Long-term outcomes after capitate fractures: a median 16-year follow-up.

INTRODUCTION: The long-term effects of a capitate fracture are unknown. The aim of this study was to assess both clinical and radiological long-term outcomes after a capitate fracture. MATERIALS AND METHODS: From a cohort of 526 consecutive patients with post traumatic radial sided wrist pain, 23 were identified diagnosed with a capitate fracture. 16 of these (11 males and 5 females) with a median age at injury of 17.5 years (range 11-27 years) were eligible for a follow-up after a median of 16 years (range 8 to 17 years). In this study patients were examined using conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) at the time of injury and with CT at the follow-up. At follow-up radiological signs of osteoarthritis were graded in four stages and clinical outcome was evaluated by measuring range of wrist motion and grip and pinch strength. The subjective outcome was assessed using DASH and PRWE questionnaires. RESULTS: Five patients had isolated capitate fractures and 11 had concomitant fractures, 10 of which had a simultaneous scaphoid fracture. 14 patients had been treated non-surgically in a cast and two patients were treated surgically. None of the fractures were visible on conventional radiographs at the time of injury. At follow-up all fractures had healed without signs of avascular necrosis. In one patient, CT examination revealed osteoarthritis between the capitate and lunate. This did not cause clinical symptoms. Functional impairments and pain scores were low: median DASH score 0, median PRWE 3 and median VAS pain score 0. We found no impairment in range of motion or grip and pinch strength. CONCLUSIONS: At a median of 16-year follow-up, patients with a capitate fracture report normal self-assessed hand function as well as good wrist motion and strength. The risk of development of posttraumatic arthritis in the joints around the capitate is low.

Clinical and Patient-Reported Outcomes After Total Wrist Arthroplasty and Total Wrist Fusion: A Prospective Cohort Study with 2-Year Follow-up.

Background: The functional benefits of total wrist arthroplasty (TWA) over total wrist fusion (TWF) are unknown. The purpose of this prospective cohort study was to compare TWA and TWF with respect to functional outcomes and activity limitations at up to 2 years postoperatively. Methods: Between 2015 and 2020, we enrolled all adult patients undergoing TWA or TWF for the management of symptomatic end-stage wrist arthritis at 1 hand surgery department. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE). The secondary outcomes were the visual analog scale (VAS) for pain at rest, on motion, and on loading; grip strength; Disabilities of the Arm, Shoulder and Hand (DASH); and range of motion. Patients completed questionnaires and were examined by the same physiotherapist at baseline and at 3, 6, 12, and 24 months postoperatively. Mixed-model analyses adjusting for age, diagnosis, the preoperative value of the dependent variable, and time since surgery were performed to compare differences in PRWE scores, VAS pain scores, and grip strength between TWA and TWF. Results: Of the 51 patients who had been included at baseline, 47 (18 in the TWA group and 29 in the TWF group) responded to questionnaires and underwent examinations at up to 2 years postoperatively. At baseline, the 2 groups did not differ in terms of age, sex, diagnosis (inflammatory or noninflammatory arthritis), PRWE score, VAS pain score, grip strength, DASH score, or range of motion. No differences between the groups were found for the PRWE (ß, -0.1; 95% confidence interval [CI], -14 to 13; p = 0.99), VAS pain at rest (ß, -3.3; 95% CI, -15 to 9; p = 0.58), VAS pain on loading (ß, -5.3; 95% CI, -22 to 11; p = 0.52), or grip strength (ß, -0.02; 95% CI, -0.18 to 0.14; p = 0.80) on the adjusted mixed-model analyses. Conclusions: Among patients with symptomatic end-stage wrist arthritis, those who underwent TWA did not demonstrate short-term outcomes, including patient-reported disability, pain, and grip strength, superior to those of patients who underwent TWF. These findings call into question the widespread use of TWA. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Acute scaphoid fractures: making decisions for treating a troublesome bone.

Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.

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.

[Scaphoid fractures - Guidelines for diagnosis and treatment]. / Diagnostik och behandling av akuta skafoideumfrakturer.

This article suggests algorithms for diagnosis and treatment of scaphoid fractures. A clinical suspected scaphoid fracture without signs of fracture on conventional radiographs should have a supplementary MRI done within 5-7 days. Displaced fractures and all proximal fractures should be classified by CT. Fracture union should be evaluated by CT. 90 procent of non- or minimally displaced waist fractures are healed after 6 weeks of conservative treatment. Non- or minimally displaced fractures with signs of instability can be treated conservatively, but require prolonged immobilisation. Fractures with a displacement ≥1,5 mm as well as the majority of proximal scaphoid fractures should be treated surgically with internal fixation.

Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up.

PURPOSE: The aim of this study was to evaluate the functional, clinical, and radiological outcome 10 years after distal scaphoid fractures. METHODS: From a prospective epidemiological study on posttraumatic radial-sided wrist pain, we evaluated 41 cases of distal scaphoid fractures. All cases had been treated nonsurgically in a thumb spica cast. Patients were examined using radiographs, magnetic resonance imaging and computed tomography at the time of injury and with computed tomography after a median of 10 years (range, 8-11 years). Fractures were classified according to a modified Prosser classification system. The primary outcome was assessment of self-reported function using Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Reported Wrist Evaluation (PRWE). Secondary outcomes were clinical status (range of motion and grip and pinch strength) and to evaluate fracture healing and arthritis in the scaphotrapezium-trapezoid (STT) joint. RESULTS: Functional impairment and pain scores at follow-up were low: median DASH score 2, median PRWE 0, and median visual analog scale (VAS) pain score 0. We found no impairment in range of motion or strength. We found 26 type I fractures, 12 type IIA, 1 type IIC, and 2 type IV. There was 1 asymptomatic nonunion in a type I fracture. Computed tomography revealed arthritis in the STT joint in 7 out of 41 wrists, none of which caused clinical symptoms. CONCLUSIONS: From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. The risk for development of posttraumatic STT arthritis was low. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Is early mobilisation better than immobilisation in the treatment of wrist sprains?

OBJECTIVE: Posttraumatic radial sided wrist pain is common and can represent a fracture or a ligament injury. However, in some patients radiographs and MRI are normal, indicating no specific diagnosis other than a wrist sprain. There is no consensus on the ideal treatment for this patient group. The aim was to investigate if patients with posttraumatic radial sided wrist pain and MRI not showing signs of fracture or SL-ligament injury should be treated with immediate mobilisation or 2 weeks cast immobilisation. METHOD: Forty-three patients, aged 18-64 years, were randomised to either a dorsal wrist cast for 2 weeks (n = 21), or immediate mobilisation (n = 22). Follow-up at 2, 4, and 6 weeks included clinical examination, self-assessment questionnaires (DASH, VAS), and recording of days on sick-leave. RESULTS: At 2 weeks patients treated in a cast had reduced wrist range of motion, ROM (77% vs 96%, p = 0.011), and higher DASH score (median 37 vs 18, p = 0.009) compared to patients treated with immediate mobilisation. At 4 weeks, DASH score was still higher in the group treated in a cast (median 14 vs 4, p = 0.01), but there was no difference in ROM. At 6 weeks there were no differences in any outcome measure between the groups. Furthermore, there was no significant difference in sick-leave between the groups (median 27 days vs 14 days, p = 0.077). CONCLUSION: Patients with radial sided wrist pain where MRI does not demonstrate fracture or SL ligament injury do not benefit from cast immobilisation and can be treated with early mobilisation.

Conservative Treatment Versus Arthroscopic-Assisted Screw Fixation of Scaphoid Waist Fractures--A Randomized Trial With Minimum 4-Year Follow-Up.

PURPOSE: To evaluate clinical and radiological outcomes after conservative treatment and arthroscopic-assisted screw fixation of acute non- or minimally displaced scaphoid waist fractures in a randomized controlled trial. METHODS: Consecutive patients with acute non- or minimally displaced scaphoid waist fractures were prospectively randomized to conservative or surgical treatment. All patients were screened using radiographs, computed tomography, and magnetic resonance imaging. Conservative treatment consisted of a below-elbow thumb spica cast until radiological signs of union appeared. Surgical treatment consisted of wrist arthroscopy and percutaneous antegrade screw fixation. Clinical examination, radiographs, and computed tomography were used to follow the patients. Twenty-four patients were treated conservatively and 14 patients underwent surgery. The patients were followed at regular intervals for 1 year after surgery. Twenty-one patients treated conservatively and 14 treated surgically were available for follow-up after a median of 6 years (range, 4-8 y). RESULTS: At 26 weeks, the conservatively treated group had significantly better range of motion and had reached almost normal value compared with the contralateral wrist. There were no significant differences between the 2 groups concerning grip or pinch strengths at any measure point. At follow-up after a median of 6 years, radiographic signs of arthritis in the radioscaphoid joint were more common in the surgically treated group (3 of 14) than in the conservative group (2 of 21). CONCLUSIONS: Non- and minimally displaced scaphoid waist fractures are best treated conservatively. Operative treatment may provide an improved functional outcome in the short term but at the price of a possible increased risk of arthritis in the long term. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Union of Scaphoid Waist Fractures Assessed by CT Scan.

Background Union of a scaphoid fracture is difficult to assess on a standard series of radiographs. An unnecessary and prolonged immobilization is inconvenient and may impair functional outcome. Although operative treatment permits early mobilization, its influence on time to union is still uncertain. Purpose To assess union of scaphoid waist fractures based on computed tomography (CT) scan at 6 weeks, and to compare time to union between conservative treatment and arthroscopically assisted screw fixation. Patients and methods CT scan in the longitudinal axis of the scaphoid was used to provide fracture characteristics, and to assess bone union at 6 weeks in 65 consecutive patients with scaphoid waist fractures. In a randomized subgroup from this cohort with nondisplaced fractures, we compared time to union between conservative treatment (n = 23) and arthroscopically assisted screw fixation (n = 15). Results Overall, at 6 weeks we found a 90% union rate for non- or minimally displaced fracture treated conservatively, and 82% for those who underwent surgery. In the randomized subgroup of nondisplaced fractures, no significant difference in time to union was demonstrated between those treated conservatively and those who underwent surgery. The conservatively treated fractures from this subgroup with prolonged time to union (10 to 14 weeks) were comminuted, demonstrating a radial cortical or corticospongious fragment. Conclusion The majority of non- or minimally displaced scaphoid waist fractures are sufficiently treated with 6 weeks in a cast. Screw fixation does not reduce time to fracture union compared with conservative treatment. Level of Evidence level II, Therapeutic study.

Sclerosing injections in midportion Achilles tendinopathy: a retrospective study of 25 patients.

Sclerosing injections under ultrasonographic guidance is a new method of treatment for persistent pain in Achilles tendinosis. Good results, even superior to those of surgery, have been described. We report the outcome of 25 patients with midportion tendinosis receiving sclerosing treatment. Twenty-eight consecutive patients (29 tendons) with ultrasonographical findings of midportion tendinosis examined during the period November 2004 to November 2005 were identified in the database of the Department of Radiology, Malmö University Hospital. Twenty-five patients (26 tendons) were found suitable for treatment. Follow-up consisted of self-assessment questionnaire or phone interview. In 19 patients (20 tendons), results were good or excellent. Complications were few and mild. We conclude that sclerosing injections is a promising alternative to surgery in chronic Achilles midportion tendinosis. Our results are comparable to those obtained with surgery, but the procedure is less invasive. However, a few cases of tendinosis lack detectable neovessels and may still be candidates for surgery.