Detecting scaphoid fractures in wrist injury: a clinical decision rule.
ABSTRACT: INTRODUCTION:The aim of this study was to develop and validate an easy to use clinical decision rule, applicable in the ED that limits the number of unnecessary cast immobilizations and diagnostic follow-up in suspected scaphoid injury, without increasing the risk of missing fractures. METHODS:A prospective multicenter study was conducted that consisted of three components: (1) derivation of a clinical prediction model for detecting scaphoid fractures in adult patients following wrist trauma; (2) internal validation of the model; (3) design of a clinical decision rule. The predictors used were: sex, age, swelling of the anatomic snuffbox, tenderness in the anatomic snuffbox, scaphoid tubercle tenderness, painful ulnar deviation and painful axial thumb compression. The outcome measure was the presence of a scaphoid fracture, diagnosed on either initial radiographs or during re-evaluation after 1-2 weeks or on additional imaging (radiographs/MRI/CT). After multivariate logistic regression analysis and bootstrapping, the regression coefficient for each significant predictor was calculated. The effect of the rule was determined by calculating the number of missed scaphoid fractures and reduction of suspected fractures that required a cast. RESULTS:A consecutive series of 893 patients with acute wrist injury was included. Sixty-eight patients (7.6%) were diagnosed with a scaphoid fracture. The final prediction rule incorporated sex, swelling of the anatomic snuffbox, tenderness in the anatomic snuffbox, painful ulnar deviation and painful axial thumb compression. Internal validation of the prediction rule showed a sensitivity of 97% and a specificity of 20%. Using this rule, a 15% reduction in unnecessary immobilization and imaging could be achieved with a 50% decreased risk of missing a fracture compared with current clinical practice. CONCLUSIONS:This dataset provided a simple clinical decision rule for scaphoid fractures following acute wrist injury that limits unnecessary immobilization and imaging with a decreased risk of missing a fracture compared to current clinical practice. CLINICAL PREDICTION RULE:1/(1?+?EXP (-(0.649662618?×?if man)?+?(0.51353467826?×?if swelling anatomic snuffbox)?+?(-0.79038263985?×?if painful palpation anatomic snuffbox)?+?(0.57681198857?×?if painful ulnar deviation)?+?(0.66499549728?×?if painful thumb compression)-1.685). TRIAL REGISTRATION:Trial register NTR 2544, www.trialregister.nl.
Project description:Immobilization protocols for nondisplaced scaphoid fractures have included the elbow, wrist, and thumb. This study attempts to demonstrate whether or not immobilization of the thumb makes a difference in preventing motion at the scaphoid fracture site. Using six fresh frozen forearm specimens, a transverse waist scaphoid fracture was created through a dorsal approach. Metallic markers were imbedded on either side of the fracture. Sutures were secured to the flexor pollicus longus (FPL) and extensor pollicus longus (EPL). Each specimen was loaded in extension and flexion by attaching 50-g weights to the EPL and FPL, first with no casting, then with a short arm cast, and finally a short arm thumb spica cast. Angulation and displacement at the fracture site were measured in the coronal, sagittal, and axial planes utilizing image reconstructions from computed tomography. One-way ANOVA with repeated measures and Tukey-Kramer multiple comparison test post hoc analysis were used for statistical evaluation. There was no significant difference in fracture angulation or rotation between spica and short arm casts. There was a significant difference in angulation and rotation in all three planes when comparing between casting and no casting, p < 0.05. In our cadaveric model, wrist immobilization is crucial for nondisplaced scaphoid waist fractures, and short arm casting was just as effective as thumb spica casting in preventing fracture displacement.
Project description:The use of computed tomography (CT) to triage suspected scaphoid fractures is appealing because it is more readily available and less expensive than magnetic resonance imaging (MRI). Twenty-eight patients with suspected scaphoid fractures (defined as tenderness in the area of the scaphoid and initial scaphoid-specific radiographs interpreted as normal) were enrolled in a prospective protocol evaluating triage with CT. Twenty patients reached an endpoint consisting of either (1) identification of a fracture accounting for the patient's symptoms on CT or (2) normal radiographs 6 weeks or more from the time of injury. Only 2 of 28 patients (7%) were diagnosed with a nondisplaced fracture of the scaphoid waist. CT revealed an avulsion fracture of the distal pole of the scaphoid in two patients, nondisplaced fractures of the distal radius in six patients, and nondisplaced fractures of other carpal bones in four patients. Radiographs of the scaphoid taken 6 weeks or greater from the time of injury were interpreted as normal in the six patients with normal CT scans that completed the study. True scaphoid waist fractures are uncommon among patients with suspected scaphoid fractures. CT scans are useful for triage of suspected scaphoid waist fractures because alternative, less-troublesome fractures were identified in 43% of patients and no fractures were missed or undertreated. Immediate triage of suspected scaphoid fractures using CT in the emergency room has the potential to reduce unnecessary immobilization and diminish overall costs associated with treatment.
Project description:Introduction:A scaphoid fracture is the most common carpal fracture. When healing of the fracture fails (nonunion), a specific pattern of osteoarthrosis occurs, resulting in pain, restricted wrist motion and disability. Scaphoid fracture classification systems recognize fragment displacement as an important cause of nonunion. The fracture is considered unstable if the fragments are displaced. However, whether and how displaced bone fragments move with respect to one another has not yet been investigated in vivo. With a four-dimensional (4D) computed tomographic (CT) imaging technique we aim to analyze the interfragmentary motion patterns of displaced and non-displaced scaphoid fragments. Furthermore, the correlation between fragment motion and the development of a scaphoid nonunion is investigated. We hypothesize that fragment displacement is not correlated to fragment instability; and concurrent nonunion is related to fragment instability and not to interfragmentary displacement. Methods:In a prospective single-center cohort pilot study, patients with a one-sided acute scaphoid fracture and no history of trauma to the contralateral wrist are illegible for inclusion. Twelve patients with a non-displaced scaphoid fracture and 12 patients with a displaced scaphoid fracture are evaluated. Both wrists are scanned with 4D-CT imaging during active flexion-extension and radio-ulnar deviation motion. The contralateral wrist serves as kinematic reference. Relative displacement of the distal scaphoid fragment with respect to the proximal scaphoid fragment, is described by translations and rotations (the kinematic parameters), as a function of the position of the capitate. Non-displaced scaphoid fractures are treated conservatively, displaced scaphoid fractures receive intraoperative screw fixation. Follow-up with CT scans is conducted until consolidation at 1½, 3 and 6?months. This trial is registered in the Dutch Toetsingonline trial registration system, number: NL60680.018.17. Ethics:This study is approved by the Medical Ethics Committee of the Academic Medical Center, Amsterdam.
Project description:Fractures of the sesamoid bones of the metacarpophalangeal joint (MCPJ) are a rare pathology in hand trauma. Only a few case reports and case series were found in literature. The diagnosis of an ulnar sesamoid bone fracture of the MCPJ is difficult and can pose a differential diagnostic problem with Stener lesions or ulnar collateral ligament (UCL) instability. This pathology is frequently missed with subsequent poor functional outcomes. Correct and early diagnosis is important as this will allow for correct treatment with full recovery of function without sequelae.We report a case of a 35-year-old male Caucasian patient after a thumb injury due to a fall with his mountain bike. X-ray showed a fracture of the ulnar sesamoid of the MCPJ of the pollex, which is rarely reported in this literature. Anamnesis, clinical examination, and X-ray evaluation contributed to our diagnosis. The ulnar sesamoid bone fracture of the MCPJ of the right pollex was initially treated conservatively with immobilization, rest and ice application. After 3-4 weeks, physiotherapy with thenar muscles exercises was started. 10 weeks after the injury, our patient reported a total recovery of function and pain-free thumb movement during daily activities.Ulnar sesamoid fractures are rarely reported in current literature. This type of injury should be recognized as early as possible since it can be easily missed. Then a benign course can be expected after short immobilization of the MCPJ of the thumb during circa 2 weeks. UCL instability or a Stener lesion should be excluded at the emergency department by performing an ultrasound. With this case report, we underline the importance of early diagnosis and exclusion of an unstable Stener lesion.
Project description:Background Several causes of ulnar wrist pain have been described. One uncommon cause is ulnar carpal abutment associated with a notable distally facing sigmoid notch (reverse obliquity). Such an abnormality cannot be treated with ulnar shortening alone because it will result in incongruity of the distal radioulnar joint (DRUJ). Case Description A 23-year-old woman presented with ulnar wrist pain aggravated by forearm rotation. Ten years earlier she had sustained a distal radius fracture that was conservatively treated. Examination revealed mild tenderness at the DRUJ and decreased wrist flexion and grip strength on the affected side. Radiographic examination demonstrated 1 cm ulnar positive variance, ulnar styloid nonunion, and a 37° reverse obliquity of the sigmoid notch. The patient was treated with ulnar shortening and rotation sigmoid notch osteotomy to realign the sigmoid notch with the ulnar head. Literature Review Sigmoid notch incongruity is one of several causes of wrist pain after distal radius fracture. Traditional salvage options for DRUJ arthritis may result in loss of grip strength, painful ulnar shaft instability, or reossification and are not acceptable options in the young patient. Sigmoid notch osteotomy or osteoplasty have been described to correct the shape of the sigmoid notch in the axial plane. Clinical Relevance We report a coronal plane osteotomy of the sigmoid notch to treat reverse obliquity of the sigmoid notch associated with ulnar carpal abutment. The rotation osteotomy described is particularly useful for patients in whom a salvage procedure is not warranted.
Project description:The indications for repair of rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MP) joint of the thumb are debated. We studied factors predictive of operative treatment.In this retrospective study, we queried the research database from 3 affiliated urban hospitals in a single city in the United States and identified 383 patients with a thumb MP UCL injury. We recorded age, sex, treating surgeon, and whether or not a magnetic resonance imaging (MRI) was ordered. If radiographs showed a concomitant avulsion fracture, we measured fragment size and displacement. Multivariable logistic regression was used to identify factors independently associated with surgery.Surgery was independently associated with older patient age, widely displaced fractures (?2 mm), and obtaining an MRI. Two specific surgeons were less likely to operate. Compared with patients without a fracture, fractures without displacement were less likely to have surgery.The rate of surgery for acute thumb MP UCL injury varies based on patient characteristics and the individual treating surgeon. Variation might decrease with improved diagnostic techniques and consideration of practice guidelines. Future studies are needed to determine the patients and injuries that will benefit most from surgery.
Project description:Background Union of a scaphoid fracture is difficult to assess on a standard series of radiographs. An unnecessary and prolonged immobilization is inconvenient and may impair functional outcome. Although operative treatment permits early mobilization, its influence on time to union is still uncertain. Purpose To assess union of scaphoid waist fractures based on computed tomography (CT) scan at 6 weeks, and to compare time to union between conservative treatment and arthroscopically assisted screw fixation. Patients and methods CT scan in the longitudinal axis of the scaphoid was used to provide fracture characteristics, and to assess bone union at 6 weeks in 65 consecutive patients with scaphoid waist fractures. In a randomized subgroup from this cohort with nondisplaced fractures, we compared time to union between conservative treatment (n = 23) and arthroscopically assisted screw fixation (n = 15). Results Overall, at 6 weeks we found a 90% union rate for non- or minimally displaced fracture treated conservatively, and 82% for those who underwent surgery. In the randomized subgroup of nondisplaced fractures, no significant difference in time to union was demonstrated between those treated conservatively and those who underwent surgery. The conservatively treated fractures from this subgroup with prolonged time to union (10 to 14 weeks) were comminuted, demonstrating a radial cortical or corticospongious fragment. Conclusion The majority of non- or minimally displaced scaphoid waist fractures are sufficiently treated with 6 weeks in a cast. Screw fixation does not reduce time to fracture union compared with conservative treatment. Level of Evidence level II, Therapeutic study.
Project description:Background:Scaphoid fractures treated non-operatively and operatively may be complicated by nonunion. Questions/Purposes:We sought to test the primary hypothesis that the incidence density of scaphoid fracture treatment is higher than previously estimated, to determine the frequency and risk factors for nonunion treatment, and to determine whether the frequency of surgical treatment increased over time. Methods:The MarketScan® database was queried for all records of treatment (casting and surgery) for closed scaphoid fractures over a 6-year period. We examined subsequent claims to determine frequency of additional procedures for nonunion treatment (revision fixation or vascularized grafting occurring 28 days or more after initial treatment). Trend analyses were used to determine whether changes in frequency of surgical treatment or revision procedure occurred. Results:The estimated incidence density of scaphoid fracture is 10.6 per 100,000 person-years in a commercially insured population of less than 65 years of age. Of 8923 closed scaphoid fractures, 29 and 71% were treated with surgery and casting, respectively. The frequency of surgical treatment rose significantly, from 22.1% in 2006 to 34.1% in 2012. The frequency of nonunion treatment was 10.8% after surgery and 3% after casting; neither changed over time. Younger age, male sex, and surgical treatment are associated with a higher risk of nonunion treatment. Conclusions:Our estimated incidence of scaphoid fracture is higher than previously reported. The increased enthusiasm in the USA to surgically treat scaphoid fractures is reflected by our trend analysis. The frequency of surgical treatment for presumed nonunion after initial surgical management for closed scaphoid fractures exceeded 10%. Given the increased utilization of surgery, surgeons and patients should be aware of the frequency of nonunion treatment to inform treatment decisions.
Project description:Background Unstable distal ulna fractures in the setting of distal radius fractures can present a challenging problem, especially in the elderly population. Operative fixation of the subcapital distal ulna fracture may help to provide a stable ulnar buttress for attempting to reduce the distal radius fracture. Traditional fixation techniques of the distal ulna may prove unsatisfactory in the setting of osteoporosis and comminution. Description The intrafocal pin plate is placed through a small incision distally and uses the curve of the plate to obtain multiple points of fixation within the intramedullary canal. The overhang of the distal aspect of the plate helps to reduce the fracture. The plate is secured using unicortical locking screws in the ulnar head. Patients and Methods The most ideal fracture pattern for this fixation technique is a subcapital distal ulna fracture that is unstable and associated with a distal radius fracture. This technique is contraindicated in ulnar head fractures, segmental fractures with proximal extension, and open fractures with gross contamination as well as in the setting of active infection. Results This technique has provided a stable ulnar buttress and aided in the reduction of grossly unstable distal radius fractures. All of these patients have gone on to union, and we have not experienced a need for plate removal due to pain or soft tissue irritation. Conclusions We have found the intrafocal pin plate to provide both a stable ulnar buttress as well as intramedullary fixation to aid in the fixation of distal radius fractures associated with unstable distal ulna subcapital fractures.
Project description:Fracture of the scaphoid bone is the most common fracture of the carpus, and frequently, diagnosis is delayed. The unique anatomy and blood supply of the scaphoid itself predisposes to delayed union or nonunion. The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid nonunions. Our aim was to conduct a retrospective study looking at the union rate, time to union, and complications and correlating the outcome of treatment against the delay between injury and surgery and location of the fracture within the bone. This study is a review of a cohort of 30 patients treated with a cannulated Synthes scaphoid screw and corticocancellous bone grafting for scaphoid waist delayed union and nonunion at our center. We achieved 86% overall union rate. The patients with delayed union achieved a 100% union rate. Three out of four patients with persistent nonunion after surgery reported no pain and improved function. The failure rate was 75% in patients who had sustained their fracture more than 5 years previously. Our study demonstrates that delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years can be successfully treated by fracture compression and bone grafting.