Vascularised bone graft from the base of the second metacarpal for refractory nonunion of the scaphoid.
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A vascularised bone-graft procedure from the base of the second metacarpal was performed in 14 patients with nonunion of the scaphoid. There were 11 men and three women with a mean age of 22 years. In eight patients, who had dorsiflexed intercalated segment instability (DISI), an open wedge was formed at the site of nonunion, and the vascular pedicle was grafted from the volar side. In the six patients without DISI, transplantation was carried out through the same dorsal skin incision. Complete bony union was obtained in all patients after a mean post-operative period of 10.2 weeks, and DISI was corrected in all affected patients. According to Cooney's clinical scoring system, the results were excellent in five, good in six, and fair in three patients. Because of its technical simplicity and the limited dissection needed, the procedure should be considered for the primary surgical treatment of patients with nonunion of the scaphoid. (+info)
Multiple carpometacarpal dislocations and an ipsilateral scapho-trapezium-trapezoid fracture-dislocation: a rare pattern of injury.
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We report a rare case of simultaneous dorsal dislocation of 4 ulnar carpometacarpal joints and dorsoradial dislocation of the trapezium with an associated fracture of the scaphoid tuberosity. The injuries were diagnosed early and treated successfully with closed reduction and transfixation using Kirschner wires. The functional results were excellent at 17-month follow-up. (+info)
Cost effectiveness of adding magnetic resonance imaging to the usual management of suspected scaphoid fractures.
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OBJECTIVE: To determine the cost effectiveness of a magnetic resonance imaging scan (MRI) within 5 days of injury compared with the usual management of occult scaphoid fracture. METHODS: All patients with suspected scaphoid fractures in five hospitals were invited to participate in a randomised controlled trial of usual treatment with or without an MRI scan. Healthcare costs were compared, and a cost effectiveness analysis of the use of MRI in this scenario was performed. RESULTS: Twenty eight of the 37 patients identified were randomised: 17 in the control group, 11 in the MRI group. The groups were similar at baseline and follow up in terms of number of scaphoid fractures, other injuries, pain, and function. Of the patients without fracture, the MRI group had significantly fewer days immobilised: a median of 3.0 (interquartile range 3.0-3.0) v 10.0 (7-12) in the control group (p = 0.006). The MRI group used fewer healthcare units (median 3.0, interquartile range 2.0-4.25) than the control group (5.0, 3.0-6.5) (p = 0.03 for the difference). However, the median cost of health care in the MRI group (594.35 dollars AUD, 551.35-667.23 dollars) was slightly higher than in the control group (428.15 dollars, 124.40-702.65 dollars) (p = 0.19 for the difference). The mean incremental cost effectiveness ratio derived from this simulation was that MRI costs 44.37 dollars per day saved from unnecessary immobilisation (95% confidence interval 4.29 dollars to 101.02 dollars). An illustrative willingness to pay was calculated using a combination of the trials measure of the subjects' individual productivity losses and the average daily earnings. CONCLUSIONS: Use of MRI in the management of occult scaphoid fracture reduces the number of days of unnecessary immobilisation and use of healthcare units. Healthcare costs increased non-significantly in relation to the use of MRI in this setting. However, when productivity losses are considered, MRI may be considered cost effective, depending on the individual case. (+info)
Best evidence topic report. Magnetic resonance imaging or bone scintigraphy in the diagnosis of plain x ray occult scaphoid fractures.
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A short cut review was carried out to establish whether magnetic resonance scanning or bone scintigraphy is better at identifying scaphoid fractures not apparent on plain x rays. Altogether 11 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated. (+info)
Percutaneous osteosynthesis versus cast immobilisation for the treatment of minimally and non-displaced scaphoid fractures. Functional outcomes after a follow-up of at least 12 month.
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The authors compare the functional outcome of 26 patients successfully treated by percutaneous osteosynthesis and 24 patients successfully treated by a short-arm thumb cast for the acute scaphoid fracture after a follow-up of at least 12 months. The patients treated by percutaneous osteosynthesis showed a significantly better range of wrist motion at the time of re-examination. Differences in persistent complaints and in grip strength compared to the uninjured wrist between both groups were statistically insignificant yet slightly in favour of the surgically treated patients. The higher suitability of percutaneous osteosynthesis is further supported by the significantly lower failure rate compared to conservative treatment. Based on these results, percutaneous osteosynthesis seemed to be the more favourable method of treatment of minimally and non-displaced scaphoid fractures than conservative treatment. (+info)
Management of suspected scaphoid fractures in accident and emergency departments--time for new guidelines.
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INTRODUCTION: The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid. SUBJECTS AND METHODS: We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures. RESULTS: The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines. CONCLUSIONS: The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients. (+info)
Changes in patterns of scaphoid and lunate motion during functional arcs of wrist motion induced by ligament division.
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PURPOSE: To determine the in vitro motion of the scaphoid and lunate during wrist circumduction and wrist dart-throw motions and to see how these motions change after the ligamentous stabilizers of the scaphoid and lunate are sectioned in a manner simulating scapholunate instability. METHODS: Twenty-one fresh-frozen cadaver forearms were moved through a dart-throw motion and a circumduction motion using a wrist joint simulator. Scaphoid and lunate motion were measured with the wrist ligaments intact and after sectioning of the scapholunate interosseous ligament, the scaphotrapezium ligament, and the radioscaphocapitate ligament. RESULTS: In the intact wrist the scaphoid and lunate moved more during circumduction than during the dart-throw motion. With ligamentous sectioning the scaphoid flexed more and the lunate extended more during both the circumduction and dart-throw motions. During the circumduction motion both before and after sectioning the global motion of the scaphoid was greater than that of the lunate. After sectioning the scaphoid motion increased and the lunate motion decreased. CONCLUSIONS: The scaphoid and lunate motions were observed to change remarkably after ligamentous sectioning. The observed changes in carpal motion correlate with the clinical observation that after ligamentous injury arthritic changes occur in the radioscaphoid joint and not in the radiolunate joint. Analysis of the injured wrist in positions that combine flexion-extension and radial-ulnar deviation may allow noninvasive diagnosis of specific wrist ligament injuries. (+info)
The effect of ultrasound on the healing of muscle-pediculated bone graft in scaphoid non-union.
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The use of pedicled vascularised bone grafts from the distal radius makes it possible to transfer bone with a preserved circulation and viable osteoclasts and osteoblasts. Experiments performed at the basic science level has provided substantial evidence that low-intensity ultrasound can accelerate and augment the fracture healing process. Only an adequate double-blind trial comparing treatment by ultrasound stimulation in patients treated by similar surgical techniques can provide evidence of the true effect of ultrasound. This paper describes the results of such a trial. From 1999 to 2004, 21 fractures of the scaphoid with established non-union treated with vascularised pedicle bone graft were selected for inclusion in a double-blind trial. All patients were males, with an average age of 26.7 years (range 17-42 years) and an average interval between injury and surgery of 38.4 months (range 3 months-10 years). Low-intensity ultrasound was delivered using a TheraMed 101-B bone-growth stimulator (30 mW/cm2, 20 min/day), which was modified to accomplish double-blinding. These modifications did not affect the designated active units. The placebo units were adjusted to give no ultrasound signal output across the transducer. Externally, all units appeared identical but were marked with individual code numbers. Patients were randomly allocated to either an active or placebo stimulation. Follow-up averaged 2.3 years (range 1-4 years). All patients achieved fracture union (active and placebo groups), but compared with the placebo device (11 patients), the active device (ten patients) accelerated healing by 38 days (56+/-3.2 days compared with 94+/-4.8 days, p<0.0001, analysis of variance). (+info)