[A clinical and experimental study of dorsiflexed intercalated segmental instability in a scaphoid fracture]

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.