Scaphoid fractures

A Patient-Specific Three-Dimensional-Printed Surgical Guide for Dorsal Scaphoid Fracture Fixation: A Comparative Cadaver Study

Purpose

This study proposes a patient-specific three-dimensional (3D)-printed surgical guide designed for scaphoid fracture fixation through a limited dorsal approach.

Methods

Computed tomography scans of five cadaveric wrists were modeled in 3D segmentation software and cannulated screw guidewire trajectory was planned. Custom 3D-printed surgical guides for guidewire insertion were designed for each scaphoid. Guidewire placement was performed with and without the surgical guide through a dorsal approach. Postoperative scans were overlaid with the planned trajectory and compared. Five variables were measured: angular deviation, distance between entry points, distance between exit points, embedded guidewire length, and number of attempts.

Results

Mean angular deviation from the planned trajectory was 10.80 ± 6.72° for the guided and 14.08 ± 4.65° for the freehand group. The offset between entry and exit for the guided group was 2.22 ± 1.04 and 3.52 ± 2.80 mm and for the freehand group 2.95 ± 1.31 and 4.91 ± 2.37 mm, respectively. The mean length for the guided group was 23.25 ± 3.33 mm and 23.31 ± 3.07 mm for the freehand group. All guided cases took one attempt and the freehanded cases 2.0 ± 1.0 attempts. A significant positive correlation was found between trajectory and exit. No significance between groups was found between any of the measured variables. A minimum sample size of 28 was determined for follow-up studies.

Conclusions

The use of a custom surgical guide improved guidewire placement in four of five specimens when compared with a freehand approach. Specifically, the trajectory was closer to the planned trajectory. All guidewire placements were clinically acceptable. Therefore, we consider the use of this surgical guide for the dorsal approach feasible to be used in clinical practice.

Clinical relevance

This device could be used to treat nondisplaced scaphoid fractures. The use of a custom surgical guide could allow for accurate and efficient screw placement as well as reduced operating time and fluoroscopy exposure.

Bone Mineral Density in the Scaphoid

Introduction: The scaphoid bone is essential for wrist stability and movement. While fractures commonly occur at the scaphoid's waist, those at the proximal pole, though rarer, tend to result in nonunion, potentially linked to variations in bone mineral density (BMD). Previous studies have shown an increase in BMD at the proximal pole in fractured scaphoids, but BMD distribution in intact scaphoids has not been well studied. This study aims to map the BMD distribution of the intact scaphoid to better understand the etiology of fractures and optimize treatment approaches. Methods: Conducted under ethical approval, this study included 100 individuals, using computed tomography to assess the BMD in distal, middle, and proximal thirds of the scaphoid. Measurements were performed in the defined regions and analyzed using SPSS software, with significance accepted at P < .05. Results: The study comprised 34 females and 66 males, with no significant BMD difference between the right and left wrists. The proximal third exhibited significantly higher BMD (542.2 HU) compared to the middle (293.1 HU) and distal thirds (298.4 HU). A statistically significant higher BMD was observed in males, particularly in the proximal and distal thirds. A weak negative correlation between age and BMD was noted across all sections. Conclusion: The proximal scaphoid shows significantly higher BMD, potentially explaining its lower fracture incidence but higher nonunion rate. This insight into the BMD distribution within an intact scaphoid may guide the clinical management of scaphoid fractures, highlighting the need for targeted treatment strategies based on BMD variations.

A review of scaphoid fracture, treatment outcomes, and consequences

PURPOSE

Scaphoid fractures are the most common carpal fracture and can lead to severe complications like carpal collapse and osteoarthritis. This study reviewed scaphoid fracture patterns, outcomes, and consequences in conservative and surgical management.

METHODS

Sixty-four patients with scaphoid fracture who attended the hand clinic at King Hussein Medical City from January 2022 to December 2022 were included and reviewed regarding the anatomical fracture site, the associated injury, the treatment modality (conservative versus surgical), the healing time, and fracture sequelae such as nonunion and scaphoid nonunion advanced collapse.

RESULTS

Most patients were males (62 patients, 96.9%), and most (47, 73.4%) fell within 25 to 40 years. Scaphoid waist fracture was the most common location (40, 52.5%). Most patients (47, 73.4%) received conservative treatment and 17 (26.6%) were fixed acutely. However, nonunion complicated 53 fractures (82.8%). Notably, there were no differences in the union rate or time between cases of scaphoid nonunion treated with vascularized or nonvascularized grafts. Furthermore, there were no variations in union rates among genders, extremities, age, fracture locations, or among smokers. However, a higher union rate was noted in office workers and those who received conservative treatment.

CONCLUSION

Nonunions were higher in our study than in the literature, as our department is a referral center for established nonunion cases. For conservative treatment, we recommend aggressive management and follow-up with a clinical and CT scan at three months and early referral of non-united fractures to the hand clinic to avoid the advanced collapse of the scaphoid.

Principles and Evaluation of Bony Unions

Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.

Patient outcome scores between 1,2- and 2,3-intercompartmental supra-retinacular artery (ICSRA) pedicled vascularised bone grafts (PVBGs) in the treatment of proximal pole scaphoid fracture non-union - a questionnaire study

BACKGROUND

Numerous studies have been published on the use of 1,2-intercompartmental supra-retinacular artery (ICSRA) as a pedicled vascularised bone graft (PVBG) in scaphoid fracture non-union, however, only very few studies have reported their results of 2,3-ICSRA. The aim of this study was to compare the patient-rated outcome scores between these two PVBGs in proximal pole scaphoid fracture non-union.

METHODS

Nineteen patients who underwent surgery for scaphoid non-union between 2017 and 2021 at a single institution were recruited retrospectively in this study. All patients were operated by a one senior orthopaedic surgeon. A mailed questionnaire with the modified mayo wrist (MMW) and the patient rated wrist evaluation (PRWE) scores were sent to the patients.

RESULTS

All patients were males with a mean age of 22.5 years. There was no statistically significant difference in the PRWE score between the two PVBGs. However, a statistically significant difference was found in the MMW score, with the 1,2-ICSRA PVBG having better scores.

CONCLUSION

Despite the 2,3-ICSRA having a longer arc of rotation, longer nutrient arteries, and is technically easier to incorporate in a PVBG, when compared with the 1,2-ICSRA it did not result in better patient-rated outcome scores.

Defining Nonunion for Metacarpal Fractures: A Systematic Review

Purpose

Our purpose was to assess how nonunion of the metacarpals has been defined in prior investigations with respect to both clinical and radiographic criteria. We hypothesized that the definitions of nonunion would be highly variable.

Methods

A systematic review was conducted using MEDLINE and Embase databases for clinical articles related to the treatment of metacarpal fractures (surgical and nonsurgical) from 2010 to 2021. Included articles were searched to assess how nonunion was defined based on clinical and radiographic criteria. We assessed the treatment type, method of union assessment, time to union, and incidence of union as well as article factors such as the following: date of publication, level of evidence, and publishing journal.

Results

A total of 641 articles were identified, of which 102 were included for a definition of nonunion and 97 were included for the assessment of clinical management and outcomes. Of the included articles, 62% contained level IV evidence. A definition of nonunion was provided in 47% of the articles. Radiographic criteria alone, clinical criteria alone, or a combination of the 2 was used in 22%, 6%, and 19% of the cases, respectively, to define nonunion. The most common definition of nonunion was presence of fracture-site tenderness (with no time defined) in 20 articles (20%), followed by lack of radiographic healing at 6 months (15%). In the 97 included articles, the total number of fracture cases was 4,435 and nonunion was reported in 0.45%. Cases with nonunion were reported in a total of six articles that used a variety of treatment modalities.

Conclusions

The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria.

Clinical relevance

Standardizing the definition of nonunion for metacarpal fractures would allow for more accurate assessments of the incidence of this complication and may aid in improving diagnostic and management strategies.

Resource Utilization and the Use of Bone Stimulators among Operatively and Nonoperatively Managed Scaphoid Nonunion Patients

The prevalence of bone stimulator use among nonoperatively and operatively managed scaphoid nonunion patients is unknown. We hypothesize that bone stimulators are a relatively underutilized treatment for scaphoid nonunion patients.

Methods

We used the 2009-2017 Truven Marketscan Research Databases to identify patients with closed scaphoid fractures and performed an analysis of variance test to determine resource utilization and bone stimulator use among these patients.

Results

A total of 36,611 patients with scaphoid fractures were identified: 30,143 were managed nonoperatively and 6468 were managed operatively. Nonunion was diagnosed in 500 (1.66%) nonoperatively and in 1211 (19%) operatively managed patients. Bone stimulators were used in less than 2% of nonoperatively and operatively managed scaphoid nonunion patients.

Conclusion

Lack of trust in the technology and heterogenous (and occasionally burdensome) requirements for insurance approval are barriers to bone stimulator use; however, surgeons should examine how this technology may fit into the treatment algorithm for these difficult cases.

Artificial intelligence vs. radiologist: accuracy of wrist fracture detection on radiographs

OBJECTIVE

To compare the performances of artificial intelligence (AI) to those of radiologists in wrist fracture detection on radiographs.

METHODS

This retrospective study included 637 patients (1917 radiographs) with wrist trauma between January 2017 and December 2019. The AI software used was a deep neuronal network algorithm. Ground truth was established by three senior musculoskeletal radiologists who compared the initial radiology reports (IRR) made by non-specialized radiologists, the results of AI, and the combination of AI and IRR (IR+AI) RESULTS: A total of 318 fractures were reported by the senior radiologists in 247 patients. Sensitivity of AI (83%; 95% CI: 78-87%) was significantly greater than that of IRR (76%; 95% CI: 70-81%) (p < 0.001). Specificities were similar for AI (96%; 95% CI: 93-97%) and for IRR (96%; 95% CI: 94-98%) (p = 0.80). The combination of AI+IRR had a significantly greater sensitivity (88%; 95% CI: 84-92%) compared to AI and IRR (p < 0.001) and a lower specificity (92%; 95% CI: 89-95%) (p < 0.001). The sensitivity for scaphoid fracture detection was acceptable for AI (84%) and IRR (80%) but poor for the detection of other carpal bones fracture (41% for AI and 26% for IRR).

CONCLUSIONS

Performance of AI in wrist fracture detection on radiographs is better than that of non-specialized radiologists. The combination of AI and radiologist's analysis yields best performances.

KEY POINTS

• Artificial intelligence has better performances for wrist fracture detection compared to non-expert radiologists in daily practice. • Performance of artificial intelligence greatly differs depending on the anatomical area. • Sensitivity of artificial intelligence for the detection of carpal bones fractures is 56%.

Value of the 45-degree reverse oblique view of the carpal palm in diagnosing scaphoid waist fractures

OBJECTIVES

To investigate the value of 45° reverse oblique view of the carpal palm in diagnosing scaphoid waist fracture and displacement.

METHODS

Eighty-four patients with wrist injury and plain radiography including posteroanterior, lateral, Stecher, and 45° reverse oblique view of the wrist were analyzed for the detection rate in diagnosing scaphoid fractures and displacement. The degree of difficulty in the four views for detecting the scaphoid waist fracture and displacement was rated on a five-grade Likert scale.

RESULTS

Among 84 patients, scaphoid waist fractures occurred in 43, and fracture displacement in 32. A significantly (P<0.01) greater rate of detecting the scaphoid waist fracture was found in the Stecher, and 45° reverse oblique view than in the posteroanterior and lateral views. The rate of detecting fracture displacement was significantly (P<0.01) greater in the Stecher and 45° reverse oblique view than in the posteroanterior and lateral views. The Stecher view had a significantly (P = 0.006) lower rate of detecting fracture displacement than the 45° reverse oblique view. It was significantly (P<0.001) easier to identify the scaphoid waist fracture and displacement with the 45° reverse oblique view and the Stecher view than with the posteroanterior and lateral view. The 45° reverse oblique view had the easiest degree to identify the scaphoid waist fracture displacement, followed by the Stecher view, the posteroanterior and the lateral view (P<0.001).

CONCLUSIONS

The 45° reverse oblique view clearly shows the scaphoid oblique view in the long axis for better observation of the scaphoid waist fracture and displacement.

Non-Displaced Scaphoid Waist Fractures: Percutaneous Screw Fixation Versus Cast Immobilization

Background

Scaphoid waist fractures make up 66% of scaphoid fractures and are mostly non-displaced. The purpose of this study was to demonstrate that percutaneous screw fixation is preferable to cast immobilization in the treatment of non-displaced or minimally displaced scaphoid waist fractures.

Methodology

Between 2017 and 2019, we conducted a retrospective review of patients aged 17-65 years who underwent treatment for acute non-displaced scaphoid waist fractures. In total, 52 patients with scaphoid waist fractures were included in the analysis, 25 of whom underwent percutaneous screw treatment and 27 were treated with a short plaster cast. Patient satisfaction, pain, range of motion, and grip strength were evaluated using the Mayo Modified Wrist Score (MMWS). In addition, the time to return to work/sports, union time, complications, and non-union status were evaluated.

Results

A total of 52 (35 male, 15 female) patients were enrolled in this study. The average follow-up time was 24.9 months (range, 24-29 months). The mean age was 28.12 years (range, 17-45 months). Group 1 consisted of 25 patients who underwent percutaneous screw fixation, and group 2 consisted of 27 patients who were treated with a short plaster cast. There were significant differences in return to work, return to sports, and union time between the two groups (p < 0.001). The sixth-month MMWS was significantly different between the two groups (p < 0.001), but the first-year MMWS was not significantly different between the two groups (p = 0.864). There were no complications in both groups.

Conclusions

With percutaneous screw fixation, acute non-displaced or minimally displaced scaphoid waist fractures demonstrated a high rate of union and early return to work/sports.

Surgical outcomes of scaphoid fracture osteosynthesis with magnesium screws

Objectives

This study aims to evaluate the mid-term functional and radiological outcomes of magnesium-based screws in the treatment of scaphoid fractures.

Patients and methods

Between February 2015 and February 2018, a total of 21 patients (18 males, 3 females; mean age: 28.5±5.8 years; range, 19 to 39 years) with acute scaphoid waist fractures who underwent fracture fixation with biologically degradable magnesium-based compression screws were retrospectively analyzed. Fractures were classified according to the Herbert and Fisher classification. The absence of pain on palpation and painless active range of motion were accepted as the signs of union.

Results

The mean follow-up was 43.3±5.3 (range, 36 to 52) months. According to the Herbert and Fisher classification, nine patients had type B1 and 12 patients had type B2 scaphoid fractures. Union was achieved in all cases. The mean time to union was 11.2±1.5 (range, 9 to 14) weeks. The mean grip strength, flexion, and extension were 43.57°, 73.57°, and 76.43°, respectively. The grip strength, pinch strength, and range of motion of the operated side were evaluated at the final follow-up visit and compared with the contralateral side (control group). No complication occurred. Any screw was not removed.

Conclusion

Magnesium-based compression screws can be safely used for acute scaphoid fractures considering their favorable functional and radiological results.

Traumatized Hand - Update at the First Visit

The hand is the segment most exposed to trauma, with a large volume of care in urgent and emergency services. Therefore, it is necessary that physicians on duty have the essential knowledge to effectively manage these injuries. In the present article, we will review the main conditions and conduct guidelines.

Wrist and Hand Trauma Imaging

Injuries to the wrist and hands occur frequently in athletes from the high forces applied during sporting events. The examples presented illustrate the important role imaging has in the diagnosis of wrist and hand injuries. In addition, different imaging modalities are complementary and various examinations may be needed to help guide the management of wrist and hand traumatic pathology.

Thumb Carpometacarpal Joint Pathoanatomy-A Computed Tomography-Based Study

Background  Thumb carpometacarpal joint (CMCJ) osteoarthritis is common and can lead to significant morbidity making it a condition frequently treated by hand surgeons when initial conservative measures fail. The surrounding ligamentous structures are complex and important to maintain thumb CMCJ stability. Objectives  The aim of this study was to review the normal and arthritic anatomy of the thumb CMCJ, focusing on morphology and position of osteophytes and the gap between metacarpal bases, and the effect of these on intermetacarpal ligament integrity. This may be the sole ligament suspending the first metacarpal following trapeziectomy and could determine the need for further stabilization during surgery, avoiding potential future failures. Methods  Computed tomography (CT) scans of a normal cohort and those with arthritic changes who had undergone trapeziectomy following the scan were identified. The three-dimensional reconstructions were examined for osteophyte position on the saddle and the intermetacarpal distance. Results  A total of 55 patients, 30 normal and 25 arthritic, were identified and studied. The most common anatomic position for osteophytes was the intermetacarpal ulnar aspect of the trapezium. The intermetacarpal distance increased by an average of 2.1 mm in the presence of the arthritic process. Conclusions  The findings point to an increase in the intermetacarpal distance, and hence lengthening of the ligament with potential damage, possibly secondary to osteophyte formation and wear. Further prospective research is required to determine whether using preoperative CT scanning to define osteophyte position and measure the intermetacarpal distance would predict probable damage to the ligament, hence providing an indication for stabilization and reconstruction in trapeziectomy surgery. Level of Evidence  This is a Level III, retrospective cohort study.

Reliability of Radiographs and Computed Tomography in Diagnosing Scaphoid Union After Internal Fixation

PURPOSE

To evaluate the reliability of radiographs (XR) alone versus the combination of XR and computed tomography (CT) in determining scaphoid union following open reduction internal fixation (ORIF) with a headless compression screw.

METHODS

We used our imaging database to identify 32 XR and corresponding CTs over a 6-year period (from 2012 to 2018) that were performed to evaluate scaphoid healing following ORIF. Three hand surgeons evaluated the studies to assess (1) healing, (2) if partially healed, the percentage of healing, and (3) the certainty of healing. Initially, XR were reviewed alone. Three weeks later, the same XR were reviewed with the corresponding CTs. Each reviewer performed a similar 2-stage evaluation 4 weeks later. We measured interobserver and intraobserver reliabilities using linearly weighted kappa (κ) coefficients for healing status and the percentage of healing.

RESULTS

The interobserver reliability for healing (healed vs partially healed vs not healed) was moderate both with XR alone and with the combination of XR and CT. The intraobserver reliability for healing was substantial with XR alone compared to moderate with the combination of XR and CT. For the percentage of healing, both interobserver and intraobserver reliabilities were fair with XR alone or with the combination of XR and CT. Reviewers reported significantly greater certainty with the combination of XR and CT compared with XR alone.

CONCLUSIONS

Following ORIF, surgeons are more certain in their evaluation of scaphoid healing with the combination of CT and XR. However, the reliability of assessing scaphoid union may not be improved by the addition of CT to XR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Incremental diagnostic value of color-coded virtual non-calcium dual-energy CT for the assessment of traumatic bone marrow edema of the scaphoid

OBJECTIVES

To investigate the diagnostic accuracy of color-coded dual-energy CT virtual non-calcium (VNCa) reconstructions for the assessment of bone marrow edema (BME) of the scaphoid in patients with acute wrist trauma.

METHODS

Our retrospective study included data from 141 patients (67 women, 74 men; mean age 43 years, range 19-80 years) with acute wrist trauma who had undergone third-generation dual-source dual-energy CT and 3-T MRI within 7 days. Eight weeks after assessment of conventional grayscale dual-energy CT scans for the presence of fractures, corresponding color-coded VNCa reconstructions were independently analyzed by the same six radiologists for the presence of BME. CT numbers on VNCa reconstructions were evaluated by a seventh radiologist. Consensus reading of MRI series by two additional radiologists served as the reference standard.

RESULTS

MRI depicted 103 scaphoideal zones with BME in 76 patients. On qualitative analysis, VNCa images yielded high overall sensitivity (580/618 [94%]), specificity (1880/1920 [98%]), and accuracy (2460/2538 [97%]) for assessing BME as compared with MRI as reference standard. The interobserver agreement was excellent (κ = 0.98). CT numbers derived from VNCa images were significantly different in zones with and without edema (p < 0.001). A cutoff value of - 46 Hounsfield units provided a sensitivity of 91% and specificity of 97% for differentiating edematous scaphoid lesions. Receiver operating characteristic curve analysis revealed an overall area under the curve of 0.98.

CONCLUSIONS

Qualitative and quantitative analyses showed excellent diagnostic accuracy of color-coded VNCa reconstructions for assessing traumatic BME of the scaphoid compared to MRI.

KEY POINTS

• Color-coded virtual non-calcium (VNCa) reconstructions yield excellent diagnostic accuracy in assessing bone marrow edema of the scaphoid. • VNCa imaging enables detection of non-displaced fractures that are occult on standard grayscale CT. • Diagnostic confidence is comparable between VNCa imaging and MRI.

Percutaneous Scaphoid Fixation: Experience Value among Different Approaches

Background  Percutaneous scaphoid osteosynthesis is an attractive and increasingly popular option, as a treatment for acute scaphoid fractures in selected cases, and as an alternative to conservative treatment. The purpose of this study is to assess the radiographic positioning of the screw in percutaneous scaphoid fixation, taking into consideration the surgeons' experience, and the difference between volar and dorsal approaches. Methods  We retrospectively assessed patients undergoing percutaneous scaphoid fixation from 2013 to 2019. Inclusion criteria are as follows: (1) scaphoid waist fractures (Herbert's B2), (2) a minimum of 18 years of age and a maximum of 55 years of age, (3) dominant hand, (4) manual work, (5) minimum follow-up time of 6 months, and (6) without associated lesions. Criteria for correct positioning are as follows: (1) on the axis or parallel to the scaphoid axis with a maximum deviation of 1.5 mm volar/dorsal, (2) without proximal/dorsal prominence, (3) correct scaphoid alignment/reduction, and (4) absence of threads in the fracture site. Radiographs were evaluated separately by a hand surgeon, a general orthopaedic surgeon, and an orthopaedic resident. Results  With a total of 39 patients, a dorsal approach was performed in 10 patients and a palmar approach in 29 patients. We verified a very good interobserver reliability. The hand surgeon's team correctly positioned 15 (83.3%, 15/18), while the other team did 9 correctly (42.9%, 9/21). Comparing teams according to the approach used, the dorsal approach did not show a statistical difference, while the same was not true for the volar approach ( p  < 0.05). Conclusion  This points to a positive impact on the team's experience in the positioning of the screws, and therefore in the benefit of treatment by teams dedicated to the area, while daring to suggest that less-experienced surgeons should utilize the dorsal approach.

Diagnostic and Therapeutic Approach to Acute Scaphoid Fractures

The scaphoid is the carpal bone that most often fractures, accounting for up to 70% of carpal fractures and 11% of hand fractures. It is the second most common arm fracture, only surpassed by fractures of the distal radius. Despite being so common, these fractures can be difficult to diagnose and treat due to the anatomic and physiological particularities of the bone, including its precarious vascularization, its complex three-dimensional structure, and its ligament connections, which greatly contribute to the risk of complications such as malunion, pseudoarthrosis and avascular necrosis. Although there are many published studies on the treatment of these injuries, there is still controversy over what is the most suitable one for certain fracture types. The present article is a comprehensive and updated review of the literature. Combining strategies for clinical and radiological diagnosis, we propose a complete algorithm for the diagnosis of scaphoid fractures based on the varying availability of resources, and we also describe the most appropriate therapeutic approach for the different types of acute fractures of this bone.

Determining diagnosis of scaphoid healing: Comparison of cone beam CT and X-ray after six weeks of immobilization

PURPOSE

To assess the accuracy and reliability of using cone beam computed tomography (CBCT) compared to X-ray six weeks after injury for predicting scaphoid union.

MATERIALS AND METHODS

Overall; 52 patients with scaphoid fractures between April 2018 and March 2019 were prospectively included in this study. The mean age was 34.52 (13-88) years, and the gender ratio male/female 43/9. Of the fractures, 26 had occurred on the right side, and 26 on the left side. In total, 28 % of patients were manual workers. All patients underwent X-ray and CBCT six weeks after injury. Four readers, two radiologists, and two hand surgeons analyzed the findings using double-blinded X-ray and CBCT and categorized fractures as consolidated based on a 50 % visibility threshold concerning trabecular bridges. Proximal pole sclerosis, communition, cyst formation, and humpback deformity were similarly analyzed for all cases. Agreement between readers was calculated using Kappa, and sensitivity, specificity, and accuracy using RStudio software. The gold standard was the radiologic and clinical follow-up for all patients at two months.

RESULTS

Inter-reader agreement between the four readers was moderate concerning X-ray (0.543) but substantial concerning CBCT (0.641). It was almost perfect between seniors regarding CBCT (Kappa = 0.862). Sensitivity, specificity, and accuracy were 0.75-0.78, 0.4, and 0.61-0.64, respectively, for two readers regarding CBCT. The X-ray values were 0.65-0.71, 0.35-0.4, and 0.53-0.59, respectively.

CONCLUSION

CBCT proves more accurate and reliable than X-ray for diagnosing scaphoid union at an early follow-up and prevents longer immobilization and interruption of activity or work.

DEMOGRAPHIC AND CLINICAL PROFILE OF ADULT PATIENTS WITH SCAPHOID FRACTURES IN POPULATION OF DISTRICT D.I.KHAN, PAKISTAN

Background: Scaphoid fractures are common and account for 60-70 % of all carpal fractures. The objectives of this study were to determine the demographic and clinical profiles of adult patients with scaphoid fractures in population of District D.I.Khan, Pakistan. Materials & Methods: This cross-sectional study was conducted in Department of Orthopedics, Gomal Medical College, D.I.Khan, Pakistan from January 2015 to December 2019. Sample size was 40. Demographic variables were sex, age groups and time to presentation in weeks. Research variables were; cause, laterality, site, management options, time to union in months and presence of infection. All variables were categorical and analyzed by count and percentages for sample and as CI at 80% CL for proportion for population using Wilson score for binomial distribution. Results: Forty patients included 34 (85%) men & 16 (15%) women, 24 (60%) in 17-30 and 16 (40%) in age group 31-50 years. Time to presentation was ≤1 week of injury in 19 (47.5%) patients and 21 (52.5%) presented later. Cause was fall on out-stretched hand in 27 (67.5%) and RTA in 13 (32.5%) patients. Right hand was involved in 29 (72.5%), left in 9 (22.5%) while bilateral in 2 (5%) patients. Site of fracture was waist in 24 (60%), proximal pole 11 (27.5%) and distal pole 5 (12.5%) cases. Conservative treatment was done in 7 (17.50%) patients, percutaneous screw fixation 7 (17.50%), open reduction and internal fixation through palmar in 11 (27.50%) and though dorsal 15 (37.50%) cases. Time to union was ≤3 in 7 (17.50%), >3-6 months 29 (72.5%), while >6 months in 4 (10%) patients. Presence of infection was 1/40 (2.38%). Conclusion: Scaphoid fractures are more common in men and younger adults and most are presented within a week of injury. These are caused mostly by fall on outstretched hand, involving right hand and involving waist. Substantial number of cases requires open reduction with internal fixation. Mostly unite in 3-6 months.

Which Headless Compression Screw Produces the Highest Interfragmentary Compression Force in Scaphoid Fracture?

BACKGROUND

Interfragmentary compression at the fracture site facilitates healing. Headless compression screws used to treat scaphoid fractures can be grouped as shank screws, conical tapered screws and double component screws. There has been no meta-analysis of biomechanical studies to compare interfragmentary compression produced by the above screws.

METHODS

A computerised search of Pubmed, Embase and OVID database was undertaken to identify the studies. We estimated the weighted mean difference of interfragmentary compression (in Newton) with 95% confidence intervals. Random effects model was selected for meta-analysis.

RESULTS

The pooled estimate of nine studies demonstrated that conical tapered screw produced significantly higher interfragmentary compression force compared to the shank screw (WMD 19.96, 95% CI 11.2-28.8, p < 0.0001, I ² = 99%). The pooled estimate of four studies demonstrated that dual component screw produced significantly higher interfragmentary compression force compared to the shank screw (WMD 16.93, 95% CI 12.3-21.6, p < 0.0001, I ² = 97.7%). The pooled estimate of four studies showed that there was no significant difference in the interfragmentary compression force generated by either conical tapered screw or dual component screw (WMD 3.93, 95% CI - 8.3 to 16.2, p = 0.53, I ² = 99.7%). There was evidence of minimal publication bias.

CONCLUSION

Conical tapered screws and dual component screws produced statistically significant higher interfragmentary compression force at the scaphoid fracture site compared to shank screws. There was no difference in the compression force generated by either conical tapered screw or dual component screw.

Imaging of the Hand and Wrist

Imaging plays a key role in the evaluation and treatment planning of hand and wrist injuries in athletes. Depending on the suspected injury, a combination of conventional radiographs, computed tomography, magnetic resonance imaging, magnetic resonance arthrography, and/or ultrasound may be indicated. This article reviews the strengths and limitations of these imaging modalities and how they can be utilized in commonly encountered clinical questions.

Acute scaphoid fractures: guidelines for diagnosis and treatment

In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days.

Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT with reconstructions in the coronal and sagittal planes, following the longitudinal axis of the scaphoid.

After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures.

Scaphoid waist fractures with moderate displacement (0.5–1.5 mm) can be treated conservatively, but require prolonged cast immobilization for approximately eight to ten weeks.

Internal fixation is recommended for all scaphoid waist fractures with dislocation ≥ 1.5 mm.

Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after four to six weeks of immobilization, depending on fracture type.

In general, proximal scaphoid fractures should be treated with internal fixation.

Cite this article: EFORT Open Rev 2020;5:96-103. DOI: 10.1302/2058-5241.5.190025

Antegrade Versus Retrograde Technique for Fixation of Scaphoid Waist Fractures: A Comparison of Screw Placement

Background  Scaphoid waist fractures are often treated using headless compression screws using dorsal or volar approaches. Objectives  The purpose of this study is to compare differences in screw position using a volar (retrograde) or dorsal (antegrade) approach. Patients and Methods  A total of 82 patients were retrospectively evaluated: 41 treated with a volar and 41 with a dorsal approach were selected. Postoperative radiographs were reviewed by three observers who rated screw location in the proximal pole, waist, and distal pole. Results  Thirty-four patients (83%) in the antegrade group had central screw placement in the waist of the scaphoid in posteroanterior and lateral planes compared with 14 (34.9%) in the retrograde group ( p  < 0.05). For the antegrade group, the screw was central in 217 of 246 zones (88.2%) compared with 127 of 246 (51.6%) in the retrograde group ( p  < 0.05). Conclusions  The dorsal antegrade approach appears to allow the surgeon to achieve central screw placement along all three scaphoid regions. Level of Evidence  This is Level III study.

A CT-based approach with 3D modeling to determine optimal radiographic views of the scaphotrapezial and scaphotrapezoid joints

PURPOSE

To use a CT-based approach with 3D modeling to determine novel radiographic views of the scaphotrapezial (STl) and scaphotrapezoid (STd) joints.

MATERIALS AND METHODS

Consecutive wrist CT scans excluding those with pathology of the distal radius, scaphoid, trapezium, or trapezoid of subjects between ages 18 and 60 years were retrospectively reviewed. Three-dimensional reconstructions of CT scans were created and best-fit planes of the STl and STd joints were generated. Angles of these planes relative to a distal radial coordinate system were calculated to determine tilt of the wrist and the X-ray beam for novel radiographic views of these joints.

RESULTS

Fifty eligible wrist CT scans were identified. The mean age was 38 years (range, 18 to 59). For the novel STl PA view, the wrist is supinated 17° from the standard PA view and the X-ray beam is canted 6° caudad. In the STl lateral view, the wrist is pronated 17° from the standard lateral view, and the X-ray beam is canted 20° caudad. In the STd PA tilt view, the wrist is supinated 28° from the standard PA view, and the X-ray beam is canted 13° caudad. In the STd joint lateral tilt view, the wrist is pronated 28° from the standard lateral view, and the X-ray beam is canted 29° caudad.

CONCLUSION

We describe novel radiographic views of the STl and STd joints based on 3D modeling of wrist CT scans. Further studies are required to assess the efficacy of these views in detecting joint pathology.

Scaphoid Healing Required for Unrestricted Activity: A Biomechanical Cadaver Model

PURPOSE

To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid.

METHODS

Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoid's distal pole. Load to failure and stiffness were measured.

RESULTS

Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control.

CONCLUSIONS

A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending.

CLINICAL RELEVANCE

This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.

Imaging of Sports-related Hand and Wrist Injuries: Sports Imaging Series

Hand and wrist injuries are common occurrences in amateur and professional sports and many of them are sport-specific. These can be divided into two categories: traumatic injuries and overuse injuries. The aim of this article is to review the most common hand and wrist sports-related lesions. Acute wrist injuries are predominantly bone fractures, such as those of the scaphoid, hamate hook, and ulnar styloid. Ligament lesions are more challenging for radiologists and may lead to carpal instability if undiagnosed. Overuse wrist injuries are mainly represented by tendinous disorders, with De Quervain syndrome and extensor carpi ulnaris tendon disorders being the most common among them; however, there are other possible disorders such as impaction syndromes, stress fractures, and neurovascular lesions. Finally, finger lesions, including closed-tendon injuries (mallet and boutonniere injuries, jersey finger, and boxer's knuckle), flexor pulley injuries, and skier's thumb, should also be detected. (©) RSNA, 2016 Online supplemental material is available for this article.

Sports-related wrist and hand injuries: a review

Background

Hand and wrist injuries are common during athletics and can have a significant impact especially if initially disregarded. Due to their high level of physical demand, athletes represent a unique subset of the population.

Main body

The following is an overview of hand and wrist injuries commonly seen in athletics. Information regarding evaluation, diagnosis, conservative measures, and surgical treatment are provided.

Conclusion

Knowledge of these entities and special consideration for the athlete can help the team physician effectively treat these players and help them achieve their goals.

Anatomic Locking Plate Fixation for Scaphoid Nonunion

Nonunion can occur relatively frequently after scaphoid fracture and appears to be associated with severity of injury. There have been a number of techniques described for bone grafting with or without screw fixation to facilitate fracture healing. However, even with operative fixation of scaphoid fractures with bone grafting nonunion or malunion rates of 5 to 10 percent are still reported. This is the first report of an anatomic locking plate for scaphoid fracture repair in a 25-year-old right hand dominant healthy male.

Characterization of a Pre-Clinical Mini-Pig Model of Scaphoid Non-Union

A fractured scaphoid is a common disabling injury that is frequently complicated by non-union. The treatment of non-union remains challenging because of the scaphoid's small size and delicate blood supply. Large animal models are the most reliable method to evaluate the efficacy of new treatment modalities before their translation into clinical practice. The goal of this study was to model a human scaphoid fracture complicated by non-union in Yucatan mini-pigs. Imaging and perfusion studies were used to confirm that the anatomy and blood supply of the radiocarpal bone in mini-pigs were similar to the human scaphoid. A 3 mm osteotomy of the radiocarpal bone was generated and treated with immediate fixation or filled with a dense collagen gel followed by delayed fixation. Bone healing was assessed using quantitative micro computed tomography and histology. With immediate fixation, the osteotomy site was filled with new bone across its whole length resulting in complete bridging. The dense collagen gel, previously shown to impede neo-vascularization, followed by delayed fixation resulted in impaired bridging with less bone of lower quality. This model is an appropriate, easily reproducible model for the evaluation of novel approaches for the repair of human scaphoid fractures.