Can we avoid casting for suspected scaphoid fractures? A randomized controlled trial.

Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review

Scaphoid fractures are the most common type of carpal injuries that occur in children and adolescents. The injury pattern seen in children and adolescents who have scaphoid fractures has recently shifted to resemble that of adults who have scaphoid fractures, with scaphoid waist fractures being the most common injury pattern. This shift has been attributed to increased body mass index in children and adolescents as well as more intense participation in extreme sports by both children and adolescents. The diagnosis of scaphoid fractures is based on both a clinical examination and radiographic fi ndings. If a scaphoid fracture is clinically suspected but initial radiographs are negative, cast immobilization followed by repeat imaging can lead to accurate diagnosis of the injury. MRI can aid in the diagnosis of a scaphoid injury in pediatric patients with incomplete ossifi cation of the scaphoid. Acute nondisplaced scaphoid fractures have a high rate of healing with cast immobilization; however, surgery should be considered in patients who have displaced scaphoid fractures with delayed presentation. In general, patients with scaphoid fractures who undergo appropriate treatment and achieve successful union have excellent long-term functional outcomes.

Background: The human scaphoid bone is one of the carpal bones of the wrist. Its fracture is the most common type of carpal bone fracture. Scaphoid nonunion is a well-known and common problem. Both clinical and biological factors contribute to the development of nonunion. Several techniques of bone grafting have been used in the management of scaphoid fracture nonunion. The union rate achieved with standard nonvascularized bone grafts was poor, especially in case of avascular necrosis and pseudarthroses, whereas the use of vascularized bone grafts results in better union rates. Pronator quadratus pedicled bone graft is described as one of the successful techniques that treat delayed union of the scaphoid fracture. Objective: To evaluate the outcomes and results of pronator quadratus muscle pedicle bone graft for patients who were suffering from delayed union or nonunion of scaphoid bone fracture. Patients and Methods: Ten patients suffering from delayed and non-united scaphoid fractures, seven males and three females, aging from 17 to 54 years old. We used the pronator quadratus muscle pedicled bone graft to treat all these patients. Results: Complete union was achieved in seven patients, 6 patients of them were suffering from waist non united scaphoid fracture, and one patient of four patients suffering from non-united proximal pole scaphoid fracture. Conclusion: The use of the pronator quadratus pedicled bone graft in delayed union of the scaphoid waist fractures achieved a high rate of union with excellent and good functional outcomes. A poor result occurred on using the pronator quadratus pedicled bone graft in delayed union of the scaphoid proximal pole fracture.

Background The management of delayed scaphoid fractures in physically demanding patients remains ‎controversial. This article discusses a simple treatment that accelerates healing and allows early mobilization. ‎ The purpose of the study was to evaluate results of percutaneous headless compression screw fixation with bone ‎marrow injection in scaphoid delayed-union fractures, which allows early mobilization of wrist to achieve early ‎return to activities of daily living (ADL).‎ Patients and methods A total of 20 patients (22 scaphoid) with scaphoid delayed-union fractures underwent percutaneous headless screw fixation with bone marrow injection from iliac bone. The inclusion criteria in this series were scaphoid delayed-union fractures with intact cartilaginous envelope, no sclerosis, and no avascular necrosis. Results The mean follow-up period as 20.4 months (range: 12–24), the average radiographic union was 7.8 weeks (range: 6–10 weeks), and the average visual analog scale score was 0.05 (range: 0–1). Average wrist range of motion was flexion of 85° (range: 75–90), extension 76.5° (range: 70–85), radial tilt 18.5° (range: 15–20), and ulnar tilt 42.5° (range: 39–45). The average grip strength was 95% (85–100%). Conclusion Percutaneous technique fixation for scaphoid fractures is a reliable and less harmful method and helps in early return to activity. The dorsal approach allows proper screw positioning and allows the use of hook to correct minimal displacement and gain best compression at the fracture site. Refreshing of the fracture ends by k-wire and bone marrow injection help to accelerate union with the less-invasive method. The best results of the percutaneous technique in delayed-union scaphoid fractures are achieved with intact cartilaginous envelope, no sclerosis, and no avascular necrosis. Level of evidence This was a level IV therapeutic study.

Background: The human scaphoid bone is one of the carpal bones of the wrist. Its fracture is the most common type of carpal bone fracture. Scaphoid nonunion is a well-known and common problem. Both clinical and biological factors contribute to the development of nonunion. Several techniques of bone grafting have been used in the management of scaphoid fracture nonunion. The union rate achieved with standard nonvascularized bone grafts was poor, especially in case of avascular necrosis and pseudarthroses, whereas the use of vascularized bone grafts results in better union rates. Pronator quadratus pedicled bone graft is described as one of the successful techniques that treat delayed union of the scaphoid fracture. Objective: To evaluate the outcomes and results of pronator quadratus muscle pedicle bone graft for patients who were suffering from delayed union or nonunion of scaphoid bone fracture. Patients and Methods: Ten patients suffering from delayed and non-united scaphoid fractures, seven males and three females, aging from 17 to 54 years old. We used the pronator quadratus muscle pedicled bone graft to treat all these patients. Results: Complete union was achieved in seven patients, 6 patients of them were suffering from waist non united scaphoid fracture, and one patient of four patients suffering from non-united proximal pole scaphoid fracture. Conclusion: The use of the pronator quadratus pedicled bone graft in delayed union of the scaphoid waist fractures achieved a high rate of union with excellent and good functional outcomes. A poor result occurred on using the pronator quadratus pedicled bone graft in delayed union of the scaphoid proximal pole fracture.

Fracture displacement is the most important factor associated with nonunion of a scaphoid waist fracture.We evaluated the performance characteristics of radiographs and computed tomography (CT) in the diagnosis of intraoperative displacement and instability of scaphoid waist fractures using wrist arthroscopy as the reference standard. During a six-year period (2004 to 2010) at two institutions, forty-four adult patients with a scaphoid waist fracture underwent arthroscopy-assisted operative fracture treatment at a mean of nine days (range, two to twenty-two days) after injury. Subjects included all of those with a displaced scaphoid fracture seen on radiographs and a selection of patients with a nondisplaced scaphoid fracture. All patients had preoperative radiographs and CT. Arthroscopy with up to 5 kg of traction was the reference standard for fracture displacement and instability. The reference standard (arthroscopy) led to a diagnosis of twenty-two displaced fractures (all unstable) and twenty-two nondisplaced fractures (seven unstable). Displacement was diagnosed in eleven patients (25%) with the use of radiographs and in twenty (45%) with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative displacement were 45%, 95%, and 70%, respectively, with the use of radiographs and 77%, 86%, and 82%, respectively, with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative instability were 34%, 93%, and 55%, respectively,with the use of radiographs and 62%, 87%, and 70%, respectively, with CT. Assuming a 10% prevalence of fracture displacement and instability among all scaphoid waist fractures, the positive and negative predictive values for displacement were 53% and 94%, respectively, with the use of radiographs and 39% and 97% with CT whereas the positive and negative predictive values for instability were 36% and 93%, respectively, with radiographs and 34% and 95% with CT. Radiographs and CT scans cannot be relied on to accurately diagnose intraoperative scaphoid fracture displacement or instability compared with arthroscopic examination. The influence, with regard to the risk of nonunion, of intraoperative instability of a scaphoid fracture that is seen to be nondisplaced on radiographs or CT is currently unknown. Diagnostic Level III.

To assess injury patterns and outcomes after navicular fractures. Retrospective radiographic review using the Schmid classification. Academic Level 1 Trauma Center; PATIENTS/PARTICIPANTS:: Thirty-nine navicular fractures associated with additional foot injuries. Open reduction internal fixation. Radiographic evaluation of nonunion, malunion, and post-traumatic arthritis; secondary operations. A total of 12/18 (67%) Schmid type II fractures healed without complications. Ten fractures were treated with tension band plates (56%) and 8 with screws (44%). Three complications were in cases treated with screws (3/8 = 37.5%). No case went on to develop avascular necrosis. In the 21 Schmid type III fractures, radiographic results were uniformly poor. Only 3 healed after the index procedure without evidence of radiographic post-traumatic arthritis. Four required a primary talonavicular (TN) fusion for an unreconstructable articulation found at the time of the index surgical treatment. The remaining 14 (67%) all had radiographic evidence of severe collapse, end-stage post-traumatic arthritis, and/or a significant midfoot deformity at the time of follow-up examination. Three of these required a late triple arthrodesis. Type II navicular body fractures are substantial injuries in which the amount of comminution belies the amount of damage to the talonavicular articulation. Tension band plate augmentation seemed to keep the navicular fracture secure and prevent lag screw loosening. Schmid type III navicular body fractures are devastating injuries. They are associated with additional severe trauma to the foot and require extensive surgical reconstruction of the medial column, lateral column, or both. Residual problems should be expected and may not be due to the navicular injury, but rather to the associated fractures and dislocations. Patients should be aware that their foot will be stiff and may require further reconstructive treatment. Level IV. See Instructions for Authors for a complete description of levels of evidence.

The suspected fracture of the scaphoid: a rational approach to diagnosis

The Benefit of Magnetic Resonance Imaging for Patients With Posttraumatic Radial Wrist Tenderness

Conventional radiographic imaging is the first imaging tool of choice in scaphoid fractures. The majority of undisplaced scaphoid waist fractures unite after 6weeks of cast immobilization. We hypothesized that conventional radiographic imaging at 6weeks after injury can both accurately and reliably predict union in undisplaced scaphoid waist fractures. Fleiss' kappa statistics were used concerning the opinions of four observers reviewing 47 sets of good-quality scaphoid radiographs of undisplaced scaphoid waist fractures. As reference standard for union, radiographs were taken at a minimum of 6months after injury to determine validity. Overall agreement was defined as moderate. (κ=0.583) "No consolidation" (κ=0.816), "full consolidation" (κ=0.517) and "partial consolidation" (κ=0.390) were defined as good, moderate and fair agreement, respectively. The average sensitivity and specificity of diagnosing scaphoid waist fracture union on standard scaphoid radiographs were 0.65 and 0.67, respectively. The positive predictive value for diagnosing union was 0.93 and the negative predictive value was 0.22. Conventional radiographic imaging is accurate and moderately reliable in diagnosing union, and reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6weeks follow-up.

Background:This study aims to investigate the characteristics of concomitant distal radius and scaphoid fractures and determine outcome differences of operative and nonoperative management.Methods:A retrospective search of a level-1 trauma center’s database over a 15-year period (2007-2022) for concomitant distal radius and scaphoid fractures in adult patients was completed. In all, 31 cases were reviewed for mechanism of injury, method of fracture management, distal radius fracture AO Foundation/Orthopaedic Trauma Association classification, scaphoid fracture classification, time to radiographic scaphoid union, time to motion, and other demographics. A multivariate statistical analysis was completed comparing outcomes in operative versus conservative management of the scaphoid fracture in these patients. Outcomes were defined as time to radiographic union and time to motion.Results:In all, 22 cases of operative fixation of the scaphoid and 9 cases of nonoperative management of the scaphoid were reviewed. One case of nonunion was identified in the operative group. Operative management of scaphoid fractures resulted in a statistically significant reduction in time to motion (2-week reduction) and time to radiographic union (8-week reduction).Conclusions:This study demonstrates that operative management of scaphoid fractures in the setting of a concomitant distal radius fracture reduces the time to radiographic union and time to clinical motion. This suggests that operative management is ideal in patients who are good candidates for surgery and desire earlier return of motion. However, conservative management should be considered, as nonoperative care showed no statistical difference regarding union rates of scaphoid or distal radius fractures.

Besides conventional radiographs, the use of MRI, CT, and bone scintigraphy is frequent in the diagnosis of a fracture of the scaphoid. However, which techniques give the best results remain unknown. The investigation of a new imaging technique initially requires an analysis of its precision. The primary aim of this study was to investigate the interobserver agreement of high-resolution peripheral quantitative CT (HR-pQCT) in the diagnosis of a scaphoid fracture. A secondary aim was to investigate the interobserver agreement for the presence of other fractures and for the classification of scaphoid fracture. Two radiologists and two orthopaedic trauma surgeons evaluated HR-pQCT scans of 31 patients with a clinically-suspected scaphoid fracture. The observers were asked to determine the presence of a scaphoid or other fracture and to classify the scaphoid fracture based on the Herbert classification system. Fleiss kappa statistics were used to calculate the interobserver agreement for the diagnosis of a fracture. Intraclass correlation coefficients (ICCs) were used to assess the agreement for the classification of scaphoid fracture. A total of nine (29%) scaphoid fractures and 12 (39%) other fractures were diagnosed in 20 patients (65%) using HR-pQCT across the four observers. The interobserver agreement was 91% for the identification of a scaphoid fracture (95% confidence interval (CI) 0.76 to 1.00) and 80% for other fractures (95% CI 0.72 to 0.87). The mean ICC for the classification of a scaphoid fracture in the seven patients diagnosed with scaphoid fracture by all four observers was 73% (95% CI 0.42 to 0.94). We conclude that the diagnosis of scaphoid and other fractures is reliable when using HR-pQCT in patients with a clinically-suspected fracture. Cite this article: Bone Joint J 2020;102-B(4):478-484.

HISTORY: year-old right-handed senior male golfer presented with right wrist pain. History was significant for 4 months of pain that worsened after striking a tree root while playing golf in the spring. He was evaluated and radiographs were negative at that time. His pain subsided with 3 weeks of rest. He returned to his home in Europe for summer vacation, and had increasing pain with golfing activity over 6-8 weeks. An MRI in Europe was reported to show edema in scaphoid, and a CT scan reportedly showed a non-displaced healing scaphoid fracture. He was treated with relative rest and physiotherapy for 6 weeks. At his follow-up visit upon returning to school for the fall, he reported improvement in symptoms. He was able to do normal daily activities without pain, but still had some pain with weight-bearing activities. PHYSICAL EXAMINATION: Examination of his right wrist revealed normal alignment without deformity, ecchymosis, erythema or swelling. He had no pain to palpation over the anatomic snuffbox. He had full range of motion and normal strength of his right wrist to flexion, extension, ulnar deviation, radial deviation, pronation, and supination without pain. He had normal grip strength. He had mild discomfort on the radial side of his right wrist with weight-bearing on his right hand. Neurovascularly intact in his right upper extremity. DIFFERENTIAL DIAGNOSES: Scapholunate ligament injury Kienbock’s disease Scaphoid impaction syndrome Scaphoid fracture De Quervain’s tenosynovitis TESTS AND RESULTS: X-ray of right wrist: --Scaphoid waist fracture with evidence of healing CT of right wrist: --Scaphoid waist fracture with evidence of partial non-union along the volar margin FINAL WORKING DIAGNOSIS: Partial union of mid waist scaphoid fracture TREATMENT AND OUTCOME: Initially, immobilization in an Exos thumb spica splint. Bone stimulator twice daily for 20 minutes. Gradually progressed him back to golfing activity starting with chipping and putting. He was still healing as of last set of X-rays at 8 week follow-up. He progressed through putting and chipping without pain. We cleared him to start full golf activity.

Unusual case report of concomitant lunate and scaphoid fractures without associated dislocation in a 16-year-old male

Background: Scaphoid fractures are the most common type of carpal fractures, with the majority (approximately 70–80%) occurring at the waist region, an area with limited blood supply and high risk of non-union. Two primary approaches for internal fixation are the volar (retrograde) and dorsal (antegrade) techniques, but the optimal choice remains controversial. Objective: To evaluate the advantages and disadvantages of volar and dorsal approaches in the fixation of scaphoid waist fractures based on biomechanical, radiological, and clinical outcome data. Methods: A literature review was conducted on clinical, biomechanical, and radiological studies comparing both approaches, focusing on screw positioning, fixation stability, bone healing, complications, and functional outcomes (DASH, PRWE, VAS). Results: The dorsal approach allows for more central screw placement along the scaphoid axis, provides greater biomechanical stability, and avoids injury to volar ligaments. However, it poses risks to extensor tendons and the articular surface of the radius. Conversely, the volar approach is more suitable for distal fractures and deformity correction but carries a higher risk of injury to the STT joint. Functional outcomes and union rates between the two approaches show no clinically significant differences. Complications such as non-union and post-traumatic arthritis may occur, particularly with suboptimal screw positioning or delayed intervention. Conclusion: The success of scaphoid waist fracture fixation is more dependent on achieving central screw placement than on the surgical approach itself. Technique selection should be tailored to the fracture pattern and surgeon expertise to optimize healing and minimize complications. Keywords: Scaphoid fracture, volar approach, dorsal approach, central screw placement