Treatment of AVN-Induced Proximal Pole Scaphoid Nonunion Using a Fifth and Fourth Extensor Compartmental Artery as a Vascularized Pedicle Bone Graft: A Retrospective Case Series.

BACKGROUND Scaphoid nonunion (SN) is a challenging condition in wrist pathology, often resulting in severe consequences if left untreated. Surgical intervention, particularly using vascularized bone grafts (VBGs), is a promising but uncertain approach. The 4+5 extensor compartment artery (ECA) pedicled graft, less commonly used for SN, has potential benefits due to its vascular supply and accessibility to the scaphoid. This study aimed to evaluate the effectiveness of the 4+5 ECA pedicled graft combined with headless compression screw fixation in treating avascular necrosis (AVN)-induced proximal pole SN. Radiological results, functional outcomes, and complications related to this method were assessed. MATERIAL AND METHODS This was a retrospective analysis of 19 proximal pole SN cases with AVN treated using the 4+5 ECA-VBG technique from 2016 to 2022. Patients underwent preoperative evaluation and postoperative follow-up for at least 1 year. Data on surgery, demographics, radiological assessments, and functional outcomes were recorded and analyzed statistically. RESULTS All patients achieved radiographic union within 8.5 weeks postoperatively, with revascularization of proximal pole necrosis. Significant improvements in functional outcomes were observed, including pain reduction, increased wrist range of motion, improved grip and pinch strength, and enhanced wrist scores. No major complications were reported. CONCLUSIONS The 4+5 ECA-VBG technique, with headless compression screw fixation, showed high success rates in treating AVN-induced proximal pole SN. This method offers comprehensive restoration of wrist function and minimal complications, making it a viable option for SN management, especially in AVN cases. Further research is needed to confirm these results and establish standardized protocols for SN treatment.

A comparative study of volar locking-plate fixation with corticocancellous and pure cancellous bone grafts for scaphoid nonunion with dorsal intercalated segmental instability secondary to scaphoid humpback deformity.

INTRODUCTION: Bone grafts for scaphoid nonunion with deformity include cortcicocancellous or pure cancellous bone grafts. This study compared the outcomes between two types of bone grafts when employing a volar locking-plate in patients with scaphoid nonunion with dorsal intercalated segmental instability (DISI). PATIENTS AND METHODS: This retrospective study included 34 patients with scaphoid nonunion and DISI due to humpback deformity treated between March 2017 and January 2022. Two types of bone grafts were obtained from iliac crest. Twenty of the corticocancellous (CC) group underwent a wedge-shaped graft, while 14 patients of the pure cancellous (C-only) group received graft chips. In both groups, a 1.5-mm anatomically pre-contoured locking plate was used for fixation. Radiographic evaluations included the union rate and carpal alignment including scapholunate angle (SLA), radiolunate angle (RLA), intrascaphoid angle (ISA) and scaphoid height to length ratio (HLR). Clinical assessments encompassed wrist range-of-motion, grip strength, and patient-reported outcomes. RESULTS: Nineteen of the 20 patients in the CC group and 12 of the 14 patients in the C-only group respectively, achieving osseous union. The mean follow-up period in CC group was 14.7 (range, 12 ∼ 24) months and that in C-only group was 12.6 (range, 12 ∼ 15) months. Postoperatively, there were no significant intergroup differences of radiographic parameters including SLA (CC; 49.9° ± 6.7° vs. C-only; 48.9° ± 3.5°, P = 0.676), RLA (1.7° ± 6.4° vs. 2.4° ± 3.3°, P = 0.74), ISA (36° ± 7.5° vs. 36.6° ± 12.2°, P = 0.881), and HLR (0.54 ± 0.09 vs. 0.53 ± 0.05, P = 0.587). Clinical outcomes, including the flexion-extension arc (137° ± 30° vs. 158° ± 33°, P = 0.122), grip strength (93.4 % ± 15.4% vs. 99.5 % ± 16.7 %, P = 0.39), Quick Disabilities of the Arm, Shoulder, and Hand scores (11.2 ± 8.3 vs. 12.5 ± 7.7, P = 0.74) and Mayo Wrist Scores (81.2 ± 13.1 vs. 89 ± 11.4, P = 0.242) also showed no significant intergroup differences. CONCLUSIONS: Volar locking-plate fixation with pure cancellous bone grafts achieved outcomes comparable to those achieved with corticocancellous bone grafts in scaphoid nonunion with deformity, possibly due to the biomechanical advantages of the volar plate to provide structural supports.

Proximal row carpectomy versus four-corner arthrodesis: a retrospective comparative study.

BACKGROUND: Four-corner arthrodesis with scaphoid excision (FCA) and proximal row carpal resection (PRC) are frequently performed in wrists with post-traumatic Scaphoid Non- Union Advanced Collapse (SNAC)/Scapho-Lunate Advanced Collapse (SLAC) osteoarthritis. The aim of this study was to compare the clinical outcomes of these two procedures. METHODS: This single-center, retrospective cohort study included all patients who had PRC or FCA between January 1st, 2009 and January 1st, 2019 and who were followed up. Follow-up included: mobility (radial deviation, ulnar deviation, flexion, extension), strength (grip test, pinch test), function (QuickDash, patient-rated wrist evaluation [PRWE]), subjective mobility, and global satisfaction scores. RESULTS: Among 25 patients included, 11 had PRC and 14 had FCA with a mean follow-up of 69.5 months [12-132]. Radial deviation was 18° versus 14° (p = 0.7), ulnar deviation was 21° versus 22° (p = 0.15), flexion was 39° versus 30° (p = 0.32), extension was 32.5° versus 29.5° (p = 0.09), grip test compared to the controlateral side was 72% versus 62% (p = 0.53), Quick Dash score was 12.5 versus 17.6 (p = 0.84), PRWE was 18.7 versus 17.6 (p = 0.38), subjective mobility was 7.8 versus 7.5 (p = 0.23), and satisfaction score was 8.7 versus 9 (p = 0.76), respectively, in the FCA group and the PRC group. Re-operation rates were 14% patients in the FCA group and 0% in the PRC group. CONCLUSION: This study found no significant difference between FCA and PRC on strength, mobility, and function in patients with post-traumatic SLAC or SNAC stage II wrist arthritis. Both FCA and PRC seem to be reliable surgical techniques with good outcomes with more revision in the FCA group.

Retrospective analysis of scaphoid trapezium pyrocarbon implant intervention in STT arthritis: a 3-year follow-up study.

AIM: The purpose of this study was to evaluate clinical, patient rated and radiological outcome of the scaphoid trapezium pyrocarbon implant (STPI) at a minimum of three years follow-up. METHODS: Consecutive patients operated with the STPI due to scaphotrapeziotrapezoidal (STT) arthritis between 2012 and 2019 were included. Patients were evaluated preoperatively and annually after surgery for range of motion, grip strength, key pinch, quick-DASH, pain, and satisfaction. Radiographs were evaluated for implant position, signs of dorsal intercalated segment instability (DISI), capitolunate (CL) angle, scapholunate (SL) distance, and presence of osteophytes. RESULTS: Twenty-six patients (29 implants) were included. Seven implants were revised during the follow up, mainly due to pain: three implants were removed, four patients received a new STPI of a different size, leaving 22 implants in 20 patients available for follow up, 9 males and 11 females. Median age was 61.7 years (51-78 years). Median follow-up time was 68 months (37-105 months). Comparing preoperative status to the last follow-up, wrist extension and deviation, thumb abduction, and grip strength did not change. Key Pinch, quick DASH, pain, and patient satisfaction improved significantly at last follow-up. Radiographic signs of DISI were seen in six cases preoperatively and in 12 cases at last follow-up. CONLUSION: At a minimum of three years follow-up, the STPI used for STT-arthritis improve pain, quick-DASH result, and patient satisfaction significantly. ROM and grip strength did not change compared to preoperative values. Radiographic signs of carpal instability were common at the follow-up and the revision rate was high.

Capitate Proximal Fragment Migration Compressing the Median Nerve in Scaphocapitate Fracture: A Case Report.

BACKGROUND Scaphocapitate syndrome is a rare clinical entity consisting of a combined scaphoid and capitate fracture along with a 90- or 180-degrees rotation of the proximal capitate fragment. The syndrome is scarcely described in the literature, with proximal migration of the capitate fragment being reported only by Mudgal et al in 1995. Concurrent compression of the median nerve is a highly unfortunate event, suggesting a unique case presented here. CASE REPORT We present a unique case of scaphocapitate fracture-dislocation in a 25-year-old man with volar dislocation of the capitate's fragment deep to the median nerve. X-rays and CT scan were performed and the patient was treated few hours after the injury by a hand specialist, in order to prevent median neuropathy and avascular necrosis of the fragment. Open reduction and internal fixation utilizing a Herbert screw for the scaphoid fracture and 3 additional K-wires was performed. Immediately post-operatively, the acute neurological symptoms had subsided and good reduction was acquired radiologically. One year post-operatively the patient had regained good hand and wrist functionality, with no extension or flexion ROM deficits. CONCLUSIONS Immediate intervention in a specialized center with reduction and fixation utilizing a Herbert screw and K-wires showed favorable 1-year results in our case of scaphocapitate syndrome. The impending complications of median neuropathy and capitate avascular necrosis were avoided despite the high-risk injury pattern.

The rate of nonunion in the MRI-detected occult scaphoid fracture.

Aims: There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods: This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results: A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion: MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients.

Clinical Features and Classification of Proximal Carpal Fracture Dislocation Through the Radiocarpal Joint.

Background: The most common types of wrist dislocation are trans-scaphoid lunate dislocation (TLD) and trans-scaphoid perilunate dislocation, in which the lunate and proximal scaphoid are dislocated through the midcarpal joint. There is another rare type of dislocation in which the proximal carpi are dislocated through the radiocarpal joint. The purpose of this study is to examine the clinical features of this type of dislocation. Methods: Six cases of the proximal carpal fracture dislocation via the radiocarpal joint were retrospectively reviewed. All patients underwent open reduction and internal fixation with the ligament reconstruction. A Mayo wrist score was assigned to each patient based on the assessment of pain, functional status, range of motion and grip strength at the last follow-up. Clinical subjective evaluation of function and pain was assessed using the patient-rated wrist evaluation (PRWE) method. Results: All patients were male and injured with a median age of 33.5 years. The median follow-up period was 10 months. There were three types of dislocations: Scaphoid fracture dislocation, TLD and scaphoid-lunate dislocation. All patients had satisfactory results with an average PRWE of 7.2 ± 4.7. The preoperative VAS was 6.7 ± 1.0 and the postoperative VAS was 0.7 ± 0.7 (p < 0.01). Postoperative grip strength accounted for 89.2% ± 9.8% of the contralateral side; the Mayo wrist score averaged 90.0 ± 6.5, with four patients obtaining excellent and two good results. Conclusions: Fracture dislocation of the proximal carpal bones through the radiocarpal joint is an independent type of wrist dislocation that tends to occur in young men with high-energy impact. The wrist is most often injured in a pronation hyperextension position. If treatment is timely and appropriate, the prognosis is quite good. Level of Evidence: Level IV (Therapeutic).

Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review.

PURPOSE: To review the existing literature to (1) determine the diagnostic efficacy of artificial intelligence (AI) models for detecting scaphoid and distal radius fractures and (2) compare the efficacy to human clinical experts. METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried for studies investigating the development, validation, and analysis of AI for the detection of scaphoid or distal radius fractures. Data regarding study design, AI model development and architecture, prediction accuracy/area under the receiver operator characteristic curve (AUROC), and imaging modalities were recorded. RESULTS: A total of 21 studies were identified, of which 12 (57.1%) used AI to detect fractures of the distal radius, and nine (42.9%) used AI to detect fractures of the scaphoid. AI models demonstrated good diagnostic performance on average, with AUROC values ranging from 0.77 to 0.96 for scaphoid fractures and from 0.90 to 0.99 for distal radius fractures. Accuracy of AI models ranged between 72.0% to 90.3% and 89.0% to 98.0% for scaphoid and distal radius fractures, respectively. When compared to clinical experts, 13 of 14 (92.9%) studies reported that AI models demonstrated comparable or better performance. The type of fracture influenced model performance, with worse overall performance on occult scaphoid fractures; however, models trained specifically on occult fractures demonstrated substantially improved performance when compared to humans. CONCLUSIONS: AI models demonstrated excellent performance for detecting scaphoid and distal radius fractures, with the majority demonstrating comparable or better performance compared with human experts. Worse performance was demonstrated on occult fractures. However, when trained specifically on difficult fracture patterns, AI models demonstrated improved performance. CLINICAL RELEVANCE: AI models can help detect commonly missed occult fractures while enhancing workflow efficiency for distal radius and scaphoid fracture diagnoses. As performance varies based on fracture type, future studies focused on wrist fracture detection should clearly define whether the goal is to (1) identify difficult-to-detect fractures or (2) improve workflow efficiency by assisting in routine tasks.

Reasons for scaphoid non-union: Analysis of behavior of health care providers and patients.

To assess factors related to health-system and patient behavior in scaphoid fracture non-union, a retrospective analysis of 134 patients treated by scaphoid reconstruction was performed. Mean age at the accident was 26 years (range, 9-75 years), and the mean age at surgery was 28 years (range, 13-75 years). Mean time to first consultation was 233 days (range, 0-12,136 days), and time to surgery 740 days (range, 19-12,362 days). The physician was mainly a general practitioner (52.2%), or an orthopedist/traumatologist (17.9%), general surgeon (12.7%), or hand surgeon (17.2%). The initial diagnostic procedure was X-ray in 76.9% of cases, computed tomography (CT) in 20.9%, magnetic resonance imaging (MRI) in 13.4%, and none in 11.2%. A fracture was diagnosed in 32.8% of cases, and non-union in 14.9%. Patients mainly presented late: 63% within 3 weeks, and a minority on the day of the accident (39%). In 11% of cases, healthcare providers performed either no or inadequate imaging (77%) and missed correct diagnosis in 52% of cases. 128 patients had a second consultation, and 77 a third, with the same or different physicians, before surgery, leading to increased healthcare costs due to delayed diagnosis and treatment. Delayed presentation and lack of suspicion by attending physicians were the main reasons. Speeding up diagnosis and improving physician training are vital and could significantly reduce health care costs. CT or MRI should be performed if scaphoid fracture is suspected.

A comparative study of image quality and diagnostic confidence in diagnosis and follow-up of scaphoid fractures using photon-counting detector CT and energy-integrating detector CT.

PURPOSE: Scaphoid fractures in patients and assessment of healing using PCD-CT have, as far as we know, not yet been studied. Therefore, the aim was to compare photon counting detector CT (PCD-CT) with energy integrating detector CT (EID-CT) in terms of fracture visibility and evaluation of fracture healing. METHOD: Eight patients with scaphoid fracture were examined with EID-CT and PCD-CT within the first week post-trauma, and with additional scans at 4, 6 and 8 weeks. Our clinical protocol for wrist examination with EID-CT was used (CTDIvol 3.1 ± 0.1 mGy, UHR kernel Ur77). For PCD-CT matched radiation dose, reconstruction kernel Br89. Quantitative analyses of noise, CNR, trabecular and cortical sharpness, and bone volume fraction were conducted. Five radiologists evaluated the images for fracture visibility, fracture gap consolidation and image quality, and rated their confidence in the diagnosis. RESULTS: The trabecular and cortical sharpness were superior in images obtained with PCD-CT compared with EID-CT. A successive reduction in trabecular bone volume fraction during the immobilized periods was found with both systems. Despite higher noise and lower CNR with PCD-CT, radiologists rated the image quality of PCD-CT as superior. The visibility of the fracture line within 1-week post-trauma was rated higher with PCD-CT as was diagnostic confidence, but the subsequent assessments of fracture gap consolidation during healing process and the confidence in diagnosis were found equivalent between both systems. CONCLUSION: PCD-CT offers superior visibility of bone microstructure compared with EID-CT. The evaluation of fracture healing and confidence in diagnosis were rated equally with both systems, but the radiologists found primary fracture visibility and overall image quality superior with PCD-CT.

3D printed guide-assisted percutaneous screw fixation for minimally displaced scaphoid waist fractures with delayed diagnosis or presentation.

OBJECTIVES: To Investigate the value of 3D printed guide-assisted percutaneous management of minimally displaced scaphoid waist fractures(Herbert's B2) with delayed diagnosis or presentation. METHODS: From October 2018 to February 2022, 10 patients with established delayed diagnoses and presentation of minimally displaced scaphoid waist fractures were treated with 3D printed guides assisted with percutaneous internal fixation without bone grafting. This technique was based on the patient's preoperative CT and imported into the software. Based on Boolean subtraction, the most centralized screw placement position was identified and a customized guide was produced. Intraoperative percutaneous insertion of the guide wire was assisted by the custom guide. RESULTS: All 10 patients were successful in one attempt. The fractures healed at a mean of 7.7 weeks postoperatively (range 6-10 weeks). At a mean follow-up of 7.7 months (6-13 months), patients had excellent recovery of wrist function with minimal pain reduction. There were no major postoperative complications and the patients all returned to their previous activities before the injury. CONCLUSIONS: Percutaneous internal fixation based on 3D printed guides is a safe and effective technique for delayed diagnosis or presentation of patients with minimally displaced fractures of the scaphoid waist. This method allows for easy insertion of screws and avoids multiple attempts.

Scaphoid proximal pole ejection in perilunate injury: a case report and pathophysiological hypothesis.

Isolated ejection of the scaphoid proximal pole in perilunate injuries is rare, with only 4 reports in the literature, and does not correspond to the biomechanical situations in the Herzberg or Mayfield classifications. Bone ejection incurs a risk of avascular necrosis despite good osteosynthesis, notably because of precarious vascularization. We present a case of scaphoid proximal pole ejection and a theoretical hypothesis of the biomechanics of this injury. LEVEL OF EVIDENCE: 4.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparison of corticocancellous bone graft from the anterolateral metaphysis of the distal radius versus iliac crest for the treatment of unstable scaphoid nonunion with humpback deformity.

BACKGROUND: Corticocancellous bone grafting from the iliac crest is acceptable treatment for unstable scaphoid nonunion with a viable proximal pole. However, harvesting graft from the iliac crest is associated with donor site morbidity and the requirement of general anesthesia. Thus, bone grafting from the anterolateral metaphysis of the distal radius (DR) can be a treatment option. However, no study has compared the clinical effect between the two grafting techniques. METHODS: From 2014 to 2019, patients with unstable scaphoid nonunion with humpback deformity underwent corticocancellous bone grafting from the anterolateral metaphysis of the DR (group DR) or iliac crest (group IC). Humpback deformity was determined by evaluating the scapholunate angle (SLA) ≥ 60°, intrascaphoid angle (ISA) ≥ 45°, and radiolunate angle (RLA) ≥ 15° from preoperative radiographs and computed tomography scans. The SLA, ISA, and RLA served to gauge carpal alignment. The operative time, grip strength, active range of motion (ROM), the Modified Mayo Wrist score (MMWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score were assessed postoperatively. RESULTS: Thirty-eight patients qualified for the study (group DR, 15; group IC, 23). Union rates did not differ by patient subset (group DR, 100%; group IC, 95.7%; P = .827), and grip strength, ROM, MWS, and DASH score were similar between groups at the last follow-up. The operative time (minutes) was significantly shorter in group DR (median, 98; quartiles, 80, 114) than in group IC (median, 125; quartiles, 105, 150, P < .001). The ISA, RLA, and SLA improved postoperatively in both groups (P < 0.001). The degree of restoring carpal alignment, as evaluated by SLA, showed superior correction capability in group DR (median, 25.3% quartiles, 21.1, 35.3, P < 0.05). Donor site complications were not significantly different between the groups. CONCLUSIONS: Corticocancellous bone graft from the anterolateral metaphysis of the DR for unstable scaphoid nonunion is associated with a shorter operation time and comparable results with that from the iliac crest in regard to union, restoration of carpal alignment, and wrist function. LEVEL OF EVIDENCE: Level III.

Tripolar Dislocation: Elbow Terrible Triad-Essex-Lopresti Injury-Trans-scaphoid Perilunate Dislocation: A Case Report.

CASE: A 23-year-old man presented with a right upper limb injury after a 10-m fall. Initial evaluation demonstrated a terrible triad elbow injury associated with a trans-scaphoid perilunate dislocation. Elbow stabilization with radial head replacement and carpal fixation was performed. Radiographs on postoperative day 7 demonstrated an ipsilateral Essex-Lopresti injury, which had been initially missed, and revision surgery was performed to reconstruct the interosseous membrane. CONCLUSION: Surgeons should maintain a high degree of suspicion for an ipsilateral Essex-Lopresti injury in patients with a terrible triad elbow fracture-dislocation in combination with a trans-scaphoid perilunate dislocation. Both preoperative imaging, including the contralateral side, and intraoperative evaluation are recommended to rule out longitudinal instability of the forearm in the setting of combined wrist and elbow fracture-dislocations.

Scapholunate Ligament Rupture and Coincident Fracture Proximal Pole Scaphoid Presenting Late with Osteonecrosis: A Rare Case Report with Unique Management.

CASE: A 29-year-old young active man with ununited necrosed proximal fifth of scaphoid with chronic scapholunate ligament disruption was managed by excision of proximal pole fragment and interosseous scapholunate reconstruction using modified Brunelli triple ligament tenodesis technique with satisfying outcome at 6 months and return to sports instructor job by the end of 1 year. CONCLUSION: Meticulous understanding and algorithmic itemwise approach of injury components can lead to optimal management of complex unstable wrist injuries such as scapholunate dissociation. To the best of our knowledge, this is the first report on excision of proximal pole of scaphoid coupled with scapholunate ligament reconstruction.

Approach to chronic wrist pain in adults: Review of common pathologies for primary care practitioners.

OBJECTIVE: To develop an approach for identifying, investigating, and initially managing common causes of chronic wrist pain seen by primary care practitioners. SOURCES OF INFORMATION: Relevant clinical evidence and literature were identified using the PubMed database. MAIN MESSAGE: Chronic wrist pain is a common presentation in the primary care setting. The complex anatomy of the wrist leads to a broad differential diagnosis. Elements of history, findings of physical examinations and investigations, and management relevant to the following pathologies are discussed, including scaphoid fracture nonunion, thumb carpometacarpal joint osteoarthritis, scapholunate ligament instability, triangular fibrocartilage complex injuries, de Quervain tenosynovitis, extensor carpi ulnaris tendinopathy, carpal tunnel syndrome, and ganglion cysts. When evaluating chronic wrist pain, diagnostic imaging with x-ray scans can serve as an important ancillary investigation tool but should not override clinical suspicion. Advanced imaging (computed tomography or magnetic resonance imaging) is generally best ordered by a hand surgeon when it will help clarify a diagnosis and guide treatment. CONCLUSION: Chronic wrist pain is a functionally limiting problem best managed with timely diagnosis and treatment. A thorough history and physical examination are the cornerstones of an effective evaluation. When diagnosis is delayed, some wrist pathologies can lead to relatively poor outcomes, such as a scaphoid fracture nonunion resulting in diffuse wrist osteoarthritis.

Subchondral Radial and Ulnar K-Wire Positioning With Cancellous Bone Graft Shortens Union Time in Scaphoid Waist Nonunion.

BACKGROUND: Bone grafting in patients with scaphoid waist nonunion can present several technical challenges. In this study, we aimed to present a modified surgical technique for scaphoid waist nonunion, which consisted of subchondral radial and ulnar K-wires positions with cancellous bone graft, and to compare the clinical outcome of this modified technique with the conventional method. METHODS: We retrospectively reviewed 72 patients with scaphoid waist nonunion who had been surgically treated between January 2011 and December 2020. Of these, 34 patients were treated with the modified method and 38 with the conventional method. Debridement of the nonunion site was performed using a curette, rongeur, and microburr. Two or 3 K-wires were inserted along the cancellous portion of the scaphoid in the conventional method. In the modified method, 2 K-wires were inserted along the ulnar and radial subchondral portion of the scaphoid to increase the space for bone grafting in the cancellous portion of the scaphoid. The autologous cancellous bone grafted in both the methods. Demographic, radiological, and clinical outcomes were reviewed and compared between the groups. RESULTS: There were no significant differences in demographics and characteristics of nonunion between the 2 groups of patients. The modified method group showed significantly shorter union time than the conventional method group (conventional group: 13.0 ± 1.3 weeks, modified group: 11.4 ± 1.1 weeks; P < 0.001). The bony union rate was 97.1% for the modified method and 89.5% for the conventional method. Satisfactory clinical outcomes (excellent and good Mayo wrist scores) were achieved in 27 cases (81.8%) using the modified method and 22 cases (64.7%) using the conventional method. CONCLUSION: Subchondral radial and ulnar K-wire positioning with cancellous bone graft (modified method) can improve the union time with satisfactory clinical outcomes in the treatment of scaphoid waist nonunion.

Clinically Significant Treatment Delay in Pediatric Scaphoid Fractures.

PURPOSE: Pediatric scaphoid fractures present to treatment in a delayed manner 8% to 29% of the time. The indications for cast immobilization in this population are not clear. The definition of a clinically important treatment delay is based only on anecdotal reports. Successful treatment with a cast may be more desirable than surgical intervention. However, it remains unclear what clinical and radiographic factors may predict success with casting. METHODS: A retrospective analysis of all scaphoid fractures treated at a single pediatric hospital was performed to identify fracture characteristics, the presence of cystic change, treatment method, and healing rate. A cut-point analysis was performed to determine the number of days of treatment delay, predictive of casting failure. Kaplan-Meier assessments were performed to determine the differences in time in cast. Characteristics of the delayed group were described and stratified by treatment success or failure. RESULTS: After review, 254 patients met the inclusion criteria. Cut-point analysis determined that a presentation delay of ≥21 days was associated with failure to unite with casting. The median time in the cast for the acute and delayed groups was not significantly different. The casting union rate of delayed fractures was less than acute fractures (75.0% vs 97.0%). CONCLUSIONS: Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure; however, the union rate remains high with comparable time in cast. Cast immobilization for scaphoid fractures presenting 21 days or more after injury is a reasonable option. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Radiographic evaluation of radial flexion osteotomy effect on static scapholunate instability: a preliminary cadaveric study.

INTRODUCTION: The optimal treatment of chronic scapholunate instability has yet to be established. Scapholunate ligament grafts are still far from being the ideal solution. We conducted an experimental study to evaluate whether flexion-opening wedge osteotomy of the distal radius improves misalignment and avoids rotatory subluxation of the scaphoid in a cadaveric model of static scapholunate dissociative instability. MATERIALS AND METHODS: Radiographic studies were performed on 15 cryopreserved specimens after recreating a model of scapholunate instability by division of the scapholunate interosseous ligament (SLIL) and secondary stabilizers, taking radiographs at baseline, after the instability model, and after distal radius osteotomy. Static and dynamic (under controlled tendon traction) anteroposterior and lateral views were obtained to measure the length (in mm) of the carpal scaphoid and scapholunate interval, scapholunate angle, radio-lunate angle, and palmar tilt of the distal joint surface of the radius and to measure the dorsal scaphoid translation by the concentric circles method. The Wilcoxon test was used for statistical comparisons. RESULTS: The scapholunate interval was significantly decreased after osteotomy in all static anteroposterior views and in all lateral views under tendon traction. Dorsal scaphoid translation was significantly reduced in static lateral view in extension and in dynamic lateral view under 5-pound flexor carpi radialis tendon tension controlled by a digital dynamometer. CONCLUSIONS: Flexion-addition osteotomy of the distal radius appears to improve carpal alignment parameters in a cadaveric model of static scapholunate instability, achieving similar values to those obtained before instability.