Twenty Questions about Scaphoid Fractures

Barton, N. J.

doi:10.1016/0266-7681(92)90118-l

Cited by 170 publications

(106 citation statements)

References 155 publications

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“…54 Prior scaphoid fracture diagnostic reviews provide a narrative synopsis of physical examination in the evaluation of wrist injuries, but none provides a systematic review or meta-analysis to quantify diagnostic accuracy. 1,115,116 Without explicitly defined methods for various physical examination maneuvers, significant interspecialty heterogeneity occurs when evaluating for these findings. 117 Insufficient clarity by researchers describing the methods for physical examination of the injured wrist for scaphoid fracture might explain some of the interstudy heterogeneity observed in this meta-analysis for physical examination as well as advanced imaging.…”

Section: Discussionmentioning

confidence: 99%

“…Failure to immobilize scaphoid fractures risks nonunion, functional morbidity, and eventual arthritic degeneration. 1 Therefore, the concern for occult (i.e., "clinical") scaphoid fractures that may not be evident on initial x-rays has led to traditional teaching that emphasizes immobilization of any suspected scaphoid fractures with outpatient reevaluation and repeat radiographs in patients with continued concern for fracture. 1 Standard emergency medicine (EM) textbooks still advocate for scaphoid immobilization in forearmbased thumb-spica wrist splints until follow-up evaluation for all patients with tenderness at the anatomical snuffbox.…”

mentioning

confidence: 99%

“…1 Therefore, the concern for occult (i.e., "clinical") scaphoid fractures that may not be evident on initial x-rays has led to traditional teaching that emphasizes immobilization of any suspected scaphoid fractures with outpatient reevaluation and repeat radiographs in patients with continued concern for fracture. 1 Standard emergency medicine (EM) textbooks still advocate for scaphoid immobilization in forearmbased thumb-spica wrist splints until follow-up evaluation for all patients with tenderness at the anatomical snuffbox. These textbooks do not provide quantitative estimates of diagnostic accuracy for elements of the history, physical examination signs, or results of the variety of imaging modalities currently available.…”

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confidence: 99%

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Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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ObjectivesScaphoid 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.MethodsA 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.ResultsA 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.ConclusionsExcept 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.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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“…The main explanation for this is a decreased arterial supply, attributable to the retrograde intraosseous blood supply to the proximal pole that makes fractures in that area more likely to progress to non-union and limits potential healing, and another important reason for non-union is the bone instability [8]. In the surgical treatment of non-union of the proximal pole of the scaphoid, failure rates of approximately 65 % have been reported [9,10]. In such adverse conditions, determination of the vascular status of the scaphoid segments is essential [11].…”

Section: Introductionmentioning

confidence: 99%

Scaphoid fracture nonunion: correlation of radiographic imaging, proximal fragment histologic viability evaluation, and estimation of viability at surgery

Bervian

Ribak

Livani

2014

International Orthopaedics (SICOT)

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Purpose The purpose of this study was to correlate the preoperative imaging, vascularity of the proximal pole, and histology of the proximal pole bone of established scaphoid fracture non-union. Methods This was a prospective non-controlled experimental study. Patients were evaluated pre-operatively for necrosis of the proximal scaphoid fragment by radiography, computed tomography (CT) and magnetic resonance imaging (MRI). Vascular status of the proximal scaphoid was determined intra-operatively, demonstrating the presence or absence of puncate bone bleeding. Samples were harvested from the proximal scaphoid fragment and sent for pathological examination. We determined the association between the imaging and intra-operative examination and histological findings. Results We evaluated 19 male patients diagnosed with scaphoid nonunion. CT evaluation showed no correlation to scaphoid proximal fragment necrosis. MRI showed marked low signal intensity on T1-weighted images that confirmed the histological diagnosis of necrosis in the proximal scaphoid fragment in all patients. Intra-operative assessment showed that 90 % of bones had absence of intra-operative puncate bone bleeding, which was confirmed necrosis by microscopic examination. Conclusions In scaphoid nonunion MRI images with marked low signal intensity on T1-weighted images and the absence of intra-operative puncate bone bleeding are strong indicatives of osteonecrosis of the proximal fragment.

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“…The proximal pole of the scaphoid depends solely on intramedullary blood flow. The rare retrograde pattern of the scaphoid's blood supply makes it more susceptible to non-union and proximal pole avascular necrosis [7,8] . n that a limited n Orthopaedic atient [13,14] .…”

Section: Introductionmentioning

confidence: 99%

Diagnostic imaging of suspected scaphoid fractures: A literature review

Ali

Elamin

Mohamed

2016

IJDI

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The scaphoid plays a pivotal role in the movement of the wrist carpal complex. Scaphoid fractures can be difficult to assess clinically with relatively innocuous symptoms. Avascular necrosis, mal-union or non-union can complicate scaphoid fractures. Early diagnosis and treatment improves outcomes and reduces complication rates. Imaging plays a vital role in the diagnosis and management of such fractures, reducing significant long-term disability. We will discuss the different diagnostic modalities, techniques and protocols for diagnosing Scaphoid fractures.

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Twenty Questions about Scaphoid Fractures

Cited by 170 publications

References 155 publications

Adult Scaphoid Fracture

Adult Scaphoid Fracture

Scaphoid fracture nonunion: correlation of radiographic imaging, proximal fragment histologic viability evaluation, and estimation of viability at surgery

Diagnostic imaging of suspected scaphoid fractures: A literature review

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