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PubMed2005

Combined fractures of the scaphoid and distal radius: a revised treatment rationale using percutaneous and arthroscopic techniques.

Revision of the treatment rationale for combined fractures of the scaphoid and distal radius is based on evolution of treatment goals. The trend toward early recovery of hand function requires rigid fixation of both fractures before the start ofa hand therapy program. It is clear that prolonged immobilization of the scaphoid fracture jeopardizes early motion protocols for the distal radius. The fixation of unstable distal radius fractures with volar locking plates appears to offer the most stable construct to permit early motion. Evaluation, reduction, and fixation should be accomplished without disruption of the uninjured ligaments required for stable motion or the soft tissue envelope required for healing. Minimally invasive or percutaneous techniques are the meth-ods required. The tools needed are a clear understanding of anatomy, minifluoroscopic imaging units, and small-joint arthroscopy instruments. Many investigators advocate these techniques for scaphoid and distal radius fractures. It is only natural that these techniques should be used for these combined injuries. The key to success is a three-step process: (1)percutaneous reduction of the scaphoid fracture and provisional stabilization with a guide wire placed along its central axis, (2) percutaneous/arthroscopic reduction and rigid fixation of the distal radius fracture to permit early motion, and(3) fixation of the scaphoid fracture. This final step is accomplished by dorsal percutaneous implantation of a cannulated headless compression screw along the central scaphoid axis. Dorsal percutaneous fixation of scaphoid fractures with headless compression screws and rigid fixation of unstable distal radius fractures with a volar lock-ing plate system offer the most secure fixation. This small series suggests that the goals of early recovery of hand function can be accomplished using percutaneous/miniopen techniques for fracture reduction with rigid fixation and minimal risks.

Adolescent↗
PubMed2005

Scaphoid excision with four-corner fusion.

The scaphoid plays a critical role in maintain-ing normal carpal kinematics. SLAC and SNAC wrist arthritis demonstrate the ramifications ofscaphoid pathology on wrist biomechanics. In the past, symptomatic SLAC or SNAC pathology spelled total wrist arthrodesis. Over the past 20 years there has been a movement toward limited wrist arthrodesis in the treatment of SLAC/SNAC wrists. In the long-term follow-up of four-corner fusions, patient satisfaction is high, patients are able to return to their previous vocation, and wrist function averages 60%-70% of the contralateral wrist. The Spider plate is a recent advancement in the four-corner fusion armamentarium that has thus far shown great promise in respect to fusion rates (100% in the first documented series [36]),functional range of motion, intercarpal stability[37], and patient satisfaction.

Arthritis↗
PubMed2006

Idiopathic avascular necrosis of the scaphoid: Preiser's disease.

Preiser's disease, or idiopathic avascular necrosis of the scaphoid, is a rare, albeit often debilitating, condition. Although unknown, the etiology is probably multifactorial, with biomechanical or anatomical variations leading to an "at risk" scaphoid. Most commonly the diagnosis is made with the use of plain radiographs, but one should not hesitate to use MRI for both confirming the diagnosis and evaluating the stage of the disease. Current treatment algorithms are not standardized, and many scaphoids degenerate to a point that a salvage procedure is required. The authors attempt a revascularization procedure if the disease is caught early and the scaphoid has not yet gone on to collapse and degenerate. We save our salvage procedures for advanced cases with periscaphoid arthritis.

Humans↗
PubMed2005

Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques.

PURPOSE: To review the clinical and radiographic results of scaphoid excision and four-corner arthrodesis using a circular plate and screws compared with traditional fusion techniques (wires, staples, screws). METHODS: Fifty-eight patients with four-corner arthrodesis (plate fixation, n = 27; traditional fixation, n = 31) were evaluated for radiographic and clinical success using wrist radiographs and functional assays. Patients were subjectively surveyed using the standardized Disabilities of the Arm, Shoulder, and Hand questionnaire and classification scales for pain and satisfaction. Objective measurements included grip-strength and range-of-motion measurements. RESULTS: Radiographic analysis showed 26% nonunion with loose hardware in the plate group compared with 3% in the traditional group and 22% hardware impingement in the plate group compared with 3% in the traditional group. Clinical evaluation yielded a mean grip strength of 31 kg (70% of opposite side) for plate fixation and 33 kg (79% of opposite side) for traditional fixation. The mean flexion-extension arc was 48% and 50% of the opposite wrist for plate and traditional patients, respectively. The mean adjusted Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 27 out of 100 for plate patients and 8 out of 100 for traditional patients. Pain classification scores showed that only 2 patients in the plate group were pain free whereas there were 8 patients in the traditional group who were pain free. Overall patient satisfaction was 60% for the plate group whereas the traditional patient group reported 100% satisfaction. CONCLUSIONS: The rate of major complications (nonunion or impingement) was much greater with circular plate fixation (48%) versus traditional fixation techniques (6%). With the plate procedure the grip strength and arc of motion decreased approximately 30% and 52%, respectively, compared with decreases of 21% and 50%, respectively, for traditional fusion methods. Additionally, subjective patient dissatisfaction was 40% in the plate group compared with 0% in the traditional group. We postulate that the increased complication and dissatisfaction rates associated with plate fixation may be attributable to possible biomechanical imperfections or increased technical demands with this fusion system.

Adolescent↗
PubMed2006

Resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed previous surgical treatment.

PURPOSE: To evaluate the results of resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed prior surgical treatment. METHODS: Thirteen patients who were treated with resection of the scaphoid distal pole for persistent nonunion after previous surgical treatment were included in this study. The mean follow-up period was 5 years. Evaluation included measurement of wrist range of motion, assessment of pain, and evaluation of radiographic parameters. The Disabilities of the Arm, Shoulder, and Hand score was used to determine the functional outcome after the excision. RESULTS: Before surgery all but 1 patient reported pain. After surgery 2 patients presented with mild pain during strenuous activity. Mean wrist flexion and extension increased significantly, by 23 degrees and 29 degrees, respectively. The postoperative Disabilities of the Arm, Shoulder, and Hand score was 25 +/- 19 points. There was a significant increase in the radiolunate angle, indicating dorsal intercalated segment instability deformity in 6 patients. CONCLUSIONS: Scaphoid distal pole excision remains a valuable treatment option for patients for whom multiple attempts at union have failed previously and who have no associated complete scapholunate ligament tears. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Adult↗
PubMed2005

Carpal ligament injuries with acute scaphoid fractures - a combined wrist injury.

Fifty-two consecutive patients with acute scaphoid fractures were treated by closed reduction and percutaneous screw fixation. In addition, all underwent a wrist arthrogram and 22 patients also underwent a wrist arthroscopy. Eighteen patients (34%) had an associated carpal ligament injury (four scapholunate ligament, eight lunotriquetral ligament, two combined, three TFCC and one minor leak from the distal carpal row). These patients had worse Mayo wrist scores (no ligament injury median score=95: ligament injury median score=85) at a mean final follow-up of 61 weeks. We advocate that scaphoid fractures with associated carpal ligament injuries should be defined as a combined wrist injury.

Adolescent↗
PubMed2006

Scaphotrapeziotrapezoid joint arthritis: a pilot study of treatment with the scaphoid trapezium pyrocarbon implant.

Isolated scaphotrapeziotrapezoid osteoarthritis is rare but can cause weakness and wrist pain. We present the results of a pilot study of interposition arthoplasty with a scaphoid trapezium pyrocarbon implant (STPI) by an open and arthroscopic approach for this problem. We performed this procedure in 10 hands in eight patients, all women, with a mean age of 60.5 (range 51-70) years. The average follow-up was 19 (range 2-24) months. Pre-operative X-rays in all cases identified an isolated degenerative arthritis of the scaphotrapeziotrapezoid joint. Average DASH evaluation pre-operatively of 49 was reduced to 39. All of the patients had functional improvement and returned to daily activities after 3 months. The results of this pilot study suggest that the STPI may prove a useful compromise treatment for this problem.

Aged↗
PubMed2003

[Non-traumatic osteoarthritis of the wrist: chondrocalcinosis].

Post-traumatic arthritis of the wrist is a common disorder, mostly after scapho lunate or scaphoid injury. Some patients in our experience and in literature have no known trauma, are bilateral and have a mean age much higher than usual post-traumatic cases. Radiological (during an often-extensive medical history) and biological studies of these patients led us to think there is a form of chondrocalcinosis of the wrist, with a four stages evolution, similar to SLAC and SNAC wrist but with often no scapho lunate gap, vertical embedding of the scaphoid in the radius and chalky incrustation of the joint. We called that form of dislocation of the carpus: scaphoid chondrocalcinosis advanced collapse or SCAC wrist. Surgical treatment of advanced cases is described. Scaphoidectomy and resection of triquetrum are performed, associated with hamato-luno-capitate fusion. Other rare forms are described and literature (mostly radiological and rheumatological because these patients are often been mistaken as SLAC wrist) is studied.

Chondrocalcinosis↗
PubMed2004

[Coronal fractures of scaphoid].

Two cases of frontal fracture of the scaphoid proximal pole after a high energy trauma are reported. Diagnosis was delayed in both cases and was only possible with a CT-scan. One fracture was slightly displaced: the patient was treated conservatively and followed during 11 years with an excellent result. The other patient was operated on because of persistent pain and malunion. Only during surgery was the correct diagnosis made and due to scaphoid malunion, a proximal row carpectomy was performed. At a post operative assessment, in both cases, X-rays showed a double contour of the proximal pole of the scaphoid. We believe than an arthroCT-scan or MRI is necessary to assess the fracture displacement and search for an associated ligamentous injury.

Adult↗
PubMed2006

[Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis].

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.

Adult↗
PubMed2003

Scaphoid and pronator fat stripes are unreliable soft tissue signs in the detection of radiographically occult fractures.

AIM: To determine the clinical value of scaphoid and pronator fat stripes in identifying occult underlying scaphoid and distal radius fractures, respectively. MATERIALS AND METHODS: In our department, all patients with clinically suspected scaphoid fractures and normal scaphoid series of radiographs undergo magnetic resonance imaging (MRI) of the wrist. We selected 50 cases with unequivocal MRI evidence of scaphoid fracture, 50 cases with distal radius fracture and 50 cases with no MRI evidence of bony injury. All 150 initial plain radiographs were examined retrospectively in random order without knowledge of the MRI findings and the scaphoid and pronator fat stripes scrutinized. RESULTS: The scaphoid fat stripe was abnormal in only 25 cases (50%) with confirmed scaphoid fracture on MRI. The pronator fat stripe was abnormal in 13 cases (26%) with confirmed distal radius fracture. In the 50 cases with no MRI evidence of bony injury, the scaphoid fat stripe and pronator fat stripe were abnormal in 25 (50%) and 15 (30%) cases, respectively. The sensitivity and specificity for an abnormal scaphoid fat stripe was 50%. The sensitivity and specificity for an abnormal pronator fat stripe was 26 and 70%, respectively. CONCLUSION: Scaphoid and pronator fat stripes are poor predictors of the presence or absence of underlying occult fractures.

Adipose Tissue↗
PubMed2001

Arthroscopic and open management of dynamic scaphoid instability.

This article focuses on the pathophysiology and treatment of dynamic scaphoid instability. Cadaver studies suggest that dynamic instability results from isolated injury to the scapholunate interosseous ligament without damage to the dorsal intercarpal and dorsal radial lunotriquetral ligaments. The diagnosis may be made by dynamic fluoroscopic examination, including stress and load views. The role of arthroscopy is twofold: (1) it enables the surgeon to distinguish between a complete, grossly unstable scapholunate interosseous space that requires open treatment and (2) it permits direct visualization of the reduction and percutaneous pinning of the articulation in an effort to stabilize the joint. Operative indications, open and arthroscopic techniques, and results are discussed.

Arthroscopy↗
PubMed2003

Scaphotrapezial joint arthroscopy: a palmar portal.

PURPOSE: Arthroscopy of the scaphotrapezial trapezoid (STT) joint is performed traditionally through a dorsal radial midcarpal portal. This portal allows visualization of the dorsal rim of the STT joint but is difficult to approach owing to lack of surface landmarks and it passes close to the radial artery and nerve. The purpose of this study was to assess the safety, ease of access, and visualization of the STT joint through a palmar portal. METHODS: Five cadaveric wrists were dissected initially to identify the anatomy around the palmar aspect of the STT joint and to identify a safe route for an arthroscopic portal. A further 5 cadaveric wrists then were used to confirm the efficacy of the portal. RESULTS: A palmar portal to the STT joint can be established 3 mm ulnar to the abductor pollicis longus tendon, 6 mm radial to the scaphoid tubercle, and midway between the radial styloid and base of the first metacarpal. CONCLUSIONS: A palmar arthroscopic portal to the STT joint can be identified readily because of the palpable surface landmarks, improves the visualization of its articular surface compared with a dorsal portal because of the orientation of the joint, is safe, and provides a second portal through which therapeutic interventions may be considered.

Arthroscopy↗
PubMed2003

Results of arthroscopic debridement for isolated scaphotrapeziotrapezoid arthritis.

PURPOSE: Symptomatic isolated scaphotrapeziotrapezoid joint arthritis affects approximately 10% of the population. Investigation of the technique of arthroscopic debridement of this joint was done to assess symptom relief achieved and record any resulting postoperative morbidity. METHODS: Ten consecutive patients with persistent symptoms were assessed prospectively by a research nurse. Measurements of range of motion and grip strength were obtained before and after surgery. Visual analogue scores for pain and satisfaction levels also were recorded and any limitation to activities of daily living were noted. RESULTS: Good or excellent subjective results were achieved in 9 patients at final review at an average of 36 months (12-65 mo) after arthroscopic debridement. One patient graded the result as fair owing to failure to achieve normal range of motion. All patients showed a reduction in visual analogue pain scores, which improved from a mean of 86 to 14 points. The mean Green and O'Brien wrist scores improved from 63 to 91. CONCLUSIONS: Arthroscopic debridement can provide good short-term symptomatic relief for isolated scaphotrapeziotrapezoid arthritis with low risk for surgical complications.

Adult↗
PubMed2000

[A adaptive proximal scaphoid implant].

INTRODUCTION: In this study, the insertion of a pyrocarbon implant (APSI) has been described, which is shaped to allow adaptive mobility during carpal movement in the first row of carpals. This implant replaces the proximal part of the scaphoid; it is designed to treat styloscaphoid arthritis, and to prevent further deterioration and carpal collapse by restoring the first carpal row to its original height, i.e., 'SNAC wrist' after scaphoid pseudoarthritis, and 'SLAC wrist' following scapho-lunate dissociation. MATERIALS AND METHOD: This retrospective series included 25 cases which were examined and analyzed at an average of six years post-surgery (between three and ten years) by an independent observer using the EVAL expert database system: 1) 14 cases involved pseudoarthritis, which developed from the scaphoid ('SNAC wrist'); 2) ten cases were connected with scapho-lunate nonunion ('SLAC wrist'); 3) one case involved carpal collapse with siliconite, which had previously been inserted as a scaphoid silicone partial implant for the treatment of pseudoarthritis involving a stage II fracture. RESULT: In all cases, the reason for the preoperative-consultation for degenerative arthritis was the presence of pain, which post-surgery was no longer apparent in 60% of cases, and only persisted during effort in 28% of cases. Thus 88% of the patients were satisfied with the results, and were able to resume their normal professional and sports activities at the same level as before. Strength connected with digitopalmar grip and pinch force were found to have increased compared to the function in the healthy hand. No implant dislocation was detected by radiological investigation. Dynamic X-rays of the implant in flexion, extension, and frontal inclination confirmed this adaptive mobility. Carpal height was in all cases maintained. The radio-lunate angle remained unchanged in 15 cases, was improved in six cases, and was worse in four cases. Two poor results were connected with severe ligament lesions prior to surgery. CONCLUSION: The preliminary results regarding the APSI implant seem to be promising for cases of polar pseudoarthritis in which curative treatment is no longer possible. This technique avoids further deterioration and carpal collapse ('SNAC wrist'). However, in cases of scapho-lunate nonunion ('SLAC wrist') where ligament lesions are severe, this method does not resolve the problem of ligament destabilization, which requires further treatment.

Adult↗