Chronic with arthritic changes CMC arthrodesis

scaphoid, capitate, and second metacarpal bones. It is wedge-shaped; the dorsal facet is twice the size of the palmar facet, which causes fractures and dislocations to displace dorsally when the second metacarpal is driven into extreme flexion [7,9,93]. In addition to the orientation, the palmar ligaments are stronger than its dorsal attachments, and therefore the bone is susceptible to displacement dorsally. The trapezoid is perfused by separate circulations on the volar and dorsal surfaces, where 70% of the blood supply is delivered dorsally. When there is dorsal displacement, the vasculature may be ruptured, predisposing the trapezoid to avascular necrosis [93].

Fracture dislocations are the result of high-energy forces that create multiple injuries. Therefore the metacarpals, as well as the carpal bones, require a thorough inspection during treatment planning. Isolated injuries are caused by extreme palmar flexion by the second metacarpal leading to fracture or dorsal dislocation. Clinically, there is point tenderness at the dorsal trapezoid as well as pain exacerbation with manipulation of the second metacarpal bone. Plain radiographs often do not suffice, and a CT scan is required to make a definitive diagnosis. PA and oblique views may show an empty space with proximal migration of the second metacarpal or dorsal displacement of the trapezoid, respectively [7-9,93,94].

Nondisplaced fractures should be managed nonoperatively with a short-arm thumb spica cast for 4 to 6 weeks. Displaced fractures should be treated with closed reduction internal fixation versus ORIF. Closed reduction may be achieved by distraction of the thumb and second meta-carpal as well as palmarly directed pressure over the dorsal aspect of the trapezoid [93,94]. If closed reduction fails, ORIF is performed through a dorsal incision. Carpometacarpal arthrodesis is reserved for chronic mal- or nonunion with arthritic changes. Box 7 provides diagnosis and treatment guidelines.

Summary

Carpal fractures are uncommon but potentially devastating injuries. Physical examination and standard plain radiographs may reveal only subtle findings. Knowledge of expected fracture patterns and use of special radiographic views or CT scans should aid in making the diagnosis. Nondisplaced fractures should be treated nonoperatively. For intra-articular carpal bone fractures, virtually any amount of displacement is unacceptable and requires reduction and fixation. Depending on the bone, differing blood supply anatomy may play a role in the prognosis of nonunion and risk of AVN. Chronic cases of carpal nonunion, AVN, and arthritis my require salvage procedures of proximal row carpectomy, partial or complete wrist arthrodesis, or arthroplasty.

References

[1] Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg [Am] 2001;26:908-15.

[2] Hove T. Fractures of the hand. Scand J Plast Recons Surg 1993;27(4):317-9.

[3] Van Onselen EB, Karim RB, Hage JJ, et al. Prevalence and distribution of hand fractures. J Hand Surg [Br] 2002;28:491-5.

[4] Shaheen MAE, Badr AA, Al-Khudairy N, et al. Patterns of accidental fractures and dislocations in Saudi Arabia. Injury 1990;1(21):347-50.

[5] Emmet JE, Breck LW. A Review and analysis of 11,000 fractures seen in a private practice of orthopaedic surgery 1937-1956. J Bone Joint Surg [Am] 1958;40:1169-75.

[6] Teisen H, Hjarbaek J. Classification of fresh fractures of the lunate. J Hand Surg [Br] 1988;13: 458-62.

[7] Botte MJ, Gelberman RH. Fractures of the carpus, excluding the scaphoid. Hand Clin 1987;3(1): 149-61.

[8] Bryan RS, Dobyns JH. Fractures of the carpal bones other than lunate and navicular. Clin Orthop 1980; 149:107-11.

[9] Cohen MS. Fractures of the carpal bones. Hand Clin 1997;13(4):587-99.

[10] Rand JA, Linscheid RL, Dobyns JH. Capitate fractures: a long-term follow-up. Clin Orthop 1982;165: 209-16.

[11] Harrigan AH. Fracture of the os magnum. Ann Surg 1908;48(6):917-22.

[12] Adler JB, Shaftan GW. Fractures of the capitate. J Bone Joint Surg [Am] 1962;44:1537-47.

[13] Calandruccio JH, Duncan SFM. Isolated nondis-placed capitate waist fracture diagnosed by magnetic resonance imaging. J Hand Surg [Am] 1999;24: 856-9.

[14] Guiral J, Gracia A, Diaz-Otero JM. Isolated fracture of the capitate with a volar displaced fragment. Acta Orthop Belg 1993;59:406-8 [in French].

[15] Hopkins SR, Ammann W. Isolated fractures of the capitate: use of nuclear medicine as an aid to diagnosis. Int J Sports Med 1990;11:312-4.

[16] Richards RR, Paitich CB, Bell RS. Internal fixation of a capitate fracture with Herbert screws. J Hand Surg [Am] 1990;15:885-7.

[17] Young TB. Isolated fracture of the capitate in a 10-year old boy. Injury 1986;17:133-4.

[18] Enna CD. Isolated pathological fracture of the capitate bone: a case report. Hand 1979;11: 329-31.

[19] Vizkelety T, Wouters HW. Stress fracture of the capitate. Arch Chir Neerl 1972;24:47-57.

[20] Kuniyoshi K, Toh S, Nishikawa S, et al. Long-term follow-up of a malunited isolated fracture of the capitate in a 6-year old boy. J Pediatr Orthop 2005;14B: 46-50.

[21] Thompson NW, O'Donnell M, Thompson NS, et al. Internal fixation of an isolated fracture of the capitate using the Herbert-Whipple screw. Injury 2004; 35(5):541-2.

[22] Yoshihara M, Sakai A, Toba N, et al. Nonunion of the isolated capitate waist fracture. J Orthop Sci 2002;7(5):578-80.

[23] De Schrijver F, De Smet L. Isolated fracture of the capitate: the value of MRI in diagnosis and follow up. Acta Orthop Belg 2002;68(3):310-5 [in French].

[24] Rebuzzi E. Isolated fracture of the capitate with proximal pole dorsal dislocation. A case report. Acta Orthop Belg 2001;67(3):283-5 [in French].

[25] Mikes K. Isolated fracture of the capitate bone. Acta Chir Orthop Traumatol Cech 1964;31:417-21 [in Czech].

[26] Gandolfi M, Zanoli S. The isolated fracture of the capitate eminence. Arch Ortop 1959;72:1485-93 [in Italian].

[27] Mullett H, Shannon F, Syed A, et al. Nonunion of the capitate with associated triangular fibrocarti-lage tear. Arch Orthop Trauma Surg 2001;121: 362-3.

[28] Rico AA, Holguin PH, Martin JG. Pseudoarthrosis of the capitate. J Hand Surg [Br] 1999;24(3): 382-4.

[29] Gelberman RH, Gross MS. The vascularity of the wrist: identification of arterial patterns at risk. Clin Orthop 1986;202:40-9.

[30] Gelberman RH, Panagis JS, Taleisnik J, et al. The arterial anatomy of the human carpus. Part I: the extraosseous vascularity. J Hand Surg [Am] 1983; 8:367-75.

[31] Panagis JS, Gelberman RH, Taleisnik J, et al. The arterial anatomy of the human carpus. Part II: the intraosseous vascularity. J Hand Surg [Am] 1983;8: 375-82.

[32] Fenton RL, Rosen H. Fractures of the capitate bone. Report of two cases. Bull Hosp Joint Dis 1950;11:134-9.

[33] Minami M, Yamazaki J, Chisaka N, et al. Nonunion of the capitate. J Hand Surg [Am] 1987;12: 1089-91.

[34] Schmitt O, Temme C. Carpaltunnelsyndrome bei Pseudarthrosebildung nach isolierter Fraktur des Os capitatum [Carpal tunnel syndrome in developing pseudarthrosis following isolated fracture of os capitatum]. Arch Orthop Trauma Surg 1978;93: 25-8 [in German].

[35] Grend VR, Dell PC, Glowczewskie F, et al. Intraosseous blood supply of the capitate and its correlation with aseptic necrosis. J Hand Surg [Am] 1984;9: 677-80.

[36] Dahlin LB, Besjakov J. An unusual variant of fracture through the capitate bone—a case report. Acta Orthop Scand 2002;73(2):232-3.

[37] Albertsen J, Mencke S, Christensen L, et al. Isolated capitate fracture diagnosed by computed tomography. Case report. Handchir Mikrochir Plast Chir 1999;31(2):79-81 [in German].

[38] Bretlau T, Christensen OM, Edstrom P, et al. Diagnosis of scaphoid fracture and dedicated extremity MRI. Acta Orthop Scand 1999;70(5):504-8.

[39] Rayan GM. Occult wrist pain due to capitate nonunion. South Med J 1994;87(3):402-4.

[40] Schick S, Trattnig S, Gabler C. Okkulte Handgelenkfrakturen: Feinfokusvergrosserungsrontren versus MRT [Occult fractures of the wrist joint: high resolution image magnification roentgen versus MRI]. Rofo 1999;170(1):16-21 [in German].

[41] Volk AG, Schnall SB, Merkle P, et al. Unusual capitate fracture: a case report. J Hand Surg [Am] 1995; 20:581-2.

[42] Heim U. Pseudarthrose des Kapitatums [Pseudarth-rosis of the capitate]. Handchirurgie 1986;18:158-60 [in German].

[43] Lowry WE Jr, Cord SA. Traumatic avascular necrosis of the capitate bone—case report. J Hand Surg [Am] 1981;6:245-8.

[44] Fleege MA, Jebson PJ, Renfrew DL, et al. Pisiform fractures. Skeletal Radiol 1991;20:169-72.

[45] Palmieri TJ. Pisiform area pain treatment by pisiform excision. J Hand Surg [Am] 1982;7:477-80.

[46] Marti T, Gimilio GG. Study of the isolated fracture of the pisiform bone. Schweiz Rundsch Med Prax 1973;62:968-9 [in French].

[47] Vasilas A, Grieco VR, Bartone NF. Roentgen aspects of injuries to the pisiform bone and pisotriquetral joint. J Bone Joint Surg [Am] 1960; 42:1317-28.

[48] Carroll RE, Coyle MP Jr. Dysfunction of the pisotriquetral joint: treatment by excision of the pisiform. J Hand Surg [Am] 1985;10:703-7.

[49] Israeli A, Engel J, Ganel A. Possible fatigue fracture of the pisiform bone in volleyball players. Int J Sports Med 1982;3:56-7.

[50] Turecki E. Isolated fracture of the pisiform bone. Chir Narzadow Ruchu Ortop Pol 1972;37:17-9 [in Polish].

[51] Dufek P, Thormahlen F, Ostendorf U. Fracture of the pisiform bone in inline skating. Sportverletz Sportschaden 1999;13(2):59-61 [in German].

[52] Cavlak Y. Fracture of the pisiform bone. Aktuelle Traumatol 1994;24(2):68-9 [in German].

[53] Lacey JD, Hodge JC. Pisiform and hamulus fractures: easily missed wrist fractures diagnosed on a reverse oblique radiograph. J Emerg Med 1998;16: 445-52.

[54] Abbit PL, Riddervold HO. The carpal tunnel view: helpful adjuvant for unrecognized fractures of the carpus. Skeletal Radiol 1987;16(1):45-7.

[55] Failla JM, Amadio PC. Recognition and treatment of uncommon carpal fractures. Hand Clin 1988;4: 469-76.

[56] Matsunaga D, Uchiyama S, Nakagawa H, et al. Lower ulnar nerve palsy related to fracture of the pisiform bone in patients with multiple injuries. J Trauma 2002;53:364-8.

[57] Howard FM. Ulnar-nerve palsy in wrist fractures. J Bone Joint Surg 1961;43:1197-201.

[58] Georgoulis A, Hertel P, Lais E. Fracture and dislocation fracture of the os pisiforme. Unfallchirurg 1991;94(4):182-5 [in German].

[59] Rettig ME, Dassa GL, Raskin KB, et al. Wrist fractures in the athlete. Distal radius and carpal fractures. Clin Sports Med 1998;17(3):469-89.

[60] Geissler WB. Carpal fractures in athletes. Clin Sports Med 2001;20(1):167-88.

[61] Muniz AE. Unusual wrist pain: pisiform dislocation and fracture. J Emerg Med 1999;17:78-9.

[62] Palmieri TJ. The excision of painful pisiform bone fractures. Orthop Rev 1982;11:99-103.

[63] Razemon JP. Fractures of the carpal bones. In: Tubiana R, editor. The hand, vol. II. Philadelphia: WB Saunders; 1985. p. 821-43.

[64] Borgeskov S, Christiansen B, Kjaer A, et al. Fractures of the carpal bones. Acta Orthop Scand 1966; 37:276-87.

[65] Cooney WP III, Chao EYS. Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg [Am] 1977;59:27-36.

[66] Inston N, Pimpalnerkar AL, Arafa MAM. Isolated fracture of the trapezium: an easily missed injury. Injury 1997;28(7):485-8.

[67] McGuigan FX, Culp RW. Surgical treatment of in-tra-articular fractures of the trapezium. J Hand Surg [Am] 2002;27:697-703.

[68] Cordrey LJ, Ferrer-Torells M. Management of fractures of the greater multangular. J Bone Joint Surg [Am] 1960;42:1111-8.

[69] Palmer AK. Trapezial ridge fractures. J Hand Surg [Am] 1981;6:561-4.

[70] Freeland AE, Finley JS. Displaced vertical fracture of the trapezium treated with a small cancellous lag screw. J Hand Surg [Am] 1984;9:843-5.

[71] Jones WA, Ghorbal MS. Fractures of the trapezium —a report on three cases. J Hand Surg [Br] 1985;10: 227-30.

[72] Jones JA, Pellegrini VD. Transverse fracture-dislocation of the trapezium. J Hand Surg [Am] 1989; 14:481-5.

[73] Horch R. A new method for treating isolated fractures of the os trapezium. Acta Orthop Trauma Surg 1998;117:180-2.

[74] Taleisnik J. The wrist. New York: Churchill Livingston; 1985.

[75] Garavaglia G, Bianchi S, Santa DD, et al. Trans-trapezium carpo-metacarpal dislocation of the thumb. Arch Orthop Trauma Surg 2004; 124:67-8.

[76] Foster RJ, Hastings H II. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop 1987;214:121-9.

[77] Walker JL, Greene TL, Lunseth PA. Fractures of the body of the trapezium. J Orthop Trauma 1988; 2:22-8.

[78] Pointu J, Schwenck JP, Destree G, et al. Fractures of the trapezium. Mechanisms. Anatomo-pathology and therapeutic indications. Rev Chir Orthop Reparatrice Appar Mot 1988;74(5):454-65 [in French].

[79] Gelberman RH, Vance RM, Zakaib GS. Fractures at the base of the thumb: treatment with oblique traction. J Bone Joint Surg [Am] 1979; 61:260-2.

[80] Freeland AE, Ahmad N. Oblique shear fractures of the lunate. Orthopedics 2003;26(8):805-8.

[81] Gelberman RH, Bauman TD, Menon J, et al. The vascularity of the lunate bone and Kienbock's disease. J Hand Surg [Am] 1980;5:272-8.

[82] De Beer JD, Hudson DA. Fractures of the trique-trum. J Hand Surg [Br] 1987;12:52-3.

[83] Hocker K, Menschik A. Chip fractures of the trique-trum. Mechanism, classification and results. J Hand Surg [Br] 1994;19:584-8.

[84] Garcia-Elias M. Dorsal fractures of the triquetrum —avulsion or compression fractures? J Hand Surg [Am] 1987;12:266-8.

[85] Suzuki T, Nakatsuchi Y, Tateiwa, et al. Osteochon-dral fracture of the triquetrum: a case report. J Hand Surg [Am] 2002;27:98-100.

[86] Milch H. Fracture of the hamate bone. J Bone Joint Surg [Am] 1932;16:459-62.

[87] Scheufler O, Andresen R, Radmer S, et al. Hook of hamate fractures: critical evaluation of different therapeutic procedures. Plast Reconst Surg 2005; 115(2):488-97.

[88] Whalen JL, Bishop AT, Linsheid RL. Nonoperative treatment of acute hamate hook fractures. J Hand Surg [Am] 1992;17:507-11.

[89] Fujioka H, Tsunoda M, Noda M, et al. Treatment of ununited fracture of the hook of hamate by low-intensity pulsed ultrasound: a case report. J Hand Surg [Am] 2000;25:77-9.

[90] Demirkan F, Calandruccio JH, Diangelo D. Biome-chanical evaluation of flexor tendon function after hamate hook excision. J Hand Surg [Am] 2003;28: 138-43.

[91] Van Demark RE, Parke WW. Avascular necrosis of the hamate: a case report with reference to the hamate blood supply. J Hand Surg [Am] 1992;17: 1086-90.

[92] Ebraheim NA, Skie MC, Savolaine ER, et al. Coronal fracture of the body of the hamate. J Trauma 1995;38(2):169-74.

[93] Cuenod P, Della Santa DR. Open dislocation of the trapezoid. J Hand Surg [Br] 1995;20:185-8.

[94] Miyawaki T, Kobayashi M, Matsuura S, et al. Trapezoid bone fracture. Ann Plast Surg 2000;44:444-6.

[95] Putnam MD, Meyer NJ. Carpal fractures excluding the scaphoid. In: Trumble TE, editor. Hand surgery update 3. Rosemont (IL): American Society for Surgery of the Hand; 2003. p. 175-87.

Hand Clin 22 (2006) 517-528

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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