The natural history of suspected scaphoid fractures

Clinically suspected scaphoid fractures are common injuries. The authors prospectively followed up, by serial radiography and bone scanning, 23 patients who had a history of trauma to the carpus and associated localized tenderness to the anatomic "snuff box": in 15 patients the radiographs and bone scans were negative; in 5 the radiograph was equivocal and the bone scan positive. The authors concluded that patients with clinically suspected scaphoid fractures and negative radiographs can be treated symptomatically without immobilization in a cast. Patients with equivocal radiographs should be assumed to have a fractured scaphoid and treated accordingly.     

The natural history of scaphoid non-union

A retrospective radiographic and clinical analysis of 102 symptomatic patients with 104 scaphoid non-unions of at least 1 year's duration was conducted. Osteoarthritis occurred in 22% of non-unions of less than 5 years' duration, 75% of those of 5 to 9 years' duration, and 100% of those of 10 years' duration or more. An all-over incidence of osteoarthritis in the wrist was 55%. Osteoarthritic changes occurred initially at the scaphoid-radial styloid joint which were manifested by radial styloid pointing and/or dorsal radioscaphoid osteophyte formation, later progressing to the midcarpal joint. Osteoarthritis at the scaphoid-radial styloid joint was significantly associated with dorsiflexed intercalated segment instability (DISI) deformity. An overall incidence of DISI deformity of the wrist was 56%, and the frequency of DISI pattern increased with longer duration of non-union. There was an increased incidence of avascular necrosis of the proximal fragment with time, especially after 20 years. There was no correlation between symptoms of pain and the severity of arthritis or the duration of non-union, but a good correlation between the duration of non-union and reduced grip strength or decreased wrist motion. A symptomatic non-union of the scaphoid is significantly likely to progress to osteoarthritis according to a predictable sequence, becoming worse both radiographically and clinically with time.     

The natural history of scaphoid non-union. A review of fifty-five cases

We reviewed the cases of fifty-six scaphoid non-unions in fifty-five patients, none of whom had received treatment of any kind before examination. In the thirty-two patients who had been injured five years or more earlier, arthritis developed in thirty-one (97 per cent). The one patient in whom osteoarthritis developed less than four years after injury also had avascular necrosis of the scaphoid. The incidence of osteoarthritis increased with time after injury. We concluded that patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop.     

Epidemiology of scaphoid fractures in Odense, Denmark.

During a 7-year period, 273 scaphoid fractures were diagnosed in the approximately 175,000 residents of the municipality of Odense. The average annual incidence of scaphoid fracture was 8 per 100,000 women and 38 per 100,000 men, predominantly in young persons. The cause of injury was a fall in 69 percent and a blow in 28 percent.     

Incidence, natural history, and treatment of scoliosis in Friedreich's ataxia

We carried out a retrospective study of 42 patients with documented Friedreich's ataxia to answer four questions: what is the incidence and natural history of scoliosis in Friedreich's ataxia, and what are the results of operative and nonoperative treatment? We concluded that the incidence of scoliosis in true Friedreich's ataxia is extremely high. The curves tend to progress with the severity of the disease and often tend to progress after skeletal maturity. Bracing and electrospinal instrumentation have no role in treatment. Patients with progressive curves should have early surgical stabilization.     

Epidemiology of scaphoid fractures in Bergen, Norway.

During a three-year period, 330 fractures of the scaphoid were diagnosed, 273 of these in subjects resident in Bergen, Norway. The population at risk was 211719, and 82% of the fractures occurred in male subjects. The mean (range) age was 25 (11-79) years. The annual incidence was 4.3/10000 people. The age-specific incidence for men was highest between the ages of 20-30 years followed by a rapid decrease. The age-specific incidence for men was significantly higher than the corresponding rates for women up to about 50 years of age, whereas the rates for men and women over 60 were similar. Fractures of the scaphoid accounted for about 2% of the total number of fractures in our area, 11% of the hand fractures, and 60% of the carpal fractures.     

Percutaneous fixation of scaphoid fractures.

The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated screw along the central axis of the scaphoid. This technique permits the reduction of displaced fractures and the stable repair of fractures of the proximal pole. In addition, selected scaphoid fibrous union or delayed union may also be repaired, with realistic expectations of healing. The proven benefits of the percutaneous technique include decreased soft tissue trauma; arthroscopic visualization of the fracture, ensuring anatomic reduction; and stable fixation, allowing early physical rehabilitation. The theoretical benefits of the technique include decreased risk of interruption of the tenuous scaphoid blood supply. Percutaneous internal fixation of scaphoid fractures provides faster rehabilitation, earlier return to work, and quicker bony union in most patients.     

Incidence, mechanism of injury, and treatment of fractures of the patella in children.

Fractures of the patella in skeletally immature patients are rare. The charts of 185 patients treated for patella fractures at the University of Kentucky Medical Center between 1976 and 1988 were retrospectively reviewed. The 12 patients of these 185 aged 8 to 16 years were included in this study. The incidence was calculated to be 6.5% of all patella fractures. All patients studied were male with an average age of 12.7 years. Sleeve fractures were the most common type of patella fracture observed (five), followed by transverse fractures (four). Ten of the 12 cases required operative management ranging from irrigation and debridement to open reduction and internal fixation. Partial patellectomy was performed when indicated. Indications for operative management in this age group were similar to those for adults. As in adults, the mechanism of injury was predominantly motor vehicle and motorcycle crashes. Laws requiring seatbelt restraints for children should have a positive effect on the incidence of such fractures resulting from dashboard injuries. One mechanism of injury not reported previously was that of a flexed knee striking the gym wall after performing a basketball lay-up because the basket was placed flush with the wall.     

Closed cast treatment of scaphoid fractures.

Cast immobilization of the wrist remains the treatment of choice for stable fractures of the waist and distal pole of the scaphoid. Criteria for diagnosis of stability should be stringent; plain radiographs may be misleading. CT may provide more accurate information on displacement. Immobilization of the thumb confers no advantage and restricts function unnecessarily. Evidence to support immobilization of the elbow is weak, but it may be useful for selected fractures. A cast does not protect the carpus from the effects of axial loading, which can produce large angulatory forces at the fracture. A gap or fracture offset of 1 mm or more are indicators of instability with potential for nonunion or malunion; internal fixation should be considered for these fractures. Internal fixation may also be considered routinely for proximal pole fractures, regardless of the degree of displacement, in view of their long healing time and high risk of nonunion after cast treatment.     

Arthroscopic aided fixation of scaphoid fractures.

Acute nondisplaced scaphoid fractures have traditionally been managed with cast immobilization. Although cast immobilization may be successful in approximately 90% of cases, prolonged casting may lead to muscle atrophy, joint contracture, disuse osteopenia, and potential financial hardship. An athlete or worker may be inactive for 6 months or longer as the fracture heals. Arthroscopic assisted fixation offers a middle ground between traditional cast immobilization and open reduction for scaphoid fractures. These techniques reduce exposure and minimize soft tissue dissection with potential loss of vascularity, avoid division of the important radioscaphocapitate ligament, and allow for detection and management of any associated intracarpal soft tissue injuries. This article presents the indications and describes in detail the various applications for wrist arthroscopy in management of scaphoid fractures.     

Coronal fractures of scaphoid

Two cases of frontal fracture of the scaphoid proximal pole after a high energy trauma are reported. Diagnosis was delayed in both cases and was only possible with a CT-scan. One fracture was slightly displaced: the patient was treated conservatively and followed during 11 years with an excellent result. The other patient was operated on because of persistent pain and malunion. Only during surgery was the correct diagnosis made and due to scaphoid malunion, a proximal row carpectomy was performed. At a post operative assessment, in both cases, X-rays showed a double contour of the proximal pole of the scaphoid. We believe than an arthroCT-scan or MRI is necessary to assess the fracture displacement and search for an associated ligamentous injury.     

Electrical and ultrasound stimulation for scaphoid fractures.

The standard treatment for delayed union or nonunion of the scaphoid is operative management. Electrical stimulation has been employed in these clinical situations in patients unable or unwilling to undergo surgical intervention. Recent interest has also focused on the use of low-intensity ultrasound as an adjunct to healing in distal radius and tibial fractures. Results with the use of ultrasound for scaphoid fractures is encouraging. A review of the mechanisms of action, clinical results, and possible indications is presented for these two nonoperative modalities.     

Magnetic resonance imaging in scaphoid fractures.

The use of a 1.5 tesla superconducting M.R. imager and surface coil was found to enhance the ability of M.R.I. to depict the fine anatomy of the wrist. Five healthy volunteers and 28 patients with scaphoid fractures underwent M.R.I., which made possible a definitive diagnosis of scaphoid fractures at an early stage. A fresh fracture was identified by decreased or iso signal intensity on the T1-weighted image and increased signal intensity on the T2-weighted image. This increase continued until bony union was apparent on radiographs. On the T2-weighted image, high signal intensity was characteristic of fresh fractures and suggested that bony union was possible. When bony union was complete, the intensity of the signal for the scaphoid on both T1- and T2-weighted images returned to normal. M.R.I. should thus prove useful in the diagnosis of scaphoid fractures.     

Suspected scaphoid fractures. The value of radiographs

Twenty observers reported independently on the presence or absence of a fracture of the scaphoid on 60 sets of radiographs; these included initial and 2- to 3-week views in patients in whom the outcome was known, normal scaphoids and random copies of these. Analysis of variance of the accuracy of observations revealed that the 2- to 3-week radiographs did not improve diagnostic ability and that this was independent of the experience or seniority of the observer. For normal radiographs, 20% of the observations reported a fracture. Reproducibility of opinion improved with experience but this did not help with accuracy. Radiographs without accurate clinical observation should not determine the management of the suspected scaphoid fracture.     

Diagnostic value of ultrasound in scaphoid fractures.

Diagnostic ultrasound was used in 103 patients with a clinically suspected fracture of the scaphoid bone in order to achieve an early diagnosis. There were 48 women and 55 men aged 10-75 years (mean 31.4 years) tested with ultrasound. Of the patients, 72 were tested within 3 days after injury the remainder between 4 and 42 days. Fracture was confirmed radiologically in 27. We found that the ultrasound test, applied with a frequency of 1 MHz and intensity of 0.5 W/cm2 and 2.0 W/cm2 for 30s, had a sensitivity of 37 per cent and a specificity of 61 per cent. We thus conclude that ultrasound is not suitable for early diagnosis of scaphoid fracture.     

Incidence and natural history of Paget's disease of bone in England and Wales.

This study used a large, primary care, record-linkage resource (the General Practice Research Database [GPRD]) to evaluate the incidence, clinical presentation, and natural history of Paget's disease of bone in England and Wales. Between 1988 and 1999, we identified 2465 patients with the recorded diagnosis of Paget's disease of bone, within the five million subjects > or = 18 years old who were registered in the GPRD. The validity of diagnostic recording was assessed by questionnaire to individual general practitioners (GPs) in 150 patients; the diagnosis was confirmed in 93.8% of responders. The mean age of patients with Paget's disease was 75 years and 51% were men. The prevalence of the disorder was 0.3% among men and women aged > or = 55 years; incidence rates for clinically diagnosed Paget's disease rose steeply with age (men, 5 per 10,000 person-years; women, 3 per 10,000 person-years at the age of 75 years). Over the 11-year period of the study, the age- and sex-adjusted incidence rate of clinically diagnosed Paget's disease declined from 1.1 per 10,000 person-years to 0.7 per 10,000 person-years. Each patient with Paget's disease was matched to three controls matched by age, gender, and general practice. Cases had a greater risk of back pain (relative risk [RR], 2.1; 95% CI, 1.9-2.3), osteoarthritis (OA; RR, 1.7; 95% CI, 1.5-1.9), hip arthroplasty (RR, 3.1; 95% CI, 2.4-4.1), knee arthroplasty (RR, 1.6; 95% CI, 1.0-2.6), fracture (RR, 1.2; 95% CI, 1.0-1.5), and hearing loss (RR, 1.6; 95% CI, 1.3-1.9). Seven patients with Paget's disease developed a malignant bone neoplasm (0.3%). Using life table methodology, the estimated number of people who died within 5 years of follow-up was 32.7% among the patients with Paget's disease and 28.0% among the control patients.     

Non-union of carpal scaphoid fractures in children.

Fracture of the carpal scaphoid is uncommon in children, but does occur and may fail to unite. Eight patients with established non-union have been reiewed, with an average follow-up of almost four years. All non-unions were grafted with autogenous bone. Excellent clinical and radiological results have been obtained. It is concluded that non-union in children is best managed by bone grafting through the anterior approach. Possible aetiological factors concerned in non-union of scaphoid fractures in this age group are discussed.     

Open volar repair of acute scaphoid fractures.

Internal fixation of acute scaphoid fractures has significant advantages over conservative treatment, using cast immobilization. Healing rates are improved, functional recovery is accelerated, and morbidity is reduced. Percutaneous fixation has become the treatment of choice for the majority of acute fractures, since it is an out-patient procedure, which produces virtually no scarring and enables an extremely-rapid recovery; however, in those cases where a stable and anatomical reduction cannot be achieved by closed means, open volar repair remains the best method of treatment. With careful attention to technique, and the avoidance of postoperative immobilization, excellent results can be achieved, even in the case of transscaphoid fracture-dislocation of the carpus.