Outcome of routine bone scintigraphy in suspected scaphoid fractures

Undisplaced scaphoid fractures are easily missed on conventional scaphoid radiographs, but these occult fractures may seriously impair hand function. Routine bone scintigraphy (BS) is often advocated if there are clinical signs of a scaphoid fracture without radiological evidence. However, the results require careful therapeutic management. OBJECTIVE: To determine the diagnostic value of BS in daily practice for clinically suspected scaphoid fractures. METHODS: We evaluated our protocol of routine BS in suspected scaphoid fractures. SUBJECTS: In a retrospective study, we analysed 111 consecutive cases with signs of a scaphoid fracture on physical examination. Radiographs revealed 55 fractures, the remaining 56 patients all underwent BS. MAIN RESULTS: On average, the BS was performed after 4 days. It showed a fracture in 38/56 of the patients. The distribution of fractures was: scaphoid bone 15, distal radius 11, other carpal bones 9 and metacarpal bones 3. CONCLUSION: If there is a strong clinical suspicion of a scaphoid fracture, which cannot be confirmed by conventional radiology, BS is a valuable diagnostic tool.     

Segmental fracture of the scaphoid: report of a rare fracture pattern

Introduction:To the best of our knowledge, there are no reports in the orthopaedic and trauma literature of true segmental fracture of the scaphoid bone. We present such a case with a brief discussion of the morphology and mechanisms of injury of scaphoid fractures and the problems they present, particularly in diagnosis. Case history: A 43-year-old male with polytrauma sustained in a motorcycle road traffic accident was treated at our hospital. His injuries included a fracture initially thought to involve the waist of the scaphoid. Because he had bilateral upper limb injuries, we elected to treat the fracture surgically to facilitate rehabilitation. At the time of surgery, the fracture was noted to be truly segmental, an unsuspected and rare finding. The fracture was internally fixed, with a satisfactory result. Discussion: Scaphoid fracture patterns are generally consistent and predictable, occurring most commonly through the waist of the bone. Mechanism for injury is thought to be hyperextension of the wrist. Comminution, with or without a butterfly fragment, is occasionally seen, as are simultaneous tuberosity fractures. We suggest that the mechanism in this case may have been multiple or secondary trauma, or an effect of loaded rotation. We highlight the need for careful imaging of the scaphoid bone prior to choosing treatment.     

The total scaphoid titanium arthroplasty: A 15-year experience

Scaphoid nonunion followed by necrosis of bone segments is a common pathologic condition for the hand surgeon, and the difficulty of its management is well known. The total titanium scaphoid replacement, although not well-described in the literature, in our experience represents a reasonable choice in the treatment of this condition. Strict patient selection is necessary to achieve good clinical results. The titanium avoids the silicone synovitis, a well-described complication of silastic implants. Furthermore, this technique permits other surgical steps in case of failure.     

Radiographic evaluation of vascularity in scaphoid nonunions: A review

Scaphoid fractures, particularly those that occur more proximally, are unreliable in achieving union due to the retrograde blood supply of the scaphoid bone. Vascular compromise is associated with the development of nonunions and avascular necrosis of the proximal pole. Due to the tenuous blood supply of the scaphoid, it is imperative that the vascularity be assessed when creating diagnostic and treatment strategies. Early detection of vascular compromise via imaging may signal impending nonunion and allow clinicians to perform interventions that aid in restoring perfusion to the scaphoid. Vascular compromise in the scaphoid presents a diagnostic challenge, in part due to the non-specific findings on plain radiographs and computed tomography. Magnetic resonance imaging techniques have dramatically improved our ability to assess the blood supply to the scaphoid and improve time to intervention. This review aims to summarize these advances and highlights the importance of imaging in assessing vascular compromise in scaphoid nonunion and in reperfusion following surgical intervention.     

Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture

Background

This study aims to identify the physical examination tests most indicative of bone injury in patients with clinically suspected occult scaphoid fractures.

Methods

Ten physical examination manoeuvres were performed on 41 patients with a history of a fall on an outstretched hand and tenderness at the anatomical snuffbox and scaphoid tubercle without a radiographically visible fracture line. The results of wrist examination and subsequent magnetic resonance imaging (MRI) were recorded. The sensitivity, specificity, positive and negative predictive values, accuracy and likelihood ratio of the physical examinations were calculated for the patients who had bone injury confirmed by MRI.

Results

The distribution of MRI-confirmed conditions was as follows: 13 cases—no bone involvement; 12 cases—scaphoid fractures; 9 cases—fissures at the distal end of the radius; 6 cases—bone-bruise and 1 case—triquetral fracture. The symptoms most indicative of bone injuries were ‘pain during pinching by the thumb and index fingers’ and ‘pain during pronation of the forearm’.

Conclusion

The two above-mentioned manoeuvres were most indicative of bone injury in patients with clinically suspected occult scaphoid fracture. These examinations may reduce the number of unnecessary MRI examinations.     

Clinical prediction rule for suspected scaphoid fractures: A Prospective Cohort Study

Background

The low prevalence of true fractures amongst suspected fractures magnifies the shortcomings of the diagnostic tests used to triage suspected scaphoid fractures.

Purpose

The objective was to develop a clinical prediction rule that would yield a subset of patients who were more likely to have a scaphoid fracture than others who lacked the subset criteria.

Methods

Seventy-eight consecutive patients diagnosed with a suspected scaphoid fracture were included. Standardised patient history, physical examination, range of motion (ROM) and strength measurements were studied. The reference standard for a true fracture was based on the results of magnetic resonance imaging, bone scintigraphy, follow-up radiographs and examination.

Results

Analysis revealed three significant independent predictors: extension <50%, supination strength ≤10% and the presence of a previous fracture.

Conclusion

Clinical prediction rules have the potential to increase the prevalence of true fractures amongst patients with suspected scaphoid fractures, which can increase the diagnostic performance characteristics of radiological diagnostic tests used for triage.     

CT 引导下经皮 Herbert 螺钉微创治疗腕舟骨骨折21例报告

目的：探讨CT引导下经皮穿刺复位Herbert螺钉治疗腕舟骨骨折的疗效。方法2010年9月～2012年10月对21例腕舟骨骨折在CT引导下完成Herbert螺钉内固定。疗效评定包括骨折愈合、疼痛、握力和腕关节活动度,采用腕关节功能评分标准对患者自觉恢复情况进行评定。结果手术时间25～55 min,平均35．3 min;术中出血量8～40 ml,平均18．6 ml。骨折断端均获得骨性愈合,平均愈合时间10．4周（8～17周）。21例随访8～13个月,平均9．8月,末次随访：VAS评分（1．2±0．8）分,显著低于术前（5．3±1．4）分（t＝11．785,P＝0．000）;握力（39．6±3．5）kg,显著高于术前（19．4±2．4）kg （t＝-21．624,P＝0．000）;腕关节屈伸角度115．3°±7．4°,显著高于术前89．8°±10．4°（t＝-9．103,P＝0．000）;腕关节尺桡偏角度53．7°±5．5°,显著高于术前39．4°±3．4°（t ＝-10．116,P＝0．000）;腕关节功能优18例,良3例,优良率100％。结论在CT引导下经皮穿刺复位Herbert螺钉微创治疗腕舟骨骨折疗效满意。     

Percutaneous Screw Fixation of Scaphoid Waist Fracture Non-Union Without Bone Grafting

The aim of the study was to evaluate results of volar percutaneous headless compression screw fixation without bone grafting in 21 patients with scaphoid waist nonunion fractures. The inclusion criteria in this series were scaphoid waist fracture nonunion with intact cartilaginous envelope, minimal fracture line at nonunion interface, no cyst or sclerosis, no avascular necrosis and normal scapholunate angle without humpback deformity. There were 17 male and 4 female patients with an average age of 23 years (range 16–45 years). All patients had radiographic examinations that included Posteroanterior, lateral, oblique and scaphoid views. Preoperative MRI to assess the cartilaginous shill and vascularity of scaphoid was done. CT scans were performed postoperatively to confirm scaphoid fracture healing. The average clinical follow-up was at 25 months (range 18–35) postoperatively. All fractures united successfully with no additional procedures. The average DASH score (disabilities of the arm, shoulder, and hand) at final follow-up was 8 (range 0–16). Percutaneous fixation for selected scaphoid nonunion can avoid the morbidity of an open approach and bone grafting.     

A prospective comparison for suspected scaphoid fractures: bone scintigraphy versus clinical outcome

Early diagnosis and treatment of scaphoid fractures limits the number of delayed and non-unions. Bone scintigraphy proved to be a sensitive diagnostic tool for the detection of occult scaphoid fractures. However, the results have to be interpreted with care. OBJECTIVE: To prospectively correlate the results of bone scintigraphy with clinical outcome. METHODS: In a prospective study, we analysed 50 consecutive patients with signs of a scaphoid fracture at physical examination but no evidence of a scaphoid fracture on scaphoid radiographs. All patients had a protocolised follow up at fixed intervals. The clinical outcome was defined according to a standardised algorithm. MAIN RESULTS: Bone scintigraphy revealed 32% (16/50) occult scaphoid fractures and 40% (20/50) occult other fractures. Clinical outcome proved that bone scintigraphy was false positive in five patients and in one case false negative for a scaphoid fracture. CONCLUSION: Bone scintigraphy in combination with protocolised physical examination is the gold standard for patients with signs of a scaphoid fracture that cannot be proven on scaphoid radiographs.     

‘Clinical scaphoid fracture’: is it time to abolish this phrase?

INTRODUCTION

Most patients with post-traumatic painful wrists and negative radiographs are treated as having a clinical scaphoid fracture. Such cases are usually followed up with repeat radiographs. If the radiographs are inconclusive further imaging is done. However, this traditional approach results in the vast majority of patients being unnecessarily immobilised for an unspecified period, leading to loss of productivity and income to the patient and the community. A number of studies have highlighted the use of early CT or MRI scans to identify these fractures. The aim of this study was to evaluate our current practice in managing patients with suspected fractures of the scaphoid.

PATIENTS AND METHODS

A retrospective audit was carried out. The period studied was from January to August 2008. Fifty consecutive patients who were investigated for occult fractures of the scaphoid were included.

RESULTS

92% of the patients studied had a repeat radiograph in the fracture clinic. 84% of the patients had their wrists immobilised in a cast while awaiting further imaging. Only 6% had confirmed fracture of the scaphoid; all of these healed uneventfully. 76% of patients with negative scans had their wrists immobilised for an average period of 30.63 days.

CONCLUSIONS

It is time we rethink this dogmatic approach to patients with clinical signs but negative radiographs. We recommend that patients with a painful wrist following an injury and negative radiographs should be referred early to an appropriate clinician and earlier recourse to advanced imaging should be advocated.     

Technique for percutaneous fixation of displaced and nondisplaced acute scaphoid fractures and select nonunions

Percutaneous surgical intervention for scaphoid fractures and some nonunions is increasingly common. There is a considerable learning curve for these procedures. Here we review basic and advanced techniques for volar and dorsal fixation of acute nondisplaced and displaced fractures as well as nonunions with minimal resorption and no humpback deformity.     

A Qualitative Evaluation of Scaphoid Remodeling in Bone-Grafted Scaphoid Nonunions

The purpose of this case series is to identify and illustrate the phenomenon of scaphoid remodeling in skeletally mature subjects following bone grafting for scaphoid nonunion. Nine patients with scaphoid nonunions were treated with interpositional bone grafting (with iliac crest bone graft) and K-wire fixation. The mean length of follow-up was 28.6 ± 9 months. Radiographs and CT scans were reviewed and assessed for degree of union and a qualitative assessment of scaphoid architecture. Following surgery, there was marked distortion of the scaphoid. Once healed, the contour of the scaphoid was still significantly distorted in all nine patients. Remodeling then became evident along the articular surfaces between 8 and 12 months. By 3 years, the scaphoid was completely recontoured and the normal architecture was completely restored in all nine patients. We conclude that the articular surface of the scaphoid remodels over time in skeletally mature subjects.