[Aetiology of Kienböck's Disease]. / Atiologie der Lunatumnekrose.

A definite pathogenesis for Kienböck's disease (KD) has not been identifed yet. Considering our clinical experience, mechanical factors, acute trauma or repetitive minor trauma seem to not be a primary cause, but rather factors that cause symptom aggravation of an already present KD. I feel we should look for a biological more than for a mechanical cause. Probably a vascular non-traumatic process, with a minor infarction pattern in the proximal subchondral area, is nearest to the truth. Bone remodelling results from bone resorption by osteoclasts and the formation of new bone by osteoblasts. Why osteoclast action should overpass the osteoblastic activity in the repair process is still not known. Studies of genes related to osteogenesis with polymerase chain reaction (PCR) arrays are a new option. Considering avascular necrosis as a possible reactive arthritis, PCR and viral RNA analysis could help in making the diagnosis.

Infantile and juvenile lunatomalacia.

Lunatomalacia or avascular necrosis of the lunate in children is a rare disease not described by Kienböck. It is somewhat surprising that the term Kienböck's disease has been used to describe this disease of the lunate in children. We report our experience in 13 cases and review the literature. In children under 12, the prognosis is very good after immobilization alone. Persistent symptoms may indicate surgery, probably radial shortening, in some older teenagers although the outcome appears better than in adults. We suggest the term lunatomalacia to describe this disorder, in recognition of the term originally used by Kienböck.

Controversias en el tratamiento de las fracturas del extremo distal del radio / Controversies in the treatment of distal radius fractures

En las fracturas del radio distal se origina un componente lesional de impactación y pérdida de tejido óseo esponjoso que provoca que la fractura vuelva a impactarse pese a una correcta reducción e inmovilización con yeso. En los pacientes jóvenes el tratamiento conservador ofrece generalmente buenos resultados por la calidad ósea, pero cualquier deformidad residual va a implicar un mayor riesgo de fracaso funcional a medio y largo plazo, así como la existencia de frecuentes lesiones asociadas. Presentamos unas reflexiones sobre la evolución y controversias del tramiento de esta frecuente lesión

Distal radial fractures are characterized by impaction and loss of cancellous bone, which causes the fracture to impact again despite correct reduction and plaster cast immobilization. In young patients, conservative management generally yields good results due to the existing bone quality, though any residual deformity will give rise to an increased risk of functional failure over the middle and long term, together with frequent associated lesions. We discuss the evolution and controversies of the management of this common type of injury

Etiología y clasificación de la enfermedad de Kienböck / Aetiology and classification of Kienböck´s disease

La etiología de la necrosis del semilunar sigue siendo unaincógnita, casi un siglo después de la publicación del artículopionero del Dr. Kienböck. Ninguna de las múltiples teoríasha sido probada con certeza, ni explica su presentación enun colectivo tan dispar como la experiencia clínica nosmuestra que es posible. De idéntica forma, las clasificacionesclásicas, basadas en los hallazgos radiológicos, debenactualizarse teniendo en cuenta la resonancia magnética.Por último, debemos diferenciar las lunatomalacias que sepresentan en los niños y adolescentes, de las que ocurrenen los adultos y en los pacientes de edad avanzada

To find the cause of Kienböck´s disease before onecentury has elapsed since its first description is a realchallenge for all of us. Probably we need to look for amore biological rather than a mechanical approach, tothe aetiology and treatment of lunatomalacia. MRI hasprovided very interesting data in the early stages of thedisease, to add to classic radiological findings. Also,when looking for an aetiological cause for Kienböck´sdisease, we need to consider the age of the onset ofthe disease. The prognosis and findings of the diseaseare different in children than in adults

Osteosíntesis con tornillo del polo proximal del escafoides carpiano / Proximal screw fixation of the carpal scaphoid

Objetivos. La aparición de la técnica del atornillado introduciendo el tornillo de proximal a distal, ha supuesto una alternativa a la osteosíntesis convencional (atornillado de distal a proximal) en el tratamiento de las fracturas y seudoartrosis del escafoides con un pequeño fragmento proximal, por su fácil abordaje y la relativa sencillez de la técnica. El objetivo de esta presentación es exponer nuestra experiencia con la utilización de un tornillo de titanio, adaptable al pequeño tamaño del polo proximal, que presenta una cabeza plana que permite su inclusión en el espesor del cartílago. Material y métodos. Presentamos nuestra experiencia con el atornillado de proximal a distal del escafoides en 18 casos, intervenidos entre 1992-2003. Actualmente utilizamos un tornillo de titanio de cabeza plana (Leibinger) debido a su versatilidad, a la estabilidad que proporciona, a la escasa lesión del cartílago en la zona de entrada y a su bajo coste. Resultados. Se ha conseguido la consolidación en los 3 casos de fracturas recientes. En los retrasos de consolidación hemos logrado la consolidación de la fractura en 8 de los 9 pacientes intervenidos (89%), mientras en las seudoartrosis inveteradas, la consolidación ha sido conseguida en 3 casos (75%) de los 4 que acudieron a revisión al año de la intervención. Dos pacientes con seudoartrosis se han eliminado a efectos estadísticos, al no acudir a la revisión al año de la intervención. Conclusiones. Por su simplicidad técnica, coste y resultados obtenidos, consideramos que la osteosíntesis con un tornillo de titanio de cabeza plana, introducido de proximal a distal, permite conseguir la consolidación de las fracturas y seudoartrosis del polo proximal de escafoides en un alto porcentaje de casos, que justifican a la misma como nuestra técnica de elección en el momento presente

Aim. The development of a fixation technique consisting of bone fixation of proximal fragment with a screw inserted proximal to distal is an alternative to conventional osteosynthesis (distal to proximal fixation) for the treatment of fractures and nonunions of scaphoid fractures with a small proximal fragment. The approach is easy and the technique is relatively simple. In this report we describe our experience with a titanium screw that is small enough to use on the proximal fragment and has a flat head that can be buried in the articular cartilage. Materials and methods. We used this screw for proximal fixation of the scaphoid fragment in 18 cases treated between 1992 and 2003. At present we use a flathead titanium screw (Leibinger) due to its versatility, stability, small cartilaginous injury at the entry site, and low cost.Results. Bone healing was achieved in 3 cases of recent fracture. In delayed union we achieved fracture healing in 8 of the 9 patients treated (89%) and in inveterate nonunions, consolidation was achieved in 3 of 4 patients (75%) who were followed up one year after the intervention. Two patients with nonunion were censored from data analysis because they did not return for the one-year follow-up visit. Conclusions. The technical simplicity, low cost, and good results obtained with a flathead titanium screw introduced proximally for scaphoid fixation, together with bone healing of the proximal scaphoid fragment in a high percentage of cases of fracture and nonunion, justify it as our current technique of choice

[Simultaneous dorsal luxation of metacarpophalangeal joints of the four long fingers. Apropos of a case]. / Luxation dorsale simultanée des articulations métacarpophalangiennes des quatre doigts longs.

PURPOSE OF THE STUDY: The authors describe an unusual case of simultaneous dorsal dislocation of the metacarpophalangeal joints of the index, long, ring, and little fingers. MATERIAL AND METHODS: A 67-year-old man fell on the pavement when walking, striking his outstretched left hand. A diagnosis of multiple fingers dislocation was easily clinically and radiologically established. The wound was cleaned and the dislocations reduced by closed manipulation at the operating room. RESULT: The patient had an uneventful recovery, after a three week period of immobilization with a dorsal extension block splint. DISCUSSION AND CONCLUSIONS: The use of art extension block splint allowed a minimal healing delay for disrupted volar metacarpophalangeal structures, allowing a good fingers range of motion.

Perilunar dislocation of the carpus. A diagnosis still often missed.

A retrospective study of patients with dorsal perilunar dislocation of the carpus (DPD) from seven different centres has been made. There were 91 cases with adequate documentation and radiographs; of these, 61 attended for review between 12 months and 22 years (follow-up average: 42 months). Functional results were assessed by a modified Witvoet score (Witvoet & Allieu, 1973). There were only 33/61 good results. Statistical evaluation disclosed that, whatever the morphology of the initial injury, prognosis had a significant relation to the delay of time between accident and diagnosis (p less than 0.001) to the accuracy of reduction and its maintenance (p less than 0.025) and to the rotation degree of the semilunar bone (p less than 0.001). Authors conclude by saying that there is no problem in DPD itself. The problem exist in the fact that these injuries are still often missed and, subsequently, mismanaged.