Occult fractures of the scaphoid: the role of ultrasonography in the emergency department

Objective: To evaluate ultrasonography (US) performed by an emergency radiologist in patients with clinical suspicion of scaphoid fracture and normal radiographs. Materials and methods: Sixty-two consecutive adult patients admitted to our emergency department with clinical suspicion of scaphoid fracture and normal radiographs underwent US examination of the scaphoid prior to wrist computed tomography (CT), within 3days following wrist trauma. US examination was performed by a board-certified emergency radiologist, non-specialized in musculoskeletal imaging, using the linear probe (5-13MHz) of the standard sonographic equipment of the emergency department. The radiologist evaluate for the presence of a cortical interruption of the scaphoid along with a radio-carpal or scapho-trapezium-trapezoid effusion. A CT of the wrist (reference standard) was performed in every patient, immediately after ultrasonography. Fractures were classified into two groups according to their potential for complication: group 1 (high potential, proximal or waist), group 2 (low-potential, distal or tubercle). Results: A scaphoid fracture was demonstrated by CT in 13 (21%) patients: eight (62%) of them belonged to group 1 (three in the proximal pole, five in the waist), five (38%) to group 2 (three in the distal part, two in the tubercle). US was 92% sensitive (12/13) in demonstrating a scaphoid fracture. It was 100% sensitive (8/8) in demonstrating a fracture with a high potential of complication (group 1). Conclusions: Our data show that, in emergency settings, US can be used for the triage to CT in patients with clinical suspicion of scaphoid fracture and normal radiograph

L'ostéotomie d'extension des métacarpiens longs. Solution thérapeutique aux vices de consolidation en flexion. A propos de 14 cas

Fourteen extension osteotomies were performed in 13 patients with angular metacarpal malunion. Surgery was indicated by the limitation of mobility, the reduction in gripping capacity, and pain following digitopalmar grasping movements. After surgery, the patients regained good articular mobility. However, in 60% of cases a teno-arthrolysis was required upon removal of consolidation hardware to restore digital function. The operation allowed pain relief in two-thirds of the patient population; in the remaining subjects, pain was experienced when making grasping movements. At the final examination, in the majority of cases gripping strength was similar to that of the contralateral hand. In conclusion, correction of angular malunion by extension osteotomy is a demanding procedure, and whenever possible should be avoided by a precise reduction of the metacarpal fracture during initial surgery. A fractured metacarpal with a palmar angulation of over 15 degrees should systematically be reduced and fixed if unstable

La fracture instable du radius distal et son traitement : comparaison de trois méthodes reconnues : fixateur externe, embrochage centromédullaire et plaque AO

This retrospective study compares 94 distal radius fractures. Sixty one women (median age 66) and 33 men (median age 42) were reviewed clinically and radiologically by a surgeon not involved in treatment. Fractures were classified into three AO groups. Standard X-rays were used for radiological evaluation. Fractures of the distal ulna were evaluated separately. Chi-square tests, Wilcoxon, Mann-Whitney and Fisher's tests were used for statistical evaluation. Women presented mainly "A" type fractures. They were treated by intramedullary pinning. Forty two fractures were grafted, using autogenous bone for young patients and bone substitute for the elderly. Twelve scapholunate dissociations were recorded, all but one were detected in women, 50 years of age or more. Four were painfree, two presented climatic pain and six claimed pain during effort; none had snapping. Radio-ulnar laxity was similar with or without styloid fractures. External fixator and autogenous grafts appeared the most efficient technique for maintaining radial length. Ulnar head fractures were related to a significant higher incidence of sympathetic dystrophy with reduced prono-supination, a correlation not previously noted to your knowledge. This suggests that radius and ulnar head fracture should be classified independently. The amount of pain was not related to classification, internal fixation or gender

Unstable distal radial fractures treated by external fixation: an analytical review

A "Hoffman type 2" external fixator was applied in 33 patients being treated for distal radial fractures that were classified according to the three basic types of the AO/ASIF system. Thirty fractures were suitable for statistical evaluation. Fixators were used alone (n = 10) or in combination with internal fixation of the intra-articular component. Fixators were removed sooner when they were combined with internal devices and these patients had significantly less pain. There was no relation between pain, classification, primary displacement, function, position on the radiograph, and Green and O'Brien score. Primary displacement was more important in patients over 50 years of age. Reflex sympathetic dystrophy was associated with fractures of the ulnar head. Ulnar styloid fractures were not related to increased laxity or symptoms at the distal radioulnar joint. There were no signs of intracarpal "instability" in patients less than 50 years of age and the condition caused no specific symptoms. Maintenance of stability was better when grafts were used, but not significantly so. Green and O'Brien scoring was no more informative than a simple ordinal pain ranking system

Y a-t-il une place pour le traitement conservateur de la fracture du radius distal chez l'adulte ?

Contrary to Colles'opinion which pretended the fracture of the distal radius would heal without sequellae, many studies devoted to this problem showed that complications will affect one third of the cases (malunion, nerve compression, dystrophy, tendon rupture). It is important for the surgeon to know well the different fracture types, the general condition of his patient as well as his osteoarticular state to make the good choice of treatment. Our study shows that the nonoperative treatment will be chosen for any fracture type as far as it concerns an old or crippled patient, especially if there is an osteoporosis. On the contrary, for a young and active patient with a good bone quality, non operative treatment will be chosen as far as the fracture will be reducible and stable. If it is not, an osteosynthesis has to be done. Many studies already published tend to demonstrate that there is a correlation between anatomical and functional results. However, concerning elderly, this correlation tend to disappear with time