Faculty Bibliography

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization

The primary prerequisites for optimal management of the athlete's fractured wrist are prompt diagnosis, anatomic and stable reduction, effective immobilization until healing is thorough, and comprehensive rehabilitation of the injured parts. Fulfillment of these fundamental criteria consistently leads to a highly favorable outcome with minimal risk of re-injury. In contrast, a compromise of these principles, especially for the sake of a speedy return to sports, invariably results in suboptimal recovery and, not infrequently, a permanent loss of skills. The exceptions to the cardinal rule that successful treatment of wrist fractures requires precise restoration of anatomic relationships are specific: displaced hamate hook fractures, displaced trapezial ridge fractures, and comminuted pisiform fractures. In such instances, successful union essentially is precluded, and early excision of the displaced fragments is the logical means of facilitating an uncomplicated recovery. For the more complex fractures requiring stabilization, continual refinements in methods of fixation are considerably diminishing fracture morbidity. The availability of small screws that provide rigid fixation of the carpus is, with increasing consistency, promoting accelerated union and rapid rehabilitation. Well-conceived combinations of low-profile, mechanically efficient external fixators and precisely used Kirschner wires achieve highly secure fracture stability for the distal radius that similarly enhances recovery with a minimum of complications. Improvements in both design and application of internal and external fixation techniques undoubtedly constitute a major advance in the management of wrist fractures among athletes. For some athletes, the return to competition can be safely expedited by the use of custom-fit protective gloves, splints, or casts. For most, however, the treatment regimen usually entails a minimum of 3 to 4 months. Although the healing and rehabilitation process is often lengthy and may seem costly, particularly in terms of time lost from competition, seldom do athletes regret the investment once they return to their highly skillful activities unencumbered by wrist impairment. Never does the sports medicine physician regret compliance with the principles of optimal care

MR imaging is emerging as an invaluable tool in the diagnosis of hand and wrist disorders. It is extremely accurate in the diagnosis of stage 1 Kienbock's disease when plain radiographs are equivocal and in evaluating bone and soft-tissue tumors of the hand and wrist. MR imaging is replacing arthrography as the imaging modality of choice for disruptions of the TFCC. With refined technology and improved resolution, abnormalities involving the intercarpal ligaments ultimately will be able to be detected with a high degree of precision

We reviewed retrospectively a series of 128 consecutive patients who had wrist arthroscopy at our institution between January 1988 and July 1991. The aim of the procedure was to establish a diagnosis in 27 patients, to challenge a pre-operative diagnosis in 95 patients and to evaluate joint surfaces in six patients. For the 27 patients with a previously unknown diagnosis, the diagnostic sensitivity was 67% and the specificity 100%. Arthrotomy or other intervention was avoided in 18. For the 95 patients with an established pre-operative diagnosis, arthrotomy was avoided in 45: in 26 the desired procedure could be done arthroscopically, and in 19 the diagnosis, as improved by arthroscopy, was felt not to require further treatment. Procedures performed arthroscopically included debridement of triangular fibrocartilage and inter-carpal ligament tears; lysis of adhesions, and synovectomy. In six patients, arthroscopy was performed to evaluate joint surfaces after fracture reduction or before ulnar shortening osteotomy. In none of the six was arthrotomy felt necessary after arthroscopy. Wrist arthroscopy avoided the need for further surgery in 66 (52%) of our patients; arthrotomy was avoided in 69 (54%). In cases with significant carpal instability evident pre-operatively, arthroscopy was unlikely to avoid the need for open treatment.

Biaxial design total wrist arthroplasty was used to salvage 13 failed total wrist arthroplasties of various designs. After a follow-up period of 31 months, two wrists had undergone further prosthetic revision for loosening and one wrist was arthrodesed. In the remaining 10 wrists, 8 had no pain, 1 had mild pain, and 1 had moderate pain. Eight patients reported feeling much better, one reported feeling better, and one reported no change. Postoperative range of motion averaged 36-degrees of extension, 19-degrees of flexion, 6-degrees of radial deviation, and 15-degrees of ulnar deviation. X-ray films at follow-up evaluation showed that two revision arthroplasties still in place were loose. The majority of patients had a satisfactory clinical result after revision total wrist arthroplasty with a biaxial design. Loosening of the revision is a significant problem.

The Gustilo and Anderson classification system is widely used to categorize open fractures. To assess its interobserver reliability, 10 patients with open fractures had photographic slides taken of their wound before and after operative treatment. These slides were then shown to a group of orthopaedic surgeons. After an explanation of the Gustilo and Anderson classification system and each patient's pertinent history and physical examination, the physicians were asked to classify the fracture. Agreement among the various raters was determined by Kappa analysis, which is the preferred measurement of interobserver reliability for nominal data such as classification schemes. Kappa analysis demonstrated only moderate agreement among the observers classifying open fractures using the Gustilo and Anderson system. This seems to indicate that, although useful, the Gustilo and Anderson open fracture classification system does have limitations; studies and treatment recommendations based on it should be interpreted with caution.