Management and Outcomes of Clinical Scaphoid Fractures in Children

Hand ◽  
2020 ◽  
pp. 155894472093029
Author(s):  
Aneesh Karir ◽  
Minh N. Q. Huynh ◽  
Sasha Carsen ◽  
Kevin Smit ◽  
Kevin Cheung
Keyword(s):  
Scaphoid Fracture ◽  
Clinical Signs ◽  
Fracture Rate ◽  
X Rays ◽  
Advanced Imaging ◽  
Scaphoid Fractures ◽  
Fractures In Children ◽  
Magnetic Resonance Imaging Mri ◽  
Mean Time ◽  
Pediatric Center

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

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

2019 ◽  
Vol 09 (01) ◽  
pp. 002-012 ◽  
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.

Imaging of gout

2016 ◽  
Author(s):  
Robert T. Keenan ◽  
Sneha Pai ◽  
Naomi Schlesinger
Keyword(s):  
Soft Tissues ◽  
Clinical Signs ◽  
Urate Oxidase ◽  
Imaging Modalities ◽  
Dual Energy Ct ◽  
X Rays ◽  
Advanced Imaging ◽  
Crystal Deposition ◽  
Bone Changes ◽  
Magnetic Resonance Imaging Mri

Gout is a systemic metabolic disease. The enzyme urate oxidase (uricase) that catalyses the oxidation of uric acid to the more soluble compound allantoin is inactive in humans. This may lead to hyperuricaemia. Hyperuricaemia is often present for many years prior to clinical signs of gout. Acute attacks occur as a result of an inflammatory response to monosodium urate (MSU) crystal deposition leading to intense pain and inflammation in the affected joints. Uncontrolled hyperuricaemia and resultant gout can evolve into a destructive arthritis. Imaging may be helpful in the diagnosis of gout as well as in monitoring the response to gout treatment. Plain X-rays are widely used for joint imaging in patients with gout. However, plain X-rays of joints affected by gout are frequently normal, especially early in the disease. In these cases, advanced imaging modalities may be useful. Advanced imaging can help evaluate inflammation, structural joint changes, and magnitude of tophaceous deposits. Advanced imaging modalities include computed tomography (CT), dual-energy CT (DECT), magnetic resonance imaging (MRI), and ultrasound (US). CT may be most suitable to evaluate bone changes in gouty joints and DECT to evaluate tophaceous deposits. MRI may best evaluate soft tissues and Inflammation. US is useful during patients’ visits to the rheumatologist and allows evaluation of cartilage, soft tissues, synovium, and tophaceous deposits. This chapter reviews imaging modalities used in gout patients and discusses their application in the diagnosis and management of gout.

1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
J Cullen ◽  
R Donovan ◽  
K Vipulendran ◽  
E Lostis ◽  
N Blewitt ◽  
...  
Keyword(s):  
Scaphoid Fracture ◽  
Degenerative Change ◽  
Clinic Visit ◽  
Bone Bruise ◽  
X Rays ◽  
Scaphoid Fractures ◽  
Time Period ◽  
Audit Reports ◽  
The Impact ◽  
Limited Sequence

Abstract Introduction MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit. Method A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period. Results he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort. Conclusions Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

Diagnostic Strategy for Suspected Scaphoid Fractures in the Presence of Other Fractures in the Carpal Region

2006 ◽  
Vol 31 (4) ◽  
pp. 416-418 ◽  
Author(s):  
F. J. P. BEERES ◽  
M. HOGERVORST ◽  
P. DEN HOLLANDER ◽  
S. J. RHEMREV
Keyword(s):  
Bone Scintigraphy ◽  
Bone Fractures ◽  
Scaphoid Fracture ◽  
Diagnostic Process ◽  
Scaphoid Bone ◽  
Diagnostic Strategy ◽  
X Rays ◽  
Scaphoid Fractures ◽  
Bone Injury ◽  
Suspected Scaphoid Fracture

Bone scintigraphy will identify up to 25% of occult scaphoid bone fractures after negative scaphoid X-rays. Consequently, it deserves a place in the diagnostic process of suspected scaphoid fractures. However, the role of bone scintigraphy is less clear if scaphoid X-rays show other fractures in the carpal region. We analysed 111 consecutive patients with a suspected scaphoid fracture on physical examination. Scaphoid X-rays revealed 61 fractures. Fifty-five patients had scaphoid fractures only and six patients had other fractures in the carpal region but no scaphoid fracture. In 50 cases, no bone injury was seen on these X-rays. In three out of the six patients with other fractures in the carpal region, bone scintigraphy revealed four occult concomitant fractures: one scaphoid, one scaphoid and trapezial and one capitate fracture. In conclusion, bone scintigraphy is required when scaphoid X-rays do not confirm a suspected scaphoid fracture, even in the presence of other fractures in the carpal region.

scholarly journals The Clinical Scaphoid Fracture: Early Computed Tomography as a Practical Approach

2008 ◽  
Vol 90 (6) ◽  
pp. 488-491 ◽  
Author(s):  
Q Nguyen ◽  
S Chaudhry ◽  
R Sloan ◽  
I Bhoora ◽  
C Willard
Keyword(s):  
Ct Scan ◽  
General Hospital ◽  
Scaphoid Fracture ◽  
False Negative ◽  
False Negative Rate ◽  
District General Hospital ◽  
X Rays ◽  
Fracture Clinic ◽  
Non Union ◽  
Scaphoid Fractures

INTRODUCTION Up to 40% of scaphoid fractures are missed at initial presentation as clinical examination and plain radiographs are poor at identifying scaphoid fractures immediately after the injury. Avoiding a delay in diagnosis is essential to prevent the risk of non-union and early wrist arthritis. We demonstrate the use of CT scanning for the early confirmation of a scaphoid fracture. PATIENTS AND METHODS We conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a small district general hospital. We performed a CT scan on all ‘clinical scaphoid’ patients who had negative plain X-ray films. RESULTS Overall, 70% of patients had a CT scan within 1 week of injury and not from date of accident and emergency attendance; 83% of patients had a CT scan within 2 weeks of injury. Of 118 patients identified, 32% had positive findings and 22% of ‘clinical scaphoid’ patients had scaphoid fractures. The proportion of positive findings for an acute scaphoid fracture was 68%. Additional pathologies identified on CT were capitate, triquetral and radial fractures. CONCLUSIONS Our audit shows that it is practical to perform CT on suspicious scaphoid fractures in a small district general hospital. We identified an extremely high false-negative rate for plain X-rays and demonstrate that the appropriate use of CT at initial fracture clinic attendance with ‘clinical scaphoid’ leads to an earlier diagnosis and reduces the need for prolonged immobilisation and repeated clinical review.

The Role of Carpal Instability in Scaphoid Nonunion: Casual or Causal?

1986 ◽  
Vol 11 (2) ◽  
pp. 201-206
Author(s):  
J. J. MONSIVAIS ◽  
P. A. NITZ ◽  
T. J. SCULLY
Keyword(s):  
Scaphoid Fracture ◽  
Surgical Care ◽  
Critical Factor ◽  
Carpal Instability ◽  
X Rays ◽  
Fracture Displacement ◽  
Scaphoid Fractures ◽  
Satisfactory Outcome ◽  
Stabilization Procedure ◽  
Ligamentous Reconstruction

We studied twenty consecutive scaphoid nonunions in twenty patients between the ages of eighteen and thirty-eight years. There were nineteen males and one female. The mean age was 25.2 years. Factors evaluated were fracture displacement, delay in treatment, and carpal instability. Fracture displacement and carpal instability were documented in patients by abnormal x-rays showing fragment displacement, abnormal scapholunate and radiolunate angles, etc., or by fluoroscopically controlled arthrography. We concluded that intercarpal ligamentous instability is consistently present and, therefore, the critical factor in wrists with ununited scaphoid fractures. Thirteen patients have been treated surgically; ligamentous disruption was confirmed at surgical exploration. In twelve patients, treatment of the nonunion included intercarpal ligamentous reconstruction. A satisfactory outcome was achieved in all twelve of these patients. One patient’s treatment did not include ligament reconstruction. Although the scaphoid fracture united after a Russe bone graft, he remains symptomatic with persistent intercarpal instability. The remaining seven patients are being evaluated or awaiting surgery. Since ligamentous injury is so common in nonunion, we believe it is causal and that surgical care of nonunion involves ligamentous repair or other stabilization procedure. Prevention of nonunion involves early attention to the therapy of carpal instability when associated with scaphoid fracture.

scholarly journals Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures

2019 ◽  
Vol 09 (01) ◽  
pp. 081-089
Author(s):  
Henrik Constantin Bäcker ◽  
Chia H. Wu ◽  
Robert J. Strauch
Keyword(s):  
Systematic Review ◽  
Ct Scan ◽  
Bone Scintigraphy ◽  
Sensitivity And Specificity ◽  
Imaging Modality ◽  
Scaphoid Fracture ◽  
Diagnostic Tools ◽  
Search Term ◽  
X Rays ◽  
Scaphoid Fractures

Background Scaphoid fracture accounts for approximately 15% of acute wrist fractures. Clinical examination and plain X-rays are commonly used to diagnose the fracture, but this approach may miss up to 16% of fractures in the absence of clear-cut lucent lines on plain radiographs. As such, additional imaging may be required. It is not clear which imaging modality is the best. The goal of this study is to summarize the current literature on scaphoid fractures to evaluate the sensitivity, specificity, and accuracy of four different imaging modalities. Case Description A systematic-review and meta-analysis was performed. The search term “scaphoid fracture” was used and all prospective articles investigating magnetic resonance imaging (MRI), computed tomography (CT), bone scintigraphy, and ultrasound were included. In total, 2,808 abstracts were reviewed. Of these, 42 articles investigating 51 different diagnostic tools in 2,507 patients were included. Literature Review The mean age was 34.1 ± 5.7 years, and the overall incidence of scaphoid fractures missed on X-ray and diagnosed on advanced imaging was 21.8%. MRI had the highest sensitivity and specificity for diagnosing scaphoid fractures, which were 94.2 and 97.7%, respectively, followed by CT scan with a sensitivity and specificity at 81.5 and 96.0%, respectively. The sensitivity and specificity of ultrasound were 81.5 and 77.4%, respectively. Significant differences between MRI, bone scintigraphy, CT, and ultrasound were identified. Clinical Relevance MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound. Level of Evidence This is a Level II systematic review.

Cost-effectiveness of MRI in managing suspected scaphoid fractures

2009 ◽  
Vol 34 (5) ◽  
pp. 627-630 ◽  
Author(s):  
T. B. HANSEN ◽  
R. B. PETERSEN ◽  
J. BARCKMAN ◽  
P. UHRE ◽  
K. LARSEN
Keyword(s):  
Cost Effectiveness ◽  
Sick Leave ◽  
Scaphoid Fracture ◽  
Treatment Algorithm ◽  
Hospital Costs ◽  
Clinical Signs ◽  
Cost Effective ◽  
Effectiveness Study ◽  
Scaphoid Fractures ◽  
Cost Effectiveness Study

In a cost-effectiveness study, we compared a treatment algorithm using repeated radiological examination with an algorithm using subacute MRI in patients with clinical signs of scaphoid fracture but normal initial radiography. Twenty-seven patients were included in both groups, and MRI reduced the immobilisation time from 20 days (range, 6–54) to 4 days (range, 1–19) and sick leave from 27 days (1–92) to 11 days (0–28). Use of MRI increased hospital costs by €151 ( P<0.05), but reduced non-hospital costs by €2869 ( P<0.05), making MRI cost-effective in the treatment of suspected scaphoid fractures.

scholarly journals Suspected scaphoid injuries managed by MRI direct from the emergency department

2021 ◽  
Vol 2 (6) ◽  
pp. 447-453
Author(s):  
Benjamin J. F. Dean ◽  
Christopher Little ◽  
Nicholas D. Riley ◽  
Edward Sellon ◽  
Warren Sheehan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Scaphoid Fracture ◽  
Clinical Signs ◽  
Early Discharge ◽  
Median Number ◽  
Service Evaluation ◽  
Delayed Union ◽  
Cast Immobilization ◽  
Wrist Trauma ◽  
Scaphoid Fractures

Aims To determine the role of early MRI in the management of suspected scaphoid fractures. Methods A total of 337 consecutive patients presenting to an emergency department (ED) following wrist trauma over a 12-month period were prospectively included in this service evaluation project. MRI was not required in 62 patients with clear diagnoses, and 17 patients were not managed as per pathway, leaving a total of 258 patients with normal scaphoid series radiographs who were then referred directly from ED for an acute wrist MRI scan. Patient demographics, clinical details, outcomes, and complications were recorded at a minimum of a year following injury. Results The median time from injury to ED presentation was one day and the median number of positive clinical signs was two out of three (snuffbox tenderness, tubercle tenderness, pain on telescoping). Of 258 patients referred for acute MRI, 208 scans were performed as 50 patients either did not tolerate (five patients) or did not attend their scan (45 patients). MRI scans demonstrated scaphoid fracture (13%), fracture of another bone (22%), scaphoid contusion (6%), other contusion/ligamentous injury (20%), or solely degenerative pathology (10%). Only 29% of scans showed no abnormality. Almost 50% of those undergoing MRI (100 patients) were discharged by ED with advice, with only one re-presentation. Of the 27 undisplaced occult scaphoid fractures, despite prompt cast immobilization, two experienced delayed union which was successfully treated with surgery. Conclusion The use of MRI direct from ED enables prompt diagnosis and the early discharge of a large proportion of patients with normal radiographs following wrist trauma. Cite this article: Bone Jt Open 2021;2(6):447–453.

Diagnosis and Treatment of Scaphoid Waist Fractures: A Literature Review

2020 ◽  
Author(s):  
Mohammad Ali Okhovatpour ◽  
Adel Ebrahimpour ◽  
Mohammadreza Minator Sajjadi ◽  
Mehrdad Sadighi ◽  
Reza Zandi ◽  
...  
Keyword(s):  
Ct Scan ◽  
Scaphoid Fracture ◽  
Diagnosis And Treatment ◽  
Wrist Flexion ◽  
Work Time ◽  
Scaphoid Fractures ◽  
Magnetic Resonance Imaging Mri ◽  
Nondisplaced Fracture ◽  
Tomography Scan

Scaphoid fracture can cause serious complications and its diagnosis and treatment approaches are still contentious. Tenderness of anatomical snuffbox (ASB), longitudinal compression (LC) of the thumb, and scaphoid tubercle (ST) tenderness are very sensitive tests for clinical diagnosis of scaphoid factures all together. Previous studies recommend taking four standard views of the wrist for non-displaced scaphoid fractures diagnosis. Magnetic resonance imaging (MRI), computed tomography scan (CT scan), bone scintigraphy, and ultrasound are used for triage of suspected scaphoid fractures. MRI has the highest sensitivity and specificity. CT scan images captured in planes by the long axis of the scaphoid guide the diagnosis of nondisplaced scaphoid fracture. Displaced fractures need surgical treatment, but the best way of treating a nondisplaced fracture is controversial. Same results have been determined using a short arm or long arm cast for treatment of nondisplaced scaphoid fractures as well as similar outcomes with or without a thumb-spica component to the cast. Wrist position immobilization did not affect the rate of nonunion, wrist flexion, pain, or grip strength. Percutaneous screw fixation can shorten return to work time. CT scan and MRI both can be applied for assessment of union of fracture during follow-up period. This study aims to review the literature on challenges about clinical and radiologic diagnosis of nondisplaced scaphoid fractures and also present concepts about definite management of nondisplaced and minimally-displaced scaphoid waist fractures.

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