was less than that in the fluoroscopy group (10.91 ± 2.62) (p < 0.05). All fractures in the arthroscopy group healed after the operation, and the fracture healing time was 11.44 ± 1.25W. Ten patients in the fluoroscopy group healed. The fracture healing time was 13.60 ± 2.32 W. The fracture healing time in arthroscopy group was less than that in the fluoroscopy group (p < 0.05). One patient in the fluoroscopy group had nonunion and healed after bone grafting and internal fixation. At the postoperative 6-month follow-up, the modified Mayo wrist function score was used to evaluate the clinical results. The wrist function score of patients in the arthroscopy group was 90 (85, 95), which was >80 (80, 90) in the fluoroscopy group (z = 2.74, p < 0.05).

CONCLUSION

For Herbert B2-type acute scaphoid fracture with fracture displacement > 1 mm, the arthroscopy-assisted percutaneous cannulated screw internal fixation has less fluoroscopy times, short fracture healing time, and good recovery effect of wrist function compared to the fluoroscopy.

Traumatic Nondissociative Carpal Instability: A Case Series

PURPOSE

We report 8 cases of acute or subacute unilateral nondissociative carpal instability (CIND) in the context of nondisplaced scaphoid fractures.

METHODS

Eight patients from 3 centers developed abnormal volar intercalated segment instability (VISI) or dorsal intercalated segment instability (DISI) following the diagnosis of a nondisplaced scaphoid fracture. An operative inspection in each patient confirmed intact scapholunate and lunotriquetral interosseous ligaments. We outline the demographic characteristics of our patient cohort, radiologic and operative findings of CIND-DISI and CIND-VISI, and the outcomes of acute and delayed treatment.

RESULTS

Two patients were diagnosed with CIND-DISI and 6 with CIND-VISI associated with ipsilateral nondisplaced scaphoid fractures. The average time from injury to diagnosis of CIND was 11 weeks, and the mean clinical and radiographic follow-up was 18 months. Rapid healing of the scaphoid fractures was achieved in all patients (4 open reduction internal fixation, 4 cast). All patients underwent surgery to improve proximal carpal row alignment: in 3 of the 4 patients who were diagnosed and treated surgically within 12 weeks of injury, the radiolunate angle (RLA) was successfully restored. A contracture release and ligament repair or reconstruction with tendon graft 12 or more weeks following injury was unsuccessful in restoring proximal row alignment in all 4 patients. Two patients in the delayed treatment group required secondary surgery for partial fusion.

CONCLUSIONS

Based on the arthroscopic, imaging, and operative findings, we propose that the ligamentous restraints to CIND-VISI are dorsal at the radiocarpal joint and volar at the midcarpal joint. Conversely, the ligamentous restraints to CIND-DISI are dorsal at the midcarpal joint and volar at both the radiocarpal and midcarpal joints. In our series, a delayed diagnosis and late reconstructive surgery were associated with no improvement in RLA. We recommend early recognition of traumatic CIND and prompt treatment of injured ligaments prior to the development of a fixed deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Ligamentization and Remnant Integration: Review and Analysis of Current Evidence and Implications for Scapholunate Reconstruction

Background  Scapholunate interosseous ligament injuries are common but remain a therapeutic challenge. Current treatment modalities prioritize restoration of normal anatomy with reconstruction where appropriate. To date no reconstructive technique has been described that discusses the potential benefit of preservation of the scapholunate ligament remnant. Little is known about the "ligamentization" of grafts within the wrist. However, a growing body of knee literature suggests that remnant sparing may confer some benefit. In the absence of wrist specific studies, this literature must guide areas for potential augmentation of current surgical practices. Objective  The purpose of this study was to perform a review of the process of ligamentization and a systematic review of the current literature on the possible role of ligament sparring and its effect on ligamentization. Methods  A systematic search of the literature was performed to identify all the studies related to remnant sparing and the ligamentization of reconstructed tendons, regardless of graft type or joint involved from MEDLINE, EMBASE, and PubMed until February 1, 2016 using the following keywords: ligamentization, graft, remodelling, reconstruction, biomechan*, histolo∗, scapholunate ligament. Each selected study was evaluated for methodological quality and risk of bias according to a modified Systematic Review Center for Laboratory Animal Experimentation criteria. Conclusions  The available literature suggests that ligament sparring demonstrated a trend toward improvements in vascularity, mechanoreceptors, and biomechanics that lessens in significance over time. Clinical Relevance  This review suggests that remnant sparing may be one way to improve outcomes of scapholunate ligament reconstructive surgery. Level of Evidence  This is a level I/II, review study.

The role of arthroscopy in the diagnosis of concomitant soft tissue injuries in scaphoid fractures and the effect of concomitant soft tissue injuries and fracture comminution on outcomes: A case-control study

Objectives

This study aims to evaluate the role of arthroscopy in the diagnosis of concomitant injuries, to investigate the relationship between comminution and concomitant injuries, and to analyze the effect of concomitant injuries on functional outcomes in acute and subacute scaphoid fracture.

Patients and methods

Between January 2011 and September 2018. A total of 32 acute scaphoid fracture patients (29 males, 3 females; mean age: 30±12 years; range, 18 to 65 years) were retrospectively analyzed. None of them had an obvious ligament injury in the radiological assessment. Functional outcomes were compared between concomitant and non-concomitant injuries and between comminuted and non-comminuted injuries. The percentage of range of motion (ROM), grip, and pinch strength were recorded according to the contralateral extremity to detect the restriction rate. The Mayo Wrist Score (MWS), the Turkish version of the Quick Disability of the Arm, Shoulder, and Hand (Q-DASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to evaluate the functional results. Subjective pain was assessed using the Visual Analog Scale (VAS). The relationship between concomitant injuries and comminution was investigated.

Results

There were 13 patients with comminuted fractures. Concomitant injuries were diagnosed in 17 patients. The presence of concomitant injuries was higher in comminuted fractures than in non-comminuted fractures. There was no significant difference between the groups in ROMs. The final follow-up Q-DASH, PRWE, MWS, and VAS scores and the pinch strength of non-comminuted fractures were found to be statistically better than those of comminuted fractures. There were statistically worse Q-DASH, PRWE, MWS, and VAS scores in patients with concomitant injuries.

Conclusion

Arthroscopic scaphoid fracture surgery allows the diagnosis and treatment of concomitant lesions. The functional outcomes of concomitant lesions and comminuted fractures seem to be worse than those of others, while the ROM is comparable.

Incidence of Scaphoid Fractures and Associated Injuries at US Trauma Centers

Backgound  The scaphoid is the most commonly fractured carpal bone and often presents as a diagnostic challenge. Fractures can often go unnoticed on initial radiographic evaluation and clinical presentation can vary significantly among patients. Awareness of high-risk cohorts assists practitioners in making the appropriate clinical diagnosis of acute scaphoid fracture. Materials and Methods  The National Trauma Data Bank is the world's largest trauma data repository. Utilizing the 2016 public use file, we isolated scaphoid fractures by anatomic fracture location by utilizing International Classification of Diseases, 10th revision coding. Reported cases of distal pole (S62.01), waist (S62.02), and proximal pole (S62.03) were included. This data was then queried to determine trends in mechanism of injury, demographic information, and associated injuries. Results  There were a total of 968,665 patients with 2,769 cases of reported scaphoid fractures resulting in 286 scaphoid fractures per 100,000 person-years. Males were more likely to sustain a scaphoid fracture than females. The most commonly encountered associated injuries were distal radius fractures, distal ulnar fractures, and nonscaphoid carpal bone fractures, respectively. Conclusions  Scaphoid fractures presenting to trauma centers are more commonly reported among males and those involved in motor vehicle accidents or falls. Appropriate scaphoid-specific radiographic imaging should be obtained as well as wrist and elbow images to evaluate for concomitant injuries, especially distal radius fractures.

Hand, Wrist, and Forearm Injuries in Male Professional Soccer Players: A Prospective Cohort Study of 558 Team-Seasons From 2001-2002 to 2018-2019

Background

The literature on upper extremity injuries in professional soccer players is scarce, and further insight into the onset and cause of these injuries as well as potential differences between goalkeepers and outfield players is important.

Purpose

To investigate the epidemiology of hand, wrist, and forearm injuries in male professional soccer players between 2001 and 2019.

Study Design

Descriptive epidemiology study.

Methods

Between the 2001-2002 and 2018-2019 seasons, 120 European male soccer teams were followed prospectively for a varying number of seasons (558 team-seasons in total). Time-loss injuries and player-exposures to training sessions and matches were recorded on an individual basis in 6754 unique players. Injury incidence was reported as the number of injuries per 1000 player-hours, and between-group differences were analyzed using Z statistics and rate ratios (RRs) with 95% CIs. Between-group differences in layoff time were analyzed.

Results

In total, 25,462 injuries were recorded, with 238 (0.9%) of these affecting the hand (71.4%; n = 170), wrist (16.8%; n = 40), and forearm (11.8%; n = 28), producing an incidence of 0.065 injuries per 1000 hours. A majority of the injuries were traumatic with an acute onset (98.7%; n = 235). Fractures were the most common injuries recorded (58.8%; n = 140), often involving the metacarpal bones (25.2%; n = 60) and phalanges (10.1%; n = 24). The injury incidence was significantly higher for goalkeepers (115 injuries; 0.265 per 1000 hours) compared with outfield players (123 injuries; 0.038 per 1000 hours) (RR, 7.0 [95% CI, 5.4-9.0]). Goalkeepers also had a significantly longer mean layoff time than outfield players (23 ± 27 vs 15 ± 27 days; P = .016).

Conclusion

Injuries to the hand, wrist, and forearm constituted less than 1% of all time-loss injuries in male professional soccer players. Fractures were most common and constituted more than half of all injuries. Goalkeepers had a 7-fold higher incidence and an over 1-week longer mean layoff time compared with outfield players.

Evaluating Accuracy of Plain Magnetic Resonance Imaging or Arthrogram versus Wrist Arthroscopy in the Diagnosis of Scapholunate Interosseous Ligament Injury

Introduction Scapholunate interosseous ligament injury (SLIL) is the most common cause of wrist instability and a cause of morbidity in a proportion of patients with wrist injuries.

Aim To evaluate the accuracy of plain magnetic resonance imaging (MRI) and MR arthrogram (MRA) in the diagnosis of SLIL injury against the existing gold standard-wrist arthroscopy.

Materials and Methods We retrospectively reviewed 108 cases by comparing MRI/MRA reports and their wrist arthroscopy operation notes.

Results Overall MRI sensitivity to SLIL injuries was 38.5% (91.0% specificity). When broken down into plain MRI and MRA the results were: plain MRI sensitivity = 19.2% (91.4% specificity) and MRA sensitivity = 57.7% (90.5% specificity).

Conclusion Neither MRI nor MRA scanning is sensitive enough compared with the gold standard. Positive predictive value remains too low (62.5 and 88.2%, respectively) to consider bypassing diagnostic arthroscopy and treating surgically. The negative predictive value (60.4 and 63.6%, respectively) is inadequate to confirm exclusion of injury from MRI results alone.

Epidemiology of scaphoid fractures and non-unions: A systematic review

BACKGROUND

The scaphoid is the most commonly fractured carpal bone in adults as well as in children. Previous studies have reported a wide range of fracture incidences. Scaphoid fractures and non-unions in children have been sparsely investigated.

AIM

To perform a systematic review of the current literature on epidemiology of scaphoid fractures and non-unions in adults and children.

METHODS

An electronic literature search was conducted investigating all studies in the literature published between January 1989 and June 23 2020. The systematic review following the PRISMA guidelines and searching in PubMed, Embase, Web of Science and Cochrane library databases was done in June 2020.

RESULTS

42 studies met our inclusion criteria, 6 studies were prospective, 32 were retrospective and 4 were register studies. The majority of studies relied on conventional radiographs for diagnosis. Scaphoid fractures in adults are predominately found in males with a peak incidence in the age group from 20 to 29 years. Incidence rates in males are reported from 107 to 151/100 000. Females have an earlier peak, in the age group 10 to 19 years, with an incidence from 14 to 46/100 000. Most fractures occur in the middle third of the scaphoid representing 60-69 % of cases. Scaphoid fractures in children are predominately found in boys age 12 and above, while it seldomly occur for children younger than 9 years. In adults the risk for developing a scaphoid non-union is between 2 % and 5 %, the majority affecting males and predominately located at the middle third of the scaphoid. Non-unions among children are rare and mainly due to missed or delayed diagnosis of a fracture in the middle third of the scaphoid.

CONCLUSION

This review revealed a substantial heterogeneity among studies concerning study population, diagnosis criterial and outcome measures. Currently, evidence on epidemiology for scaphoid fractures and non-unions are low.

Arthroscopic treatment for nonunion of the scaphoid

Scaphoid nonunion has traditionally been treated by open surgery where the pseudarthrosis has been cleaned while either a structural wedged bone graft, or chips of cancellous bone has been used to fill the defect. K-wires or a screw has been used to stabilize the bone. Using the arthroscopic technique for treatment of nonunion of the scaphoid gives us small exposure to the joint, however with an excellent view of the bones, the articular surfaces and the intraarticular ligaments. The results from arthroscopic treatment for scaphoid nonunion with bone grafting using chips of cancellous bone are as good as from the open technique. The arthroscopic treatment, though, helps us to diagnose and treat concomitant lesions. There is less damage of blood supply, nerves and capsule, which might lead to a faster recovery and rehabilitation. The technique will be described and discussed.

Imaging evaluation of traumatic carpal instability

PURPOSE

To review the epidemiology, pertinent wrist anatomy, classification system, and emergent imaging evaluation of carpal instability with a focus on radiographic assessment of instability.

METHODS

A review of current literature on carpal instability was performed with summary presentation of carpal instability epidemiology, carpal anatomy, imaging evaluation, and classification with imaging evaluation focused on diagnosis in the emergency setting.

RESULTS

Carpal instability is a common pathology in falls on outstretched hand and is likely underdiagnosed due to instability being occult or demonstrating subtle malalignment on static imaging of the wrist. While there is a complex network of intrinsic and extrinsic ligaments contributing to carpal instability, a detailed knowledge of these ligaments is not necessary for radiologists to make an accurate diagnosis in the emergency setting, as identification and classification of carpal instability is based on identification of carpal malalignment patterns on radiography as opposed to identification of specific ligament injuries on advanced imaging. The Mayo classification is the most widely used classification system, which divides carpal instability into four categories: dissociative, non-dissociative, complex, and adaptive. Understanding this classification system allows radiologists to successfully classify almost all carpal instability injuries they will encounter, even in the setting of unusual or rare instability patterns.

CONCLUSION

In working with the treating clinician, it is essential that the emergency radiologist is comfortable with identifying and classifying carpal instability. This will ensure prompt treatment of seemingly benign injuries and those that require intervention, surgical or otherwise, improving the likelihood of a good outcome.

Acute scaphoid fractures: guidelines for diagnosis and treatment

In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days.

Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT with reconstructions in the coronal and sagittal planes, following the longitudinal axis of the scaphoid.

After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures.

Scaphoid waist fractures with moderate displacement (0.5–1.5 mm) can be treated conservatively, but require prolonged cast immobilization for approximately eight to ten weeks.

Internal fixation is recommended for all scaphoid waist fractures with dislocation ≥ 1.5 mm.

Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after four to six weeks of immobilization, depending on fracture type.

In general, proximal scaphoid fractures should be treated with internal fixation.

Cite this article: EFORT Open Rev 2020;5:96-103. DOI: 10.1302/2058-5241.5.190025

Scaphoid fractures with scapholunate ligament involvement: Instability or ligamentous laxity? Role of arthroscopy and pinning

PURPOSE

Percutaneous fixation of scaphoid fractures often does not allow the evaluation of potential ligamentous lesions. Arthroscopy is an useful tool in the management of scaphoid fractures to visualize potentially associated lesions. With arthroscopic assistance, we often found scapholunate ligament lesions. Our study's aim was to evaluate the role of arthroscopy in the treatment of scaphoid fracture and in particular if the alteration found was a real lesion causing instability or just a paraphysiologic laxity. Furthermore, we evaluated whether the scapholunate joint pinning alters the outcome.

METHODS

We performed a retrospective study on 39 patients (33 males and 6 females), with an average age at trauma of 31.2 years (range 15-67), who underwent surgery for scaphoid fractures between 2010 and 2016 in our Center of Hand Surgery. Patients were divided into four groups based on surgical technique and finding of scapholunate lesions.

RESULTS

Differences between the four groups analyzed, both in terms of clinical scores and ROM, were not statistically significant. This corroborates the hypothesis that all four treatments are equivalent.

CONCLUSIONS

Based on our experience and the literature available, we believe the systematic use of arthroscopy to be useful in patients needing surgical treatment for scaphoid fractures. This is because arthroscopy allows the control of the fracture reduction, screw protrusion evaluation and ligamentous lesions assessment. In cases of partial scapholunate ligament alteration in which no sign of acute lesion is present (hemorrhage and clear rupture), pinning is not necessary since it might just be a paraphysiologic laxity.

LEVEL OF EVIDENCE

IV.

APSI scaphoid hemiarthroplasty – long-term results

Objective

This study is aimed at evaluating the long-term results of proximal scaphoid hemiarthroplasty for post-traumatic avascular necrosis at this institution.

Methods

Twelve patients who underwent this procedure were identified, and the mean follow-up time was 6.5 years (range: 5–8 years). All patients were male, with a mean age of 39 years (range: 28–55 years). In eight patients, the non-dominant limb was affected. The procedure was carried out through a dorsal approach and all patients underwent the same rehabilitation protocol. Cases were evaluated regarding complications, pain, range of motion, functional status (Mayo Wrist Score), and disability (QuickDASH Score).

Results

No immediate post-operative complications, such as infection or dislocation of the implant, were observed. All patients presented with peri-implant osteolysis at follow-up, on a radiograph study. None of the patients was forced to abandon their previous professional activity, although about 50% required some type of adaptation at their workplace. The mean functional capacity was, according to the Mayo Wrist Score, of 67.5 points (range: 50–80), corresponding to a satisfactory degree of function. The QuickDASH disability score presented a mean of 25 (range: 3–47.7).

Conclusion

The results of this series are in line with previously published studies about this technique. Hemiarthroplasty with a pyrocarbon implant is a safe technique for the treatment of post-fracture avascular necrosis of the scaphoid proximal pole. This technique allowed for satisfactory functional results at a mean follow-up of 6.5 years.

Análisis artroscópico de las lesiones asociadas a las fracturas de escafoides carpiano

Objetivo: La artroscopia de muñeca ha permitido el diagnóstico y el tratamiento de las fracturas a nivel de la muñeca, así como de las lesiones asociadas a estas.

Existen lesiones asociadas a las fracturas de escafoides que pueden condicionar el éxito del tratamiento y llevarnos a resultados poco satisfactorios y a un retraso en la recuperación funcional.

Material y método: Se estudiaron y cuantificaron las lesiones asociadas encontradas en 17 casos con fractura aguda de cintura de escafoides que fueron tratadas mediante reducción y colocación artroscópica de un tornillo canulado de escafoides. Se analizaron los resultados del tratamiento con la escala de muñeca de la Clínica Mayo (Mayo Wrist Score) y la consolidación con radiografías simples.

Resultados: Se diagnosticaron lesiones asociadas de tejidos blandos y/o condrales/osteocondrales en 14 casos, lo que supone un 82% de los casos. Las lesiones más frecuentemente encontradas fueron las lesiones del ligamento escafolunar (53%) en diferentes grados, las lesiones del fibrocartílago triangular (35,3%) y las lesiones osteocondrales (35,3%). Los resultados funcionales (Mayo Wrist Score) fueron excelentes o buenos en 13 de los pacientes (76,5%), en 3 casos (17,5%) los resultados fueron regulares y solo un caso (5,9%) tuvo un pobre resultado.

Conclusiones: La artroscopia ofrece una valoración completa de la muñneca y consigue diagnosticar lesiones asociadas a las fracturas de cuello de escafoides que pueden condicionar el resultado final del tratamiento.

The Role of Dynamic (4D) CT in the Detection of Scapholunate Ligament Injury

Background Scapholunate (SL) interosseus ligament injuries detected at an early stage could allow the surgeon to prevent progression through the spectrum of injury that leads to instability, and eventually osteoarthritis. We contend that early instability following injury can be detected by visualizing the relative motions and distances between the involved carpal bones (scaphoid and lunate) during wrist movement in vivo. The purpose of this study is to demonstrate the utility of dynamic CT (i.e., 4DCT) in diagnosing SL interosseus ligament injuries in two patients with clinical suspicion of SL interosseus ligament injury during flexion-extension (FE), radial-ulnar (RU) deviation, and dart thrower's (DT) motions. Case Description 4DCT images obtained from two individual cases were analyzed to assess the proximity between the scaphoid and lunate during wrist motion using standard image processing techniques. Proximity maps representing the distances between the scaphoid and lunate bones during each phase of wrist motion were determined. These maps provide insight into the severity of diastasis (large separation) and location of diastasis at the SL joint. The patients' proximity maps indicated dorsal diastasis and subtle uniform diastasis. Literature Review Complex musculoskeletal abnormalities, such as wrist joint instabilities, elude diagnosis during 2D fluoroscopy due to the 3D geometry of the anatomy and the inherent 3D nature of the bony kinematics. Even the most recent advances with MR arthrography lack good correlation with wrist arthroscopy. Wrist arthroscopy remains the gold standard for diagnosis to assess for intercarpal laxity. However, arthroscopy is an invasive procedure subjecting patients to the risk of infection, nerve injury, pain, and stiffness. Clinical Relevance 4DCT allows noninvasive characterization of where ligament injuries likely occur; this may allow for a more selective surgical treatment directed at the specific location of the tear.

The Effect of Debridement of Coexisting Partial Ligament Injuries on Outcomes Following Arthroscopic Osteosynthesis for Minimally Displaced Scaphoid Nonunions

PURPOSE

Partial intercarpal ligament injuries can coexist with scaphoid nonunions. However, whether these injuries should be debrided simultaneously when scaphoid nonunions are treated is unclear. The purpose of this study was to compare union rates and clinical outcomes after arthroscopic management of scaphoid nonunions, in which coexisting partial ligament injuries were, or were not, simultaneously debrided.

METHODS

This retrospective study included 46 patients with scaphoid nonunions and coexisting partial intercarpal ligament injuries who underwent arthroscopy-guided bone grafting and fixation (K-wires or headless screws) between March 2008 and May 2014 with a minimum follow-up of 1 year. None of the cases had necrosis of the proximal fragment (determined by contrast-enhanced magnetic resonance imaging), severe deformities, or advanced arthritis. The partial intercarpal ligament injuries were either simultaneously debrided (25 patients; group D) or not debrided (21 patients; group ND). Visual analog scale pain scores, grip strength, flexion-extension arc of the wrist, Mayo Wrist Scores, and Disabilities of Arm, Shoulder, and Hand scores were used to compare clinical outcomes between the 2 groups.

RESULTS

The nonunions united in 93% (43 of 46) of the patients. There were no differences between the 2 groups with regard to patient demographics, preoperative outcome measures, location of scaphoid nonunion, and degree of ligament injury. The overall union rate was similar between group D (92%; 23 of 25) and group ND (95%; 20 of 21). At a median follow-up of 24 months for group D and group ND, the visual analog scale pain score, grip strength, Mayo Wrist Scores, and Disabilities of the Arm, Shoulder, and Hand scores were significantly improved in both groups, compared with preoperative scores. Flexion-extension arc showed no change in both groups compared with preoperative angles. All of the follow-up measurements were similar in the 2 groups.

CONCLUSIONS

In patients who underwent arthroscopic bone grafting and fixation of scaphoid nonunions, simultaneous debridement of incidentally found partial intercarpal ligament injuries did not result in a better union rate or clinical outcomes than not debriding the partial ligament injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Is Arthroscopic Bone Graft and Fixation for Scaphoid Nonunions Effective?

BACKGROUND

Arthroscopic management of scaphoid nonunions has been advanced as a less invasive technique that allows evaluation of associated intrinsic and extrinsic ligamentous injuries; however, few studies have documented the effectiveness of arthroscopic treatment of scaphoid nonunions and which intraarticular pathologies coexist with scaphoid nonunions.

QUESTIONS/PURPOSES

(1) What are the outcomes of arthroscopic management of scaphoid nonunions as assessed by the proportion of patients achieving osseous union, visual analog scale (VAS) pain score, grip strength, range of motion, Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder and Hand (DASH) score? (2) What complications are associated with arthroscopic scaphoid nonunion management? (3) What forms of intraarticular pathology are associated with scaphoid nonunions?

METHODS

Between 2008 and 2012, we treated 80 patients surgically for scaphoid nonunions. Of those, 45 (56%) had arthroscopic management. During that time, our general indications for using an arthroscopic approach over an open approach were symptomatic scaphoid nonunions without necrosis of the proximal fragment, severe deformities, or arthritis. Of the patients treated arthroscopically, 33 (73%) were available for followup at least 2 years later. There were five distal third, 19 middle third, and nine proximal third fractures. The mean followup was 33 months (range, 24-60 months). Union was determined by CT taken at 8 to 10 weeks after operation with bridging trabecula at nonunion site. VAS pain scores, grip strength, active flexion-extension angle, MWS, and DASH scores were obtained preoperatively and at each followup visit. The coexisting intraarticular pathologies and complications were also recorded.

RESULTS

Thirty-two (97%) scaphoid nonunions healed successfully. At the last followup, the mean VAS pain score decreased (preoperative: mean 4.5 [SD 1.8], postoperative: mean 0.6 [SD 0.8], mean difference: 3.9 [95% confidence interval {CI}, 3.2-4.6], p < 0.001) and the mean active flexion-extension angle increased (preoperative: mean 100° [SD 26], postoperative: mean 109° [SD 16], mean difference: 9° [95% CI, 2-16], p = 0.017). The mean grip strength increased (preoperative: mean 35 kg of force [SD 8], postoperative: mean 50 kg of force [SD 10], mean difference: 15 kg of force [95% CI, 11-19], p < 0.001). The mean MWS increased (preoperative: mean 56 [SD 23], postoperative: mean 89 [SD 8], mean difference: 33 [95% CI, 26-41], p < 0.001) and the mean DASH score decreased (preoperative: mean 25 [SD 18], postoperative: mean 4 [SD 3], mean difference: 21 [95% CI, 15-28], p < 0.001). There were no operation-related complications and no progression of arthritis at the last followup. Seventeen patients had coexisting intraarticular pathology, including nine triangular fibrocartilage complex tears (seven traumatic and two degenerative), 17 intrinsic ligament tears (nine scapholunate interosseous ligament tears and eight lunotriquetral interosseous ligament tears), and five mild radioscaphoid degenerative changes.

CONCLUSIONS

Arthroscopic management of scaphoid nonunions without severe deformities or arthritis was effective in this small series. Although intraarticular pathologies such as triangular fibrocartilage complex tears and intrinsic ligament injuries commonly coexisted with scaphoid nonunions, patients generally achieved good results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

[Scapholunate lesions]

Injuries to the scapholunate ligament are the most frequent cause of carpal instability. Therefore, if a scapholunate lesion is not diagnosed, it may result in a severe dysfunction of the wrist. This review describes the anatomy, and the kinematics of the wrist with an intact as well as a disrupted scapholunate ligament. The diagnostic of an isolated ligament lesion and a ligament injury associated with a fracture of the distal radius is presented. Finally, an algorithm for treatment based on the stage of injury is proposed.

Scapholunate Ligament Tears: Acute Reconstructive Options

Left untreated, scapholunate dissociation can lead to posttraumatic wrist arthritis. Multiple surgical procedures have been designed to reduce the scapholunate interval, restore normal wrist kinematics, and prevent the development of arthritis. Unfortunately, current surgical procedures have not been shown to consistently maintain radiographic alignment at long-term follow-up and result in decreased wrist range of motion and strength compared with the contralateral side. The purpose of this article is to review the current reconstructive options for scapholunate ligament tears without evidence of radiographic arthritis.

Cine MRI: a new approach to the diagnosis of scapholunate dissociation

OBJECTIVE

To evaluate the feasibility of cine MRI for the detection of scapholunate dissociation (SLD) and to compare the sensitivity and specificity of cine MRI with those of cineradiography and arthroscopy.

MATERIALS AND METHODS

To evaluate feasibility, healthy subjects underwent cine MRI of the wrist. To evaluate sensitivity and specificity, patients with clinically suspected scapholunate ligament (SLL) injury after trauma to the wrist were prospectively included and underwent radiographic examination, cineradiography, and cine MRI. In 25 out of 38 patients, subsequent arthroscopy was performed. Results of cineradiography and cine MRI correlated with those of arthroscopy.

RESULTS

Cine MRI was of diagnostic quality in all healthy subjects and patients with good interrater agreement. There was excellent correlation between cineradiography and cine MRI. Scapholunate distance differed significantly between healthy subjects and patients with scapholunate dissociation (p < 0.001), but not between imaging modalities in the patient group. Cine MRI had 85% sensitivity and 90% specificity for the detection of SLD.

CONCLUSION

Cine MRI of the wrist is a fast and reliable technique for the detection of SLD with diagnostic accuracy comparable to cineradiography. It can be easily implemented as a routine clinical MRI examination, facilitating diagnostic workup of patients with suspected SLD while avoiding radiation exposure.

Imaging of radial wrist pain. Part II: pathology

Pain on the radial side of the wrist is a common clinical presentation. Such wrist pain may provide a diagnostic challenge for radiologists, in view of the small size of the anatomic structures, the occasional subtlety of the imaging findings, the diversity of potential etiologies, as well as the non-infrequent occurrence of incidental asymptomatic findings in this area. This review discusses the imaging findings in both the more common and less common causes of radial-sided wrist pain, concentrating particularly on the detection of early disease and less readily apparent abnormalities.

[Percutaneous tightening of the carpal scaphoid with Herbert' screw--about 10 cases]

Les fractures du scaphoïde carpien sont de diagnostic et de traitement difficiles. Les auteurs rapportent les résultats du traitement de ces fractures par le vissage percutané par la vis de Herbert. Les résultats étaient intéressants vu la rapidité de consolidation et la qualité du résultat fonctionnel.

Dorsal scapholunate ligament injury: a classification of clinical forms

The dorsal scapholunate (SL) ligament may disrupt in variety of ways. Each form of injury requires specific fixation. To investigate the incidence of each type of ligament failure, the records of 45 patients with adequate information, good quality pictures, or videos demonstrating injury characteristics were reviewed. Four types of SL injury were found: type 1 (lateral avulsion from the scaphoid) was the most frequent, present in 19 patients (42%); type 2 (medial avulsion from the lunate) was the least frequent, with 7 cases (16%); type 3 (mid-substance rupture) was found on 9 occasions (20%); and type 4 (partial rupture plus elongation) was observed on 10 occasions (22%). Based on our observations, we submit that an arthroscopically assisted SL capsuloplasty may not be possible in all cases, particularly not when the ligament has avulsed off the bone (60% of the cases), leaving no ligament remnant on one side. Most patients will require ligament reattachment techniques using transosseous sutures, bone anchors, or ligament reconstruction.

The benefit of magnetic resonance imaging for patients with posttraumatic radial wrist tenderness

PURPOSE

To describe fractures revealed by magnetic resonance imaging (MRI) in a series of skeletally mature patients with radial wrist pain after an acute injury and clinically suspected to have a scaphoid fracture. Additionally, we attempted to assess the diagnostic value of radiographs and computed tomography (CT) in patients with scaphoid and other carpal fractures verified by MRI.

METHODS

We conducted the study prospectively over a 3-year period on skeletally mature patients presenting at our emergency department with tenderness on the radial side of the wrist after an injury. A total of 300 wrists in 296 patients underwent clinical and radiographic examination. We performed low-field, 0.23-T MRI of all injured wrists within 3 working days from inclusion in the study. If the radiographs or MRI revealed a scaphoid fracture, we immediately carried out a supplementary 16-slice CT scan of the wrist. We calculated the sensitivity and specificity of radiographs and CT for the diagnosis of scaphoid fractures using MRI as the reference standard.

RESULTS

We diagnosed a total of 224 fractures in 196 wrists using MRI; 42% were scaphoid fractures, 15% were distal radius fractures, 6% were triquetrum fractures, and 5% were capitate fractures. The most commonly found fracture combinations were that of the scaphoid and distal radius, followed by scaphoid and capitate fracture. The sensitivity of radiographs for visualization of scaphoid fractures was 70% and the specificity was 98%. Radiographic sensitivity for other fractures was less than 60%. The sensitivity of CT for visualization of scaphoid fractures was 95%, and between 75% and 100% for other fractures.

CONCLUSIONS

Low-field MRI showed a high incidence of fractures in patients with posttraumatic radial wrist tenderness and demonstrated more fractures than radiographs and CT. A scaphoid fracture was by far the most common injury. However, it is not clear whether diagnosis of subtle injuries only demonstrated on MRI improves outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic I.

The scaphoid

The scaphoid is vitally important for the proper mechanics of wrist function. Its unique morphology from its boat like shape to its retrograde blood supply can present with challenges in the presence of a fracture. Almost completely covered with articular cartilage, this creates precise surface loading demands and intolerance to bony remodeling. Fracture location compounds risk of malunion and non-union. Scaphoid fractures may significantly impair wrist function and activities of daily living, with both individual and economic consequences.

Diagnostic performance of radiographs and computed tomography for displacement and instability of acute scaphoid waist fractures

BACKGROUND

Fracture displacement is the most important factor associated with nonunion of a scaphoid waist fracture.We evaluated the performance characteristics of radiographs and computed tomography (CT) in the diagnosis of intraoperative displacement and instability of scaphoid waist fractures using wrist arthroscopy as the reference standard.

METHODS

During a six-year period (2004 to 2010) at two institutions, forty-four adult patients with a scaphoid waist fracture underwent arthroscopy-assisted operative fracture treatment at a mean of nine days (range, two to twenty-two days) after injury. Subjects included all of those with a displaced scaphoid fracture seen on radiographs and a selection of patients with a nondisplaced scaphoid fracture. All patients had preoperative radiographs and CT. Arthroscopy with up to 5 kg of traction was the reference standard for fracture displacement and instability.

RESULTS

The reference standard (arthroscopy) led to a diagnosis of twenty-two displaced fractures (all unstable) and twenty-two nondisplaced fractures (seven unstable). Displacement was diagnosed in eleven patients (25%) with the use of radiographs and in twenty (45%) with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative displacement were 45%, 95%, and 70%, respectively, with the use of radiographs and 77%, 86%, and 82%, respectively, with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative instability were 34%, 93%, and 55%, respectively,with the use of radiographs and 62%, 87%, and 70%, respectively, with CT. Assuming a 10% prevalence of fracture displacement and instability among all scaphoid waist fractures, the positive and negative predictive values for displacement were 53% and 94%, respectively, with the use of radiographs and 39% and 97% with CT whereas the positive and negative predictive values for instability were 36% and 93%, respectively, with radiographs and 34% and 95% with CT.

CONCLUSIONS

Radiographs and CT scans cannot be relied on to accurately diagnose intraoperative scaphoid fracture displacement or instability compared with arthroscopic examination. The influence, with regard to the risk of nonunion, of intraoperative instability of a scaphoid fracture that is seen to be nondisplaced on radiographs or CT is currently unknown.

LEVEL OF EVIDENCE

Diagnostic Level III.

In vivo changes in contact regions of the radiocarpal joint during wrist hyperextension

PURPOSE

Distal radius and scaphoid fractures commonly occur after a fall with the hand outstretched and wrist hyperextended. We investigated contact characteristics of the radiocarpal joint in neutral position, hyperextension, and hyperextension combined with radial deviation in vivo.

METHODS

Eight volunteers without a known history of wrist injury were enrolled. We obtained computed tomography scans with 3-dimensional reconstructions of the subjects' right wrists in neutral, hyperextension, and hyperextension with 10° of radial deviation. The contact regions of the radiocarpal joint were mapped. The direction and distance of changes in the contact region centers were recorded and analyzed.

RESULTS

From neutral position to hyperextension, the contact of the scaphoid substantially shifted from the middle to the dorsal part of the articular surface of the radius in 5 of the 8 wrists. With these wrists further deviated radially, the contact shifted to the surface over the radial styloid. In the other wrists, the contact of the scaphoid remained in the center of the radial articular surface. In all wrists, the contact of the radius on the scaphoid shifted from the proximal lateral surface of the scaphoid to the proximal dorsal surface of the scaphoid, and the contact of the radius on the lunate shifted dorsally.

CONCLUSIONS

During wrist hyperextension, the contact of the scaphoid on the distal radius exhibited 2 possible types of changes: either shifting from the mid-portion to the dorsal ridge of the articular surface of the radius or remaining at the center of the articular surface. Combined wrist hyperextension with radial deviation caused the scaphoid to contact the radius over the radial styloid. The contact of the radius on the scaphoid shifted from proximal lateral to proximal dorsal scaphoid, and that on the lunate shifted dorsally.

CLINICAL RELEVANCE

This study provided in vivo mechanical findings to improve our understanding of the mechanism of hyperextension injuries of carpus.

Lesions of the scapholunate ligament associated with minimally displaced or non-displaced fractures of the scaphoid waist. Which incidence?

INTRODUCTION

It was commonly considered that a non-displaced or minimally displaced isolated scaphoid fracture was mechanically incompatible with a lesion of the scapholunate ligament (SL). However, some authors who described such an association have recently challenged this statement. The aim of this prospective study was to determine, after screw fixation and using arthroscopy, the existence and incidence of lesions of the SL as associated with acute non-displaced or minimally displaced isolated fractures of the scaphoid.

METHODS

Between December 2009 and January 2011, the study included all patients presenting with an acute non-displaced or minimally displaced isolated fracture of the scaphoid waist, eligible for percutaneous screw fixation and accepting the procedure after informed consent. The surgical protocol included a first retrograde arthroscopically controlled percutaneous screwing of the scaphoid, followed by a second arthroscopy seeking only lesions of the SL. Geissler's classification was used for the classification of SL lesions.

RESULTS

Eighteen patients were included in the study. The mean was 29 years. In 17 cases, the scaphoid fracture was due to a low-energy fall, and in 1 case, to a road accident. No SL lesion was evidenced by the diagnostic arthroscopy.

CONCLUSION

Unlike some published reports, we did not observe any SL lesion associated with non-displaced or minimally displaced isolated fractures of the scaphoid. Nevertheless, despite such results and based on the literature, we recommend arthroscopy with percutaneous scaphoid screw fixation, with the triple advantage of providing reduction control, adequate screw fixation verification, and diagnosis of potential associated ligament lesions.

Current innovations in wrist arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.

Immunohistochemical composition of the human lunotriquetral interosseous ligament

PURPOSE

The human lunotriquetral ligament (LTL) is a functionally important intrinsic hand ligament, which is assumedly subjected to insertion angle changes at the entheses during movement. To clarify whether the current model of the ligament's mechanical environment is reflected in its structural composition, we determined the regional distribution of extracellular matrix-related antigens.

METHODS

The extracellular matrix was immunohistochemically investigated in 12 LTLs from both wrists of 6 human donors (Mean age: 60 y).

RESULTS

The dorsal, proximal, and volar portions of the ligament immunolabeled for type I, III collagen and versican. Both entheses labeled strongly for type II collagen, aggrecan, and link protein and were distinctly cartilaginous. The ligament midsubstance was positive for collagen II in 30%, for aggrecan in 40%, and for keratocan and lumican in 100% of specimens. In contrast, keratocan and lumican were absent from the fibrocartilaginous entheses and the articular cartilage. Ligament insertion at a carpal bone occurs either directly through fibrocartilage or indirectly through a bilayered configuration of fibrocartilage and hyaline-like cartilage. The hyaline-like cartilage is continuous with the neighboring articular cartilage.

CONCLUSIONS

The LTL has an extracellular matrix comparable with that of ligaments experiencing a combination of tensile and shear/compressive load at the attachment sites. All regions of the LTL exhibit fibrocartilaginous entheses; purely fibrous attachment sites are rare. The ligament midsubstance shows a more fibrous phenotype than the entheses and expresses keratocan and lumican, which previously have not been recorded in any human hand ligament.

Factors associated with arthroscopically determined scaphoid fracture displacement and instability

PURPOSE

To identify factors associated with arthroscopically diagnosed scaphoid fracture displacement and instability.

METHODS

This was a secondary use of data from 2 prospective cohort studies. The studies included 58 consecutive adult patients with a scaphoid fracture who elected arthroscopy-assisted operative fracture treatment: some for displacement, some as part of a prospective protocol, and others to avoid a cast. All patients had preoperative computed tomography with reconstructions in planes defined by the long axis of the scaphoid.

RESULTS

Arthroscopy revealed 38 unstable fractures (movement between fracture fragments; 66%), 27 of which were also displaced. All arthroscopically determined displaced fractures were unstable, and 11 of the 31 arthroscopically determined, nondisplaced fractures were unstable. There was a significant correlation between radiographic comminution (more than 2 fracture fragments) and arthroscopically determined displacement and instability.

CONCLUSIONS

Radiographic comminution is associated with displacement and instability as determined by arthroscopy.

Percutaneous screw and axial Kirschner wire fixation for acute transscaphoid perilunate fracture dislocation

PURPOSE

In this retrospective, nonrandomized study, we evaluated the clinical outcomes of percutaneous screw and K-wire fixation in the treatment of acute transscaphoid perilunate fracture dislocation.

METHODS

Between 2004 and 2009, we studied 24 patients treated by fixation with a 2.0-mm (0.078-in) axial K-wire across the capitolunate joint and a percutaneous screw (3.0-mm AO cannulated screws were used in 13 patients, and Herbert-Whipple screws were used in 11 patients) within 7 days of the injury. We performed a comparative radiographic assessment of the scapholunate angle, radiolunate angle, capitolunate angle, revised carpal height ratio, and gap between the scapholunate joint between the injured wrist and the contralateral, healthy wrist. Clinical outcomes were evaluated on the basis of range of motion, pain, functional status, and Mayo scores.

RESULTS

Twenty-three patients (96%) achieved scaphoid union at a mean union time of 18 weeks (range, 14-28 wk). Radiographic assessments revealed no statistically significant difference between the injured wrist and the contralateral, healthy wrist. However, significant differences were noted in the mean range of motion during flexion and forearm supination between the injured wrist and contralateral healthy wrist. The mean wrist function results were encouraging, and the average Mayo score was 83.

CONCLUSIONS

A percutaneous procedure involving screw fixation for the scaphoid fracture and an axial K-wire fixation for intercarpal dislocation is a successful treatment for acute transscaphoid perilunate fracture dislocation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Percutaneous screw fixation for scaphoid fractures

Long-term results of percutaneous treatment for 36 scaphoid fractures, types B1 and B2 according to Herbert, are reported. Outcomes were satisfactory in nearly all cases. In three patients, the screw was too long and had to be removed, and pseudoarthrosis developed in one patient. Consolidation was observed after 6-8 weeks, less than literature reports for immobilization with casts. The percutaneous approach is particularly suitable for younger patients who work or play sports.