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Musculoskeletal trauma
Published in Ian Greaves, Keith Porter, Chris Wright, Trauma Care Pre-Hospital Manual, 2018
Ian Greaves, Keith Porter, Chris Wright
The proximal row of carpal bones articulates with the distal aspect of the radius and ulna, whilst the distal row articulates with the metacarpals. The scaphoid bone, located in the well of the ‘anatomical snuffbox’, is vulnerable if the patient falls onto an outstretched hand. Diagnosis is not possible without imaging, and the patient with a painful wrist following a fall is likely to require hospital assessment. Management consists of analgesia and the application of a splint or sling. Malleable splints are useful.
SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
The anatomical snuffbox is an important region clinically for three reasons. First, tenderness within the anatomical snuffbox may indicate a fractured scaphoid bone. This is important to recognize since X-rays are often unremarkable in the early stages and, if left untreated, there is a risk of avascular necrosis of the scaphoid (in fact, the proximal scaphoid segment necroses since it receives its blood supply from distal to proximal). Second, tendonitis of the abductor pollicis longus and extensor pollicis brevis tendons may occur; this is known as DeQuervain’s tenovaginitis stenosans. Third, the cephalic vein is almost invariably found in the region of the anatomical snuffbox. The anatomical snuffbox therefore forms a useful landmark for the purpose of gaining intravenous access.
Anatomy
Published in Jonathan M. Fishman, Vivian A. Elwell, Rajat Chowdhury, OSCEs for the MRCS Part B, 2017
Jonathan M. Fishman, Vivian A. Elwell, Rajat Chowdhury
Tenderness within the anatomical snuffbox may indicate a fractured scaphoid bone. This is important to recognise since x-rays are often unaltered in the early stages and if left untreated, there is a high risk of avascular necrosis of the scaphoid (in fact, the proximal scaphoid segment necroses since the scaphoid receives its blood supply from distal to proximal).
Rib osteochondral graft for scaphoid proximal pole reconstruction
Published in Journal of Plastic Surgery and Hand Surgery, 2023
Tomoyuki Koike, Naoki Kato, Kenta Saito, Kenichi Kokubo, Jiro Maegawa
Patient 1, a 21-year-old male who played rugby in college, had persistent left wrist pain. The preoperative function of the wrist was 50° in flexion, 60° in extension, grip strength was 31 kg, and the modified wrist function score of Green and O’Brien was 50 points. Preoperative radiographs and CT scans showed nonunion and atrophy of the proximal pole (Figure 2(A)) of the scaphoid bone. The cartilage on the proximal surface had degenerated. Therefore, an osteotomy was performed at the scaphoid waist region to remove the proximal bone fragments. The rib osteochondral graft was inserted into the proximal part of the scaphoid and fixed with Kirschner wires (Figure 2(B)). Two years post-operation, there was no progression to osteoarthritis, and the carpal bone alignment was maintained (Figure 2(C)). The wrist function was 60° in flexion, 65° in extension, grip strength was 40 kg, and the modified wrist function score of Green and O’Brien was 90 points. He now works in the transportation industry and teaches rugby.
Patient-reported ‘treatment injuries’ after hand surgery. A review of 1321 claims submitted to the Norwegian system of patient injury compensation 2007–2017
Published in Journal of Plastic Surgery and Hand Surgery, 2021
Sunniva Martine Kolstad Addison, Lisa Sofie Albrigtsen, Ida Rashida Khan Bukholm, Hebe Désirée Kvernmo
Of 45.5% of the 712 trauma claims were accepted, varying from 8 to 52.9% (Table 2). The proportion of men was much greater than women (63.6 vs. 36.4% p < .05). Mean age was 38.7 years (SD 15.5). Around 1/5 of the claims were falling into each of the age groups of 20–29, 30–39, 40–49 and 50–59 years. Diagnosis ‘S62 – Fracture at wrist and hand level’ dominated, accounting for almost half of the accepted trauma claims. Note that this diagnosis code does not include distal radius or ulna fractures. Almost ¼ of the claims for hand fractures were due to ‘S62.0 – Fracture of scaphoid bone of wrist’. Of 63% of these were accepted, which is almost 15% higher than for all hand fractures. The second-largest trauma diagnosis was ‘S63 – Dislocation, sprain and strain of joints and ligaments at wrist and hand level’ at 17% (Table 2). ‘S66 – Injury of muscle and tendon at wrist and hand level’ had the highest percentage of accepted claims (52.6%), accounting for 12.7% of accepted trauma claims. The grounds for acceptance were almost equally distributed between ‘treatment failure’ and ‘diagnostic failure’ (Figure 2). However, 2/3 of all accepted hand fracture claims were based on treatment failure, but more than 2/3 of accepted scaphoid fracture claims were based on diagnostic failure. The reasons for failure in treatment or diagnostics are shown in Figures 3 and 4.
Pain, impaired functioning, poor satisfaction and diminished health status eight years following perilunate (fracture) dislocations
Published in Disability and Rehabilitation, 2020
Charlotte M. Lameijer, Caren K. Niezen, Mostafa El Moumni, Corry K. van der Sluis
Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist and comprise only 7% of all carpal injuries [1–5]. PLFDs occur more frequently than PLDs (ratio 2:1), in which the scaphoid bone is most often fractured [6]. Most PLD/PLFDs are seen following injury with high energy transmission. Twenty percent of all PLD/PLFDs are associated with polytrauma [7]. Diminished range of motion of 59–82% and grip strength measurements ranging from 59–87% in comparison to the uninjured wrist were reported 6-months to 5 years following PLD/PLFDs [3,8–11]. In addition, poor outcomes regarding PROs have been reported with Disability of Arm Shoulder Hand (DASH) scores ranging from 14–40 and Patient Rated Wrist Evaluation (PRWE) scores ranging from 13–41 [3,8–13]. Complicated PLD/PLFD is thought to result in poorer outcomes due to extensive soft tissue damage [7]. Late identification of PLD/PLFDs ligament ruptures or accompanying fractures also lead to worse outcomes [2,7,14–16]. Bone necrosis and posttraumatic arthritis is known to develop following this injury [17]. Prevalence of posttraumatic arthritis following PLD/PLFDs of up to 56% has been reported 6 years post-injury [7]. The development of posttraumatic arthritis of the wrist increases with direct or indirect impact load on the joint, soft tissue contusion, joint dislocation, and intra-articular fractures (most often scaphoid bone fractures) [18–20]. Posttraumatic arthritis can result in severe functional impairment with regard to range of motion and grip strength [18].