Outcome of carpal tunnel release in patients with normal nerve conduction studies.

BACKGROUND: We evaluated outcome after carpal tunnel release (CTR) in patients with clinically diagnosed carpal tunnel syndrome (CTS) but normal results in nerve conduction studies (NCS), and compared these results with those from a prospective group of patients with NCS-verified CTS. METHODS: Over a 5-year period, we prospectively included 103 patients with clinical CTS. NCS were done at inclusion, with surgeon and patient being kept blind regarding the result. The patients underwent endoscopic CTR. QuickDASH and satisfaction score were recorded preoperatively and 4 months after surgery. 94 patients, 47 of whom had NCS-verified CTS, completed the study. RESULTS: A significant improvement in QuickDASH score (18 and 20 points respectively, p < 0.01) was found for both groups. Satisfaction score was significantly higher in the group with NCS-verified CTS. However, the overall satisfaction rates were 87% in the normal NCS group and 95% in the group with abnormal NCS. CONCLUSIONS: Clinical outcome after CTR in patients with normal NCS was favourable and similar to that obtained in patients with NCS-verified CTS. Nonetheless, patients with normal result in NCS gave a lower satisfaction score.

Epidemiology of scaphoid fractures and non-unions: A systematic review.

BACKGROUND: The scaphoid is the most commonly fractured carpal bone in adults as well as in children. Previous studies have reported a wide range of fracture incidences. Scaphoid fractures and non-unions in children have been sparsely investigated. AIM: To perform a systematic review of the current literature on epidemiology of scaphoid fractures and non-unions in adults and children. METHODS: An electronic literature search was conducted investigating all studies in the literature published between January 1989 and June 23 2020. The systematic review following the PRISMA guidelines and searching in PubMed, Embase, Web of Science and Cochrane library databases was done in June 2020. RESULTS: 42 studies met our inclusion criteria, 6 studies were prospective, 32 were retrospective and 4 were register studies. The majority of studies relied on conventional radiographs for diagnosis. Scaphoid fractures in adults are predominately found in males with a peak incidence in the age group from 20 to 29 years. Incidence rates in males are reported from 107 to 151/100 000. Females have an earlier peak, in the age group 10 to 19 years, with an incidence from 14 to 46/100 000. Most fractures occur in the middle third of the scaphoid representing 60-69 % of cases. Scaphoid fractures in children are predominately found in boys age 12 and above, while it seldomly occur for children younger than 9 years. In adults the risk for developing a scaphoid non-union is between 2 % and 5 %, the majority affecting males and predominately located at the middle third of the scaphoid. Non-unions among children are rare and mainly due to missed or delayed diagnosis of a fracture in the middle third of the scaphoid. CONCLUSION: This review revealed a substantial heterogeneity among studies concerning study population, diagnosis criterial and outcome measures. Currently, evidence on epidemiology for scaphoid fractures and non-unions are low.

Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up.

PURPOSE: The aim of this study was to evaluate the functional, clinical, and radiological outcome 10 years after distal scaphoid fractures. METHODS: From a prospective epidemiological study on posttraumatic radial-sided wrist pain, we evaluated 41 cases of distal scaphoid fractures. All cases had been treated nonsurgically in a thumb spica cast. Patients were examined using radiographs, magnetic resonance imaging and computed tomography at the time of injury and with computed tomography after a median of 10 years (range, 8-11 years). Fractures were classified according to a modified Prosser classification system. The primary outcome was assessment of self-reported function using Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Reported Wrist Evaluation (PRWE). Secondary outcomes were clinical status (range of motion and grip and pinch strength) and to evaluate fracture healing and arthritis in the scaphotrapezium-trapezoid (STT) joint. RESULTS: Functional impairment and pain scores at follow-up were low: median DASH score 2, median PRWE 0, and median visual analog scale (VAS) pain score 0. We found no impairment in range of motion or strength. We found 26 type I fractures, 12 type IIA, 1 type IIC, and 2 type IV. There was 1 asymptomatic nonunion in a type I fracture. Computed tomography revealed arthritis in the STT joint in 7 out of 41 wrists, none of which caused clinical symptoms. CONCLUSIONS: From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. The risk for development of posttraumatic STT arthritis was low. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

MRI shows a high incidence of carpal fractures in children with posttraumatic radial-sided wrist tenderness.

Background and purpose - The epidemiology and optimal diagnostics of wrist injuries in children are not knotwn. We describe fractures revealed by magnetic resonance imaging (MRI) in a prospective population of children and adolescents with posttraumatic radial-sided wrist tenderness, and compare the diagnostic value of radiographs and computed tomography (CT) with that of MRI. Patients and methods - From 2004 to 2007, patients less than 18 years of age who presented at our emergency department were included in the study. 90 wrists in 89 patients underwent clinical, radiographic, and low-field MRI investigation. If plain radiographs or MRI revealed a scaphoid fracture, a supplementary CT scan was performed. Sensitivity and specificity of radiographs and CT for diagnosis of scaphoid fractures was calculated using MRI as the reference standard. Results - 74 fractures were diagnosed in 61 of 90 wrists using MRI; 48 wrists had a scaphoid fracture, 8 had a distal radius fracture, 7 had a capitate fracture, and 3 had a triquetrum fracture. The most common combination of fractures was scaphoid and capitate. The sensitivity of radiographs for visualization of scaphoid fractures was 54% and the specificity was 100%. The sensitivity for other fractures was <50%. The sensitivity of CT for visualization of scaphoid fractures was 96% and it was between 33% and 100% for other fractures. Interpretation - MRI showed a high incidence of fractures in children and adolescents with posttraumatic radial wrist tenderness, and it led to the diagnosis of more fractures than plain radiographs and CT. A scaphoid fracture was the most common carpal injury, followed by fracture of the capitate.

Is early mobilisation better than immobilisation in the treatment of wrist sprains?

OBJECTIVE: Posttraumatic radial sided wrist pain is common and can represent a fracture or a ligament injury. However, in some patients radiographs and MRI are normal, indicating no specific diagnosis other than a wrist sprain. There is no consensus on the ideal treatment for this patient group. The aim was to investigate if patients with posttraumatic radial sided wrist pain and MRI not showing signs of fracture or SL-ligament injury should be treated with immediate mobilisation or 2 weeks cast immobilisation. METHOD: Forty-three patients, aged 18-64 years, were randomised to either a dorsal wrist cast for 2 weeks (n = 21), or immediate mobilisation (n = 22). Follow-up at 2, 4, and 6 weeks included clinical examination, self-assessment questionnaires (DASH, VAS), and recording of days on sick-leave. RESULTS: At 2 weeks patients treated in a cast had reduced wrist range of motion, ROM (77% vs 96%, p = 0.011), and higher DASH score (median 37 vs 18, p = 0.009) compared to patients treated with immediate mobilisation. At 4 weeks, DASH score was still higher in the group treated in a cast (median 14 vs 4, p = 0.01), but there was no difference in ROM. At 6 weeks there were no differences in any outcome measure between the groups. Furthermore, there was no significant difference in sick-leave between the groups (median 27 days vs 14 days, p = 0.077). CONCLUSION: Patients with radial sided wrist pain where MRI does not demonstrate fracture or SL ligament injury do not benefit from cast immobilisation and can be treated with early mobilisation.

Conservative Treatment Versus Arthroscopic-Assisted Screw Fixation of Scaphoid Waist Fractures--A Randomized Trial With Minimum 4-Year Follow-Up.

PURPOSE: To evaluate clinical and radiological outcomes after conservative treatment and arthroscopic-assisted screw fixation of acute non- or minimally displaced scaphoid waist fractures in a randomized controlled trial. METHODS: Consecutive patients with acute non- or minimally displaced scaphoid waist fractures were prospectively randomized to conservative or surgical treatment. All patients were screened using radiographs, computed tomography, and magnetic resonance imaging. Conservative treatment consisted of a below-elbow thumb spica cast until radiological signs of union appeared. Surgical treatment consisted of wrist arthroscopy and percutaneous antegrade screw fixation. Clinical examination, radiographs, and computed tomography were used to follow the patients. Twenty-four patients were treated conservatively and 14 patients underwent surgery. The patients were followed at regular intervals for 1 year after surgery. Twenty-one patients treated conservatively and 14 treated surgically were available for follow-up after a median of 6 years (range, 4-8 y). RESULTS: At 26 weeks, the conservatively treated group had significantly better range of motion and had reached almost normal value compared with the contralateral wrist. There were no significant differences between the 2 groups concerning grip or pinch strengths at any measure point. At follow-up after a median of 6 years, radiographic signs of arthritis in the radioscaphoid joint were more common in the surgically treated group (3 of 14) than in the conservative group (2 of 21). CONCLUSIONS: Non- and minimally displaced scaphoid waist fractures are best treated conservatively. Operative treatment may provide an improved functional outcome in the short term but at the price of a possible increased risk of arthritis in the long term. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Union of Scaphoid Waist Fractures Assessed by CT Scan.

Background Union of a scaphoid fracture is difficult to assess on a standard series of radiographs. An unnecessary and prolonged immobilization is inconvenient and may impair functional outcome. Although operative treatment permits early mobilization, its influence on time to union is still uncertain. Purpose To assess union of scaphoid waist fractures based on computed tomography (CT) scan at 6 weeks, and to compare time to union between conservative treatment and arthroscopically assisted screw fixation. Patients and methods CT scan in the longitudinal axis of the scaphoid was used to provide fracture characteristics, and to assess bone union at 6 weeks in 65 consecutive patients with scaphoid waist fractures. In a randomized subgroup from this cohort with nondisplaced fractures, we compared time to union between conservative treatment (n = 23) and arthroscopically assisted screw fixation (n = 15). Results Overall, at 6 weeks we found a 90% union rate for non- or minimally displaced fracture treated conservatively, and 82% for those who underwent surgery. In the randomized subgroup of nondisplaced fractures, no significant difference in time to union was demonstrated between those treated conservatively and those who underwent surgery. The conservatively treated fractures from this subgroup with prolonged time to union (10 to 14 weeks) were comminuted, demonstrating a radial cortical or corticospongious fragment. Conclusion The majority of non- or minimally displaced scaphoid waist fractures are sufficiently treated with 6 weeks in a cast. Screw fixation does not reduce time to fracture union compared with conservative treatment. Level of Evidence level II, Therapeutic study.

The benefit of magnetic resonance imaging for patients with posttraumatic radial wrist tenderness.

PURPOSE: To describe fractures revealed by magnetic resonance imaging (MRI) in a series of skeletally mature patients with radial wrist pain after an acute injury and clinically suspected to have a scaphoid fracture. Additionally, we attempted to assess the diagnostic value of radiographs and computed tomography (CT) in patients with scaphoid and other carpal fractures verified by MRI. METHODS: We conducted the study prospectively over a 3-year period on skeletally mature patients presenting at our emergency department with tenderness on the radial side of the wrist after an injury. A total of 300 wrists in 296 patients underwent clinical and radiographic examination. We performed low-field, 0.23-T MRI of all injured wrists within 3 working days from inclusion in the study. If the radiographs or MRI revealed a scaphoid fracture, we immediately carried out a supplementary 16-slice CT scan of the wrist. We calculated the sensitivity and specificity of radiographs and CT for the diagnosis of scaphoid fractures using MRI as the reference standard. RESULTS: We diagnosed a total of 224 fractures in 196 wrists using MRI; 42% were scaphoid fractures, 15% were distal radius fractures, 6% were triquetrum fractures, and 5% were capitate fractures. The most commonly found fracture combinations were that of the scaphoid and distal radius, followed by scaphoid and capitate fracture. The sensitivity of radiographs for visualization of scaphoid fractures was 70% and the specificity was 98%. Radiographic sensitivity for other fractures was less than 60%. The sensitivity of CT for visualization of scaphoid fractures was 95%, and between 75% and 100% for other fractures. CONCLUSIONS: Low-field MRI showed a high incidence of fractures in patients with posttraumatic radial wrist tenderness and demonstrated more fractures than radiographs and CT. A scaphoid fracture was by far the most common injury. However, it is not clear whether diagnosis of subtle injuries only demonstrated on MRI improves outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Diagnostic performance of radiographs and computed tomography for displacement and instability of acute scaphoid waist fractures.

BACKGROUND: Fracture displacement is the most important factor associated with nonunion of a scaphoid waist fracture.We evaluated the performance characteristics of radiographs and computed tomography (CT) in the diagnosis of intraoperative displacement and instability of scaphoid waist fractures using wrist arthroscopy as the reference standard. METHODS: During a six-year period (2004 to 2010) at two institutions, forty-four adult patients with a scaphoid waist fracture underwent arthroscopy-assisted operative fracture treatment at a mean of nine days (range, two to twenty-two days) after injury. Subjects included all of those with a displaced scaphoid fracture seen on radiographs and a selection of patients with a nondisplaced scaphoid fracture. All patients had preoperative radiographs and CT. Arthroscopy with up to 5 kg of traction was the reference standard for fracture displacement and instability. RESULTS: The reference standard (arthroscopy) led to a diagnosis of twenty-two displaced fractures (all unstable) and twenty-two nondisplaced fractures (seven unstable). Displacement was diagnosed in eleven patients (25%) with the use of radiographs and in twenty (45%) with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative displacement were 45%, 95%, and 70%, respectively, with the use of radiographs and 77%, 86%, and 82%, respectively, with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative instability were 34%, 93%, and 55%, respectively,with the use of radiographs and 62%, 87%, and 70%, respectively, with CT. Assuming a 10% prevalence of fracture displacement and instability among all scaphoid waist fractures, the positive and negative predictive values for displacement were 53% and 94%, respectively, with the use of radiographs and 39% and 97% with CT whereas the positive and negative predictive values for instability were 36% and 93%, respectively, with radiographs and 34% and 95% with CT. CONCLUSIONS: Radiographs and CT scans cannot be relied on to accurately diagnose intraoperative scaphoid fracture displacement or instability compared with arthroscopic examination. The influence, with regard to the risk of nonunion, of intraoperative instability of a scaphoid fracture that is seen to be nondisplaced on radiographs or CT is currently unknown. LEVEL OF EVIDENCE: Diagnostic Level III.

Factors associated with arthroscopically determined scaphoid fracture displacement and instability.

PURPOSE: To identify factors associated with arthroscopically diagnosed scaphoid fracture displacement and instability. METHODS: This was a secondary use of data from 2 prospective cohort studies. The studies included 58 consecutive adult patients with a scaphoid fracture who elected arthroscopy-assisted operative fracture treatment: some for displacement, some as part of a prospective protocol, and others to avoid a cast. All patients had preoperative computed tomography with reconstructions in planes defined by the long axis of the scaphoid. RESULTS: Arthroscopy revealed 38 unstable fractures (movement between fracture fragments; 66%), 27 of which were also displaced. All arthroscopically determined displaced fractures were unstable, and 11 of the 31 arthroscopically determined, nondisplaced fractures were unstable. There was a significant correlation between radiographic comminution (more than 2 fracture fragments) and arthroscopically determined displacement and instability. CONCLUSIONS: Radiographic comminution is associated with displacement and instability as determined by arthroscopy.

Extension block pinning of mallet fractures.

The operative treatment of mallet fractures of more than one third of the articular surface is controversial. The purpose of this study was to evaluate the complications and functional outcome of extension block pinning technique. Thirty-six consecutive patients with mallet fractures that involved more than one third of the joint surface were treated by extension block pinning a median of 3 days after injury (range 0-35, mean 7). Clinical outcome was graded according to Crawford's criteria. At a median follow-up of 16.5 months (range 2.5-52, mean 20) 23 patients had an excellent or good result, 11 patients had a fair, and 2 patients a poor, clinical outcome according to Crawford's criteria. None of the patients complained of pain. The median extension loss was 0 degrees (range 0-20, mean 4) and the median flexion was 70 degrees (range 30-95, mean 68). Eight patients had operative or direct postoperative complications including superficial infection (n = 6), loss of Kirschner wire (K-wire) fixation (n = 1), and K-wire mal position (n = 1). The extension block pinning technique is a minimally invasive method of treating mallet fractures with low morbidity and a good functional outcome.

The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures.

PURPOSE: To determine the incidence of associated intrinsic and extrinsic ligament injuries in patients with a nondisplaced or displaced scaphoid waist fracture. METHODS: During a 3-year period, a study of all scaphoid fractures was performed at our institution. Diagnosis was confirmed by plain radiographs, computed tomography, and magnetic resonance imaging. A 3-part anatomic classification was used to categorize the scaphoid fractures. The study population comprised 40 patients with 41 scaphoid waist fractures who had wrist arthroscopy for treatment and evaluation of the scaphoid fracture and associated carpal injuries. RESULTS: We observed fresh intrinsic ligament injuries in 34 of 41 wrists. In 29 cases, the scapholunate ligament was injured, with complete rupture occurring in 10 wrists. The lunotriquetral ligament was injured in 8 wrists, and the triangular fibrocartilage complex was injured in 11 wrists. Statistically, the number of intrinsic ligament injuries did not differ between nondisplaced and displaced scaphoid fractures (p> .30). CONCLUSIONS: In this study of acute scaphoid waist fractures, the overall incidence of associated ligament injuries was surprisingly high, at 34 of 41 wrists. Complete scapholunate ligament rupture was found in 10 of 41 wrists. This incidence is higher than previously reported and emphasizes the need for careful assessment of the intrinsic and extrinsic ligaments, particularly the scapholunate ligament, before deciding on treatment.

Osteonecrosis of the metacarpal head in a patient with a prothrombin 20210A gene mutation.

Osteonecrosis of the metacarpal head is rare and of unknown cause. We describe a 17-year-old girl with osteonecrosis of the fourth metacarpal head and a mutated prothrombin 20210A gene, which suggests a possible relation between a hypercoagulable state and osteonecrosis of the metacarpal head.

Ulnar shortening osteotomy after Colles fracture.

Ulnar shortening is well accepted in the treatment of ulnar abutment but less so in patients with a shortened radius and ulnar-sided wrist pain as a result of a Colles fracture. Sixteen patients with pain and reduced range of movement (ROM) and a median preoperative ulnar positive variance of 5 mm (range 0.5-11) had 17 osteotomies. Nine were male and seven female with a median age of 35 (range 15-55) years were operated on. Fifteen patients with 16 osteotomies could be reached for follow-up. The ulna was shortened by a median of 4.5 mm (range 3-12). The median pain score was reduced by 3 points (range 0-5). Postoperative ROM was improved in nine, unchanged in six, and reduced in one wrists. There were four complications: one re-fracture, two transient paraesthesiae, and one superficial infection. Seven of the patients regarded the result as excellent, six as good, three as fair, and none regarded it as poor. Thirteen of the 16 would have chosen the operation again, three would not.

Rupture of the extensor pollicis longus tendon: a study of aetiological factors.

Although rupture of the extensor pollicis longus (EPL) tendon is a well-known complication of distal radial fractures, a number of patients rupture the EPL because of other conditions. We have retrospectively studied the aetiology of 27 ruptures of the EPL in 26 consecutive patients. Of 19 patients with injured wrists 12 had distal radial fractures, five had blunt trauma, and two had stab wounds that resulted in rupture. In the radial fractures operated on, the EPL rupture was caused by chafing against a dorsal plate (n = 2) or wear against the pins of an external fixator (n = 2). Six patients were taking steroids for systemic diseases and in two cases a local steroid injection was given just before the rupture. We conclude that previous injury is the most common cause of rupture of the EPL. but that rheumatoid arthritis or local or systemic steroids, or both, are also important aetiological factors. Seven patients had an iatrogenic cause for their rupture.