Occult Fractures Research Articles

Radiologic blind spots in hip and pelvic radiographs.

The purpose of our study was to identify the locations at which hip and pelvic fractures are commonly missed on radiographs. A retrospective study was performed at four non-Level 1 trauma center emergency departments. IRB approval was obtained. All emergency department hip or pelvic radiographs with subsequent CT performed within 48h were identified from 2017 to 2022. Reports for each radiograph and CT were scored for the presence or the absence of fracture in the following locations: ilium, sacrum, superior pubic ramus, inferior pubic ramus, pubis, acetabulum, subcapital femoral, femoral neck, greater trochanter, lesser trochanter, intertrochanteric, and subtrochanteric. The CT report was used as the gold standard. The false-negative radiography cases were reviewed on a PACS workstation to determine whether the case had an "unexpected miss" of a fracture, a subtle fracture, radiographically occult fracture, or exam was limited by artifact. The percentage of missed fractures at each location was calculated. Nine hundred seventy-five radiography cases with subsequent CT were identified. One hundred forty-six cases did not meet entry criteria; therefore, 829 cases were analyzed further. Seventy-four percent of patients were female with age of 74 ± 16 (mean ± standard deviation) years (range 1-103). Three hundred fifty-two cases had at least one fracture, and many cases had multiple fractures. There were 68 false-negative cases. The most commonly missed fractures by percentage were pubis, ilium, and greater trochanter. The most common unexpectedly missed fractures were greater trochanter and femoral subcapital. A careful systematic evaluation of hip and pelvic radiographs, with particular attention to the pubis, ilium, greater trochanter, and subcapital region, may improve radiographic fracture detection and decrease delays in diagnosis.

Use of a comprehensive systemic ultrasound evaluation in the diagnosis and analysis of acute lateral region ankle sprain

BackgroundFor the diagnosis of acute lateral ankle sprain, many clinicians use ultrasound; they typically focus on the lateral ligament complex, which is the most common site of lesions in ankle sprain. However, this approach risks missing other foot and ankle lesions. The present study aimed to provide and analyze the results of a new ultrasound method of diagnosis for acute lateral ankle sprain which can thoroughly investigate overall lesions of the foot and ankle.MethodsRetrospective cross-sectional cohort study of 123 patients who underwent diagnostic ultrasound within 1 week of acute lateral ankle injury was performed. Causes of ankle sprain, incidence and severity of each ligament injury, location of anterior talofibular ligament (ATFL) injury, accompanying ligament injury, and occult fracture were analyzed.ResultsAmong the 102 cases of ATFL injuries, 60 (58.5%) had islolated ATFL injury, 28 (27.5%) had accompanying calcaneofibular ligament injury (CFL), and 14 (13.7%) had accompanying midtarsal or syndesmosis injury. ATFL injuries occurred on the fibula attachment in 48 (47.1%) cases, ligament mid-substance in 24 (23.5%) cases, and talus attachment in 30 (29.4%) cases. Among the 165 lesions from 123 cases, injuries of the fourth or fifth dorsal tarsometatarsal (12 cases, 7.3%), bifurcate (11 cases, 6.7%), and anterior tibiofibular (11 cases, 6.7%) ligaments were not rare.ConclusionThese findings suggest that an ultrasound examination involving investigation of the midtarsal joint and syndesmotic ligament, as well as the ATFL and CFL, is useful for comprehensive, systemic diagnosis of acute lateral ankle sprain.

Periprosthetic Occult Femoral Fracture: An Unknown Side Effect of Press-Fit Fixation in Primary Cementless Total Hip Arthroplasty.

The objectives of this study were to examine the prevalence and risk factors for development of periprosthetic occult femoral fractures during primary cementless total hip arthroplasty (THA) and to assess the clinical consequences of these fractures. A total of 199 hips were examined. Periprosthetic occult femoral fractures were defined as fractures not detected intraoperatively and on postoperative radiographs, but only observed on postoperative computed tomography (CT). Clinical, surgical, and radiographic analysis of variables was performed for identification of risk factors for periprosthetic occult femoral fractures. A comparison of stem subsidence, stem alignment, and thigh pain between the occult fracture group and the non-fracture group was also performed. Periprosthetic occult femoral fractures were detected during the operation in 21 (10.6%) of 199 hips. Of eight hips with periprosthetic occult femoral fractures that were detected around the lesser trochanter, concurrent periprosthetic occult femoral fractures located at different levels were detected in six hips (75.0%). Only the female sex showed significant association with an increased risk of periprosthetic occult femoral fractures (odds ratio for males, 0.38; 95% confidence interval, 0.15-1.01; P=0.04). A significant difference in the incidence of thigh pain was observed between the occult fracture group and the non-fracture group (P<0.05). Occurrence of periprosthetic occult femoral fractures is relatively common during primary THA using tapered wedge stems. We recommend CT referral for female patients who report unexplained early postoperative thigh pain or developed periprosthetic intraoperative femoral fractures around the lesser trochanter during primary THA using tapered wedge stems.

Occult fractures detected on radiographs in young children with a concern for abusive head trauma.

To determine the incidence of children < 2 years old with suspected abusive head trauma, to evaluate usage of dedicated skeletal radiographs and the incidence of clinically occult fractures on dedicated skeletal radiographs. This is a retrospective single centre study of children < 2 years old with traumatic brain injury, referred to the University Hospital's Social Services Department between December 31, 2012 and December 31, 2020. Clinical and demographic data was retrieved from medical notes and imaging was reviewed by paediatric radiologists. 26 children (17 males), 2 weeks to 21 months of age (median age 3 months) were included. Eleven children (42%) had traumatic history, fourteen children (54%) had one or more bruises, eighteen children (69%) had abnormal neurological findings. 16 children (62%) had dedicated skeletal radiographs, 7 children (27%) had radiographs of part of the skeleton and 3 children (11%) had no skeletal radiographs. 5 out of 16 children (31%) with dedicated skeletal radiographs had a clinically occult fracture. 15 (83%) of clinically occult fractures had high specificity for abuse. The incidence of suspected abusive head trauma in children < 2 years old is low. Clinically occult fractures were detected in one third of children with dedicated skeletal radiographs. The majority of these fractures have high specificity for abuse. Dedicated skeletal imaging is not performed in more than one third of the children and hence fractures may be missed. Efforts should be taken to increase awareness of child abuse imaging protocols.

Quantitative evaluation of bone marrow characteristics in occult and subtle rib fractures by spectral CT.

The present study aimed to determine whether the water content change in the medullary cavity of occult rib fractures by spectral computed tomography (CT). The material decomposition (MD) images were reconstructed using the water-hydroxyapatite basis material pairs from spectral CT. The water contents of the medullary cavity in subtle or occult rib fractures and the symmetrical sites of the contralateral ribs were measured, and their difference was calculated. The absolute value of the water content difference was compared to patients without trauma. An independent samples t-test was adopted to compare the consistency of the water content in the medullary cavity of the normal ribs. Intergroup and pairwise comparisons were applied to the difference in water content among the subtle/occult fractures and normal ribs, followed by receiver operating characteristic curve calculations. p < 0.05 was considered to have a statistically significant difference. A total of 100 subtle fractures, 47 occult fractures, and 96 pairs of normal ribs were included in this study. The water content of the medullary cavity in the subtle and occult fractures was both higher than that in their symmetrical sites with the difference value of 31.06 ± 15.03mg/cm3 and 27.83 ± 11.40mg/cm3, respectively. These difference values between the subtle and occult fractures were not statistically significant (p = 0.497). For the normal ribs, the bilateral water contents were not statistically different (p > 0.05) with a difference value of 8.05 ± 6.13mg/cm3. The increased water content of fractured ribs was higher than that of normal ribs (p < 0.001). According to the classification based on whether the ribs were fractured, the area under the curve was 0.94. The water content measured on MD images in spectral CT in the medullary cavity increased as a response to subtle/occult rib fractures.

Radiological-nuclear medicine hybrid diagnostics with SPECT/CT for chronic foot and ankle diseases : Anew and important diagnostic tool

In contrast to standard methods (sonography, X‑ray, CT(computed tomography), MRI(magnetic resonance imaging), numerous diseases of the foot or ankle can be diagnosed using SPECT/CT (single photon emission computed tomography/computed tomography) with regard to their clinical relevance with high accuracy (up to > 90%). The aim of this review is to provide an up-to-date overview of the importance of SPECT/CT in selected diseases of the foot and ankle. Aliterature search was carried out in the Pubmed database using the following terms: SPECT/CT, SPECT, skeletal scintigraphy, CT, computed tomography, foot and ankle disease, OSG, tarsal root, foot pain. The publications were selected with regard to questions and diagnoses that frequently occur in foot and ankle diagnostics. Furthermore, papers that describe amore precise diagnosis, achange in therapy management or areduction in symptoms due to the use of SPECT/CT were selected. Several studies have shown that afocally increased bone metabolism in osteoarthritis and osteochondral lesions correlates significantly with the development of pain. The presence of symptomatic ossicles such as the os naviculare accessorium typeII and os trigonum can be clearly demonstrated with the help of SPECT/CT and cannot be assigned as the source of the symptoms as accurately with any other imaging method. Bony reactions in the area of coalitions, arthrodesis, osteosynthesis, occult fractures, prostheses and diabetic foot cannot be detected with comparable accuracy using any other imaging method, so that therapy concepts in unclear cases, based only on standard imaging are changed inup to 2/3 of cases by SPECT/CT information. SPECT/CT is useful when there are clinical uncertainties despite standard imaging.

Cervical spine fractures in ankylosing spondylitis patients: an analysis of the presentation and clinical results of 110 surgically managed patients in two spine centers.

In this work, a two-center study was performed to study the clinical presentation of cervical spine fractures in ankylosing spondylitis (AS) patients and assess the surgical management of these fractures. A retrospective analysis of prospectively collected data in two level-1 spine surgery centers was performed. Both spine centers have a standard database for all admitted patients. Inclusion criteria were surgically treated AS with cervical spine fracture diagnosis (from C1 to Th3) and postoperative follow-up minimum of 12months. One hundred ten patients (105 male/5 female) were included. The mean age was 62 ± 10years. The mean time between trauma and surgery was 49 ± 42days. There was a history of mild trauma in 72 patients (65.4%). The clinical presentation was a pain in all patients. Twenty-seven (24.6%) had a neurological deficit at admission. The most common fracture level was C6/7 in 63 patients (57.23%). The VAS was 7 ± 1, and NDI was 34 ± 8 in the preoperative assessment. The mean preoperative kyphosis angle was 48 ± 26° between C2 and C7. Positioning and preparing of the patients on the operation table took a mean of 57 ± 28min. The surgical approach was dorsal in 59 patients (53.6%), combined in 45 patients (40.9%), and ventral in 6 patients (6,5%). The mean number of the fixed levels was 6 ± 2 levels. Intraoperative complications occurred in 9 patients (8.2%). Postoperative Cobb angle improved to a mean of 17 ± 9 degrees. Neurological improvement occurred in 20/27 patients. In 12 patients, the recovery was complete. The mean postoperative follow-up was 46 ± 18months. VAS improved to 3 ± 1, and NDI improved to 14 ± 6 at the last postoperative visit. The improvement was clinically significant (p = 0.01 and 0.00, respectively). High suspicion of cervical spine fractures is necessary for patients with AS. CT and MRI images are necessary to rule out cervical spine fractures in AS patients, especially to detect occult fractures. Surgical treatment is safe, and the posterior approach with long-segment fusion is the approach of choice in this group of patients.

Clinical study of occult fractures around the prosthesis in primary total hip arthroplasty

ABSTRACT Objective To determine the prevalence, prevention measures, and risk factors for occult periprosthetic fractures after primary total hip arthroplasty (THA), as well as to determine whether or not they are the root of early THA failure. Methods From January 2014 to December 2018, 755 patients (769 hips) underwent primary total hip arthroplasty were retrospectively analyzed, including 327 males (339 hips) and 428 females (430 hips). X-ray, CT and 3D reconstruction of hip were performed before and after operation. By using CT to diagnose the occult fractures, the patients were then monitored and evaluated. Age, sex, body mass index (BMI), preoperative diagnosis, osteoporosis, kind of prosthesis, and the surgeon’s experience should all be considered. Patients with occult fracture were followed up, the fracture healing and prosthesis stability were recorded and analyzed. Results There are 23 of 769 cases (23/769) had occult fracture around the prosthesis, with an incidence of 2.99% (23/769);. The total revision rate was 0.52% (4/769). The revision patients accounted for 17.39% (4/23) of the patients with occult femoral fractures. The remaining patients received conservative care and successfully joined without their prostheses slipping. Osteoporosis, body mass index, and the surgeon’s experience were identified as the risk variables for periprosthetic occult fractures by univariate analysis (P < 0.05). Conclusion Periprosthetic occult fracture was a complication that can not be ignored in primary total hip arthroplasty. It is the cause of early failure of prosthesis. Osteoporosis, BMI and the surgeon’s experience are all risk factors for periprosthetic occult fractures.

Automated detection of scaphoid fractures using deep neural networks in radiographs

The scaphoid is one of the most common carpal bone fractures diagnosed using radiographs. However, occult scaphoid fractures not visible on radiographs make early diagnosis and treatment difficult. Hence, the objective of this study was to develop a high-performing deep-learning model for the detection of apparent fracture and non-apparent occult scaphoid fractures using only plain wrist radiographs. This work used 525 x-ray images, 250 of which were normal scaphoids, 219 were fractured scaphoids, and 56 were occult fracture X-rays. These X-ray images were obtained from the Department of Orthopaedics, Kasturba Medical College’s (KMC), Manipal. A CNN-based deep learning model was developed for two classes (normal VS fracture) and three classes (normal VS fracture VS occult). For fracture localization, gradient-weighted class activation mapping (Grad-CAM) was used. For two-class classification, the proposed CNN model achieved sensitivity, specificity, accuracy and AUC of 92%, 88%, 90% and 0.95, respectively. For three-class classification, the proposed model achieved an overall performance of 85% sensitivity, 91% specificity, 90% accuracy and 0.88 AUC. Wrist radiograph images used to train the model did not undergo a segmentation process, saving time and improving efficiency if implemented in a hospital setting.

Skeletal survey yields in low vs. high risk pediatric patients with skull fractures

BackgroundTo assess for occult fractures, physicians often opt to obtain skeletal surveys (SS) in young, acutely head-injured patients who present with skull fractures. Data informing optimal decision management are lacking. ObjectiveTo determine the positive yields of radiologic SS in young patients with skull fractures presumed to be at low vs. high risk for abuse. Participants and setting476 acutely head injured, skull-fractured patients <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. MethodsWe conducted a retrospective, secondary analysis of the combined, prospective Pediatric Brain Injury Research Network (PediBIRN) data set. Results204 (43 %) of 476 patients had simple, linear, parietal skull fractures. 272 (57 %) had more complex skull fracture(s). Only 315 (66 %) of 476 patients underwent SS, including 102 (32 %) patients presumed to be at low risk for abuse (patients who presented with a consistent history of accidental trauma; intracranial injuries no deeper than the cortical brain; and no respiratory compromise, alteration or loss of consciousness, seizures, or skin injuries suspicious for abuse). Only one of 102 low risk patients revealed findings indicative of abuse. In two other low risk patients, SS helped to confirm metabolic bone disease. ConclusionsLess than 1 % of low risk patients under three years of age who presented with simple or complex skull fracture(s) revealed other abusive fractures. Our results could inform efforts to reduce unnecessary skeletal surveys.

Can a Deep Learning Algorithm Improve Detection of Occult Scaphoid Fractures in Plain Radiographs? A Clinical Validation Study.

Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting. (1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level? This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured. Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures. CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective. Level II, diagnostic study.

Management of stenosing flexor tenosynovitis in primary care.

Management of stenosing flexor tenosynovitis in primary care.

Comparison of multislice spiral CT and MRI in diagnosis of occult fracture of knee joint with meniscus and ligament injury

To investigate the diagnostic value of multislice spiral CT (MSCT) and MRI in occult fracture of knee joint with meniscus and ligament injury. From January 2020 to March 2021, 63 patients with knee occult fracture with meniscus and ligament injury, including 41 males and 22 females, aged from 21 to 67 years old, with an average of (44.35±8.77) years old, the course of disease ranged from 1 to 6 days, with an average of (4.64±1.75) days, the body mass index (BMI) was (19.85±2.78) kg/m2. MSCT and MRI data of 63 patients were collected and statistically analyzed to evaluage their diagnist value. The detection of MRI for occult knee fravtures with meniscus and ligament injury, joint cavity effusion, bone marrow edema, and articular surface injury were 100.00% (63/63), 95.24% (60/63), 42.86% (27/63) and 36.51% (23/63), respectively. The detection rates of MSCT were 49.21% (31/63), 41.27% (26/63), 0.00% (0/63) and 1.59% (1/63), respectively, significantly lwver than that of MRI (P<0.05). The diagnostic sensitivity, specificity and accuracy of MRI were significantly higher than those of MSCT(P<0.05). The sensitivity, specificity and accuracy of magnetic resonance imaging in the diagnosis of occult fracture of knee joint with meniscus and ligament injury are significantly better than that of MSCT. MRI has higher accuracy in the diagnosis of peripheral tissue diseases such as joint cavity, articular surface and bone marrow, and can reduce the risk of clinical misdiagnosis.

Protocolised MRI as an adjunct to CT in the diagnosis of femoral neck fracture in high energy ipsilateral femoral shaft fractures – A break-even analysis

BackgroundIn high-energy femoral shaft fractures (FSFs), ipsilateral femoral neck fractures (FNFs) can be missed by conventional trauma computed topography (CT) imaging, resulting in increased treatment costs and patient complications. Preliminary evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to establish the economic break-even point for implementing such an MRI protocol in all high-energy FSFs. MethodsWe used an adapted break-even economic tool to determine whether the costs of a targeted MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged admission and re-operation). Sensitivity analyses were performed to demonstrate reliability of the economic modelling across a range of assumptions. ResultsAssuming a baseline of FNFs missed on CT of 12%, an MRI cost of £129 and cost of treating each missed FNF of £2457.5, the equation yielded a break-even rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 FSFs, MRI would need to diagnose 5 of the 12 missed FNF to be economically viable (number needed to treat (NNT)=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost-savings. ConclusionA rapid, limited-sequence MRI protocol to exclude occult ipsilateral FNFs in all high-energy FSFs appears to be economically justified measure. Further research exploring the feasibility of such a protocol, as well as the role of intra-operative fluoroscopy in this context, is required.

Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly.

Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference. A retrospective review was performed of patients ≥ 65years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard. 177 patients were included, with a total of 555 fractures. The mean age was 81years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%. Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.

Occult Fractures in Children with a Radiographic Fat Pad Sign of the Elbow: A Meta-Analysis of 10 Published Studies.

A radiographic fat pad sign after an elbow injury in children may indicate an occult fracture. Different incidences and locations of occult fractures have been reported. The primary objective of this meta-analysis was to assess the overall rate of occult fractures in children with a positive fat pad sign from the data of original studies. Secondary objectives were to assess the fracture types and to identify risk factors for sustaining an occult fracture. A systematic literature search of the Embase, MEDLINE, and Cochrane databases was performed according to PRISMA guidelines. Studies on pediatric populations with a positive fat pad sign identified using a lateral elbow radiograph and with follow-up imaging were included in this meta-analysis. Included studies were assessed for risk of bias with use of the MINORS (Methodological Index for NOn-Randomized Studies) instrument. Ten studies with a total of 250 patients, of whom 104 had an occult fracture, were included. Accounting for heterogeneity between the studies, the overall occult fracture rate was 44.6% (95% confidence interval: 30.4% to 59.7%). The most common fracture locations were the supracondylar humerus (43%), proximal ulna (19%), proximal radius (17%), and lateral humeral condyle (14%). Definitions of a positive pad fad sign were not uniform among studies, and the follow-up imaging modality also varied (radiography, magnetic resonance imaging, or computed tomography). The average MINORS score was 10.1 for the 7 noncomparative studies and 18.7 for the 3 comparative studies, with both averages classified as moderate quality. We were not able to identify risk factors for an occult fracture in the presence of a positive fat pad sign. The occult fracture rate was 44.6% in pediatric elbow injuries with a positive fat pad sign. Supracondylar humeral fractures were the most frequently encountered type. The findings of this meta-analysis underline the potential clinical relevance of a positive fat pad sign in children and denote the opportunity for future studies to create evidence-based guidelines. Level II. See Instructions for Authors for a complete description of levels of evidence.

Morphological risk factors for scaphoid fracture: a case–control study

PurposeMost patients with a clinically suspected scaphoid fracture and normal initial radiograph are unnecessarily treated. Previously developed prediction rules using demographic and clinical risk are unable to accurately predict occult fractures. Adding other risk factors could enhance this. Therefore, we aim to explore if there are morphological risk factors of the wrist for sustaining a scaphoid fracture.MethodsWe retrospectively included adult patients with a clinically suspected scaphoid fracture between 2013 and 2019 in our case–control study. There were 82 patients with a scaphoid fracture and 158 patients with a wrist contusion. Morphological risk factors were identified using statistical shape modelling (SSM) and linear measurements. Independent wrist shape variations on posteroanterior and lateral radiographs were captured in modes using SSM. Associations between outcomes and a scaphoid fracture were explored using logistic regression and the reliability was assessed.ResultsOf the 15 posteroanterior modes and 8 lateral modes identified and linear measurements performed, 1 PA mode was associated with a scaphoid fracture (PA mode 4; OR 1.40, CI 1.04–1.93, p = 0.031). We described this mode as an ulna plus and narrower distal radius with more volar tilt and radial inclination. The reliability of the posteroanterior modes and linear measurements was mostly good/excellent and moderate/poor for the lateral modes.ConclusionThere was one complex wrist shape significantly associated with a scaphoid fracture. Since the association was weak and the shape is difficult to identify radiographs, we believe this morphological risk factor would not enhance identifying occult scaphoid fractures in the future.

A Virtual Fracture Clinic Pathway for Managing Suspected Paediatric Scaphoid Fractures.

Introduction: The mismanagement of an occult scaphoid fracture is a significant concern in patients presenting with anatomical snuffbox tenderness and no radiographic signs of injury.Aim: This study investigated whether a virtual fracture clinic (VFC) could improve care efficiency and expedite management decisions surrounding suspected pediatric scaphoid fractures.Method: Data was reviewed for patients referred via the VFC for suspected scaphoid fractures at a local trauma unit over 19 months. Patients received an "appointment" in VFC. Based on their notes and imaging, patients were referred to an outpatient clinic for repeat radiographs within two weeks (if initial radiographs demonstrated no fracture). Patients with unremarkable second x-rays were contacted and informed to mobilize and return if the pain persisted at four weeks.Results: The pathway received 175 referrals; 114 male, 61 female, mean age 14 years, range 9-17) with 42 scaphoid fractures diagnosed, 35 (83.3%) on first x-ray, and 7 (16.7%) occult fractures. The pathway managed all patients as intended; 71 patients were seen face-to-face in the clinic due to age or pathology picked up on the first x-ray, and 104 required repeat radiographs. Following the second radiograph, 78 patients were discharged directly. Twenty-six patients required further review in a face-to-face clinic after their second radiograph.Conclusion: VFC appears to be a safe and efficient method of managing patients with suspected scaphoid fractures on short-term follow-up analysis. This cohort presents no 'missed' injuries and therefore appears safe compared to conventional treatment pathways.

Artificial intelligence in orthopaedic and trauma surgery imaging

Artificial intelligence (AI) is playing an increasing role in radiological imaging in orthopaedics and trauma surgery. The algorithms available to date are predominantly used in the detection of (occult) fractures and in length and angle measurements in conventional X‑ray images. However, current AI solutions also enable the analysis and pattern recognition of CT datasets, e.g. in the detection of rib or vertebral body fractures. Aspecial application is EOS™ (ATEC Spine Group, Paris, France), which enables a3‑D simulation of the axial skeleton and semi-automatic length and angle calculations based on adigital 2‑D X‑ray image. In this paper, the current spectrum of AI applications for orthopaedics and trauma surgery is presented and discussed.

SP5.2.3 Protocolised MRI as an Adjunct to CT in the Diagnosis of Femoral Neck Fracture in High Energy Ipsilateral Femoral Shaft Fractures – a Breakeven Analysis

Abstract Background In high-energy femoral shaft fractures, ipsilateral femoral neck fractures can be missed by conventional trauma computed-topography (CT) imaging, resulting in increased treatment costs and patient complications. Evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to analyse the economic viability of implementing a such an MRI protocol for all high-energy femoral shaft fractures. Methods We used an adapted break-even economic tool to determine whether the costs of an MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged inpatient admission, re-operation and implant costs). Sensitivity analyses were performed to demonstrate the reliability of the economic modelling across a range of assumptions. Results Assuming a baseline of hip fractures missed on CT of 12%, an MRI cost of £129 and cost of treating each missed hip fracture of £2633.5, the equation yielded a breakeven rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 femoral shaft fractures, MRI would need to diagnose 5 of the 12 missed hip fractures to be economically viable (NNT=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost effectiveness. Conclusion A rapid, limited-sequence MRI protocol to exclude occult ipsilateral hip fractures in all femoral shaft fractures would be an economically justified measure.