Fracture of the radius with instability of the wrist

Radiographic Incidence and Functional Outcomes of Distal Radius Fractures Undergoing Volar Plate Fixation With Concomitant Scapholunate Widening: A Prospective Analysis

Background: Scapholunate (SL) ligament injuries can occur concomitantly with distal radius fractures (DRFs), and the management of acute SL injury in the setting of DRFs remains controversial. The purpose of the study is to identify the radiographic incidence of SL widening in DRF treated with volar plate fixation and to determine the functional outcomes of DRF with concomitant radiographic SL-widening. Methods: One hundred and seventeen patients with DRFs, with and without radiographic SL-widening, and treated with volar locked plating, were prospectively enrolled. No SL ligament repairs or reconstructions were performed in any cases. Patients with DRFs with radiographic criteria for SL widening were compared to those without. Patients were evaluated at 3 months and 1 year postoperatively with Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation (PRWE) questionnaires. Results: Thirty-one patients (26.5%) were found to have radiographic evidence of SL widening. Patients with concomitant SL widening had less wrist extension at 3 months (52.4 degrees vs 60.8, P = .034) and at 1 year (64.5 degrees vs 71.8, P = .023). The group with SL widening had greater articular step off at 3 months (0.33 vs 0.06, P = .042), but no difference at 1 year (0.11 vs 0.05, P = .348). There were no differences in wrist flexion, supination, pronation, volar tilt, radial inclination, radial height, ulnar variance, PRWE scores, and Quick Dash scores at 3 months and 1 year. Conclusions: Radiographic SL-widening is a common finding associated with DRFs undergoing surgical repair. There are similar clinical outcomes between those with untreated SL widening compared to those without an SL widening at 1-year postoperatively.

Identification of critical molecular pathways involved in exosome-mediated improvement of cardiac function in a mouse model of muscular dystrophy

Duchenne muscular dystrophy (DMD) is a progressive disease characterized by skeletal muscle atrophy, respiratory failure, and cardiomyopathy. Our previous studies have shown that transplantation with allogeneic myogenic progenitor-derived exosomes (MPC-Exo) can improve cardiac function in X-linked muscular dystrophy (Mdx) mice. In the present study we explored the molecular mechanisms underlying this beneficial effect. We quantified gene expression in the hearts of two strains of Mdx mice (D2.B10-DmdMdx/J and Utrntm1Ked-DmdMdx/J). Two days after MPC-Exo or control treatment, we performed unbiased next-generation RNA-sequencing to identify differentially expressed genes (DEGs) in treated Mdx hearts. Venn diagrams show a set of 780 genes that were ≥2-fold upregulated, and a set of 878 genes that were ≥2-fold downregulated, in both Mdx strains following MPC-Exo treatment as compared with control. Gene ontology (GO) and protein-protein interaction (PPI) network analysis showed that these DEGs were involved in a variety of physiological processes and pathways with a complex connection. qRT-PCR was performed to verify the upregulated ATP2B4 and Bcl-2 expression, and downregulated IL-6, MAPK8 and Wnt5a expression in MPC-Exo-treated Mdx hearts. Western blot analysis verified the increased level of Bcl-2 and decreased level of IL-6 protein in MPC-Exo-treated Mdx hearts compared with control treatment, suggesting that anti-apoptotic and anti-inflammatory effects might be responsible for heart function improvement by MPC-Exo. Based on these findings, we believed that these DEGs might be therapeutic targets that can be explored to develop new strategies for treating DMD.

Effectiveness of Percutaneous Pinning of Acute Partial Scapholunate Injury during Volar Locking Plating for Distal Radius Fractures: A Comparative Study of Pinning and Conservative Treatment

Backgroud

We hypothesized that concurrent temporary fixation of scapholunate ligament (SL) injury during volar locking plate (VLP) fixation of distal radius fractures (DRFs) would improve restoration outcomes based on both radiological and clinical results. Here, we performed a prospective, comparative study investigating the effectiveness of temporary percutaneous reduction/pinning during VLP fixation in DRFs.

Methods

The first 43 consecutive SL injuries were treated concurrently after VLP fixation by closed pinning (group 1); the next 36 consecutive injuries were treated nonoperatively (group 2). Patients were followed up for at least 5 years after treatment. Basic demographic data, radiological measurements, arthroscopic findings of SL injury, and other clinical outcomes were evaluated.

Results

The mean follow-up period was 7.2 years. No significant differences in basic demographic data were evident between groups. Fracture patterns were not distinctively different between groups. The initial scapholunate angle measured immediately after surgery was 23° ± 3° in group 1 and 38° ± 13° in group 2, indicating a significantly hyperextended scaphoid position in group 1. The final scapholunate angles were also significantly different between groups although the final angle in group 2 (58° ± 11°) was within normal limits. Final visual analog scale scores, Disabilities of the Arm, Shoulder and Hand scores, Gartland and Werley system scores, and wrist motions were not different between groups; however, grip strength at the time of final follow-up was closer to that of the contralateral uninjured wrist in group 1. Arthrosis was less advanced in group 1.

Conclusions

Temporary fixation for SL injury with a DRF can be an effective option for the maintenance of scapholunate angle. The non-fixed group exhibited a more pronounced collapse of the scapholunate angle although the angle was still within normal limits, and clinical outcomes were similar between groups regardless of the fixation status.

Comparing Outcomes between Arthroscopic-Assisted Reduction and Fluoroscopic Reduction in AO Type C Distal Radius Fracture Treatment

Background  Distal radius fracture is one of the most common injuries. Poor functional result with restricted wrist motion can be developed when there is intra-articular fibrous tissue development arising from articular step-off and gapping. Objectives  The aim of this study is to compare the functional and radiological outcome between arthroscopic-assisted reduction and fluoroscopic reduction in treating unstable intra-articular distal radius fracture. Methods  We retrospectively analyzed 12 patients with intraarticular AO type C distal radius fracture treated with arthroscopic-assisted fracture reduction and internal fixation and compared them with another group of 12 patients in which fracture reduction is assessed by fluoroscopy alone (15 males and 9 females, mean age 57.3, range 27-73). The two cohorts were analyzed for differences in radiological parameters including articular stepping and gapping, palmar tilt, radial inclination, ulnar variance as well as functional outcome in range of motion, grip strength, modified mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score at an average of 12.5 months (range 5-26) after surgery. Results  Arthroscopic-assisted fracture reduction group has statistically better restoration of articular stepping and gapping, volar tilt and ulnar variance. Range of motion, grip strength, modified mayo wrist score and Quick DASH score also had statistically significant improvement in arthroscopic group. Conclusion  Our study showed arthroscopic-assisted technique can precisely restore radiological parameters in highly comminuted distal radius fracture with good functional outcome. Also, associated intra-articular soft tissue injury can be detected and treated simultaneously. Level of Evidence  This is a level III, retrospective cohort study.

CRISPR-based gene knockout screens reveal deubiquitinases involved in HIV-1 latency in two Jurkat cell models

The major barrier to a HIV-1 cure is the persistence of latent genomes despite treatment with antiretrovirals. To investigate host factors which promote HIV-1 latency, we conducted a genome-wide functional knockout screen using CRISPR-Cas9 in a HIV-1 latency cell line model. This screen identified IWS1, POLE3, POLR1B, PSMD1, and TGM2 as potential regulators of HIV-1 latency, of which PSMD1 and TMG2 could be confirmed pharmacologically. Further investigation of PSMD1 revealed that an interacting enzyme, the deubiquitinase UCH37, was also involved in HIV-1 latency. We therefore conducted a comprehensive evaluation of the deubiquitinase family by gene knockout, identifying several deubiquitinases, UCH37, USP14, OTULIN, and USP5 as possible HIV-1 latency regulators. A specific inhibitor of USP14, IU1, reversed HIV-1 latency and displayed synergistic effects with other latency reversal agents. IU1 caused degradation of TDP-43, a negative regulator of HIV-1 transcription. Collectively, this study is the first comprehensive evaluation of deubiquitinases in HIV-1 latency and establishes that they may hold a critical role.

Using MicrobiomeAnalyst for comprehensive statistical, functional, and meta-analysis of microbiome data

MicrobiomeAnalyst is an easy-to-use, web-based platform for comprehensive analysis of common data outputs generated from current microbiome studies. It enables researchers and clinicians with little or no bioinformatics training to explore a wide variety of well-established methods for microbiome data processing, statistical analysis, functional profiling and comparison with public datasets or known microbial signatures. MicrobiomeAnalyst currently contains four modules: Marker-gene Data Profiling (MDP), Shotgun Data Profiling (SDP), Projection with Public Data (PPD), and Taxon Set Enrichment Analysis (TSEA). This protocol will first introduce the MDP module by providing a step-wise description of how to prepare, process and normalize data; perform community profiling; identify important features; and conduct correlation and classification analysis. We will then demonstrate how to perform predictive functional profiling and introduce several unique features of the SDP module for functional analysis. The last two sections will describe the key steps involved in using the PPD and TSEA modules for meta-analysis and visual exploration of the results. In summary, MicrobiomeAnalyst offers a one-stop shop that enables microbiome researchers to thoroughly explore their preprocessed microbiome data via intuitive web interfaces. The complete protocol can be executed in ~70 min.

Incidence and Functional Outcomes of Scapholunate Diastases Associated Distal Radius Fractures: A 2-year Follow-Up Scapholunate Dissociation

BACKGROUND

The Scapholunate Interosseous Ligament (SLIL) is the first intrinsic carpal ligament to be injured in wrist trauma, present in up to 64% of the distal radius fractures. However, it remains unclear what patients develop symptoms, making primary treatment of these injuries accompanying distal radius fractures remains questionable.

OBJECTIVE

The aim of this study was to evaluate the functional outcomes of patients with scapholunate diastasis associated with distal radius fractures.

METHODS

We evaluated 391 patients with a distal radius fracture. Using Computer Tomography (CT) scans the scapholunate interval was measured. We identified 14 patients with an SLD (>3mm) of the injured wrist, which underwent a CT-scan of the contralateral wrist. To evaluate the functional outcomes at a mean follow up of 136±90 weeks, we used the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) Score.

RESULTS

There were 8 patients with bilateral SLD and 6 patients with unilateral SLD. Five patients had a qDASH score of 0 and one patient showed a qDASH score of 18.2. The patient with a poor score had bilateral preexisting osteoarthritis of the wrist. No patient had additional surgery of the SLIL.

CONCLUSION

In patients with distal radius fractures, more than half of the 14 patients with an SL gap on CT had widening on the contralateral side. It is therefore worthwhile to image the contralateral wrist before diagnosing a SLD. The patients with unilateral SLD should not be surgically treated at initial presentation because they may have good functional outcomes after a follow up of 2 years.

Scapholunate instability after distal radius volar plating

BACKGROUND

Prior to volar locked plating and early motion protocols, ligamentous injuries incidentally associated with distal radius fractures may have been indirectly treated with immobilization. Our goal was to determine the prevalence of scapholunate instability in our population, while identifying those who may have had progression of instability.

METHODS

We retrospectively reviewed 221 distal radius fractures treated with a volar locking plate during a 6-year period. Average patient age was 59 years. Standard posteroanterior and lateral radiographs from the first and last postoperative visits were analyzed for scapholunate instability, using the criteria of scapholunate gap ≥3 mm and scapholunate angle ≥60°.

RESULTS

Six patients (3 %) met neither or only one criterion for instability at the first postoperative visit and did not have ligament repair and then went on to meet both criteria at the last postoperative visit after an early motion protocol. Seven patients (3 %) met both criteria at the first and last postoperative visits and did not have ligament repair. Five patients (2 %) underwent primary scapholunate ligament repair at the time of distal radius fixation.

CONCLUSIONS

In our representative population, scapholunate instability was uncommon, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. Thus, we did not find strong evidence for routinely delaying motion or pursuing further workup. When early radiographs clearly demonstrate acute scapholunate instability, more aggressive treatment may be appropriate for selected patients.

Association of injury mechanism with the risk of cervical spine fractures

Objective:

A full understanding of an injury event and the mechanical forces involved should be important for predicting specific anatomical patterns of injury. Yet, information on the mechanism of injury is often overlooked as a predictor for specific anatomical injury in clinical decision-making. We measured the relationship between mechanism of injury and risk for cervical spine fracture.

Methods:

Our case-control study is a secondary analysis of data collected from the Canadian C-Spine Rule (CCR) study. Data were collected from 1996 to 2002 and included patients presenting to the emergency departments of 9 tertiary care centres after sustaining acute blunt trauma to the head or neck. Cases are defined as patients who were categorized in the CCR study with a clinically important cervical spine fracture. Controls had no radiologic evidence of cervical spine injury. Bivariate and multivariate unconditional logistic regression models were used. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results:

Among the 17 208 patients in the CCR study, 320 (2%) received a diagnosis of a cervical spine fracture. Axial loads, falls, diving incidents and nontraffic motorized vehicle collisions (e.g., collisions involving snowmobiles or all-terrain vehicles) were injury mechanisms that were significantly related to a higher risk of fracture. For motor vehicle collisions, the risk of cervical spine injury increased with the posted speed, being involved in a head-on collision or a rollover, or not wearing a seat belt (p< 0.05). The occurrence of cervical spine fracture was negligible in simple rear-end collisions (1 in 3694 cases; OR 0.015, 95% CI 0.002–0.104]).

Conclusion:

Our study quantitatively demonstrates the relationship between specific mechanisms of injury and the risk of a cervical spine fracture. A full understanding of the injury mechanism would assist providers of emergency health care in assessing risk for injury in trauma patients.

Management of complications of ligament injuries of the wrist

Despite advances in understanding the anatomy and biomechanics of wrist motion, intrinsic carpal ligament injuries are difficult to diagnose and treat. Even when an accurate diagnosis is made, there is no consensus on the most appropriate and reliable treatment. Injury predisposes to a progressive decline in wrist function and a predictable pattern of degenerative arthritis. To prevent inadequate outcomes, many treatment options exist, all having inherent benefits and complications. This article reviews the complications of intrinsic carpal ligament injuries and complications of their treatment. Methods to prevent and principles to manage the complications are discussed.

The clinical outcome after extra-articular colles fractures with simultaneous moderate scapholunate dissociation

Background An increased scapholunate gap is sometimes seen in patients with a distal radial fracture. The question remains as to whether this represents a scapholunate ligament injury that requires treatment. Questions/purposes We wished to examine the natural history of an increased scapholunate gap in patients following an extra-articular distal radial fracture. Patients and Methods We reviewed 260 patients who had sustained a distal radial fracture at a mean of 6.2 (2.7-11.9) years previously and identified 12 extra-articular fractures with an increased gap between the lunate and scaphoid. The mean scapholunate gap was 2.6 (2.1-3.4) mm, and the mean scapholunate angle 62° (39°-90°). Controls were found among the remaining patients with extra-articular fractures. Selection criteria were same sex, age at fracture within 5 years, time between injury and review within 2 years, ulnar variance within 2 mm, and dorsal angulation within 5° of index patient. When more than one control fulfilled the criteria for an index patient, their values were averaged. In total there were 54 controls for the 12 index patients. Results The mean difference between index patients and controls in wrist range of motion was 4%, in grip strength 5%, in visual analog scale (VAS) for pain 1 (on a scale from 1 to 100), in Quick-DASH (Disability of the Arm, Shoulder, and Hand) score 5, and in PRWE score 1. The study was calculated to have the power to detect a difference in Quick-DASH scores and in Patient-Rated Wrist Evaluation (PRWE) scores of 14. Conclusions We conclude that at a mean follow up of 6.2 years following an extra-articular distal radial fracture, no surgical treatment is usually needed with a scapholunate gap of between 2.1-3.4 mm. Level of Evidence III, Case control study.

Radiographic assessment of ligamentous injuries in distal radius fractures after open reduction and internal fixation

OBJECTIVES

Concomitant ligamentous injury in distal radius fractures (DRF) may explain continued pain following surgery. The purpose of this study was to compare radiographic measurements assessing scaphoid translation in DRF after reduction, to measurements performed on normal radiographs. This may allow noninvasive evaluation of radiocarpal ligamentous integrity.

METHODS

Fifty postoperative radiographs were evaluated. The distance between the ulnar border of the radial styloid and the radial border of the scaphoid was measured midway between the styloid tip and scaphoid base, and then divided by scaphoid width at the same level. The measured ratios were compared to previously established normal data, established radiographic measurements of fracture reduction, fracture characteristics and fixation methods.

RESULTS

Radiographic scaphoid position measurements differed significantly from normals (p = 0.0001). Fracture characteristics, surgical difficulty, and technique were not associated with scaphoid position.

CONCLUSIONS

Despite accurate surgical reduction, abnormal positioning of the scaphoid may persist. This may reflect ligamentous injury, which generates suboptimal clinical results. Identifying and addressing ligamentous injury during surgery may prevent the development of instability and improve outcome after DRF.

RADIOGRAPHIC SIGNS OF STATIC CARPAL INSTABILITY WITH DISTAL END RADIUS FRACTURES: IS CURRENT TREATMENT ADEQUATE?

Patients presenting with distal end radius fractures may have concomitant carpal instability due to disruption of the scapholunate ligament. This study examined the incidence of static radiographic signs of carpal instability in patients with distal radial fractures before and after fracture treatment. We performed a retrospective radiographic study of 141 patients presenting to Central Middlesex Hospital, London between January 2002–May 2004 with distal end radius fractures. We used abnormal scapholunate angle as the primary indicator of possible carpal dissociation. Abnormal scapholunate angles were noted in 39% of patients at presentation and 35% of patients after treatment with no statistically significant intra-patient variability. Persistent static radiographic signs of carpal instability are high in this subset of patients. The long-term morbidity of persistent wrist instability may be avoided by early radiological diagnosis with clinical correlation to identify carpal ligament injuries and initiate treatment that addresses both the bony and ligamentous components of the injury.

The diagnosis and treatment of scapholunate instability

Scapholunate instability is the most common form of carpal instability. Pain produced by this condition is caused by the wrist's inability to sustain physiologic loads because of an injury to the linkage between the scaphoid and lunate. The term scapholunate instability may describe a wide spectrum of clinical conditions ranging from mild wrist dysfunction and partial ligamentous tear to debilitating pain with associated rupture of the scapholunate interosseus ligament complex. This article reviews the pathophysiology of scapholunate instability and its identification and treatment.

The diagnosis and treatment of scapholunate instability

Scapholunate instability is the most common form of carpal instability. Pain produced by this condition is caused by the wrist's inability to sustain physiologic loads because of an injury to the linkage between the scaphoid and lunate. The term scapholunate instability may describe a wide spectrum of clinical conditions ranging from mild wrist dysfunction and partial ligamentous tear to debilitating pain with associated rupture of the scapholunate interosseus ligament complex. This article reviews the pathophysiology of scapholunate instability and its identification and treatment.

[Frequency of acute and chronic scapholunate dissociation in distal radius fractures. Different treatment plans]

BACKGROUND

Early diagnosis and appropriate treatment of acute scapholunate dissociation (SLD) is crucial for obtaining a favorable result in fractures of the distal radius. The aim of this study was to determine the incidence of acute SLD in a prospective study and to differentiate this entity from chronic SLD.

PATIENTS AND METHODS

A total of 120 patients with unilateral distal radius fractures were prospectively evaluated for SLD. Stress radiographs were obtained for all patients on the injured side after fixation of the distal radius fractures. In cases of SLD the unaffected side was examined to rule out chronic, bilateral SLD.

RESULTS

Acute SLD was detected in 13 patients (11%), 11 (9.1%) of whom had stage 3 injury. Chronic SLD with bilateral asymptomatic instability was seen in three patients (2.5%).

CONCLUSION

When treating fractures of the distal radius, acute SLD has to be ruled out and to be discriminated from chronic SLD. While acute SLD requires appropriate treatment, immediate treatment of chronic SLD is not indicated.

Okkulte skapholunäre Dissoziation bei distaler Radiusfraktur

INTRODUCTION

The aim of this study was to investigate the clinical consequences of scapholunate dissociation associated with fractures of the distal radius and the impact on wrist function. Fractures of the distal radius and scapholunate dissociation overlap in pathomechanics. The diagnosis however is frequently missed initially.

PATIENTS AND METHODS

We reviewed 45 consecutive patients with closed distal radius fractures with a mean follow up of 48 months. Ten patients underwent surgery and 35 patients were treated by fracture reduction and cast immobilization during 4.5 (range 3 to 8) weeks. All patients were re-examined clinically and radiographs of both wrists were compared.

RESULTS

Four patients showed evidence of SLD in the scapholunate joint region based on specific criteria (scapholunate gaps > 2 mm on anterior-posterior radiograph and the scapholunate angle > 60 degrees on lateral radiograph). All patients with SLD showed a poor radioulnar deviation. Three patients reported mild to moderate pain.

DISCUSSION

The difficulties in management of SLD may be avoided by early detection and treatment. In all investigated patients the diagnosis was missed after the initial trauma. Untreated SLD can lead to carpal collapse and arthrosis of the wrist, and ultimately to scapholunate advanced collapse.

Can cast immobilization successfully treat scapholunate dissociation associated with distal radius fractures?

During a 3.5-year period, 20 of 424 consecutive patients with fractures of the distal radius presented with evidence of scapholunate dissociation upon x-ray films and traction view fluoroscopy. The sequential changes of x-ray abnormalities of the scapholunate joint were consistently observed over a 1-year period, and wrist functions were evaluated 1 year after injury. The scapholunate gaps were 3.5 +/- 0.5 mm at the time of injury, 3.2 +/- 0.4 mm immediately after closed reduction of the fracture, 3.4 +/- 0.5 mm at the time after removal of fixation, and 3.8 +/- 0.4 mm 1 year after injury. By the modified clinical scoring system of Green and O'Brien, of these 20 patients, none had excellent, 2 had good, 14 had fair, and 4 had poor wrist function 1 year after injury. The wrists with scapholunate dissociation had significantly worse function as compared to a selected subgroup of 228 wrists with no signs of intercarpal ligament disruption. All 20 patients with signs of scapholunate dissociation on x-ray examination at the time of injury had clinical signs in the scapholunate joint and positive x-rays findings of dissociation 1 year later. After 1 year, 8 of the 20 patients underwent surgery for relief of symptoms and to stabilize the joint. Arthrography in the patients with persistent symptoms showed disruption in scapholunate interosseous ligaments. This study indicates that scapholunate dissociation with concomitant fractures of the distal radius cannot be cured by cast immobilization of the fracture. Early operative treatment should be instituted for the concomitant scapholunate dissociation.

Cineradiographic study of wrist motion after fracture of the distal radius

Residual dorsal tilt is one of the main deformative factors in the malunion of fractures of the distal radius. We investigated the effect of such tilt on the range of wrist motion and on carpal alignment in a cineradiographic study of wrist motion in 30 patients with extra-articular Colles' fracture. With increased dorsal tilt, the range of wrist motion became more restricted and abnormalities of carpal alignment during wrist motion became apparent. When the dorsal tilt was less than 10 degrees, the effects on the range of motion and on the dynamic carpal alignment were small.

[Lesions of the ligaments associated with distal fractures of the radius. 58 intraoperative arthrographies]

Intracarpal ligamentous tears and fractures of the radius often have a similar mechanism. For instance, no prospective studies have defined the real incidence of such associations, which are not antagonistic. The authors performed a systematic operative wrist arthrogram during distal radius fractures in a group of 58 patients with a mean age less than 50 years. Such a population was at low risk of degenerative ligamentous tears. Triangular fibrocartilage complex was torn in two-thirds of all types fractures. Extra-articular radius fractures were associated with an intracarpal ligamentous tear in 25% and always a luno-triquetral lesion type. In contrast, intra-articular and radius styloid fractures were frequently associated with a scapho-lunate lesion.

Scapholunate interosseous reconstruction and imbrication of palmar ligaments

Twenty-eight patients with scapholunate interosseous ligament disruption, carpal instability, and persistent wrist pain were treated by carpal reduction, stabilization, and palmar ligament reconstruction. In twenty-two of these patients pain was well controlled, carpal alignment was maintained, and they were able to resume their previous employment. Grip and pinch strengths averaged eighty-two percent and range of motion averaged seventy-six percent of the normal uninvolved side.

Acute scaphoid fracture with scapholunate gap

Disruptive forces from wrist trauma are thought to fracture bone or disrupt ligaments. Two cases are presented to demonstrate the simultaneous occurrence of acute scaphoid fracture and scapholunate gap. Recommended treatment in acute cases is open reduction and internal fixation of the fracture and open stabilization of the scaphoid. In chronic cases, we recommend open reduction and internal fixation with bone graft to the scaphoid nonunion combined with fusion of the scaphoid-trapezium-trapezoid joint.

Radiology of trauma to the wrist: dislocations, fracture dislocations, and instability patterns

Radiologic changes from trauma to the carpus are described. Emphasis is placed upon pathomechanics and characterization of greater and lesser arc injury patterns. Finally, the various posttraumatic instability patterns of the wrist are discussed.