Treatment of nonunion of the scaphoid by a limited combined approach.
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Seven patients with nonunion of the scaphoid were treated by a limited approach combining a palmar wedge graft with insertion of a dorsal (retrograde) Herbert screw through small incisions. All patients had palmar bone deficiency and a 'difficult' proximal fragment. They were followed up for a minimum of 12 months (12 to 38). Radiological union was achieved in all. In five patients correction of instability of the dorsal intercalary segment which was present before operation, was achieved. On a wrist-scoring chart, all patients had an excellent or good rating. The limited combined approach allows correction of the deformity with rigid fixation and has the advantage of preserving most of the palmar ligaments. (+info)
Review of the current methods in the diagnosis and treatment of scaphoid fractures.
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If neglected or misdiagnosed, non-union of a scaphoid fracture will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist with subsequent morbidity and lifelong disability, especially in young males in which the fracture is more common. Fractures of the scaphoid bone are the most common fractures of the carpus and second in occurrence among fractures of the wrist. The diagnosis and treatment are not simple. Familiarity with different imaging methods and treatment options is required. The treatment in most cases is conservative and will lead to uneventful union, but an operation may be needed in certain cases primarily and in the treatment of non-union. The current literature on the diagnosis and treatment of scaphoid fractures is reviewed, and the authors try to make a clear and concise picture of this complex and sometimes controversial field. (+info)
Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment.
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We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw. The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms. Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work. (+info)
Assessing the outcome of disorders of the hand. Is the patient evaluation measure reliable, valid, responsive and without bias?
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The different attributes of the Patient Evaluation Measure (PEM) questionnaire were investigated in 80 patients with a fracture of the scaphoid. Assessments were made at 2, 8, 12, 26 and 52 weeks. Reliability was assessed by measurement of the internal consistency of the different questions in 275 completed PEM forms. Cronbach's alpha, which needs to lie between 0.7 and 0.9, was 0.9 for the PEM. Pain, tenderness, swelling, wrist movement and grip strength correlated with the PEM score confirming the validity of the assessment. Changes in the different variables between visits correlated significantly with changes in the PEM score; its effect size and standardised response mean were comparable to those of grip strength and movement, confirming the responsiveness of this questionnaire. Gender, dominance and the side injured did not influence the scores. Older patients had a poorer outcome as assessed by the score which appeared to be a true effect and not age bias. Our study confirmed that the PEM is a reliable, valid and responsive instrument in assessing outcomes of disorders of the hand. (+info)
Scaphoid blood flow and acute fracture healing. A dynamic MRI study with enhancement with gadolinium.
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We have investigated whether assessment of blood flow to the proximal scaphoid can be used to predict nonunion in acute fractures of the scaphoid. We studied 32 fractures of the scaphoid one to two weeks after injury, by dynamic fat-suppressed T1-weighted gradient-echo MRI after the intravenous administration of gadopentetate dimeglumine (0.1 mmol/kg body-weight). Steepest slope values (SSV) and percentage enhancement values (%E) were calculated for the distal and proximal fragments and poles. All the fractures were treated by immobilisation in a cast, and union was assessed by CT at 12 weeks. Nonunion occurred in four fractures (12%), and there was no statistically significant difference between the proximal fragment SSV and %E values for the fractures which united and those with nonunion. The difference between the proximal pole SSV and %E values for the union and nonunion groups reached statistical significance (p < 0.05), but with higher enhancement parameters for the nonunion group. Our results suggest that poor proximal vascularity is not an important determinant of union in fractures of the scaphoid. (+info)
Methicillin-resistant Staphylococcus aureus osteomyelitis of the scaphoid from a catheter in the radial artery.
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We describe the development of methicillin-resistant Staphylococcus aureus osteomyelitis of the scaphoid in a 49-year-old man from an infection occurring around a catheter in the radial artery. Total scaphoidectomy and appropriate antibiotic therapy eradicated the infection. (+info)
Management of scaphoid nonunion with avascular necrosis using 1, 2 intercompartmental supraretinacular arterial bone grafts.
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BACKGROUND: Poor reduction or neglect of an unstable carpal scaphoid fracture may lead to scaphoid nonunion or avascular necrosis. When pre-operative suggestion of avascular necrosis of the proximal pole is confirmed by intra-operative evaluation, conventional bone graft is not enough and a vascularized bone graft is strongly recommended. METHODS: Five patients with nonunion of scaphoid fractures associated with avascular necrosis based on results of radiography and further confirmed by magnetic resonance images and intra-operative findings were operatively managed with 1, 2 intercompartmental supraretinacular arterial (1, 2 ICSRA) vascularized bone graft combined with supplemental cancellous bone grafts from the radius. Follow-up periods were at least 18 months. The functional outcomes and radiographs were analyzed. RESULTS: In four of the five patients, the nonunion sites united within 4 months after surgery. The other patient had a superficial pin tract infection and bone healing was complete 6 months after the operation. The functional results were good in all five patients. CONCLUSION: 1, 2 ICSRA is superficial to the retinaculum and runs directly into the bony tubercle. It is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study. (+info)
Rotatory subluxation of the scaphoid in Kienbock's disease is not a cause of scapholunate advanced collapse (SLAC) in the wrist.
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We have examined whether the rotatory subluxation of the scaphoid which is seen in patients with advanced Kienbock's disease is associated with scapholunate advanced collapse (SLAC) wrist. We studied 16 patients (11 men, 5 women) who had stage-IV Kienbock's disease with chronic subluxation of the scaphoid. All had received conservative treatment. The mean period of affection with Kienbock's disease was 30 years (14 to 49). No wrist had SLAC. In eight patients, 24 years or more after the onset of the disease, the articular surface of the radius had been remodelled by the subluxed scaphoid with maintenance of the joint space. The wrists of six patients were considered to be excellent, nine good, and one fair according to the clinical criteria of Dornan. Our findings have shown that rotatory subluxation of the scaphoid in Kienbock's disease is not a cause of SLAC wrist and therefore that scaphotrapeziotrapezoid arthrodesis is not required for the management of these patients. (+info)