Use of Particulated Juvenile Articular Cartilage Allograft for Osteochondral Lesions of the Wrist.

BACKGROUND: Articular cartilage injuries are a common injury among young, active patients, and the most appropriate treatment for these injuries remains controversial. A promising new technology in the treatment of high-grade cartilage injuries is particulated juvenile articular cartilage (PJAC) allograft (DeNovo NT, Zimmer, Warsaw, Indiana). This has been shown to be successful in multiple joints including the knee, talus, and elbow. No studies or case reports exist in supporting or discouraging its use in injuries of the wrist, in specific, the scaphoid. METHODS: The use of PJAC allograft is described for the treatment of an active 21-year-old male with an Outerbridge Grade IV chondral lesion on the proximal pole of his right scaphoid and right distal radius scaphoid facet who had failed conservative management. The patient was followed clinically and radiographically for 21 months. RESULTS: The patient had return to full sport (jujutsu) and full range-of-motion, both of which represented an improvement from his preoperative exam. Radiographically, the chondral lucency seen had decreased in size and was almost completely absent on radiographs after 21 months. CONCLUSIONS: The results of this case suggest that PJAC can be used safely and effectively in the wrist thereby potentially broadening the indications for its use.

Hand and Wrist Injuries in Boxing and the Martial Arts.

Hand and wrist injuries in martial arts are typically a reflection of the combat nature of this discipline. In striking sports, the axial load mechanism of injury is common and causes fractures and dislocations; in grappling sports, sprain injuries and degenerative changes predominate. There is clear evidence to support that hand protection reduces the risk of hand injury. Traditional training in martial arts on proper technique and target selection in striking sports reduces the risk of hand injury, and is an important component of hand and wrist injury prevention.

Lunate and perilunate dislocations.

Lunate and perilunate dislocations are uncommon, but devastating carpal injuries, which, if unrecognized in the emergency department and not treated promptly, lead to a high incidence chronic wrist pain and long-term functional disability. In this case report, we will review the wrist joint anatomy as pertaining to these injuries, mechanism of injury, signs and symptoms, radiological findings, and treatment of such injuries.

Prevalence of musculoskeletal injuries sustained by students while attending a chiropractic college.

OBJECTIVE: The purpose of this study was to assess the prevalence, distribution, severity, risk factors of, and response to musculoskeletal injuries to the low back, hand/wrist, and neck/shoulder among chiropractic students while receiving and/or administering adjustments/manipulation while attending a chiropractic college. METHODS: The study was an epidemiologic survey of chiropractic students at all levels of training (n = 890) at one chiropractic college. A self-administered anonymous 3-paged questionnaire was used. The questionnaire was divided into sections for collecting data separately on injuries associated with receiving or administering chiropractic adjustments. RESULTS: The response rate was 64.3% with 62.6% male respondents. The overall prevalence of injuries sustained in college was 31.5%, 44.4% of which was exacerbations of prior complaints. Injuries from receiving adjustments/manipulation were most prevalent to neck/shoulder (65.7%), whereas hand/wrist injuries were most common when administering adjustments (45.6%). The risk difference among students receiving adjustments was 81.6/1000 neck/shoulder injuries, and the etiologic fraction was 76.6%. The risk difference was 170/1000 hand/wrist injuries with etiologic fraction of 96.5% among students administering adjustments. Diversified, Gonstead, and upper cervical adjusting techniques were perceived to be the most injury-related. CONCLUSION: Some students enroll in a chiropractic college with preexisting injuries that can easily be exacerbated. Others sustain new injuries of moderate severity from receiving and administering adjustments. Potential risk factors may include height, body mass index, and nonexercising. The risk factors and mechanisms responsible for the high levels of hand/wrist injuries need further examination. This research identifies an important need to design a comprehensive and logical protocol to prevent injury to chiropractic students.

3-year follow-up of 215 fracture patients from a prospective and consecutive osteoporosis screening program. Fracture patients care!

BACKGROUND AND PURPOSE: Fractures can be prevented if osteoporosis is identified and treated. Starting in 2002, we have been using a screening program in which patients between 50 and 75 years of age with a wrist, shoulder, vertebral, or hip fracture are assessed by DEXA of the hip and spine and if osteoporotic or osteopenic, they are encouraged to see a doctor of their own choice. The patients receive documents containing information, the results of DEXA, and a letter to present to their doctor with suggestions regarding blood tests and treatment. Here we report the 3-year follow-up regarding compliance to the recommended treatment. METHODS: A questionnaire was sent to fracture patients who participated in the initial screening study from November 2002 through November 2003. Questions included whether they had seen a doctor, whether treatment had been initiated, and their opinions about osteoporosis. RESULTS: 215 of the 236 patients answered the questionnaire, with a mean follow-up of 39 months. 76/87 of those with osteoporosis, 70/99 of those with osteopenia, and 11/29 of those with normal BMD had seen a doctor. Anti-resorptive treatment was prescribed to two-thirds of the osteoporotic patients, to one-sixth of the osteopenic patients, and to none of the patients with normal bone density. Calcium-vitamin D supplementation as monotherapy was given to one-third of the osteoporotic patients, to half of the osteopenic patients, and to half of the normal patients. Only a few osteoporotic patients, one-third of the osteopenic patients, and half of the normal patients received no treatment. Compliance to treatment was 80% over 3 years in those treated. Most patients felt that they could influence their skeletal health. INTERPRETATION: Screening of fracture patients for osteoporosis effectively identifies patients with low bone mineral density and the patient can be trusted to seek appropriate medical advice for treatment of osteoporosis. Based on the bone scan diagnosis, the treatment that these patients received reflects current treatment guidelines well.

Case study: musicians' playing-related injuries.

Professional and student musicians are at high risk of acquiring a playing-related injury at some point in their careers. Yet, specialized healthcare for musicians is scarce and expensive for most self-employed musicians. Diagnosing these injuries is challenging, and simply taking a break from an activity that has caused physical problems does not address the ergonomic and biomechanic causes of the problem. Under these circumstances, it is not surprising that musicians are reluctant to seek care, and when they do, lack trust in the care that is provided to them. This article is a case presentation of the experiences of a graduate student musician studying performance at a North American university. A narrative style is used to reflect the quality and nature of experiences this musician encountered, followed by a discussion of how to advance a more participatory and holistic approach to enabling return to function.

Seasonal periodicity of serum vitamin D and parathyroid hormone, bone resorption, and fractures: the Geelong Osteoporosis Study.

UNLABELLED: In this population-based study, seasonal periodicity was seen with reduced serum vitamin D, increased serum PTH, and increased bone resorption in winter. This was associated with an increased proportion of falls resulting in fracture and an increased risk of wrist and hip fractures. INTRODUCTION: In a population of women who reside in a temperate climate and do not generally receive dietary vitamin D supplementation, we investigated whether seasonal vitamin D insufficiency is associated with increased risk of fracture. MATERIALS AND METHODS: An observational, cross-sectional, population-based study set in southeastern Australia (latitude 38-39 degrees S). Participants were drawn from a well-defined community of 27,203 women >/=55 years old: 287 randomly selected from electoral rolls, 1635 with incident fractures, and 1358 presenting to a university hospital with falls. The main outcome measures were annual periodicities of ultraviolet radiation, serum 25-hydroxyvitamin D [25(OH)D], serum parathyroid hormone (PTH), serum C-telopeptide (CTx), BMD, falls, and fractures. RESULTS: Cyclic variations in serum 25(OH)D lagged 1 month behind ultraviolet radiation, peaking in summer and dipping in winter (p < 0.001). Periodicity of serum PTH was the inverse of serum 25(OH)D, with a phase shift delay of 1 month (p = 0.004). Peak serum CTx lagged peak serum PTH by 1-2 months. In late winter, a greater proportion of falls resulted in fracture (p < 0.001). Seasonal periodicity in 439 hip and 307 wrist fractures also followed a simple harmonic model (p = 0.078 and 0.002, respectively), peaking 1.5-3 months after the trough in 25(OH)D. CONCLUSIONS: A fall in 25(OH)D in winter is accompanied by increases in (1) PTH levels, (2) bone resorption, (3) the proportion of falls resulting in fracture, and (4) the frequency of hip and wrist fracture. Whether vitamin D supplementation in winter can reduce the population burden of fractures requires further investigation.

Missing a therapeutic window of opportunity: an audit of patients attending a tertiary teaching hospital with potentially osteoporotic hip and wrist fractures.

OBJECTIVE: To establish the rate of and the predictors for performance of a bone mineral density (BMD) test and the treatment of osteoporosis in an at-risk cohort of patients attending a tertiary teaching hospital with fracture possibly related to osteoporosis. METHODS: A list of all patients between ages 40 and 85 who had been admitted to a tertiary teaching hospital in the last 18 mo with hip fracture or seen in the accident and emergency department with a wrist fracture over the last 30 mo was obtained from computer records; those patients were invited to participate in the audit. In a followup telephone questionnaire, they were queried about potential risk factors for osteoporosis and subsequent fracture, the performance of a BMD test, any information received on osteoporosis and the source of this information, and the prescription of any treatment for osteoporosis. RESULTS: In total, 218 patients were included in the audit from a potential 374 eligible patients. The majority were female (78%), with hip and wrist fractures in 42% and 58%, respectively; 32% subsequently had BMD measured and 39% were offered treatment for osteoporosis. Ninety-four percent of patients had heard of osteoporosis, with the major source of information being the media (83%) and friends (23%), with little information from the medical profession (34%). The major predictors for a patient to have a subsequent BMD test were female sex (OR 3.4, 95% CI 1.3-9.9), history of a previous fracture after the age of 50 (OR 2.3, 95% CI 1.0-5.6), family history of osteoporosis (OR 3.5, 95% CI 1.3-9.5), or the use of concurrent medications with a potential to cause osteoporosis (OR 2.5, 95% CI 1.1-5.8). The main predictors of treatment for osteoporosis being offered were age (risk increased by 1.04 for every year of life), abnormal result on the BMD test (OR 19, 95% CI 6-60), history of fracture after the age of 50 (OR 2.6, 95% CI 1.1-6.7), and a history of fracture with minimal trauma (OR 2.6, 95% CI 1.1-4.2). There was a range of treatments offered, with calcium supplementation alone accounting for 60% of treatments. CONCLUSION: Osteoporosis was overlooked by medical practitioners responsible for the care of this at-risk patient cohort, with little evidence of the medical profession offering information, further investigation, or treatment of patients who presented with a probable osteoporotic fracture of the hip or wrist. This suggests that greater education of the accident and emergency and orthopedic medical staff as well as the general public is required concerning this opportunity to investigate and treat symptomatic osteoporosis.

Fractal analysis of radiographic trabecular bone texture and bone mineral density: two complementary parameters related to osteoporotic fractures.

Trabecular bone microarchitecture and bone mineral density (BMD) are two main factors related to osteoporotic fractures. Currently, however, microarchitecture is not evaluated. We have developed and validated a trabecular bone texture analysis from radiographic images. The objective was to determine if the fractal analysis of texture was able to distinguish osteoporotic fracture groups from control groups, either in vertebrae, hip, or wrist fractures, and to determine if this indicator and BMD were independent and complementary. In this cross-sectional unicenter case-control population study in postmenopausal women, 107 fracture cases were enrolled and age-matched with 197 control cases. This population comprised 40 vertebral fractures (with 70 controls), 30 hip fractures (55 controls), and 37 wrist fractures (62 controls). Hip and lumbar spine BMD were measured by double-energy X-ray absorptiometry. Fractal analysis of texture was performed on calcaneus radiographs and the result was expressed as the H parameter (H = 2-fractal dimension). The H parameter showed a lower value (0.679 +/- 0.053 SD) in fracture cases versus control cases (0.696 +/- 0.030; p = 0.007), the statistical significance persisting after adjustment for age and for lumbar spine (LS) or hip BMD. This result was confirmed in vertebral fractures (p = 0.0001) and hip fractures (p = 0.003) but not wrist fractures (p = 0.07). We determined the threshold between high and low H values and then the odds ratios (OR) of fracture for low H for BMD < or = -2.5 SD in T score and for the combinations of both parameters. The OR of fracture for low H was 1.6 (95% CI, 1.1-2.6). For LS BMD < or = -2.5 SD the OR of 6.1 (3.4-10.8) shifted to 9.0 (4.0-20.4) when we added low H and for hip BMD it shifted from 5.6 (3.3-9.4) to 8.1 (4.0-16.8). In vertebral, hip, and wrist fracture cases the results were also significant. These data have shown that the fractal analysis of texture on calcaneus radiographs can distinguish osteoporotic fracture groups from control groups. This analysis and BMD provide independent and complementary information. These data suggest that we can improve the fracture risk evaluation by adding information related to microarchitecture, derived from analysis of conventional radiographic images.

Sports-specific injuries.

Injuries to the upper extremities can happen in any sport. Injury patterns are common to specific sports. Understanding which injuries occur with these sports allows the examiner to diagnose and treat the athlete easily. This article reviews some of the injuries common in sports such as bicycling, golf, gymnastics, martial arts, racquet sports, and weightlifting.

Traumatic volar dislocation of the second, third and fourth carpometacarpal joints: mechanism and manipulation.

Traumatic volar dislocation of the second, third and fourth carpometacarpal joints without associated fracture is extremely rare. A single case, treated successfully by manipulative reduction supplemented with splint immobilization and isometric and isotonic muscle exercise is reported, with restoration of complete anatomical alignment revealed by postmanipulative radiographs. The radiology of carpometacarpal joint dislocation is discussed. The conservative traction-dorsiflexion manipulative reduction for multiple volar carpometacarpal joint dislocations is described and recommended before using open reduction. Based on the case, it is postulated that the mechanism of a carpometacarpal joint dislocation is due to a sudden violent force acting almost perpendicularly to the metacarpal head or heads; the reactive forces create the opposite directed forces as a lever type of strain on the involved carpometacarpal joint and produce the dislocation.