Robert J. Belsole

The fractured scaphoid

In this volume, a leading authority on scaphoid fractures shares his insights and techniques in this engagingly written, liberally illustrated volume. The book offers a clinical approach to the successful treatment of this common, potentially troublesome, wrist injury. It approaches the problem of the fractured scaphoid from the viewpoint of a practicing clinician who may be approached by a patient who is relatively symptom-free in the initial stage of the injury, necessitating the use of effective imaging techniques for proper diagnosis.

Carpal orientation from computed reference axes

Carpal instability is usually diagnosed by abnormal two-plane radiographic angles. These angles are often unreliable. A method that eliminates interpretation of overlapping shadows and uses all of the carpal geometry should improve clinical diagnoses. The digital data from computed tomography scans can be manipulated to describe the carpal orientation in the normal wrist. The digital data from the computed tomography scans of twenty-two normal wrists were used to compute distances with and without directions between the volumetric centroids of the carpal bones. An expansion technique also extracted from the computed tomography data an orthogonal set of vectors, the principal axes. The first principal axis describes the longest dimension of each bone. The average angle produced by the first principal axes of the scaphoid and lunate was 23.6 degrees, scaphoid and capitate was 73.2 degrees, and the capitate and the lunate was 93.5 degrees. These computations represent new carpal axes and intercarpal angles that are not related to the commonly measured two-plane radiographic angles. They should prove helpful in the study of kinematics and pathomechanics in the wrist joint.

Radiography of the wrist.

The painful wrist frequently poses a diagnostic dilemma. Although increased understanding of normal carpal motion has led to more constructive use of roentgenography, the diagnostic acumen of the examiner is greatly enhanced by the standardization of radiographic views as well as by the use of special projections and when indicated, arthrograms.

Percutaneous treatment of carpal, metacarpal, and phalangeal injuries.

Percutaneous fixation of hand fractures is a common technique that takes advantage of the subcutaneous nature of hand bones, their small size, and their limited loading potential for stress placed on hardware. Percutaneous wire fixation supplements cast fixation when plaster cannot hold particular reductions, and allow surgical fixation with limited postoperative swelling. In the first part of the current study, the types of wires that are used for hand fixation, fluoroscopy, helpful instruments, and the basic techniques used for this type of surgery are discussed. In the second part of the study, specific fixation techniques for different fractures of the carpals, metacarpals, and phalanges are outlined.

Distal ulnar physeal injury.

We reviewed 18 patients and two traumatic amputation specimens with injuries involving the distal ulnar physis. Type 1 growth mechanism injuries were the most common fracture pattern with premature physeal closure and ulnar shortening occurring in 55% of the patients. Other consequences included radial bowing, ulnar angulation of the distal radius, and ulnar translocation of the carpus. Most of the patients, however, were asymptomatic. Initial radiographic diagnosis of this physeal injury may be difficult because of the relatively late ossification of the distal ulnar physis. Concomitant ulnar physeal injuries must be suspected in any injury to the distal radius, especially when an ulnar metaphyseal or styloid fracture is not readily evident.

Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques.

The techniques of tension band fixation are applied in the treatment of metacarpal and phalangeal fractures. The technique uses standard, readily available materials. The variability of the fixation techniques allows for secure fixation of virtually any long bone fracture in the hand, even when other methods are not applicable. Nonunion, malunion, loss of fixation, infection, or tendon rupture have not occurred. The technique allows for early active motion and return to full activity usually within for to six weeks. Most patients achieve full painless motion in that time.

Transulnar percutaneous pinning of displaced distal radial fractures: a preliminary report.

Difficulty in maintaining the reduction of displaced radial fractures has prompted the use of numerous techniques to address this problem. The purpose of this study was to determine if four or five 0.045-in Kirschner pins when placed percutaneously through the ulna into the radius could maintain the reduction of this unstable fracture configuration. A 15-month average follow-up of 14 patients, averaging 48 years old, included subjective patient responses and range-of-motion measurements of the forearm, wrist, and digits in addition to grip strength determinations. Analyses of the radial angle and radial height were made on the posteroanterior radiograph, and the articular inclination was assessed on the lateral radiograph. Overall results were 2 excellent and 12 good using the Scheck demerit system of evaluation. The advantages of this technique are as follows: Radial sensory nerves are avoided; use of a lightweight splint at 3 weeks promotes patient comfort and facilitates finger range-of motion exercises; percutaneous pins are easily removed in the office without anesthesia; and pin site scars are barely perceptible at follow-up in the majority of patients.

Composite wiring of metacarpal and phalangeal fractures

Composite wiring techniques using various configurations of Kirschner pins and stainless steel wire sutures have been applied to the treatment of 63 fractures of the long bones of the hand. The secure fixation achieved allowed active motion within 1 week of operation. Thirty-three metacarpal fractures achieved a final mean total active motion of 256 degrees (standard deviation 13.4) (normal total active motion -260 degrees). Twenty-one phalangeal fractures achieved a mean total active motion of 215 degrees (standard deviation, 46 degrees). There were no instances of infection, malunion, nonunion, loss of reduction, or tendon rupture in the 63 fractures that were treated.

Ossification and pseudoepiphysis formation in the “nonepiphyseal” end of bones of the hands and feet

Metacarpals, metatarsals, and phalanges were studied to assess the developmental morphology of “secondary” ossification in the “nonepiphyseal” ends of these bones as well as the formation of the pseudoepiphysis as an epiphyseal ossification variant. Both direct ossification extension from the metaphysis into the epiphysis and pseudoepiphysis formation preceded, and continued to be more mature than, formation and expansion of the “classic” epiphyseal (secondary) ossification center at the opposite end of each specific bone. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously. In contrast, when remnants of “physis” were retained, while juxtaposed epiphyseal cartilage was replaced, a pseudoepiphysis formed. There were three basic patterns of pseudoepiphysis formation. First, a central osseous bridge extended from the metaphysis across the “physis” into the epiphysis and subsequently expanded to create a mushroom-like osseous structure. In the second pattern a peripheral osseous bridge formed, creating either an osseous ring or an eccentric bridge between the metaphysis and the epiphysis. In the third pattern, multiple bridging occurred. In each situation the associated remnant “physis” lacked typical cell columns and was incapable of significantly contributing to the postnatal longitudinal growth of the involved bone. Pseudoepiphyses were well formed by 4–5 years and coalesced with the rest of the bone months of years before skeletal maturation was attained at the opposite epiphyseal end, which ossified in the typical pattern (i.e., formation of a secondary center de novo completely within the cartilaginous epiphysis). This process may also affect the development and appearance of ossification within the longitudinal epiphyseal bracket (“delta phalanx”).

Radial nerve injury after routine peripheral vein cannulation

The dorso-radial aspect of the wrist and hand is a common location for intravenous (IV) cannulation prior to anesthesia. The sensory branch of the radial nerve lies superficially in this area, and it can be injured during routine insertion of IV catheters. In this case, the nerve was lacerated during insertion and a painful neuroma developed after elective surgery and anesthesia. Knowledge of this complication may help with its recognition and treatment.