Is intrasound vibration useful in the diagnosis of occult scaphoid fractures?

This study was designed to confirm the results of Finkenberg et al. (J Hand Surg 1993;18A: 4-7), who found a high sensitivity (100%) and specificity (95%) of the intrasound vibration method in diagnosing occult scaphoid fractures. These occult scaphoid fractures are not visible on x-ray films, but clinically the patients are suspected of having a scaphoid fracture. A vibratory apparatus is placed over the anatomical snuff-box and a vibration of 100 mW is emitted; a painful sensation is produced if the scaphoid is fractured. Thirty-seven consecutive patients with a clinically suspected scaphoid fracture were evaluated. In 6 patients, a scaphoid fracture was radiographically identified; in the remaining 31 patients, a 3-phase bone scan was obtained. Eleven wrists showed increased uptake over the scaphoid and were considered to have an occult scaphoid fracture. In this group, bone scintigraphy was used as the reference standard. The vibration test was painful in 1 of 6 patients with a proven scaphoid fracture and in 3 of the 11 patients with a positive bone scan. In contrast to the results of Finkenberg et al, the intrasound vibration method shows a sensitivity of 24%, a specificity of 85%, a positive predictive value of 40%, and a negative predictive value of 65%. We conclude that the accuracy of intrasound vibration is low and that it is not useful in the diagnosis of scaphoid fractures.

The value of additional carpal box radiographs in suspected scaphoid fracture.

RATIONALE AND OBJECTIVES: Carpal Box (CB) radiographs, transverse and longitudinal, produce elongated and magnified views of the carpus. These radiographs can be used after carpal injury, in addition to conventional scaphoid x-rays. In this study, the use of CB radiographs was evaluated in patients with possible scaphoid fracture. METHODS: Seventy-one consecutive patients who presented at the First Aid department from May 1994 to May 1995 were included. All patients were examined for scaphoid fracture after a fall on the out-stretched hand. If a scaphoid fracture was seen on the scaphoid x-rays, patients were immobilized. If the x-rays remained negative or dubious for fracture, additional transverse and longitudinal CB radiographs were obtained. If CB radiographs remained negative or inconclusive, patients were referred for three-phase bone scintigraphy. The results of independent and masked judgment by three different observers were used for an inter- and intraobserver analysis. RESULTS: Twenty of 71 patients initially showed a scaphoid fracture on the conventional scaphoid x-rays, 41 were negative, and 10 inconclusive. All 41 negative patients remained negative on CB radiograph; however, the bone scintigraphy was positive for scaphoid fracture in 11 patients and in 9 patients a hot spot elsewhere in the carpus was found. Of the 10 patients with inconclusive x-rays, 2 showed a clear fracture of the scaphoid on CB radiograph, 5 were negative, and 3 remained inconclusive. The agreement between observers, calculated in kappa values, was highest in CB radiographs. CONCLUSIONS: In the diagnosis of scaphoid fracture, Carpal Box radiography is of limited value in patients with clinically suspected scaphoid fracture. In two of 10 patients with initial dubious scaphoid x-ray, bone scintigraphy can be avoided. Furthermore, the reliability of the interpretation of the radiographs is increased by additional Carpal Box radiography.

Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial.

BACKGROUND: The efficacy of prophylactic antibiotics in fracture surgery remains controversial for lack of well-documented prospective studies. We report here the findings of the Dutch Trauma Trial, a prospective, randomised, double-blind, placebo-controlled study of antibiotic prophylaxis in the primary operative treatment of limb fractures. Ceftriaxone was chosen because of its pharmacokinetic profile, including high serum levels, high tissue penetration, and long elimination half-life, makes it suitable for single-dose prophylaxis. METHODS: Patients aged 18 years or more, attending one of fourteen Dutch centres for acute treatment of closed fractures, were randomly allocated to a single preoperative dose of ceftriaxone 2 g or placebo, and evaluated for development of wound infection and nosocomial infection at 10 days, 30 days, and 120 days. To assess the effects of drop-outs and withdrawals, best-case and worst-case analyses were performed. FINDINGS: A total of 2195 patients were included. The incidence of superficial and deep wound infections after placebo was 8.3%, compared with 3.6% in the ceftriaxone group (p < 0.001, Pearson chi 2-test). The rate of nosocomial infection in the first month was 10.2% with placebo and 2.3% with ceftriaxone (p < 0.001, Pearson chi 2-test). Gram-positive bacteria were found in 74.5% of wound infections and 13.4% of nosocomial infections. INTERPRETATION: Adequate single-dose prophylaxis with a long-acting broad-spectrum antibiotic substantially reduces the incidence of wound infection and early nosocomial infection after surgery for closed fractures.

Choosing a strategy for the diagnostic management of suspected scaphoid fracture: a cost-effectiveness analysis.

UNLABELLED: To assess the cost-effectiveness of various strategies for the diagnostic management of clinically suspected scaphoid fracture, a decision-analytic model was built to evaluate three strategies and to compare them with a (clairvoyant) reference diagnostic management strategy. METHODS: Evaluated strategies were: (A) repeated radiography up to 2 wk; (B) repeat radiography up to 6 wk; and (C) radiography, followed by bone scintigraphy in patients with negative initial radiographs. Therapy consisted of 12 wk of immobilization for a radiographically or scintigraphically proven fracture. Diagnostic costs, therapeutic costs, period of immobilization and nonunion rate were calculated for all three strategies. Estimates were derived from a descriptive management study using bone scintigraphy and available literature. Sensitivity analyses were performed. RESULTS: Overall costs were 273.7, 317.7 and 316.1 European Currency Units (ECU) for Strategies A, B and C, respectively (1 ECU = 1.15 U.S. dollar). Strategy B led to the longest average period of immobilization (8.6 wk), while Strategy A resulted in the highest nonunion rate (4.7%). The costs per nonunion saved for the additional use of bone scintigraphy (Strategy C) was ECU 2618 when compared to Strategy A. CONCLUSION: The use of bone scintigraphy in the diagnostic management of scaphoid fractures is accurate, convenient for patients and cost-effective.

Significance of a hot spot on the bone scan after carpal injury--evaluation by computed tomography.

The use of bone scintigraphy in patients with negative radiographs after carpal injury is widely advocated. However, focally increased activity on the bone scan in the scaphoid or other carpal bones cannot always be radiologically confirmed as a fracture. To confirm scintigraphically suspected carpal fractures, computed tomography (CT) of the wrist was performed in patients with clinically suspected scaphoid fracture and initially negative radiographs. All patients underwent plain radiography, bone scintigraphy and CT. The combination of plain radiographs and CT, as judged by a panel of experienced observers, was used as the reference standard. In 18 patients, 21 out of 22 carpal hot spots on bone scintigraphy could be radiologically confirmed as a fracture. The diagnosis was missed by CT scan in three patients with proven fractures on plain radiographs. We conclude that, in patients with negative initial radiographs following carpal injury, a positive bone scan must be interpreted as a fracture.

Radiography of the carpal scaphoid. Experimental evaluation of "the carpal box" and first clinical results.

RATIONALE AND OBJECTIVES: The authors describe a new device ("the carpal box") for the radiographic detection of occult scaphoid fracture. METHODS: Fractures in the scaphoid of five cadaver specimens were mechanically produced. Subsequent examinations included conventional scaphoid radiography, multi-angle radiography, and radiography using the new device. The anatomic analysis of the specimens served as the standard for comparison. A pilot study was performed in six consecutive patients with suspected scaphoid fracture. RESULTS: Neither scaphoid radiography nor multi-angle radiography could confirm a fracture in two specimens, whereas all fractures were recognized on the carpal box radiographs. All scaphoid fractures were visualized by carpal box radiography, whereas scaphoid radiography was equivocal in one patient and negative in the other. CONCLUSIONS: Carpal box radiography may have additional value in the diagnosis of occult scaphoid fracture. This may lead to a reduction in costs and inconvenience for patients with clinically suspected scaphoid fracture and negative scaphoid radiography.