-
Lakartidningen Jun 2019This article suggests algorithms for diagnosis and treatment of scaphoid fractures. A clinical suspected scaphoid fracture without signs of fracture on conventional... (Review)
Review
This article suggests algorithms for diagnosis and treatment of scaphoid fractures. A clinical suspected scaphoid fracture without signs of fracture on conventional radiographs should have a supplementary MRI done within 5-7 days. Displaced fractures and all proximal fractures should be classified by CT. Fracture union should be evaluated by CT. 90 procent of non- or minimally displaced waist fractures are healed after 6 weeks of conservative treatment. Non- or minimally displaced fractures with signs of instability can be treated conservatively, but require prolonged immobilisation. Fractures with a displacement ≥1,5 mm as well as the majority of proximal scaphoid fractures should be treated surgically with internal fixation.
Topics: Acute Disease; Algorithms; Fracture Healing; Fractures, Bone; Humans; Magnetic Resonance Imaging; Practice Guidelines as Topic; Radiography; Return to Sport; Return to Work; Scaphoid Bone; Tomography, X-Ray Computed
PubMed: 31211404
DOI: No ID Found -
JAMA Surgery Nov 2016Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique,...
IMPORTANCE
Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors.
OBJECTIVE
To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion.
DESIGN, SETTING, AND PARTICIPANTS
An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012.
EXPOSURES
Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis.
RESULTS
The final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all).
CONCLUSIONS AND RELEVANCE
The probability of fracture nonunion can be based on patient-specific risk factors at presentation. Risk of nonunion is a function of fracture severity, fracture location, disease comorbidity, and medication use.
Topics: Adolescent; Adult; Analgesics, Opioid; Anti-Bacterial Agents; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Anticonvulsants; Arthritis, Rheumatoid; Bone and Bones; Comorbidity; Diabetes Mellitus, Type 1; Female; Femur; Fibula; Follow-Up Studies; Fracture Healing; Fractures, Ununited; Humans; Insulin; Male; Middle Aged; Obesity; Osteoarthritis; Protective Factors; Renal Insufficiency; Risk Factors; Scaphoid Bone; Sex Factors; Smoking; Tibial Fractures; Trauma Severity Indices; Vitamin D Deficiency; Young Adult
PubMed: 27603155
DOI: 10.1001/jamasurg.2016.2775 -
Journal of Clinical Medicine Jun 2022Scaphoid fractures correspond to 60% of all carpal fractures, with a risk of 10% to progress towards non-union. Furthermore, ~3% present avascular necrosis (AVN) of the... (Review)
Review
BACKGROUND
Scaphoid fractures correspond to 60% of all carpal fractures, with a risk of 10% to progress towards non-union. Furthermore, ~3% present avascular necrosis (AVN) of the proximal pole, which is one of the main complications related to the peculiar vascularization of the bone. Scaphoid non-union can be treated with vascularized and non-vascularized bone grafting. The aim of the study is to evaluate the rates of consolidation of scaphoid non-union treated using two types of grafts.
METHODS
A systematic review of two electronic medical databases was carried out by two independent authors, using the following inclusion criteria: non-union of the proximal pole of the scaphoid bone, treated with vascular bone grafting (VBG) or non-vascular bone grafting (NVBG), with or without the use of internal fixation, patients aged ≥ 10 years old, and a minimum of 12 months follow-up. Research of any level of evidence that reports clinical results and regarding non-union scaphoid, either using vascularized or non-vascularized bone grafting, has been included.
RESULTS
A total of 271 articles were identified. At the end of the first screening, 104 eligible articles were selected for the whole reading of the text. Finally, after reading the text and the control of the reference list, we selected 26 articles following the criteria described above.
CONCLUSIONS
The choice of the VBG depends mainly on the defect of the scaphoid and on the surgeon's knowledge of the different techniques. Free vascular graft with medial femoral condyle (MFC) seems to be a promising alternative to local vascularized bone grafts in difficult cases.
PubMed: 35743472
DOI: 10.3390/jcm11123402 -
Tidsskrift For Den Norske Laegeforening... Jun 2015About 2,000 patients annually incur a fractured scaphoid in Norway. Assessment and diagnosis can be difficult, and fractures are overlooked. Scaphoid fractures have... (Review)
Review
BACKGROUND
About 2,000 patients annually incur a fractured scaphoid in Norway. Assessment and diagnosis can be difficult, and fractures are overlooked. Scaphoid fractures have traditionally been cast-immobilised, but for the last decade screw fixing has been used increasingly, and offers hope of a higher healing frequency and improved function. Some scaphoid fractures are not diagnosed in the acute phase and some do not heal after treatment. Patients may then end up with painful pseudarthrosis. The purpose of this article is to provide an overview of the assessment, treatment and outcomes of scaphoid fractures.
METHOD
The article is based on literature searches in PubMed and the authors' own clinical experience.
RESULTS
Primary diagnosis of scaphoid fractures and subsequent plaster cast immobilisation yield very good clinical results. Surgery should be limited to displaced fractures, fractures forming part of more extensive wrist injuries and exceptional other cases. Results comparable a quality equivalent to cast immobilisation are achieved by experienced surgeons in this area. Untreated scaphoid fractures often result in painful pseudarthrosis with subsequent abnormal position of the carpal bones and secondary arthrosis. This outcome can be counteracted by surgery on old fractures with bone grafting, internal fixation and cast immobilisation.
INTERPRETATION
Norwegian procedures for treating scaphoid fractures/pseudarthrosis are consistent with internationally documented good practice. Assessment of wrist pain following falls can be improved by conducting clinical tests for scaphoid fracture and radiology with four wrist projections. In the event of clinical suspicion, but no X-ray findings, the patient should be referred for a CT or MRI scan.
Topics: Bone Screws; Casts, Surgical; Critical Pathways; Fracture Fixation, Internal; Fractures, Bone; Humans; Pseudarthrosis; Radiography; Scaphoid Bone; Wrist Injuries
PubMed: 26130547
DOI: 10.4045/tidsskr.14.1256 -
Hand (New York, N.Y.) May 2017The purpose of this systematic review is to analyze the indications, outcomes, and complications of scaphoid fixation with a staple. (Review)
Review
BACKGROUND
The purpose of this systematic review is to analyze the indications, outcomes, and complications of scaphoid fixation with a staple.
METHODS
The literature was reviewed for all cases of the scaphoid staple. Five articles including 188 patients, of 77 primary scaphoid fractures and 111 other indications that included delayed union, nonunion, and avascular necrosis, were reviewed. Demographic data, outcomes, and complications were recorded.
RESULTS
The union rate of the scaphoid staple is 94.7%, and 95.7% of patients return to work after an average of 9.8 weeks after a 4.7-week period of immobilization. The complication rate was 9.0%, and 7.5% required hardware removal. Clinical and radiographic healing was higher in primary fractures as compared with other indications. Other indications, as compared with primary fracture, had a higher rate of hardware removal.
CONCLUSIONS
For all indications, the scaphoid staple has a high union rate and a low complication rate. In the authors' experience, the procedure is fast, not technically challenging, and may be considered for primary fracture, delayed union, nonunion, and avascular necrosis of the scaphoid.
Topics: Fracture Fixation, Internal; Fracture Healing; Fractures, Bone; Fractures, Ununited; Humans; Scaphoid Bone; Surgical Stapling
PubMed: 28453341
DOI: 10.1177/1558944716658747 -
Academic Emergency Medicine : Official... Feb 2014Scaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Scaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency medicine (EM) imaging studies for scaphoid fracture has not been previously described in the EM literature. Plain x-rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial-sided tenderness on physical examination. This study was a meta-analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x-ray in adult emergency department (ED) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after ED discharge.
METHODS
A medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED and EMBASE. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (LRs) for predictors of scaphoid fracture detected on follow-up in patients with normal ED x-rays.
RESULTS
A total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non-ED settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall QUADAS-2 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult ED patients with concern for scaphoid injuries, nondiagnostic index x-rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (LR- = 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (MRI) is superior to bone scan, computed tomography (CT), or ultrasound (US) to both rule in and rule out scaphoid fractures. Both MRI and CT share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.
CONCLUSIONS
Except for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. MRI is the most accurate imaging test to diagnose scaphoid fractures in ED patients with no evidence of fracture on initial x-rays. If MRI is unavailable, CT is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.
Topics: Adult; Emergency Service, Hospital; False Negative Reactions; False Positive Reactions; Fractures, Bone; Humans; Likelihood Functions; Magnetic Resonance Imaging; Medical History Taking; Physical Examination; Scaphoid Bone; Sensitivity and Specificity; Tomography, X-Ray Computed; Ultrasonography; Wrist Injuries
PubMed: 24673666
DOI: 10.1111/acem.12317 -
Hand (New York, N.Y.) May 2022The scaphoid-trapezoid-trapezium (STT) articulation stabilizes the scaphoid and links the proximal and distal carpal rows. The purpose of the study was to determine...
The scaphoid-trapezoid-trapezium (STT) articulation stabilizes the scaphoid and links the proximal and distal carpal rows. The purpose of the study was to determine whether trapezium excision in the treatment of trapeziometacarpal (TM) arthritis affects carpal stability. A retrospective chart and radiographic review was performed on all wrists that underwent trapeziectomy with suspensionplasty or ligament reconstruction, and tendon interposition for TM arthritis between 2004 and 2016. Radiographic outcome measures included the modified carpal height ratio (MCHR) and radioscaphoid (RS), radiolunate (RL), and scapholunate (SL) angles. Degenerative change at the TM and STT joints was classified according to the Eaton-Littler, and Knirk and Jupiter classification systems. Radiographic parameters were compared between preoperative and final follow-up time points. A total of 122 wrists were included in the study with a mean follow-up of 3.5 years (range: 1.0-13.0 years). The mean RL (range: -2.2° ± 11.8° to -10.7° ± 16.5°) and RS angles (range: 52.6° ± 13.8° to 44.4° ± 17.8°) decreased significantly (<.001) without significant change in SL angle, indicating progressive lunate and scaphoid extension after trapeziectomy. The mean MCHR decreased significantly (range: 1.6 ± 0.1 to 1.5 ± 0.1) following trapeziectomy, indicating progressive carpal collapse. Progressive scaphoid-trapezoid arthrosis was observed following trapeziectomy. No other preoperative radiographic factors investigated were associated with significant differences in preoperative and postoperative values for radiographic outcome measures. Trapeziectomy can lead to loss of carpal height, coordinated extension of both the lunate and scaphoid, and progressive scaphotrapezoid arthrosis. As such, in wrists with dynamic or static carpal instability, trapeziectomy should be performed with caution due to the risk of carpal collapse with a nondissociative pattern of dorsal intercalated segment instability.
Topics: Humans; Lunate Bone; Osteoarthritis; Retrospective Studies; Scaphoid Bone; Wrist Joint
PubMed: 32666846
DOI: 10.1177/1558944720939198 -
Medicinski Glasnik : Official... Feb 2021Aim To illustrate the surgical treatment of bilateral post-traumatic scaphoid fracture. Methods We came across a young student, who sustained bilateral, undisplaced...
Aim To illustrate the surgical treatment of bilateral post-traumatic scaphoid fracture. Methods We came across a young student, who sustained bilateral, undisplaced scaphoid waist fractures following a fall during a football match. Despite careful clinical and radiographic evaluation by four views at the Accident and Emergency (A&E) Department, we initially performed only the diagnosis of the left scaphoid fracture treating it with a percutaneous Acutrack headless screw. Eight months later this patient returned to the A&E department due to a new trauma to his right wrist with the onset of painful symptoms: cystic scaphoid non-union. No pain had been reported on the wrist in those months. Results We performed osteosynthesis with Herbert headless screw through an extended volar approach placing a non-vascularized cortico-spongious bone grafts taken from radius. Periodic follow up by clinical examination, X-ray and CT scan with evidence of bone healing was performed. Conclusion Bilateral scaphoid fractures are rarely encountered, mostly as stress fractures in athletes and manual workers. If left untreated, arthritis, deformity, and instability can lead to significant disability. Comprehensive imaging should be done in case of suspected scaphoid fractures, especially after a trauma, even in the presence of modest symptoms, as failure to do so may lead to missed fracture. Considering what was exposed, the radiographic check on the right wrist repeated about two weeks after the trauma would have avoided a missed diagnosis, even in the absence of reported clinical symptoms. We therefore recommend to repeat the radiographic examination in all situations like these.
Topics: Bone Screws; Fracture Fixation, Internal; Fractures, Bone; Fractures, Ununited; Humans; Scaphoid Bone; Wrist Injuries
PubMed: 33480228
DOI: 10.17392/1332-21 -
Lakartidningen Jun 2019Early diagnosis and correct treatment of acute scaphoid fractures is mandatory and of great importance in terms of the long-term prognosis for these young patients....
Early diagnosis and correct treatment of acute scaphoid fractures is mandatory and of great importance in terms of the long-term prognosis for these young patients. Missed acute scaphoid fractures tend to lead to pronounced symptoms later on. A SNAC wrist, with the gradual progression of degenerative osteoarthritis is most often debilitating, with pain, limited and restricted range of motion, and loss of strength.
Topics: Acute Disease; Adolescent; Adult; Diagnostic Errors; Fractures, Bone; Humans; Male; Osteoarthritis; Scaphoid Bone; Young Adult
PubMed: 31211402
DOI: No ID Found -
Hand (New York, N.Y.) May 2022Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves...
Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves immobilization and repeat radiographs in 10 to 14 days. When repeat radiographs are normal but a scaphoid fracture is still clinically suspected, the optimal management in children is unknown. This study retrospectively assessed the management and outcomes of pediatric patients diagnosed with clinical scaphoid fractures. A retrospective study was performed of all patients over a 2-year period treated for a clinical scaphoid fracture at a tertiary pediatric center. Patients were included if they had clinical signs of a scaphoid fracture and 2 negative x-rays 7 to 14 days apart postinjury. Ninety-one patients with a mean age of 13.2 years (range: 7.8-17.7) were included. Sixteen patients (17.6%) underwent computed tomography (CT) or magnetic resonance imaging (MRI) at a mean time of 10.2 weeks postinjury. Five patients (5.5%) were diagnosed with a scaphoid fracture by x-ray or CT at an average of 4.5 weeks postinjury (range: 3-6). Six patients were diagnosed with other wrist fractures at a mean time postinjury of 3.1 (range: 3-6.5) weeks. Out of 195 total radiographs, the surgeon and radiologist disagreed on 59 (30.2%) images. No patients underwent surgery. Management of clinical scaphoid fractures at our institution was relatively uniform: nearly all patients were immobilized and less than 20% received advanced imaging. Our findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and lack of advanced imaging, providing an avenue for future prospective studies.
Topics: Adolescent; Child; Fractures, Bone; Fractures, Closed; Hand Injuries; Humans; Prospective Studies; Retrospective Studies; Scaphoid Bone; Wrist Injuries
PubMed: 32609009
DOI: 10.1177/1558944720930293