Faculty Bibliography

PURPOSE/OBJECTIVE:Early diagnosis and treatment of scaphoid fractures is critical to achieve union and prevent wrist degenerative arthritis. Plain radiographic measurements can guide the early approach to suspected fractures. Specifically, the ability to predict fracture or fracture stability from plain radiographs may allow the traumatologist to expand initial referral to three-dimensional imaging. We evaluated the ability of four measured angles to predict presence of a scaphoid fracture and stability. METHODS:Fifty patients with a scaphoid fracture and 50 patients without fracture were evaluated for the cortical ring sign, scapho-lunate gapping, lateral scapholunate (SL), radio-scaphoid (RS), radio-lunate (RL), and radio-capitate (RC) angles by two-blinded observers. RESULTS:Measurement of an increased SL interval was associated with the presence of a scaphoid fracture as diagnosed on three-dimensional imaging [odds ratio (OR) 3.0, confidence interval (CI) 1.53-5.87, p =  < 0.01]. The measured RL angle was associated with fracture displacement (OR 1.13, 95% CI 1.02-1.25, p = 0.02). CONCLUSIONS:Scapholunate gapping on plain radiographs in the context of a clinically suspected scaphoid fracture should increase suspicion for a fracture and may prompt earlier 3-dimensional imaging, while the presence of an abnormal radiolunate angle should increase wariness for instability and can be used in preoperative planning.

Cryptococcal infection is well-documented in immunocompromised individuals. Cutaneous manifestations are not as common and are often difficult to diagnose due to variable presentations. Furthermore, there have been reports of coexisting cutaneous Cryptococcus and malignancy. We describe a patient that presented with a fast-growing mass (suspected sarcoma) in the hand that was ultimately treated for a Cryptococcus skin infection. We believe familiarity with the possibility of coexistence of these two conditions in an immunocompromised host could have brought about earlier diagnosis and possibly more effective treatment. Level of Evidence: Level V (Therapeutic).

BACKGROUND:Cubital tunnel syndrome and the resulting loss of hand dexterity and strength may necessitate surgical management. Studies have demonstrated no difference in outcome between surgical techniques. In an attempt to leave more ulnar nerves in situ while providing for stability within the cubital tunnel, we suggest a surgical treatment approach. METHODS:The approach addresses individual anatomy methodically, eliminating muscular obstruction first and providing further decompression and stability as required. A retrospective review of 27 adult patients with ulnar neu- ropathy treated according to this method was performed. RESULTS:The mean duration of symptoms prior to surgery was 2.75 years (SD = 2.4). The mean follow-up was 17.1 months (SD = 16.9). All patients improved following surgery. Two revision surgeries were performed 4 years following the original surgery. CONCLUSIONS:We believe the nerve recovers best when left in situ, provided it is stable and not compressed within the cubital tunnel. A further comparison study is necessary to substantiate the advantage of this "personalized" approach over other surgical techniques for cubital tunnel release.

BACKGROUND:Identifying and treating patients with fragility fractures may be effective in prevention of subsequent fractures because a first fragility fracture often predicts a second fracture. OBJECTIVES/OBJECTIVE:To evaluate a multidisciplinary anti-osteoporotic clinic for patients with prior distal radius fragility fractures (DRFF). To assess whether addressing this early fracture may prevent a second fracture. METHODS:A retrospective case-control study was performed. Cases included patients treated surgically for DRFF who were assessed at a tertiary, multidisciplinary, fracture-prevention clinic. Controls were a series of similarly treated patients who did not attend the clinic. The primary outcome measure was a second fracture. RESULTS:Average follow-up was 42 months for the treated group and 85 months for the untreated group. The treated group received more treatment for osteoporosis than controls; however, despite one new fracture in the treated group and six new fractures in the control group, there was no significant difference in fracture occurrence. CONCLUSIONS:This pilot study supports the effectiveness of our multidisciplinary anti-osteoporotic clinic in treating osteoporosis but not in reducing subsequent fractures. Further study with larger cohorts and longer follow-up is needed to improve our ability to implement effective prevention of fragility fractures.

BACKGROUND:Gout is a common condition and its prevalence is increasing. In the wrist, acute gouty arthritis is difficult to distinguish from infection and may occur concomitantly. Though aspiration is helpful, it is not always technically feasible or definitive. Imaging may assist in the differential diagnosis. CASE PRESENTATION/METHODS:Two cases are described in which the use of ultrasound evaluation assisted in the diagnosis and ultimate treatment. CONCLUSION/CONCLUSIONS:Ultrasound can be a helpful adjunct in the diagnosis of arthritis of the wrist, helping to tailor treatment in complex cases.