Longstanding Complicated Wrist Swelling: A Typical Presentation of Primary Tuberculosis a Case Report and Mini Review

Tuberculosis of the wrist joints is an uncommon clinical entity that most frequently presents with insidious pain and swelling. Isolated carpal bones involvement due to tuberculosis is a relatively uncommon event. In this report, the authors describe the case of a 36-year-old female patient presenting with fracture of the scaphoid bone. The diagnosis of tuberculosis was suspected based on the ultrasound and magnetic resonance imaging findings of the wrist joint, and confirmed by joint fluid culture. Introducing anti-tuberculous drugs under appropriate supervision resulted in clinical improvement and optimal regain of function. No reactivation of the disease was noted after 2 years of follow‑up. This case report describes a rare presentation of wrist joint tuberculosis.

Clinical case of preiser disease, bilateral femoral head and humeral head osteonecrosis associated with chronic corticosteroid therapy

Osteonecrosis is a pathologic process that is associated with numerous conditions and therapeutic interventions. Most commonly the hip is involved but almost any bone can develop osteonecrosis. It can occur in the femoral head, but also affect the femoral condyles, humeral heads, proximal tibia, vertebrae, and small bones of the hand and foot. The most frequent etiological factors are trauma, alcoholism, and chronic corticosteroid therapy; the latter causing the most devastating form of osteonecrosis. Glucocorticoid-induced osteonecrosis is a known toxicity in pediatric and young adult patients treated for Acute Lymphoblastic Leukemia (ALL) and Non-Hodgkin Lymphoma (NHL). Osteonecrosis of the shoulders and weight-bearing joints of the lower extremities has emerged as a major adverse effect of modern ALL therapy. Pain in the absence of activity (ie, rest pain) occurs in approximately two-thirds of patients, and nocturnal pain occurs in one-third. MRI continues to be the gold standard for diagnosis in symptomatic and asymptomatic patients, especially in early-stage disease. Respectively to Preiser disease, this condition is a rare disease of unknown etiology characterized by Avascular Necrosis (AVN), also known as osteonecrosis, of the scaphoid bone and the clinical manifestations include insidious and progressive pain lasting from months to years, edema, loss of strength and reduced range of motion in the wrist. The treatment of non-traumatic osteonecrosis remains one of the most controversial subjects in the orthopedic literature. The purpose of this case report is to bring to attention osteonecrosis as a potential side effect of corticosteroid use in the pediatric population, as a delayed or missed diagnosis can lead to several joints destruction.

Validation of Automated Ultrasound-based Registration for Navigated Scaphoid Fixation

Fractures of the scaphoid bone may be treated in a minimally-invasive fashion. Conventionally, fluoroscopy is required to guide the placement of an osteosynthesis screw. In this work, an alternative method based on volumetric ultrasound is validated. Methods: The fully automatic and fast image processing pipeline involves two machine learning architectures for segmentation and registration. A pre-operatively acquired 3D bone model is registered to the 3D bone surface segmented from the intra-operative ultrasound. Screw positioning is planned in an automated fashion and evaluated in an in-vitro setting: Volumetric ultrasound images of a 3D-printed phantom of a human wrist are acquired for 22 different probe poses. For 220 test runs with different initial displacements, the resulting screw placement within a defined safe zone is evaluated. If the screw lies within the safe zone, its placement is assumed to be successful. Results: An isolated analysis of the registration results in a surface distance error of the registered meshes of 0.49 ± 0.01mm, with successful screw placement in all of the evaluated 220 test runs. The full pipeline, combining segmentation and registration, achieves a mean surface distance error of 0.79 ± 0.37mm, leading to successful screw placements for 149 out of 220 test runs. Poses not suited for the registration could be determined. Excluding these from the analysis, 139 out of 160 test runs are successful. Conclusion: The method proves to be promising when evaluating the registration alone, even given the challenging setup of sub-optimal probe positions. The experiments also demonstrate that further improvement regarding the segmentation is necessary.

Segmentation of the Scaphoid Bone in Ultrasound Images

For the percutaneous fixation of scaphoid fractures, navigated approaches have been proposed to facilitate screw placement. Based on ultrasound imaging, navigation can be carried out in a cost-effective and fast manner, furthermore avoiding harmful radiation. For this purpose, a fast and efficient architecture for the automated segmentation of scaphoid bone in ultrasound volume images is needed. Methods: For 2D segmentation of the scaphoid, two architectures are taken into account: 2D nnUNet and Deeplabv3+. These architectures are trained and evaluated on a newly created dataset consisting of 67 annotated in-vivo ultrasound volume images (4576 slice images). Results: In terms of Dice coefficient, the 2D nnUNet achieves 0.67 compared to 0.57 for the Deeplabv3+. In terms of distance metrics, the 2D nnUNet shows an average symmetric surface distance error of 0.66mm, while the Deeplabv3+ achieves 0.55mm. Conclusion: Fast and accurate segmentation of the scaphoid in ultrasound volumes is feasible. Both architectures show competitive results.

Comparison of two different screw trajectories in the treatment of oblique scaphoid fractures: A mechanical study on composite bone models

Objectives: In this mechanical study, we aimed to compare two different screw trajectories in terms of durability against axial loads on oblique scaphoid fractures using composite bone models. Materials and methods: Oblique osteotomies were made along the dorsal sulcus of 14 composite scaphoid bone models. Following this, all bone models were randomly classified. One group of bones were fixed with a screw placed perpendicular to the osteotomy line and the other group was fixed with a screw placed centrally down the long axis of the scaphoid bone. Each scaphoid bone model was positioned on a mechanical testing machine. Subsequently, axial loading tests were applied on each bone model to measure the amount of loading required to cause 2-mm displacement and failure on the osteotomy side and maximum displacement at the time of failure on scaphoid bone models. Results: There was no statistically significant difference in load to 2-mm displacement and failure between the two groups (p>0.05). Also, there was no statistically significant difference between the two groups in terms of maximum displacement seen on failure (p>0.05). Conclusion: In our study, we found that the stability of the screws which laid perpendicular to the fracture line and parallel to the long axis of the scaphoid was the same in fixing oblique scaphoid fractures.

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.

Scaphoid Fracture Reconstruction with Rib Autograft: Case Report and Literature Review

Objective. To evaluate the results of scaphoid bone proximal pole reconstruction with rib osteochondral autograft due to comminuted scaphoid fracture. Material and methods. We present a clinical case of fragmented scaphoid bone proximal pole fracture reconstruction by rib osteochondral autograft. The modified wrist function score of Green and O’Brien and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measuring scales were used for clinical evaluation before and 6 months after the reconstruction. Additio­nally, a literature review was conducted for case reports and previous literature reviews describing scaphoid bone proximal pole fracture surgical treatment. Medline (PubMed), ScienceDirect and UpToDate databases were used. Results. Conventional treatment methods for the treatment of comminuted proximal pole scaphoid bone fractures are often inappropriate due to technical issues or potential adverse outcomes. In these cases, reconstruction with rib autograft is possible. The study patient’s modified wrist function score of Green and O’Brien increased from 75 to 95 points out of 100 at 6 months postoperatively, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score decreased from 13.64 to 4.55 points. The results of this technique have been investigated in several studies (Sandow, 1998, 2001; Veitch et al., 2007). All subjects (22, 47 and 14 patients, respectively), except one, experienced improvement of wrist function – enhanced wrist movement, grip strength, reduced pain and restored wrist function to the pre-injury performance level. Conclusions. Scaphoid bone proximal pole fragmented fracture reconstruction with osteochondrial rib autograft achieves favorable recovery of wrist function and avoids complications or unfavorable functional consequences of alternative surgical procedures.

Normal ranges for measurements of the scaphoid bone from sagittal computed tomography images

This study aimed to determine normal values of three parameters commonly used to determine malunion by investigating intact scaphoids on sagittal computed tomography images from healthy individuals. We analysed 62 normal scaphoids and found the mean height–length ratio, lateral intrascaphoid angle and dorsal cortical angle to be 0.58, 27° and 128°, respectively. These measurements had good-to-excellent, poor-to-moderate and moderate-to-good inter- and intra-rater reliabilities, respectively. This study provides information on normal parameters of the scaphoid that may inform clinical decision making when assessing malunion. We suggest that the lateral intrascaphoid angle should be used with great caution as a measure of deformity. Level of evidence: III