Comparison of Radiographic Measurement Parameters of the Wrist in Patients with and without Scaphoid Fracture after Fall on an Outstretched Hand.

PURPOSE OF THE STUDY: To investigate the effects of anatomical variations on the mechanism of scaphoid fracture by comparing the radiologic parameters of the wrist of patients with and without scaphoid fracture after a fall on an outstretched hand. MATERIAL AND METHODS: Cross-sectional comparative retrospective analysis of radiographs of patients with (Group 1, n=169) and without scaphoid fracture (Group 2, n=188). Morphometric data were measured including radial inclination (RI), radial height (RH), ulnar variance (UV), carpal height (CH) ratio, revised carpal height (RCH) ratio and palmar tilt of the distal radius (PT). Receiver operating characteristics (ROC) curve analysis was used to assess the diagnostic performance for each variable with statistically significant difference. RESULTS: The mean RI and PT degrees and RH length were statistically significantly higher, and the mean UV was lower in Group 1 compared to Group 2. No difference was determined between the groups with respect to the CH ratio and RCH ratio. With ROC curve analysis, the cut-off value with the highest odds ratio was determined as RH (Cut-off value=10.77 mm, OR=21.886). CONCLUSIONS: Although higher RI, RH, PT values and more negative ulnar variance were observed in the scaphoid fracture group compared to the non-fracture group, ROC curve analysis showed that only increased RH can be considered as a possible risk factor for scaphoid fractures after fall on an outstretched hand. KEY WORDS: radiographs, risk factor, scaphoid fracture, wrist morphology.

Treatment of Hand and Wrist Cartilage Defects in Athletes.

Cartilage injuries of the hand and wrist can be debilitating in the athlete. Diagnosis is difficult given the broad spectrum of presenting symptomatology. History and physical examination is crucial to achieve the correct diagnosis, and advanced imaging can offer helpful assistance to the clinician as well. TFCC injuries and ulnar impaction syndrome are among the most common conditions in athletes with hand and wrist pain. Treatment of these injuries is initially nonoperative, but elite athletes may elect to bypass nonoperative treatment in favor of earlier return to sport. Surgical treatment varies but can include open and arthroscopic methods. The clinician should tailor treatment plans to each athlete based on level of competition, type of sport, and individual preferences and goals.

Perilunate Fracture-Dislocation: Results at Mean Follow-Up of 7 Years after ORIF.

Background: Perilunate fracture-dislocations are frequently associated with a high risk of developing post-traumatic arthritis. Current studies indicate that during mid-term follow-ups, radiological signs of arthritis do not appear to correspond with functional score. The aim of this study was to assess the occurrence of posttraumatic arthritis and the wrist function after perilunate dislocations (PLD) and fracture dislocations at a mid-term follow-up of 7 years. Methods: We report the clinical and radiological outcomes of 17 wrists treated for PLD or fracture-dislocation by open reduction and internal fixation through a dorsal approach with dorsal ligament repair. Functional outcomes were evaluated using the short version of the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the Patient-Rated Wrist Evaluation questionnaire (PRWE) and the Mayo Wrist Score (MWS). Results of radiographs were assessed using the Herzberg Radiological Scoring Chart. Results: The MWS showed five excellent, five good, five fair and two poor results with an average score of 81%. Radiological analysis using the Herzberg classification revealed midcarpal and/or radiocarpal arthritis in 65% of cases, lunate collapse in 59% and an increase in the mean ulnar translocation ratio in 53% of the cases. Complications included one case of lunate osteonecrosis and one case of stage 3 scapholunate advanced collapse that required revision surgery. Conclusions: Although the clinical and functional outcomes are favourable at mid-term follow-up, radiological evaluation shows a progression towards osteoarthritis (OA). Further research is warranted to refine treatment strategies and investigate factors influencing the development of OA. Level of Evidence: Level IV (Therapeutic).

Pediatric Wrist.

Pediatric wrist injuries pose unique diagnostic challenges due to distinct bone characteristics in children and their diverse injury patterns. The dynamic development of the wrist, marked by changes in bone age and emerging ossification centers, is crucial to evaluate growth and identify potential pathologies. The skeletal composition, rich in cartilage, renders bones relatively weaker yet more elastic, impacting their susceptibility to fracture. Forearm fractures display diverse patterns influenced by torsional forces. Scaphoid fractures, less common in children, differ from those in adults. Conditions like Madelung's deformity and ulnar variance are more common wrist disorders in the pediatric population. In addition, the scarcity and nonspecificity of symptoms in those with tendon injuries and triangular fibrocartilage complex lesions can be diagnostically challenging. This article reviews pediatric wrist injuries, emphasizing ossification patterns, common fracture types, and developmental variants. Grasping these complexities in pediatric wrist development and associated pathologies is essential for precise diagnosis and treatment.

[Trans-scapho-perilunar fracture-dislocation: a case report]. / Fractura-luxación transescafo-perilunar: reporte de un caso clínico.

Trans-scaphoid perilunate fractures-dislocations are rare injuries caused by high-energy trauma of the wrist. Diagnosis is based on medical history, physical examination, and tools such as radiographs, computed tomography scan, and magnetic resonance imaging. Early treatment consists of closed reduction and casting to stabilize the limb. Definitive treatment is surgical and includes bone and soft tissue repair. A case of trans-scaphoid perilunate fracture-dislocation is presented, along with diagnosis, management and outcome.

Las fracturas-luxaciones transescafo-perilunares son lesiones infrecuentes causadas por impactos de alta energía hacia la muñeca. El diagnóstico se basa en la historia clínica, exploración física y herramientas como la radiografía, la tomografía computarizada y la resonancia magnética. El manejo inmediato consiste en una reducción cerrada e inmovilización para estabilizar la extremidad. El tratamiento definitivo es de carácter quirúrgico e incluye la reparación ósea y de tejidos blandos. Se presenta un caso de fractura-luxación transescafo-perilunar, su diagnóstico, manejo y evolución.

Post-processing of quantitative 4D-CT for initial evaluation of scapholunate Instability: Assessment of simplified approaches to data analysis.

OBJECTIVES: To evaluate the diagnostic performance of simplified post-processing approaches for quantitative wrist 4D-CT in the assessment of scapholunate instability (SLI). METHODS: A prospective monocentric case-control study included 60 patients with suspected post-traumatic scapholunate ligament (SLL) tears and persistent pain. Of these, 40 patients exhibited SLL tears, subdivided into two groups of 20 each: one group with completely torn ligaments and the other with partially torn ligaments. The remaining 20 patients, whose SLLs were intact, served as controls. 4D-CT and CT arthrography were performed, and post-processed by two readers using three approaches: the standard method with full data assessment and dedicated software, partial data assessment with post-processing software (bone locking), and partial data assessment without post-processing software (no bone locking). The scapholunate gap (SLG) parameter was measured in millimeters to evaluate scapholunate diastasis during radioulnar deviation (RUD). The scapholunate ligament status on CT arthrography was considered the gold standard. RESULTS: The SLG-derived parameters (range, mean, and maximal values) were significantly increased in patients with both intact and torn scapholunate ligaments across all post-processing approaches (P values ranging from 0.001 to 0.004). SLG range was the best parameter for diagnosing SLL tears, with ROC AUC values ranging from 0.7 to 0.88 across the three post-processing methods. The interobserver reproducibility was better with the alternative approaches (ICC values 0.93-0.96) compared to the standard approach (ICC values 0.65-0.72). Additionally, post-processing time was shorter with the alternative approaches, especially when specific software was not used (reduced from 10 to three minutes). CONCLUSION: Simpler approaches to wrist 4D-CT data analysis yielded acceptable diagnostic performances and improved interobserver reproducibility compared to the standard approach.

Ultrasound examination for injury of the wrist extensor retinaculum.

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Chronic Volar Dislocation of the Distal Radioulnar Joint Stabilised by a Partial Extensor Carpi Ulnaris Tendon Strip - A Case Report.

Volar dislocation of the distal radioulnar joint is a rare injury that is often missed at initial presentation. We report a 21-year-old male patient who presented 2 months after sustaining this injury. He was successfully managed by open reduction and reconstruction of the dorsal radioulnar ligament using a partial distally based extensor carpi ulnaris tendon strip. A literature review showed only a few reported cases with varied methods for management. The technique utilised is analysed in comparison to the others. Level of Evidence: Level V (Therapeutic).

Distinct patterns of fracture propagation in distal radial fractures and the relationship to the ulnar head.

BACKGROUND: The aim was to assess the direction of distal radius fractures and their relationship to the ulnar head. METHODS: We reviewed the 160 wrist radiographs. The fracture line was measured on the postero-anterior and lateral radiographs relative to the long axis of the forearm and the relationship to the ulnar head. FINDINGS: PA radiographs: the fracture line ran distal ulnar to proximal radial (ulnar to radial) in 11%, transverse in 74% and distal radial to proximal ulnar (radial to ulnar) in 16%. Lateral radiographs: the fracture line ran distal volar to proximal dorsal in 88%, transverse in two 1% and dorsal to volar in 11%. Radial shift (7.5%) only occurred with ulnar to radial or transverse fractures. The ulnar to radial fracture line started at the proximal end of the ulnar head/distal radio-ulnar joint in 88%. The radial to ulnar fracture line started ended a mean of 2.5 mm proximal to the distal radio-ulnar joint (p < 0.01). The transverse fracture line started at the base of the distal radio-ulnar joint in 53% and proximally in 47%. INTERPRETATION: There are two distinct coronal patterns: radial to ulnar ending c. 2 mm proximal to the distal radio-ulnar joint; ulnar to radial starting at the proximal distal radio-ulnar joint. There may be third pattern - transverse fractures; these may be variants of the above. Sagittally the main direction is volar to dorsal but 11% are obverse. This is the first description of distinct fracture patterns in extra-articular distal radius fractures. In addition the fracture patterns appear to correlate with different directions of force transmission which fit with our understanding of falling and the relatively uncontrolled impact of the wrist/hand with the ground. These patterns of fracture propagation help understand how the biomechanics of wrist fractures and may enable prediction of collapse.

Detection of scapholunate interosseous ligament injury using dynamic computed tomography-derived arthrokinematics: A prospective clinical trial.

Scapholunate interosseous ligament injuries are a major cause of wrist instability and can be difficult to diagnose radiographically. To improve early diagnosis of scapholunate ligament injuries, we compared injury detection between bilateral routine clinical radiographs, static CT, and dynamic four-dimensional CT (4DCT) during wrist flexion-extension and radioulnar deviation. Participants with unilateral scapholunate ligament injuries were recruited to a prospective clinical trial investigating the diagnostic utility of 4DCT imaging for ligamentous wrist injury. Twenty-one participants underwent arthroscopic surgery to confirm scapholunate ligament injury. Arthrokinematics, defined as distributions of interosseous proximities across radioscaphoid and scapholunate articular surfaces at different positions within the motion cycle, were used as CT-derived biomarkers. Preoperative radiographs, static CT, and extrema of 4DCT were compared between uninjured and injured wrists using Wilcoxon signed rank or Kolmogorov-Smirnov tests. Median interosseous proximities at the scapholunate interval were significantly greater in the injured versus the uninjured wrists at static-neutral and maximum flexion, extension, radial deviation, and ulnar deviation. Mean cumulative distribution functions at the radioscaphoid joint were not significantly different between wrists but were significantly shifted at the scapholunate interval towards increased interosseous proximities in injured versus uninjured wrists in all positions. Median and cumulative distribution scapholunate proximities from static-neutral and 4DCT-derived extrema reflect injury status.

Torus fractures - diagnosis and management.

Torus fractures are a common paediatric injury involving the distal radius. Patients typically present following a fall onto the outstretched hand, with wrist pain as their primary complaint. The principal investigation of choice is a plain radiograph of the wrist joint. These fractures should be managed with a soft-bandage and immediate discharge approach and do not require specialist follow-up. Clinicians have historically had differing views regarding optimal management of torus fractures. It is therefore important for hospital clinicians to uniformly understand the most up-to-date management of this condition. This review provides an overview of the epidemiology, anatomy, diagnosis and management, with an aim to improve outcomes.

Dorsal Radiocarpal Dislocation with Radial Styloid Fracture Treated with Arthroscopy-Assisted Reduction and Internal Fixation: A Report of Two Cases.

Radiocarpal dislocation is an uncommon injury that is usually caused by high-energy trauma. Herein, we present two cases of dorsal radiocarpal dislocation with radial styloid fractures that were treated by arthroscopy-assisted reduction and internal fixation. Wrist arthroscopy provides accurate information on intra-articular fractures and carpal and/or intracarpal ligamentous tears of the radiocarpal joint. Furthermore, the procedure enables simultaneous anatomical reduction of intra-articular fractures and radiocarpal and/or intercarpal ligament repair. Arthroscopy-assisted reduction and internal fixation yield satisfactory outcomes for patients presenting with dorsal radiocarpal dislocation and radial styloid fractures.

Surgical management and functional outcomes of perilunate dislocations and fracture dislocations through the dorsal approach.

BACKGROUND: Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist, with surgical management leading to acceptable functional results. PURPOSE: The purpose of this study was to assess the functional outcomes of the patients of our department who were treated with surgical management of PLDs/PLFDs through dorsal approach, as well as to report any complications on their follow-up. PATIENTS AND METHODS: In this retrospective study, 52 patients with PLD/PLFD, fulfilling the inclusion and exclusion criteria of the study, underwent surgical management of their injury. All patients were followed up at 6 weeks, 12 weeks, 6 months, 1 year postoperatively with radiographic imaging as well as functional scores measured with the modified mayo wrist score and the QuickDASH questionnaire. RESULTS: The mean postoperative modified Mayo score was 76.8 ± 8.8 and the mean QuickDASH score was 1.52 ± 2.18. Of the 52 cases, 20% had excellent results, 42% had good results, 29% had fair results and 9% had poor results as per the modified Mayo wrist score. No patient signed any symptoms of median nerve neuropathy. CONCLUSION: In conclusion, open reduction and internal fixation through dorsal approach is a reliable technique to manage perilunate injuries in spite of radiological evidence of wrist arthritis, as it also provides consistently good results in terms of functional outcomes. LEVEL OF EVIDENCE IV: Retrospective case series study.

Diagnostic power of ChatGPT 4 in distal radius fracture detection through wrist radiographs.

Distal radius fractures rank among the most prevalent fractures in humans, necessitating accurate radiological imaging and interpretation for optimal diagnosis and treatment. In addition to human radiologists, artificial intelligence systems are increasingly employed for radiological assessments. Since 2023, ChatGPT 4 has offered image analysis capabilities, which can also be used for the analysis of wrist radiographs. This study evaluates the diagnostic power of ChatGPT 4 in identifying distal radius fractures, comparing it with a board-certified radiologist, a hand surgery resident, a medical student, and the well-established AI Gleamer BoneView™. Results demonstrate ChatGPT 4's good diagnostic accuracy (sensitivity 0.88, specificity 0.98, diagnostic power (AUC) 0.93), surpassing the medical student (sensitivity 0.98, specificity 0.72, diagnostic power (AUC) 0.85; p = 0.04) significantly. Nevertheless, the diagnostic power of ChatGPT 4 lags behind the hand surgery resident (sensitivity 0.99, specificity 0.98, diagnostic power (AUC) 0.985; p = 0.014) and Gleamer BoneView™(sensitivity 1.00, specificity 0.98, diagnostic power (AUC) 0.99; p = 0.006). This study highlights the utility and potential applications of artificial intelligence in modern medicine, emphasizing ChatGPT 4 as a valuable tool for enhancing diagnostic capabilities in the field of medical imaging.

[Basic principles of surgical treatment of distal radius fractures]. / Grundprinzipien der operativen Versorgung der distalen Radiusfraktur.

Distal radius fractures are one of the most frequent fractures of the upper extremities. The decision for conservative or surgical treatment is made after appropriate diagnostics using conventional radiographic and usually computed tomography imaging examinations. If the indications for surgical treatment are present, various options for reduction and fixation are available. The spectrum ranges from closed to open procedures up to accompanying arthroscopic support. Appropriate preoperative patient education about the procedure and the planned postinterventional treatment is essential. The goal of treatment is to restore wrist function while maintaining mobility and strength with a low risk of complications. All surgical procedures share the principle of reduction to restore anatomical relationship followed by fixation. Closed procedures include fixation with Kirschner wires and the construction of an external fixator. Volar locking plate osteosynthesis has become established in recent years as the method of choice for the majority of the fractures to be treated. For special fracture patterns and the treatment of accompanying injuries, arthroscopic support can be indicated. There is no uniform consensus on the best choice of procedure. This article discusses the possible procedures including the approaches, fixation techniques and specific follow-up treatment.

[Diagnostics and classification of distal radius fractures]. / Diagnostik und Klassifikation der distalen Radiusfraktur.

Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X­ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized.

Fracture Dislocation of the Pisiform Bone in 14-Year-Old Boy-A Case Report.

We present the case of a 14-year-old patient who suffered fracture dislocation of the pisiform bone (PB) along with fractures of the scaphoid, proximal radius, and proximal phalanx of the thumb due to high-energy trauma directly to the extended wrist. This combination of fractures has not been previously reported in the literature. Currently, there is no consensus in the literature regarding the optimal treatment approach for such cases. In our management, initial attempts at closed and open reduction were unsuccessful, leading to the decision for primary pisiformectomy. Our report includes a follow-up of 3.5 years, demonstrating a very good outcome. Based on this case and a few similar published cases, primary pisiformectomy appears to be a viable and well-accepted option, particularly among young patients. Additionally, we conducted a review of radiographic criteria and management strategies for this specific injury and related conditions.

Prevalence of asymptomatic TFCC tears on MRI: A systematic review.

BACKGROUND: Recent studies show a high prevalence of triangular fibrocartilage complex (TFCC) tears in asymptomatic wrists. While a TFCC tear may be identified when evaluating ulnar sided wrist pain, this could be incidental and not the true cause of pain. The purpose of this review was to (1) examine the frequency of which TFCC tears are diagnosed on MRI in asymptomatic versus symptomatic wrists and (2) determine whether rates of asymptomatic TFCC tears are higher in two important subgroups commonly at risk for this pathology: elderly patients and high-impact athletes. METHODS: Articles of level IV or higher evidence were selected from PubMed, Ovid MEDLINE, and Cochrane Central Register of Controlled Trials Database to compare patient demographics, study parameters, and clinical outcomes. RESULTS: Seven studies met inclusion criteria with a total of 501 wrists (205 symptomatic and 296 asymptomatic). All studies included asymptomatic patients with wrist MR imaging and included information on the structural integrity of the TFCC. Variability in outcome measures reported across studies prevented the conduction of a meta-analysis. CONCLUSIONS: TFCC abnormalities are present in patients of all ages, symptomatology, and levels of involvement in high-impact sports. Although, there are differences in tear and abnormality prevalence when comparing these three factors, the difference was not significant. Given these findings, using MRI to assess ulnar-sided wrist pain should be fortified with clinical suspicion, physical exam, and physician judgment.

The rate of nonunion in the MRI-detected occult scaphoid fracture.

Aims: There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods: This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results: A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion: MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients.