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We report the case of a 15-year-old boy with combined fractures of the scaphoid, capitate, and hamate that represents a rare variation of the well-known Fenton's syndrome. Fixation was performed for the unstable fractures of the scaphoid and capitate with the use of cannulated Herbert screws and K‑wires respectively. K‑wires were removed after 6 months, with subsequent physiotherapy. After 6 months, CT confirmed complete consolidation of the two surgically treated carpal fractures and the conservatively treated fracture of the hamate. Regarding function, the patient is able to incorporate the hand into his school-related activities and has a good range of motion, with strong closure of the fist.

Introduction: Carpal fractures in children are rare, but can be missed, as their clinical symptoms are unspecific and discrete. Even X-ray diagnosis is difficult. Timely diagnosis and consistent therapy are especially important for scaphoid fractures, as they can help to avoid complications such as non-union or avascular necrosis. A diagnostic approach to paediatric carpal fractures will be discussed on the basis of the following group of patients., Methods: Retrospective analysis of children under 14 years treated in our institution between 09/2010 and 02/2012 for clinically suspected carpal fracture. In the primary evaluation, all children underwent standard X-rays of the hand and/or wrist. All patients were treated by cast immobilisation until complete clinical recovery. All patients with clinical signs of carpal fracture were treated by cast immobilization, even with normal X-rays. The clinical follow-up examination was after 10 to 14 days. In patients with persistent complaints, MRI was performed. We retrospectively evaluated the records of all patients: the fractured carpal bone, and X-ray and MRI-diagnosis were stated. We calculated the mean difference between first presentation and MRI and the mean period for total recovery, in patients with fracture or non-fracture., Results: 61 children (27 boys and 34 girls, mean age 11.5 y) were included in our study. The mean delay between accident and time of first presentation to our paediatric ED was 0.6 days. In primary X-rays, a carpal fracture was demonstrated in only in 2 (3.3 %) patients, but was suspected in only 6 (9.8 %) of patients. In 53 (87.9 %) patients, there was no radiographic evidence of carpal fracture. 14 patients underwent additional scaphoid views, but scaphoid fracture was confirmed in only 1 (7 %) of these patients. In 3 (21.4 %) patients, a scaphoid fracture was suspected and in 10 patients a carpal fracture could be excluded. After a mean time of 11.8 days, all patients underwent a clinical follow-up examination. 32 (54 %) patients had persistent symptoms and MRI was done after a mean time of 17 days. Carpal fracture was then excluded in 12/32 (37 %) patients and was diagnosed in another 20/32 (63 %) children. There were 14 scaphoid fractures, including 3× bone bruise lesions, 4 capitate fractures, 3 triquetral fractures, including 1× bone bruise lesion and 1 bone bruise lesion of the trapezoid. In patients with proven carpal fracture, it took a mean time of 56 days for complete recovery, in comparison with 15 days in patients with excluded carpal fracture. Surgical therapy was unnecessary in any of the patients, and there were no complications., Conclusion: In children with clinical and radiographic carpal fracture, diagnosis is difficult and often unsuccessful at first. Even in discrete clinical complaints, generous cast immobilization is essential and clinical follow up is recommended not later then 14 days. In patients with persistent clinical symptoms, MRI is the imaging method of choice, as it is capable of detecting carpal fractures and even bone bruise lesions with high sensitivity, thereby avoiding unnecessary diagnostic or therapeutic stress for the patients., (Georg Thieme Verlag KG Stuttgart · New York.)

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.

This article reviews the most common complications associated with the management of carpal fractures. Discussion focuses on the recognition of commonly "missed" fractures and fracture patterns and the negative sequelae that can result from these delayed diagnoses. The pitfalls of conservative treatment of specific carpal fractures are reviewed, and the most common complications resulting from the operative management of carpal injuries are described., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The objectives of this article are to discuss the imaging of carpal dislocations and fracture-dislocations and to review the ligamentous anatomy of the wrist, mechanisms of injury, and routine management of these injuries., Conclusion: Perilunate dislocations, perilunate fracture-dislocations (PLFDs), and lunate dislocations are high-energy wrist injuries that can and should be recognized on radio-graphs. These injuries are a result of important sequential osseous and ligamentous injuries or failures. Prompt and accurate radiographic diagnosis aids in the management of patients with perilunate dislocations, PLFDs, and lunate dislocations while assisting orthopedic surgeons with subsequent surgical planning. CT may better show the extent of the injury and help in treatment planning particularly in cases of delayed treatment or chronic perilunate dislocation. A CT examination with coronal, sagittal, and 3D reformatted images is ordered at our institution in cases in which the extent of the carpal injuries is poorly shown on radiographic examination.

Ulnar-sided wrist pain is a frequent cause for loss of practice time and competitive play for athletes. Ulnocarpal abutment, a common source of ulnar-sided pain, typically burdens athletes who participate in gymnastics, racket sports, and baseball. Although many athletes respond to nonoperative management, surgical intervention should be considered when symptoms persist. Surgical options include arthroscopic debridement, arthroscopic wafer, open wafer, or ulnar-shortening osteotomy. Treatment should be tailored to the athletes' level of function, expectations, and goals. The timing of interventions also influences the treatment algorithm. A successful outcome can be anticipated when appropriate treatment is rendered., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Patients presenting with distal end radius fractures may have concomitant carpal instability due to disruption of the scapholunate ligament. This study examined the incidence of static radiographic signs of carpal instability in patients with distal radial fractures before and after fracture treatment. We performed a retrospective radiographic study of 141 patients presenting to Central Middlesex Hospital, London between January 2002-May 2004 with distal end radius fractures. We used abnormal scapholunate angle as the primary indicator of possible carpal dissociation. Abnormal scapholunate angles were noted in 39% of patients at presentation and 35% of patients after treatment with no statistically significant intra-patient variability. Persistent static radiographic signs of carpal instability are high in this subset of patients. The long-term morbidity of persistent wrist instability may be avoided by early radiological diagnosis with clinical correlation to identify carpal ligament injuries and initiate treatment that addresses both the bony and ligamentous components of the injury.

In contrast to the common intra- or extra-articular fractures of the distal radius, radiocarpal fracture dislocations are rare injuries. Concerning this issue, only a small number of publications can be found. Nevertheless, it is important to be informed about this injury since prompt operative treatment is often required and immobilization alone will not be sufficient. Sometimes, radiocarpal fracture dislocations are combined with carpal injuries. In such cases, both the radiocarpal dislocation and carpal injury have to be treated. Diagnostic difficulties can lead to misinterpretation or underdiagnosis. Insufficient reduction and fixation may result in joint incongruity and subsequent osteoarthritis. Reconstruction of the radiocarpal ligaments is a substantial part of operative treatment.

Over the last years, many special instruments and implants were designed for operative treatment of fractures of the wrist and hand. Therefore, conservative treatment of these injuries became old-fashioned in the eyes of most patients and surgeons. Nevertheless, conservative treatment of nondislocated stable fractures of the wrist and hand usually shows better clinical results than operative treatment does. On the other hand, conservative treatment of displaced fractures is very difficult. The key to success is thorough knowledge of the use of casts, splints, and functional therapy and good patient compliance to avoid complications. Opportunities for conservative treatment of fractures of the wrist and hand are herein described.

Perilunate injuries are severe disruptions of the wrist joint that produce variable patterns of injury to the carpal anatomy. Most surgeons advocate an open reduction followed by ligament repair or internal fixation. We tried to reduce and fix the carpal bones under arthroscopic control to minimize surgical trauma and to preserve blood supply. While viewing the articular surface with the arthroscope, the disrupted proximal carpal row was anatomically reduced using Kirschner wires as joysticks, and fixed percutaneously without any repair of the capsuloligamentous tears. Three patients with dorsal perilunate dislocations or fracture-dislocations were treated by this technique. All the patients achieved accurate reduction and stable fixation, and showed successful healing of the carpal fractures with proper alignment after 10 to 12 weeks of immobilization. At 16 to 22 months follow-up, all patients showed normal radiographic findings with no evidence of instability or arthritis. The arthroscopic treatment of acute dorsal perilunate injuries is technically feasible in achieving anatomic reduction and stable fixation. Our preliminary clinical results were encouraging, but the long-term results need to be observed.

A 6-year-old boy with an isolated fracture of the capitate was presented. First radiograghs at our clinic revealed an oblique fracture with a displacement of 5 mm on the lateral view, which we successfully treated with immobilization. When complete union was recognized in the radiographs, the capitate had a deformity consisting of a large prominence on the palmar aspect. During follow-up, the capitate showed marked remodeling and at four and a half years after injury it had regained an almost normal shape. Eleven years after injury, there were no radiographic changes such as malalignment or arthrosis in the carpal bones.

We present a case of volar luxation of the scaphotrapezial bone, in which radiographs suggested luxation of the scaphoid, but unclear relations to the other carpal bones. Computer tomographic reconstruction showed an isolated scaphotrapezial luxation. This was treated by closed reduction and a plaster cast, after which the patient regained normal function of her wrist.

Distal radioulnar joint disorders have become increasingly recognized. Over the past decade, advances in functional anatomy, kinematics, advanced imaging, and arthroscopy have improved understanding of distal radioulnar joint disorders and their management. In the past, injuries to the triangular fibrocartilage complex and distal radioulnar joint have been regarded as related but separate entities. The authors' classification and treatment algorithm perceives these injuries as a single entity, differing only in their progressively severe anatomic pathology and subsequent clinical manifestations. A discussion of pertinent anatomy, clinical characteristics, ancillary studies, and a new classification system help establish recommended management options of this disorder.

Four new cases of carpal scaphoid nonunion in children are presented. This rare injury is characterized by delay in treatment of the scaphoid fracture or incorrect immobilization. The Matti-Russe procedure was performed with autograft harvested from the proximal cubitus, achieving complete consolidation in every patient. No complications occurred and there was no significantly limited mobility. The author speculates about the posibility of partial or complete consolidation of the scaphoid fracture without treatment as a part of the natural history of this fracture in children.

Acute fracture-dislocations of the carpus are uncommon. If treated inadequately, however, these injuries can lead to wrist pain and dysfunction as a result of progressive traumatic arthritis. Accurate diagnosis and early intervention are essential for optimal recovery. This article presents the anatomy, epidemiology, and mechanisms of injury of the carpus and the diagnosis, treatment, and treatment results of dislocation of the carpus.

We report a case of trapezium fracture treated by continuous traction. The fracture involved the trapezium alone and was associated with scapho-trapezium subluxation. Three percutaneously inserted pins were used for traction, one scapho-capitate pin and two pins in the first and second metacarpal bones. This allowed distraction of the entire first row. Good anatomic reconstruction of the trapezium was evidenced radiographically. The functional outcome was quite satisfactory with mobility strictly the same as the healthy side and complete pain relief.

In 27 cases with acute scapholunate ligament injury, minimal invasive treatment was performed. After closed reduction scapholunate transfixation was achieved by Kirschner wires. Postoperatively, a short-arm cast was applied for six weeks. All patients have been reexamined on average 26 months after operation. Follow-up results have been good concerning clinical examination and patients' satisfaction. Radiological examination has shown recurrence of scapholunate instability in 15 cases. In fact, 11% of the patients had dynamic and 44% static instability at follow-up. Recurrence has been most frequent in cases involving primary static instability. Consequently, these cases should be treated by open reduction. Minimal invasive treatment of acute scapholunate dissociation is not recommended. The therapeutic procedure must be adapted to the different stages of scapholunate ligament injury.

Isolated injury of the lunotriquetral interosseous ligament complex and associated structures is less common and is poorly understood compared with the other proximal-row ligament injury, scapholunate dissociation. The spectrum of injuries ranges from isolated partial tears to frank dislocation, and from dynamic to static carpal instability. The diagnosis may be difficult to establish because of the many possible causes of ulnar-sided wrist pain and the often normal radiographic appearance. The mechanism of injury is variable and includes attrition by age, positive ulnar variance, and perilunate or reverse perilunate injury. Appropriate treatment requires assessment of the degree of instability and the chronicity of the injury. Options include corticosteroid injection, immobilization, ligament repair, ligament reconstruction with tendon grafts, limited intercarpal arthrodesis, and ulnar shortening.

Intracarpal ligamentous lesions associated with fractures of the distal radius (FDR) are frequent. The prevalence of these lesions has been assessed either by arthrography or by arthroscopy, but their outcome remains unknown. We carried out a radiographic study to assess the incidence of intracarpal ligamentous lesions with scapholunate (SL) and/or lunotriquetral (LT) dissociation and their outcome at one year. These lesions were termed "dissociative ligamentous lesions" (DLL). This prospective series consisted of 102 consecutive FDR's. The initial x-rays, immediate postoperative x-rays and x-rays at 1 year were studied. We studied the relationships of the bones of the first carpal row, abnormal joint space widening, Gilula's lines and the values of the intracarpal angles. The evolution of the carpal height ratio between day 0 and one year was studied. Complete xrays were available for 95 patients. There were 9 epiphyseal, 45 metaphyseal and 41 mixed fractures. DLL's were diagnosed in the early stages in 40 patients. There were 29 isolated SL lesions, 2 isolated LT lesions and 9 cases of associated SL and LT lesions. At 1 year, the diagnosis was confirmed in all these cases but a further case of SL dissociation was diagnosed. At 1 year, 61% of DLL's showed significant loss of carpal height and were considered as progressive. There was an association between the type of fracture and the presence or absence of DLL (p = 0.02). This study, based on radiographic analysis alone, showed 43% DLL's. The majority could be identified immediately. These findings are similar to those in recent arthrographic or arthroscopic studies, but the interest of plain radiographic study is to diagnose only those lesions having a definite effect on the carpus ("static instability"). At 1 year, 61% of lesions diagnosed have significantly affected carpal height.

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.

We present a review of the current literature involving fractures of the pisiform and hook of the hamate. This is highlighted by two cases in which the fracture lines are seen only on the reverse oblique wrist radiograph, a view obtained with the wrist in a supinated rather than a pronated position. These fractures are not seen on standard two or three view wrist examination. Both of these fractures were initially missed in the emergency department. Serious sequelae can result from both of these injuries and can be avoided if diagnosed acutely. The reverse oblique radiograph can be quick, cost-effective, and diagnostic in this setting. If properly treated by immobilization or excision, the results can be excellent.

A dislocated pisiform associated with type II Salter-Harris fractures of the distal radius and ulna in a 9-year-old child is described. Closed reduction followed by immobilization achieved good radiological and clinical results. The current literature on dislocation of the pisiform is reviewed.

Two cases of radiocarpal dislocation without associated intra-articular distal radius fractures are described. Treatment is dependent on the ability to reduce the dislocation and associated intercarpal instability. Satisfactory results have been reported with closed reduction and cast immobilization, although one should beware of associated carpal instability. Open reduction and internal fixation are required for irreducible dislocations and cases in which there is intercarpal instability.

We are reporting the case of a patient with a rare fracture of the corpus of the triquetrum after falling on the ulnar abducted and extended hand. The magnetic resonance imaging (MRI) of the wrist surprisingly showed an additional fracture of the hamate.

We present an unusual case of carpal dislocation which to our knowledge has not previously been described in any of the current classifications of such injuries. Despite the extensive damage sustained, the case was managed without difficulty and outcome has been very satisfactory.

We report four cases with six episodes of concurrent carpal and elbow fractures or dislocations. Few such combinations of injuries have been reported in the literature. We discuss the mechanism and management of such injuries and conclude that elbow injuries should be suspected in severe carpal injuries. Surgical treatment may be required in their management.

The purpose of this study was to clarify the pathomechanics of dorsiflexed intercalated segmental instability (DISI) in a scaphoid fracture. Twenty two patients with a scaphoid fracture were used for the clinical study. DISI was recognized in 6 patients. There was no statistically significant difference between the DISI(+) group and the DISI(-) group in total ROM, or in grip strength. In the DISI(+) group, however, ROM shifted dorsally (p < 0.05). Clinical factors for DISI were as follows. (1) pseudoarthrosis without treatment: 2 cases; (2) bone union taking place in a humpbacked position: 3 cases; (3) resection of proximal fragment: 1 case. Two fresh cadavers were used for the experimental study. In one cadaver which received simple osteotomy of the scaphoid, DISI was not seen after 216,000 repeated wrist movements (15 times/min., 10 days). In the other cadaver which underwent a volar wedge osteotomy of the scaphoid, the proximal fragment of the scaphoid and the lunate dorsiflexed temporarily under axial compression force immediately after surgery. After 8 days (172,800 repeated movements), static DISI could be seen without axial compression force. These results suggested that a volar bone defect was important for DISI after a scaphoid fracture. When an axial compression force was added, both the proximal fragment of the scaphoid and the lunate could be dorsiflexed in proportion to the volar bone defect due to the linkage between the proximal fragment and the lunate. Loosening in the surrounding tissue occurred gradually during continuous wrist movement and static DISI was finally observed. Therefore, immediate and proper treatment should be recommended to prevent mal-union as well as non-union.

Thirty per cent of the carpal dislocations are missed although a significant injury was sustained by the wrist. The extent of the ligamentous tears is relative to the magnitude of the forces applied and the anterior lunate dislocation corresponds to the more severe lesions. When a scaphoid fracture is associated, its treatment is predominant. Conservative treatment of a perilunate dislocation results very frequently in carpal instability and subsequently in wrist osteoarthritis after a variable period of time. Surgical treatment is now indicated in a great majority of cases, for reduction and fixation of a displaced scaphoid, or for ligament repairs.

Of 231 patients with fractures of the triquetrum, 65 were followed up after a mean period of 46.8 months. The fractures were classified and radiological and clinical follow-up was carried out. Pathomechanical aspects of the origin of the fracture were also considered. It appears that the chisel action of the dorso-proximal edge of the hamate striking against the fully extended and ulnar-deviated wrist is the major cause of the dorsal chip fracture of the triquetrum. Conservative therapy involving immobilization of the injured wrist for 3 weeks proved to be successful. If the bone fragment healed, it took 6 to 8 weeks. There was no indication for surgical intervention. We found no signs of post-traumatic instability of the joint. There was good vascularization of the bone, which excluded the possibility of avascular necrosis. All fractures involving the main body of the triquetrum united.

In 231 patients, 65 underwent a follow-up control after a mean interval of 46.8 months. Fractures of the triquetrum are classified, considerations on the pathomechanism are explained, and the clinical and radiological outcome are evaluated. In case of a fall to the extended and ulnar deviated wrist, chip fractures of the triquetrum are caused by the chisel-like effect of the dorsoproximal edge of the hamate. Our mode of conservative treatment with immobilisation for three weeks has proven successful. Healing of the bony fragment occurs not before six to eight weeks. Surgical treatment was never indicated. A posttraumatic instability of the wrist was not observed. On the basis of good vascularisation, avascular necrosis of the triquetrum is not to be feared. All fractures of the body of the triquetrum resulted in osseous consolidation.

18 patients with Bennett's fracture were evaluated after a mean follow-up period of 10.7 years. Treatment consisted of closed reduction and K-wire fixation in seven cases and open reduction with osteosynthesis in 11 cases. Overall, symptoms were few and restricted mobility of the thumb could not be demonstrated. The strength of the affected hand was decreased in all patients regardless of the type of treatment. Osteoarthritis was found to correlate with the quality of reduction of the fracture, but had developed in almost all cases even after exact reduction. Exact reduction, either by the open or closed method, should be the aim of treatment of Bennett's fracture.

Two unusual cases of isolated dislocation of the carpal scaphoid are presented. They were treated in a conservative way, and both of them achieved good functional results.

From a review of the literature and in the authors' practice, fractures of the hook of the hamate (hamulus) are rare and commonly not identified in the acute phase. When fractures are found initially, plaster immobilization has resulted in healing in 46% of cases. However, excision has given a good result when selected in 42% of acutely treated fractures. The method of treatment chosen depends on the lifestyle requirements of the patient.

Injuries involving the perilunar carpal bones require accurate diagnosis and appropriate treatment to prevent carpal instability and collapse. Carpal anatomy and wrist kinematics must be clearly understood before these injuries are evaluated. In addition, the recognition of subtle intercarpal disruptions is improved by an appreciation of the sequential stages of progressive perilunar instability through the vulnerable carpal zone. With consideration of these concepts, a methodical approach to perilunar carpal injuries is presented to improve early recognition and treatment of these complex injuries.

Transscapho-transcapitate fracture dislocation of the carpus is a rare form of perilunate dislocation. It occurs after acute high-energy hyperdorsiflexion trauma and longitudinal compression of the wrist, with concurrent fractures of the scaphoid and capitate neck and rotation of the proximal fragment of the capitate up to 180 degrees. Four cases and their treatments are described, and the literature is reviewed. A possible explanation of the mechanism underlying this condition is offered, and methods of treatment are discussed. If a stable anatomic situation is not obtained with closed reduction, surgical reduction and internal fixation of the scaphoid and capitate bones are recommended to prevent loss of function.

The results of conservative treatment of a perilunate fracture dislocation were retrospectively studied. In six patients, the treatment consisted of closed reduction and immobilization in a below the elbow cast for 12 to 16 weeks. Five patients had a compromised healing of the scaphoid fracture. The frail vascularization of the scaphoid, extensive ligamentous injury and possible mid-carpal instability in case of perilunate fracture dislocation as well as a non-anatomical reduction of a scaphoid fracture are causative factors in ensuing scaphoid pseudarthrosis. If anatomical reduction of a perilunate fracture dislocation cannot be obtained, open reduction and internal fixation should be considered. This will offer the scaphoid the best chance at fracture healing and will restore the stabilizing function on the mid carpus.

A case of isolated dorsal dislocation of the scaphoid is reported. The patient was treated surgically with a good result.