Scaphoid Fracture Patterns—Part Two: Reproducibility and Demographics of a Simplified Scaphoid Fracture Classification

Abstract Objective To analyze the reproducibility, reliability, and demographics of a simplified anatomical scaphoid fracture classification based on posteroanterior radiographs using a large database of scaphoid fractures. Methods The study consisted of a retrospective review of electronic medical records of 871 consecutive patients. All patients presented between 2003 and 2014 at two centers. Patient- and surgeon-related factors were analyzed. Additionally, interobserver reliability of the Herbert and simplified scaphoid fracture classifications were tested. Results Proximal pole fractures were defined as fractures in which the center of the fracture line was proximal to the distal scapholunate interval (n = 30), waist fractures (n = 802) were defined as fractures involving the scaphocapitate interval, and distal tubercle fractures (n = 39) were defined as fractures involving the scaphotrapeziotrapezoid (STT) interval. The interobserver reliability of the simplified classification was fair (κ = 0.37) as for the Herbert classification (κ = 0.31). The average doubt of the answers of the observers was 2.1 on a scale from 0 to 10 for the simplified classification and 3.6 for the Herbert classification (P < 0.05). Conclusions All complete fractures across the entire scaphoid distal to the scapholunate articulation and proximal to the STT joint can be classified as waist fractures; nonwaist scaphoid fractures are uncommon (6%) and have somewhat different presentations compared to waist fractures. Simplifying the fracture classification slightly improves interobserver reliability, although remaining fair, and significantly reduces doubt. Level of Evidence This is a Level III, prognostic study.

Download Full-text

Interobserver Variability of the Diagnosis of Scaphoid Proximal Pole Fractures

Journal of Wrist Surgery ◽

10.1055/s-0038-1641716 ◽

2018 ◽

Vol 07 (04) ◽

pp. 350-354

Author(s):

Reinier Beks ◽

Tessa Drijkoningen ◽

Femke Claessen ◽

Thierry Guitton ◽

David Ring ◽

...

Keyword(s):

Interobserver Reliability ◽

Tertiary Hospital ◽

Adverse Outcomes ◽

Consecutive Series ◽

Proximal Pole ◽

Level Of Evidence ◽

Fracture Location ◽

Scaphoid Fractures ◽

Improve Reliability ◽

Control Study

Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonunion and avascular necrosis. Distinction of scaphoid proximal pole fractures from waist fractures is important for management but it is unclear if the distinction is reliable. Methods A consecutive series of 29 scaphoid fractures from one tertiary hospital was collected consisting of 5 scaphoid proximal pole and 24 scaphoid waist fractures. Fifty-seven members of the Science of Variation Group (SOVG) were randomized to diagnose fracture location and displacement by using radiographs alone or radiographs and a computed tomography (CT) scan. Results Observers reviewing radiographs alone and observers reviewing radiographs and CT scans both had substantial agreement on fracture location (κ = 0.82 and κ = 0.80, respectively; p = 0.54). Both groups had only fair agreement on fracture displacement (κ = 0.28 and κ = 0.35, respectively; p = 0.029). Conclusion Proximal pole fractures are sufficiently distinct from proximal waist fractures that CT does not improve reliability of diagnosis. Level of Evidence Level IV interobserver reliability case-control study.

Download Full-text

CORRELATION BETWEEN FRACTURES AND ABUSE IN CHILDREN: A RETROSPECTIVE ANALYSIS

Acta Ortopédica Brasileira ◽

10.1590/1413-785220212901236964 ◽

2021 ◽

Vol 29 (1) ◽

pp. 30-33

Author(s):

VITOR LUIS PEREIRA ◽

BERNARDO LOPES CRISOSTOMO ◽

GIULIA CARVALHO SILVA ◽

EIFFEL TSUYOSHI DOBASHI

Keyword(s):

Retrospective Study ◽

Electronic Medical Records ◽

Medical Records ◽

National Literature ◽

Level Of Evidence ◽

Fracture Patterns ◽

Associated Lesions ◽

Reference Hospital ◽

The Subject ◽

The Relationship

ABSTRACT Objective: The aim of this work is to provide evidence for the relationship between suspicion and diagnosis of cases of child abuse and fractures, since, in national literature, studies are still scarce on the subject. Methods: Retrospective study involving electronic medical records of a public reference hospital, in a city of the state of São Paulo, in a 8-year period (2010 to 2018). Cases involving children up to 12 years of age were selected when notified as abuse and presenting fractures; data were statistically analyzed. Results: Among 83 cases of abuse, 19 patients (20.5%) had 23 different fractures. The victims were mainly boys (68.42%) with a mean age of 5 years old, who suffered physical aggression (79%). The majority had no identified aggressor (52%) and 21% were related to the mother. The fracture patterns found involved, mostly, skull fractures (43.48%) and diaphysary fractures (34.78%). Seven patients (30.43%) had other associated lesions and four patients died (21%). Conclusion: Despite the number of cases, it was possible to identify relevant characteristics and patterns. These data indicate that the diagnosis is underestimated and show small epidemiological differences compared with international literature. Level of Evidence II, Retrospective study.

Download Full-text

Importance of Computed Tomography in Determining Displacement in Scaphoid Fractures

Journal of Wrist Surgery ◽

10.1055/s-0037-1604136 ◽

2017 ◽

Vol 07 (01) ◽

pp. 038-042 ◽

Cited By ~ 1

Author(s):

Emily Gilley ◽

Sameer Puri ◽

Krystle Hearns ◽

Andrew Weiland ◽

Michelle Carlson

Keyword(s):

Computed Tomography ◽

Ct Scan ◽

Interobserver Reliability ◽

Scaphoid Fracture ◽

High Rate ◽

Radiographic Evaluation ◽

Angular Deformity ◽

Level Of Evidence ◽

Scaphoid Fractures ◽

The Mean

Background Displaced scaphoid fractures have a relatively high rate of nonunion. Detection of displacement is vital in limiting the risk of nonunion when treating scaphoid fractures. Questions/Purpose We evaluated the ability to diagnose displacement on radiographs and computed tomography (CT), hypothesizing that displacement is underestimated in assessing scaphoid fracture by radiograph compared with CT. Materials and Methods Thirty-five preoperative radiographs and CT scans of acute scaphoid fractures were evaluated by two blinded observers. Displacement and angular deformity were measured, and the fracture was judged as displaced or nondisplaced. Scapholunate, radiolunate, and intrascaphoid angles were measured. Radiograph and CT measurements between nondisplaced and displaced fractures were compared. Intraobserver reliability was measured. Results Reader 1 identified 12 fractures as nondisplaced on radiograph, but displaced on CT (34%). Reader 2 identified 9 fractures as nondisplaced on radiograph, but displaced on CT (26%). For displaced fractures, the mean intrascaphoid angle was over three times greater when measured on CT than on radiograph (56 vs. 16 degrees). Scapholunate angle >65 degrees and radiolunate angle >16 degrees were significantly associated with displacement on CT. Interobserver reliability for diagnosing displacement was perfect on CT but less reliable on radiograph. Conclusion Scaphoid fracture displacement on CT was identified in 26 to 34% of fractures that were nondisplaced on radiograph, confirming that radiographic evaluation alone underestimates displacement. These results underscore the importance of CT scan in determining displacement and angular deformity when evaluating scaphoid fractures, as it may alter the decision on treatment and surgical approach to the fracture. We recommend considering CT scan to evaluate all scaphoid fractures. Level of Evidence Level III.

Download Full-text

Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation

Journal of Wrist Surgery ◽

10.1055/s-0039-3402769 ◽

2020 ◽

Vol 09 (02) ◽

pp. 141-149

Author(s):

Pooja Prabhakar ◽

Lauren Wessel ◽

Joseph Nguyen ◽

Jeffrey Stepan ◽

Michelle Carlson ◽

...

Keyword(s):

Internal Fixation ◽

Open Reduction ◽

Scaphoid Fracture ◽

Receiver Operating Curve ◽

Scaphoid Nonunion ◽

Retrospective Case ◽

Level Of Evidence ◽

Fracture Location ◽

Scaphoid Fractures ◽

Time From Injury

Abstract Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods We performed a retrospective case–control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence This is a Level III, therapeutic study.

Download Full-text

Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420979465 ◽

2020 ◽

pp. 175319342097946

Author(s):

Preetham Kodumuri ◽

Andrew McDonough ◽

Victoria Lyle ◽

Zaf Naqui ◽

Lindsay Muir

Keyword(s):

Outcome Measure ◽

Cost Benefit Analysis ◽

Scaphoid Fracture ◽

Cost Benefit ◽

Clinical Suspicion ◽

Secondary Outcome ◽

Secondary Outcome Measure ◽

Post Injury ◽

Level Of Evidence ◽

Scaphoid Fractures

We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent ( n = 602) with a low clinical suspicion were discharged and 35% ( n = 320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666. Level of evidence: III

Download Full-text

Pediatric Scaphoid Nonunions: A Case Series, Review of the Literature, and Evidence-Based Guidelines

Journal of Wrist Surgery ◽

10.1055/s-0039-3401035 ◽

2019 ◽

Vol 09 (01) ◽

pp. 002-012 ◽

Cited By ~ 1

Author(s):

Kerstin Oestreich ◽

Tatiana Umata Yoko Jacomel ◽

Sami Hassan ◽

Maxim David Horwitz ◽

Tommy Roger Lindau

Keyword(s):

Nonoperative Management ◽

Pediatric Population ◽

Scaphoid Fracture ◽

Case Series ◽

Fracture Site ◽

X Rays ◽

Review Of The Literature ◽

Level Of Evidence ◽

Scaphoid Fractures ◽

Magnetic Resonance Imaging Mri

Abstract Background Scaphoid fractures represent less than 3% of hand and wrist fractures in the pediatric population. Nonunions are very rare. We present a case series (n = 18) of nonunions in skeletally immature children and adolescents. We further present a review of the literature on pediatric scaphoid nonunions. Materials and Methods We reviewed the literature by searching the main databases on pediatric scaphoid nonunions, but to identify factors that lead to nonunion, we also searched for databases on scaphoid fractures. Seventy articles were found for the period between 1961 and 2019, all with level 4/5 evidence. Results The nonunion rate of pediatric scaphoid fractures in the literature is on average 1.5%, occurring mostly as a result of missed or underdiagnosed injuries, similar to our presented case series. Half (n = 9) of the injuries in our case series were missed initial injuries, leading to scaphoid nonunions and half developed nonunions after initial treatment. We found excellent outcomes and with surgical and nonoperative management, with few complications. Not surprisingly, the duration of immobilization is longer with nonoperative management. Conclusions Based on the literature, we recommend a period of nonoperative management before surgery in undisplaced nonunions. In displaced nonunions, open reduction and internal fixation ± bone grafting is necessary. In pediatric scaphoid fractures, similar to adult cases, we identified that suspicious scaphoid fractures should be considered for initial immobilization, and repeat X-rays and early magnetic resonance imaging (MRI) or computed tomography (CT) scans should be considered at follow-up. Immobilization time and type of plaster should be appropriate in relation to the fracture site, similar to the adult scaphoid fracture. Level of Evidence This is a Level IV study.

Download Full-text

Gadolinium Enhanced Mr Assessment of Proximal Fragment Vascularity in Nonunions after Scaphoid Fracture: Does It Predict the Outcome of Reconstructive Surgery?

Journal of Hand Surgery (European Volume) ◽

10.1016/j.jhsb.2004.03.012 ◽

2004 ◽

Vol 29 (5) ◽

pp. 444-448 ◽

Cited By ~ 41

Author(s):

A.K. SINGH ◽

T.R.C. DAVIS ◽

J.S. DAWSON ◽

J.A. ONI ◽

N.D. DOWNING

Keyword(s):

Internal Fixation ◽

Reconstructive Surgery ◽

Scaphoid Fracture ◽

Proximal Fragment ◽

Proximal Pole ◽

Scaphoid Fractures ◽

Fracture Nonunion ◽

Fracture Nonunions ◽

Outcome Of Surgery ◽

Mr Scanning

This study investigated whether the outcome of bone graft and internal fixation surgery for nonunion of scaphoid fractures could be predicted by gadolinium-enhanced MR assessments of proximal fragment vascularity. Sixteen established scaphoid fracture nonunions underwent gadolinium-enhanced MR scanning before surgical treatment with bone grafting and internal fixation. No relationship was found between MR enhancement and the outcome of surgery. Union was achieved in eight of the 12 nonunions with more than 50% enhancement, and three of the four with less than 50% enhancement, of the proximal pole. Furthermore, union was achieved in both of the nonunions which had less than 25% enhancement of the proximal pole. We conclude that enhanced MR assessments of the vascularity of the proximal fragment of a scaphoid fracture nonunion do not accurately predict the outcome of reconstructive surgery.

Download Full-text

Abstract 16935: Cardiovascular Disease in Head Neck Squamous Cell Carcinoma Patients - A Case-Control Study Using Electronic Medical Records Data

Circulation ◽

10.1161/circ.142.suppl_3.16935 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Amrita Mukherjee ◽

Howard Wiener ◽

Russell Griffin ◽

Lisle M Nabell ◽

Carrie G Lenneman ◽

...

Keyword(s):

Risk Factors ◽

Electronic Medical Records ◽

Medical Records ◽

Cancer Site ◽

Cancer Stage ◽

Cvd Risk Factors ◽

Cvd Risk ◽

Related Factors ◽

Traditional Risk Factors ◽

Head Neck

Introduction: Cancer survivors have higher rates of cardiovascular disease (CVD) compared to age-adjusted general population. However, traditional CVD risk factors alone do not fully explain increased CVD risk in cancer patients. Cancer-related factors like cancer site, stage and chemotherapy may also contribute to CVD. Despite increase in head neck squamous cell carcinoma (HNSCC) cases in recent years, little is known about CVD risk in HNSCC patients. We aim to assess association of traditional risk factors and cancer-related factors with CVD in HNSCC patients. Methods: Electronic medical records data of 2391 HNSCC patients diagnosed between 2012-2018 at the UAB O’Neal Comprehensive Cancer Center, were included. ICD-9/10 codes were used to identify HNSCC patients, CVD cases and traditional risk factors. CVD cases were defined as those with composite events of ischemic heart disease and/ or heart failure; controls were without any CVD diagnosis. Cancer site, stage and treatment were included. Logistic regression [OR(95%CI)] was used to assess association of risk factors with CVD, adjusting for age, race, and gender. Results: HNSCC patients were mostly white (82.7%), male (74.7%) and had Stage III/IV cancer (46.6%). Oral cavity was the most common cancer site (32.9%), followed by oropharynx (31.7%); 55.4% patients had hypertension, 23.0% had dyslipidemia, and 16.1% had diabetes. CVD was diagnosed in 16.1% patients, who were more likely to be older [median age 67.0 vs 60.0 years, p<0.0001]. In the multivariable model, hypertension [2.08(1.54-2.80)], diabetes [2.03(1.52-2.70)] and dyslipidemia [2.36(1.82-3.07)] were associated with CVD. Smoking status was not associated. Association of cancer stage with CVD varied by cancer site. Stage III/IV oropharynx cancer patients had lower odds of CVD than stage I/II oropharynx patients [0.38(0.30-0.92)]. No association with cancer stage was observed in oral cavity patients. Compared to chemotherapy, surgery [0.85(0.63-1.14)] and other treatments {0.61(0.41-0.89)] had lower odds of CVD. Conclusions: Traditional CVD risk factors remain associated with CVD in HNSCC patients. In addition, cancer-related factors (oropharynx cancer, advanced cancer stage and chemotherapy) are also associated with CVD.

Download Full-text

Angular Stable Miniplate Fixation of Chronic Unstable Scaphoid Nonunion

Journal of Wrist Surgery ◽

10.1055/s-0037-1603202 ◽

2017 ◽

Vol 07 (01) ◽

pp. 024-030 ◽

Cited By ~ 1

Author(s):

Peter Brink ◽

Martijn Poeze ◽

Pascal Hannemann ◽

Philip Schormans

Keyword(s):

Range Of Motion ◽

Cancellous Bone ◽

Bone Grafting ◽

Scaphoid Fracture ◽

Scaphoid Nonunion ◽

Previous Surgery ◽

Level Of Evidence ◽

Cancellous Bone Grafting ◽

Scaphoid Fractures ◽

Radiological Healing

Background Around 5 to 15% of all scaphoid fractures result in nonunion. Treatment of long-lasting scaphoid nonunion remains a challenge for the treating surgeon. Healing of scaphoid nonunion is essential for prevention of scaphoid nonunion advanced collapse and the subsequent predictable pattern of radiocarpal osteoarthritis. Purpose The purpose of this study was to investigate the feasibility of fixation of the scaphoid nonunion with a volar angular stable miniplate and cancellous bone grafting. We hypothesized that this technique could be successful, even in patients with previous surgery for nonunion and in patients with a long duration of nonunion. Patients and Methods A total of 21 patients enrolled in a single-center prospective cohort study. Healing of nonunion was assessed on multiplanar computed tomography scan of the wrist at a 3-month interval. Functional outcome was assessed by measuring grip strength, range of motion, and by means of the patient-rated wrist and hand evaluation (PRWHE) questionnaire. Results During follow-up, 19 out of 21 patients (90%) showed radiological healing of the nonunion. The range of motion did not improve significantly. Postoperative PRWHE scores decreased by 34 points. Healing occurred regardless of the length of time of the nonunion (range: 6–183 months) and regardless of previous surgery (38% of patients). Conclusion Volar angular stable miniplate fixation with autologous cancellous bone grafting is a successful technique for the treatment of chronic unstable scaphoid nonunion, even in patients with long-lasting nonunion and in patients who underwent previous surgery for a scaphoid fracture. Rotational interfragmentary stability might be an important determining factor for the successful treatment of unstable scaphoid nonunion. Level of Evidence Level IV.

Download Full-text

Effect of Screw Length and Geometry on Interfragmentary Compression in a Simulated Proximal Pole Scaphoid Fracture Model

Hand ◽

10.1177/1558944718795281 ◽

2018 ◽

Vol 15 (3) ◽

pp. 378-383

Author(s):

Samik Patel ◽

Juan M. Giugale ◽

Richard E. Debski ◽

John R. Fowler

Keyword(s):

Analysis Of Variance ◽

Scaphoid Fracture ◽

Fracture Site ◽

Proximal Pole ◽

Scaphoid Fractures ◽

Screw Length ◽

Significant Difference ◽

Headless Compression Screws ◽

With Screws ◽

Interfragmentary Compression

Background: The objective of this study was to determine interfragmentary compression forces based on screw length and geometry for simulated proximal scaphoid fractures. Methods: Sixty-four foam model simulated fractures were stabilized with screws of various length (10 mm, 18 mm, 20 mm, or 24 mm) and geometry (central threadless or fully threaded) across a proximal fracture. Interfragmentary compression was measured at the simulated fracture site upon fixation. An independent sample t test and 1-way analysis of variance were performed to assess differences in interfragmentary compression. Results: Fixation utilizing a 10-mm screw generated significantly less interfragmentary compression than fixation utilizing a 20-mm or 24-mm screw. When accounting for both screw length and geometry, an 18-mm central threadless screw generated greater interfragmentary compression than a 20-mm and 24-mm fully threaded screw; there was no significant difference in compression between an 18-mm and 24-mm central threadless screw. Conclusions: The design of headless compression screws allows for maximal interfragmentary compression at the screw midpoint; we questioned whether a short screw centered on the fracture site resulted in superior compression to a longer, noncentered screw. Our data suggest that centering a small screw (10 mm) along a proximal fracture generates significantly less interfragmentary compression than a longer, noncentered screw. Our results demonstrate that balance between maximizing screw length and centering the screw on the fracture is vital toward maximizing interfragmentary compression for the fixation of proximal third scaphoid fractures.

Download Full-text