Occult Fractures Research Articles

Does the Use of Magnetic Resonance Imaging Scan in Occult and Suspected Metastatic Pathological Neck of Femur Fractures Affect the Choice of Surgical Intervention?

Background: Magnetic resonance imaging (MRI) is often employed as the diagnostic modality of choice in occult and suspected pathological femoral neck fractures. We evaluated the clinical utility of MRI scan in this patient population. Method: Retrospective observational analysis of cases with a radiologically occult or suspected metastatic pathological neck of femur fracture. Results: From a total of 894 femoral neck fractures treated in our institution, 100 patients had and MRI scan pre-operatively for either occult fracture or suspected fracture secondary metastatic disease. Magnetic resonance imaging confirmed the presence of 13 simple fractures. A total of 14 patients had pathological features suggestive of metastasis, of which 12 were clearly visible on plain radiographs. Surgical plan did not change after MRI for any of these pathological fractures. Conclusion: Results of this study demonstrate that an MRI scan had an impact on treatment selection only when a simple but radiographically occult fracture is suspected and but not in the context of suspected metastatic pathological fractures.

Use of Multislice CT for Investigation of Occult Geriatric Hip Fractures and Impact on Timing of Surgery.

Introduction:The National Institute of Health and Clinical Excellence guidelines in the United Kingdom recommend magnetic resonance imaging (MRI) as the first-line investigation for radiographically occult hip fractures, if available within 24 hours. In our department, however, multislice computerized tomography (MSCT) is instead used as a first-line investigation due to significant delays associated with obtaining MRI. Our aim was to determine the validity and practicality of MSCT for diagnosis of occult hip fractures and its impact on timing of surgery.Materials and Methods:We retrospectively analyzed medical records and imaging for consecutive patients who underwent MSCT to investigate occult hip fractures between January 2014 and October 2016. We reviewed subsequent imaging and reattendances for patients with negative MSCT to exclude initially missed fractures.Results:Two hundred six patients underwent MSCT to investigate occult hip fracture during the study period. Hip fractures were identified in 59 patients, comprising 35 (59.3%) subcapital, 12 (20.0%) intertrochanteric, 8 (13.6%) transcervical, and 4 (6.8%) basicervical fractures. One missed hip fracture was identified: a patient with a negative MSCT was further investigated with MRI that demonstrated acute subcapital hip fracture. Multislice computerized tomography was obtained within 24 hours of initial radiograph in 145 (70.4%) patients. A total of 44.5% of occult hip fractures had surgery within the nationally recommended 36 hours of admission (hospital average for all hip fractures was 76.4% over the same period).Discussion and Conclusions:Multislice computerized tomography is a pragmatic approach to investigate the majority of occult hip fractures in a timely manner and minimize associated delay to surgery. However it cannot completely exclude the diagnosis, especially in abnormal anatomy. The lack of a true gold standard comparison (ie, MRI) means a true sensitivity and specificity cannot be calculated, although can be cautiously estimated by lack of subsequent reattendance or investigation. Further prospective randomized CT versus MRI trials are required.

The Role of MRI in Non-Traumatic Chronic Hip Joint Pain

MRI is changed the face of diagnostic techniques, it has been used for diagnosing the hip pathologies & is the earliest applications of MRI in diagnosing musculoskeletal disorders. MRI detects articular, extra articular and osseous pathologies in hip joint. Thus is important in diagnosing the cases of chronic hip pain which indicates a long list of causes. MRI is also the investigation of choice for imaging avascular necrosis, radiographically occult fractures, marrow replacement disorders, musculoskeletal neoplasms, and various arthritides involving the hip joint.

Quality Improvement Initiative to Improve Abuse Screening Among Infants With Extremity Fractures.

The aim of this study was to evaluate the effectiveness of clinical pathway implementation and quality improvement (QI) interventions to increase the percentage of infants with extremity fractures undergoing evaluation for suspected physical abuse, including skeletal survey (SS), and consultation with social work, and/or Child Protection Team. Charts were retrospectively reviewed to establish percentage of infants less than 12 months old with extremity fractures undergoing an SS and consultation during the prepathway (January 1, 2012 to December 31, 2013) and postpathway (January 1, 2014 to June 30, 2015) periods. Using an Ishikawa framework, key process drivers were identified and additional QI interventions (clinical decision support and provider education) were developed and implemented. Impact of QI interventions on study metrics during active QI (July 1, 2015 to June 30, 2016) and post-QI periods (July 1, 2016 to December 31, 2016) was monitored using statistical process control charts. Logistic regression assessed predictors of obtaining an SS, consultation use, and occult fracture detection. Skeletal survey use pre- and postpathway averaged 40%, surpassing 60% on average during active QI and post-QI periods. Consultation performance averaged 46% pre- and postpathway, increasing to nearly 67% during active QI; consultation performance decreased during post-QI to 60%. A lack of trauma history and presence of femur or humerus fracture were associated with increased SS use and consultation (both P < 0.001). Overall 20% of SS revealed occult fractures.

Bone Scintigraphy: A Review of Technical Aspects and Applications in Orthopedic Surgery

Due to its high sensitivity, low cost, accessibility, and ease of use, bone scintigraphy is used in orthopedic surgery for the diagnosis and management of varied pathology. It is commonly used for insufficiency fractures, metastatic neoplasia, staging and surveillance of sarcoma, and nonaccidental trauma. It augments diagnoses, including stress or occult fractures, musculoskeletal neoplasia or infection, and chronic regional pain syndrome, in patients presenting with normal results on radiographs. Bone scan images are resistant to metal-based implant artifact, allowing effective evaluation of failed total joint prostheses. Bone scintigraphy remains an underused tool in the evaluation and management of orthopedic patients. [Orthopedics. 2019; 42(1):e14-e24.].

Bedside Ultrasonography for Early Diagnosis of Occult Radial Head Fractures in Emergency Room: A CT-Comparative Diagnostic Study.

Some of the Mason type I fractures cannot be detected on early radiographic images. These occult fractures are considered as a diagnostic challenge for physicians. Our aim was to determine the value of bedside ultrasonography for the detection of Mason I radial head fractures that are non-visible in early X-ray's. A prospective blind single-center diagnostic study was conducted (from June 2012 till May 2013) concerning 23 patients who were clinically suspicious of having a radial head fracture. These patients were evaluated with a bedside high frequency ultrasound in the Emergency Room (E.R.). The two sonographic criteria that were considered to be diagnostic for fracture were: a. effusion besides the radial head-neck and b. cortical discontinuity of the radial head or neck. All patients also underwent a Computed Tomography (CT) as the gold standard imaging modality for diagnosis of occult radial head fractures. Fifteen out of 23 patients were diagnosed with radial head fracture using both ultrasound and CT. On the other hand, there were three patients with negative ultrasound and positive CT, in addition two patients were found positive in the ultrasonographic exam, while this result was not confirmed by the CT scan. In comparison with CT, ultrasound exam appeared to have 83.3% sensitivity, 60% specificity, 88.2% positive prognostic value and 50% negative prognostic value (when at least one diagnostic sonographic criterion was positive). The accuracy of the sonographic study for the diagnosis of the aforementioned fractures was 78.2%. Effusion in contact with the radial neck was the most sensitive sonographic sign (14/15 of the true positive radial head ultrasounds). Bedside ultrasound in the E.R. was proven to be a sensitive tool for early (day-1) diagnosis of the occult radial head fractures. It could be used as an adjacent imaging modality in patients suspicious for radial head fracture, when the initial X-rays are negative. II.

Skeletal Survey Yield in Young Children with Femur Fractures

BackgroundFractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse. ObjectiveWe describe circumstances of injury, prevalence of suspicion for physical abuse, and use of imaging to identify additional occult fractures in young children with femur fractures. MethodsWe reviewed the medical records for children younger than 48 months old with femur fractures treated at a pediatric referral hospital (2011–2013). We abstracted age, ambulation, injury circumstances, bruising, head trauma, additional fractures, and determination of injury suspicious for abuse. ResultsIn 22 of 127 (17%) children with femur fractures, there was strong suspicion for physical abuse. Infants ≤ 12 months old accounted for 19 of 22 (86%) of those with suspicious injuries. In 2 of 22 (9%) with suspected abuse, the child could walk independently. In 8 of 22 (36%) with suspicious injuries, an injury event was reported as directly witnessed versus 50 of 105 (48%) of the unintentional injuries. Six of 22 (27%) with suspicious injuries had bruises versus 11 of 105 (10%) with unintentional injuries (χ2, p < 0.03). Four of 22 (18%) children with suspicious injuries had head trauma, versus 0 of 105 with unintentional injuries. Of the 8 with occult fractures identified on a skeletal survey (designated suspicious for abuse), all were ≤ 12 months old and none were walking independently. ConclusionsMost children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.

Missed fractures of the greater tuberosity

BackgroundFractures of the greater tuberosity may result from a variety of mechanisms. Missed injury remains a persistent problem, both from a clinical and medico-legal point-of-view. Few studies on this topic are available in the literature. We present the clinical and radiological findings of a consecutive series of 17 patients who were diagnosed and managed with undisplaced greater tuberosity fractures.MethodsA retrospective study of a consecutive series of 17 patients who sustained an occult greater tuberosity fracture were performed. Patients sustained a traumatic occult greater tuberosity fracture, underwent shoulder radiographs after trauma in 5 days and they were diagnosed as negative by a consultant radiologist. All patients received a standard assessment using MRI (Magnetic Resonance Imaging) scans Each patient was evaluated for arm dominance, trauma history, duration and type of symptoms and post-treatment Oxford Shoulder Score.ResultsAt the final follow up the mean OSS (Oxford Shoulder Score) was 38.3 (range 17–46; SD 9.11). Three patients required a glenohumeral joint injection for post-traumatic pain and stiffness and three patients required subacromial decompression for post-traumatic impingement.ConclusionsThough undisplaced greater tuberosity fracture can be managed non-operatively with good results, patients with persistent post-traumatic shoulder pain, tenderness and limitation of shoulder function warrant investigation with MRI to identify occult fractures. Prompt identification of these fractures can facilitate patient treatment and counselling, avoiding a source of patient dissatisfaction and litigation.

Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in Young Injured Children

ObjectiveTo describe the percentage and characteristics of children aged <24 months with non-motor vehicle crash (MVC)-related injuries who undergo a skeletal survey and have occult fractures. MethodsWe performed a retrospective chart review of a stratified, systematic random sample of 1769 children aged<24 months with non-MVC–related bruises, burns, fractures, abdominal injuries, and head injuries at 4 children's hospitals between 2008 and 2012. Sampling weights were assigned to each child to allow for representative hospital-level population estimates. Logistic regression models were used to test for associations between patient characteristics with outcomes of skeletal survey completion and occult fracture identification. ResultsSkeletal surveys were performed in 46.3% of children aged 0 to 5 months, in 21.1% of those aged 6 to 11 months, in 8.0% of those aged 12 to 17 months, and in 6.2% of those aged 18 to 24 months. Skeletal surveys were performed most frequently in children with traumatic brain injuries (64.7%) and rib fractures (100%) and least frequently in those with burns (2.1%) and minor head injuries (4.4%). In adjusted analyses, older age, private insurance, and reported history of accidental trauma were associated with decreased skeletal survey use (P ≤ .001 for all). The prevalence of occult fractures on skeletal surveys ranged from 24.6% in children aged 0 to 5months to 3.6% in those aged 18 to 24 months, and varied within age categories based on the presenting injury (P < .001). ConclusionsThe high rate of occult fractures in infants aged 0 to 5 months underscores the importance of increasing the use of skeletal surveys in this population. Further research is needed to identify the injury characteristics of older infants and toddlers most at risk for occult fractures.

Hip Fractures: A Practical Approach to Diagnosis and Treatment

To summarize relevant anatomy, imaging, and treatment of hip fractures, and to synthesize a treatment-based approach for description and classification of hip fractures. Hip fractures are predominantly seen in the elderly, where they are increasing in incidence, and can substantially reduce healthy life-years. The osseous and vascular anatomy of the proximal femur can help to understand the clinical implications of various types of hip fracture. Radiographs are the principal imaging modality for assessment of hip fracture, although there is a clear role for CT and MRI for assessment of radiographically occult fractures. There are multiple classifications of hip fractures in the orthopedic literature; however, these are not commonly used in clinical practice due to complexity, poor reported inter-observer agreement, and relatively few methods of surgical fixation. A simplified anatomic and treatment-based approach to hip fractures can help guide image interpretation and clinical management.

Ultrasound for diagnosing radiographically occult scaphoid fracture.

To systematically review the literature on the performance of ultrasound in diagnosing radiographically occult scaphoid fracture. A systematic search was performed in the MEDLINE and Embase databases. Original studies investigating the performance of ultrasound in diagnosing radiographically occult scaphoid fracture in more than 10 patients were eligible for inclusion. Studies that included both radiographically apparent and occult scaphoid fractures (at initial radiography) were only included if independent data on radiographically occult fractures were reported. Methodological quality of the studies included was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Accuracy data were extracted. Sensitivity and specificity were pooled with a bivariate random-effects model. The inclusion criteria were met by 7 studies; total sample size comprised 314 patients. All studies, except 1, included cortical disruption of the scaphoid in their diagnostic criteria. The sensitivity and specificity of ultrasound in diagnosing radiographically occult scaphoid fracture ranged from 77.8% to 100% and from 71.4% to 100% respectively, with pooled estimates of 85.6% (95% CI: 73.9%, 92.6%) and 83.3% % (95% CI: 72.0%, 90.6%) respectively. Exclusion of two studies with a high risk of bias in any QUADAS-2 domain did not affect the pooled results. Ultrasound can diagnose radiographically occult scaphoid fracture with a fairly high degree of accuracy. Because of its relatively low costs and fairlyhigh sensitivity, ultrasound seems more cost-effective than empiric cast immobilization and may be used when CT and MRI are not readily available.

Diagnóstico por imagem em paciente com traumatismo da coluna vertebral

O traumatismo raquimedular (TRM) pode ser definido como qualquer agressão que acarrete lesão anatômica ou funcional dos elementos neurais (medula espinhal, raízes nervosas), dentro do canal vertebral com ou sem fraturas e / ou deslocamento da coluna vertebral, resultando em mudança, seja ela permanente ou temporária, na sua função motora, sensitiva e autonômica. Odiagnóstico das lesões traumáticas de coluna vertebral é o evento inicial e fundamental para o sucesso terapêutico. Dentre as mais utilizadas estão a radiografia simples, a tomografia computadorizada (TC) e a ressonância magnética (RM). A abordagem inicial do paciente com suspeita de traumatismo de coluna vertebral deve ser feita através do estudo com radiografia simples, que consiste em método disponível e rápido. A TC é capaz de diagnosticar fraturas ocultas à radiografia simples, fornecendoinformações adicionais para avaliação mais detalhada da fratura e elaboração do seu tratamento e definindo melhor os contornos ósseos. Já a RM pode visualizar com mais vantagem o canal espinhal e o grau e a extensão de tecidos moles, como nas lesões medulares, vasculares, discos e os hematomas epidurais. Assim, a escolha do exame no momento da avaliação inicial do paciente irá influenciar em melhor prognóstico devendo ser realizada com autonomia e segurança.

Imaging of non-accidental injury; what is clinical best practice?

Non‐accidental injury (NAI) remains the leading cause of morbidity and mortality in children. Fractures are the second most common findings of NAI, after cutaneous lesions such as bruises and contusions. Imaging in NAI remains a controversial issue with little agreement concerning how, when and what imaging modalities should be used in the investigation of suspected cases. This review addresses the radiological investigations and findings of NAI, and the differential diagnoses of these findings. Adherence to the international guidelines for skeletal survey imaging is recommended. This ensures the content and quality of the radiographic series are of an optimal standard to improve the detection of occult fractures, and ensuring the accurate reporting of images. The involvement of a paediatric radiologist is important, if not essential in the diagnosis of NAI. In the evaluation of suspected cases, the role of the radiologist includes the detection of radiological findings suggestive of NAI, and the differentiation of these findings from normal variants and underlying pathologies. The diagnosis of NAI relies not only on radiological imaging, but also a combination of clinical and social findings. It is mandatory that all physicians work in close collaboration to improve diagnostic accuracy, as failure to diagnose NAI carries significant risk for morbidity.

Pre-operative radiographic findings predicting concomitant posterior malleolar fractures in tibial shaft fractures: a comparative retrospective study

BackgroundA concomitant tibial shaft and posterior malleolar fracture is a type of regular compound fracture. The associated posterior malleolar fractures are mostly occult fractures, which often do not show a fracture line on ordinary films, and thus lead to a high rate of misdiagnosis. The aim of the present study was to investigate factors helpful for the pre-operative detection of concomitant posterior ankle fractures using the ipsilateral radiographic tibia and fibula shaft fracture characteristics.MethodsOne hundred eleven adult patients with tibial shaft fractures were selected using inclusion and exclusion criteria. Pre-operative ankle radiographs and computed tomography (CT) scans were obtained for all patients, and clinical data, including age and gender, were collected. Patients were divided into two groups (posterior malleolar fracture and no posterior malleolar fracture groups). Fracture height, fracture length, fracture shape, and Haraguchi type of posterior malleolar fracture were measured on radiographs and CT images, and were compared between the two groups. Multiple logistic regression analysis was performed to identify the factors that significantly contributed to concomitant posterior malleolar fractures. Receiver operating characteristic curves were calculated, and cut-off values were used to predict posterior malleolar fractures on pre-operative imaging measurements.ResultsOf the 111 patients with tibial shaft fractures, 42 (37.8%) had a concurrent posterior malleolar fracture. Age, gender and affected side were not significantly different, but tibial fracture location, fracture length, and fibular and tibial fracture shape were significantly different between the two groups. In the multiple logistic analysis, tibial fracture location, fracture length, and tibial fracture shape were shown to be significant factors contributing to posterior malleolar fractures. Receiver operating characteristic curves showed that the status of tibial shaft fractures is closely related to the associated posterior malleolar fracture.ConclusionIpsilateral posterior ankle fractures are commonly associated with tibial shaft fractures, especially spiral-type injuries. An analysis of the imaging features of such fractures and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options.

How can MRI change the treatment strategy in apparently isolated greater trochanteric fracture?

IntroductionThe purpose of this study was to evaluate the proportion of greater trochanter (GT) fractures with occult extension to the intertrochanteric region on magnetic resonance imaging (MRI) among apparently isolated GT fractures and to investigate the use of MRI for formulating a treatment strategy in patients with isolated GT fractures. Patients and methodsThis retrospective cohort study reviewed 37 patients with isolated GT fractures on plain radiography. Surgical or conservative treatment was decided according to MRI findings. We divided patients into 3 groups according to the extension of the fracture line. In group 1, the fracture line was within the lateral one-third in the coronal plane. In group 2, the fracture line extended from the lateral one-third to the medial one-third. In group 3, the fracture line extended over the medial one-third and/or to the medial cortex of the femur. Conservative treatment was performed in groups 1 and 2, and surgical treatment was performed in group 3. The clinical results, radiography findings, and MRI findings were investigated. ResultsMRI revealed hidden intertrochanteric fractures (groups 2 [n = 10] and 3 [n = 4]) in 38% of apparently isolated GT fractures on radiography. No displacement was found in groups 1 (n = 23) and 2. Of the 4 patients in group 3, 3 were treated surgically and achieved good functional results and 1 refused to undergo surgery and finally developed complete intertrochanteric fracture. This patient presented 5 days later with increased hip pain, and radiography demonstrated displacement of the fracture, prompting surgical intervention. ConclusionsThe evaluation of apparently isolated GT fractures using MRI can be useful to diagnose the extent of the occult fracture and determine the treatment strategy.

Early detection of occult fractures around the hip with magnetic resonance imaging

Hip fractures may not be evident on initial radiographs but can be demonstrated with special imaging studies. These “occult fractures” can displace if not promptly treated. In a four-year period, 3...

Computed tomography for occult fractures of the proximal femur, pelvis, and sacrum in clinical practice: single institution, dual-site experience.

The purpose of this study was to evaluate the diagnostic performance of CT for assessment of occult fractures of the proximal femur, pelvis, and sacrum. A retrospective review was performed on patients who received a CT of the hip or pelvis for suspected occult fracture after negative or equivocal radiographs performed within 24h. The official radiology report was utilized for the determination of CT findings and calculation of sensitivity and specificity. Surgical reports, MRI reports, and clinical follow-up were used as the standard of reference. Sensitivity and specificity were calculated with 95% confidence intervals. Seventy-four patients received CT of the hip or pelvis for clinical concern for occult fracture after negative or equivocal radiographs. By the reference standard, a total of 40 fractures were present in 25/74 (33.8%) patients, including 35 conservatively treated fractures of the greater trochanter, pelvis, and sacrum, and 5 operatively treated proximal femoral fractures. A total of 14/74 (18.9%) of patients had an MRI within 1day of CT. MRI identified an operatively treated femoral neck fracture not seen on CT and an operatively treated intertrochanteric fracture, which CT described as a greater trochanteric fracture. There were two false negative conservatively treated pelvic fractures not seen on CT but diagnosed on MRI. On a per-patient basis, CT had an overall sensitivity of 88% (22/25; 95% confidence intervals 69-97%), specificity of 98% (48/49; 95% confidence intervals 89-100%), and negative predictive value of 94%. For the five operative proximal femoral fractures, the sensitivity of CT was 60% (3/5; 95% confidence intervals 15-95%), specificity was 99% (68/69; 95% confidence intervals 92-100%), and negative predictive value was 97%. In the clinical setting of suspected occult fracture, the sensitivity of clinical CT reports for detection of any type of fracture of the proximal femur, pelvis, or sacrum was 88%. For the small number of operatively treated proximal femoral fractures seen in the study, sensitivity of CT was 60% (3/5) and negative predictive value was 97%, although the relatively few patients needing fixation precludes statistical analysis.

HOW SCAPHOID FRACTURES ARE TREATED IN BRAZIL.

ABSTRACTObjectiveTo verify how hand surgeons manage scaphoid fractures and their complications.MethodsTwo hundred questionnaires were distributed during the 36th Brazilian Hand Surgery Congress (2016).ResultsOn suspicion of fracture without radiographic confirmation, 57% of surgeons request a CT or MRI scan, while 43% opt for immobilization and consecutive radiographs. In stable fractures the preference was for treatment with plaster cast. In fractures with no scaphoid waist displacement, 33% opt for percutaneous fixation. In displaced waist or proximal pole fractures, 66% and 99.4%, respectively, opted for surgical treatment. Most surgeons treat waist nonunion with a nonvascularized bone graft. When absorption at the site of nonunion is greater than 4 mm, 50% prefer to use iliac graft and screw fixation. In proximal pole nonunion, the Zaidemberg technique is preferred by 64%. More experienced surgeons are more likely to request tests in occult fractures (63.9% versus 47.6%; p=0.04), and tend to recommend surgery for distal third fractures more frequently (16.4% versus 4.7%; p=0.02).ConclusionsWe have provided an overview of treatment preferences for scaphoid fractures. It should be noted that more experienced surgeons are more likely to request additional tests for occult fractures and to recommend surgical treatment of distal third fractures. Level of Evidence IV, Cross-sectional survey.

A Scoring System to Demonstrate the Risk for Bone Injury in Patients with Clinically Suspected or Occult Scaphoid Fracture.

Background:It is important to diagnose a scaphoid fracture accurately and start the correct treatment in the shortest time possible. However, the fracture of bone may not be visible on x-ray. In such cases, patients are clinically diagnosed with suspected or occult scaphoid fractures. The aim of this study was to define a scoring system based on physical examination to demonstrate the risk for bone injury in patients with clinically suspected and occult scaphoid fractures with negative radiographs and anatomical snuff box tenderness and to decrease the costs and workforce loss due to unnecessary treatment and magnetic resonance imaging (MRI).Materials and Methods:Patients were initially evaluated by the attendant orthopedic physician in the emergency service with X-ray of the wrist, and ten wrist physical examination techniques were used. The X-rays of patients were evaluated by three orthopedic surgeons. Finally sixty patients, who were diagnosed as having no fracture by all three orthopedic surgeon, were included in the study. The wrists of these patients were evaluated with MRI.Results:There were 46 male (77%) and 14 female (23%) patients with a mean age of 21.5 years (range 7–61 years). About 3.3% had triquetrum fracture, 15% had bone edema in the scaphoid and radius, 18.3% had distal radius fracture, 31.6% had scaphoid fracture, and 31.8% had no bone injury. A scoring system was also proposed. It can be predicted that in the physical examination of the wrist if the total score is higher than 6.5, the probability of fracture is 2.87 (positive likelihood ratio) fold compared to scores below 6.5.Conclusions:Proposal of this new scoring system was thought to be useful for predicting the risk for bone injury in patients with clinically suspected scaphoid fractures and making decision regarding therapeutic options.

Concomitant hook of hamate fractures in patients with scaphoid fracture: more common than you might think

ObjectiveThe scaphoid is the most commonly fractured carpal bone. The presence of a concomitant hook of hamate fracture is of particular relevance given that it is often occult on routine wrist/scaphoid radiographs and that hook of hamate fractures are prone to symptomatic non-union, resulting in chronic ulnar wrist pain. Prompt diagnosis and immobilisation/fixation may minimise such complications. Our study is aimed at assessing the frequency of concomitant hook of hamate fractures in patients with scaphoid fractures.MethodsHook of hamate fracture is often occult on wrist/scaphoid radiographs. Hence, we identified all 2,568 CT and MRI studies performed to investigate scaphoid fracture at our institution from April 2005 to March 2016. Three hundred and twelve out of 2,568 cases were confirmed to have a scaphoid fracture. Images were then retrospectively reviewed by a Consultant Musculoskeletal Radiologist and Musculoskeletal Radiologist Trainee to assess for the presence of concomitant hook of hamate fracture and, if present, whether this was identified on initial reporting.ResultsConcomitant hook of hamate fracture was identified in 10.3% of cases (32 out of 312, 30 on CT, 2 on MRI); most were minimally/non-displaced. Sixty percent of fractures identified on CT were missed on the initial review (18 out of 30). Both cases identified on MRI had been initially reported.ConclusionScaphoid fracture is associated with higher than expected rates of concomitant hook of hamate fracture. Given the potential morbidity associated with hook of hamate fracture, this should be considered a review area when investigating scaphoid injury. These fractures are often minimally displaced, hence easily overlooked on CT. MRI may therefore be superior when investigating radiographically occult scaphoid fractures.