[Proximal row carpectomy and replacement of the proximal pole of the capitate by means of a pyrocarbon cap (RCPI) in advanced carpal collapse]. / Die Resektion der proximalen Handwurzelreihe mit Ersatz des Kapitatum-Pols durch eine Pyrocarbonkappe (RCPI) beim fortgeschrittenen karpalen Kollaps.

The results of 5 patients suffering from advanced carpal collapse after proximal row carpectomy and replacement of the proximal pole of the capitate by means of a pyrocarbon cap are presented.5 patients with an average age of 40.2 years (23-66 years) suffering from advanced carpal collapse were treated by means of proximal row carpectomy and replacement of the proximal pole of the capitate between January 2005 and August 2008. Clinical and radiological follow-ups within an average post-operative period of 54.4 months (25-68 months) were conducted. For the assessment of the outcome the DASH score and the traditional Krimmer score were used.At the follow-up all patients were fully recovered and could expose the wrist to higher exertions. Radiologically the implants in 3 of 5 patients were found to be tight and at the original post-operative location in comparison with the post-operative X-rays. In 2 of 5 patients a mild seam of loosening was detected around the implant. In the traditional Krimmer score the patients reached 81 points (75-85 points) and in the DASH score 8 points (2.5-23.33 points).The described results of the present procedure define it as an alternative in treating patients suffering from advanced carpal collapse as far as evidence from this small collective can be considered. The small seam of loosening around implants in 2 of 5 patients suggests that we may expect further loosening of implants in the long run. Larger patient collectives are necessary to confirm these provisional results.

Traction radiography for the diagnosis of scapholunate ligament tears.

The diagnosis of scapholunate ligament injury by traction radiography was investigated within a consecutive study. The right wrists of 25 healthy volunteers and 22 wrists with arthroscopically proven complete scapholunate ligament tears were examined. Traction radiography was performed under fluoroscopy with a force of 5 kg applied to the thumb. In the normal wrists, this led to selective widening of the scapholunate joint space whereas the lunotriquetral distance remained unchanged. In 25 healthy right wrists, the median scapholunate distance measured 2.1 (range 1.3-2.6) mm on resting radiographs and 2.2 (range 1.7-3.5) mm on the stress radiographs. For the 22 wrists with complete scapholunate ligament tears, the median scapholunate distance was increased from 2.0 (range 1.0-3.0) mm to 3.8 (range 3.0-5.5) mm by traction (median difference of 1.8 (range 1.0-3.0) mm). In conclusion, a scapholunate distance of 3.0 mm or more in unloaded wrists or widening of the scapholunate interval by 1.0 mm or more under thumb traction should both be considered as pathological findings. We recommend traction radiography as a simple and valuable diagnostic procedure for suspected scapholunate ligament injury.

[Fractures of the scaphoid tubercle]. / Die Frakturen des Tuberculum ossis scaphoidei.

BACKGROUND: Avulsion fractures of the scaphoid tubercle (Herbert type A1) are rare. Recommendations in the literature focus on a four to six week plaster immobilization including the thumb. Surgery is recommended in case of additional injuries to the carpus. MATERIAL AND METHODS: In a retrospective investigation including a 36 month period we reviewed acute fractures of the scaphoid and avulsion fractures of the scaphoid tubercle. RESULTS: We found 81 acute scaphoid fractures, four of them (4.9 %) were isolated tuberculum avulsions. Three cases were extra-, one case an intraarticular fracture. The first were treated conservatively, the last with a percutaneous screw. CONCLUSIONS: Following our own experiences with those rare injuries we recommend a differentiation of the fracture type into extraarticular injuries where conservative treatment should still be performed and intraarticular fractures where percutaneous screw osteosynthesis should be discussed.

Scapholunate ligament injury occurring with scaphoid fracture--a rare coincidence?

In a retrospective study the results of a series 34 wrist arthroscopies in 189 acute scaphoid fractures were analysed. Scapholunate ligament tears were found in 13 cases. In 10 cases there was complete disruption of scapholunate interosseous ligament causing dynamic instability. Partial ligament tears without instability were seen in three cases. Despite the limitations of this series we conclude that occurrence of scapholunate ligament injury with a scaphoid fracture may be more common than generally thought.

[Minimal invasive cannulated screw osteosynthesis of Bennett's fractures]. / Minimalinvasive Hohlschrauben-Osteosynthese von Bennett-Frakturen.

PURPOSE OF THE STUDY: The current study presents a new technique and results of minimal invasive screw osteosynthesis in the treatment of Bennett's fractures and discusses its advantages and disadvantages. OPERATIVE TECHNIQUE: The Bennett's fragment has to be of sufficient size (at least one quarter of the articular surface) and closed reduction must be possible to achieve. Temporary fixation by K-wire is followed by minimal invasive osteosynthesis using a cannulated 3.0 mm screw in the lag screw technique. RESULTS: 18 patients underwent minimal screw osteosynthesis, of whom two were lost for follow-up. Average time of follow-up of the remaining 16 patients was 17.2 weeks. Fracture healing was achieved in all of the 16 patients. There were good to excellent results in 13 patients, fair results in one patient and poor results in two patients. CONCLUSION: Good results can be achieved by minimal invasive screw osteosynthesis in the treatment of Bennett's fractures. Correct indications and minute operation technique are indispensable preconditions for this new kind of treatment.

[Dislocation of the pisiform bone. A review of the literature]. / Die Luxation des Os pisiforme. Literaturanalyse zu einer seltenen karpalen Verletzung.

Dislocation of the pisiform bone is extremely rare. So far, only 25 cases proved by radiographs have been reported. The sturdiness and stability of its ligamentous attachments may explain why dislocations of the pisiform are so rare. Often the dislocation is the result of direct trauma to the palmar and ulnar aspect of the wrist and less frequently due to indirect force or forceful muscular contraction. Dislocation of the pisiform bone occurs predominantly in young and active males. Usually, the pisiform is dislocated proximally or distally. The diagnosis is made by plain radiography. Operative treatment with pisiform excision and meticulous reapproximation of the attached soft-tissue structures yielded the most reliable results with preservation of wrist-flexion strength. Thus, although being very heterogenous with regard to mechanism of injury and displacement, pisiform dislocations should receive uniform treatment to obtain predictable results.

Measurement of torsion angles of long finger bones using computed tomography.

OBJECTIVE: Rotational dislocation at the fracture site is a complication of long finger bone fractures of the metacarpals and phalanges. To evaluate such deformities, we performed CT of the articular surfaces of these bones to demonstrate the torsion angles. DESIGN: We evaluated 10 pairs of cadaver hands. These were placed flat, with the bones of interest perpendicular to the gantry to acquire axial images. The torsion of the long bone axes was defined as the angle between a tangent positioned parallel to the proximal articular surface and a tangent parallel to the distal articular surface of individual bones. RESULTS: The maximum difference between repeated measurements was 4 degrees. Intraobserver differences measured between right and left hands are less than 3 degrees. CONCLUSION: Side differences in torsion angles exceeding 3 degrees are strongly suspicious of a malrotation after fracture. These measurements might help to plan derotational osteotomy and assess the results of therapy.

[Arthroscopic diagnosis of concomitant scapholunate ligament injuries in fractures of the distal radius]. / Arthroskopisch gesicherte Begleitverletzungen des skapholunären Bandapparates bei distalen Radiusfrakturen.

To investigate the occurrence of carpal ligamentous injuries in patients with fractures of the distal radius, the results of 122 wrist arthroscopies were analysed within a retrospective study. Indications for arthroscopy included suspected carpal instability according to radiographic findings and/or the necessity for internal fixation of the radius fracture. Arthroscopy revealed acute scapholunate ligament tears in 84 patients. Scapholunate separation was found to be of prognostic value for ligament tears. There was no association between ligamentous lesions and carpal angles or fracture dislocation. Scapholunate ligament tears were most frequent in sagittal articular fractures. In these cases, wrist arthroscopy should be performed during operative treatment of the radius fracture to allow direct visualization and subsequent repair of ligamentous tears.

[MRI or arthroscopy in the diagnosis of scapholunate ligament tears in fractures of the distal radius?]. / Magnetresonanztomographie oder Arthroskopie in der Diagnostik skapholunärer Bandschäden bei distalen Radiusfrakturen?

In a prospective study, 45 patients with fractures of the distal radius and radiologically suspected tears of the scapholunate interosseous ligament were examined. Magnetic resonance imaging was performed prior to wrist arthroscopy. The latter examination gave the definite diagnosis. MRI was performed in conventional technique (without contrast medium) in 25 cases and after additional intravenous injection of contrast medium in the remaining 20 patients. The images were obtained with a 1.0-T clinical imager using a T(2)-weighted turbo spin echo sequence (slice 3 mm, transversal) and a FLASH 2D sequence (slice 2 mm, oblique/coronal). Three independent observers assessed the MRI scans before arthroscopy was performed. The correct diagnosis was made by MRI in 76 %. Overall sensitivity and specificity came to 71 % and 86 %, respectively. The use of intravenously applied contrast medium did not improve MRI accuracy. In conclusion, MRI is not recommended for the diagnosis of scapholunate ligament tears. Presumably, the results of MRI could be improved by a more sophisticated technique.

[Primary arthroscopic treatment of TFCC tears in fractures of the distal radius]. / Die arthroskopische Therapie frischer Discus articularis-Verletzungen bei distalen Radiusfrakturen1 - Operative Technik und vorläufige Ergebnisse -

The primary simultaneous diagnosis and therapy of TFCC tears in distal radius fractures is still the exception. We present our results of arthroscopic treatment of these injuries. From January 1998 until September 1999, we treated 21 patients with a type C fracture (AO classification) of the distal radius and one patient with a scaphoid fracture and TFCC tears. The Palmer 1A (n = 5) and 1 C (n = 4) tears have been arthroscopically shaved as well as the meniscal tear (n = 1). The Palmer 1B tears were refixed either in an outside-inside technique (n = 6) or in a new all-inside technique (n = 6). Palmer 1D tears were refixed in the Fellinger technique (n = 5). In the clinical follow-up examination six to fifteen months later, we saw symptoms of ulnar-sided wrist pain only in one case of a Palmer 1B tear treated in an outside-inside technique. Especially the patients treated by the new all-inside technique were free from symptoms of TFCC instability. We conclude, that arthroscopic treatment of TFCC tears in acute radius fractures is possible with good results. The new technique of all-inside repair is minimally invasive and shows good results.

MRI versus arthroscopy in the diagnosis of scapholunate ligament injury.

In a prospective study 103 patients with clinically or radiologically suspected tears of the scapholunate interosseous ligament were investigated with magnetic resonance imaging (MRI) and wrist arthroscopy. MRI was performed with the conventional technique in 72 cases and after intravenous injection of contrast medium in the remaining 31 patients. The correct diagnosis was made by MRI in 75% of cases and its overall sensitivity and specificity were 63% and 86% respectively. There was no statistical difference in the accuracy of MRI for acute or chronic tears and the use of intravenous contrast medium did not improve its accuracy. In conclusion, MRI is not recommended for the diagnosis of scapholunate ligament injury.

[Results after minimally invasive therapy of acute scapholunate dissociation]. / Ergebnisse nach minimal-invasiver Therapie der akuten skapholunären Dissoziation.

In 27 cases with acute scapholunate ligament injury, minimal invasive treatment was performed. After closed reduction scapholunate transfixation was achieved by Kirschner wires. Postoperatively, a short-arm cast was applied for six weeks. All patients have been reexamined on average 26 months after operation. Follow-up results have been good concerning clinical examination and patients' satisfaction. Radiological examination has shown recurrence of scapholunate instability in 15 cases. In fact, 11% of the patients had dynamic and 44% static instability at follow-up. Recurrence has been most frequent in cases involving primary static instability. Consequently, these cases should be treated by open reduction. Minimal invasive treatment of acute scapholunate dissociation is not recommended. The therapeutic procedure must be adapted to the different stages of scapholunate ligament injury.

[Percutaneous osteosynthesis of scaphoid fracture with the Herbert-Whipple screw--technique and results]. / Die perkutane Osteosynthese der Skaphoidfraktur mit der Herbert-Whipple-Schraube--Technik und Resultate.

In order to diminish the surgical trauma a percutaneous osteosynthesis of acute fractures of the scaphoid was performed in 22 cases using the cannulated Herbert-Whipple screw. Displaced fractures were reduced under fluoroscopy in a position of extension and supination while pulling the thumb with a weight of 5 kg by means of a Japanese finger trap. Additional correction could be achieved by using Kirschner wires as joysticks. The guide wire allowed a correct positioning of the cannulated screw. We have found that radiocarpal and midcarpal arthroscopy was of little benefit for fracture reduction. However, arthroscopy was important for the detection of concomitant carpal injuries. Due to minor projection over the distal scaphoid pole, three screws had to be removed underlining the difficulty of exact length determination. Sound bony union was achieved in all 22 cases even in those treated without plaster immobilisation. Limitations in wrist motion and grip strength have been found after concomitant injuries such as fractures of the distal radius and scapholunate ligament injury. On the other hand, there was no impairment of wrist function after percutaneous osteosynthesis of isolated scaphoid fractures. In conclusion, percutaneous osteosynthesis of the fractured scaphoid with the cannulated Herbert-Whipple screw permits a reliable treatment with minimal operative trauma.

[Arthroscopically controlled minimal invasive screw fixation of scaphoid fractures. A pilot study]. / Die arthroskopisch kontrollierte minimalinvasive Verschraubung von Skaphoidfrakturen. Eine Pilotstudie.

We could not find any systematic studies about the value of arthroscopy in scaphoid fractures in the literature, and therefore undertook a pilot study of 20 scaphoid fractures which were treated arthroscopically by the Herbert-Whipple screw and were minimally invasive. We found very good radiological and clinical results in 17 patients and good results in 3 patients evaluated by the Wozasek and Moser score. For reduction of dislocated fractures we used distraction with 5 kg in the wine waiters position. In four cases we used additional K wires as joysticks. Arthroscopy is less valuable in reduction, however, it is important in verification of the compression force of the Herbert-Whipple screw and for diagnosis and therapy of lesions of the scapholunate ligament and TFC complex. We found seven SL instabilities, two lesions of the meniscus, and one Palmer 1B lesion of the TFC complex. From these results we conclude that arthroscopy should necessarily be done by minimally invasive osteosynthesis of scaphoid fractures to detect and treat discoligamentous injuries of the wrist.