Management of clinical fractures of the scaphoid: results of an audit and literature review (original) (raw)
Related papers
The management of scaphoid fractures
Journal of Science and Medicine in Sport, 2005
Appropriate management of scaphoid fractures is important because of the risk of longterm complications such as delayed or non-union, pain and disability. Up to 25% of scaphoid fractures are not visible on the initial radiographs. Consequently, all clinically suspected scaphoid fractures are treated as fractures with cast immobilisation until cause of the symptoms is clarified. The diagnosis often utilises a number of second line investigations that are generally performed 10-14 days after the injury. Bone scintigraphy is currently the most commonly used of these as it rarely misses a fracture. However. it does not visualise anatomical structure and therefore alternative diagnoses are difficult. Magnetic resonance imaging (MRI) is at least as sensitive and more specific than bone scanning and has the advantages of being able to identify other lesions and not expose the patient to any radiation. Furthermore. the scan may be performed as early as 2.8 days following an injury rather than 10 days later in the case of a bone scan. Although the cost of MRI is higher than other imaging modalities, it may be costeffective in the overall management of patients with occult scaphoid fractures since it may prevent unnecessary cast immobilisation in active people. The most appropriate method of cast immobilisation is presently unclear but evidence exists for improved clinical outcomes in those that have both the thumb and elbow immobilised for the first six weeks. (J Sci Med Sport 2005;8:2:181-189) The importance of scaphoid fractures Wrist injuries are common, ranging from simple sprains to more severe fractures and dislocations. Literature has indicated that 3%-9% of all athletic injuries involve the hand or wrist 1. Most of these heal uneventfully, even with delayed treatment, but some injuries result in long-term disability and pain if not diagnosed quickly and treated correctly.
Current methods of diagnosis and treatment of scaphoid fractures
International Journal of Emergency Medicine, 2011
Fractures of the scaphoid bone mainly occur in young adults and constitute 2-7% of all fractures. The specific blood supply in combination with the demanding functional requirements can easily lead to disturbed fracture healing. Displaced scaphoid fractures are seen on radiographs. The diagnostic strategy of suspected scaphoid fractures, however, is surrounded by controversy. Bone scintigraphy, magnetic resonance imaging and computed tomography have their shortcomings. Early treatment leads to a better outcome. Scaphoid fractures can be treated conservatively and operatively. Proximal scaphoid fractures and displaced scaphoid fractures have a worse outcome and might be better off with an open or closed reduction and internal fixation. The incidence of scaphoid nonunions has been reported to be between 5 and 15%. Non-unions are mostly treated operatively by restoring the anatomy to avoid degenerative wrist arthritis.
The utility of cross-sectional imaging in the management of suspected scaphoid fractures
Journal of Medical Radiation Sciences
Introduction: Scaphoid fractures are the commonest carpal bone fracture. If untreated they pose significant risk to patients, thus if a scaphoid fracture is suspected, patients are managed with immobilisation. Although scaphoid fractures may be difficult to diagnose on plain radiography, sometimes for months after injury, ongoing radiographic surveillance is preferred due to its low upfront cost. Patients in immobilising casts for long periods experience significant personal and social ramifications such as difficulty working and selfcaring. This study examines whether cross-sectional imaging by computed tomography (CT) or magnetic resonance imaging (MRI) is quicker than serial X-ray surveillance at allowing a scaphoid fracture to be either excluded or confirmed. Methods: A retrospective record review was performed of the 1709 patients who presented to Royal North Shore Hospital in 2015 with wrist injuries, finding 104 patients clinically suspicious for a fractured scaphoid. Results: All patients were examined by X-ray during their initial hospital presentation, providing 33.7% of final diagnoses in 0.6 AE 1.7 days. However, if initial X-ray proved inconclusive, subsequent serial X-ray surveillance made a final diagnosis after a mean of 24.1 AE 17.2 days, with some being immobilised for up to 67 days before diagnosis. Cross-sectional imaging significantly reduced diagnosis time to 9.8 AE 5.8 days (P = 0.0016), with a maximum immobilisation time of 24 days. Conclusion: Cross-sectional imaging allows for faster scaphoid fracture diagnosis than X-ray. We propose a protocol for scaphoid fracture diagnosis wherein patients undergo two episodes of X-ray separated by 7 days, followed by a single MRI if clinical suspicion remains, minimising unnecessary immobilisation.
Survey of the initial management and imaging protocols for occult scaphoid fractures in UK hospitals
Skeletal Radiology, 2009
Objective The aim of this research was to survey how occult fractures of the scaphoid bone are both imaged and managed initially. Materials and methods A total of 832 questionnaires were sent via e-mail to active associate members of the British Orthopaedic Association. Included was a series of questions regarding the timing of initial and subsequent orthopaedic review of this group of patients and the use of serial radiographs and second-line imaging techniques. Results Nearly half of the UK's acute NHS trusts were represented (45%). The response rate was 16% (130 out of 832). Only 16% of respondents were aware of a local imaging protocol for the investigation of suspected fractures of the scaphoid. Ninety-four percent of respondents performed a second radiograph at first fracture clinic review. Fifty-eight percent used magnetic resonance imaging (MRI) as a second-line investigation; with computed tomography scan and radionuclide isotope bone scan being performed by 26% and 16% respondents, respectively. Conclusions The survey revealed a wide variation in the management of occult fractures of the scaphoid. MRI has been shown to be both sensitive and specific in diagnosing occult carpal bone fractures. There is a need to standardise the management of these injuries to ensure early diagnosis and limit unnecessary wrist immobilisation.
Fractures of the scaphoid, diagnosis and managementa review
Acta chirurgica iugoslavica, 2013
The scaphoid is vitally important for the proper mechanics of wrist function. Fracture of the scaphoid bone is the most common carpal fracture. Among all wrist injuries the incidence of scaphoid fracture is second only to fractures of the distal radius. Scaphoid fractures are significant because a delay in diagnosis can lead to a variety of adverse outcomes that include nonunion, delayed union, decreased grips strength, range of motion and osteoarthritis of the radiocarpal joint. To avoid missing this diagnosis, a high index of suspicion and a through history and physical examination are necessary, because initial radiographs are often negative. Regardless of the technique of bone grafting, there will almost always be some loss of motion even if the fracture unites.
Diagnosis of occult scaphoid fractures and other wrist injuries
Langenbeck's Archives of Surgery, 2001
To examine the efficacy of repeated clinical examinations and follow-up radiographs, 121 patients were prospectively and consecutively randomised and clinically followed until a final diagnosis was achieved. All of these patients additionally underwent magnetic resonance imaging (MRI) scans within an average of 3 days after trauma to control the results of this study. MRI detected 112 injuries in 82 patients (67%). Twenty-eight (25%) of these injuries were scaphoid fractures. There were 15 fractures of other carpal bones, 14 avulsion fractures of extrinsic ligaments (AFL), 26 other bone injuries (fractures of distal radius, fractures of radial styloid, ulnar head fracture metacarpal fracture, bone bruises), and 29 soft tissue injuries (triangular fibro-cartilaginous complex injuries, complete or partial ruptures of the scapholunate ligament, ruptures of the radial collateral ligament, hemarthrosis). By means of repeated clinical examinations and plain scaphoid views, experienced observers were able to detect all the occult scaphoid fractures within 38 days, as well as most of the other fractures about the wrist except one fracture of the triquetrum. Soft tissue injuries, however, were diagnosed only in two cases of complete scapholunate ligament tears. It was further obvious that 70% of all scaphoid fractures and 60% of the AFLs were detected in a review of the initial X-rays by experienced surgeons. Only 30% of all scaphoid fractures detected were really occult and all of these were diagnosed correctly. This prospective study demonstrates that clinical and radiological standard procedures are reliable in the diagnosis of occult fractures of the carpus and wrist when performed by experienced observers. MRI scans are indicated for early diagnosis of occult fractures and soft tissue injuries about the wrist.
Injury Extra, 2007
Introduction: Scaphoid fracture nonunion presents a challenging problem. The best series in the literature report union rates of 85% following internal fixation with nonvascularised bone grafting. Despite bony union residual wrist stiffness often persists and some patients continue to complain of loss of function. Aims: We undertook prospective assessment of a consecutive series of 34 patients with scaphoid waist fracture nonunion treated at our hand unit, to determine union rate and functional outcomes following internal fixation with a cannulated compression screw (Twin fix-Stryker) and interpositional structural bone grafting. Materials and methods: The mean age was 29 years. The mean time from the original injury was 30 months (range 8 months-10 years) with an average post operative follow up of 20 months. All patients had upto date radiographs. Mayo wrist score and a subjective satisfactory scoring system (scale 1-5) were used to measure the functional outcomes. Grip strengths were recorded using a Jamar dynamometer. Results: The average time for union was 14 weeks with only 2 patients having persistent symptomatic nonunions. The average Mayo score was 86 (out of 100). The mean grip strength was 80% of the normal side with only modest improvement in the arc of wrist movements. The majority of them were very satisfied with the outcome and 85% of the patients returned to their pre injury activities including employment status. Conclusion: Our results of scaphoid fracture fixations with Twin fix screw show excellent union rates and good functional improvement, and we commend this procedure.