Abstract
IntroductionData from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks.Materials and methodsIn a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization.ResultsUnclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons’ decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28–6.81, p = 0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as ‘other’) (OR 2.64; 95% CI 1.31–5.33, p = 0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18–19.52, p = 0.01 versus Europe) were more likely to recommend continued immobilization.ConclusionAdoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance.
Highlights
Data from clinical trials suggest that computed tomography (CT)-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization
Evidence from clinical trials suggests that a scaphoid waist fracture that is nondisplaced on computed tomography (CT) will heal with adequate immobilization [1,2,3,4,5]
Random forest analysis demonstrated that the most predictive factors for recommending to continue cast immobilization or not were in order of importance: radiographic fracture healing, duration of cast immobilization, and fracture tenderness; followed by age and sex which were of equal importance (Fig. 1)
Summary
Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization. Results Unclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons’ decision to recommend continued cast immobilization. Among five clinical prospective and one retrospective series that used CT or MRI to diagnose displacement, only two in 362 (0.6%) of the nondisplaced waist fractures treated with cast immobilization did not heal [1,2,3,4,5, 9] It is not clear whether the diagnosis of nonunion in these two fractures was based on imaging 4–12 weeks after injury, or confirmed radiologically 6 months or more after injury [3, 4]. It is possible that at least one of these fractures was displaced as it demonstrated moderate translation on the 4-week CT scan and there was no CT scan at the time of injury [4]
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