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PubMed2002

Subchondral bone mineral density patterns representing the loading history of the wrist joint.

Ten cadaver wrists were examined with CT-Absorptiometry in order to assess bone density in the subchondral bone. In normal wrists the distal radius contained two centroids of bone density, one in the lunate fossa and another in the scaphoid fossa. Pathologically altered wrists showed a shift in bone density towards the scaphoid fossa, with the subchondral bone in the lunate fossa and distal ulna becoming less dense. Bone density patterns in the wrist reflect the long-term force transmission. As bone density alters according to loading conditions, this method can be used to determine force transmission patterns before and after wrist surgery.

Absorptiometry, Photon↗
PubMed1998

Vascularised bone graft applications in upper extremity problems.

Between 1990 and 1996, 16 cases of bone defects were treated by vascularised bone grafting by the authors. Free vascularised fibula was used in 10 cases and one free iliac crest graft was used for upper extremity bone defects. Four vascular pedicled first metacarpal bone and one radial styloid bone were used for scaphoid nonunion. Average follow-up was 26 months (6-78 months) and success rate was 94%. We recommend vascularised bone grafts in the upper extremity when there is risk of infection; the defect is greater than five centimeters when the forearm rotation is unlimited. The avascularity of the scaphoid pseudarthrosis must be verified radiologically or through magnetic resonance imaging. This technique should only be used when other reconstructive techniques are unlikely to succeed.

Adolescent↗
PubMed2001

Scaphoid injuries in children.

In order to establish an acceptable working protocol for the care of children with scaphoid injuries, an independent study was undertaken by the author. This paper describes the various aspects of this study: understanding what the scaphoid is and its function, the correct examination of the hand and wrist and the rationale behind it, the rationale behind the current treatment of suspected scaphoid injuries, and the development of the carpal bones and skeletal age. Opinions differ as to what age the scaphoid develops and therefore when it may be fractured, and so a review of research and literature on scaphoid injuries is also outlined.

Adolescent↗
PubMed1999

DISI Deformity and Post-Operative Symptoms of Scaphoid Non-Union.

The correlation between the residual dorsal intercalated segmental instability (DISI) deformity and symptoms of the wrist was investigated in 20 patients with healed scaphoid non-union who had open reduction and bone grafting. In seven patients, inlay corticocancellous bone grafting (modified Russe procedure) was performed. In four of the seven patients, an additional Herbert bone screw was used for internal fixation. The remaining 13 patients were treated with open reduction, anterior bone grafting, and internal fixation with Herbert bone screw. Average duration of follow-up period after operation was 20 months (range, 6 to 57 months). The average extension-flexion arc of the injured wrists was 129 degrees, which was 31 degrees less than that of the uninjured wrists. The average grip strength of the injured wrists was 89% of that of the uninjured wrist. Before the operation, all 20 patients were symptomatic and complained of wrist pains. Post-operatively, three patients experienced mild pains and only one complained of moderate wrist pains. Post-operative radiolunate angle ranged from 0 degrees to 34 degrees (average 10 degrees ). DISI deformity remained uncorrected in eight patients. Post-operative symptoms were compared amongst the eight patients who had DISI deformity and 12 patients who had no deformity. There was no significant difference in range of motion, grip strength, and incidence of pain between these two groups of patients. The presence of DISI deformity after bone grafting for a symptomatic scaphoid non-union was not predictive of post-operative symptoms of the wrist.

Journal Article↗
PubMed1995

A contact-coupled finite element analysis of the radiocarpal joint.

A plane-strain finite element contact model of the radiocarpal joint has been developed to investigate the mechanical relationship between initial intra-articular fracture of the distal radius, subsequent imprecise reduction of articular incongruency, and final onset of osteoarthrosis. The model includes the radius, two carpal bones (the lunate and the scaphoid), and the articulations and ligamentous connections between the bones. The model has been validated through comparisons with previous experimental and computational models of the wrist. The relationship between malreduced intra-articular fracture of the distal radius and the subsequent onset of posttraumatic radiocarpal osteoarthrosis is clinically important but poorly understood. The broad objective of the current research is the development of a well-verified computational model of the radiocarpal joint, which in concert with previously developed experimental models, will be capable of providing guidance toward rigorously grounded improvements in distal radius intra-articular fracture management techniques. This model represents a first step toward this objective as well as a new level of computational simulation of wrist mechanics.

Biomechanical Phenomena↗
PubMed2006

Scaphoid fracture in children.

Scaphoid fractures in children are uncommon. A high index of suspicion is required in children when clinical signs and symptoms indicate a scaphoid fracture in a child. Radiographic evaluation with multiple views should be performed to assess for fracture. If necessary, advanced imaging studies such as MRI should be performed. Most scaphoid fractures can be treated with cast immobilization, which results in healing in the vas majority of cases. Scaphoid nonunion is usually the result of delayed presentation or missed diagnosis. Fortunately union can be achieved reliably with cast immobilization or surgical fixation.

Casts, Surgical↗
PubMed2005

The carpal bones: a basic test of medical students' and junior doctors' knowledge of anatomy.

With the changing emphasis of the modern medical school curriculum, many senior doctors and authors are commenting on a decline in anatomical knowledge of trainees. This study was conceived to provide a snapshot of medical students' and junior doctors' knowledge of anatomy. The carpal bones were chosen as a benchmark for anatomical knowledge as they are easily objectively examined and have clinical relevance to junior doctors in a number of disciplines. Twenty five fourth and final year medical students, fifteen pre-registration house officers (PRHOs) and ten senior house officers (SHOs) were recruited and the questionnaires were completed in the presence of one author. Of all participants recruited only fifteen could correctly name all eight carpal bones. Seven of these were SHOs in Surgery or Accident and Emergency (A&E). Seventeen medical students (68%) and nine PRHOs (60%) correctly identified less than five carpal bones. Most SHOs (90%) could name five or more bones; the proportion of PRHOs and medical students correctly naming more than five bones was similar (40% vs 32%). The scaphoid was the most frequently identified bone, with an accuracy of 92%. Only 15 candidates (30%) managed to name the triquetrum. The overall recognition scores obtained by medical students was poor, however the SHO's results were more reassuring. Anatomy teaching should be encouraged in undergraduate and postgraduate training.

Carpal Bones↗
PubMed2006

Minimally invasive management of scaphoid nonunions.

UNLABELLED: Not all proximal pole scaphoid nonunions with avascular necrosis require vascularized bone graft or a formal open incision. If the distal scaphoid is well perfused and the proximal pole can be secured rigidly after percutaneous bone grafting, then nonunion repair and healing can proceed. We describe minimally invasive techniques that permit fracture site débridement, establishment of distal perfusion by central axis reaming, arthroscopic assessment of perfusion, percutaneous bone grafting, and rigid internal fixation. As surgeons develop new minimally invasive techniques, it is still imperative to continue to base treatment on scaphoid nonunion pathology and the key principles in the treatment of any non-union. LEVEL OF EVIDENCE: Level V (expert opinion).

Arthroscopy↗
PubMed1995

Iliac crest bone grafting and Herbert screw fixation of nonunions of the scaphoid with avascular proximal poles.

Between 1989 and 1991, 137 nonunions of the scaphoid were treated by the senior author, who noted that 26 of these nonunions had an avascular proximal pole (no punctate bleeding from the bone at the time of surgery). All 26 nonunions were treated with iliac crest bone grafting and Herbert screw fixation. Of these 26 patients, 17 were followed for more than 1 year after their surgery (average follow-up period, 31 months). The average time from injury to surgery was 31 months. Of the 17 patients included in this study, 12 were treated with a palmar approach to the nonunion, 5 with a dorsal approach. The 12 nonunions that occurred at either a midwaist or distal location were approached through a palmar modified Russe incision and treated with interpositional corticocancellous iliac crest bone graft in addition to the Herbert bone screw. The five nonunions with a very small proximal fragment were approached through a dorsal incision and treated with cancellous iliac crest bone graft and Herbert screw fixation. All patients were immobilized after operation in a short-arm thumb spica cast for 3 months and were then allowed active range of motion of their wrists. Return to full activity was permitted once preoperative wrist motion was restored. Radiographic union, as defined as bridging trabeculae of bone present in all x-ray films, occurred in nine patients, an incomplete union or persistent fibrous union in seven, and a nonunion in one patient. Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength, and patient satisfaction, functional results were graded as excellent in six patients, good in five patients, fair in four patients, and poor in two patients. The average range of motion of the wrist did not significantly improve after surgery, but the average grip strength of the injured hand increased by 29 lbs. There were no intraoperative complications. However, three patients required further operative procedures including radial styloidectomy, pin removal, and carpal tunnel release. No patient has required either a proximal row carpectomy or wrist arthrodesis. Previously published results of avascular proximal pole scaphoid nonunions suggest that union cannot be obtained and functional results are uniformly poor. In contrast, the functional and x-ray results of our patients are markedly improved over these previous studies--emphasizing the importance of iliac crest bone grafting, rigid internal fixation, and appropriate postoperative immobilization.

Adolescent↗
PubMed1999

The Ununited Scaphoid:Prognostic Factors in Delayed and Nonunions of the Scaphoid.

This study attempts to classify scaphoid nonunions, identify the prognostic indicators of scaphoid nonunions and report the clinical, functional and radiographic results of scaphoid nonunions treated by Herbert screw and bone grafting. The patient population included 51 scaphoid nonunions in 50 patients treated by Herbert screw with or without bone graft. Group I was patients with delayed union; Group II was stable nonunions, Group IIIA consisted of unstable nonunions without DISI; Group IIIB included unstable nonunions with DISI deformity. Although the overall union rate was 84%, 87% stable nonunions (Groups I and II) united compared to only 60% unstable (Groups IIIA and B). This was statistically significant using the Chi-square test at p < 0.05. Thus, delayed unions and stable nonunions unite readily but unstable and displaced nonunions have significantly lower rates of union even after Herbert screw and bone grafting.

Journal Article↗
PubMed2005

Trapezium fracture associated with occult fracture of the proximal pole of the scaphoid.

There has been no case of simultaneous fracture of the trapezium and the proximal pole of the scaphoid. We have treated a case with this combination. The fracture of the proximal pole of the scaphoid was only found on computed tomography imaging. We performed accurate reduction and fixation of both fractures with cannulated headless compression screws in a minimally invasive technique. We obtained rigid initial fixation and good clinical and radiographical results.

Adult↗
PubMed2006

Failure of surgery for scaphoid non-union is associated with smoking.

Scaphoid fractures predominantly affect young men, in whom the UK smoking prevalence approaches 40%. We examined the association between smoking and failure of non-vascularized bone grafting and screw fixation for scaphoid non-union and delayed union in a retrospective cohort study. Adequate follow-up was obtained in 64 of 87 patients treated (74%). Union was defined as the presence of trabecular continuity on at least two films from a four-view radiographic series. Union was achieved in 47 of 64 cases. Seventeen were smokers. Thirteen of the 17 patients with non-union were smokers (relative risk 3.7; 95% CI: 1.3-10.1, p=0.005). Proximal pole fractures, long injury-grafting interval and non-compliance were not more frequent in smokers than non-smokers. Smoking is strongly associated with failure of union after screw fixation and non-vascularized bone grafting of the scaphoid. Smokers should be advised to avoid smoking pre-operatively and during the healing period.

Adult↗
PubMed2001

Anatomic placement of the Herbert-Whipple screw in scaphoid fractures: a cadaver study.

An anthropometric cadaver study was performed to determine the optimal placement of a Herbert-Whipple screw in the scaphoid. Twenty pairs of cadaver wrists were examined and anthropometric analysis of the scaphoids using plain radiography, computed tomography, and en bloc resection was performed. Scaphoid vascularity was evaluated using India ink injection. Radiographic and actual measurements of height and width confirmed symmetry in paired scaphoids. Anatomic evaluation defined a safe zone for screw placement. K-wire placement defined the extent of this zone. The entry point of this zone was found by moving dorsally and distally 15% of the lateral radiographic length of the contralateral scaphoid from the volar aspect of the scaphoid tuberosity. Moving 10% of this same length from the membranous central portion of the scapholunate ligament defined the target site. Computed tomography confirmed proper position of the screw to maximize bony purchase and avoid articular penetration while maintaining dorsal vascular integrity.

Anthropometry↗
PubMedDate not supplied

Evaluation of the Kidner procedure in treatment of symptomatic accessory tarsal scaphoid.

The Kidner operation is a successful method of treatment for symptomatic feet with Type II and Type III accessory tarsal scaphoids that do not respond to conservative methods of treatment. The success of this operation is related more to the elimination of the bony prominence on the medial aspect of the foot and its mechanical irritation than to the correction of the pronated foot by means of posterior tibial tendon transfer. The age of occurrence of symptoms can be correlated with the level of physical activity and ossification or growth of this accessory bone. Symptoms in older patients develop after injury. The pronated foot or mechanically insufficient foot increases the stress on the bony prominence of the accessory tarsal scaphoid bone and precipitates in symptoms.

Adolescent↗