How to ease the fixation of carpal bones? Twenty-four lesions treated by 1,5 mm headless compression screws

Abstract

Background

Carpal bone lesions are common, even in acute injuries or as sequalae of missed fractures. If not correctly diagnosed and treated, can lead to loss of function, especially in active patients. The surgical management remain difficult particularly in case of small, atypical or non-unions fragments. The treatment of heterogenic shape fractures should require a fragment specific fixation using, traditionally, Kirschner-wire (K-wire). This method of treatment remains the most popular but could be prone to some complication as: not stable fixation, need to long time immobilization and wire mobilization. Methods Nineteen patients presented with carpal bone lesions were treated by the use of HCS 1,5 mm headless compression screws. Patients were evaluated post-operative by Patient-Rated Wrist Evaluation (PRWE), the Visual Analogic Scale (VAS), Quick-DASH Score and the grip strength was measured by Jamar dynamometer.

Results

Authors observed improvement of pain control and common activity; fine movements were restored; we observed no post-operative functional instability.

Conclusions

HCS 1,5 mm headless compression screws are suitable and smart technique to treat these uncommon fractures to achieve a stable primary fixation and allow an early mobilization and conciliate the versatility of K-wire and the compression action due to screws also in small bone fragment.

1. Introduction

Fractures of the carpal bones and sequalae (as non-union) are frequent lesions that involve in the major cases the scaphoid but can be include the other bones and presented in combinate pattern with often articular involvement.^{1, 2, 3} The surgical management remain difficult especially in case of small, atypical or non-unions fragments. To clarify the treatment approaches, the pattern of lesion can be schematized into 3 main groups: 1) single acute bone fracture (scaphoid, trans-scapho-perilunate, trapezium, hamate), 2) combined acute axial injuries (with multiple bone lesion) and 3) non-union (with or without bone deformity). Clinical examination must be rigorous, and a detailed physical examination must be undertaken, especially in polytraumatized patients, because the clinical signs may be not clear and subtle and standard X-Ray is frequently misleading and not sufficient to show a fracture line. CT scan is mandatory, especially in case of atypical lesions, comminuted scaphoid fracture, capitate or triquetrum involvement. These heterogenic lesions often need of a fragment specific and stable primary fixation to achieve an anatomical restoration and allow an early mobilization. The most popular methods of fixation are the K-wire; they can be use without duty of introduction and way of direction but are unable to give a compression and require a long-time immobilization with cast. In the other hand, the screws could be helping the surgeon but are often non cannulates and their introduction remain not always easy especially in small fragments or complex fractures who require multidirectional fixation. Again, the cannulated compression screws with diameter from 2.2 to 3.0 mm are orientable and undertaken a good primary stability, but in case of trivial fragments, multijointed fractures shape or loss of bone stock, could be remain too big to achieve an effective stabilization. In this paper, the Authors discuss the management of the carpal bone lesions using a 1,5 mm HCS De Puy Synthes® headless compression screws as suitable and smart technique to ease the fixation of these peculiar fractures.¹

2. Materials and methods

Authors reported nineteen patients treated with HCS De Puy Synthes® 1,5 mm headless compression screws to fix carpal bone lesions (total of 24 lesions: 14 scaphoid and carpal fractures (10 scaphoid: 7 shaft and 2 proximal pole and 1 distal pole), 2 capitate, 2 hamate fractures; 10 scaphoid non-union (3 shaft and 10 proximal pole) (Fig. 5). The patients included 17 men and 2 women with a mean age of 29.5 years (range 16–45). 18 fractures were initially treated conservatively, but secondary displacement occurred after first x-ray control (1 week later). In 6 cases were present associate injury: 5 multiple carpal fractures (4 triquetrum and 1 capitate) and 1 distal radius fractures (DRFs) with triquetrum fractures (Fig. 1). In 12 cases were used 2 or more screws in the same bone or in association with other type of fixation (much more screws diameter, K-wire). All the patients had a TC-scan before surgery. The mean time from injury to surgical intervention was 80,6 days (range 1–730d). A total of patients underwent regional or general anesthesia under tourniquet. The fractures were reduced under fluoroscopy and temporarily fixed with K-wire used, as guide to HCS De Puy Synthes® 1,5 mm headless compression screws implantation. In two cases the 1,5 mm screws were placed in association with 2,5 mm headless compression screw (1 to scaphoid and the other to capitate fixation). The osteosynthesis technique changed on the basis of the side and the type of the fracture. In 1 case the fixation was associated with arthroscopic debridement of scaphoid proximal pole non-union. In the other cases it used an open reduction and relative fixation in 8 cases using a dorsal wrist approach and in 11 case spending the volar approach. This technique resulted more practical in cases where the fragments were tiny, in case of multijointed fractures line or in loss of bone stock where are indicated the K-wire fixation and the use of more large headless screw was difficult to control the fragment. Afterwards the correct position of the screw is checked under fluoroscopy. Concluded the surgical procedure, the wrist was dressed in splint in neutral position. Patients are encouraged to actively move the finger immediately after surgery. The follow-up is scheduled 15, 30, and 90 days after surgery. Except first two follow-up, Rx-ray control is planned. The patients are followed-up for an average of 10,9 months (range 6–18 m). At the final follow up were calculated, the Patient-Rated Wrist Evaluation (PRWE), the Visual Analogic Scale (VAS), Quick-DASH Score and the grip strength was measured by Jamar dynamometer (Patterson Medical Holding, Warrenville, IL, USA).

Fig. 5.

AP view: two 1.5 mm headless compression screws used to reduce and fix a scaphoid fracture.

Fig. 1.

Distal radius fracture with scaphoid and triquetrum involvement.

3. Results

We observed improvement of pain control at a distance of 15–90 days after surgery (before surgery VAS rest and VAS stress had respectively a median of 5.6 and 7.6 against 0.2 and 0.6 at last follow-up) (Fig. 7). Common activity and fine movements were restored at a distance of weeks after surgery with a PRWE pre-operative median of 83.6, postoperative PREW of 3. Measurements of Quick-DASH Score with a median of 10.48 points showed no post-operative residual functional disability (Table 1).

Fig. 7.

Clinical result after scaphoid fixation.

Table 1.

Pre and post-operative patients datas relative to the type of injury, surgery and healing outcome.

N°	Sex	Age (at surgery)	FU (m)	Injury	Diagnosis	Time from injury to surgery (d and m)	Associated procedure	Associated injuries	Number of screws	Time to surgery to mobilisation (d)	T healing (d) X-Ray
1	M	45	18	Bike Fall	Scaphoid proximal pole non union	24 m	Arthroscopically assisted		1	30d	115d
2	M	32	12	Fall	Scaphoid shaft fractures (comminuted)	5 d			2 (association with 2,4 mm)	15d	210d
3	M	23	10	Motobike fall	Scaphoid shaft fracture	7 d			2	15d	95d
4	M	30	6	Bike Fall	Scaphoid shaft fracture	10 d		Triquetrum coronal fractures	2 + 2 (Scaphoid and Triquetrum)	15d	95d
5	M	40	8	Fall	Scaphoid proximal pole non union	18 m			2	15d	110d
6	F	16	12	Fall	Scaphoid shaft fracture	30 d		Humerus and distal DRF	2	15d	90d
7	M	32	10	Football fall	Scaphoid shaft fracture	60d			2	15d	115d
8	F	17	12	Fall	Scaphoid shaft fractures (comminuted)	30d				15d	220d
9	M	22	9	Motobike fall	Carpo-metacarpal fracture dislocation	emergency	Intermetacarpal ligament fixation	Trapezoid, capitate and hamate	2 + 2+1 (Capitate, hamate and ligmament fix	21d	90d
10	M	22	12	Fall	Scaphoid shaft fractures	20 d		Triquetrum	2	15d	/
11	M	32	10	Car accident	Distal radius fracture	10d	ORIF distal radius fractures	Triquetrum	1	15d	/
12	M	21	8	Football fall	Scaphoid proximal pole fracture	30d			1	30d	110d
13	M	43	12	Fall	Scaphoid proximal pole fracture	10d			1	30d	115d
14	M	38	8	Bike fall	Scaphoid proximal pole fracture	15d			1	30d	110d
15	M	34	6	Fall	Capitate fracture	5d			1	15d	/
16	M	27	8	fall	Scaphoid diistal pole delayed union	70d	no		2	40d
17	M	27	12	fall	Scaphoid shaft non union	Not known	no	no	1 2,4 mm and 1 1,5 mm	30 d	360d
18	M	26	8	fall	Scaphoid proximal pole non union			Triquetrum	1 + 1 (Scaphoid and Triquetrum)	30 d	220d
19	M	39	10	fall	Scaphoid shaft non union				2	30 d	300d

4. Discussion

Missed diagnosis of carpal bone lesions or conservative treatment failure may lead to sequelae as fracture non-union, avascular necrosis and carpal instability.^{1, 2, 3} Surgical management of non-unions or uncommon fractures with small fragments of the carpus, remains difficult and not complete clarified. K-wire fixation represents the most popular methods of multiple carpal fractures fixation, especially in case of acute small and displaced fractures, they are easily available, easy to place on and cheap.^{2, 3, 4} However, this requests a long-time of cast immobilization, no primary stable bone fixation and infection related complication could occur. Another method of internal fixation is the use of headless compression screws fixation from 2,2–3.0 mm of diameter.^{2, 3, 5, 6} Screws are inserted using K-wire as guide, and achieve a primary stable and compressive force, which rigid fixation. These devices could prevent bone fragment displacement and shortens the time of immobilization.^{6, 7, 8, 9, 10, 11} The cannulation allows an easier screw placement over a guide K-wire in order to fix big fragments, but in case of small fragments, usually require a demanding and precise multidirectional fixation. In the other hand, these screws are not easy to use, not always available, are quite expensive and sometimes are too long to use in small fractures or in unconventional fracture line of carpal bones. In these circumstances, the placement of screw bigger than 1,5 mm of diameter could be trivial and more troubled. The K-wire problems and the limits of headless compression screws with conventional diameter, can be overcome using the HCS De Puy Synthes® 1,5 mm headless compression screws. These devices gain the advantage of both most popular fixation systems. They are simple to drive during the bone insertion, are small and indicate in case of multifragmentary situations, is possible to achieve a precise and fragment specific fixation and can be use in multiple number to improve stability. For example, in scaphoid fixation is possible to choose the best insertion line and fix the fracture following the orientation and distribution of one or more fracture line pattern. Authors found that 1,5 mm screw diameter allows more practice fixation in case of tiny fragment, multijointed fractures line or in case of loss of bone stock, either in case of carpal bone lesions as primary treatment or in case of non-union achieved after conservative management. The use of 1,5 mm headless compression screws can be helpful to obtain accurate reduction of carpal bone fractures, especially in case of small size fragments and multi fragmentary patterns that are composed of multidirectional fracture lines, requiring small diameters screws to allow the appliance of a major number of these (Fig. 1, Fig. 2, Fig. 3, Fig. 4). They can be used in difficult situations as after sequelae like non-union lesions, bone stock loss, or in case of multiple carpal bone lesions when the use of bigger screws diameters could be more troubled and may not achieve primary stable fixation or determine loss of reduction. They are easy to handle for surgeon embodying the benefits of K-wire fixation but dissimilar to these, they also achieve early post-operative mobilization. In order to improve stability and allow the fragment specific fixation, the 1.5 mm HCS screws can help the surgeon. In 2016, Jurkowitsch and collogues showed than two headless screws in B2 type scaphoid fractures, increase the healing rates and fragment stabilization by one screw with equally functional outcome.¹² This concept could be translated also in other type of scaphoid and carpal bone fractures, because the one or more 1.5 mm HCS screws make it easy and feasible the multiplanar fixation of big and small fragments during open or arthroscopic approaches (Fig. 6, Fig. 7, Fig. 8). This surgical technique does not affect the natural history of fracture healing with improvement of clinical and functional post-operative outcomes. Another aspect to consider are avulsion fractures of the carpal bones excluding the scaphoid that are not uncommon lesions and are frequently sign of significant ligamentous disruption or may be associated complex carpal fractures. Failure to recognize a global injury pattern can result in undertreatment and permanent wrist dysfunction. The most common lesions fixed in our population are triquetrum avulsion fracture: dorso-radial component (DIC ligament avulsion) and volo-radial aspect, both easily missed sign of perilunate injury. In one case we fixed the insertion of dorsal metacarpal ligament in axial injury. Indeed, the indication to avulsion fractures fixation are: 1) lesions that if left untreated can cause chronic pain and functional impairment, 2) fragments encountered during surgery that can be fixed.

Fig. 2.

Carpo-metacarpal joint dislocation with small bone key fragments.

Fig. 3.

AP view: 1.5 mm headless compression screws, fixing the key fragments.

Fig. 4.

LL view: 1.5 mm headless compression screws, fixing the key fragments.

Fig. 6.

LL view: two 1.5 mm headless compression screws used to reduce and fix a scaphoid fracture.

Fig. 8.

Clinical result after scaphoid fixation.

Authors’ contributions

AP was the creator and the major contributor in writing the manuscript. CS recorded all datas related to the article and was the code reviewer contributor to the article datas and drafting of the manuscript.

All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no conflict of interests.