Diagnosis and treatment of scaphoid fractures, can non-union be prevented?

In order to evaluate the diagnostic management of scaphoid fracture, 100 consecutive patients with clinically suspected scaphoid fractures were investigated. If a scaphoid fracture was seen on scaphoid radiographs, patients were immobilized in a plaster cast. If the radiographs were negative or dubious for scaphoid fracture, patients were referred for three phase bone scintigraphy. Then the patient was treated according to the result of the bone scan. A long-term follow-up (minimum 1 year) was performed in order to evaluate the incidence of non-union. In 49 of the 100 patients, a fracture of the scaphoid was recognized, in 29 of whom their scaphoid X-series was positive for scaphoid fracture. In 3 of the remaining 71 patients with negative scaphoid X-series, additional carpal box radiographs showed a scaphoid fracture, while 68 patients were referred for three-phase bone scintigraphy. Of these 68 patients, 17 patients (25%) showed a hotspot on the bone scan in the region of the scaphoid. We found that scaphoid radiographs, additional carpal box radiographs and the bone scan (in radiographically negative patients) in combination with conservative therapy did not lead to non-union at long-term follow-up in patients who were treated for scaphoid fracture. We conclude that when a scaphoid fracture is diagnosed within the 1st week followed by plaster immobilization, non-union of the scaphoid could be prevented.

Three-dimensional dynamic external fixation of distal radial fractures. A prospective study.

This prospective study describes the experience with a new dynamic external fixator which provides three degrees of freedom, while the centre of rotation of all these movements is located in the wrist. 44 patients with unstable fractures of the distal radius were included. During the period of dynamisation, with a median flexion of 30 degrees, extension of 18 degrees, radial deviation of 0 degree and ulnar deviation of 20 degrees the range of motion needed to perform activities of daily living was approached. In spite of early mobilisation reduction was maintained. The radiological result was excellent or good in 82% of the patients and the functional result was excellent or good in 92% of the cases. Pin track infections were noted rather frequently, possibly related to the interaction between the soft tissues and the fixator pins. Based on the experiences of the study the device needs further improvement.

Improved wrist fracture localization with digital overlay of bone scintigrams and radiographs.

UNLABELLED: The diagnosis of scaphoid fracture is often difficult and of interest in traumatology. Because of the low sensitivity of repeated scaphoid radiographs, a bone scintigram is advocated and considered the gold standard. In this study, we tried to simplify the interpretation of the bone scintigram of hand and wrist in localizing the hot spot by the digital overlay of the radiograph and the bone scintigram, using a simple device, in patients after wrist trauma. METHODS: Twenty-one consecutive patients (22 wrists) with clinically-suspected scaphoid fracture and negative initial radiographs were included. The PA view of the wrist was obtained with the hand of the patient placed in an acrylic device with three lead markers. For the bone scan, a similar device was used with 57Co markers at the same positions. We called this device the "hand-fix." The PA radiograph was digitized with a videocamera and overlaid on the bone scan. Each bone scan was interpreted twice by each of three observers, one nuclear physician and two residents in nuclear medicine. The first interpretation was made without the digital overlay, and the second was made with the digital overlay. RESULTS: The bone scintigrams were positive in the scaphoid, distal radius and in other carpal bones. Out of the 22 bone scans, Observer 1 judged 19 correctly, Observer 2 judged 16 correctly and Observer 3 judged 10 correctly without the digital overlay images. All three observers gave a correct localization in the 22 wrists using the digital overlay images. CONCLUSION: The digital overlay of a radiograph and a bone scintigram, using the hand-fix, simplifies and improves interpreting and localizing the hot spot on bone scintigrams in patients with wrist injuries.

Experimental evaluation of scaphoid X-series, carpal box radiographs, planar tomography, computed tomography, and magnetic resonance imaging in the diagnosis of scaphoid fracture.

AIM: In this study, we evaluated scaphoid X-series, Carpal Box radiographs (longitudinal and transverse), planar tomography, computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis of scaphoid fracture. The aim of this study was to evaluate the planar technique in the diagnosis of scaphoid fracture. The use of planar tomography, CT, and MRI was to see whether these methods are useful in the diagnosis of scaphoid fracture when other diagnostics modalities remains negative. METHODS: Twenty-eight embalmed human cadaver specimens were used, in 23 of which fractures of the scaphoid were produced mechanically. Scaphoid X-series, Carpal Box posterior-anterior radiographs in ulnar deviation (X-CB), Carpal Box posterior-anterior views with the hand in 15-degree supination and ulnar deviation (X-CB 15-degree) were acted in all specimens, CT in eight wrists, planar tomography in seven wrists, and MRI in five wrists. The anatomic analysis of the specimens was used as the gold standard for comparison. Scaphoid X-series, Carpal Box radiographs, and planar tomography were judged independently and in a blind fashion by six observers, and CT and MRI were also judged independently and in a blind fashion by three radiologists. The observers were asked if they could recognize a scaphoid fracture. The agreement among the six observers for the scaphoid X-series and X-CB was measured. RESULTS: In the 23 fractured wrists, scaphoid X-series, X-CB, X-CB 15-degree, was true positive in 12, 14, and 15 wrists, respectively, whereas these methods were true negative in cadaver wrists 1, 3, and 5. CT was true positive in five of five fractured wrists and true negative in three of three negative wrists. Planar tomography was true positive in one of four fractured wrists and true negative in two of three nonfractured wrists. MRI was obtained in five wrists (one without a fracture), of which the fracture was recognized in only two. The highest agreement between observers was found in the X-CB 15-degree. CONCLUSION: From the planar investigated methods, the 15-degree Carpal Box posterior-anterior, longitudinal and transverse views were most accurate in recognizing scaphoid fracture with also the highest agreement between the observers.

The diagnostic management of suspected scaphoid fracture.

The role of radiography and bone scintigraphy in the diagnostic management of patients with clinically suspected scaphoid fracture after carpal injury is reviewed. Evidence is provided that bone scintigraphy is indicated in patients with negative initial scaphoid radiographs. A normal bone scan excludes scaphoid fracture, and a positive bone scan sufficiently confirms the presence of clinically relevant scaphoid fracture. Furthermore, this review assesses the possibility on non-invasive additional radiographs, for the diagnosis or exclusion on scaphoid fracture as a means of avoiding bone scintigraphy in patients with negative first-day X-series.

Magnetic resonance imaging versus bone scintigraphy in suspected scaphoid fracture.

Magnetic resonance imaging (MRI) has become increasingly useful in the evaluation of musculoskeletal problems, including those of the wrist. In patients with a wrist injury, MRI is used mainly to assess vascularity of scaphoid non-union. However, the use of MRI in patients in the acute phase following carpal injury is not common. Three-phase bone scintigraphy is routinely performed from at least 72 h after injury in patients with suspected scaphoid fracture and negative initial radiographs. We evaluated MRI in this patient group. The bone scan was used as the reference method. Nineteen patients were included. Bone scintigraphy was performed in all 19 patients, but MRI could be obtained in only 16 (in three patients, MRI was stopped owing to claustrophobia). In five patients, MRI confirmed a scintigraphically suspected scaphoid fracture. In one patient, a perilunar luxation, without a fracture, was seen on MRI, while bone scintigraphy showed a hot spot in the region of the lunate bone, suspected for fracture. This was confirmed by surgery. In two patients, a hot spot in the scaphoid region was suspected for scaphoid fracture, and immobilization and employed for a period of 12 weeks. MRI was negative in both cases; in one of them a scaphoid fracture was retrospectively proven on the initial X-ray series. In another two patients, a hot spot in the region of MCP I was found with a negative MRI. In both, the therapy was adjusted. In the remaining six patients, both modalities were negative. We conclude that in the diagnostic management of patients with suspected scaphoid fracture and negative initial radiographs, the use of MRI may be promising, but is not superior to three-phase bone scintigraphy.

Carpal Box radiography in suspected scaphoid fracture.

We have assessed the value of using a simple apparatus,the Carpal Box, in patients with suspected scaphoid fracture, to produce elongated and magnified radiographs of the carpus. The interobserver agreement between 60 observers of standard scaphoid radiographs and longitudinal and transverse Carpal Box radiographs (X-CB) was compared in 11 patients. Three-phase bone scanning was used as a comparative standard. If at least 75% of the observers agreed and the result was confirmed by three-phase bone scanning, the outcome was termed reliable. Scaphoid radiographs and the longitudinal X-CB films were reliable in four patients and the transverse X-CB films in six patients. The bone scan suggested a scaphoid fracture in five of the 11 patients. Agreement in the interpretation of the standard scaphoid radiographs was acceptable in only 36% of patients: in interpretation of transverse Carpal Box radiographs this figure increased to 55%.

[Cervical avulsion fracture caused by an air bag]. / Cervicale avulsiefractuur door airbag.

In a 30-year-old man who had crashed his car into a stationary vehicle at a speed of 100 km/h, after which an airbag inflated, a fracture of the spinous process CVII was diagnosed. The patient had not used a seat belt. This injury has not previously been reported in the literature as an airbag related injury. The patient was very tall (2.00 m) which probably led to hyperflexion of the cervical spine over the airbag.

[Markedly varying physiotherapeutic treatment following carpal injuries]. / Sterk wisselende fysiotherapeutische behandeling na carpaal trauma.

OBJECTIVE: To inventory long-term symptomatic and physiotherapeutic results in patients treated conservatively for a carpal injury. DESIGN: Follow-up investigation and case control study. SETTING: University Medical Centre, Amsterdam. METHOD: A follow-up investigation was conducted in a group of 100 patients with carpal injury. In this group clinical parameters of patients treated conservatively and with physiotherapy (PT) (n = 16) were compared with 16 case controls without PT, selected for age, sex, diagnosis and duration of immobilisation. RESULTS: After removal of the plaster cast, 16 patients had been referred to a physiotherapist because pain was a major complaint. PT was given 2-3 times a week for an average of 11 days after a period of immobilisation of about 9.5 weeks. Treatment varied strongly among the physiotherapists. Follow-up took place 13-50 months after injury. Patients treated with PT had significantly more complaints concerning the traumatised hand than patients without PT. In the long run only 2 patients benefited from PT. CONCLUSION: Physiotherapy after carpal injury lacks method. Applications were arbitrary added or omitted. Patients with carpal injury who were treated with physiotherapy after immobilisation had more complaints in the long run. This difference may be due to selectivity in the policy of referring for physiotherapy.

Three-dimensional dynamic AO external fixation of distal radial fractures--a preliminary report.

External fixation of unstable and intra-articular distal radial fractures has become increasingly popular. Dynamic external fixation, allowing movement of the wrist during the fixation period, is a relatively new approach which may further improve functional end results. To permit early functional treatment, the small AO external fixator was supplemented by a joint allowing all three degrees of rotational freedom. The centre of rotation is located at a point outside the device and lies approximately in the head of the capitate. With the natural centre of wrist rotation coincident with that of the fixator, admissable movements of the wrist include both flexion-extension and radio-ulnar deviation, without threatening fracture reduction. In vitro testing and initial clinical experience with a prototype are encouraging. Several improvements of the original design have been made and a multicentric clinical study is scheduled for further evaluation of the new dynamic external fixator.

The value of radiographs and bone scintigraphy in suspected scaphoid fracture. A statistical analysis.

The role of radiography and bone scintigraphy in the diagnostic management of suspected scaphoid fracture is controversial. Two strategies were compared for patients with initial negative radiographs: repeated radiography versus selective bone scintigraphy. Using the known positive predictive value of scintigraphy, the sensitivity and specificity of both diagnostic strategies were evaluated in a series of 78 consecutive patients. The kappa value for initial radiographs was 0.76 but decreased to 0.5 for follow-up radiographs. Similarly, sensitivity decreased from 64% to 30% in follow-up radiographs. Specificity of the bone scan was 98%. The best diagnostic strategy in the management of clinically suspected scaphoid fractures consists of initial radiography followed by bone scintigraphy in patients with negative radiographs.

Carpal instability, the missed diagnosis in patients with clinically suspected scaphoid fracture.

To determine the incidence of carpal instability and its relation to clinical findings in patients with suspected scaphoid fracture, we performed a long-term follow-up investigation in a consecutive series of 160 patients who were treated in our department of traumatology for suspected scaphoid fracture after a fall on the outstretched hand. Radiography of the carpus was obtained. Bone scintigraphy was performed in all patients with negative initial radiographs. Follow-up investigation was performed in 100 patients and consisted of history, clinical examination, including measurement of grip strength and wrist movement, synovia stress test, Watson's scaphoid test, and radiographic examination. In 22 patients, clinical or radiological signs of carpal instability were found. The incidence of complaints and a positive synovia test were significantly higher in patients with suspected carpal instability. The bone scan was not useful for the detection or exclusion of carpal instability. The three-phase bone scan gave no additional information in the diagnosis of carpal instability.

Radiography and scintigraphy of suspected scaphoid fracture. A long-term study in 160 patients.

Radiographs of the scaphoid after injury are difficult to interpret, and bone scintigraphy is widely used to increase the accuracy of diagnosis, though many fractures suspected on scintigraphy cannot be confirmed radiologically. We have reviewed the clinical consequences, after one year, of managing suspected scaphoid fractures according to the bone-scan results. We studied 160 patients, 35 of whom had initially positive radiographs and were treated in a cast for 12 weeks. The other 125 had bone scintigraphy and were managed according to the result. After a minimum of one year 119 patients were reviewed. Scintigraphically suspected scaphoid fracture could not be confirmed radiologically in 25%. There were no cases of nonunion. The long period of immobilisation in patients with positive radiographs or positive bone scans did not influence the frequency or severity of late symptoms compared with those with a normal bone scan.

Diagnosing scaphoid fractures: radiographs cannot be used as a gold standard!

To evaluate the reproducibility of the interpretation of radiographs for the diagnosis of scaphoid fractures, 134 radiographs (60 consecutive patients) were blindly observed by a resident radiologist, consultant radiologist, resident trauma surgeon and consultant trauma surgeon. The results of radiographs were analysed using kappa (kappa) statistics and stratified according to the results of the corresponding bone scan. In 23 patients the bone scan was positive for fracture of the scaphoid. Irrespective of training and experience, the kappa of the comparison of the scores of the radiographs between any two observers did not exceed 40 per cent. After stratification of the outcome of the bone scan, the kappa did not increase significantly. A panel of three experienced observers gave their opinion of all radiographs. The results were compared with the bone scan results. We conclude that radiographs in suspected scaphoid fracture cannot be used as a reliable diagnostic approach because of the low inter-observer agreement in the interpretation, irrespective of the experience and training of the observer.

A rare combination of fractures of the upper extremities: a diagnostic problem.

The rare case is reported of fractures concurrently of the bilateral proximal radius and the right proximal carpal row. Initial radiographs of the patient showed only fractures in the bilateral proximal radius and the right triquetral bone. In addition, the bone scan showed focal increased uptake in the right scaphoid bone and lunate bone as well, suggesting fractures. Fractures of the entire right proximal row were confirmed by computer tomography. The patient received functional treatment for the elbows and had a scaphoid plaster-of-Paris cast for the wrist. This resulted in a complete recovery after one year.

The Brooker-Wills interlocking nail in the treatment of femoral fractures.

Interlocking nails have expanded the indication for intramedullary fixation to almost any type of fracture of the shaft of the femur. Distal locking with the Brooker-Wills femoral nail is obtained by a wing fixator. This simplifies the operative technique and diminishes exposure to radiation. Adequate control of angulation, shortening and rotation could be achieved in a first series of 25 patients, thus leading to firm bone healing and to early functional recovery.

External fixation and vascular damage: report of a case.

The case history is presented of a patient in whom the anterior tibial artery was clearly perforated by the distal pin of an external fixation device. This necessitated a dorsal pedis free flap instead of transposition of the flap to cover a degloved heel and sole. Review of the literature showed only a few case reports on vascular damage, suggesting that this complication is uncommon. In most cases, secondary erosion seems to be the cause, but as noticed by us direct arterial and/or venous damage is possible.

Performance of external fixation devices in femoral fractures; the ultimate challenge? A laboratory study with plastic rods.

Whether or not external fixation should be applied to the femur, and on what grounds, will depend upon a variety of factors. It is rarely considered to be the treatment of first choice. External fixation can, however, be indicated in certain circumstances. Looking for optimal rigidity in such cases we tested and compared the stability of 14 different femoral external fixators in an experimental model. It was found that the weight of the different frames varied from 400 to 2000 g. The comparative stability also varied widely. Movements of between 1 mm and 4 cm and rotations varying from almost 0 degrees to 16 degrees were measured at the (experimental) fracture site, based upon the geometry of an adult patient. In view of this finding primary bone-healing would not be expected to occur, since it demands more stability than external femoral fixation can offer. A relatively simple two-dimensional (unilateral) frame can be as rigid as a three-dimensional one, in response to all but transverse loading.