Paul W.L. ten Berg

Classifications of Acute Scaphoid Fractures: A Systematic Literature Review

Background In the lack of consensus, surgeon-based preference determines how acute scaphoid fractures are classified. There is a great variety of classification systems with considerable controversies. Purposes The purpose of this study was to provide an overview of the different classification systems, clarifying their subgroups and analyzing their popularity by comparing citation indexes. The intention was to improve data comparison between studies using heterogeneous fracture descriptions. Methods We performed a systematic review of the literature based on a search of medical literature from 1950 to 2015, and a manual search using the reference lists in relevant book chapters. Only original descriptions of classifications of acute scaphoid fractures in adults were included. Popularity was based on citation index as reported in the databases of Web of Science (WoS) and Google Scholar. Articles that were cited <10 times in WoS were excluded. Results Our literature search resulted in 308 potentially eligible descriptive reports of which 12 reports met the inclusion criteria. We distinguished 13 different (sub) classification systems based on (1) fracture location, (2) fracture plane orientation, and (3) fracture stability/displacement. Based on citations numbers, the Herbert classification was most popular, followed by the Russe and Mayo classifications. All classification systems were based on plain radiography. Conclusions Most classification systems were based on fracture location, displacement, or stability. Based on the controversy and limited reliability of current classification systems, suggested research areas for an updated classification include three-dimensional fracture pattern etiology and fracture fragment mobility assessed by dynamic imaging.

Quantifying Scaphoid Malalignment Based Upon Height-to-Length Ratios Obtained by 3-Dimensional Computed Tomography

PURPOSE To determine if 3-dimensional height-to-length (H/L) measurements including coronal plane assessment will improve malalignment detection of scaphoid fractures and to determine if more waist than proximal pole nonunions are malaligned. METHODS Computed tomography scans of uninjured wrists (n = 74) were used to obtain 3-dimensional models of healthy scaphoids. These models were used to determine 95% normal ranges of the H/L ratio in standard sagittal and coronal planes in an automated fashion. Subsequently, the H/L ratios of fibrous nonunions (n = 26) were compared with these normal ranges and were classified as either aligned or malaligned. RESULTS The mean normal H/L ratio in the sagittal plane was 0.61 (range, 0.54-0.69) and in the coronal plane 0.42 (range, 0.36-0.48). The mean H/L ratios of the nonunions differed from those of the healthy scaphoids in these planes: 0.65 and 0.48, respectively. Based on sagittal plane evaluation of all nonunions, 46% exceeded the normal H/L range versus 54% based on combining sagittal and coronal plane measurements. More waist nonunions (71%) than proximal pole nonunions (22%) exceed the normal H/L range. CONCLUSIONS Evaluation of the H/L ratio in the coronal plane provided valuable additional information for the detection of scaphoid deformities. More malaligned cases were found for waist nonunions than for proximal pole nonunions. CLINICAL RELEVANCE This method may be a helpful diagnostic tool to detect malalignment and to choose between in situ fixation or reconstruction.

Three-Dimensional Assessment of Bilateral Symmetry of the Scaphoid: An Anatomic Study

Preoperative 3D CT imaging techniques provide displacement analysis of the distal scaphoid fragment in 3D space, using the matched opposite scaphoid as reference. Its accuracy depends on the presence of anatomical bilateral symmetry, which has not been investigated yet using similar techniques. Our purpose was to investigate symmetry by comparing the relative positions of distal and proximal poles between sides. We used bilateral CT scans of 19 adult healthy volunteers to obtain 3D scaphoid models. Left proximal and distal poles were matched to corresponding mirrored right sides. The left-to-right positional differences between poles were quantified in terms of three translational and three rotational parameters. The mean (SD) of ulnar, dorsal, and distal translational differences of distal poles relative to proximal poles was 0.1 (0.6); 0.4 (1.2); 0.2 (0.6) mm and that of palmar rotation, ulnar deviation, and pronation differences was −1.1 (4.9); −1.5 (3.3); 1.0 (3.7)°, respectively. These differences did not significantly differ from zero and thus were not biased to left or right side. We proved that, on average, the articular surfaces of scaphoid poles were symmetrically aligned in 3D space. This suggests that the contralateral scaphoid can serve as reference in corrective surgery. No level of evidence is available.

Is there a trend in CT scanning scaphoid nonunions for deformity assessment?—A systematic review

PURPOSE The effect of scaphoid nonunion deformity on wrist function is uncertain due to the lack of reliable imaging tools. Advanced three-dimensional (3-D) computed tomography (CT)-based imaging techniques may improve deformity assessment by using a mirrored image of the contralateral intact wrist as anatomic reference. The implementation of such techniques depends on the extent to which conventional CT is currently used in standard practice. The purpose of this systematic review of medical literature was to analyze the trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally. MATERIALS AND METHODS Using Medline and Embase databases, two independent reviewers searched for original full-length clinical articles describing series with at least five patients focusing on reconstructive surgery of scaphoid nonunions with bone grafting and/or fixation, from the years 2000-2015. We excluded reports focusing on only nonunions suspected for avascular necrosis and/or treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging. For data analysis, we evaluated the use of CT scans and distinguished between uni- and bilateral, and pre- and postoperative scans. RESULTS Seventy-seven articles were included of which 16 were published between 2000 and 2005, 19 between 2006 and 2010, and 42 between 2011 and 2015. For these consecutive intervals, the rates of articles describing the use of pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively. Hereof, only two (3%) articles described the use of bilateral CT scans. CONCLUSION There is an evident trend in performing unilateral CT scans before and after reconstructive surgery of a scaphoid nonunion. To improve assessment of scaphoid nonunion deformity using 3-D CT-based imaging techniques, we recommend scanning the contralateral wrist as well.

A Rare Case of Bilateral Lunotriquetral Coalition and Bilateral Scaphoid Nonunion.

To the Editor: Carpal coalition is rare in Caucasians, with a prevalence of 0.1%, but it is more prevalent in WestAfrican populations. Lunotriquetral (LT) coalitions are most common and can be classified into 4 Minnaar types. Type 1 includes a fibrocartilage coalition resembling pseudoarthrosis, type 2 is incomplete osseous fusion with a distal notch, type 3 is complete osseous fusion, and type 4 is complete fusion with other abnormalities. We wish to report a rare case of bilateral LT coalition with bilateral scaphoid nonunion, which to our knowledge has not been reported previously in the Englishliterature. A 16-year-old African boy playing American football presented with right-sided wrist pain 2 months after a fall. Radiographs showed no acute osseous pathology. Half a year later, the patient had a similar injury to the opposite wrist. After a delay of 3 months, he presented with persisting pain of both wrists. A bilateral computed tomography scan showed a bilateral scaphoid nonunion and left-sided Minnaar type 1 and right-sided Minnaar type 3 coalitions (Fig. 1). The left-sided nonunion was successfully treated with screw fixation. The right-sided nonunion was initially treated with screw fixation in conjunction with cancellous bone grafting. However, because of persistent nonunion and additional fracturing of the proximal pole postoperatively, a subsequent salvage procedure was performed including styloidectomy, proximal scaphoid excision, and pyrocarbon implant insertion (APSI; Tornier, Montbonnot-SaintMartin, France). Lunotriquetral coalition is often an asymptomatic and incidental finding. Some patients present with pain resulting from fracturing of the fused part of the joint after trauma. One French article evaluated 32 wrists

Chapter 8 – Classification Systems of Scaphoid Fractures

There is a great variety of classification systems with considerable controversies. In this chapter an overview is provided on different classification systems, all of which are based on radiographs. Thirteen different (sub)classification systems are found in literature based on (1) fracture location, (2) fracture plane orientation, and (3) fracture stability/displacement. Looking at citations numbers, the Herbert classification was most popular, followed by the Russe and Mayo classifications. Based on the controversy and limited reliability of current classification systems, suggested research areas for an updated classification include three-dimensional fracture pattern etiology and fracture fragment mobility assessed by dynamic imaging.

Chapter 25 – Three-Dimensional Planning of Scaphoid Malunion and Nonunion Correction

IMPORTANCE OF THE PROBLEM In scaphoid waist nonunions, fragment displacement, often manifested as a humpback deformity, is common. Osseous union with the proximal and distal scaphoid pole in a displaced configuration results in a so-called malunion.1 It remains a surgical challenge to restore the anatomy of a scaphoid nonunion or malunion by realigning the fragments, because of the small and complex anatomy of the scaphoid.2 Moreover, fragment displacement is a 3D problem.3–5 Besides a flexion deformity in the sagittal plane, there may also be a rotational deformity in the axial plane, which may be difficult to assess on standard radiography or fluoroscopy. There is much controversy about the clinical consequences of a scaphoid malunion.6 Some clinical series suggested that a scaphoid malunion will lead to pain, loss of motion, and an increased risk of carpal osteoarthritis in the long-term.7–10 Contrary, other clinical studies observed no relationship of malunion with range of motion and grip strength, nor with patient satisfaction.6,11 It is likely that this controversy can be explained by the less reliable use of standard two-dimensional imaging tools to evaluate the level of scaphoid malalignment.12–14 The importance of restoring scaphoid alignment in scaphoid nonunion surgery and the advisability of osteotomy in malunion treatment remain, therefore, areas of debate.14 Nevertheless, it seems that in the treatment of scaphoid nonunions, many surgeons agree that a restoration as close as possible to the original anatomy would benefit patient outcome and should be pursued in additional to fracture healing.4 In the past decades, radiologic software developments have enabled planning scaphoid reconstructions, CHAPTER 25

Observer Variability in Evaluating Pisotriquetral Osteoarthritis using Pisotriquetral View

A pisotriquetral (semilateral) view of the wrist may improve the assessment of pisotriquetral osteoarthritis (OA), but its reliability and reproducibility are unclear. The purpose of this cross-sectional observer study was to investigate (1) the inter- and intraobserver agreement of evaluating pisotriquetral OA using pisotriquetral views with a special focus on sclerosis, joint space width (JSW) narrowing and osteophyte formation, and (2) the incidence of these latter radiographic features in patients suspected for pisotriquetral OA. Five independent observers rated independently at two different occasions 27 pisotriquetral views from patients treated for ulnar-sided wrist pain suspected for pisotriquetral OA requiring a pisiform resection. The agreement was calculated using kappa statistic. Agreement between observers ranged from 0.38 (fair) to 0.56 (moderate). Average intraobserver agreement ranged from 0.43 (moderate) to 0.52 (moderate). In 36% of the ratings, JSW narrowing was observed, followed by osteophyte formation (30%) and sclerosis (28%). Observers found it especially difficult to detect JSW narrowing. Despite the availability of a pisotriquetral view to enhance visualization of the pisotriquetral joint, assessment of the specific features indicating pisotriquetral OA leads to only fair-to-moderate agreement. This limits the applicability of a radiographic assessment. A rationale for a more reliable radiologic approach in assessing the level of pisotriquetral OA is needed, which may require the use of more advanced imaging techniques.

Does a Comparison View Improve the Reliability of Staging Wrist Osteoarthritis

Background: Radiological grading of wrist osteoarthritis associated with scaphoid nonunion advanced collapse (SNAC) can be difficult. A comparison radiograph of the contralateral healthy wrist and an educational training in the various SNAC stages may improve reliability. Our purposes were to evaluate the difference in the reliability: (1) between observers who rate SNAC wrists with and without a comparison radiograph; and (2) between observers who receive training prior to ratings and those who do not. Methods: In this cross-sectional survey study, 82 fully trained orthopedic or hand surgeons rated anteroposterior radiographs of 19 patient wrists following a scaphoid nonunion based on SNAC stages 0 to 4. Observers were randomized online in 4 groups: one group rated unilateral views without training, a second group unilateral views with training, a third group bilateral views without training, and a fourth group bilateral views with training. Training included a 1-page clarification of the SNAC stages. Interobserver agreement was calculated using kappa statistics. Results: There was no significant difference between agreement between observers who rated unilateral radiographs (κ = 0.55) and who rated bilateral radiographs (κ = 0.58) (P = .14), nor between agreement between observers who received training (κ = 0.59) and who did not (κ = 0.54) (P = .058). Conclusions: The use of an additional comparison view and/or training does not seem to be clinically relevant in SNAC staging. There is room for improvement in the way we assess patients with SNAC wrists.

Joint Space Narrowing in Patients With Pisotriquetral Osteoarthritis

Background: Patients with suspected pisotriquetral osteoarthritis may show joint space narrowing. However, the extent of joint space narrowing and its deviation from the joint space width (JSW) in normal anatomy is unknown. In this pathoanatomic study, we therefore compared the JSW in the pisotriquetral joint between osteoarthritic patient wrists and healthy wrists. Methods: We reviewed preoperative computed tomography (CT) scans of 8 wrists of patients with ulnar-sided wrist pain who underwent a pisiformectomy with confirmed pisotriquetral osteoarthritis at surgery. We also reviewed CT scans of 20 normal wrists from healthy volunteers serving as control group. Three-dimensional CT models of the pisiform and triquetrum were obtained from both affected and normal wrists, after which the minimum JSW was calculated in an automated fashion. Results: In the patient group, the median (interquartile range) of the minimum JSW was 0.1 mm (0.0-0.2), and in the control group, 0.8 mm (0.3-0.9) (P = .007). Conclusions: We showed that the pisotriquetral joint space in osteoarthritic patient wrists was significantly narrowed compared with healthy wrists. These results suggest that JSW evaluation has a potential diagnostic value in the work-up of patients with suspected pisotriquetral osteoarthritis. This is an interesting area for future clinical research, especially because no gold standard for diagnosing pisotriquetral osteoarthritis has been established yet.