J.A. Oni

MRI and plain radiography in the assessment of displaced fractures of the waist of the carpal scaphoid

We treated 50 patients with fractures of the waist of the scaphoid in a below-elbow plaster cast for up to 13 weeks. Displacement of the fragments was assessed independently by two observers using MRI and radiographs performed within two weeks of injury. The MRI assessments showed that only the measurement of sagittal translation of the fragments and an overall assessment of displacement had satisfactory inter- and intra-observer reproducibility and revealed that nine of the 50 fractures were displaced. Only three of the 49 fractures with adequate follow-up failed to unite, and all were displaced with more than 1 mm of translation in the sagittal plane. If the MRI assessment of displacement of the fracture was used as the measurement of choice, assessment of displacement on the initial scaphoid series of radiographs showed a sensitivity of between 33% and 47% and a positive predictive value of between 27% and 86%. Neither observer was able correctly to identify more than 33% to 47% of the displaced fractures from the plain radiographs. Although the overall assessment of displacement and gapping and translation in the coronal plane on the plain radiographs influenced the rate of union, none of these parameters identified all three fractures which failed to unite. We conclude that the assessment of displacement of scaphoid fractures on MRI can probably be used to assess the likelihood of union although the small number of nonunions limits the power of the study. In contrast, the assessment of displacement on routine radiography is inaccurate and of less value in predicting union.

Partial Union of Acute Scaphoid Fractures

Sixty-six patients with acute scaphoid fractures were treated non-operatively in a below elbow plaster for 8 to 12 weeks and underwent CT scans along the longitudinal axis of the scaphoid at 12 to 18 weeks. These scans showed that 14 fractures had not united and that 30 had united throughout the whole cross-section of the scaphoid. The other 22 had partially united with bridging trabeculae in some areas of the cross-section. These 22 partial unions were graded as 0% to 24% union (0 cases), 25% to 49% union (5 cases), 50% to 74% union (7 cases), and 75% to 99% union (10 cases). The 12 patients who had less than 75% fracture union were followed-up further and nine underwent another CT scan at 23 to 40 weeks after the initial injury. These showed union across the whole of the cross-section of the fracture in seven cases and 75% to 99% union in the other two cases, who had full and painless wrist function. We conclude that partial union of the scaphoid is a common occurrence but, in most cases, it progresses to full union without the need for prolonged plaster immobilization.

GANGLIA: THE PATIENT'S PERCEPTION

This study investigates the concerns of 50 patients with ganglia and their reasons for primary care consultation and referral to a hand unit. Although a minority of patients sought advice and treatment because of pain, more (38%) were concerned about the cosmetic appearance and a significant number (28%) were concerned that their ganglion was a malignant growth. The general practitioners referred 70% of patients to the hand clinic for “excision of the ganglion” and 30% for further “advice and treatment”. However, 74% of patients were satisfied with aspiration of the ganglion and general advice.

Displaced scaphoid waist fractures: the use of a week 4 CT scan to predict the likelihood of union with nonoperative treatment

This study assessed whether nonunion of displaced scaphoid waist fractures with nonoperative treatment could be predicted from 4 week CT scans. Thirty-one patients with unilateral displaced scaphoid waist fractures and adequate follow-up were included. CT scans in the longitudinal axis of the scaphoid with sagittal and coronal slices were done 4 weeks after the index injury. The effects of fracture gap, sclerosis and bone resorption on union were assessed. Fracture union was observed in all 13 displaced fractures with a <2 mm gap, four of the seven with a gap of 2–3 mm and only four of the 11 with a gap >3 mm (p = 0.01). Bone resorption involving more than 50% of the fracture cross-section was also associated with nonunion, but sclerosis was not.

Palmar plate interposition (Tupper) arthroplasty for post-traumatic metacarpophalangeal osteoarthritis

We report the results of five interposition palmar plate (Tupper) arthroplasties for post-traumatic or post-infection osteoarthritis of metacarpophalangeal joints. All were pain free at a median follow-up of 4 years. The mean arc of joint flexion was 55° and finger to thumb tip pinch was 60% of normal. All patients had reduced grip strength, but were satisfied with the procedure.

Preservation of the Ulnar Bursa Within the Carpal Tunnel: Does It Improve the Outcome of Carpal Tunnel Surgery?

BACKGROUND It was hypothesized that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression. METHODS Patients consented to randomization to treatment with either preservation of the parietal layer of the ulnar bursa beneath the flexor retinaculum at the time of open carpal tunnel decompression (fifty-seven patients) or division of this gliding layer as part of a standard open carpal tunnel decompression (sixty-one patients). Grip strength was measured, scar pain was rated, and the validated Patient Evaluation Measure questionnaire was used to assess symptoms and disability preoperatively and at eight to nine weeks following the surgery in seventy-seven women and thirty-four men; the remaining seven patients were lost to follow-up. RESULTS There was no difference between the groups with respect to age, sex, hand dominance, or side of surgery. Grip strength, scar pain, and the Patient Evaluation Measure score were not significantly different between the two groups, although there was a trend toward a poorer subjective outcome as demonstrated by the questionnaire in the group in which the ulnar bursa within the carpal tunnel had been preserved. Preserving the ulnar bursa within the carpal tunnel did, however, result in a lower prevalence of suspected wound infection or inflammation (p = 0.04). CONCLUSIONS In this group of patients, preservation of the ulnar bursa around the median nerve during open carpal tunnel release produced no significant difference in grip strength or self-rated symptoms. We recommend incision of the ulnar bursa during open carpal tunnel decompression to allow complete visualization of the median nerve and carpal tunnel contents.

MRI assessment of scaphoid fracture displacement: Does it predict union?

Fifty patients with acute scaphoid waist fractures were treated non-operatively in a below elbow plaster cast for 8-13 weeks. Each underwent a MRI scan of the scaphoid within 2 weeks of injury and fracture displacement was assessed on these by two observers who were unaware of the outcome (union or nonunion) by measuring a variety of parameters. The only quantitative measurements of displacement which were reproducible were fracture gapping (distraction) and translation. Qualitative categorisation of the fractures into undisplaced (41 cases) and moderately (7 cases) and severely (2 cases) displaced groups according to their overall MRI appearances was equally reproducible. Three of 49 fractures (one undisplaced fracture lost to follow up) failed to unite: two of these were moderately displaced and one was severely displaced. All the undisplaced fractures united. We conclude that MRI assessment of fracture displacement probably affects the likelihood of union with non-operative treatment though our small number of nonunions weakens the power of this study. We thus recommend that all acute scaphoid fractures should be assessed with MRI scans or tomography and classified as undisplaced and displaced. Undisplaced fractures can be treated conservatively in plaster with a high chance of union, whereas open operative fixation could be considered for displaced fractures.