The Conservative and Operative Treatment of Carpal Fractures.

BACKGROUND: Carpal fractures (incidence: 30-60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones. METHODS: This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV). RESULTS: The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2-4 weeks) than with conservative treatment (6-8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobilization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available evidence is limited to expert consensus. CONCLUSION: Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.

The Treatment of Closed Finger and Metacarpal Fractures.

BACKGROUND: Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures. METHODS: This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature. RESULTS: The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis. CONCLUSION: Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

[Arthroplasty of the hand and wrist]. / Endoprothetik an Hand und Handgelenk.

Arthrosis and autoimmune arthritis frequently lead to major impairment of hand function. Primary therapy consists of well- tried conservative treatments and joint preserving surgical options for special indications. In advanced stages silicon spacers remain the gold standard surgical option for replacement of proximal interphalangeal and metacarpophalgeal joints of the fingers. Alternatively, surface replacement prostheses can restore the biomechanical properties of these joints more porperly. In case of the carpometacarpal (CMC) joint of the thumb, arthroplasty is gaining popularity as modern implants show excellent mid-term outcome. Although current forth generation implants for wrist replacement are promising, total wrist arthroplasty is currently reserved for exceptional indications.

[Radiocarpal dislocations and fracture dislocations]. / Radiokarpale Luxationen und Luxationsfrakturen.

Radiocarpal dislocations and fracture dislocations are rare but always severe and complex injuries. They occur frequently in young and active patients as a result of high energy accidents. A detailed clinical and imaging examination and an accurate classification leads to a suitable and mostly surgical treatment strategy. The strategy should consider the most important components of the injury, the bony, the ligamentous and the intracarpal lesions. Delayed sequelae, residual pain and functional impairment are frequent after these severe injuries, but with adequate treatment, good, even long-term functional results are possible.

[Resection arthroplasty for thumb basal joint arthritis]. / Die Resektionsarthroplastik bei Rhizarthrose.

Due to the crucial role of the thumb for gripping, osteoarthritis of the first carpometacarpal joint leads to a substantial impairment of hand function. There are effective nonoperative and joint-preserving surgical treatment options for early stages of the disease. In advanced cases, after exploiting conservative treatment, carpometacarpal thumb arthrodesis or arthroplasty may be indicated in selected cases but trapeziectomy with or without interposition or suspension constitutes the gold standard surgical procedure. This reliably provides favorable results, irrespective of the technique, with pain relief, good physical function, excellent patient global assessment and low complication rates.

[Fractures of the carpal bones without the scaphoid bone]. / Frakturen der Handwurzel ohne Os scaphoideum.

With the exception of the relatively frequent fractures of the scaphoid bone, isolated fractures of individual carpal bones are rare. Because these injuries are uncommon and because of the complex anatomy and function of the carpus, treatment of carpal bone fractures can be challenging. Carpal bone fractures generally occur in young, sports active and professional patients, can be easily overlooked in plain radiographs and are frequently associated with ligamentous instability, neurovascular injuries and tendon lesions. Small posttraumatic alterations of the precisely aligned carpal structure can cause chronic pain and functional impairment. Therefore, if a wrist fracture is suspected a thorough clinical examination and appropriate differentiated imaging is always necessary, at the end of which a fracture can be excluded or an appropriate conservative or surgical treatment is initiated, with the aim of restoration of carpal anatomy and function.

Regression of glioma in rat models by intranasal application of parvovirus h-1.

PURPOSE: In previous studies, we have shown that the apathogenic rat parvovirus H-1 (H-1PV) is capable to induce regression of advanced symptomatic rat and human gliomas in a rat model, when the virus was injected in the tumor (intracranially) or intravenously. Infection with H-1PV did not provoke any pathology in nontumor tissue. This study addresses the question whether also intranasal application of this oncolytic virus is suitable and sufficient for treating gliomas in this animal model. EXPERIMENTAL DESIGN: Rat (RG-2) or human (U87) glioma cells were grafted stereotactically in the brain of rats (Wistar or RNU, respectively), and after development of tumors visible by MRI, H-1PV was instilled intranasally. Tumor regression was monitored by MRI, and survival was analyzed by Kaplan-Meier analysis. Brains from sacrificed animals were analyzed for histologic alterations, presence of viral DNA and proteins and infectious virions. In addition, distribution of virus to other organs was determined. RESULTS: A single intranasal instillation of H-1PV was sufficient to induce efficient regression of rat glioma, leading to significant prolongation of survival without any toxicity for other tissues. It is shown that the virus reaches brain and other tissues, and that the viral replication-associated (and oncolysis-associated) regulatory proteins are exclusively expressed in the tumor tissue. In rats with xenografts of human glioma, oncolytic activity of H-1PV was less pronounced, however, leading to significant prolongation of survival. CONCLUSION: In view of an ongoing clinical trial on the use of H-1PV for oncolytic virotherapy of glioma, the option of applying the virus intranasally may be a valuable alternative to invasive routes of infection.

Regression of advanced rat and human gliomas by local or systemic treatment with oncolytic parvovirus H-1 in rat models.

Oncolytic virotherapy is a potential treatment modality under investigation for various malignancies including malignant brain tumors. Unlike some other natural or modified viruses that show oncolytic activity against cerebral neoplasms, the rodent parvovirus H-1 (H-1PV) is completely apathogenic in humans. H-1PV efficiently kills a number of tumor cells without harm to corresponding normal ones. In this study, the concept of H-1PV-based virotherapy of glioma was tested for rat (RG-2 cell-derived) and for human (U87 cell-derived) gliomas in immunocompetent and immunodeficient rat models, respectively. Large orthotopic rat and human glioma cell-derived tumors were treated with either single stereotactic intratumoral or multiple intravenous (iv) H-1PV injections. Oncolysis was monitored by magnetic resonance imaging and proven by histology. Virus distribution and replication were determined in brain and organs. In immunocompetent rats bearing RG-2-derived tumors, a single stereotactic intratumoral injection of H-1PV and multiple systemic (iv) applications of the virus were sufficient for remission of advanced and even symptomatic intracranial gliomas without damaging normal brain tissue or other organs. H-1PV therapy resulted in significantly improved survival (Kaplan-Meier analysis) in both the rat and human glioma models. Virus replication in tumors indicated a contribution of secondary infection by progeny virus to the efficiency of oncolysis. Virus replication was restricted to tumors, although H-1PV DNA could be detected transiently in adjacent or remote normal brain tissue and in noncerebral tissues. The results presented here and the innocuousness of H-1PV for humans argue for the use of H-1PV as a powerful means to perform oncolytic therapy of malignant gliomas.