Trapezoidal fractures: Overview and introduction of a novel diagnostic classification system.

INTRODUCTION: Trapezoidal fractures account for only 0.4% of all carpal bone fractures. Owing to their rarity, there is paucity in the literature regarding the clinical findings and treatment. This paper aims to summarize the current understanding of trapezoidal fractures and present a novel classification algorithm. METHODS: A diagnostic classification algorithm was created based on the known blood supply and ligamentous attachment of the trapezoid. The proposed treatment algorithm was then applied to trapezoidal fractures in the literature to validate the algorithm and determine whether patients received treatment that was in accordance. RESULTS: A total of 19 articles, representing 22 trapezoidal fractures were included, with two additional cases presented by the authors. Presenting symptoms were pain (n = 21) and swelling (n = 12). Diagnosis was made on CT in a majority of the time, 79.2% (n = 18). All outcomes were favorable with symptomatic resolution and full range of motion after treatment, except in four patients that had co-existing wrist injuries. When the algorithm was applied, 89.5% (n = 17) of the patients received treatment in accordance with the proposed algorithm and demonstrated good outcomes. In the remaining patients (n = 2) whose treatment differed, one had diminished grip strength and the other was lost to follow-up. CONCLUSIONS: Given a degree of clinical suspicion including a history of blunt trauma to the hand and persisting pain, trapezoidal fractures should remain on the differential when plain radiographs fail to identify any fracture. Operative treatment is suggested if there is any significant displacement, compromise of the dorsal surface, or breech of the trapezoidal ligaments causing possible dislocation. LEVEL OF EVIDENCE: IV - Diagnostic.

Collapsed scaphoid non-union with dorsal intercalated segment instability and avascular necrosis treated by vascularised wedge-shaped bone graft and fixation.

Patients with the specific problem of a collapsed Nakamura volar type, scaphoid synovial pseudarthrosis with avascular necrosis on both magnetic resonance imaging and intraoperative inspection were studied to determine the ability of a trapezoidal wedge-shaped structural bone graft vascularised by the 1,2 intercompartmental supraretinacular artery to simultaneously achieve correction of the scaphoid dimension and a high union rate. Fifteen patients with this specific problem were followed for a mean of 32.1 months and achieved union in all cases at a mean of 11.5 weeks. Improvements were seen postoperatively in wrist flexion and extension, grip strength, degree of dorsal intercalated segment instability and degree of scaphoid collapse. Two complications relating to the fixation technique occurred. Although technically difficult, it is possible to achieve a high rate of union for scaphoid pseudarthrosis while correcting substantial collapse deformity by the use of a structural, wedge-shaped, vascularised bone graft.