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At the heart of general practice since 1960

Developments on the horizon

How are scaphoid non-union and other carpal problems managed?

Fractured scaphoid remains one of the common conditions that produce

poor outcome. Not only is it frequently hard to diagnose with certainty but, despite the best care, there is an incidence of mal-union, non-union

and avascular problems.

We pay a more attention now to ligament tears accompanying fractures: the fracture is only one feature of the injury. Many operations are being devised to stabilise the carpus, while maintaining movement. Avascular problems of both the scaphoid and the lunate, as in Kienbock's disease, are still relatively resistant to treatment.

In the early stages, new procedures aim to restore blood supply by way of vascularised sections of bone that are transferred on an arterial pedicle to bring in new blood into the avascular bone.

Once avascular necrosis proceeds to collapse of the architecture, these procedures do not restore stability.

What advances are being researched?

A most spectacular advance is in hand transplantation. This recently made headlines not only because to date some seven transplants have been performed, but also because of new and potent anti-rejection medical regimes. Lifelong anti-rejection therapy increases mortality and morbidity so patients are carefully selected.

Surgical techniques of hand replantation are not new.

Replanting an amputated hand or arm is much harder than taking a donor hand or arm and transplanting it to a recipient.

When a hand has been amputated much tissue has been destroyed, leaving you insufficient tissue to work with. If you select a 'new' hand from a donor there is ample length of all structures, which can be tailored to suit the recipient.

In view of the significant drug morbidity, most will limit their selection criteria to patients with bilateral hand amputations and possibly other disabilities such as blindness like victims of bomb blasts.

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