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.     

Computed tomography of wrist trauma

We devised a rapid and sensitive computed tomography (CT) method to assess the acutely injured wrist, healing carpal fractures and post-traumatic osteonecrosis, when the plain films offer insufficient information. The wrist is positioned in a simple reverse-L-shaped Perspex immobilizer. With the scaphoid as the center of the arc and the long axis of the distal radius as the reference 0 degrees line, sequential coronal scans of the wrist were done in 10 degrees increments in an arc of 40 degrees to give 0 degrees, 10 degrees, 20 degrees, 30 degrees and 40 degrees scans. The 0 degrees and 10 degrees arc scans were best for evaluating the distal radius and ulna and soft tissues, the 10 degrees and 20 degrees scans for the carpal bones other than the scaphoid, and their relation to each other, the 30 degrees and 40 degrees scans, parallel to the long axis of the scaphoid, for fractures of the scaphoid and the hook of the hamate. In addition the 40 degrees scan offered an excellent carpal tunnel view. In 22 patients examined for wrist trauma CT was found to be more accurate than plain films and plain-film tomography in determining the presence of a fracture (4 scaphoid and 1 distal radius), in assessing the degree of osseous union (12) and in evaluating intercarpal fusion (2). In addition CT detected avascular necrosis of the lunate in two patients and erosions of the scaphoid and distal radius attributed to rheumatoid arthritis in one.     

Skeletal scintigraphy of the wrist in suggested scaphoid fracture

Skeletal scintigraphy was performed in 187 patients with clinical suspicion of a scaphoid fracture but with normal radiographic findings. In 85 patients focally moderately (12 patients) or markedly to intensely (73 patients) increased radionuclide uptake was seen, over either the distal radius or carpal bones. A fracture corresponding to markedly increased uptake was eventually verified in 15 out of 26 patients in the distal radius, in 21 out of 28 in the scaphoid but in only 6 out of 18 in other carpal bones. One fracture of the body and one of the hook of the hamate were found, one fracture of the capitate and three of the triquetrum. Not a single fracture was verified in 10 patients with markedly, often intensely, increased activity over the trapezium/trapezoid. It is concluded that scintigraphy is of value in carpal trauma not only to exclude scaphoid fracture but also to direct the attention to the possibility of other carpal fractures, otherwise usually missed.     

掌骨受轴向压力作用下的腕部生物力学分析

目的 研究正常腕部载荷传递及关节接触应力分布情况,以及腕横韧带切除对腕部生物力学的影响.方法 通过CT扫描图像数据对腕部进行三维有限元建模,计算并分析掌骨受轴向压力作用下正常腕部载荷传递及接触应力的分布,以及腕横韧带切开前后腕骨运动的变化情况.结果 腕部载荷传递及关节接触应力分布情况与前人实验数据相当接近;腕横韧带的切除导致舟骨发生向桡侧和掌侧的偏移,以及掌向屈曲和向桡侧的转动,而整个腕管结构则产生更大的桡侧偏移.结论 立体构架了包括整个腕管结构、远端尺骨和桡骨以及近端掌骨的腕部整体三维有限元模型.本模型可以较好地模拟腕管和桡腕关节载荷传递与接触应力的分布情况,为进一步探讨腕部结构的力学行为提供了一个可操作的平台.通过计算分析腕管松解术对腕骨运动的影响,为腕管综合征的临床手术、术后康复等提供了相关的理论依据.     

Athletic injuries of the wrist and hand. Part I: traumatic injuries of the wrist

Hand and wrist injuries in sports are some of the most common injuries reported. This review discusses briefly the causes of hand and wrist injuries in sports and discusses pertinent biomechanical findings regarding the range of motion required in different sports activities. The bulk of the review discusses specific traumatic and overuse injuries to the hand and wrist commonly seen in the athlete. Emphasis is placed on problematic traumatic injuries such as carpal scaphoid fractures and hook of the hamate fractures, as well as ligament injuries to the wrist with regard to diagnosis, treatment, and return to athletic competition.     

Scaphoid bone]

The scaphoid is the most important carpal bone due to the frequency of its pathological involvement. Two points of radiological anatomy are stressed: the presence of the scaphoid tubercle whose projection gives rise to the scaphoid ring, the solid radio-capitatum ligament which bridges the scaphoid. Scaphoid fracture represents 70% of all carpal bone fractures and its presence must therefore be meticulously investigated on appropriate x-rays or on tomographies or CT scans, rather than by the classical repeat examination a fortnight later. CT provides good analysis of scaphoid fragments when consolidation is delayed (pseudarthrosis), allowing earlier and more justified indications for surgery. The wrist ligaments are poorly visualised by MRI at the present time; but it allows study of the cartilage and, most importantly, is a decisive examination when there is a doubt about bone vitality.     

Early MRI in the management of clinical scaphoid fracture

The incidence of MRI detected scaphoid and other wrist fractures was determined in a clinical setting in patients with suspicion of scaphoid injury and negative initial radiographs. The influence on subsequent patient management was examined. Patients attending Accident and Emergency over a 25 month period with suspected scaphoid fracture and normal scaphoid series plain films were referred for wrist MRI. Scans comprising T(1) weighted spin echo and short tau inversion recovery (STIR) coronal sequences were performed in a dedicated extremity low field MRI scanner within 14 days of injury. Subsequent effects on patient management were ascertained by clinician completed questionnaire. 195 patients were scanned. There were 37 scaphoid fractures (19%), 28 distal radius fractures (14%), 9 fractures of other carpal bones (5%) and 119 studies with no fracture. The management of 180 patients (92%) was altered as a result of the MRI scan. Occult fractures are present in almost two fifths of patients with suspected scaphoid fracture and normal initial plain films. Half of these are scaphoid fractures. MRI allows an early definitive diagnosis to be made, changing patient management in over 90% of cases and should be regarded as the gold standard investigation in this population.     

The role of arthroscopy in the treatment of wrist injuries in the athlete.

As a minimally invasive procedure, wrist arthroscopy provides the advantages of accurate, direct visual inspection of intra-articular structures for diagnostic purposes and dramatically reduced morbidity for surgical treatment of certain disorders. For an athlete who has a limited window of opportunity to compete, arthroscopy can offer an earlier, more accurate, more complete diagnosis than other imaging techniques for soft-tissue disorders of the wrist. Arthroscopic surgery can frequently offer an abbreviated recuperation period and earlier return to competition. Arthroscopy offers advantageous treatment options for extrinsic and intrinsic ligament injuries, removal of loose bodies, reduction of articular fractures of the distal radius and scaphoid and definitive treatment of injuries to the triangular fibrocartilage complex. It is a modality well worth including in the treatment armamentarium for wrist disorders in athletes.     

Distal radio-ulnar joint. Traumatic and degenerative diseases]

The distal radio-ulnar joint participates in the biomechanics of the wrist both by transmission of carpal stresses and by its role in the mobility of the wrist. Fractures of the distal radio-ulnar joint are often missed as they are frequently only a radiation of fractures of the radius to the distal radio-ulnar joint. Computed tomography is the most useful examination to assess the severity of these lesions. Distal radio-ulnar dislocations may also be associated with fractures of the radius, but usually occur in isolation. The diagnosis is difficult, as the slightest rotation on plain X-rays interferes with the evaluation criteria. A CT scan in the neutral position and in pronation and supination is the examination of choice for dislocations and subluxations, but must be interpreted according to strict criteria. In contrast, a tea of the triangular ligament can only be assessed on arthrography and the distinction between traumatic and degenerative rupture is difficult. The patient's age, the site of the perforation and the length of the ulna are important elements in the diagnostic decision. MRI appears to be a promising examination for investigation of this joint, but the quality of the images is not yet perfectly reproducible.     

Gymnastic wrist injuries

During gymnastic activities, the wrist is exposed to many different types of stresses, including repetitive motion, high impact loading, axial compression, torsional forces, and distraction in varying degrees of ulnar or radial deviation and hyperextension. Many of these stresses are increased during upper extremity weight-bearing and predispose the wrist to high rates of injury during gymnastics. Distal radius stress injuries are the most common and most documented gymnastic wrist conditions. Other conditions include scaphoid impaction syndrome, dorsal impingement, scaphoid fractures, scaphoid stress reactions/fractures, capitate avascular necrosis, ganglia, carpal instability, triangular fibrocartilage complex tears, ulnar impaction syndrome, and lunotriquetral impingement. It is important to diagnose quickly and accurately the specific injury to initiate expediently the proper treatment and limit the extent of injury. In addition, a gymnast's training regimen should also include elements of injury prevention.     

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.     

MRI of fractures of the distal radius: comparison with conventional radiographs

Objective. To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury. Design and patients. Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation. Results. Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid.Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears. Conclusion. MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intra-articular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.     

Wrist fractures: what the clinician wants to know

With the recent improvements in diagnosis and treatment of distal radius and carpal injuries, the hand surgeons' expectations of relevant radiologic interpretation of imaging studies are heightened. Conventional radiographic examinations, as well as more sophisticated and invasive studies, have important roles in the evaluation of wrist fractures and dislocations. On the basis of physical examination results and the mechanism of injury, the onus is on the examining surgeon to pinpoint potential sites of bone or ligament disruption. After this evaluation, appropriate imaging studies appropriately performed and interpreted will help direct treatment and improve outcome with greater clarity and certainty.     

Lesions of the scapholunate ligaments in acute wrist trauma – arthroscopic diagnosis and minimally invasive treatment

The final result of the treatment of distal intra-articular radius fractures depends both on the accuracy of the fracture reduction and on the presence of additional carpal injuries. In particular, lesions of the intrinsic ligaments usually lead to severe degenerative damage of the wrist joint if they are missed primarily. With the introduction of wrist arthroscopy, these tears can be evaluated and treated earlier. Since 1993 arthroscopically assisted treatment has been performed in 23 patients with distal intra-articular fractures of the radius (mainly C-fractures according to the AO classification system or group VII and VIII fractures according to Frykman). Scapholunate (SL) tears were found in 11 patients (47.8%), 7 of whom showed marked instability intraoperatively and were stabilised at the time of surgery.     

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.     

Radiography of the carpal scaphoid. Experimental evaluation of "the carpal box" and first clinical results.

RATIONALE AND OBJECTIVES. The authors describe a new device ("the carpal box") for the radiographic detection of occult scaphoid fracture. METHODS. Fractures in the scaphoid of five cadaver specimens were mechanically produced. Subsequent examinations included conventional scaphoid radiography, multi-angle radiography, and radiography using the new device. The anatomic analysis of the specimens served as the standard for comparison. A pilot study was performed in six consecutive patients with suspected scaphoid fracture. RESULTS. Neither scaphoid radiography nor multi-angle radiography could confirm a fracture in two specimens, whereas all fractures were recognized on the carpal box radiographs. All scaphoid fractures were visualized by carpal box radiography, whereas scaphoid radiography was equivocal in one patient and negative in the other. CONCLUSIONS. Carpal box radiography may have additional value in the diagnosis of occult scaphoid fracture. This may lead to a reduction in costs and inconvenience for patients with clinically suspected scaphoid fracture and negative scaphoid radiography.     

Fracture of the carpal scaphoid: frequency and distribution in a well-defined population.

The incidence, location, and type of scaphoid fractures found in a well-defined population is described. Fractures of the carpal scaphoid (n = 442) were identified during an eight-year period, of which 19 (5%) were nonunions. At the initial radiographic examination the fractures were visible on PA views in 70% of the cases (true lateral 10%, scaphoid view neutral 77%, scaphoid view ulnar deviated 73%, and scaphoid view with the X-ray tube tilted 30 degrees distally 71%). Among inhabitants living in the Odense Municipality (population at risk 170648 in 1983 to 174948 in 1989) 222 males and 51 females (age range 9-87 year) sustaining scaphoid fractures during a seven-year were period used for computation of incidences. During the survey, there was an average annual incidence of scaphoid fracture of 8 per 100000 females, and 38 per 100000 males. All patients (except a 9-year-old male) were aged 10 years or over. In the age-group 10-14 years there was an average annual incidence of 3 per 100000 females, and 39 per 100000 males. Average annual incidence per 100000 inhabitants of carpal scaphoid fractures according to the location was proximal 6, middle 15, and distal (fractures of the tuberosity included) 2. Average annual incidence per 100000 inhabitants of carpal scaphoid fractures according to type was transverse 7, horizontal oblique 9, vertical oblique 1, avulsion/fracture of the tuberosity 5, and not stated 1.     

桡骨远端关节内骨折伴腕关节不稳定放射诊断

目的 分析继发性腕关节不稳定与桡骨远端骨折类型的关系，讨论腕关节不稳定发生机制和防治措施。方法 对67例共75个腕部桡骨远端关节内骨折随访2a～6a，在复位前、后和去除外固定后的腕关节正侧位平片上分别测量腕高指数、尺腕距离比、舟月骨距、舟月骨角、桡月骨角、头月骨角，并测定腕关节功能的主、客观指标。比较合并与不合并腕关节不稳定两组的功能恢复情况。结果 伴有腕关节不稳定的发生率为58．67％（44／75），其中，腕背侧镶嵌不稳定（DISI）29例（38．67％），舟月骨分离9例（12．00％），其他为掌侧镶嵌不稳定、尺侧偏移和头月骨间不稳定等，多发生在严重骨折移位患者。骨折愈合后，合并腕关节不稳定的功能明显差于单纯桡骨远端骨折患者。结论 桡骨远端骨折类型、关节面弧度和掌倾角对腕关节不稳定的发生及类型有显著影响。对骨折移位严重或高能量损伤的桡骨远端骨折，要注意是否合并腕关节不稳定。对合并腕关节不稳定的桡骨远端骨折．复位时应尽可能恢复掌倾角.     

Transscaphoid palmar lunate dislocation with scapholunate dissociation.

Concurrent scaphoid fractures with scapholunate ligament injuries have been felt to be mutually exclusive. A case with concurrent injuries is presented along with a discussion of the literature on perilunate injuries.