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PubMed2005

Carpal fractures in children.

Carpal injuries in children are relatively rare. Diagnosis is likely to be missed, or the severity of the injury might not fully be appreciated at the time of presentation. Fortunately, in the majority of cases the fracture heals uneventfully with a low incidence of complications. As in adults, the scaphoid is most susceptible to injury and the capitate, which often presents in association with other carpal bone injuries, the next most susceptible. Other carpal bone fractures are very unusual and the literature largely is confined to case reports or very small series. This review article lists the common carpal injuries in children and suggests a treatment plan in each case, emphasizing the importance of having a high index of suspicion when faced with a child with a wrist injury and seemingly normal radiographs.

Adolescent↗
PubMed2004

A kinematic model of the wrist based on maximization of joint contact area.

The wrist is a complex joint and the factors governing its behaviour are poorly understood. A hypothesis that the movement of the carpal bones could be predicted using a minimum energy principle was tested. Carpal bones were dissected from a cadaveric forearm and their shapes were laser-digitized to obtain three-dimensional computer models. A computer program was created to measure contact area between neighbouring articular surfaces and to maximize this quantity by adjusting the six degrees of freedom of the bone models. This procedure was performed for 1.0 degree increments of rotation applied to the capitate bone up to 20 degrees of ulnar and 10 degrees of radial deviation. The model correctly predicted certain aspects of the complex behaviour of the carpal bones. The results for the scaphoid in particular displayed characteristics in common with known behaviour of this bone. During 20 degrees of unlar deviation and 10 degrees of radial deviation, the bone demonstrated 11.3 degrees of extension and 9.4 degrees of flexion respectively. The novelty of the study lay in the fact that the model did not rely upon ligamentous constraints. The results are encouraging, considering the only information used by the algorithm was the shape of the articular surfaces.

Biomechanical Phenomena↗
PubMed2005

Osteoblastoma of the scaphoid: a case report.

Osteoblastoma is an uncommon primary bone tumor that rarely is found in the hand or wrist. Recurrent osteoblastomas often have a more aggressive appearance than the original tumor, and differential diagnosis from osteosarcoma is difficult. The pain that can accompany this tumor is debilitating. Therefore, successful treatment requires complete removal of the tumor. The purpose of this report is to present an unusual case of osteoblastoma of the carpal scaphoid. This tumor was treated successfully by curettage and bone grafting. At 1 year postoperatively, the patient presented with a stable, painless wrist with full range of motion.

Adult↗
PubMed2001

Distal radius epiphysiolysis associated with scaphoid fractures in immature patients: report of two cases and review of the literature.

Two cases of carpal scaphoid fractures associated with distal radius epiphysiolysis are presented. Only three cases of this unlikely combination were found in the English literature. One of the scaphoid fractures had to be confirmed by bone scan. Conservative treatment after gentle reduction of the radius fracture gave excellent results.

Accidental Falls↗
PubMed1999

Scaphoid nonunion and flexor pollicis longus tendon rupture.

Four patients presented with a rupture of the flexor pollicis longus tendon that was associated with a longstanding scaphoid nonunion. A radiocarpal arthrosis was present in 3 of the 4 patients and a dorsiflexed intercalated segment instability deformity was also seen in 3 of the 4 patients. Three patients underwent surgery consisting of an osteosynthesis with an iliac bone graft for the scaphoid nonunion and a palmaris longus tendon graft for the ruptured flexor pollicis longus tendon. An osseous union of the scaphoid and a functional active range of motion of the thumb interphalangeal joint (33 degrees on average) was attained in all 3 of the patients treated surgically. Preoperative radiologic examinations and intraoperative findings suggest that the volarly protruding distal scaphoid segment is the cause of the rupture.

Aged↗
PubMed2001

Anatomy and histology of the scapholunate ligament.

The scapholunate ligament links the scaphoid to the lunate. It runs transversally at its posterior aspect and obliquely at its anterior aspect, allowing significant relative motion between the two bones. From the neutral position to the full extension position, the lunate rotates by 28 degrees and the scaphoid by 30 degrees; from the neutral position to the full flexion position, the lunate rotates by 30 degrees, whereas the scaphoid rotation is 60 degrees because of the motion of the scaphoid around the capitate. The ligament's dorsal part is shorter and more resistant than the anterior part, allowing a pseudodissociation during flexion. Kauer described an additional movement of the scapholunate pair attributable to differences in the shapes of the scaphoid and lunate proximal poles. The scaphoid curve is more important and the scaphoid needs to glide on the lunate to maintain radioscaphoid congruity. As a result, there is sagittal ligament torsion. This can be a partial explanation for failure of scapholunate arthrodesis. This description of the scapholunate ligament is of interest to understand the relative importance of the three parts of this ligament. It can, in particular, explain the failure of ligamentous reconstruction that considers the scapholigament as a homogeneous structure. In addition, the three parts do not have the same tensile strength. The posterior part is the most resistant to tear forces and needs more than a 300 N tensile stress to fail. The anterior part fails with 150 N stress and the intermediary portion can withstand only a 25 N to 50 N stress. In comparison, the triquetrolunate ligament (which is also divided in three parts--anterior intermediate, and posterior) has failure coefficients opposite those of the scapholunate ligament: The anterior part is more resistant (300 N) than the posterior (150 N); the intermediate part has the same tensile strength as the scapholunate intermediate part. These biomechanical studies demonstrate the importance of the scapholunate ligamentous posterior part in controlling flexion and extension motion and the anterior part for rotational control. Both parts of the ligament are necessary for an harmonious functioning of the scapholunate pair.

Biomechanical Phenomena↗
PubMed1993

[Partial arthrodesis of the carpal bones in advanced carpal collapse in chronic scapho-lunar instability and following scaphoid pseudoarthrosis].

Degenerative arthritis of the wrist as a consequence of chronic scapho-lunate instability or chronic scaphoid non-union follows very specific patterns. Joint destruction occurs primarily in the radio-scaphoid and in the luno-capitate joints while the radio-lunar joint is preserved. Treatment by partial carpal fusion between capitate, scaphoid and lunate aims at reconstruction of correct length of the central column and restoration of normal carpal height by reducing the dorsiflexed lunate bone, thereby decompressing the painful radio-scaphoid joint. We have carried out the procedure in 21 cases. At follow up (19 months) 17 patients were free of pain and 4 patients experienced major improvement but had some residual pain. The mean range of motion of the wrist was 57 degrees, representing a loss of 34% of preoperative range of movement. Bony union was achieved in all cases. All patients returned to their former occupation. Partial carpal fusion for treatment of SLAC-wrist and scaphoid nonunion has proven successful with respect to pain relief and partial preservation of wrist motion avoiding complete fusion or arthroplasty of the wrist.

Adult↗
PubMed2004

The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability.

PURPOSE: Scapholunate instability (SLI) is the most common carpal instability. Recent studies have suggested that the dorsal intercarpal (DIC) and the dorsal radiocarpal ligaments play an important role in stabilization of the scaphoid and lunate. Differences between dynamic SLI and static SLI with a dorsal intercalated segment instability (DISI) are clearly described in the clinical literature; however, there has never been a clear explanation of the anatomic differences. This study describes the role of the DIC in the development of dynamic and static SLI with DISI in a cadaver model. METHODS: Five fresh cadavers were studied radiographically and by 3-dimensional digitization. Six increasing stages of instability were developed by sectioning progressively the following structures: the dorsal capsule, the palmar and proximal (membranous) portion of the scapholunate interosseous ligament, the DIC from its insertion on the scaphoid and trapezium, the dorsal scapholunate interosseous ligament from the scaphoid, the DIC ligament from its attachment on the lunate, and the lunotriquetral interosseous ligament. RESULTS: The scaphoid position and the scapholunate gap changed significantly after sectioning the entire scapholunate interosseous ligament and DIC from the scaphoid when a 5-kg load was applied. The lunate position was unchanged in both the loaded and the unloaded conditions. After detaching the DIC from the lunate, both the scaphoid and lunate moved and the scapholunate gap increased significantly in both loaded and unloaded conditions and showed a DISI deformity. CONCLUSIONS: This study describes an anatomic difference between dynamic and static scapholunate instability. Complete disruption of the scapholunate ligament did not result in the development of a static collapse of the lunate. The DIC had an important role in stabilizing the scaphoid and lunate and preventing DISI deformity. This study suggests that in the clinical setting the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction of the DIC ligament attachments to both the scaphoid and the lunate.

Aged↗
PubMed2001

Temporary ischaemia of the scaphoid in a child.

We describe a case of a 12-year-old boy who developed acute ischaemia of the entire scaphoid following simple trauma to the wrist. No fracture was evident; however, MRI and bone scintigraphy at the time of the injury revealed complete ischaemia of the scaphoid. A repeat MRI at 6 months showed evidence of incomplete revascularisation of the scaphoid.

Child↗
PubMed1997

Ununited proximal pole scaphoid fractures. Treatment with a Herbert screw in 16 cases followed for 0.5-8 years.

We treated 16 cases of delayed union and nonunion of proximal one-third scaphoid fractures with cancellous bone grafting and retrograde insertion of a Herbert screw through a dorsal approach. Definite radiographic union was obtained in 13 of 16 patients after a median of 2 (0.5-8) years of follow-up. Using Cooney's clinical scoring system, 5 cases were excellent, 5 good, 5 fair and 1 poor. The treatment of ununited proximal pole scaphoid fractures with retrograde insertion of the Herbert screw offers the advantages of a short period of immobilization and a good function.

Adolescent↗
PubMed1992

High-resolution bone scintigraphy of the adult wrist.

Bony anatomic landmarks of the wrist (e.g., pisiform, hook of hamate, radioulnar joint, and styloid processes of the radius and ulna) were routinely identified in 28 adult patients examined for wrist pain. With the wrists prone and immobilized, bone scintigrams were obtained for 500,000 counts with an asymmetric (133 to 161 keV) Tc-99m energy window and either a converging (best choice) or straight-bore, high-resolution collimator. High-resolution scintigraphy precisely localized degenerative joint disease (nine patients), scaphoid fractures (five), pisiform fracture (one), lunate avascular necrosis (one), radioulnar arthritis (one), septic or inflammatory arthritis (six), ulnocarpal impingement (two), and reflex sympathetic dystrophy syndrome (two). Images obtained palm down with the wrist in ulnar deviation helped identify increased uptake within the scaphoid. Fracture and significant bone or joint disease were excluded in one patient.

Adult↗
PubMed1999

Proximal scaphoid nonunion-osteosynthesis.

Proximal pole fractures of the scaphoid have a high incidence of nonunion and avascular necrosis. Because of their poor prognosis, the treatment of these fractures remains controversial. 102 patients with symptomatic nonunion of the proximal pole were treated by simple osteosynthesis, using retrograde screw fixation through a direct dorsal approach to the scaphoid. Fracture preparation and bone grafting were kept to a minimum, in order to preserve as much bone stock as possible, and to avoid damage to the already compromised vascularity of the proximal fragment. No postoperative splinting was used and most patients were able to return to their normal work within a few weeks of surgery. 69 patients were followed-up at an average of 34 months. 59 (85%) were asymptomatic, and had regained excellent wrist function, in spite of the fact that sound radiological union was present in only 50% of these. Union was often slow (3 to 36 months) and appeared to be related to the vascularity of the bone fragments. However, even when bone union was incomplete, the fracture remained stable, with no loss of fixation. The ten patients with unsatisfactory results had all developed late avascular necrosis of the proximal pole, requiring salvage surgery. Stable internal fixation of proximal pole nonunion leads to rapid symptomatic improvement in the majority of cases and sets the scene for revascularisation and healing. Even when union is incomplete the scaphoid remains intact, thus preserving excellent wrist function and, at the same time, offering the best possible long term prognosis.

Adolescent↗