Dual-energy computed tomography in high-pressure injection injuries caused by grease: an experimental study

Abstract

severe wrist pain. MRI again revealed widespread scaphoid oedema although CT scan demonstrated no fracture. His condition had become chronic and the severity of pain was such that he could not pursue his golfing career. The concern of bone stress within the scaphoid progressing to a potential fracture prompted the decision to consider a prophylactic internal fixation. This was performed percutaneously in a retrograde fashion using a headless titanium intraosseous compression screw, under regional anaesthetic (Figure 1(c)). His wrist was supported in a forearm splint for 2 weeks. He returned to golf after 3 weeks and played in his first tournament 4 weeks after surgery. He began weightlifting, as a part of his conditioning programme, 6 weeks after surgery with no pain or weakness. A repeat MRI scan and CT scan 1 year after surgery revealed no abnormalities. At final review 48 months after surgery, he had experienced no recurrence of pain and demonstrated symmetrical range of active movements with a grip strength of 56 kg (54 kg in the left) and had returned to his career as a professional golfer. Stress fractures mostly affect high-level athletes in their lower limbs and occur in situations where the normal damage–repair cycle in bone becomes unbalanced due to a change in load repetition. Radiographs are mostly normal in the early stages of abnormal bone stress, with changes developing only when a cortical break occurs. Abnormal radiographs should therefore be considered a late sign, occurring when prevention is no longer possible. Diagnosis of stress responses and impending stress fractures (prefracture) in bone by MRI scan are important to detect because successful prophylactic treatment carries minimal morbidity, results in early functional restoration and provides long-term protection from complications and relapse. Although most stress responses may heal within a few weeks with rest and load avoidance, recurrence is inevitable if the athletic overload resumes without amendment, resulting in fracture. Prophylactic internal fixation may be appropriate, particularly in a bone such as the scaphoid that has a potential to develop nonunion when it fractures. The different movement patterns of the dominant and non-dominant wrists in a golfer leads to predictable injury patterns (Hawkes et al., 2013). The relationship of scaphoid stress responses to flexion–extension athletic movement patterns suggests that the incidence of stress fractures will be higher in the dominant wrist of golfers (Kohyama et al., 2016). Sports with no side-preference may develop bilateral stress responses (Haflah et al., 2014). Apart from the case described in this study, we identified a total of 18 published cases of scaphoid stress fracture in 15 patients, all of which presented after fracture had occurred. This patient developed an abnormal scaphoid stress response that repeatedly recurred despite prolonged periods of rest and multiple technique amendments. This report demonstrates the successful application of a surgical technique applied to manage stress responses in other bones, not previously undertaken in the scaphoid.