Evidence library

There was no clinically or statistically significant difference in PRWE at one year between early fixation and casting. Complications potentially linked to surgery were more frequent in the fixation group, whereas the cast group needed occasional later fixation for non-union.

Immediate MRI was associated with lower mean costs per patient; the saving was not statistically significant at three months but became significant at six months. MRI also picked up significantly more fractures other than the scaphoid and had higher diagnostic accuracy than standard care.

The cast excluding the thumb produced significantly greater extent of union on CT at 10 weeks; overall union was almost universal and there were no significant differences in motion, grip, wrist scores or pain.

Male sex, sports injury, snuffbox pain on ulnar deviation within 72 hours and scaphoid tubercle tenderness at two weeks independently predicted fracture. Absence of snuffbox pain on ulnar deviation early on was associated with no fracture, and when all four factors were present the fracture risk was very high.

CT and MRI performed comparably with no significant difference in sensitivity, specificity or accuracy; both were better at excluding than confirming a fracture, and MRI produced more false positives.

Pain relief, grip strength and satisfaction were broadly similar between the two salvage procedures; four-corner fusion had more complications, while proximal row carpectomy carried a higher risk of later radiocapitate arthritis.

Early fixation offered no lasting functional advantage over casting by one year, although some early benefits in function were seen. Non-unions in the cast group united after subsequent fixation, and surgery carried its own complications.

Class 1 traumatic tears are subdivided by site (central, ulnar, distal and radial attachments), and Class 2 degenerative lesions are graded progressively from TFCC wear through perforation, chondromalacia and lunotriquetral ligament tear to ulnocarpal arthritis, reflecting ulnar impaction.

Described the scapholunate advanced collapse (SLAC) pattern as the commonest form of wrist degenerative arthritis, with scaphotrapeziotrapezoid arthritis the next most frequent; in SLAC, arthritis progresses from the radioscaphoid to the capitolunate joint while the radiolunate joint is characteristically spared.

Three progressive radiographic groups were seen - change confined to the scaphoid, radioscaphoid arthritis, then generalised wrist arthritis - with longer non-union duration in each successive group. Displacement and carpal instability correlated with more severe arthritis, and few non-unions remained arthritis-free after ten years.

Defined four progressive stages of perilunar instability: scapholunate disruption, capitolunate disruption, lunotriquetral disruption and finally volar lunate dislocation.