Common wrist injuries

Patients with wrist injuries often present to primary care physicians. Many times, mild clinical injury involves significant damage to carpal bones and soft tissue elements. The long-term outcome of these injuries depends on prompt diagnosis and appropriate therapy. Familiarity with the functional anatomy and physical examination of the wrist, accompanied by radiologic evaluation, may aid the physician in differentiating simple sprains from potentially debilitating wrist injuries.     

Diagnostic value of MR arthrography in detection of intrinsic carpal ligament lesions: use of cine-MR arthrography as a new approach

Twenty-five patients with chronic wrist pain and a preliminary diagnosis of carpal instability were examined with conventional MR imaging and MR arthrography with single compartment intra-articular injection. A new cine-MR arthrography technique, with image acquisition at every 5 s during intra-articular injection, was performed in 17 subjects. The purpose of this study was to determine the diagnostic value of MR arthrography in ligamentous lesions of the wrist and to assess the value of cine-MR arthrography in comparison with arthroscopy and/or surgery. Magnetic resonance arthrography, a semi-invasive technique, increased the diagnostic accuracy of intrinsic carpal ligament injuries. Cine-MR arthrography can be considered as a promising technique especially for the evaluation of lunatotriquetral and scapholunate ligament injuries of the wrist.     

Improved wrist fracture localization with digital overlay of bone scintigrams and radiographs

The diagnosis of scaphoid fracture is often difficult and of interest in traumatology. Because of the low sensitivity of repeated scaphoid radiographs, a bone scintigram is advocated and considered the gold standard. In this study, we tried to simplify the interpretation of the bone scintigram of hand and wrist in localizing the hot spot by the digital overlay of the radiograph and the bone scintigram, using a simple device, in patients after wrist trauma. METHODS: Twenty-one consecutive patients (22 wrists) with clinically-suspected scaphoid fracture and negative initial radiographs were included. The PA view of the wrist was obtained with the hand of the patient placed in an acrylic device with three lead markers. For the bone scan, a similar device was used with 57Co markers at the same positions. We called this device the "hand-fix." The PA radiograph was digitized with a videocamera and overlaid on the bone scan. Each bone scan was interpreted twice by each of three observers, one nuclear physician and two residents in nuclear medicine. The first interpretation was made without the digital overlay, and the second was made with the digital overlay. RESULTS: The bone scintigrams were positive in the scaphoid, distal radius and in other carpal bones. Out of the 22 bone scans, Observer 1 judged 19 correctly, Observer 2 judged 16 correctly and Observer 3 judged 10 correctly without the digital overlay images. All three observers gave a correct localization in the 22 wrists using the digital overlay images. CONCLUSION: The digital overlay of a radiograph and a bone scintigram, using the hand-fix, simplifies and improves interpreting and localizing the hot spot on bone scintigrams in patients with wrist injuries.     

Follow-up skeletal surveys in suspected child abuse

OBJECTIVE: The purpose of this study was to assess the additional yield of a repeat skeletal survey in identifying and dating skeletal injury for cases in which child abuse was strongly suspected. MATERIALS AND METHODS: Twenty-three infants and toddlers strongly suspected of being physically abused on the basis of findings on the initial skeletal survey, other imaging studies, history, or physical examination underwent a follow-up examination approximately 2 weeks after the initial examination. The high-detail imaging system included a single-emulsion, single-screen combination with a low-absorption carbon-fiber cassette. The skeletal survey protocol entailed tightly collimated anteroposterior views of the appendicular skeleton and anteroposterior and lateral views of the axial skeleton. Between the two studies, all children were in Department of Social Services custody or living in a safe home. RESULTS: The follow-up skeletal survey yielded additional information regarding skeletal injury in 14 (61%) of 23 cases. Follow-up study increased the number of definite fractures detected from 70 to 89 (27%) (p = .005). Most of these additional injuries were classic metaphyseal lesions or rib fractures. In 13 of the 70 fractures previously detected, the follow-up skeletal survey also provided important information about the age of those injuries. CONCLUSION: When child abuse is strongly suspected on the basis of the findings on the initial skeletal survey, other imaging studies, history, or physical examination, a follow-up skeletal survey is recommended to provide a through and accurate assessment of osseous injuries.     

Resurfacing a circumferentially degloved hand by using a full-thickness skin graft harvested from an avulsed skin flap

Twelve patients with circumferentially degloved hands were treated with full-thickness skin grafts harvested from defatted avulsed flaps. All injuries were industrial accidents caused by various roller machines, not crush injuries. Of these 12 patients, 9 patients were degloved from the wrist level and 3 patients were degloved from the forearm. There were 11 distally based skin flaps and one flap was completely detached. Four patients were avulsed distally to the mid palm, with volar neurovascular bundles damaged at the "fenestrae" of the palm, which resulted in devascularization of the involved fingers. Among them, distal fingers were successfully revascularized by microsurgical techniques in 3 patients. The full-thickness skin grafts were prepared from the attached, avulsed skin flap to avoid junctional hypertrophic scarring. The graft was then secured to its anatomic position with multiple skin staples to improve skin graft take. Initial take of the graft averaged 93% (range, 85%-100%). Compared with conventional methods, this approach provides a higher rate of skin take and better cosmetic and functional results.     

'Clearing' cervical spine injuries in polytrauma patients: is it really safe to remove the collar?

Polytrauma patients are at increased risk for occult cervical spine injuries. Those unable to provide clinical clues to injury either remain in hard collars until they are able to cooperate with the physical examination or are deemed "clear of cervical injury" if the emergency room screening radiographs are without obvious bony abnormality. Cervical immobilization for a lengthy period of time is not without morbidity. Missed ligamentous injuries can lead to cervical instability, which in turn can result in permanent neurologic sequelae. This article reviews the current methodologies to "clear the cervical spine" and highlights the inadequacies.     

Arthroscopy of the knee under general anesthesia: an aid to the determination of ligamentous instability

During a 34-month period (March 1976 through December 1978), 790 patients underwent arthroscopic examination of the knee under general anesthesia. Preoperative assessment of ligementous instability was compared with the ligamentous examination while under general anesthesia. Eight percent of the patients with no preoperative instability first demonstrated ligamentous instability under general anesthesia. Thirty-six percent of the patients with preoperative instability and 27% of the patients with previous surgery had either an increased grade or additional component of instability found when examined under general anesthesia. Information gained from arthroscopy without a comprehensive ligament examination under anesthesia may result in an incomplete diagnosis and ineffective treatment. Patients at high risk include those with acute injuries, preoperative instability, or previous surgery.     

Carpal instability

Traumatic carpal instability implies that the normal relationships of the radiocarpal and mid carpal joint are distorted either statically or during dynamic stress. Normal kinematics of the carpus are dysfunctional. The causes of carpal instability are dissociation of the intercarpal ligaments on either side of the lunate, a so-called scapholunate dissociation or a luno-triquetral dissociation. Carpal instability nondissociative is generally due to a laxity or attenuation of the intrinsic ligaments of the carpus and are associated with deformity of the distal radius. Ulnar translation of the carpus on the distal radioulnar articular surfaces occurs with shear stretching of the origins of the radiocarpal ligaments. The radial styloid attenuation of the ligaments may result in abnormal motions of the carpal bones going from ulnar to radial deviation at which time a catch-up click may occur. Carpal instabilities are usually associated with malalignment of the lunate with respect to the longitudinal axes of the radius and capitate and tends to assume an extended position with scaphoid fractures or injuries to the scapholunate ligament, a palmar flexed position with injuries to the luno-triquetral area or the ulnar capsule.     

Soft-tissue sarcomas in the adult: news and trends]

The mechanism of growth retardation in Turner's syndrome has not been resolved. It is often referred to as a bone dysplasia, although endocrine derangement has not been ruled out. The present study was undertaken to evaluate the maturation of individual bones of the hand and wrist in girls with Turner's syndrome and thereby obtain information which may aid in elaborating the possible mechanism of the growth retardation in girls with Turner's syndrome. Hand and wrist films of 24 girls with Turner's syndrome, 11 normal girls with short stature and 23 normal controls were evaluated, using the references of Greulich and Pyle. Each bone or epiphysis was given an individual 'age'. During childhood the Turner patients showed the greatest delay in bone age of the phalangeal bones while the least delayed were the radius and ulna (long bones) and metacarpals. The carpal bones showed intermediate retardation. This pattern and extent of maturational retardation was clearly different from that of the short stature normal group, who showed uniform retardation of all bones. During adolescence, the phalangeal bones were further retarded and the carpal bones showed a moderate retardation. The unique profile of bone maturation in Turner's syndrome suggests an insult to chondroplasia, which may be related to estrogen deficiency or to an as yet undetermined endocrine or paracrine derangement.     

Common upper-extremity injuries

In the daily practice of family medicine, injuries to the upper extremity are frequently encountered. Most of these injuries can by easily treated by the primary care physician who has an understanding of the joint anatomy and treatment principles. Some injuries, however, may appear relatively minor, yet require prompt referral for surgical care. We reviewed the pathoanatomy, historical and physical examination findings, and treatment of the more common injuries to the hand, wrist, elbow, and shoulder.     

Rehabilitation psychology: Exploring issues.

Rehabilitation Psychology has several goals. One of its primary functions is to disseminate information that promotes the effective use of knowledge. While really new and current developments in rehabilitation interventions having psychological components may be known to the reader long before discussion of them appears in Rehabilitation Psychology, few "new findings" are dealt with to everyone's complete satisfaction. Many opinions exist about the efficacy of most innovative strategies; these conflicting views often are diverse, if not controversial. Therefore, it is helpful to provide professionals a forum in which they can discuss a problem and offer different viewpoints and perspectives that promote its resolution. I hope to make the journal such a forum within which these varying viewpoints can be heard. As Editor, I view Rehabilitation Psychology as being the single most significant organ through which the field can acquire additional clarity and identity. I view the role of Editor as being similar to that of a gatekeeper. The role entails major responsibility for ensuring that clinicians and academicians have an opportunity to present their findings and their opinions about critical issues facing the field. It is a role I hope to fulfill with competence and sensitivity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is Handedness Recognition Automatic? A Study Using a Simon-Like Paradigm.

The authors used a modified Simon task (J. R. Simon, 1969) to assess the automatic recognition of handedness. Participants responded to the color of a circle in the center of the photograph of a right or a left hand, displayed in the center of the computer screen. A regular Simon effect was found for back views, whereas a reverse Simon effect was found for palm views. This pattern of results was found when the forearm was present (Experiment 2), when 1 finger at a time was rendered invisible (Experiment 3), and when the hands were connected to a body image (Experiment 4). When the hands were cut at the wrist, no effect emerged (Experiment 1). These findings suggest an automatic encoding of the relative position of the hand in relation to the body (imaginary or real) rather than the automatic encoding of handedness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of the injured wrist on the field and in the office

The wrist is a common site of injury in sports, both acute and chronic. Evaluation of wrist injuries requires knowledge of anatomy kinematics, attention to the mechanism of injury, the intensity of training, and a focus on the physical examination for specific injuries.     

Standardized CT examination of the multitraumatized patient

The aim of this study was to develop a standardized non-helical-CT protocol including head, body and proximal extremities in order to achieve a good time efficiency and diagnostic accuracy in the initial radiological evaluation of the multitraumatized patient. A total of 111 circulatory stable blunt trauma patients, brought in to a trauma level II-III hospital, were examined according to a standardized CT protocol. After examining the head with contiguous 10-mm slices without i.v. contrast medium injection, the trunk was examined with 10-mm slices every 30 mm through thorax-abdomen-pelvis with i.v. contrast medium enhancement (occasionally modified). All data in the medical reports were collected and used as "end-point", and the outcome of the CT examination was compared with this final diagnosis. Mean examination time was 20 min (range 12-32 min). In total, 55 head injuries, 89 thoracic injuries, 27 abdominal/pelvic injuries and 62 fractures were found. Computed tomography correctly identified the injuries, except one brain stem injury, one contusion/rupture of the heart, one hepatic injury, two intestinal injuries, eight vertebral injuries and one joint dislocation. A standardized non-helical-CT examination of the head and body may be achieved in 20 min. Its diagnostic accuracy was high, except for vertebral column injuries, which is why we recommend it as the method of choice for initial radiological examination of multitraumatized patients. When available, helical scanning would improve both examination speed and accuracy.     

Snowboarding injuries

Snowboarding is a popular winter sport that involves riding a single board down a ski slope or on a half-pipe snow ramp. Compared with injuries resulting from traditional alpine skiing, snowboarding injuries occur more frequently in the upper extremities and ankles and less frequently in the knees. Different types of snowboard equipment, rider stance and snowboarding activity tend to result in different types of injury. Snowboarder's ankle, a fracture of the lateral talus, must be considered in a snowboarder with a "severe ankle sprain" that has not responded to treatment. Risk of injury may be lowered by using protective equipment, such as a helmet and wrist guards.     

Rehabilitation of injuries in competitive swimmers

Competitive swimmers perform highly repetitive motions, therefore characteristic overuse injuries of the shoulder, back, and knee can occur. A thorough history and examination should be performed by both physician and physical therapist. The combination of hypovascularity, fatigue, poor stroke mechanics, and the progressive instability of a hypermobile joint results in shoulder impingement. Medical evaluation should determine the existence of any glenohumeral joint instability or signs of impingement. Back injuries are most commonly due to disc degeneration, hyperextension, or myofascial involvement. Medial knee pain is most common in breaststroke swimmers and may be due to excessive valgus and rotatory stress. Frequently seen diagnosis includes patellofemoral pain, medial collateral ligament stress syndrome, and medial synovitis. Treatment will focus on elimination of inflammation. Rehabilitation should focus on stabilisation exercises for hypermobile joints, postural correction, strengthening and flexibility.     

Inline skating, an old sport, newly discovered: harmless or a potential danger with socioeconomic effects?]

Over a period of one year, all accidents associated with in-line skating (ILS) were surveyed. Sport-specific data was recorded with a standardized questionnaire. The study comprised 66 patients with 75 injuries (48 upper limb, 16 skull, eight lower limb, three trunk). We were looking after 42 male and 24 female patients with an average age of 20 years (5-53 years). Twenty-seven patients (40%) had to be treated as inpatients. Overall, the most frequent injury (one third of all injuries) was forearm fracture close to the wrist (21 radius fractures, four radioulnar fractures). It had to be reset in 20 cases. Additional internal fixation was required in 10 cases (Kirschner wire osteosynthesis, intramedullary nailing or plate osteosynthesis). Only five patients could be treated with plaster cast fixation alone. Most patients with injuries in the vicinity of the wrist were not wearing a wrist protector at the time of the accident. The most frequent reasons given for not wearing protectors was forgetfulness or the high price of protectors. However, there were also two distal radius fractures and a disc injury in the wrist in patients who had been wearing wrist protectors. In most cases, ILS accidents lead to appreciable damage requiring a healing period of several weeks to months (average period of loss of work 41 days). The bfu (advisory center for accident prevention) reckons with 60,000 ILS cases annually in Switzerland. These injuries are thus of great socioeconomic importance. In the future, better risk behavior must be achieved by informing the population (wearing protectors, especially for the wrist and head, attendance of training courses).     

Surgical principles and planning for the rheumatoid hand and wrist

Each surgical procedure available for the rheumatoid hand has a score card. The most indicated and necessary procedures include: extensor tenosynovectomy and Darrach for the impending or already ruptured extensor tendons; flexor tenosynovectomy and carpal tunnel release for the patient with impaired median nerve function; stabilization of the deformed unstable thumb with MP or IP arthrodesis; and flexor tenosynovectomy in the palm and finger of a motivated patient with significant disparity between active and passive motion. Relative indications for surgery include arthrodesis for the unstable wrist; MP arthroplasty for the fixed MP volar and ulnar subluxation with inability to open the hand; synovectomy for the occasional patient with painful boggy synovitis of the MP or PIP joint; and reconstruction of the fixed swan neck deformity with relatively good PIP joints. Both MP and PIP joints can and should be operated on at the same time. Extensive wrist surgery, that is, tenosynovectomy and Darrach or arthrodesis, should not be performed at the same time as MP arthroplasty. Try to do the "winner operations" first.     

Aggressive fibrous dysplasia of the maxillary sinus

Fibrous dysplasia is usually a slowly progressive, benign disease that develops over several years and presents with deformity or mild symptomatology. Five of 34 patients (ages 4-21 years), who were subsequently diagnosed histologically as having fibrous dysplasia of the maxillary sinus, rapidly developed soft tissue masses of the malar region over a period of less than 4 months with accompanying pain (2 patients) and nasal obstruction and exophthalmos (2 patients). Each was clinically suspected of having a sarcoma; two had been thought to have an "osteofibrosarcoma" on initial biopsy at outside hospitals. After resection, all lesions developed regrowth. At histopathologic examination, both initial and recurrent masses proved to be typical fibrous dysplasia with spicules of woven bone in cellular, sometimes vascular, fibrous tissue. No malignant degeneration was found. On conventional radiography, aggressive fibrous dysplasia produced opacification and expansion of the maxillary sinus and apparent disruption of its wall with an associated soft tissue mass. Computed tomography (CT) demonstrated voluminous heterogeneous masses with "ground glass appearance", calcifications, areas of enhancement, low attenuation, cystic areas, and a thinned, sometimes interrupted, maxillary wall. Despite the aggressive clinical course for both initial and recurrent lesions, the CT findings of a "ground glass" mass with calcifications surrounded by a maxillary sinus wall, even if incomplete, can suggest the diagnosis of aggressive fibrous dysplasia.     

Radiologic features of shoulder instability

Roentgenographic studies in a patient with shoulder instability generally identify the presence of a Hill-Sachs lesion, the presence of bony abnormalities of either the anterior or posterior rim, the presence or absence of fractures, and thick pathologic changes in the joint structure, which not only may provide insight into the diagnosis, but also may give the clinician insight into whether these pathologic changes are likely to be improved with operative and nonoperative treatment modalities. Clearly, the anteroposterior view, particularly with internal rotation, seems important in the diagnosis of the unstable shoulder. The West Point axillary view seems to be a useful one to identify the presence of glenoid rim problems. An additional view, such as the Stryker notch view, may identify the extent and presence of Hill-Sachs lesion when this may not be present on the other two views. Computed tomography arthrography, magnetic resonance imaging scan, and stress testing probably has limited applicability in the routine roentgenographic diagnosis of the unstable shoulder.