Metastatic esophageal adenocarcinoma of the carpus

We report on a rare case of metastatic esophageal adenocarcinoma to the wrist developing years after diagnosis and treatment of the primary lesion. Awareness of the potential for developing these lesions should be raised, particularly in the absence of systemic symptoms.

Clinical findings, diagnosis, prevalence and predisposing factors for lameness localised to the middle carpal joint in young Standardbred racehorses

REASONS FOR PERFORMING STUDY

Lameness related to the middle carpal joint (MCJ) occurs in up to 30% of young Standardbred horses in race training and the incidence increase with radiographic severity of third carpal bone (C3) sclerosis on DPr-DDIO (skyline) view of the carpus. Factors predisposing horses to carpal injury have not been well investigated.

OBJECTIVES

To determine the importance of MCJ lameness as a cause of wastage in young Standardbred racehorses, stage of training at which it occurs and predisposing factors, and to describe clinical findings and diagnosis.

METHODS

Standardbred horses (n = 114) entering their first year of race training were examined at approximately 3-month intervals over 12-18 months. For 87 of the horses, a training diary was available and these horses were trained at 3 different stables, each using a different exercise regime. At each examination, forelimb conformation, MCJ effusion, MCJ lameness and radiographic findings were graded, and training history and reasons for lost training days recorded. Nuclear scintigraphy and exploratory arthroscopy were performed on a limited selection of horses. Results for horses that developed MCJ lameness during the study period were compared statistically with results for horses that did not.

RESULTS

Carpal lameness occurred in 28% of horses and was present in 56% with forelimb lameness. In most cases lameness was mild, bilateral and with little or no MCJ effusion and was attributed to subchondral bone pain associated with radiographic evidence of C3 sclerosis. Carpal lameness was the most common reason for >1 month's rest during the study period. It occurred at any stage of training but, in most cases, some speed training had begun. Of the variables studied, poor forelimb conformation and more intense speed training were predisposing factors.

CONCLUSIONS AND POTENTIAL RELEVANCE

The information gained should assist in making recommendations regarding training young Standardbreds to reduce the incidence of MCJ lameness. However, further investigations to determine the optimal training regime are warranted.

Radiographic evaluation of sclerosis of the third carpal bone associated with exercise and the development of lameness in Standardbred racehorses

REASONS FOR PERFORMING STUDY

Sclerosis of the third carpal bone is a common radiographic finding in both lame and sound racehorses, but there are no guidelines correlating degree of sclerosis and incidence of lameness.

OBJECTIVES

To develop a protocol for describing subchondral bone sclerosis in C3 on dorsoproximal-dorsodistal oblique (DPr-DDiO) radiographs of the carpus and to correlate these changes with exercise history and carpal lameness.

METHODS

One hundred and six Standardbreds entering their first year of training (exercise group) and 7 age-matched Standardbreds at pasture (controls) were examined at approximately 3 month intervals over 12-18 months. Examinations consisted of lameness evaluation and carpal radiographs (DPr-DDiO and flexed lateromedial projections). A grading system (very mild, mild, moderate and severe) for C3 sclerosis seen on the DPr-DDiO radiograph was developed that utilised a combination of the criteria of trabecular thickening (trabecular score; TS) and total percent area of the C3 radial facet affected (TAA).

RESULTS

Exercise group horses showed significant increase in TS and TAA throughout training compared to control horses. Middle carpal joint lameness developed in 32/106 (30%) exercise group horses and none of the control horses. Incidence of middle carpal joint (MCJ) lameness was lower in horses with mild (2/30, 6.7%) than moderate (10/32, 31.2%) and severe (20/44, 45.4%) sclerosis throughout training.

CONCLUSIONS

Horses with higher grades of sclerosis, as defined by this novel grading system, were more likely to develop MCJ lameness at some point of training. The proposed grading system gave a quantitative assessment of radiographic sclerosis that could then be used to correlate increasing severity of sclerosis with increasing incidences of lameness.

POTENTIAL RELEVANCE

These results serve as a basis for further investigation into determining the degree of C3 sclerosis at which pathological changes and lameness can be expected.

Pathology and therapeutic results in patients with intraosseous ganglia of the carpal bone

This study evaluated the pathology and therapeutic results of seven patients with intraosseous ganglia of the carpal bone. The mean age at the time of surgery was 27.6 years. The lesions were localized in the proximal carpal row in six patients and in the distal carpal row in only one. Surgical treatment was performed in all patients with good bone union. None had pain during activity or at rest and no recurrence had occurred. The intraosseous ganglia in four patients was of the idiopathic type, and in the other three patients was of the penetrating type. Although intraosseous ganglia of the carpal bone is reported as a rare disease, there were 159 cases in the literature. The pathology was intra- or extraosseous development, showing variation, but most cases were localized in the proximal carpal row.

The effect of landmarks and bone motion on posture-related changes in carpal tunnel volume

BACKGROUND

Deviated wrist postures have been linked to carpal tunnel syndrome development, yet the effect of posture on carpal tunnel volume remains unclear. The purposes of this study were (i) to evaluate the effect of boundary definitions on tunnel volume estimates in neutral and non-neutral (30 degrees flexion, 30 degrees extension) wrist postures and (ii) to develop a biomechanical wrist simulation to predict posture-related changes in tunnel volume.

METHODS

Two carpal tunnel volume measures were calculated using (i) ulnar bony landmarks and (ii) radial and ulnar bony landmarks identified directly from magnetic resonance imaging (MRI) scans. A third volume measure combined computerized tunnel reconstructions with modelled bone surfaces to calculate an anatomically landmarked volume. Six individual simulations were then generated to predict volume in the flexed and extended postures based on individual carpal bone motions.

FINDINGS

Boundary definitions influenced the absolute volume in each posture and the relative changes between postures. Relative to fully reconstructed volumes, radial and ulnar landmarked volumes were 15-25% larger across postures (681 (SD 467) mm(3); P=0.01), while the ulnar-only landmarked volumes were 10-20% smaller (562 (343) mm(3); P<0.01). Simulation predicted volumes were not significantly different from the reconstructed anatomically landmarked volumes, with less inter-individual variability between postures compared to MRI-based volumes.

INTERPRETATION

Comparison of volume measures indicated the importance of capturing posture-related changes in the orientation of the proximal and distal tunnel boundaries, and revealed potential sources of error associated with volume reconstruction. Simulations can enable changes in tunnel dimensions to be related to bone movements throughout a range of motion.

Treatment of Kienböck disease in an 11-year-old girl with temporary fixation of the scaphotrapeziotrapezoidal joint

An 11-year-old girl with Kienböck disease (stage IIIA) was treated by temporary scaphotrapeziotrapezoidal fixation. It was fixed in a cast for four weeks and wires removed after eight weeks. Follow up examinations showed that movement of the wrist and grip strength were improved, and she had no pain while revascularisation of the lunate could be seen on magnetic resonance imaging.

Outcome of proximal row carpectomy

Fifty-one patients who had had proximal row carpectomy between 1992 and 2002 with a minimum follow-up of one year were followed up clinically and radiologically retrospectively. Their diagnoses included Kienböck disease (n=21), avascular necrosis of the scaphoid (n=4), nonunion of the scaphoid with osteoarthritis (n=9), and scapholunate advanced collapse (n=17). The mean follow-up was 5 years, 8 months. The mean "disabilities of the arm, shoulder and hand" (DASH) score was 18. The mean patient-rated wrist evaluation (PRWE) score list was 25% of maximum disability for the function and pain score. Thirty-four patients (87%) were able to return to work a mean of six months after operation (range 3 weeks - 35 months). Nine patients (11%) required arthrodesis of the wrist and are considered as failures. Mean flexion of the wrist was 66%, extension 73%, radial deviation 74%, ulnar deviation 76%, and grip force 70% of the opposite side. Excision of the proximal row provided predictable and durable pain relief, restored functional movement and grip strength, and allowed returned to gainful employment in most of the patients.

Carpal tunnel syndrome caused by an intraosseous ganglion of the capitate

Intraosseous ganglions often arise in the foot and ankle but are less common within the carpal bones. We present a case of an intraosseous ganglion of the capitate bone associated with compression of the median nerve that was seen on plain radiographs and magnetic resonance images.

The orthopedic and renal manifestations of idiopathic carpal tarsal osteolysis

Idiopathic carpal tarsal osteolysis (ICTO) is a rare congenital disorder that results in the destruction and resorption of bone, leading to severe functional deficits and cosmetic deformities. This report includes a literature review describing the orthopedic and renal manifestations of ICTO. An additional case report of ICTO with atypical features is included.

Carpal-tarsal osteolysis with elbow involvement

Carpal-tarsal osteolysis is a rare condition that manifests as the progressive resorption of carpal and tarsal bones in young children. The diagnosis of this condition is often difficult and delayed as the initial clinical presentation is non-specific. Radiographic changes occur gradually, are often not seen at presentation and depend on recognising loss of bone in the ossification centres of the carpus and tarsus. MRI demonstrates morphological abnormalities in the cartilaginous, as well as the osseous components, of the developing carpal and tarsal bones and therefore may be helpful in predating the radiographic changes. Ultrasound appears to contribute little to the diagnosis and may be misleading. Exclusion of other conditions, particularly juvenile idiopathic arthritis, is important in making the diagnosis. MRI can be useful in excluding an inflammatory arthropathy, and suggesting the diagnosis of carpal-tarsal osteolysis.

Multicentric carpal-tarsal osteolysis with nephropathy treated successfully with cyclosporine A: a case report and literature review

Multicentric carpal-tarsal osteolysis is a rare skeletal disorder characterized by osteolysis of the metacarpal, carpal, and tarsal bones and leading to crippling joint deformities. Progressive nephropathy occurs in more than half the cases. All previously reported series with renal biopsies showed only end-stage renal disease on histological examination because of the late presentation to nephrologists. Accurate diagnosis of the underlying renal pathological state therefore has not been possible. We report the first case in which early and sequential renal biopsies were performed. These show the renal lesion to be focal and segmental glomerulosclerosis, which was treated successfully with cyclosporine A.

A three-dimensional quantitative analysis of carpal deformity in rheumatoid wrists

We have measured the three-dimensional patterns of carpal deformity in 20 wrists in 20 rheumatoid patients in which the carpal bones were shifted ulnarwards on plain radiography. Three-dimensional bone models of the carpus and radius were created by computerised tomography with the wrist in the neutral position. The location of the centroids and rotational angle of each carpal bone relative to the radius were calculated and compared with those of ten normal wrists. In the radiocarpal joint, the proximal row was flexed and the centroids of all carpal bones translocated in an ulnar, proximal and volar direction with loss of congruity. In the midcarpal joint, the distal row was extended and congruity generally well preserved. These findings may facilitate more positive use of radiocarpal fusion alone for the deformed rheumatoid wrist.

Dysplasia epiphysealis hemimelica: two cases in two different regional expression

Dysplasia epiphysealis hemimelica most commonly presents as an overgrowth of the epiphysis in the lower limb. We report two cases, one a classical form involving the lower limb, and the other in a relatively rarer location in the wrist. Both cases were treated surgically by excision of the masses. We recommend excision of symptomatic intra-articular lesions by using MRI, which provides additional information concerning physeal line and extension of the mass, to prevent the development of angulation and to keep the range of motion.

A modification of the Omeract RA MRI score for erosions for use with an extremity MRI system with reduced field of view

OBJECTIVES

To develop and test the reliability of a modified version of the OMERACT rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for erosions using extremity MRI (eMRI) with reduced field of view (RAMRIS-RV).

METHODS

Using a MagneVu 0.2 T machine, the preliminary RAMRIS-RV assessed erosions in metacarpophalangeal (MCP) joints 2-3, bases of metacarpal (MC) 2-5, and all wrist bones excluding base MC 1, pisiform and trapezium. T1 weighted images of >/=500 MCP and wrist bony sites from a mixed severity RA and control cohort were evaluated. An inter-reader reliability study evaluating 300 wrist and 160 MCP bony sites was then performed.

RESULTS

Mean per cent exact (and close) agreement results were as follows: MCP proximal sites 83.5 (96.2), MCP distal 54.4 (77.2), bases MC 2-4 85.2 (96.7), carpal bones 79.0 (92.1), distal radius/ulna 66.4 (87.8). The base of MCP 5 was visualised in </=50% cases (13/25) and was removed from the final RAMRIS-RV.

CONCLUSIONS

The RAMRIS-RV is a practical tool that can be used with eMRI with a reduced field of view. This study shows excellent inter-reader reliability for erosion assessment, albeit in a reduced number of bony sites.

[Numerical variants and congenital fusions of carpal bones]

The number of carpal bones may be increased or decreased by the fact of anatomical variants or true congenital anomalies. Numerical increment arises from additional or from split bones. Over twenty accessory carpal bones have been described but the commonest are the os centrale carpi, the os radiale externum, the triangular bone and the styloideum bone. Additional carpal bones usually result from a failure of fusion of their ossification centers. A congenital origin is not clearly established for all these ossicles. The scaphoid and lunate may split into two or three bones and several cases of bipartite hamulus of the hamatum have been reported. A carpus with only seven bones results from the congenital absence of a normal bone, which mainly affects the scaphoid, lunate and triquetrum, or from a synostosis between two carpal bones, usually the lunate and triquetrum. Congenital fusions originate from an absence of joint cavitation into the embryo and chondrification of the joint interzone. Numerical carpal variants are uncommon as independent entities but occur with a relative high frequency in association with complex malformations of the hand. These anomalies are detectable on plain radiographs of the wrist, but CT-scan and MR-Imaging are useful to differentiate bipartite and accessory bones from carpal fractures or posttraumatic injuries, carpal fusions having to be distinguished from bony ankylosis.

Congenital proximal radioulnar synostosis associated with bilateral hypoplasia of the scaphoid bone, bilateral os lunatotriquetrum, and anomalies of the carpometacarpal complex

We describe a unique case of bilateral os lunatotriquetrum associated with bilateral hypoplasia of the scaphoid bone. On both sides, the medial carpi were in a single row. The capitate bone occupied the lunate position, whereas the lunatotriquetral bone was displaced ulnarly and tilted. The capitate thus articulated with the radius and metacarpal bones, consistent with carpal collapse. In addition, there was congenital proximal radioulnar synostosis on the left side.

Salvage procedures for degenerative osteoarthritis of the wrist due to advanced carpal collapse

Arthrodesis of the wrist has been considered as the gold standard for osteoarthritis of the wrist. In 1984 Watson and Ballet identified a specific pattern of carpal collapse (scapholunate advanced collapse = SLAC) with progressive osteoarthritis. In order to preserve some motion, other alternative procedures have been proposed: proximal row carpectomy (PRC) and scaphoidectomy combined with a four-corner arthrodesis (4CA). In this cohort of 63 patients, three types of surgical treatment were performed (arthrodesis in 19, PRC in 26 and scaphoidectomy with 4CA in 18). The DASH questionnaire was used to evaluate the residual disability. PRC had a significantly better outcome (DASH=16), while there were no significant differences between full arthrodesis (DASH=45) and four corner arthrodesis (DASH=39). In PRC and in four corner arthrodesis a functional range of motion could be preserved (resepectively 44 degrees and 52 degrees flexion/extension arc). Gripping force remained inferior to the non operated side. There was a significant increase in gripping force in the PRC group, but not in the others. The final gripping force was not significantly different in the three treatment regimes.

Concomitant Kienböck's and Preiser's diseases: a case report

Reports of simultaneous carpal avascular necrosis in more than 1 bone are rare. This is a report of simultaneous Kienböck's disease and Preiser's disease in a 50-year-old woman with a remote history of steroid use but without a history of trauma or systemic illness.

Occult scaphoid fractures: comparison of multidetector CT and MR imaging--initial experience

PURPOSE

To compare the diagnostic performance of multidetector computed tomography (CT) and magnetic resonance (MR) imaging in patients clinically suspected of having a scaphoid fracture and who had normal initial radiographs, with radiographs obtained 6 weeks after trauma as the reference standard.

MATERIALS AND METHODS

The ethics committee approved the study, and all patients gave written informed consent. Twenty-nine patients (17 male, 12 female; age range, 17-62 years; mean age, 34 years +/- 13) underwent multidetector CT and MR imaging within 6 days after trauma. CT data were obtained with 0.5-mm collimation. For image review, 0.7-mm-thick multiplanar reformations were performed in transverse, coronal, and sagittal planes relative to the wrist. The 1.0-T MR examination consisted of coronal and transverse short inversion time inversion-recovery, coronal and transverse T1-weighted spin-echo, and coronal volume-rendered T2-weighted gradient-echo sequences. Two radiologists analyzed the CT and MR images. A binomial test was used to evaluate the significance of the differences between MR imaging and CT in detection of scaphoid fractures and cortical involvement (P < .05).

RESULTS

The 6-week follow-up radiographs depicted a scaphoid fracture in 11 (38%) patients. Eight patients had a cortical fracture, while three patients had only a bandlike lucency within the trabecular portion of the scaphoid. MR imaging depicted all 11 fractures but only three [corrected] cortical fractures. Multidetector CT depicted all eight cortical fractures but failed to depict trabecular fractures. No false-positive fractures were seen on MR or CT images. Differences between MR imaging and CT were not significant for the detection of scaphoid fractures (P = .25) but were significant for cortical involvement (P = .03).

CONCLUSION

Multidetector CT is highly accurate in depicting occult cortical scaphoid fractures but appears inferior to MR imaging in depicting solely trabecular injury. MR imaging is inferior to multidetector CT in depicting cortical involvement.

Scaphoid fractures and nonunions: diagnosis and treatment

BACKGROUND

Scaphoid fractures are commonly seen in orthopedic practice. An organized and thoughtful approach to diagnosis and treatment can facilitate good outcomes. However, despite optimal treatment, complications may ensue. In the setting of nonunion or an avascular proximal pole, vascularized bone grafting may be needed.

METHODS AND RESULTS

In this article we review the literature regarding these injuries and describe an approach to diagnosis, treatment, and management of scaphoid fractures and nonunions.

CONCLUSION

Scaphoid fractures and nonunions may present as challenging problems in practice, but a systematic and deliberate approach can facilitate optimal results.