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BACKGROUND: Primary thumb carpometacarpal (CMC) osteoarthritis is one of the most common conditions encountered by hand surgeons. Of the vast number of operations that have been proposed, none have demonstrated results significantly superior to trapeziectomy alone. AIM: The purpose of our study was to determine why surgeons opt for their technique in treating CMC arthritis. METHODS: A cross-sectional survey of active members of the American Society for Surgery of the Hand was conducted to evaluate the reasons behind their preferred technique in the treatment of isolated thumb CMC arthritis. Surgeons were contacted by e-mail once and provided with a link to a de-identified survey consisting of 5 treatment questions and 5 demographic questions. RESULTS: Of 950 responses were received. 40.5% of surgeons preferred trapeziectomy + ligament reconstruction tendon interposition (LRTI), followed by trapeziectomy + suspensionplasty (28.2%), suture button suspension (5.9 %), trapeziectomy alone (4.6%), prosthetic arthroplasty (3.2%), arthrodesis (1.1%), and other (6.6%). Proponents of trapeziectomy + LRTI cited familiarity (73.2%), exposure during fellowship (48.8%) and less proximal migration (60%) to be the main reasons affecting their decision. Surgeons who preferred trapeziectomy + suspensionplasty most reported simplicity (74.9%), fewer complications (45.3%), less proximal migration (43.8%), and avoidance of autogenous tissue harvest (42.7%). Advocates of suture button suspension cited avoidance of autogenous tissue harvest (80.4%), shorter immobilization (76.8%), and quicker recovery (73.2%) with their technique. Advocates of trapeziectomy alone cited simplicity (97.7%), fewer complications (86.4%), and avoidance of autogenous tissue harvest (59.1%). In their comments, 45% of surgeons choosing trapeziectomy alone cited evidence as an additional rationale. Advocates of prosthetic arthroplasty cited improved pinch strength (83.3%) and improved range of motion (63.3%), while those preferring arthrodesis cited better pinch strength (90%) and frequently in their comments, durability. Of the surgeons who preferred a technique other than LRTI, 41.8% reported they had tried LRTI in the past, citing complexity of the procedure, flexor carpi radialis harvest, and longer operative time as reasons for moving on. CONCLUSION: Our study provides an update on current treatment trends and offers new insight into the reasons behind surgeons' decision making in the management of thumb carpometacarpal osteoarthritis. Despite strong Level 1 evidence supporting the use of trapeziectomy alone, our findings demonstrate that most surgeons continue to supplement trapeziectomy with other techniques such as LRTI or suspensionplasty. Several factors including familiarity, personal experience (Level 4 evidence), and comfort may be more influential than Level 1 evidence in determining the techniques in a surgeon's armamentarium. Further prospective studies are needed to determine the optimal technique for surgical management of Eaton stages II-IV CMC arthritis and how these studies will affect surgeons' choice.
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Treating flexor tendon injuries within the digital flexor sheath (commonly referred to as palmar hand zone 2) presents both technical and logistical challenges. Success hinges on striking a delicate balance between safeguarding the surgical repair for tendon healing and initiating early rehabilitation to mitigate the formation of tendon adhesions. Adhesions between tendon slips and between tendons and the flexor sheath impede tendon movement, leading to postoperative stiffness and functional impairment. While current approaches to flexor tendon repair prioritize maximizing tendon strength for early mobilization and adhesion prevention, factors such as pain, swelling, and patient compliance may impede postoperative rehabilitation efforts. Moreover, premature mobilization could risk repair failure, necessitating additional surgical interventions. Pharmacological agents offer a potential avenue for minimizing inflammation and reducing adhesion formation while still promoting normal tendon healing. Although some systemic and local agents have shown promising results in animal studies, their clinical efficacy remains uncertain. Limitations in these studies include the relevance of chosen animal models to human populations and the adequacy of tools and measurement techniques in accurately assessing the impact of adhesions. This article provides an overview of the clinical challenges associated with flexor tendon injuries, discusses current on- and off-label agents aimed at minimizing adhesion formation, and examines investigational models designed to study adhesion reduction after intra-synovial flexor tendon repair. Understanding the clinical problem and experimental models may serve as a catalyst for future research aimed at addressing intra-synovial tendon adhesions following zone 2 flexor tendon repair.
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INTRODUCTION: There are many reasons why orthopaedic surgeons move or change careers. We asked the questions: (1) What is the geographic distribution of orthopaedic surgeons with respect to age, sex, and race and ethnicity? (2) How has our workforce changed over time with regard to these factors? (3) Are there any patterns or trends detected regarding policy or regulatory events that coincide with these differences? METHODS: The American Academy of Orthopaedic Surgeons surveys over 30,000 members, collecting data on demographics, age, race sex, and practice statistics. We calculated geographic distributions and evaluated these differences over time-potential influences from malpractice suits or tort reform were investigated. RESULTS: Overall surgeon density increased over time. The largest negative changes were noted in District of Columbia, Wyoming, and North Dakota and positive changes in Colorado, South Dakota, and West Virginia. Age across all states increased (mean 1.7 years). Number of female surgeons increased in most states (4.6% to 5.7%). Number of African Americans increased from 1.6% to 1.8%, Hispanic/LatinX from 1.8% to 2.2%, Asian from 5.5% to 6.7%, and multiracial from 0.8% to 1.2%. No change was noted in the percentage of Native American surgeons. DISCUSSION: Surgeon density increased from 2012 to 2018; the cause for this change was not evident. Small increases in surgeon population, female surgeons, and in some underrepresented minorities were seen.
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Cirurgiões Ortopédicos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Etnicidade/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Mão de Obra em Saúde/tendências , Cirurgiões Ortopédicos/estatística & dados numéricos , Ortopedia , Inquéritos e Questionários , Estados Unidos , Recursos Humanos , Diversidade de Recursos Humanos , Negro ou Afro-Americano , Hispânico ou Latino , Asiático , Grupos Raciais , Indígena Americano ou Nativo do AlascaRESUMO
OBJECTIVE: To demonstrate the potential of low-dose ultra-high-resolution CT (UHRCT) images to generate high-quality radiographic images on extremity phantoms and to estimate the radiation dose required for this. MATERIALS AND METHODS: A hand and knee phantom containing real human bones was imaged on an UHRCT scanner at full-dose, half-dose, and quarter-dose levels using a high-resolution extremity protocol. The raw data was reconstructed using both filtered back projection (FBP) and an iterative reconstruction algorithm (AIDR3D). Using custom designed software, each CT volume data set was converted to attenuation coefficients, and then a synthesized radiograph (synDX) was generated by forward projecting the volume data sets from a point source onto a 2D synthetic detector. The signal-to-noise ratio (SNR) was measured in the synDXs across all dose levels and the root-mean-squared error (RMSE) was computed with the FD synDXs as the reference. RESULTS: The proposed workflow generates high-quality synDXs at any arbitrary angle. For FBP, the SNR largely tracked with the radiation dose levels for both the knee and hand phantoms. For the knee phantom, iterative reconstruction provided a 6.1% higher SNR when compared to FBP. The RMSE was overall higher for the lowest dose levels and monotonically decreased with increasing dose. No substantial differences were observed qualitatively in the visualization of skeletal detail of the phantoms. CONCLUSION: The fine detail provided by UHRCT acquisitions of extremities facilitates the ability to generate quality radiographs, potentially eliminating the need for additional scanning on a conventional digital radiography system.
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Extensor tendon entrapment in the presence of distal radius fracture is a known but relatively uncommon complication. Single tendon or entire compartment entrapment has been described through the literature in youths and adults. However these findings generally are limited to a certain age demographic or are found on advanced imaging but are unable to be confirmed intraoperatively. We describe to our knowledge the first known description of second extensor compartment entrapment in an adult seen on computerized tomography scan and confirmed intraoperatively.
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OBJECTIVE: To systematically review the association of pain, function, and progression in first carpometacarpal (CMC) osteoarthritis (OA) with imaging biomarkers and radiography-based staging. DESIGN: Database searches in PubMed, Embase, and the Cochrane Library, along with citation searching were conducted in accordance with published guidance. Data on the association of imaging with pain, functional status, and disease progression were extracted and synthesized, along with key information on study methodology such as sample sizes, use of control subjects, study design, number of image raters, and blinding. Methodological quality was assessed using National Heart, Lung, and Blood Institute tools. RESULTS: After duplicate removal, a total of 1969 records were screened. Forty-six articles are included in this review, covering a total of 28,202 study participants, 7263 with first CMC OA. Osteophytes were found to be one of the strongest biomarkers for pain across imaging modalities. Radiographic findings alone showed conflicting relationships with pain. However, Kellgren-Lawrence staging showed consistent associations with pain in various studies. Radiographic, sonographic, and MRI findings and staging showed little association to tools evaluating functional status across imaging modalities. The same imaging methods showed limited ability to predict progression of first CMC OA. A major limitation was the heterogeneity in the study base, limiting synthesis of results. CONCLUSION: Imaging findings and radiography-based staging systems generally showed strong associations with pain, but not with functional status or disease progression. More research and improved imaging techniques are needed to help physicians better manage patients with first CMC OA.
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Articulações Carpometacarpais , Progressão da Doença , Osteoartrite , Humanos , Articulações Carpometacarpais/diagnóstico por imagem , Articulações Carpometacarpais/fisiopatologia , Osteoartrite/diagnóstico por imagem , Osteoartrite/fisiopatologia , Estado Funcional , Imageamento por Ressonância Magnética , Radiografia , Artralgia/diagnóstico por imagem , Artralgia/fisiopatologia , Artralgia/etiologia , Medição da Dor , Osteófito/diagnóstico por imagemRESUMO
OBJECTIVES: Magnetic resonance imaging (MRI) using 1.5T or 3.0T systems is routinely employed for assessing wrist pathology; however, due to off-resonance artifacts and high power deposition, these high-field systems have drawbacks for real-time (RT) imaging of the moving wrist. Recently, high-performance 0.55T MRI systems have become available. In this proof-of-concept study, we tested the hypothesis that RT-MRI during continuous, active, and uninterrupted wrist motion is feasible with a high-performance 0.55T system at temporal resolutions below 100 ms and that the resulting images provide visualization of tissues commonly interrogated for assessing dynamic wrist instability. METHODS: Participants were scanned during uninterrupted wrist radial-ulnar deviation and clenched fist maneuvers. Resulting images (nominal temporal resolution of 12.7-164.6 ms per image) were assessed for image quality. Feasibility of static MRI to supplement RT-MRI acquisition was also tested. RESULTS: The RT images with temporal resolutions < 100 ms demonstrated low distortion and image artifacts, and higher reader assessment scores. Static MRI scans showed the ability to assess anatomical structures of interest in the wrist. CONCLUSION: RT-MRI of the wrist at a high temporal resolution, coupled with static MRI, is feasible with a high-performance 0.55T system, and may enable improved assessment of wrist dynamic dysfunction and instability. ADVANCES IN KNOWLEDGE: Real-time MRI of the moving wrist is feasible with high-performance 0.55T and may improve the evaluation of dynamic dysfunction of the wrist.
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Articulação do Punho , Punho , Humanos , Punho/diagnóstico por imagem , Articulação do Punho/diagnóstico por imagem , Movimento (Física) , Imageamento por Ressonância Magnética/métodosRESUMO
Background: Shoulder arthroplasty is becoming increasingly common. With evolving implant designs, multiple humeral stem options exist for the surgeon to choose from. New stemless and short-stem systems are modular, remove less native bone stock, and better adapt to patient anatomy. It has been suggested that shorter stem implants may be protective against periprosthetic fracture; however, this has not been mechanistically evaluated. Therefore, this study aimed to biomechanically test synthetic humeri with long-stem, short-stem, and stemless arthroplasty components in a torsional manner to evaluate their response to loading and characterize failure. Methods: Twenty-four synthetic humeri were implanted with long stem, short stem, or stemless uncemented prosthesis, 8 in each group. Humeri were mounted in a custom testing jig with a morse taper interfacing with a mechanical testing system. After a 20N axial force, specimens were torsionally loaded to failure at 15 degrees/sec, with 50 Hz collection. Torque vs. rotation curves were generated for each specimen, and stiffness, yield, ultimate strength, and failure load were measured. ANOVA and post hoc pairwise comparisons were used to assess effect of stem type on mechanical test variable. The association of the stem type with fracture type was analyzed by a Fisher's Exact test. Statistical significance was set at P < .05. Results: During torsional loading, long-stem implants were significantly stiffer than short or stemless implants. The angle of implant yielding was similar across stem designs; however, stemless implants had a lower yield torque. This correlated with a decreased yield energy in stemless compared to short stems as well. Maximum torque and failure torque was also significantly higher in short-stem and long-stem implants compared to stemless. Discussion: Periprosthetic fractures in shoulder arthroplasty are a concern in low-energy trauma, and stem design likely plays a significant role in early implant-bone failure. Our results suggest stemless implants under torsional load fail at lower stress and are less stiff than stemmed implants. The failure mechanism of stemless implants through metaphyseal cancellous bone emphasizes the effect bone quality has on implant fixation. There is likely a balance of torsional stability to survive physiologic loads while minimizing diaphyseal stress and risk of diaphyseal periprosthetic fracture. This combined with revision and fixation options represent decisions the surgeon is faced with when performing shoulder arthroplasty.
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Free tissue flap transfer can be utilized for reconstruction following tumor resection. While flap failure occurs primarily within 72 h post-operation, late failure after day 7 is rare. We present the case of a 14-year-old with a late lower extremity free flap vascular compromise, along with the successful flap salvage.
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OBJECTIVES: Our objectives were to (1) analyze the imaging modalities utilized pre-operatively that influence surgical decision-making for wrist arthrodesis and carpectomy procedures and (2) determine the type and frequency of these procedures for the treatment of wrist arthritis. MATERIALS AND METHODS: This review was performed according to the guidelines of PRISMA Extension for Scoping Reviews. Using PubMed, Embase, and Scopus, peer-reviewed literature from 2011 to 2022 was searched for use of imaging in pre-operative decision-making for wrist arthrodesis and carpectomy surgical procedures. Data were compiled to determine the type(s) of imaging modalities used pre-operatively and types of surgical techniques reported in the literature. RESULTS: Of 307 articles identified, 35 articles satisfied eligibility criteria, with a total of 1377 patients (68% men; age mean, 50.9 years [range, 10-81]) and 1428 wrist surgical interventions. Radiography was reported for pre-operative planning in all articles for all patients. Pre-operative cross-sectional imaging was reported in 2 articles (5.7%), but no articles reported detailed data on how CT or MRI influenced pre-operative wrist arthrodesis and carpectomy procedure decision-making. A dozen different types of surgical techniques were reported. The four most common procedures were four-corner arthrodesis with scaphoid excision (846, 59%), proximal row carpectomy (239, 17%), total wrist arthrodesis (130, 9%), and scaphocapitate arthrodesis (53, 4%). CONCLUSION: Radiography is always used in pre-operative decision-making, but the literature lacks data on the influence of CT and MRI for selecting among a dozen different types of wrist arthrodesis and carpectomy procedures.
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Ossos do Carpo , Osteoartrite , Osso Escafoide , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Artrodese/métodos , Ossos do Carpo/diagnóstico por imagem , Ossos do Carpo/cirurgia , Osteoartrite/cirurgia , Amplitude de Movimento Articular , Osso Escafoide/cirurgia , Resultado do Tratamento , Punho/diagnóstico por imagem , Punho/cirurgia , Articulação do Punho/diagnóstico por imagem , Articulação do Punho/cirurgiaRESUMO
Patient race and ethnicity are important factors in health-care inequity, including care for the patient with hand and upper extremity pathologic condition. Physician diversity has been shown to promote better access, improve health-care quality, and improve satisfaction for underserved populations. Concordance, most often defined as a similarity or shared identity between physician and patient, has been shown to have a positive influence on health-care disparities. Although diversity among Hand surgeons is increasing, it is not matching the diversity of the population as a whole. It is imperative that we work to increase and maintain diversity in order to provide the best care for our patients.
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Etnicidade , Disparidades em Assistência à Saúde , Humanos , Qualidade da Assistência à SaúdeRESUMO
Background Surgical procedure selection for carpal arthritis depends on which articular surfaces are affected, but there is no consensus on how to preoperatively evaluate cartilage surfaces. Despite advances in cross-sectional imaging, the utility of advanced imaging for preoperative decision-making has not been well established. Objectives Our objective was to assess if there is an added value to presurgical advanced imaging or diagnostic procedures in planning for carpal arthrodesis or carpectomy and to determine what imaging or diagnostic procedures influence surgical treatment options. Methods A seven-question survey was sent to 2,400 hand surgeons. Questions assessed which articular surfaces surgeons consider important for decision-making, which imaging modalities surgeons employ, and how often surgeons utilize diagnostic arthroscopy before performing carpectomy or arthrodesis procedures. Results A total of 337 (14%) surveys were analyzed. The capitolunate articulation (alone or in combination) was most frequently reported to impact surgical decision-making (48.1%). Most surgeons (86.6%) reported that standard plain radiographs are usually sufficient. Few surgeons reported always obtaining magnetic resonance imaging (MRI) or computed tomography (CT), with 44.2% of surgeons believing that MRI is never useful and 38.4% believing that CT is never useful. Most surgeons (68.2%) reported that they never perform wrist arthroscopy as part of their decision-making process. Conclusions This study provides information on the decision-making process in the surgical management of carpal arthritis. Given advances in cross-sectional imaging, further studies are needed to determine the utility of MRI and CT for the planning of surgical procedures in the treatment of arthritis of the carpus. Level of Evidence Level 4.
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BACKGROUND: Primary sarcomas originating from the bones of hand and wrist are rare but carry a significant burden of morbidity. METHODS: National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 237 patients in the United States. Kaplan-Meier and Cox regression were used to determine the prognostic factors affecting survival. χ2 test was used to assess the correlation. RESULTS: Incidence of hand and wrist sarcoma was 0.017 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific 5-year and 10-year survival for the entire cohort was 90% and 84%, respectively. On multivariate analysis race "others," histology other than "osteosarcoma," "undifferentiated" grade, and size "≥6 cm" were predictors of worse disease-specific survival. Cross-tabulation of race with other significant prognostic factors on univariate analysis revealed a significant correlation of race with every other significant prognostic factor except for grade. CONCLUSIONS: The current study is an analysis of a population-based registry reporting incidence and survival data for patients with sarcoma of hand and wrist. Independent prognostic factors include race, histology, grade, and size. There is a lack of improvement in survival over the last four decades.
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Neoplasias Ósseas/epidemiologia , Mãos/patologia , Equidade em Saúde/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Osteossarcoma/epidemiologia , Neoplasias de Tecidos Moles/epidemiologia , Adolescente , Adulto , Neoplasias Ósseas/patologia , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Osteossarcoma/patologia , Prognóstico , Programa de SEER , Neoplasias de Tecidos Moles/patologia , Taxa de Sobrevida , Estados Unidos/epidemiologiaRESUMO
PURPOSE: To determine the effect of simulated radioscapholunate fusion with distal scaphoid excision (RSLF+DSE), 4-corner fusion with scaphoidectomy (4-CF), and proximal row carpectomy (PRC) on the wrist's range of motion (ROM), contact pressure, and contact force in a cadaveric model. METHODS: Ten freshly frozen cadaveric wrists were tested under 4 sequential conditions: native wrist, RSLF+DSE, 4-CF, and PRC. The simulated fusions were performed using two 1.6-mm Kirschner wires. The ROM in the flexion-extension and radioulnar deviation planes was evaluated. Contact area, contact pressure, and contact force were measured at the scaphocapitolunate joint for the RSLF+DSE simulation and radiocarpal joint for the 4-CF and PRC simulations. Mechanical testing was performed using a 35-N uniaxial load and pressure-sensitive film. RESULTS: The RSLF+DSE and 4-CF groups had a decreased wrist arc ROM compared with the native wrist. The PRC group had a greater wrist arc ROM compared with the RSLF+DSE and 4-CF groups, but compared to the native wrist, it demonstrated a mildly decreased wrist arc ROM. The carpal pressure and contact force were significantly increased in the RSLF+DSE, 4-CF, and PRC groups compared with those in the native wrist. The RSLF+DSE group had the smallest increase in the carpal pressure and contact force, whereas the PRC group had the greatest increase. CONCLUSIONS: Our study validates previous findings that PRC is motion-conserving but has the greatest contact force, whereas RSLF-DSE and 4-CF may cause a decrease in the ROM but have lower contact forces. CLINICAL RELEVANCE: Understanding the underlying native wrist biomechanics and alterations following different surgical treatments may assist hand surgeons in their clinical decision making for the treatment of stage II scapholunate advanced collapse.
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Ossos do Carpo , Osso Escafoide , Artrodese , Ossos do Carpo/cirurgia , Humanos , Amplitude de Movimento Articular , Osso Escafoide/cirurgia , Punho , Articulação do Punho/cirurgiaRESUMO
PURPOSE: Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries. Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS. METHODS: Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared. RESULTS: Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling. CONCLUSIONS: Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft. CLINICAL RELEVANCE: This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability.
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Articulações do Carpo , Instabilidade Articular , Osso Semilunar , Osso Escafoide , Humanos , Instabilidade Articular/cirurgia , Ligamentos Articulares/cirurgia , Osso Semilunar/cirurgia , Suturas , Articulação do PunhoRESUMO
OBJECTIVE: To describe the normal motion pattern at the midcarpal compartment during active radial-ulnar deviation of the wrist using dynamic MRI, and to determine the observer performance for measurements obtained in asymptomatic volunteers. METHODS: Dynamic MRI of 35 wrists in 19 asymptomatic volunteers (age mean 30.4 years, SD 8.6) was performed during active radial-ulnar deviation using a fast gradient-echo pulse sequence with 315 ms temporal resolution (acquisition time, 19 s). Two independent readers measured the transverse translation of the trapezium at the scaphotrapezium joint (STJ) and the capitate-to-triquetrum distance (CTD). Relationships between these measurements and laterality, sex, lunate type, and wrist kinematic pattern were evaluated. RESULTS: At the STJ, the trapezium moved most in radial deviation, with an overall translation of 2.3 mm between ulnar and radial deviation. Mean CTD measurements were the greatest in ulnar deviation and varied 2.4 mm between ulnar and radial deviation. Mean CTD was greater in men than women in the neutral position (p = 0.019), and in wrists with type II lunate morphology during radial and ulnar deviation (p = 0.001, p = 0.014). There were no significant differences in trapezium translation or CTD with wrist laterality and kinematic pattern. Intraobserver and interobserver correlation coefficients were 0.97 and 0.87 for trapezium translation and 0.84 and 0.67 for CTD. CONCLUSION: This study is the first to demonstrate the performance of dynamic MRI to quantify STJ motion and CTD. Dynamic MRI with a short acquisition time may be used as a tool to supplement static MRI in evaluation of the midcarpal compartment.
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Imageamento por Ressonância Magnética/métodos , Amplitude de Movimento Articular/fisiologia , Articulação do Punho/fisiologia , Adulto , Feminino , Humanos , Masculino , Estudos Prospectivos , Valores de Referência , Reprodutibilidade dos Testes , TempoRESUMO
INTRODUCTION: A rare case of traumatic, isolated dislocation of the hamate with hook fracture in the setting of concomitant acute hand compartment syndrome is presented. This is the first described case of isolated hamate dislocation presenting with symptoms and examination consistent with acute compartment syndrome of the hand. CASE REPORT: A 28-year-old man presented with a left hand crush injury. Plain radiographs demonstrated an isolated dorsal hamate dislocation without axial carpal dislocation and volar displacement of the hook fracture segment. Due to the clinical diagnosis of compartment syndrome, the patient was taken urgently to the operating room. Closed reduction of the hamate was performed, fasciotomies were performed, and the hamate was stabilized with percutaneous pinning. The patient at 6 months had full clinical recovery and returned to work. CONCLUSION: Isolated, traumatic dislocation of the hamate is a rare injury that is most commonly caused by direct impact to the wrist at the level of the carpus. This injury can be readily diagnosed by history, physical examination, and radiographs. Computerized tomography scan may aid in diagnosis, but delay in treatment should not be tolerated in emergent cases. Importantly, crush injuries with a resulting hamate dislocation should increase clinical suspicion for hand compartment syndrome. If diagnosed and treated expediently, patients may benefit from improved and excellent outcomes.
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BACKGROUND: Carpal instability is defined as a condition where wrist motion and/or loading creates mechanical dysfunction, resulting in weakness, pain and decreased function. When conventional methods do not identify the instability patterns, yet clinical signs of instability exist, the diagnosis of dynamic instability is often suggested to describe carpal derangement manifested only during the wrist's active motion or stress. We addressed the question: can advanced MRI techniques provide quantitative means to evaluate dynamic carpal instability and supplement standard static MRI acquisition? Our objectives were to (i) develop a real-time, three-dimensional MRI method to image the carpal joints during their active, uninterrupted motion; and (ii) demonstrate feasibility of the method for assessing metrics relevant to dynamic carpal instability, thus overcoming limitations of standard MRI. METHODS: Twenty wrists (bilateral wrists of ten healthy participants) were scanned during radial-ulnar deviation and clenched-fist maneuvers. Images resulting from two real-time MRI pulse sequences, four sparse data-acquisition schemes, and three constrained image reconstruction techniques were compared. Image quality was assessed via blinded scoring by three radiologists and quantitative imaging metrics. RESULTS: Real-time MRI data-acquisition employing sparse radial sampling with a gradient-recalled-echo acquisition and constrained iterative reconstruction appeared to provide a practical tradeoff between imaging speed (temporal resolution up to 135 ms per slice) and image quality. The method effectively reduced streaking artifacts arising from data undersampling and enabled the derivation of quantitative measures pertinent to evaluating dynamic carpal instability. CONCLUSION: This study demonstrates that real-time, three-dimensional MRI of the moving wrist is feasible and may be useful for the evaluation of dynamic carpal instability.
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Ossos do Carpo/diagnóstico por imagem , Articulações do Carpo/diagnóstico por imagem , Instabilidade Articular/fisiopatologia , Imageamento por Ressonância Magnética/métodos , Adulto , Ossos do Carpo/fisiologia , Articulações do Carpo/fisiologia , Humanos , Interpretação de Imagem Assistida por Computador/métodos , Masculino , Movimento (Física) , Reprodutibilidade dos TestesRESUMO
We present a method for the statistical modeling of the displacements of wrist bones during the performance of coordinated maneuvers, such as radial-ulnar deviation (RUD). In our approach, we decompose bone displacement via a set of basis functions, identified via principal component analysis (PCA). We utilized MRI wrist scans acquired at multiple static positions for deriving these basis functions. We then utilized these basis functions to compare the displacements undergone by the bones of the left versus right wrist in the same individual, and between bones of the wrists of men and women, during the performance of the coordinated RUD maneuver. Our results show that the complex displacements of the wrist bones during RUD can be modeled with high reliability with just 5 basis functions, that captured over 91% of variation across individuals. The basis functions were able to predict intermediate wrist bone poses with an overall high accuracy (mean error of 0.26â¯mm). Our proposed approach found statistically significant differences between bone displacement trajectories in women versus men, however, did not find significant differences in those of the left versus right wrist in the same individual. Our proposed method has the potential to enable detailed analysis of wrist kinematics for each sex, and provide a robust framework for characterizing the normal and pathologic displacement of the wrist bones, such as in the context of wrist instability.