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DIAGNOSING SCAPHOID FRACTURES
Anthony Hewitt
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Introduction
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Anatomy of the scaphoidn Resembles a deformed peanutn Articular cartilage covers 80% of
the surfacen It rests in a plane 45 degrees to
the longitudinal axis of the wristn Articulates with the distal radius
proximally, the lunate medially, and with the capitate, trapezoid, and trapezium distally
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Kinematics of the scaphoidn The scaphoid moves with the
proximal carpal row in flexion and extension
n Also flexes during radial deviation of the wrist and extends during ulnar deviation of the wrist
n The scaphoid is important in controlling wrist stability and is the main bony support between the proximal and distal carpal rows
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Vascularity of the scaphoid
§ Supplied by branches of the radial artery at the distal end.
§ The middle and distal pole of the scaphoid have a direct blood supply but the proximal pole receives no direct blood supply
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Mechanism of scaphoidfracturesn Most frequently fractured carpal
bone (60-70% of carpal fractures)n Second only to fractures of the
distal radiusn Most common in young men (15-
30)n Results from a fall onto the
outstretched hand with the wrist extended and in radial extension
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Mechanism of scaphoidfractures cont.n Distal radius is fractured when the
hand is more relaxed (slight extension and some horizontal component to force)
n Striking an object with the heel of the hand may also produce a scaphoid fracture
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Classification of scaphoid fractures
n Fracture direction can be horizontal oblique, transverse, or vertical oblique
n Fracture sites:Tuberosity Distal articularDistal thirdMiddle thirdProximal third
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Factors affecting healingn Fractures of the proximal pole
have a higher incidence of delayed union, nonunion, and avascular necrosis
n Vertical and oblique fractures are potentially unstable and require prolonged immobilisation
n Uncorrected displacement of more than 1mm on the lateral radiograph is likely to result in nonunion
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Factors affecting healing cont.n Delayed diagnosis and inadequate
immobilisation for longer than 4 weeks has a nonunion frequency as high as 88%
n Healing time depends on the fracture site, e.g. uncomplicated fractures of the scaphoid tubercle may heal in 4 weeks, but a proximal pole fracture may take up to 20 weeks to heal
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Factors affecting healing cont. (2)n Uncomplicated scaphoid fractures
have a union rate of 95% when diagnosed early and immobilised, but complications of scaphoid fractures have a poor prognosis
n Complications require more aggressive treatment such as prosthetic replacement of the whole bone, bone grafting, or screw fixation
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Clinical evaluationn Suspected scaphoid fractures
present with wrist pain and tenderness at the anatomic snuffbox
n Anatomic snuffbox pain is said to be only 40% specific for a scaphoid fracture. Scaphoid tubercle palpitation is considered more specific (57%)
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Clinical evaluation cont.n Resisted supination often
exacerbates scaphoid fracture pain and is more reliable than pain from resisted pronation
n Range of motion is reduced somewhat, with pain usually felt at the extremes of motion
n Swelling or bruising is generally not present except in fracture-dislocations
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Clinical evaluation cont. (2)
n Any clinical findings suggesting a scaphoid fracture should be treated as such
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Plain radiographyn This is the first investigation
following clinical suspicion of a scaphoid fracture
n PA and lateral views of the wrist are sufficient for evaluating most wrist injuries, but special views greatly increase the sensitivity in detecting occult scaphoid injury
n Special scaphoid views needed when clinical suspicion is high
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Plain radiography cont. (2)n Routine scaphoid views include a
PA in ulnar deviation, a PA oblique (also in ulnar deviation), an AP oblique, and a lateral projection
n Ulnar deviation is needed for the PA and PA oblique projections in order to bring the scaphoid more perpendicular to the x-ray beam
n An AP oblique projection is not useful (overlapping carpal bones)
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Plain radiography cont. (3)n The scaphoid view (k/a Ziter view)
should also be included, where the scaphoid is further extended by extending the wrist
n This can be achieved by:Taking the PA projection with the fist clenchedUsing a foam pad under the wristTilting the beam 30 degrees
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Diagram of scaphoidview
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Value of radiographsn Initial plain x-rays are frequently
normal (up to 65% of scaphoid fractures are initially radiographically occult)
n Though it is standard practice to immobilise the wrist and take x-rays 10-14 days post trauma, a number of cases remain false –veand it may take up to 6 weeks to see a scaphoid fracture on x-rays
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Value of radiographs cont. (2)n Radiographic interpretation has a
low interobserver agreement (•>0.6 to be reliable)
n Tiel-Van Buul et al. (1992) found that •<0.4, thus scaphoid x-rays are not reliable for diagnosis or exclusion of fractures, regardless of technique and irrespective of training/experience of the observer
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Value of radiographs cont. (3)n Dias et al. (1990) found that errors
made on 2-3 week radiographs were comparable to those made on initial x-rays. Reliability does not improve when both sets are viewed together. Intraobserver agreement was also low
n Up to 20% of normal x-rays are diagnosed as fractured. Overcome by taking a view of the other side
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Some scaphoid x-rays
Initial x-rays 8 weeks later
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Complications on x-rays
n Proximal #s are associated with delayed union/nonunion and avascular necrosis
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3-phase bone scann Rarely performed in acute bone
trauma, reserved for difficult casesn Cannot be used as a gold
standard, but allows bony disease to be ruled out when normal
n Tc-99m methylene diphosphonate (MDP) is used locally. Increased osteocyte activity due to trauma will show as a focal hot spot
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3-phase bone scan cont.n Movement of the tracer:
Phase I – blood flow (1-2mins)Phase II – soft-tissue (5-10mins)Phase III – bone (2-3hrs)
n Fractures are seen in around 95% of nonosteoporotic patients under 65 within 24hrs. Over 65, scan will be abnormal in 95% of cases within 48-72hrs
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3-phase bone images
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Value of 3-phase bone scann Murphy et al. (1995) found that a
3-phase bone scan at 4 days post-trauma had:sensitivity = 100%specificity = 92%+ve predictive value = 65%-ve predictive value = 100%accuracy = 93%
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Value of 3-phase scan cont.n Tiel-Van Buul et al. (1992) found
that:sensitivity = 100%specificity = 98%high intra/interobserver agreement •=0.88
n Negative bone scan rules out a fracture, however the value of a positive scan is less clear
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Value of 3-phase scan cont. (2) n Tiel-Van Buul et al. (1993) found
that around 25% of +ve scans are never radiographically confirmed
n Waizenegger et al. (1994) found similar results with 12 out of 19 patients continuing to have -ve x-rays despite +ve scans
n Thus, +ve scans may lead to overdiagnosis and overtreatment
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MRI of the scaphoidn MRI was traditionally used in the
diagnosis of complications of scaphoid fractures such as avascular necrosis and delayed union
n More recently, MRI has been shown to be the most reliable imaging modality for the diagnosis of suspected scaphoid fractures
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MRI of the scaphoidcont.n Though the cortex gives no signal,
MRI is very sensitive to bone marrow abnormalities so even undisplaced fractures are obvious
n MRI gives precise information about the type and location of the fracture, as well as allowing soft-tissue injuries and ligamentous injury to be diagnosed at an early stage
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MRI of the scaphoidcont. (2)n MRI scanning sequence is:
T1-weighted SESTIR (short tau inversion recovery)T2*-weighted GRE
n A fracture is considered to be present is there is or more of the following signs:cortical/trabecular # line or a diffuse bone marrow abnormality
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MRI valuen STIR – sensitivity = 100%
specificity = 100%T1 SE – sensitivity = 95%
specificity = 100%•=0.953 (compared to •=0.88 for 3-phase scan & •>0.4 for x-rays)
n Main problem of MRI is long scanning times and limited availability
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Scaphoid fractures on MRI
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Scaphoid fractures on MRI cont.
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CT of the scaphoidn Performed only as a follow-up
investigation if 3-phase bone scan is positive and MRI is unavailable or contraindicated
n The scan can be performed in less than a minute from which multiplanar and 3-D reconstructions are possible
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U/S of the scaphoidn High spatial resolution U/S has
been considered as an alternative investigation for suspected scaphoid fractures
n This imaging modality is still being evaluated for the detection of occult scaphoid fractures before being performed on a routine basis
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Conclusionn For early diagnosis of scaphoid
fractures, initial radiography followed by MRI within 7 days of trauma ( if x-rays are –ve) should ideally be performed
n 3-phase bone scans can be used as an alternative, but only if MRI cannot be performed
n CT is only used for follow-up of cases
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