Isolated scaphoid fracture with anterosuperior dislocation of the proximal fragment

Isolated fracture of the scaphoid with an associated anterosuperior dislocation of the proximal fragment is an extremely rare injury. We present two cases where open reduction and internal fixation through a palmar and dorsal approach was performed. No instances of non-union, necrosis of the proximal fragment of the scaphoid or scapholunate dissociation were noted during a mean follow-up period of 18 months. Clinical results (active motion, power grip, DASH) following such injury and intervention are presented. The aetiology of this rare injury is discussed.     

孤立闭合性腕舟骨完全脱位1例

患者,男,40岁,因车祸撞伤左上肢致左前臂腕关节肿胀疼痛、活动受限2d入院。查体:左前臂处有擦痕,肿胀,压痛,左腕关节肿胀明显,掌侧可触及脱位舟骨,腕关节背侧有凹陷感,腕关节屈伸活动明显受限。左腕X线片示:左腕舟骨完全脱位至桡骨远端掌侧(图1a,1b),近极可见细小骨折线。急诊行闭合复位失败后入院,在臂丛麻醉下采用腕背侧入路,经鼻烟窝于腕背部做"S"形切口,切开皮肤、皮下组织,     

腕舟状骨疲劳骨折3例

疲劳骨折亦称行军骨折，多发生在下肢骨骼，发生在第2、3跖骨、胫骨、股骨颈等部位的疲劳骨折已不少见，但是发生在上肢的疲劳骨折尚不多见。自2002年以来，发现3例腕舟骨疲劳骨折，现报告如下。     

背侧入路经皮加压螺钉内固定治疗舟骨骨折的临床研究

目的介绍背侧入路经皮加压螺钉内固定治疗舟骨骨折的适应证、手术方法和疗效。方法2009年4~10月,采用背侧入路经皮加压螺钉固定小切口空心钉技术治疗6例急性舟骨骨折的患者,骨折分型为HerbertB2,B3型。术中以Lister结节为标志,于其远端0·5~1cm处触及舟骨近极,在导针引导、C型臂监视下、沿舟骨轴线打入合适长度的加压螺钉。结果6例患者均有初步随访资料,随访时间为4至6个月,平均5个月。B2型骨折平均愈合时间为8周,B3型骨折平均愈合时间为12周;恢复工作时间平均为14d;活动度达到健侧90%以上;无疼痛等不适感觉。没有并发症。结论背侧入路经皮加压螺钉技术治疗急性舟骨骨折创伤小,根据骨折类型不需外固定或外固定时间较保守治疗缩短,愈合率高,治疗结果满意。     

Avulsion fractures of the scaphoid and triquetrum in a 15 year- old male

Avulsion fractures of the perilunate ligaments occur in isolation, and multiple fractures are typically not seen in the same carpus. We present a case of a 15-year-old male who injured his wrist during football practice. He presented without wrist dislocation or deformity. Radiographs demonstrated avulsion fractures to the proximal pole of the scaphoid and proximal radial aspect of the triquetrum. The patient was immobilized with an upper extremity thumb spica cast; however, there was persistent non-union of both fractured segments. Magnetic resonance imaging confirmed avulsions at the site of the scapholunate and lunotriquetral ligaments, with both ligaments relatively intact. At the last follow-up, one year after the initial injury, the patient had a normal clinical exam, with no pain and full wrist range of motion despite fracture non-union at both locations. This is a unique injury with an unclear mechanism and complicated management.     

The total scaphoid titanium arthroplasty: A 15-year experience

Scaphoid nonunion followed by necrosis of bone segments is a common pathologic condition for the hand surgeon, and the difficulty of its management is well known. The total titanium scaphoid replacement, although not well-described in the literature, in our experience represents a reasonable choice in the treatment of this condition. Strict patient selection is necessary to achieve good clinical results. The titanium avoids the silicone synovitis, a well-described complication of silastic implants. Furthermore, this technique permits other surgical steps in case of failure.     

The clinical scaphoid fracture: early computed tomography as a practical approach

INTRODUCTION

Up to 40% of scaphoid fractures are missed at initial presentation as clinical examination and plain radiographs are poor at identifying scaphoid fractures immediately after the injury. Avoiding a delay in diagnosis is essential to prevent the risk of non-union and early wrist arthritis. We demonstrate the use of CT scanning for the early confirmation of a scaphoid fracture.

PATIENTS AND METHODS

We conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a small district general hospital. We performed a CT scan on all ‘clinical scaphoid’ patients who had negative plain X-ray films.

RESULTS

Overall, 70% of patients had a CT scan within 1 week of injury and not from date of accident and emergency attendance; 83% of patients had a CT scan within 2 weeks of injury. Of 118 patients identified, 32% had positive findings and 22% of ‘clinical scaphoid’ patients had scaphoid fractures. The proportion of positive findings for an acute scaphoid fracture was 68%. Additional pathologies identified on CT were capitate, triquetral and radial fractures.

CONCLUSIONS

Our audit shows that it is practical to perform CT on suspicious scaphoid fractures in a small district general hospital. We identified an extremely high false-negative rate for plain X-rays and demonstrate that the appropriate use of CT at initial fracture clinic attendance with ‘clinical scaphoid’ leads to an earlier diagnosis and reduces the need for prolonged immobilisation and repeated clinical review.     

陈旧性腕舟骨骨折手术治疗体会

腕舟骨骨折以往常采用手法复位、石膏或夹板外固定，发生骨折不愈合的病例较多。临床上陈旧性腕舟骨骨折的治疗方法较多，方法较复杂，创伤大。2003年7月至2005年6月收治陈旧性腕舟骨骨折22例，采用切开复位钢针内固定加取桡骨背侧面火柴棒样植骨及桡骨茎突切除术治疗，取得满意效果，且用1个小切口解决了所有手术治疗，现报告如下。     

手舟骨骨折损伤机制分析

目的探讨手舟骨骨折的原因、机制，为减少手舟骨骨折的发生提供预防措施。方法2006年11月-2007年11月，临床收集手舟骨骨折病例16例，详细询问并记录病史，结合X片、CT表现，从物理力学的角度分析受伤机制。结果16例均为腕过伸位着地受伤；5例为军事训练（单双杠、倒功）中受伤，其中1例受伤时上臂呈后伸位，4例呈前屈位；8例为打球时受伤，其中2例受伤时上臂呈后伸位，6例呈前屈位；3例为高处坠落（2-6m）时受伤，均为上臂前屈位手掌着地所致。结节部骨折0例，远端（粉碎性骨折）3例，腰部横形骨折10例，斜形骨折3例，纵形骨折0例，近端骨折0例。结论手舟骨骨折主要发病原因为高强度训练、运动及高处坠落时腕关节过伸位手掌着地受伤。受伤时手掌的不同位置及人体的不同运动倾向综合作用，通过不同的损伤机制造成手舟骨不同类型的损伤。     

Scaphoid fracture and scaphoid pseudarthrosis

Summary Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixtion. The operative treatment of non- unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.      

Evaluation of bone remodeling in regard to the age of scaphoid non-unions

AIM: To analyse bone remodeling in regard to the age of scaphoid non-unions(SNU) with immunohistochemistry.METHODS: Thirty-six patients with symptomatic SNU underwent surgery with resection of the pseudarthrosis. The resected material was evaluated histologically after staining with hematoxylin-eosin(HE), tartrate resistant acid phosphatase(TRAP), CD 68, osteocalcin(OC) and osteopontin(OP). Histological examination was performed in a blinded fashion.RESULTS: The number of multinuclear osteoclasts in the TRAP-staining correlated with the age of the SNU and was significantly higher in younger SNU(P = 0.034; r = 0.75). A higher number of OP-immunoreactive osteoblasts significantly correlated with a higher number of OC-immunoreactive osteoblasts(P = 0.001; r = 0.55). Furthermore, a greater number of OP-immunoreactive osteoblasts correlated significantly with a higher number of OP-immunoreactive multinuclear osteoclasts(P = 0.008; r = 0.43). SNU older than 6 mo showed a signifi-cant decrease of the number of fibroblasts(P = 0.04). Smoking and the age of the patients had no influence on bone remodeling in SNU.CONCLUSION: Multinuclear osteoclasts showed a significant decrease in relation to the age of SNU. However, most of the immunhistochemical findings of bone remodeling do not correlate with the age of the SNU. This indicates a permanent imbalance of bone formation and resorption as indicated by a concurrent increase in both osteoblast and osteoclast numbers. A clear histological differentiation into phases of bone remodeling in SNU is not possible.     

The incidence of scaphoid fracture in a military population

Background

The rate of occurrence of scaphoid injury is not well known. The incidence of scaphoid fracture has been described mostly in small, injured cohort populations, which may underestimate its frequency. We studied the epidemiology of the scaphoid fracture using a large database in a military population.

Patients and methods

The Defense Medical Epidemiology Database (DMED), a comprehensive database which tracks medical care for all four military services of the United States, was queried for the first occurrence of scaphoid fractures using International Classification of Diseases (ICD)-9 code 814.01. Data were evaluated using multivariate Poisson analysis, controlling for co-variate factors.

Results

We noted 14,704 scaphoid fractures in a population at a risk of 12,117,749 person-years. The unadjusted incidence of scaphoid fracture was 1.21/1000 person-years. Males were significantly more likely to sustain scaphoid fractures, with an adjusted rate ratio (RR) of 1.55 (95% confidence interval (C.I.), 1.47, 1.64), compared to females. The 20–24-year-old age group had the highest incidence of scaphoid fracture at 1.64/1000 person-years, and showed a significantly higher RR compared to the population aged greater than 40 years (adjusted RR 1.55, 95% C.I., 1.38, 1.66). Whites sustained scaphoid fractures at a significantly higher rate than African Americans (adjusted RR 1.32, C.I., 1.26, 1.38).

Discussion/conclusions

When compared to the previous data on scaphoid fractures, our study showed a greater incidence of scaphoid fracture at 1.21/1000 person-years in the US military population. These data are derived from a large database which effectively captures the population at risk. Males, the younger age group and the white race were associated with higher rates of scaphoid injury in this specialised military population.     

Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture

Background

This study aims to identify the physical examination tests most indicative of bone injury in patients with clinically suspected occult scaphoid fractures.

Methods

Ten physical examination manoeuvres were performed on 41 patients with a history of a fall on an outstretched hand and tenderness at the anatomical snuffbox and scaphoid tubercle without a radiographically visible fracture line. The results of wrist examination and subsequent magnetic resonance imaging (MRI) were recorded. The sensitivity, specificity, positive and negative predictive values, accuracy and likelihood ratio of the physical examinations were calculated for the patients who had bone injury confirmed by MRI.

Results

The distribution of MRI-confirmed conditions was as follows: 13 cases—no bone involvement; 12 cases—scaphoid fractures; 9 cases—fissures at the distal end of the radius; 6 cases—bone-bruise and 1 case—triquetral fracture. The symptoms most indicative of bone injuries were ‘pain during pinching by the thumb and index fingers’ and ‘pain during pronation of the forearm’.

Conclusion

The two above-mentioned manoeuvres were most indicative of bone injury in patients with clinically suspected occult scaphoid fracture. These examinations may reduce the number of unnecessary MRI examinations.     

Unusual combined scaphoid and lunate fracture of the wrist: a case report

All perilunate fracture-dislocations combine ligament ruptures, bone avulsions, and fractures in a variety of clinical forms. The most frequent is the dorsal trans-scaphoid perilunate dislocation. In rare cases, however, these dislocations also have been associated with capitate fractures, triquetral fractures, or lunate fracture. We report a combined scaphoid and lunate fracture of the wrist that was not associated with perilunate dislocation.     

Vascularized bone grafting and mini-acutrak fixation of scaphoid non-unions with avascular proximal pole

Objectives

We studied the use of vascularized bone graft as described by Zaidemberg et al. in combination with a fixation as described by Carter et al. in patients with scaphoid non-union and avascular proximal poles. We modified this method using a cannulated mini-acutrak screw.

Methods

Between January 2006 and June 2010, we treated 12 male patients with symptomatic scaphoid non-union with avascular proximal poles. Their average age was 26 years (range 18–47 years). The average follow-up was 16 months (range 6–52 months). All the patients were assessed for any persistent pain including grade of pain, any restriction of daily activities, and osteoarthritis.

Results

All patients achieved union within an average of 15 weeks (range 6–32 weeks). In all cases we encountered the 1, 2 intercompartmental supraretinacular artery (1, 2 ICSRA) intraoperative. X-rays and CT showed a complete osseous union in all patients.

Conclusions

We have found that the technique described which combines vascularized bone graft with cannulated mini-acutrak screw, is reliable and successful in treating patients with scaphoid non-unions with avascular poles. We prefer to use the vessel described by Zaidemberg et al. as the 1, 2 ICSRA. If this vessel is occasionally absent (present in 94%), as noted by Sheetz et al., other pedicles may be used.     

带血管蒂的桡骨瓣植入治疗陈旧性腕舟骨骨折

目的 探讨治疗陈旧性舟状骨骨折的手术方法。方法 对36例陈旧性舟状骨骨折，采用带血管蒂桡骨瓣加植骨术治疗。结果 36例骨折全部骨性愈合。骨折愈合时间，术后8周24例，10周8例，12周2例，15周2例。35例腕关节功能恢复达健侧标准，活动时无疼痛。1例较术前有改善，活动时疼痛。结论 该术式手术操作简单，舟状骨骨折端植入的带血管蒂骨瓣形成“骨桥”，与植入的松质骨及舟状骨建立血供，可缩短骨折愈合时间及提高骨折愈合率，是治疗陈旧性舟状骨骨折的一种有效的手术方法。     

Anthropometry of the human scaphoid

PURPOSE: Internal fixation has become a well-established alternative to casting for acute scaphoid fractures. Screw design has evolved, and several different types of screws of varying sizes are now available. The purpose of this study was to establish morphometric data for the human scaphoid, document variation in scaphoid dimensions between genders, and to evaluate symmetry in scaphoid measurements between the two sides. METHODS: We measured length, width, and morphology of the scaphoid in 30 paired cadaveric specimens with reference to the long axis of the scaphoid from the proximal pole to the distal articular surface. The width of the bone was compared with diameters of commercially available screws. RESULTS: When measured along an axis from proximal pole to the distal articular surface, male scaphoids (31.3 mm +/- 2.1) were significantly longer than female specimens (27.3 mm +/- 1.7). The male scaphoid was also significantly wider than the female specimen when measured perpendicular to the long axis 2 mm from the proximal pole (4.5 mm +/- 1.4 vs 3.7 mm +/- 0.5) and at the waist (13.6 mm +/- 2.6 vs 11.1 mm +/- 1.2). There was no significant difference in the distal pole diameter measured 2 mm from the tip between genders (7.2 mm +/- 1.0 vs 7.2 mm +/- 1.2). The diameters of most commercially available standard screws were larger than the proximal pole of the female scaphoid. CONCLUSIONS: Allowing for countersinking of the screw 2 mm beneath either pole, our data suggest the usual screw length will be 27 mm and 23 mm for male and female scaphoids, respectively. The small width of the proximal pole of the female scaphoid will not accommodate standard-sized screws from most manufacturers, and consideration must be given to distal to proximal screw placement or use of "mini" screws if the implant is to be inserted in a proximal to distal direction.     

Palmar-divergent dislocation of the scaphoid and the lunate

We describe a patient with palmar-divergent dislocation of the scaphoid and lunate. After successful closed reduction, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach, and the anterior capsule was sutured through the palmar approach. The scapholunate and lunotriquetral joints were fixed with Kirschner wires for 7 weeks. At the 1-year follow-up, magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate, and radiographs showed no evidence of the dorsal and volar intercalated segment instability patterns associated with carpal instability. However, flexion of the scaphoid and a break in Gilula’s line remained. To our knowledge, this is the first report showing treatment of palmar-divergent dislocation of the scaphoid and lunate by suturing the carpal interosseous ligaments.     

Outcome of routine bone scintigraphy in suspected scaphoid fractures

Undisplaced scaphoid fractures are easily missed on conventional scaphoid radiographs, but these occult fractures may seriously impair hand function. Routine bone scintigraphy (BS) is often advocated if there are clinical signs of a scaphoid fracture without radiological evidence. However, the results require careful therapeutic management. OBJECTIVE: To determine the diagnostic value of BS in daily practice for clinically suspected scaphoid fractures. METHODS: We evaluated our protocol of routine BS in suspected scaphoid fractures. SUBJECTS: In a retrospective study, we analysed 111 consecutive cases with signs of a scaphoid fracture on physical examination. Radiographs revealed 55 fractures, the remaining 56 patients all underwent BS. MAIN RESULTS: On average, the BS was performed after 4 days. It showed a fracture in 38/56 of the patients. The distribution of fractures was: scaphoid bone 15, distal radius 11, other carpal bones 9 and metacarpal bones 3. CONCLUSION: If there is a strong clinical suspicion of a scaphoid fracture, which cannot be confirmed by conventional radiology, BS is a valuable diagnostic tool.