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Launonen AP, Sumrein BO, Reito A, Lepola V, Paloneva J, Berg HE, Felländer-Tsai L, Kask K, Rahnel T, Tootsi K, Märtson A, Jonsson KB, Wolf O, Ström P, Døssing K, Østergaard HK, Mechlenburg I, Mattila VM, Laitinen MK. Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial. PLoS Med 2023; 20:e1004308. [PMID: 38015877 PMCID: PMC10683994 DOI: 10.1371/journal.pmed.1004308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking. METHODS AND FINDINGS The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely. CONCLUSIONS In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments. TRIAL REGISTRATION ClinicalTrials.gov NCT01246167.
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Affiliation(s)
- Antti P. Launonen
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Bakir O. Sumrein
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Aleksi Reito
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Vesa Lepola
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Juha Paloneva
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Hans E. Berg
- Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopedics, Karolinska University Hospital, Huddinge, Sweden
| | - Li Felländer-Tsai
- Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopedics, Karolinska University Hospital, Huddinge, Sweden
| | - Kristo Kask
- Department of Orthopaedics, North Estonia Medical Centre, Tallinn, Estonia
| | - Timo Rahnel
- Department of Orthopaedics, North Estonia Medical Centre, Tallinn, Estonia
| | - Kaspar Tootsi
- Department of Traumatology and Orthopaedics, Tartu University, Tartu, Estonia
- Orthopaedics clinic, Tartu University Hospital, Tartu, Estonia
| | - Aare Märtson
- Department of Traumatology and Orthopaedics, Tartu University, Tartu, Estonia
- Orthopaedics clinic, Tartu University Hospital, Tartu, Estonia
| | - Kenneth B. Jonsson
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Peter Ström
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Kaj Døssing
- Department of Orthopaedic Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Helle K. Østergaard
- Department of Orthopaedic Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Inger Mechlenburg
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ville M. Mattila
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Minna K. Laitinen
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
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Silkjær Bak S, Johnsen B, Fuglsang-Frederiksen A, Døssing K, Qerama E. Comparison of ultrasound with electrodiagnosis of scapular winging: A prospective case control study. Clin Neurophysiol 2021; 133:48-57. [PMID: 34801963 DOI: 10.1016/j.clinph.2021.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Compare high-resolution ultrasound (HRUS) and electrodiagnostic examination (EDX) in the diagnostic workup of patients with scapulae alatae. METHODS 27 patients with scapulae alatae and 41 healthy subjects (HS) and underwent a standardized clinical examination (CEX), EDX and HRUS. We measured the thickness of the serratus anterior (SER), rhomboid major and trapezius muscles and the diameter of the long thoracic (LTN), dorsal scapular and spinal accessory nerves (SAN). RESULTS Twenty patients showed medial winging and six patients showed lateral winging on CEX. One patient had both lateral and medial winging. In patients with medial winging, the SER muscle was thinner and the LTN diameter was larger on the symptomatic side compared with the asymptomatic side and with the dominant side in HS. In this group, both EDX and HRUS detected abnormalities of SER muscle/ LTN with sensitivity of 65%, and with specificity of 100% and 57%, respectively. EDX and HRUS detected abnormalities of the trapezius muscle/ SAN with sensitivity of 60% and 40%, and specificity of 91%, and 86 % a, respectively. There was no significant difference between the two methods. CONCLUSION HRUS can contribute to the diagnostic workup of scapulae alatae by demonstrating atrophy of muscles and enlargement in nerve diameter. SIGNIFICANCE HRUS supplements EDX in the diagnostic workup of scapulae alatae.
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Affiliation(s)
- Sara Silkjær Bak
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
| | - Anders Fuglsang-Frederiksen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
| | - Kaj Døssing
- Department of Orthopaedics, Viborg Regional Hospital, Heibergs Alle 4F Indgang F, Etage 3, 8800 Viborg, Denmark
| | - Erisela Qerama
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark.
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Silkjær Bak S, Johnsen B, Fuglsang-Frederiksen A, Døssing K, Qerama E. Neuromuscular ultrasound of the scapular stabilisers in healthy subjects. Clin Neurophysiol Pract 2021; 6:72-80. [PMID: 33732970 PMCID: PMC7937536 DOI: 10.1016/j.cnp.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 12/29/2020] [Accepted: 01/24/2021] [Indexed: 11/17/2022] Open
Abstract
HRUS can be used to visualise the muscles stabilizing the scapula and their corresponding nerves. We found acceptable intra- and inter-examiner agreements. We present HRUS normative data using regression-based prediction formulas. To our knowledge, we present the first-time normative data of diameter of the dorsal scapular nerve.
Objectives To obtain normative high-resolution ultrasound (HRUS) data for thickness of the serratus anterior, the trapezius and the rhomboid major muscles and diameter of their corresponding nerves, the long thoracic, the spinal accessory and the dorsal scapular nerve. Moreover, we aimed to examine intra- and inter-examiner agreement of the HRUS measurements. Methods We included 41 healthy subjects. Muscle thickness and nerve diameter were measured bilaterally, resulting in 82 ultrasound measurements for each structure. Normative data were calculated using regression equations for the lower limit of muscle thickness and upper limit of nerve diameter, taking into account various variables. For intra- and inter-examiner agreement, ten subjects underwent two extra ultrasound examinations and Bland-Altman plots were calculated. Results This normative data set showed significant correlations between decreasing muscle thickness with increasing age and height and increasing muscle thickness with increasing weight and with male sex. Muscle thickness was larger on the dominant side compared to the non-dominant side for the trapezius and rhomboid muscles, whereas the opposite was found for the serratus anterior muscle. For all nerves, significant correlations were found between decreasing nerve diameter with increasing age and height. Intra-examiner agreement was acceptable in all sites. Inter-examiner agreement was acceptable for all sites but one site for the serratus anterior muscle and long thoracic nerve, and not acceptable for five out of six sites for the trapezius muscle. Conclusion This study provides HRUS normative data and intra- and inter-examiner agreement data for muscle thickness and nerve diameter for the muscles stabilizing the scapulae and their corresponding nerves. Significance The normative HRUS data reported may be useful in future studies investigating neuromuscular disorders.
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Affiliation(s)
- Sara Silkjær Bak
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
| | - Anders Fuglsang-Frederiksen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
| | - Kaj Døssing
- Department of Orthopaedics, Viborg Regional Hospital, Heibergs Alle 4F Indgang F, Etage 3, 8800 Viborg, Denmark
| | - Erisela Qerama
- Department of Clinical Neurophysiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 16, Plan 2, J209, DK-8200 Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 82, Incuba/Skejby, Building 2, DK-8200 Aarhus N, Denmark
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Bak SS, Johnsen B, Døssing K, Fuglsang-Frederiksen A, Montvilas EQ. O-39 High resolution ultrasound of scapula alata – A prospective case control study. Clin Neurophysiol 2019. [DOI: 10.1016/j.clinph.2019.04.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sumrein BO, Mattila VM, Lepola V, Laitinen MK, Launonen AP, Jonsson K, Wolf O, Ström P, Berg H, Felländer-Tsai L, Mechlenburg I, Døssing K, Østergaard H, Rahnel T, Märtson A. Intraobserver and interobserver reliability of recategorized Neer classification in differentiating 2-part surgical neck fractures from multi-fragmented proximal humeral fractures in 116 patients. J Shoulder Elbow Surg 2018; 27:1756-1761. [PMID: 29866397 DOI: 10.1016/j.jse.2018.03.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/15/2018] [Accepted: 03/18/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal fracture classification should be simple and reproducible and should guide treatment. For proximal humeral fractures, the Neer classification is commonly used. However, intraobserver and interobserver reliability of the Neer classification has been shown to be poor. In clinical practice, it is essential to differentiate 2-part surgical neck fractures from multi-fragmented fractures. Thus, the aim of this study was to evaluate whether surgeons can differentiate 2-part surgical neck fractures from multi-fragmented fractures using plain radiographs and/or computed tomography (CT). METHODS Three experienced upper limb specialists and trauma surgeons (B.O.S., A.P.L., and V.L.) independently reviewed and classified blinded plain radiographs and CT scans of 116 patients as showing 2-part surgical neck fractures or multi-fragmented fractures. Each imaging modality was reviewed and classified separately by each surgeon, after which each surgeon reviewed both modalities at the same time. This process was repeated by all surgeons after 24 weeks. Intraobserver and interobserver analyses were conducted using Cohen and Fleiss κ values, respectively. RESULTS The κ coefficient for interobserver reliability showed substantial correlation (0.61-0.73) and was as follows: 0.73 for radiographs alone, 0.61 for CT scans alone, and 0.72 for radiographs and CT scans viewed together. After 24 weeks, the process was repeated and intraobserver reliability was calculated.The κ coefficient for intraobserver reliability showed substantial correlation (0.62-0.75) and was as follows: 0.62 for radiographs alone, 0.64 for CT scans alone, and 0.75 for radiographs and CT scans viewed together. CONCLUSION Clinicians were able to differentiate 2-part surgical neck fractures from multi-fragmented fractures based on plain radiographs reliably.
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Affiliation(s)
- Bakir O Sumrein
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland.
| | - Ville M Mattila
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland; School of Medicine, University of Tampere, Tampere, Finland
| | - Vesa Lepola
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Minna K Laitinen
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Antti P Launonen
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
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Abstract
Background: The purpose of the present study was to investigate whether ultrasonography can be used as a diagnostic tool to exclude extremity fractures in adults. Methods: This prospective comparative study involved 91 patients (age, ≥18 years) who had been referred by general practitioners for a conventional radiographic examination of a suspected extremity fracture. No additional clinical examination was performed. Ultrasound examination was consistently carried out prior to conventional radiographic examination, which was regarded as the gold standard. At the end of the study, the positive scans were confirmed by a specialist who was highly skilled in ultrasonography. Results: The prevalence of fractures in the study population was 27%. Ultrasonography had a sensitivity of 92%, a specificity of 94%, a positive predictive value of 85%, a negative predictive value of 97%, a positive likelihood ratio of 15.33, and a negative likelihood ratio of 0.085. There seemed to be no association between the anomalous results and patient age or the specific anatomical region of the fracture. Conclusions: The present study indicates that ultrasonography, when performed and interpreted by experienced ultrasonographers, has high accuracy for the diagnosis of a suspected extremity fracture. No systematic differences were found between the results of radiography and ultrasonography, and ultrasonography showed a high sensitivity and specificity. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kaj Døssing
- Orthopaedic Department (K.D.) and Department of Physiotherapy and Occupational Therapy (H.Ø.), Viborg Regional Hospital, Denmark
| | - Inger Mechlenburg
- Orthopaedic Department (I.M. and K.S.), Centre of Research in Rehabilitation (I.M.), and Radiological Department (B.H.), Aarhus University Hospital, Denmark
| | - Lars Bolvig Hansen
- Orthopaedic Department (I.M. and K.S.), Centre of Research in Rehabilitation (I.M.), and Radiological Department (B.H.), Aarhus University Hospital, Denmark
| | - Kjeld Søballe
- Orthopaedic Department (I.M. and K.S.), Centre of Research in Rehabilitation (I.M.), and Radiological Department (B.H.), Aarhus University Hospital, Denmark
| | - Helle Østergaard
- Orthopaedic Department (K.D.) and Department of Physiotherapy and Occupational Therapy (H.Ø.), Viborg Regional Hospital, Denmark
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Lundquist CB, Døssing K, Christiansen DH. Responsiveness of a Danish version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Dan Med J 2014; 61:A4813. [PMID: 24814590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION This prospective cohort study in consecutive shoulder patients sought to determine the minimal, clinically important difference of the Danish version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and to evaluate patient responsiveness to it. The study was undertaken at the Outpatient Clinic of the Department of Orthopaedic Surgery, Viborg Regional Hospital, Denmark. MATERIAL AND METHODS During clinical examination, patients completed a baseline questionnaire including the DASH questionnaire, the EuroQol-5D index and the EuroQol-VAS. A follow-up questionnaire concerning the patient's global impression of change was posted to the patients eight to nine weeks after the initial assessment. Responsiveness was analysed by correlation analysis and receiver-operating characteristic curve statistics. Using the optimal cut-off point of the receiver-operating characteristic curve, the minimal, clinically important difference was determined. RESULTS A total of 81 patients with a variety of shoulder diagnoses were included. Only the DASH questionnaire demonstrated significant differences in change scores (p = 0.001). The area under the curve was 0.76 (95% confidence interval 0.62-0.90), and a minimal clinically important difference of 12 points was found. CONCLUSION The DASH questionnaire provides a response outcome measure in Danish-speaking orthopaedic shoulder patients. FUNDING This work was supported by the Regional Hospital of Central Jutland Research Foundation. TRIAL REGISTRATION not relevant.
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Affiliation(s)
- Camilla B Lundquist
- Fysioterapien, Regionshospitalet Viborg, Heibergs Allé 4, 8800 Viborg, Denmark.
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Abstract
A case of pneumococcal pyomyositis of the brachial and shoulder region is presented. A bacteremic right lower lobe pneumonia was the source of infection. The spread of pneumococci was presumed to be blood-borne, presenting with cellulitis over the right shoulder region, progressing over 5 days to abscess formation in the right biceps muscle and right shoulder joint despite adequate antibiotic treatment.
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Affiliation(s)
- T Ejlertsen
- Department of Clinical Microbiology, Aalborg Hospital, Denmark
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Abstract
A 30 year old woman presented with pain in her right wrist a year after operation for de Quervain's tenosynovitis. Magnetic resonance imaging showed avascular necrosis of the scaphoid without loss of volume. She was instructed to wear a brace on her wrist while working. A year later she was free of symptoms but the scan was unchanged. Avascular necrosis of the scaphoid not associated with injury is extremely rare.
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Affiliation(s)
- K Døssing
- Department of Orthopedic Surgery, University Hospital, Arhus, Denmark
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