Evaluation and Management of Carpal Fractures Other Than the Scaphoid.

Fractures of the carpus can be debilitating injuries and often lead to chronic pain and dysfunction when not properly treated. Although scaphoid fractures are more common, fractures of the other carpal bones account for nearly half of all injuries of the carpus. Often missed on initial presentation, a focused physical examination with imaging tailored to the suspected injury is needed to identify these fractures. In addition to plain radiographs, advanced imaging such as CT and MRI are helpful in diagnosis and management. Treatment of carpal fractures is based on the degree of displacement, stability of the fracture, and associated injuries. Those that require surgical fixation often affect the congruency of the articular surfaces, are unstable, are at risk for symptomatic nonunion, are associated with notable ligamentous injury, or are causing nerve or tendon entrapment. Surgical strategies involve percutaneous Kirschner wires, external fixation, screws and/or plates, excision, or fusion for salvage. Owing to the intimate articulations in the hand, small size of the carpal bones, and complex vascular supply, carpal fracture complications include symptomatic nonunion, osteonecrosis, and posttraumatic arthritis.

Preiser disease after repeated local glucocorticoid injections: A case report.

RATIONALE: Preiser disease or avascular necrosis (AVN) of the scaphoid causes intolerable wrist pain and malalignment of the carpal bones. In previously reported cases, patients have had a history of steroid use for systemic illness such as autoimmune hemolytic anemia, systemic lupus erythematosus, or renal transplantation, or have had other risk factors, such as smoking, alcoholism, or infection. In particular, systemic glucocorticoid therapy has been most commonly associated with the disease. Although there are reports of AVN of the scaphoid induced by systemic glucocorticoids, no prior report has associated AVN of the carpal bones with repeated local injections of glucocorticoids. PATIENT CONCERNS: We present a case in which it was strongly suspected that AVN of the scaphoid was induced by repeated local glucocorticoid injections. The patient had no history of excessive alcohol use, smoking, or trauma, except for local repeated steroid injections. DIAGNOSES: Initially, she had diagnosed with de Quervain's disease and was treated by repeated local glucocorticoid injections followed by surgery for de Quervain's disease. Five years after surgery for de Quervain's disease, the patient presented at our hospital with sudden onset of intolerable pain in her right wrist without a history of trauma. In spite of nonsurgical treatment with rest, immobilization, analgesia, and surgery, her wrist pain was not improved. After further repeated local steroid injections in her wrist, radiographs, and magnetic resonance imaging of her wrist showed the AVN of the scaphoid. INTERVENTIONS: Surgery was performed and the fragmented proximal scaphoid and the entire lunate were resected. OUTCOMES: The diagnosis was confirmed according to the histopathological examination of the proximal scaphoid bone, which showed the characteristic of AVN of the scaphoid. At follow-up evaluation, radiographs of the right wrist showed no progression of osteoarthritis. The patient had no tenderness or residual pain at the wrist and had no desire to pursue additional surgery. LESSONS: We have presented a case with AVN of the scaphoid, which was strongly suspected to be associated with the repeated local steroid injections. Further studies are required to more fully elucidate the association between AVN of the scaphoid and repeated local steroid injections.

Histomorphometric evaluation of the effect of early exercise on subchondral vascularity in the third carpal bone of horses.

OBJECTIVE: To investigate histomorphometric changes in the cartilage and subchondral bone of the third carpal bone associated with conditioning exercise in young Thoroughbreds. ANIMALS: Nine 18-month-old Thoroughbreds. Procedures-Both third carpal bones of 9 horses (4 exercised spontaneously at pasture only and 5 given additional conditioning exercise beginning at a mean age of 3 weeks) were evaluated. Histomorphometric variables (hyaline and calcified cartilage thickness and collagen orientation; vascular channel area, number, and orientation; and osteochondral junction rugosity) of the third carpal bone, sampled at 4 dorsopalmar sites in the radial facet, were compared between the exercised and nonexercised groups. RESULTS: The vascular channel area measured at the 4 dorsopalmar sites was larger in the exercised group than in the control group, but none of the variables were significantly different between groups. Both groups had significant site-specific variations in all measured variables. Most importantly, the vascular channel area was highest in the most dorsal aspect. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that the mild exercise imposed in both groups during the developmental period appeared to be associated with an increase in the vascular channel area beneath the calcified cartilage layer in the third carpal bone. This increased vascular channel area could also be associated with high stress in the dorsal aspect of the radial facet, a region that is known to be vulnerable to osteochondral fragmentation.

Assessment of perfusion in normal carpal bones with dynamic gadolinium-enhanced MRI at 3 Tesla.

PURPOSE: To investigate the normal enhancement patterns of the scaphoid, lunate, and capitate bones with dynamic contrast-enhanced magnetic resonance imaging (MRI). MATERIALS AND METHODS: The study was approved by the hospital's Ethics Committee. Nineteen volunteers (13 female, 6 male; mean age 38 years) were examined and all gave written consent. Perfusion was assessed at 3 Tesla using dynamic contrast-enhanced MRI. After two-dimensional (2D) motion correction of the data set, regions of interest were placed in the capitate, lunate, and distal and proximal pole of scaphoid bone and from the mean signal intensities (SI), the enhancement was computed. The four locations were compared for time to peak, delay time, maximum enhancement, and maximum slope using Friedman's two-way analysis of variance. RESULTS: Typical SI versus time curves revealed two components: a faster component with strong contrast enhancement and a slow component with prolonged enhancement. The mean value (standard deviation, SD) for maximum enhancement was 51 (33)% in the capitate, 54 (25)% in the lunate, 51 (34)% in the proximal pole and 51 (28)% in the distal pole of the scaphoid. The result of the Friedman test showed no significant difference (P < 0.05) in the perfusion variables between the capitate, lunate, and distal and proximal scaphoid bones. CONCLUSION: Assessment of perfusion in normal carpal bone using contrast-enhanced MRI is possible. Optimization of the method and understanding of the normal perfusion may allow evaluation of pathological conditions such as osteonecrosis.

Vascularized bone grafting in a canine carpal avascular necrosis model.

BACKGROUND: Limited experimental research has been performed on the treatment of avascular necrosis (AVN) by vascularized bone grafting. QUESTIONS/PURPOSES: A new model simulating carpal AVN was created to investigate surgical revascularization of necrotic bone. METHODS: In seven mongrel dogs, AVN was induced by removal of the radial carpal bones bilaterally, deep-freezing, coating in cyanoacrylate, and reimplantation. A reverse-flow vascularized bone graft from the distal radius was implanted in the avascular radial carpal bone. The contralateral side served as an untreated ischemic control. Bone blood flow, bone volume, radiography, histomorphometry, histology, and MRI were analyzed at 4 weeks. RESULTS: Blood flow was substantially higher in grafted bones when compared with controls (14.68 ± 15.43 versus 0.27 ± 0.28 mL/minute/100 g). Blood flow correlated with increased osteoid formation and higher levels of bone turnover. T1 and T2 signals on MRI did not correlate with quantitative bone blood flow measurements. Necrotic bones with no blood flow had normal T1 and T2 signals, whereas revascularized bones had signal changes when compared with adjacent carpal bones. No major collapse occurred in any radiocarpal bone. CONCLUSION: In a canine experimental model, investigation of carpal AVN shows the ability of vascularized bone grafting to revascularize and remodel avascular bone. CLINICAL RELEVANCE: Surgical revascularization of necrotic bone induced by vascularized bone grafting results in increased bone perfusion and bone remodeling as compared with untreated necrotic bone. MRI T1 and T2 signals can be normal in necrotic avascular bone.

Vascularised bone graft for Kienböck disease: preliminary results.

We treated eight patients with lunatomalacia by harvesting a pedicled, vascularised bone segment from the dorsal aspect of the distal radius and grafting it into the lunate. Its effect on carpal collapse and clinical outcome was assessed at a mean follow-up of 29 months (range 13-42). Postoperatively patients had considerably less pain (45% during activity and 74% at rest). Postoperative mean range of movement was 65% (range 43%-76%) (SD: 13) of the unaffected side. Three patients had an excellent result, three had good results, one had a fair result, and one patient was unsatisfied. The mean postoperative disabilities of the arm, shoulder, and hand score was 29.8 (compared with 40.0 preoperatively).

Osteonecrosis of the trapezium treated with a vascularized distal radius bone graft.

A 20-year-old man presented with early stage osteonecrosis of the trapezium, diagnosed by magnetic resonance imaging. A vascularized distal radius bone graft was performed, with good clinical and radiologic results over a 1-year follow-up period. The authors believe that a vascularized distal radius bone graft is an ideal treatment for early stage carpal bone necrosis.

Vascularity and osteonecrosis of the wrist.

This article outlines the vascular anatomy of the carpus, describing the extraosseous and intraosseus vascular systems and emphasizing the carpal bones at risk for osteonecrosis. Separate discussions of etiology, diagnosis, and treatment of osteonecrosis of the commonly involved carpal bones are included.

Collateral arterial pathways in the forearm.

We studied the forearm vessels and the palmar carpal arch in 41 fresh cadaver upper limbs injected with colored latex solutions. In one case, we found a complete occlusion of the radial artery. Collateralization was evident through the anterior interosseous artery, its palmar branch and the radial part of the palmar carpal arch. The diameters of these vessels were significantly enlarged. The dissections of the remaining 40 arms demonstrated that these vessels offer a possible collateralization pathway via the anterior interosseous artery. One hypothesis for the formation of such collateralization might be a dominant blood flow of the radial artery to the hand. Therefore, it seems sensible to preserve the communication between the anterior interosseous and the radial arteries through the palmar carpal arch, raising the radial artery for surgery.

[Vascularized bone transfers in the wrist and hand]. / Les transferts osseux vascularisés au poignet et à la main.

More and more vascularised bone transfer (VBT) sites, free or pedicled, in the wrist and hand have been described since the 1980s. In the distal forearm, two main VBT: the fibula and the iliac crest, are used for large bone loss (> 6 cm) or for radio-carpal reconstruction. We report our experience of radio-carpal reconstruction using the distal-radio-ulnar joint transfer. At the carpal level, VBT are essentially used for "difficult" scaphoid pseudarthrosis: osteonecrosis, sclerotic bone or failures of conventional grafts and for lunate necrosis. Two pedicled VBT are frequently used for the scaphoid, a graft harvested from the antero-medial part of the distal radius (Kuhlmann) or a graft harvested from the postero-lateral part of the distal radius (Zaidemberg). For the trapezo-metacarpal joint, two new articular pedicle transfers can be used in some cases of trapezo-metacarpal arthritis. At the hand level, VBT are used for distal bone loss, "en bout de chaîne". Bone vascularisation is indispensable to preserve sub-chondral bone and avoid articular destruction. In children VBT are necessary to preserve the growth cartilage.

Vascularised pisiform bone graft. Indications, technique and long-term results.

The authors report their experience with the use of a vascularised pisiform bone graft based on the dorsal branch of the ulnar artery to provide osseous support and an efficient vascular aid especially in non-unions of the carpal navicular bone with avascular necrosis of its proximal pole and in stage III Kienböck's disease. The pisiform can replace the proximal pole of the navicular bone in totality. When implanted into the lunate, it stops its collapse and helps to revascularize it. The authors present the results achieved in 14 patients (12 male, 2 female), of which eight had a follow-up longer than 5 years The technique appears as an interesting alternative to carpectomies and partial intracarpal fusions which are usually proposed in advanced cases of these conditions.

Vascularity of the carpus.

Relatively few studies investigating the vascular patterns of the carpus have been performed. Technical difficulties in identifying small vessels in three dimensions and in determining their location within the thick ligaments about the wrist have led to conflicting anatomic reports. Studies on cadavers in which improved techniques with arterial injection, chemical debridement, and decalcification were used allowed the arterial anatomy of the carpus to be delineated more accurately. The current authors review these arterial patterns, with attention given to the extraosseous and intraosseous vascularities.

Lunate plasty for Kienböck's disease: use of a pedicled vascularised radial bone graft combined with shortening of the capitate and radius.

We treated eight patients with Kienböck's disease (two patients each with stage 1, 2, 3a and 3b disease by Lichtman's classification) by removing a pedicled, vascularised bone segment from the dorsal aspect of the distal radius and engrafting it into the lunate. Additional shortening of the radius was performed in patients with the ulna-minus or null variant. Shortening of the capitate and capito-hamate fusion were also performed in patients with stage 3 disease. All patients were relieved of their wrist pain at rest and during movement, and the mean grip strength increased from 37% of that in the contralateral hand before surgery to 80% after surgery. The mean post-operative range of motion in the affected wrist was 92% of that in the opposite wrist in patients with stage 1 and 2 disease, and 53% in patients with stage 3 disease. Post-operative assessment revealed that four patients had excellent results, three had good results, and one had a fair result.

[The nutritive vascular canals. The magnetic resonance differential diagnosis of carpal cystic lesions?]. / Nutritialgefässkanäle. Magnetresonanztomographische Differentialdiagnose karpaler zystischer Läsionen?

PURPOSE: To find and describe potential MRI criteria of nutrient vessel canals of carpal bones. METHODS AND MATERIAL: 16 wrists of 13 patients with pain and radiographic depiction of cystic changes within the lunate were examined. The MRI protocol included coronal and sagittal T1- and T2-weighted SE sequences (4 mm slices, 120 FOV, 256 x 256 matrix) as well as coronal STIR images. Final diagnosis was confirmed by surgery (n = 5) and follow up. 10 cadaveric ossa lunata were studied to describe size, number, location and shape of nutrient vessel canals. RESULTS: Ganglion cysts (n = 6) showed characteristic signs. In ulnar impaction syndrome (n = 1) small cystic lesions in the lunate were surrounded by a sclerotic rim and located near the proximal ulnar surface. In Kienböck's disease (n = 3) cystic components were irregular and surrounded by bone marrow edema. Nutrient vessel canals (n = 7) imaged as 1 to 3 small cystic lesions within the palmar or dorsal subchondral region. CONCLUSION: MRI can aid in differential diagnosis of cystic carpal lesions. Nutrient vessel canals may not be mistaken for pathologic cystic lesions. Carpal ganglion cysts show distinct diagnostic pattern.

[Vascularized surgical rotation of a bi-articular trapezoid-trapeziometacarpal complex for the treatment of severe rhizarthrosis of the thumb]. / Rotation chirurgicale vascularisée du complexe bi-articulaire trapézoïde-trapézométacarpien pour le traitement de la rhizarthrose grave du pouce.

UNLABELLED: A new surgical procedure has been conceived to avoid persistent pain and to restore the functionality and pinch strength of the basal joint of the thumb destroyed by degenerative osteoarthritis. Since January 1998 a double total joint transposition was performed on eight patients, switching the trapezoid-metacarpal joint and the trapezio-metacarpal joint. A 180 degrees rotation of the bi-articular complex (trapezoid-trapezio-metacarpal joints) in its entirety was achieved, while preserving the intrinsic ligaments and vascular supply insured by the dorsal branch of the radial artery; the Cardan conformation in Physics of the trapezoid-metacarpal joint provided complete thumb motion. TECHNIQUE: skin dorso-radial approach of the wrist; arteriolysis of the dorsal branch of the radial artery at the anatomic snuff box and at its entrance into the first intermetacarpal space; metaphyseal osteotomy of the first and second metacarpal; capsulotomy all around the bi-articular complex; transfer and rotation of the trapezoid-trapezio-metacarpal bi-articular complex together with the dorsal branch of radial artery; osteotomy stabilisation by Kirschner wires; capsulo-ligamentous reconstruction; plaster slab immobilisation. Four weeks later the thumb moves actively; hand therapy starts six weeks post-operatively. Clinical and radiological controls were performed at two, four and six weeks, tomography at three months post-operation. Clinical assessment for three patients showed three good results and for the other five showed excellent outcomes, resulting in complete motion, stability of the first metacarpal and restored painless pinch strength of the thumb. Today the trapezoid-metacarpal joint seems to ensure pain relief, mobility and to solve the instability due to the collapse of the thumb column by restoring the bone chain of the first metacarpal ray.

Basal joint arthroplasty using an allograft tendon interposition versus no interposition: a radiographic, vascular, and histologic study.

To assess the role of a tendon spacer that fills the trapezial void, the trapeziums were excised and anterior oblique ligaments were reconstructed in 25 monkeys. In addition to the ligament reconstruction, 20 of the monkeys had the trapezial void filled with a tendon allograft. The trapezial space was investigated at 0, 3, 6, 15, and 40 weeks using routine histologic staining, arterial perfusion (Spalteholz), and standardized radiographs. There was a statistically greater decline in trapezial height in the animals without tendon interposition allografts. The tendon grafts became progressively neovascularized and populated with fibroblasts. By 40 weeks, the allograft was no longer a folded tendon but a homogeneous mass of collagen, fibroblasts, and capillaries. The specimens without an interpositional tendon graft had loose fibroadipose tissue filling the carpal void. Polarized light microscopy showed fibers crossing the subchondral bone and moving into the adjacent fibrous spacer in the specimens implanted with a tendon graft. The results indicate that filling the trapezial void with an interposition tendon spacer may aid in maintaining normal wrist anatomy.

Usefulness of gadolinium-enhanced MR imaging in the evaluation of the vascularity of scaphoid nonunions.

OBJECTIVE: The objective of this article is to identify the role of gadolinium-enhanced MR imaging in the preoperative evaluation of the vascular status of the proximal fragment in scaphoid nonunions. SUBJECTS AND METHODS: Thirty consecutive patients (27 men and three women; age range, 19-52 years; mean age, 28 years) with nonunion of the scaphoid were prospectively examined with unenhanced and gadolinium-enhanced MR imaging. MR images and surgical findings were classified in four groups according to the vascular status of the proximal fragment (normal bone, moderate ischemic bone, severe ischemic bone, and avascular necrosis). Sensitivity, specificity, and accuracy of unenhanced and gadolinium-enhanced MR studies were calculated. Surgical findings were used as the gold standard. The postoperative rate of union at 12 months was evaluated for each group. RESULTS: Unenhanced MR imaging showed a global sensitivity of 36%, specificity of 78%, and accuracy of 68% in the preoperative evaluation of the vascular status of the proximal fragment. Correlation with the surgical findings was not statistically significant (p < 0.149). Global sensitivity, specificity, and accuracy of gadolinium-enhanced MR imaging were 66%, 88%, and 83%, respectively. Correlation with the surgical findings was good (p < 0.0001). Gadolinium-enhanced sequences allowed accurate diagnosis and enabled the creation of prognostic groups having better correlation with surgical findings and postoperative results. CONCLUSION: Gadolinium-enhanced MR imaging is the most reliable imaging method for investigating the vascularity of the proximal pole in scaphoid nonunions.