406 Bioabsorbable Screws in Scaphoid Fractures; a systematic review

Background Scaphoid fractures account for 90% carpal injury. Due to the limited vascular supply achieving adequate reduction and healing is important to avoid complications including avascular necrosis. Recent technological advances have led to renewed vigour in bioabsorbable material research to develop devices which could be used without the need for removal and complications including stress shielding and suboptimal imaging. Method A systematic review was made using PubMed, Ovid Medline, and Google Scholar databases according to PRISMA guidelines. Results Initial search results yielded 852 studies. 124 studies were screened, resulting in 7 studies which were included in this review. The level of evidence of studies ranged between III-IV of low power. Analysis demonstrated mixed findings with generally comparable outcomes to traditionally used screws. Heterogeneity of studies prevented a meta-analysis. Conclusions Development in bioabsorbable materials has yielded promising results in orthopaedic studies, however there is a dearth in research using these devices in the scaphoid. Further robust research is needed to establish the efficacy and applicability of bioabsorbable devices in the scaphoid bone.

Arthroscopic Assisted Reconstruction of LT-Ligament: A Description of a New Technique

Background Injuries of the lunotrirquetral ligament (LT lig) could be part of an extensive carpal injury and are then often treated at the time of the injury. However, when an injury of the LT ligament occurs alone, the injury is often missed. Treatment of this injury has traditionally been by open surgery, such as reattachment of the LT ligament, ligament reconstruction, or arthrodesis of the LT joint. These procedures needed a large exposure to the carpus running the risk of damaging the external ligaments, the nerves important for proprioception, and the capsule with the potential of scarring and adhesions. Materials and Methods We describe a novel arthroscopic assisted technique for reconstruction of the LT ligament. Using this less invasive technique, there is a possible advantage of lesser scarring and faster mobilization. Results We have performed this technique in two patients with more than 30 months follow-up. They both have great improvement of the functional scores. Conclusion The novel arthroscopic assisted technique for LT lig reconstruction is a technically demanding procedure; however, this obtains good clinical results with more than 30 months follow-up due to less exposure of the carpus. Level of Evidence This is a Level IV, case series study.

Wounds, fractures, and orthopaedics

This chapter in the Oxford Handbook of Emergency Medicine investigates wounds, fractures, and orthopaedics in the emergency department (ED). It reviews classification and assessment of skin wounds, puncture wounds, and foreign bodies, and discusses wound cleaning, closure, aftercare, infected wounds, bites and stings, tetanus, and needlestick injury. It explores fractures, including open (compound) fracture and dislocation (and subluxation), casts and their problems, and osteoporosis, as well as soft tissue injury, physiotherapy in the ED, and fracture clinic and alternatives. It describes different areas of fracture and injury in detail, including hand, thumb, scaphoid, and carpal injury, Colles’ fracture, Smith’s fracture, Barton’s and reverse Barton’s fracture, wrist injury, forearm fracture, elbow injury, humeral fracture, shoulder dislocation, clavicle injury, neck injury, facial wounds, pelvic fracture, hip dislocation, sacral and coccygeal fracture, femur fracture, knee injury, tibial and fibular shaft fracture, pretibial laceration, calf and Achilles tendon injury, ankle injury, foot fracture and dislocation, toe injury, low back pain, arthritis, and eponymous fractures.

A Rare Case of Complex Carpal Injury: Divergent Trapezium-Trapezoid Fracture Dislocation

Background Divergent trapezium-trapezoid fracture dislocation is a rare and complex injury. The authors present an unusual case of dislocation of the trapezium-trapezoid complex with scaphoid fracture. Case Description A 25-year-old man suffered a road traffic accident leading to complex carpal injury due to axial and rotation forces (steer wheel injury) on the left wrist. X-rays and computed tomographic (CT) scan were done showing trapezium-trapezoid dissociation with fracture of distal pole of scaphoid and ulna styloid. The second metacarpal base was fractured with many ligamentous injuries in the wrist. Methods Volar flexor carpi radialis (FCR) approach was used to reduce and fix scaphoid fracture with 2.7-mm cannulated screw. Dorsal approach was used to fix fracture of second metacarpal base and perform reduction in trapezium-trapezoid complex with help of 0.8-mm K-wires, and suspension wiring of first to second and second to third metacarpal was done using 1.5-mm K-wires. The transverse flexor retinaculum (TFR) in this case was avulsed. Discussion The divergent trapezium-trapezoid joint with scaphoid fracture is not described in the literature yet. The authors implicate steering wheel injury pattern for such complex carpal fracture dislocations. CT scan is imperative to diagnose and plan treatment of such fracture morphology. Early fracture reduction and stabilization of carpal dislocations are essential for proper functioning of wrist.

Comparison of outcomes between axial radial and axial ulnar carpal injuries

Axial carpal injuries are rare entities where a traumatic force transmits through the intermetacarpal space, dissociating the carpometacarpal joint and disrupting the distal carpal row in an axial radial or axial ulnar pattern via true axial force or compressive crush mechanism. Differences in outcomes remain unclear with regard to the specific type of axial carpal injury pattern. A retrospective case series identified 37 wrists (in 37 patients) over 25 years who presented to a Level 1 trauma centre, with 20 wrists experiencing an axial radial injury and 17 wrists experiencing an axial ulnar injury. Of all the variables evaluated, only axial radial injuries were identified as predictors of poor outcome as defined by Mayo Wrist scores with univariate analysis demonstrating 6 times increased risk and multivariate analysis demonstrating 15 times increased risk of a poor outcome compared with axial ulnar injuries. This knowledge will provide prognostic information to surgeons managing patients with these severe injuries. Level of evidence: IV

Medial radio-carpal arthrodesis in three cats with a 2.0 mm locking maxillofacial plate system

SummaryThe medical records of three cats that were presented with severe carpal injury requiring radiocarpal arthrodesis were reviewed. Medial plating using the Compact 2.0 LOCKTM system a was performed in all three cases. Although screw positioning may be difficult because of the large distance between the holes of the plate and the relatively large size of screws, plate loosening or metacarpal fractures did not occur. Long-term clinical and radiographic follow-up (6 months to 4.5 years) revealed excellent outcome in two cats. In the third cat, the radiocarpal joint did not undergo complete fusion. At four and a half years following surgery, recurrence of forelimb lameness was associated with breakage of the plate.

Non-selective cutaneous sensory neurectomy as an alternative treatment for auto-mutilation lesion following arthrodesis in three dogs

Summary Objective: To describe an alternative method for the treatment of non-responsive self-mutilation injuries in three dogs after carpal/tarsal arthrodesis. Study design: Case series Animals: Two dogs with carpal injury and one dog with tarsal injury treated by arthrodesis Methods: All dogs developed self-mutilation injuries due to licking and/or chewing of the toes within 21–52 days of surgery. Clinical signs did not resolve within one week after conservative treatment with wound debridement and protective bandages. Following general anaesthesia, a deep horseshoe-shaped skin incision, including the subdermal tissue, was performed proximal to the selfmutilation injury transecting the sensory cutaneous afferent nerves. The skin incision was closed with simple interrupted sutures. Results: All wounds healed without complication. Self-mutilation resolved completely within 24 hours after surgery in all dogs. No recurrence was observed (5 months to 3 years). Conclusion: Non-selective cutaneous sensory neurectomy may lead to resolution of self-mutilation following arthrodesis in dogs. Clinical relevance: Failure of conservative treatment in self-mutilation injuries often leads to toe or limb amputation as a last resort. The technique described in this case series is a simple procedure that should be considered prior to amputation. The outcome of this procedure in dogs self-multilating due to neurological or behavioral disturbances unrelated to carpal or tarsal arthrodesis is not known.