High-energy injuries of the wrist

Predicting Acute Median Neuropathy in Perilunate Injuries

Purpose

Perilunate fracture dislocation (PLFD) injuries are associated with the development of acute carpal tunnel syndrome (CTS). The purpose of our study was to identify the factors that increase the likelihood of developing CTS in patients with PLFD. Additionally, we attempted to classify patients who did not initially undergo carpal tunnel release (CTR) at the time of injury but eventually underwent CTR within the follow-up period.

Methods

Patients presenting to a level-1 trauma center with isolated PLFDs (Mayfield III-IV) were retrospectively identified by using CPT and ICD-10 codes. Polytraumatized patients, those with a history of previous wrist trauma, or those with previous carpal tunnel symptoms or surgery were excluded. Outcomes of interest included the development of acute CTS, pre- and post-reduction changes in CTS symptoms, and associated hand and wrist fractures. Chi-square tests, Kruskal-Wallis tests, and multivariate logistic regression were used to examine the predictors of developing CTS after a PLFD.

Results

In total, 43 patients were included in the final cohort, with a mean age of 44 years, of which 77% were men. The most common fracture of the carpus included scaphoid fractures (9/43, 21%). The average time from presentation to reduction was 636 minutes. Acute CTS symptoms before reduction were present in 26% of the patients and increased post-reduction to 28%. No difference exists between the time to sedation and the presence of acute carpal tunnel symptoms (P >.05). During initial surgical intervention, 79% underwent CTR (27/34). Of the seven patients who did not initially undergo a CTR, 57% (4/7) required a CTR within the follow-up period.

Conclusion

Reduction of PLFDs did not significantly improve the number of patients with acute CTS. More than 50% of the patients who did not undergo a CTR at the initial surgery required a CTR within the follow-up period.

Type of study/level of evidence

Prognostic III.

Perilunate fracture-dislocations: Clinical and functional outcomes at a mean follow-up of 3.3 years

INTRODUCTION

Perilunate lesions in the carpus are severe injuries whose functional consequences can limit patients' ability to regain their pre-injury activity levels. The aim of this study was to evaluate the outcomes of a series of patients who suffered a perilunate fracture-dislocation and to assess their ability to resume their social and professional activities.

HYPOTHESIS

After surgical management of this injury, the medium-term functional outcomes will allow patients to return to their pre-injury social and professional activities.

MATERIALS AND METHODS

This was a single center, retrospective study. Included patients were adults who had suffered a perilunate fracture-dislocation that was treated emergently. The clinical and functional assessment consisted of comparing the mobility and grip strength between the injured and contralateral wrists, determining the functional outcome scores and the resumption of social and professional activities. A radiological assessment was done to look for instability of the proximal row of the carpus, nonunion or necrosis of the carpal bones, loss of carpal height, and presence of carpal osteoarthritis.

RESULTS

Ten patients were included with a mean follow-up of 39.4 months. The mean flexion/extension arc decreased significantly to 88° (20°-150) which was 55% of the healthy contralateral side (p=0.0026) while the grip strength decreased but not significantly (40.6 Kg vs. healthy side 62.4 Kg, p=0.063). The mean MWS was 58.75 (40-100), the mean PRWE was 32.9 (4-67.5) and the mean QuickDASH was 30.2 (0-77). Six of the ten patients (60%) were able to return to work, although three required occupational reclassifications. Four patients had signs of proximal row instability. There were seven instances of radiocarpal osteoarthritis, two of which were combined with mid-carpal osteoarthritis.

DISCUSSION

This study found shorter range of motion and worse patient-reported outcomes than other published studies, which may be due to the severity of the perilunate fracture-dislocation injuries and the inclusion of polytrauma patients. Nevertheless, the subjective scores were comparable. These injuries have serious consequences on social and professional activities of manual workers.

LEVEL OF EVIDENCE

IV; retrospective study.

Comparison of the diagnostic accuracy of X-ray and computed tomography in patients with wrist injury

BACKGROUND

This study aimed to compare CT and XR images of patients admitted to the emergency department due to wrist injuries and to evaluate the accuracy of XR in the diagnosis of fractures.

METHODS

Patients; who admitted to ED with injuries due to wrist trauma and who underwent XR imaging and CT scans in the period from 1 January 2017 to 1 January 2018, were included in the study. CT scan image interpretation reports recorded in the hospital automation system were considered eligible to be included in the study. XR images were interpreted by an orthopedics and traumatology specialist. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and Kappa (κ) coefficient of XR were calculated according to CT. Inter-rater agreement was graded according to κ values.

RESULTS

A total of 274 patients were included in the study. Fractures were identified in the XR images in 180 (66%) patients and in the CT images in 196 (72%) patients. Compared to CT, the Sn, Sp, PPV, NPV and κ coefficient of XR were 89%, 92%, 97%, 77% and 0.764 respectively. Compared to CT, the highest sensitivity of XR was measured to detecting radius (Sn: 95%, κ: 0.896) and 5th metacarpal fractures (Sn: 77%, κ: 0.859), the lowest sensitivity of XR was calculated in detecting scaphoid, capitate, pisiform, trapezium hamate, and triquetrum fractures (Sn: 59-14%, κ: 0.619-0.240). The sensitivity and κ coefficient of XR were calculated 54% and 0.530 in the adjacent bone fracture, 83% and 0.830 in joint dislocation, 75% and 0.661 in the fractures extending to the joint space.

CONCLUSIONS

XR is the first-choice imaging modality in the evaluation of wrist injuries, but CT imaging should be preferred when fractures extending to the joint space, adjacent bone fracture and carpal bone fracture are being considered.

Bilateral Scaphocapitate Fracture Syndrome: A Case Report with Long-Term Follow up

Carpal bone fracture-dislocation is an uncommon wrist injury. Regarding limited prevalence of such injury, most of orthopedic surgeons have low experience in treatment and handling of these fractures and dislocations. A 25-year-old male worker with an uncommon carpal bone fracture-dislocation, namely bilateral scaphocapitate fracture syndrome, was described. Volar and dorsal approaches were used for reduction and fixation; complete stabilization was achieved after open reduction and fixation using Herbert screws into scaphoid and capitate. A 5-year follow-up showed satisfactory functional and radiographic results. In the case of scaphocapitate fracture syndrome open reduction and internal fixation by compression screws (rather than inserting multiple pins) leads to complete union in scaphoid and capitate. Restoration of normal anatomy in carpus bones can result in long-term satisfactory functional results while preventing possible complications.

How well can step-off and gap distances be reduced when treating intra-articular distal radius fractures with fragment specific fixation when using fluoroscopy

INTRODUCTION

Although fragment specific fixation has proved to be an effective treatment regime, it has not been established how successfully this treatment could be performed using fluoroscopy and what the added value of arthroscopy could be. Establish gap and step-off distances after in intra-articular distal radius fractures that have been treated with fragment specific fixation while using fluoroscopy.

MATERIAL

Forty-four patients with an intra-articular distal radius fracture were treated with fragment specific fixation while using fluoroscopy.

METHODS

After the treatment of the intra-articular distal radius fracture with fragment specific fixation and the use of fluoroscopy, but before the completion of the surgical intervention, all gap, and step-off distances were determined by using arthroscopy. In addition, the joint was checked for any other wrist pathologies.

RESULTS

Arthroscopy after the surgical intervention showed that in 37 patients no gap distances could be detected, while in six patients a gap distance of≤2mm was found and in one patient, a gap distance of 3mm. Similarly, arthroscopy revealed no step-off distances in 33 patients, while in 11 patients a step-off distance of≤2mm was found. Although additional wrist pathologies were found in 48% of our population, only one patient needed surgical intervention. Three months after the surgical intervention wrist flexion was 41±10°, wrist extension 51±17°, ulnar deviation 19±10°, radial deviation 32±12° while patients could pronate and supinate their wrist to 85±5° and 74±20°, respectively.

CONCLUSION

Intra-articular distal radius fractures can be treated successfully with fragment specific fixation and the use of fluoroscopy. As almost all gap and step-off distances could be reduced to an acceptable level, the scope for arthroscopy to further improve this treatment regime is limited. The functional outcome scores that were found 3 months after the surgical intervention were similar to what has been reported in other studies using different treatment option. These findings suggest that fragment specific fixation is a good alternative for treating intra-articular distal radius fractures. As in most cases, only fluoroscopy is needed for fragment specific fixation, this treatment technique is a good treatment option for resource-limited hospitals, setting who do not have access to arthroscopy.

LEVEL OF EVIDENCE

III, case-control study.