Systematic approach to identifying fourth and fifth carpometacarpal joint dislocations

Dislocations of the carpometacarpal (CMC) joints are rare injuries which often have subtle radiographic findings that may be overlooked. A systematic approach for evaluation of the carpometacarpal joints is developed from analyzing the radiographic findings in 17 cases of CMC dislocations at the fourth and fifth CMC joints. Principles of parallelism, symmetry, overlapping articular surfaces, indistinct cortical rim, and parallel M lines are used in this evaluation. Ten patients had combined fourth and fifth CMC joint dislocations and seven had solitary dislocations at the fifth CMC joint. Most of these CMC dislocations are dorsal (71%). In combined fourth and fifth CMC joint dislocations, loss of parallelism and symmetry is observed at the fourth CMC joint with overlap identified primarily at the fifth CMC joint. Fracture of the fourth metacarpal base is often an associated injury. In solitary fifth CMC dislocations, slight ulnar offset of the fifth metacarpal on the hamate is the most consistent finding in association with loss of parallelism, symmetry, and overlap. Fracture of the radial margin of the fifth metacarpal base is often observed with solitary fifth CMC joint dislocations. A systematic approach and establishing the diagnosis from standard radiographic views is emphasized.     

掌指骨的X线测量及相互间数学比例关系的临床应用研究

目的　对掌、指骨进行X线测量 ,为临床诊断及手外科提供可靠的解剖学数据和资料 ,同时提供掌骨长、指骨长之间的数学比例关系式 ,对手外科掌指骨长度的确定和假体的设计提供参考依据。方法　随机选择健康汉族大学生 186人 (男 90人 ,女 96人 ) ,进行双手后前位X线拍片 ,分别测量各掌骨与指骨长 ,将所得数据应用SPSS软件进行统计学分析。结果　得出各掌骨长、各节指骨长的比例关系 ,其中一 /二、二 /四、二 /五、三 /四掌骨长比值 ,拇指 /示指、拇指 /环指、示指 /小指近节指骨长比 ,示指 /小指、中指 /小指、环指 /小指中节指骨长比 ,拇指 /示指、拇指 /中指远节指骨长比值性别差异均有显著性意义。结论　以上比例关系式在手矫形外科中对各种原因引起的手骨缺陷进行理想的掌长及指长选择 ,从而为假体设计提供帮助     

Stress fracture of the hamate body and fourth metacarpal base following military style push-ups: an unusual trauma mechanism

We report the case of a 19-year-old male soldier, who sustained stress fractures of the hamate body and fourth metacarpal base due to his daily knuckle push-up routine in the military. We introduce repetitive microtrauma due to daily knuckle push-ups as an unusual, but potential trauma mechanism for metacarpal and carpal stress fractures.     

Carpal pseudoerosions: a plain X-ray interpretation pitfall

Objective

To examine in detail images of pseudoerosion of the wrist and hand on plain radiographs.

Material and methods

The study was conducted with 28 cadaver wrists. During a single imaging session three techniques—plain radiography, tomosynthesis, and computed tomography—were used to visualize the wrist and hand specimens. For each technique, 20 radio-ulno-carpo-metacarpal sites known to present bone erosions in rheumatoid arthritis were analyzed by two radiologists using a standard system to score the cortical bone: normal, pseudoerosion, true erosion, or other pathology. Cohen’s concordance analysis was performed to determine inter-observer and intra-observer (for the senior radiologist) agreement by site and by technique. Serial sections of two cadaver specimens were examined to determine the anatomical correlation of the pseudoerosions.

Results

On the plain radiographs, the radiologists scored many images as pseudoerosion (7.3 %), particularly in the distal ulnar portion of the capitate, the distal radial portion of the hamate, the proximal ulnar portion of the base of the third metacarpal, the proximal radial portion of the base of the fourth metacarpal, the distal ulnar portion of the hamate, and the proximal portion of the base of the fifth metacarpal. The computed tomography scan revealed that none of these doubtful images corresponded to true erosions. The anatomical correlation study showed that these images could probably be attributed to ligament insertions, thinner lamina, and enhanced cortical bone transparency.

Conclusion

Knowledge of the anatomical carpal localizations where pseudoerosions commonly occur is a necessary prerequisite for analysis of plain radiographs performed to diagnose or monitor rheumatoid arthritis.     

Subtle radiographic signs of hamate body fracture: a diagnosis not to miss in the emergency department

Hamate fractures are estimated to represent 1.7% of all carpal fractures and can occur at the hamulus (hook) or hamate body depending on mechanism of injury. Fractures of the hamate body can be exceedingly difficult to identify on standard wrist and hand radiographs in the emergency department. If the diagnosis is missed in the emergency department, orthopedic referral is often delayed. This can result in lasting functional disability for the patient, as these fractures have a propensity to destabilize the fourth and fifth carpometacarpal (CMC) joints. In this pictorial essay, we present six radiographic signs indicative of hamate body fracture with computed tomography (CT) imaging correlation. Injury mechanism and fracture classification schemes are portrayed to aid in the understanding of these injuries. Once radiographs raise suspicion for a hamate body fracture, further characterization with CT and orthopedic referral is paramount. Goals of orthopedic management include reestablishment of the fourth and fifth CMC articular surface, stabilization of the CMC joints, and appropriate treatment of concomitant soft tissue injury.     

Cervical spondylolysis: imaging findings in 12 patients

Cervical spondylolysis is defined as a corticated cleft between the superior and inferior articular facets of the articular pilar, the cervical equivalent of the pars interarticularis in the lumbar spine. Associated dysplastic changes and spina bifida suggest that the lesion is congenital. It is a rare condition; only 70 cases have been previously reported in the world literature. Recognition of this disorder and differentiation from traumatic articular pilar fracture or dislocation is of paramount importance in patients who have had cervical spine trauma. The present study details radiologic features in 12 patients 20-80 years old with cervical spondylolysis. Plain film radiologic findings were correlated with hypocycloidal high-resolution tomography (nine patients), CT (six patients), and MR imaging (one patient). Seven patients had spondylolysis at C6 (three bilateral) and five had the abnormality at C4 (all unilateral). Nine of 12 patients were initially misdiagnosed. Characteristic radiologic features include (1) a well-marginated cleft between the facets, (2) a triangular configuration of the pilar fragments on either side of the spondylolytic defect, (3) posterior displacement of the dorsal triangular pillar fragment, (4) hypoplasia of the ipsilateral pedicle, (5) spina bifida at the involved level, and (6) compensatory hyper- or hypoplasia of the ipsilateral articular pillars at the level above and/or below the defect. A multistudy approach was often necessary to demonstrate these findings. Heightened awareness of the radiologic features of cervical spondylolysis should allow one to differentiate it from articular pillar fracture or dislocation.     

Importance of soft-tissue evaluation in hand and wrist trauma: statistical evaluation

Four radiologists reviewed 197 hand and wrist radiographs to determine the usefulness of routine soft-tissue evaluation in the delineation of bony trauma. Soft-tissue changes at four sites in the lateral view were evaluated. Dorsal-hand fat-plane swelling was associated with second through fifth metacarpal fractures (p less than 0.01). Dorsal-wrist fat-plane swelling was associated with carpal fractures and wrist dislocations (p less than 0.01). Pronator and dorsal radial swelling were both associated with forearm fractures and carpal dislocations (p less than 0.01). Soft-tissue changes at five sites in the posteroanterior view were evaluated. Thenar swelling was associated with thumb metacarpal fractures and dislocations (p less than 0.01). Hypothenar swelling was associated with second through fifth metacarpal fractures and dislocations (p less than 0.01). Navicular fat-pad swelling was associated with carpal fractures (p less than 0.01) and strongly suggested a navicular fracture when present. Pararadial swelling was significantly associated with distal radial fractures (p less than 0.01), while paraulnar swelling was significantly associated with ulnar fractures (p less than 0.01). The lateral view of the hand and wrist is useful in compartmentalizing fractures to the hand, wrist, and forearm. Swelling in any compartment should lead to closer evaluation of all bony structures contained within that compartment. The soft tissues found in the posteroanterior view of the hand and wrist help further localize hand and wrist fractures. Additional views should be considered when significant swelling is present in the absence of an obvious fracture or dislocation. When more than one fat plane is unequivocally disturbed, protective immobilization with reexamination in 10 days is recommended.     

第五掌骨远端骨折不同手术方式疗效比较

目的对比分析第五掌骨远端骨折不同手术方式的疗效。方法选取广西中医药大学第三附属医院骨科2009年4月—2015年4月手第五掌骨远端骨折40例,其中男性33例,女性7例;年龄17~50岁,平均27.4岁;致伤原因:拳击伤30例,摔伤4例,道路交通伤6例;受伤至手术时间1h~6d。采取数字表法随机分为3组,采取髓内针固定14例(A组),第四、五掌骨改良克氏针外固定架固定12例(B组),钢板螺钉内固定14例(C组),比较3组内固定方式的手术时间、骨折复位程度、骨折愈合时间、术后4个月第五掌骨头干角、掌指关节功能。结果所有病例骨折均获得愈合,无感染及皮肤坏死。A组在手术时间[(36±4)min]、骨折愈合时间[(11±2)周]、掌指关节功能[(86.2±4.4)°]及并发症发生方面均优于B组[(34±6)min,(12±2)周,(83.8±3.5)°]及C组[(43±3)min,(14±3)周,(80.1±4.8)°]。结论髓内针内固定治疗第五掌骨远端骨折,可以尽早恢复关节功能,值得临床推广。     

Surgical management of chronic, unreduced posterior dislocation of the shoulder

Four patients with chronic posterior dislocation of the shoulder underwent surgical treatment after an average delay of 10 months from injury. They were examined clinically and radiographically at an average follow-up of 32 months. Treatment consisted of subscapularis tendon transfer (McLaughlin procedure) into the humeral defect in one case, transfer of the lesser tuberosity (McLaughlin modified procedure) in two cases, and in the fourth case—a patient with a 19-month missed dislocation and 50% humeral head lesion—a transposition of the coracoid process and conjoined tendon was performed. X-rays and CT scan excluded avascular necrosis or severe post-traumatic arthrosis. All patients achieved complete pain relief without limitation of daily or work activities. A slight limitation of anterior elevation and external rotation was present in all patients. Our results confirm that McLaughlins original or modified procedure is suggested in cases of chronic, unreduced posterior dislocation of the shoulder (type I according to Randelli). The transposition of the coracoid process is a valid alternative to prosthesis and to autologous or homologous bone graft implants.     

Posterior bone block procedure for posterior shoulder instability

The posterior bone block procedure is an uncommon surgical procedure used in the treatment of posterior shoulder instability. The purpose of this study is to report the results of the posterior bone block procedure in the treatment of posterior shoulder instability. We retrospectively reviewed 21 shoulders that had undergone a posterior bone block procedure in the treatment of recurrent posterior shoulder instability between 1984 and 2001. Fifteen patients (16 shoulders) had a prior traumatic posterior glenohumeral dislocation and 5 patients (5 shoulders) had a prior traumatic posterior glenohumeral subluxation. The mean age at surgery was 24.8 years (range 17–40 years). Patients were evaluated with the Constant score, the Duplay score, a subjective result, and radiography. Preoperatively, ten shoulders had glenoid fractures, two shoulders had loss of the normal contour of the posterior osseous glenoid, and ten shoulders had humeral head impaction fractures (reverse Hill-Sachs lesion). Seventeen shoulders underwent preoperative computed tomography and had average glenoid retroversion of 9.6° (range 0–21°). At an average follow-up of 6 years, all patients reported their subjective results as good or excellent. At follow-up the mean Constant score was 93.3 points (range 80–103 points), and the mean Duplay score was 85.6 points (range 40–100 points). Fifteen patients returned to sports at their pre-injury level. Three patients were considered clinical failures; one with a recurrent posterior dislocation and two with substantial posterior apprehension on follow-up examination. Two shoulders had glenohumeral arthritis on radiographs at the latest follow-up. The posterior bone block is a good treatment option for posterior dislocation. The risk of recurrent dislocation is low following this procedure.     

Traumatic hip dislocation: early MRI findings

Purpose Objective of this study was to present the spectrum of early magnetic resonance imaging (MRI) findings following traumatic dislocation of the femoral head, and to identify any associated injuries that may have therapeutic or prognostic significance and be better delineated by MRI than by conventional radiography.Patients and methods Prospective MRI of both hips was performed on 18 patients (14 male, 4 female; age range 14–54 years; average age 30.5 years) within 5 weeks of a traumatic femoral head dislocation. The interval between the time of injury and the imaging studies ranged from 2 to 35 days (average 13.2 days). Posterior dislocation was present in 14 patients and anterior dislocation in 4 patients. In the majority of cases, we performed axial T1, coronal T1, and coronal T2^* (MPGR) sequences. Images were retrospectively evaluated by consensus of three radiologists for possible abnormalities of the bone and cartilage, joint space, and soft tissues. Because all patients were treated with closed reduction, surgical correlation was not obtained.Results All patients had a joint effusion or hemarthrosis. Of the 14 patients with posterior dislocation, isolated femoral head contusions (trabecular microfractures) were identified in 6 patients. Four patients had small femoral head fractures, and one had an osteochondral defect. Acetabular lip fractures were seen in six patients, and one patient had a labral tear. Four patients had intra-articular loose bodies and one had ligamentum teres entrapment. Twelve patients had iliofemoral ligament injury. All patients had muscle injury involving the gluteal region and medial fascial compartment, and 13 patients had anterior fascial compartment muscle injury. Seven patients with posterior dislocation had posterior fascial compartment injury. Of the four patients with anterior dislocation, two had bony contusion, two had cortical infraction, one had a labral tear, and all four had an iliofemoral ligament injury. All four patients in this group had muscle injury of the gluteal region and of the anterior and medial fascial compartments.Conclusions MRI can effectively identify and quantify the muscle injury and joint effusion that invariably accompany traumatic hip dislocations. It is also useful for demonstrating trabecular bone contusion (trabecular injury) and iliofemoral ligament injury, which occur commonly with acute hip dislocation.     

Metacarpal fractures in the athlete

Fifty-six fractures of the metacarpal occurring in 53 athletes were studied from September 1985 to December 1986, regarding mechanism of injury, type of fracture, type of treatment, and time lost from sport. Age range of the patients was 8 to 28 years with greater than 77% being in the 14 to 18 year age range, the high school athlete. Twenty-nine of the fractures occurred in football, 14 in basketball, and the remainder were divided between various other sports. The most common mechanism of injury involved falls or hitting an object such as a helmet or another player. Fractures were evenly divided regarding which digit was involved in football, whereas most basketball injuries occurred in the fourth and fifth metacarpal. Fractures were analyzed as to type of radiographic appearance and this was correlated with time lost from competition or participation. No significant difference among fracture type regarding time lost was noted. Forty-six of the fractures (82%) were minimally displaced or undisplaced and were treated by means of simple casting and/or splinting whereas 10 were displaced. Two of the 10 underwent closed reduction and casting; 3 underwent closed reduction and percutaneous pin fixation; and 5 (9%) underwent open reduction internal fixation using AO type plates and screws. All fractures healed primarily clinically and radiographically. The average time lost from practice or competition in this group overall was 13.7 days, (range, 0 to 56 days). Average time lost from basketball was 19.8 days and from football 10.63 days overall. Average time lost from sport in stable fractures treated with casting or splinting was 12.3 days.(ABSTRACT TRUNCATED AT 250 WORDS)     

第一掌背动脉皮瓣Ⅰ期修复拇指皮肤缺损合并神经缺损

目的 探讨第一掌背动脉皮瓣携带指神经背侧支Ⅰ期修复拇指皮肤缺损合并神经缺损的手术方法和临床效果. 方法 对14例拇指皮肤缺损伴一侧或双侧神经断裂缺损患者,应用携带示指固有神经背侧支的第一掌背动脉岛状皮瓣修复,重建手指感觉.皮肤缺损最大面积为52 mm×32 mm,最小为10 mm×8 mm.神经缺损长度9～22 mm....     

Functional cast immobilization of thumb metacarpophalangeal joint injuries

A prospective study was performed on 40 patients who were treated with a modified thumb spica cast (MTSC) for injuries involving the region of the metacarpophalangeal joint of the thumb. Twenty-seven of these injuries occurred during sports participation. The immobilization consisted of a fiberglass cast which incorporated the thumb in a balanced position and allowed full flexion and extension of the wrist. Twenty patients had injuries involving the ulnar collateral ligament (five surgical). Three patients had radial collateral ligament injuries (two surgical). Fourteen patients had fractures of the proximal phalanx, including five epiphyseal plate injuries. Two patients had dorsal dislocations and one patient had a metacarpal fracture. One patient with a nondisplaced distal metacarpal fracture was treated with simple immobilization. All patients had successful completion of their treatment within the usual time frame. There was no recurrence or increase in symptomatology during the treatment. There was no residual discomfort, loss of position or malunion of the fractures treated. The advantages of the MTSC include improved functional capabilities during immobilization, good patient acceptance, and no period of limited wrist motion or atrophy of forearm musculature. Our experience has been that the MTSC has been a reliable form of immobilization for treating injuries of the metacarpophalangeal joint of the thumb.     

Value of bone scintigraphy in patients with carpal trauma

OBJECTIVE: We planned this study to evaluate the role of bone scintigraphy in patients with suspected carpal fracture and normal or suspicious radiographs following carpal injury. METHODS: Three-phase bone scintigraphy using Tc-99m-MDP was performed on 32 patients with negative radiographs but clinically suspected fracture at two weeks after the trauma. Focally increased radiopharmaceutical uptake was interpreted as a fracture. The final diagnosis was established with clinical follow-up. RESULTS: Twelve (38%) patients had a normal scan excluding fracture. Twelve patients had a single fracture. Multifocal fracture was present in 8 (25%) patients. Eight patients showed scaphoid fractures; of these three showed single scaphoid fracture, and the other five patients revealed accompanying fractures. Distal radius fractures and carpal bone fractures other than scaphoid were both observed in 12 patients. These were eleven fractures of distal radius; three fractures of pisiform; two fractures of hamate; and single fractures of lunate, trapezium and triquetrum. In one patient there was fracture of a first metacarpal bone. CONCLUSION: In patients with suspected carpal bone fracture and normal or suspicious radiographs, bone scintigraphy can be used as a reliable method to confirm or exclude the presence of a scaphoid fracture and to detect clinically unsuspected fractures of distal radius and other carpal bones.     

Symptomatic,partial union of the hook of the hamate fracture in athletes

BACKGROUND: Many clinicians believe that after fracture of the hook of the hamate, nonunions are the rule rather than the exception. PURPOSE: To describe a previously unreported condition in which the fractured hook of the hamate unites only along its ulnar column and causes pain similar to that in cases of nonunion. STUDY DESIGN: Retrospective review. METHODS: Eight patients who had sustained a hook of the hamate fracture were identified, on the basis of their persistent pain, as having achieved only partial union. This diagnosis was made despite evidence on computed tomography of healed bone across a significant portion of the fracture. All eight patients underwent subperiosteal excision of the hamulus because of persistent pain. At an average of 4 years after excision, each patient was evaluated by dynamometer grip strength testing and a subjective outcome assessment. RESULTS: All patients were able to return to their preinjury level of sports participation at an average 8 weeks after excision of the hook of the hamate. Grip strength was not adversely affected in any patient. Subjective evaluation of each patient revealed no residual pain. CONCLUSIONS: Chronic or unresolved pain on the ulnar side of the wrist after hook of the hamate fracture can be due to partial union. This condition should be managed no differently from a symptomatic nonunion, with excision of the hook of the hamate and repair of the ligament attachments.     

改良掌背动脉逆行超大皮瓣治疗手指末节脱套伤

目的 探讨改良掌背动脉逆行超大皮瓣治疗手指末节脱套伤的临床效果.方法 自2004年1月至2008年8月,对24例24指末节脱套伤患者应用改良掌背动脉逆行超大皮瓣修复,其中示指6指、中指11指、环指5指、小指2指,缺损平面均在远侧指间关节以远,脱套末节长度0.8～3.1 cm.急诊手术22指,末节皮肤坏死Ⅱ期手术2指.结果 24例24指皮瓣全部成活,21例21指经6～28个月随访,外形、感觉和功能恢复满意,皮瓣的两点辨别觉达6～9 mm,平均7.6 mm.结论 改良掌背动脉逆行超大皮瓣治疗手指末节脱套伤具有手术简便、安全,疗程短等优点,是一种较为理想的方法.

Abstract：

Objective To discuss the clinical outcome of the modified super large dorsal metacarpal artery flap in reconstruction of circumferential fingertip avulsion. Methods Twenty-four patients with circumferential fingertip avulsion were treated by the modified super large dorsal metacarpal artery flap from January 2004 to August 2008. There were six index fingers, 11 middle fingers, five ring fingers and two little fingers with surface defects beyond the distal interphalangeal joint and the distal degloving length ranged from 0.8 cm to 3.1 cm. Emergency operation was performed on 22 fingers and stage Ⅱ surgery was done for distal skin necrosis of two fingers. Results Twenty-one patients with 21 fingers were followed up for 6-28 months, which showed that all flaps survived, with satisfactory appearance and function, and that the point discrimination of flap was for 6-9 mm ( average 7.6 mm). Conclusion Modified super large dorsal metacarpal artery flap is an ideal method for reconstruction of the circumferential fingertip avulsion with advantages of easiness, convenience and short treatment period.     

应用逆行掌背动脉蒂岛状皮瓣创面修复12例疗效分析

目的探讨应用逆行掌背动脉蒂岛状皮瓣进行手指部创面修复手术方法和效果。方法2001年3月～2006年3月以逆行第2—4掌背动脉蒂的组织瓣行创面修复12例；其中第2掌背动脉蒂岛状皮瓣逆行转移术进行示、中指创面修复3例；第3掌背动脉蒂岛状皮瓣逆行转移进行中、环指创面修复4例；第4掌背动脉蒂岛状皮瓣逆行转移进行环、小指创面修复5例。结果本组逆行转移皮瓣全部成活无坏死，术后随访3个月-2年，受区全部愈合，手指功能改善满意。本组均达到一期消灭创面、控制感染、改善局部功能的目的。结论掌背动脉蒂岛状皮瓣是临床上修复手指创面较实用、疗效可靠的轴型皮瓣之一。     

后路椎体切除减压椎间植骨融合椎弓根螺钉内固定术治疗严重胸腰椎旋转骨折脱位

目的 探讨后路椎体切除减压椎间植骨融合椎弓根螺钉内固定术治疗严重胸腰椎旋转骨折脱位的可行性及疗效.方法 2007年10月-2008年7月采用后正中切口、后路经椎弓根行椎体切除减压、椎体间植骨、长节段椎弓根螺钉内固定治疗严重胸腰椎旋转骨折脱位(AO分类C型损伤)患者9例,其中男8例,女1例;年龄23～54岁.全部患者伤椎累及T_(11)～L_2.AO分类:C1型压缩骨折伴旋转侧方移位3例,C2型牵张性损伤伴旋转脱位5例,C3型旋转剪切骨折脱位1例.神经功能Frankel分级:A级3例,B级1例,C级4例,D级1例.术后随访骨折脱位复位、植骨愈合和神经功能恢复情况.结果 9例患者全部完成手术,手术时间3.5～5.8 h,平均4.4 h.术中出血1 200～3 500 ml,平均1 800 ml.术后X线片示骨折脱位完全复位,植骨位置良好.3例Frankel A级无恢复,1例B级患者恢复到C级,4例C级患者有3例恢复到D级.随访9例患者植骨而见骨性愈合,未发生内固定或植骨材料松动、移位或断裂.结论 胸腰椎旋转骨折脱位对减压、复位、融合和固定的要求很高,后路椎体切除减压椎间植骨融合椎弓根螺钉内固定术能从单一入路同时完成上述治疗.     

Computed tomography of calcaneal fractures

Computed tomography (CT) of 25 fractured calcanei was performed to investigate the potential of CT in evaluating the pattern and biomechanics of these fractures. The characteristic findings of typical fractures are presented, including the number and type of principal fragments, size and dislocation of the sustentacular fragment, and involvement of the anterior and posterior facets of the subtalar joint. In 17 cases, the calcaneus consisted of four or more fragments. Furthermore, in 17 cases the sustentacular fragment included all or part of the posterior facet joint. In 18 of the 25 cases, the sustentacular fragment was displaced. It is concluded that well performed CT is an invaluable adjunct in understanding the fracture mechanism and in detecting pain-provoking impingement between the fibular malleolus and the tuberosity fragment. CT analysis can provide the orthopedic surgeon with comprehensive information on which to base decisions regarding surgical/nonsurgical treatment as well as surgical approach and technique.