Comparison of conventional radiography and MDCT in suspected scaphoid fractures

AIM: To determine the diagnostic accuracy and radiation dose of conventional radiography and multidetector computed tomography(MDCT) in suspected scaphoid fractures.METHODS: One hundred twenty-four consecutive patients were enrolled in our study who had suffered from a wrist trauma and showed typical clinical symptoms suspicious of an acute scaphoid fracture. All patients had initially undergone conventional radiography. Subsequent MDCT was performed within 10 d because of persisting clinical symptoms. Using the MDCT data as the reference standard, a fourfold table was used to classify the test results. The effective dose and impaired energy were assessed in order to compare the radiation burden of the two techniques. The Wilcoxon test was performed to compare the two diagnostic modalities.RESULTS: Conventional radiography showed 34 acute fractures of the scaphoid in 124 patients(42.2%). Subsequent MDCT revealed a total of 42 scaphoid fractures. The sensitivity of conventional radiography for scaphoid fracture detection was 42.8% and its specificity was 80% resulting in an overall accuracy of 59.6%. Conventional radiography was significantly inferior to MDCT(P < 0.01) concerning scaphoidfracture detection. The mean effective dose of MDCT was 0.1 m Sv compared to 0.002 m Sv of conventional radiography.CONCLUSION: Conventional radiography is insufficient for accurate scaphoid fracture detection. Regarding the almost negligible effective dose, MDCT should serve as the first imaging modality in wrist trauma.     

Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation

Acute proximal row carpectomy is an uncommon definitive treatment for perilunate fracture dislocations. In this report, we present five patients who had acute proximal row carpectomy (PRC) to treat perilunate fracture-dislocations. All patients were men between ages 31 and 87. The indication for PRC was lunate fracture in two patients, concomitant displaced scaphoid fracture and scapholunate ligament injury in two patients, and perilunate fracture-dislocation with preexisting articular damage from long-standing gout in one patient. At the final follow-up ranged from 4.5 month to 7.5 years, four patients had no pain and one patient was lost to follow-up. One patient had a concomitant PRC and a bridging plate that was never removed. The remaining three patients gained satisfactory range of motion. Our observation reveals that acute proximal row carpectomy is an option for some patients with complex carpal fracture dislocations, particularly those with fracture of the lunate, concomitant scaphoid fracture and scapholunate ligament injury, or preexisting wrist arthritis.     

Limited intercarpal fusion as a salvage procedure for advanced Kienbock disease

Background

With progressive lunate collapse, salvage procedures in advanced Kienbock disease attempt to provide pain relief and maintain motion. Scaphocapitate arthrodesis may provide a durable option with comparable outcomes to proximal row carpectomy in the well-selected patient.

Methods

We performed a retrospective chart review of all consecutive patients with Lichtman stage IIIA or IIIB Kienbock’s disease who underwent either scaphocapitate or scaphotrapeziotrapezoid-capitate arthrodesis from January 2004 to December 2013.

Results

Twelve patients were included with a mean age of 41.6 years. Ten patients underwent scaphocapitate arthrodesis, while two patients underwent scaphotrapezio-trapezoid-capitate arthrodesis with an average clinical follow-up of 13.1 months. All patients achieved fusion. The average postoperative flexion-extension arc was 53° (range 20–110°). The average ulnar deviation was 9° (range 5–15°), and the average radial deviation was 13° (range 5–25°). Postoperative pain scores were significantly improved, having changed from an average of 6.6 preoperatively to 2.8 on a 10-point scale (W = 18, P < 0.05).

Conclusions

Despite a mean flexion-extension arc that is reduced from that of a normal individual, the postoperative range of motion following a midcarpal arthrodesis was not significantly different than that reported in a recent systematic review of proximal row carpectomy (73.5° compared with 53°, respectively) (P = 0.05). Additionally, given the significant postoperative reduction in associated pain symptoms at the time of follow-up, scaphocapitate arthrodesis should be considered as a treatment option for wrist salvage in the patient with advanced Kienbock’s disease.     

扳手腕致肱骨远端粉碎性骨折1例

患者,男,19岁,因扳手腕致左上臂疼痛伴活动受限14h入院。查体:左上臂肿胀、压痛明显,可触及骨擦感,浅感觉无明显异常,左肘伸屈活动受限,左手各指活动良好,末梢血供正常,感觉正常。予肱骨远端正侧位X线片示:左侧肱骨远端骨皮质不连续,移位明显(图1a,1b)。诊断:左肱骨远端骨折(AO分型:13A3)。入院后完善相关术前检查,石膏托外固定,消肿后在全麻下行肱骨切开复位内固定术。患者取仰卧位,左上肢外展位置     

不同筋膜血管蒂骨瓣植入治疗舟状骨陈旧性骨折

目的介绍利用不同筋膜血管蒂桡骨茎突骨瓣植入治疗陈旧性腕舟状骨骨折的疗效。方法2002年9月-2010年5月,采用以桡动脉返支为蒂的骨瓣,或以骨间背动脉桡侧终末支的筋膜蒂骨瓣植入结合内固定治疗腕舟状骨陈旧性骨折41例。结果38例经6～27个月（平均19．3个月）的随访,X线片显示腕舟骨骨折均在术后4～6个月获得骨性愈合,愈合率达100％。腕关节活动度为4例腕掌屈60°背伸50°34例腕掌屈达70°-80°．背伸45°-55°。腕关节活动时无疼痛。腕关节功能按Krimmer评分表测定：总体疗效为优29例,良9例。结论采用带不同血管蒂桡骨茎突骨瓣植入治疗舟状骨陈旧性骨折疗效确切。     

Arthroscopic findings in patients with painful wrist ganglia

The aetiology of painful dorsal wrist ganglia remains obscure. In a prospective study we investigated the link between a painful dorsal wrist ganglion and wrist joint abnormality with wrist arthroscopy before excision of the ganglion. Of 16 wrists arthroscoped 12 were abnormal, 10 had an abnormal scapholunate joint, and two had abnormal lunatetriquetral joints. We think that painful dorsal wrist ganglia, like popliteal cysts in the knee, are markers of underlying joint abnormalities. Surgeons who treat painful ganglia should be aware of a possible underlying cause so that they can target treatment more accurately, particularly in recurrent cases and those patients with persistent wrist pain after excision of the ganglion.     

Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome

Twenty-eight patients were treated by ulnar shortening osteotomy for static or dynamic ulnar impaction syndrome. Ulnar variance was measured on a true anteroposterior radiograph. There were 25 wrists that were too long, two neutral, and one that was short. Bones were shortened by a mean of 3.5 mm. Mean follow-up time was 29 months (range 7–60), all with confirmed consolidation. At final follow-up mean grip strength had improved from 67% to 75%, mean Disabilities of the Arm, Shoulder, and Hand (DASH) score from 40 (range 12–83) to 26 (range 0–61) and mean range of movement from 80% (range 40%–100%) to 88% (range 50%–100%). Smoking, age at operation, type of osteotomy (transverse or oblique), dominance of hand, and sex did not influence consolidation or functionality. Special attention was paid to the anatomy of the distal radioulnar joint and the inclination of the sigmoid notch of the radius. There was no correlation between the anatomy and the functional outcome scores. Mean consolidation time (10 months) (range 2–32) and return to work were longer than in similar studies. Our findings confirm the usefulness of ulnar shortening osteotomy in the relief of ulnocarpal impingement symptoms.