Three-dimensional comparison of alternative screw positions versus actual fixation of scaphoid fractures.

PURPOSE: The recommended technique for the fixation of a scaphoid waist fracture involves a headless compression screw placed in the proximal fragment center. This is usually accomplished by placing a longitudinal axis screw as visualized by fluoroscopy. The screw length has been shown to have a biomechanical advantage. An alternative to these options, which has been debated in the literature, is a screw placed perpendicular to the fracture plane and in its center. The perpendicular screw may have a biomechanical advantage despite the fact that it may be shorter. This study examined the differences in location and length in actual patients between a screw in the center of the proximal fragment with a longitudinal axis screw, and the actual fixating screw. These were then compared to a perpendicular axis screw. METHODS: Pre- and post-operative CT scans of 10 patients with scaphoid waist fractures were evaluated using a 3D computer model. Comparisons were made between the length, location and angle of actual and virtual screw alternatives; namely, a screw along the central third of the proximal fragment (central screw axis) where the scaphoid longitudinal axis was calculated mathematically (longitudinal screw axis) and a screw placed at 90° to the fracture plane and in its center (perpendicular screw axis). RESULTS: The longitudinal axis screw was found to be significantly longer than the other axes (28.3mm). There was a significant difference between the perpendicular axis screw and the location and angle of the other screw axis, but it was only shorter than the longitudinal screw (23.6mm versus 25.5mm for the actual screw; ns.). CONCLUSIONS: A computed longitudinal axis screw is longer than a central or actual screw placed longitudinally by visual inspection by the surgeon. Although it needs to be placed using computer assisted (CAS) techniques, it may have the biomechanical advantages of a longer screw in a similar trajectory. The perpendicular screw was found to be significantly different in position and angle but not shorter than the actually placed screw. It has biomechanical advantages and does not require visualization with CAS methods, making it the more attractive alternative.

[STENOSING FLEXOR TENOSYNOVITIS - COMMON PRACTICE OF FAMILY PHYSICIANS, ORTHOPEDIC AND HAND SURGEONS].

BACKGROUND: The trigger finger is a common condition of the hand that is treated by family physicians, orthopedic and hand surgeons. The patients suffer from pain, triggering of the finger and may develop a flexion contracture of the finger, causing significant functional limitations. AIM: The objectives of this study were to evaluate factors involved in the diagnosis and treatment of this condition, as well as the differences in treatment between specialists. METHODS: The different specialists were asked to rate the importance of symptoms, examination and imaging studies regarding the decision to refer a patient for surgery as well as suggest the treatment of a hypothetical patient complaining of typical symptoms. RESULTS: In the 158 questionnaires collected, the complaint of limited finger range of motion and previous treatment were rated most important. Family physicians stated that age, occupation and rate of recent triggering were considered to be additional important factors (p=.0003). In comparison with hand surgeons, family physicians reported localized tenderness as important, and the need for passive release of the finger locked in flexion as less important (p=.0003). Family physicians were more likely to treat with NSAID [p= 0.0002), orthopedic surgeons with steroid injections (p=0.0004 and hand surgeons with surgery (p=0.0001). CONCLUSIONS: According to this survey, we found differences in the acquaintance of physicians of different backgrounds with the clinical staging of trigger finger, specifically, the significance of finger contracture and indications for surgery. This information may guide training of physicians in all fields.

Management of pelvic fractures during pregnancy.

Pelvic or acetabular fractures during pregnancy are rare, and information on managing such complex incidents has been limited. Over several years, we have gained significant experience in handling such cases. Of the 1345 pelvic and acetabular fractures treated at our level I trauma center between 1987 and 2002, 15 (1.1%) occurred in pregnant women. Eleven women received conservative treatment, and 4 were treated surgically. Of the 16 fetuses, 12 survived, and 4 pregnant women had nonviable pregnancies. One of the 15 pregnant women died. We describe our cases and propose treatment guidelines. The dilemma presented in a multitrauma situation at various stages of pregnancy necessitates making management modifications involving timing of surgery and delivery, use of radiation for imaging, and choice of appropriate surgical procedure.