Successful surgical management of a Salter-Harris type I fracture of the accessory carpal bone in a dog.

OBJECTIVE: To describe the successful surgical management of a previously unreported Salter-Harris type I fracture of the accessory carpal bone in a dog. ANIMAL: An 11-week-old intact female Golden Retriever-Poodle cross presented with a history of a marked left forelimb lameness following a suspected fall from a height. CLINICAL PRESENTATION, PROGRESSION, AND PROCEDURES: On physical examination, the patient demonstrated a severe left forelimb lameness and pain on palpation and range of motion of the left carpus. Orthogonal radiographs of the distal left forelimb demonstrated a type I Salter-Harris fracture of the accessory carpal bone with proximal displacement of the palmar fragment. TREATMENT AND OUTCOME: The patient underwent open reduction and internal fixation wherein the fracture was reduced and stabilized with two 1.1-mm Kirschner wires. Postoperatively, the patient was initially managed with a carpal flexion bandage for 2 weeks and then a soft padded bandage was maintained until 4 weeks postoperatively. The patient recovered well and was walking and weight-bearing comfortably following removal of the carpal flexion bandage. Repeat radiographs performed 4 and 8 weeks postoperatively demonstrated adequate fracture healing but showed mild proximocaudal implant displacement. Implant removal was not performed, as the patient was doing well at home and the implant migration appeared static and was not causing clinical morbidity. CLINICAL RELEVANCE: To the authors' knowledge, this was the only reported case of a Salter-Harris fracture of the accessory carpal bone in a dog and the only described case of successful surgical stabilization.

Carpal fractures: epidemiology, classification and treatment of 6542 fractures from the Swedish Fracture Registry.

This study describes the age and sex distribution, trauma mechanism, treatment and influence of patient-reported outcomes of 6542 carpal fractures from the Swedish Fracture Registry (SFR). The most commonly fractured carpal bone was the scaphoid (60%), followed by the triquetrum (25%), hamate (5%) and trapezium (4%). The mean age at injury was 41 years, and 69% of patients were male. The age and sex distribution of carpal fractures differed substantially between the different carpal bones. Men were more likely to sustain a carpal fracture after high-energy trauma and were more likely to be treated surgically. Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury.Level of evidence: IV.

Trapezial Fractures and Associated Fractures of the Ulnar Carpus: A Ring-Bone Model.

BACKGROUND: Fractures of the trapezium are rare; however, the incidence may be under-reported in the literature. The incidence of ulnar-sided carpal body fractures as a concomitant injury has not been reported. Our study aimed to evaluate the incidence of trapezium fractures in conjunction with ulnar-sided carpal body fractures. METHODS: Over a five-year period, our electronic records were queried and charts reporting carpal bone fractures were reviewed. All cases of trapezium fracture were evaluated further and presented. RESULTS: Eight trapezial fractures were identified, representing 8% of all carpal fractures and 26% of all nonscaphoid carpal fractures. Of the eight trapezium fractures identified, five (62.5%) were associated with Bennett fracture and four (50%) were associated with ulnar-sided carpal fractures. CONCLUSION: Our study demonstrates a higher incidence of trapezial fractures than previously reported. Previously unreported concomitant ulnar-sided carpal body fractures are reported at a frequency nearly equal to that of concomitant Bennett fractures in our series. We propose a mechanism of injury where the carpal canal and overlying transverse carpal ligament function as a ring-bone construct similar to the pelvis. When a trapezium fracture is identified, we recommend additional evaluation for ulnar-sided injuries of the carpus.

Epidemiology of carpal fractures: is it only about the scaphoid?

Because of their low incidence, studies about carpal fractures are rare. The aim of the present study was to analyze epidemiology and treatment of fractured carpal bones. We retrospectively analyzed data of 178 patients admitted to our emergency room with carpal fractures over 6 years. More males than woman were injured. In 91%, a CT scan was performed. The most commonly affected bone was the triquetrum followed by the scaphoid. Almost all triquetral fractures were treated conservatively as opposed to perilunate dislocations that were all operated on. Half of all patients with scaphoid fractures were operated. Young men had the highest risk to sustain a carpal fracture. The triquetrum and the scaphoid are most frequently affected. Usually a CT scan is needed. Treatment of scaphoid and perilunate luxation fractures is rather operative whereas the other fractures mostly allow conservative casting. Nevertheless, correct indication for treatment is important to avoid sequelae.

Radiocarpal fracture-dislocation: Review of the literature, new classification and decision algorithm.

BACKGROUND: Radiocarpal fractures and dislocations are rarely described in the literature. However, the consequences at the functional level are severe, with the loss of almost half of the articular amplitude. The most widespread classification is that of Dumontier, which divides the injury into two categories according to the presence or absence of a fracture. Currently, no classification considers fracture-dislocations in a global and multi-tissue manner; therefore, no therapeutic strategy has been reported. METHODS: We conducted an exhaustive bibliographic search for cohort or case report articles concerning radiocarpal fracture-dislocations published between 1990 and the present. Only descriptions of the injury were identified (noting the type of fracture, direction of displacement and carpal injuries). RESULTS: In all, data were collected from 14 retrospective series and 16 case reports involving 218 patients. Thirty-five and 183 cases involved anterior and posterior displacement, respectively. A fracture of the distal radius was found in 183 cases and 35 cases had a dislocation only, with no significant fracture. Among the posterior displacements, 44 isolated styloid fractures, 62 styloid and posterior marginal fractures, 29 bimarginal fractures (large anterior fragment and small posterior fragment) and 31 fractures of all the fragments described by Medoff with impaction of the central pavement were found. Anterior displacement fractures were found in 17 cases (styloid and/or anterior marginal fracture). We were able to group the different traumatic clinical forms according to a six-category classification. DISCUSSION: A review of the literature highlighted three major components in the management of radiocarpal fracture-dislocations: the bone component, the ligament component and the associated intracarpal lesions. These three components were included in our classification and allowed us to accurately describe all types of radiocarpal fracture-dislocations published in the literature. Authors currently agree on management of the bone component but disagree on that of the ligament component. Particular attention should be paid to intracarpal lesions, which lead to poor outcomes if ignored. Based on our biographical research, we propose a management plan for these complex injuries. LEVEL OF EVIDENCE: VI.

A Case for Acute Proximal Row Carpectomy for Perilunate Injuries.

Background: Perilunate injuries are complex injuries typically arising from high-energy injuries to the wrist. Standard treatment involves open reduction and internal fixation with ligamentous reconstruction; however, outcomes are fraught with complications including pain, stiffness, and arthrosis. Several case reports have demonstrated the role of proximal row carpectomy as a salvage procedure for complex carpal trauma in the setting of significant cartilage injury or bone loss. The authors believe that proximal row carpectomy may be an appropriate acute treatment in certain patient populations, with functional results similar to those obtained with ligamentous reconstruction. Methods: A retrospective review of two cases with perilunate dislocations managed with primary proximal row carpectomy are presented. Results: At greater than 1-year follow-up, both patients had stable radiocarpal alignment. Quick-DASH scores were 22.7 and 27.3. Conclusion: Primary proximal row carpectomy is a treatment option in the acute setting for perilunate injuries in elderly, lower-demand patients. Functional results are similar to those obtained with ligamentous reconstruction, with a shorter recovery period. Level of Evidence: IV.

Simultaneous Bilateral Chronic Volar Lunate Dislocation: A Case Report.

CASE: A 24-year-old professional judo competitor suffered injuries to both the wrists when he fell on his back while lifting a 90-kg barbell in the bilateral dorsiflexed wrist position. Simultaneous bilateral volar lunate dislocation had been missed for a year. The degenerated lunates were simultaneously removed using a palmar approach. At 12 months postoperatively, the patient returned to judo competitions without pain. Radiography showed no progression of the intercarpal alignment abnormality. CONCLUSION: Simultaneous bilateral chronic volar lunate dislocation is extremely rare. Long-term follow-up is necessary to check for carpal alignment.

Isolated distal pisiform dislocation: Case Report / Luxação distal isolada do pisiforme: Relato de caso

Abstract Isolated pisiform dislocation is a rare lesion with few cases described in the literature. This type of lesion is typically observed in young males and can be easily overlooked at first assessment. Isolated proximal dislocation is more common due to the action of the flexor carpi ulnaris (FCU) muscle. We present the case of a 19-year-old male patient with isolated distal pisiform dislocation after wrist trauma. He underwent open reduction and internal fixation with Kirschner wires with excellent functional outcomes. Although there is no consensual therapeutic method, closed reduction is a first-line treatment for acute presentations. Pisiform open reduction or excision may be performed alternatively or after a failed closed reduction.

Resumo A luxação isolada do pisiforme é uma lesão rara com poucos casos descritos na literatura. Esse tipo de lesão é observado tipicamente em adultos jovens do sexo masculino e pode ser facilmente negligenciada numa primeira avaliação. A luxação proximal isolada é mais comum devido à ação do flexor ulnar do carpo (FUC). Apresentamos o caso de um paciente do sexo masculino, com 19 anos de idade, com luxação distal isolada do pisiforme após traumatismo do punho. O paciente foi submetido a uma redução aberta e fixação interna com fios de Kirschner com excelente resultado funcional. Apesar de não existir um método de tratamento consensual, a redução fechada perfila-se como tratamento de primeira linha na apresentação aguda. Em caso de insucesso ou como método alternativo pode-se optar pela redução aberta ou a excisão do pisiforme.

Ultra-low-dose computed tomography and its utility in wrist trauma in the emergency department.

BACKGROUND: The use and frequency of computed tomography (CT) are increasing day by day in emergency departments (ED). This increases the amount of radiation exposed. PURPOSE: To evaluate the image quality obtained by ultra-low-dose CT (ULDCT) in patients with suspected wrist fractures in the ED and to investigate whether it is an alternative to standard-dose CT (SDCT). MATERIAL AND METHODS: This is a study prospectively examining 336 patients who consulted the ED for wrist trauma. After exclusion criteria were applied, the patients were divided into the study and control groups. Then, SDCT (120 kVp and 100 mAs) and ULDCT (80 kVp and 5 mAs) wrist protocols were applied simultaneously. The images obtained were evaluated for image quality and fracture independently by a radiologist and an emergency medical specialist using a 5-point scale. RESULTS: The effective radiation dose calculated for the control group scans was 41.1 ± 2.1 µSv, whereas the effective radiation dose calculated for the study group scans was 0.5 ± 0.0 µSv. The effective radiation dose of the study group was significantly lower than that of the control group (P < 0.01). The CT images in the study group showed no significant differences in the mean image quality score between observer 1 and observer 2 (3.4 and 4.3, respectively; P = 0.58). Both observers could detect all fractures using the ULDCT images. CONCLUSION: ULDCT provides high-quality images in wrist traumas while reducing the radiation dose by approximately 98% compared to SDCT without any changes in diagnostic accuracy.

Diagnostic Failure Rate in Detecting Perilunate Carpal Fractures and Dislocations Using Plain Wrist X-Rays / Índice de falha diagnóstica na detecção de fraturas e luxações perilunares do carpo utilizando radiografias simples do punho

Abstract Objectives The present study aimed to evaluate the diagnostic failure rate in detecting perilunate fractures and dislocations using plain wrist radiographs by orthopedists and orthopedic residents. A secondary objective was to identify possible groups with a greater or lesser chance of establishing a correct diagnosis. Methods An online questionnaire was sent to several orthopedists through e-mail, social networks, and smartphone-based communication applications to assess the rate of diagnostic failure in detecting perilunate fractures and dislocations using plain radiographs. Results A total of 511 responses was obtained, with a diagnostic error rate of 8.81% for simple dislocations and 1.76% for trans-scaphoid perilunate fractures. Group stratification showed that residents presented the highest error rates in simple perilunate dislocations (23.91%), whereas hand surgeons presented the lowest error rates (1.74%). Conclusion Compared with the literature, the failure rates found were lower, suggesting that plain radiography is effective and that the error rate may not be as high as reported.

Resumo Objetivos O presente estude teve como objetivo avaliar o índice de falha diagnóstica na detecção de fraturas e luxações perilunares do carpo utilizando radiografias simples do punho por ortopedistas e residentes de ortopedia. Secundariamente, identificar possíveis grupos que apresentem maior ou menor chance de acerto diagnóstico. Métodos Foi aplicado um questionário online a diversos ortopedistas através de e-mail, redes sociais e aplicativos de comunicação via smartphone, para avaliar o índice de falha diagnóstica na detecção de fraturas e luxações perilunares utilizando radiografias simples. Resultados Foram obtidas 511 respostas e observado um índice de erro diagnóstico de 8,81% para as luxações simples e 1,76% para fratura transescafoperilunar. Ao estratificar por grupos, os médicos residentes obtiveram os maiores índices de erro nas luxações perilunares simples (23,91%), já os cirurgiões de mão obtiveram os índices mais baixos (1,74%). Conclusão Ao comparar com a literatura, os índices de falha encontrados foram menores, sugerindo que a radiografia simples é eficaz e que o índice de erro pode não ser tão elevado quanto o relatado na literatura.

Treatment of Multiple Coronal Fractures in the Proximal Carpal Row with a Dorsal Distraction Bridge Plate: A Case Report.

Lunate coronal fracture is a rare injury, associated with impact along the capitate and lunate axis; neutralization of this axial force is important for satisfactory patient outcomes. This report presents a case of a 51-year-old man with a lunate coronal fracture associated with coronal fractures in the proximal carpal bones and volar and proximal dislocation of the distal carpal row. Open reduction and internal fixation with a dorsal distraction bridge plate were performed. Solid bony union was achieved at the fracture site and the patient resumed full activities without difficulty. Use of distraction bridge plate fixation can support treating this type of injury, in particular, in cases where the lunate fracture is difficult to treat with conventional osteosynthesis techniques; the presented approach provides good short-term results.

Dual-Layer Detector CT With Virtual Noncalcium Imaging: Diagnostic Performance in Patients With Suspected Wrist Fractures.

OBJECTIVE. The purpose of this study was to evaluate the diagnostic utility of dual-layer CT (DLCT) for evaluating wrist injuries and to compare it with MRI. MATERIALS AND METHODS. The cases of 62 patients with suspected wrist fractures who underwent imaging with both DLCT and MRI from January 2018 through February 2019 were retrospectively reviewed. By means of a calcium suppression algorithm, virtual noncalcium (VNCa) image reconstruction was performed, and the images were reviewed by two readers to identify fractures, bone contusions, and nontraumatic lesions in the radius, ulna, and carpal bones. Sensitivity, specificity, PPV, and NPV were calculated and compared between standard CT and VNCa images with a combination of standard CT and MRI as the reference standard. RESULTS. Use of DLCT with VNCa reconstruction increased the sensitivity of diagnosis of fractures in the radius and carpal bones over that of standard CT alone; occult fractures were detected that were not seen with standard CT. The sensitivity and specificity for detecting radius fracture were 98.1% and 93.8% for DLCT and 96.3% and 93.8% for standard CT. For detecting carpal bone fracture, sensitivity and specificity were 100% and 98.9% for DLCT and 93.8% and 100% for standard CT. VNCa reconstruction also had good diagnostic accuracy with regard to diagnosing nonfracture bone contusions in carpal bones. The accuracy was comparable to that of MRI with sensitivity of 92.9% and specificity of 94.5%. Interreader agreement in interpreting VNCa images was generally good to excellent. CONCLUSION. DLCT with VNCa reconstruction is a promising tool for identifying occult wrist fractures and nonfracture contusion injuries in patients with wrist trauma.

Imaging evaluation of traumatic carpal instability.

PURPOSE: To review the epidemiology, pertinent wrist anatomy, classification system, and emergent imaging evaluation of carpal instability with a focus on radiographic assessment of instability. METHODS: A review of current literature on carpal instability was performed with summary presentation of carpal instability epidemiology, carpal anatomy, imaging evaluation, and classification with imaging evaluation focused on diagnosis in the emergency setting. RESULTS: Carpal instability is a common pathology in falls on outstretched hand and is likely underdiagnosed due to instability being occult or demonstrating subtle malalignment on static imaging of the wrist. While there is a complex network of intrinsic and extrinsic ligaments contributing to carpal instability, a detailed knowledge of these ligaments is not necessary for radiologists to make an accurate diagnosis in the emergency setting, as identification and classification of carpal instability is based on identification of carpal malalignment patterns on radiography as opposed to identification of specific ligament injuries on advanced imaging. The Mayo classification is the most widely used classification system, which divides carpal instability into four categories: dissociative, non-dissociative, complex, and adaptive. Understanding this classification system allows radiologists to successfully classify almost all carpal instability injuries they will encounter, even in the setting of unusual or rare instability patterns. CONCLUSION: In working with the treating clinician, it is essential that the emergency radiologist is comfortable with identifying and classifying carpal instability. This will ensure prompt treatment of seemingly benign injuries and those that require intervention, surgical or otherwise, improving the likelihood of a good outcome.

Imaging of Carpal Instabilities.

BACKGROUND: The term "carpal instability" describes different debilitating wrist conditions, in which the carpus is unable to maintain its physiological range of motion and load transfer. Depending on the cause and location of the dysfunction, four groups can be defined: dissociative, non-dissociative, complex, and adaptive carpal instability. As the most common form by far, dissociative carpal instability can further be categorized as dorsal or palmar intercalated segment instability, contingent on the afflicted interosseous ligament. METHOD: This review article outlines the different entities of carpal instability, their pathophysiology, and their clinical presentation. It further discusses the diagnostic significance of different imaging methods as well as the established treatment options for each form of instability in context with the current literature. RESULTS AND CONCLUSION: Early detection and treatment of carpal instability are essential for preventing carpal osteoarthritis. Traumatic lesions of the scapholunate interosseous ligament are the most frequent cause of instability. They can occur in an isolated fashion or in context with other carpal injuries. While stress imaging and fluoroscopy facilitate the differentiation between dynamic and static forms of carpal instability, only MRI and CT/MR arthrography can directly reveal the extent of ligament discontinuity. KEY POINTS: · Carpal instability can manifest only in motion (dynamic) or at rest (static).. · Dissociative forms must be distinguished from non-dissociative, adaptive, or complex entities.. · Most instabilities are related to traumatic injuries or CPPD arthropathy.. · Fluoroscopy, stress imaging, and MR and CT arthrography are helpful for diagnosis.. CITATION FORMAT: · Grunz JP, Gietzen CH, Grunz K et al. Imaging of Carpal Instabilities. Fortschr Röntgenstr 2021; 193: 139 - 150.

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.

Carpal Fractures Other than Scaphoid in the Athlete.

Carpal fractures of bones other than the scaphoid occur at a much lower rate than scaphoid fractures. The close relationship between the carpus, intrinsic and extrinsic wrist ligaments, and wrist kinematics makes a thorough history, clinical examination, and interpretation of imaging for carpal malalignment essential. Carpal malalignment should be addressed with reduction and fixation. Nondisplaced fractures are often treated nonoperatively and displaced intraarticular fractures are almost always treatment operatively. The physician should keep in mind the athlete's specific goals and needs. Treatment must be individualized. Options for early return to play should be discussed when possible.

Hand and Wrist Injuries in the Pediatric Athlete.

This article examines the most common problematic hand and wrist injuries in the pediatric athlete. Hand and wrist injuries in the growing skeleton pose a different diagnostic and therapeutic challenge than in the mature skeleton. Ligaments are stronger than bone, and unossified cartilaginous sections of the skeleton are yet more susceptible to injury than bone. Although remodeling can correct for even moderate deformities if sufficient growth potential exists, remodeling cannot return the child to normal anatomy in many cases. Remodeling depends on intact periosteum, a nearby growing physis, and competent ligaments to direct remodeling via Hueter-Volkmann and Wolff's laws.

Fivefold Fracture in a Perilunate Fracture Dislocation Involving Scaphoid, Capitate, Hamate, Triquetrum and Lunate: A Case Report.

This case report presents a very rare fracture combination in a perilunate dislocation including the scaphoid, capitate, hamate and triquetrum and the cornu anterior of the lunate, with an intact scapholunate ligament in a left wrist. An open reduction and internal fixation of the scaphoid, capitate, hamate and triquetrum was performed.

Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update.

BACKGROUND: The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures. METHODS: A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies. RESULTS: Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13-98%, 55-73%, 14-73% and 75-100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13-89%, 45-76%, 41-77% and 63-75%, respectively. Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79-100%, 49-100% and 86-97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78-100%, 70-100%, 79-100% and 70-100%, respectively. CONCLUSIONS: Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures.