How to manage scaphoid waist fractures? Introduction of pragmatic imaging efficient pathway and literature review of the recent evidence

Clinical and Epidemiological Features of Scaphoid Fracture Nonunion: A Hospital-Based Study in Beijing, China

Objective

Studies exploring the epidemiological characteristics of scaphoid fracture nonunion are important to understand the causes and lead to effective prevention strategy. However, such knowledge is limited especially in China. This study aims to reveal the clinical and epidemiological features of scaphoid fracture nonunion in Chinese patients.

Methods

This was a retrospective study, which was based on patients with scaphoid fracture nonunion treated in a Chinese national orthopedic referral center from 1 August 2009 to 1 August 2020. The basic demographic and clinical characteristics, including gender, age at diagnosis of scaphoid fracture nonunion, dominant hand, the location of fracture, the side, the causes of the injury, age of the injury, age of the treatment for scaphoid fracture nonunion, and the delay period, were retrieved from the medical records. The patients were divided into a non‐delay group and a delay group based on whether they had visited the doctor within 1 month after the injury. Scaphoid fracture was classified into the proximal, waist, and distal fractures according to the location. The t‐test or Mann–Whitney U test was used to compare the difference between groups when the dependent variable is continuous, while a chi‐square test was used when the dependent variable is categorical.

Results

A total of 363 patients were included in this study. The mean age at the diagnosis of scaphoid fracture nonunion was 32 (ranging from 14 to 78). Waist fracture nonunion (76.5%) was most common. Among the 169 patients who sought medical care within 1 month after the injury (non‐delay group), more than half (90 cases) were misdiagnosed. 23 cases could not recall the injury, so the time of delay could not be determined. Among the 171 patients who did not seek medical care for acute injury (delay group), the average time was 52 months between the initial injury and the treatment. The proportion of waist nonunions was higher among patients in the delay group than that in the non‐delay group.

Conclusions

Nonunion of scaphoid fracture is caused mainly by delayed treatment and misdiagnosis in China, suggesting that timely treatment and improved diagnosis could lower the prevalence. The fracture location may be a factor contributing to the delaying of seeking medical care.

Evaluating cone-beam CT in the diagnosis of suspected scaphoid fractures in the emergency department: preliminary findings

OBJECTIVES

Scaphoid fractures are challenging to accurately diagnose with delayed and missed diagnoses risking poor patient outcomes. Cone beam CT (CBCT) is an emerging technology facilitating alternative access to multi-planar imaging. The aim of this study was to evaluate the use of early CBCT in the diagnosis of suspected scaphoid fractures presenting via the Emergency Department (ED).

METHODS

In this single centre the imaging pathway was adapted to include early CBCT in adult patients with a persisting high index of clinical suspicion for scaphoid fracture despite normal radiographs. Evaluation of referrals between September 2019 and February 2020 was undertaken. Statistical analysis and temporal pathway metrics were assessed including interrater agreement for CBCT and radiography examinations.

RESULTS

Over the six-month timeframe 100 CBCT wrist scans were performed on 99 adult patients. 94% of CBCT scans were performed within 1 day of referral. 25% of scans demonstrated acute injuries including 12 radius, 6 trapezium and 2 scaphoid fractures. For fracture, CBCT had a sensitivity of 96.2% and specificity of 100%. There was a highly significant difference in interobserver variation between fracture detection on CBCT and radiographs.

CONCLUSION

CBCT heralds the potential for early accurate diagnosis of radiocarpal fractures, at lower cost, shortening clinical pathways and reducing clinical risk in the ED.

Evaluating the potential for cone beam CT to improve the suspected scaphoid fracture pathway: InSPECTED - A single-centre feasibility study

BACKGROUND

The suspected scaphoid fracture remains a diagnostic conundrum with over-treatment a common risk-averse strategy. Cross-sectional imaging remains the gold standard with MRI recommended but CT used by some because of easier access or limited MRI availability. The aim of this feasibility study was to evaluate whether cone beam computed tomography (CBCT) could support early diagnosis, or exclusion, of scaphoid fractures.

METHODS

Patients with a suspected scaphoid were recruited fracture between March and July 2020. All underwent a 4-view X-ray. If this examination was normal, they were immediately referred for a CBCT scan of the wrist. Those with a normal scan were discharged to research follow-up at 2 and 6-weeks.

RESULTS

68 participants were recruited, 55 had a normal or equivocal X-ray and underwent CBCT. Nine additional radiocarpal fractures (16.2%) were demonstrated on CBCT, the remainder were discharged to research follow-up. Based on the 2-week and 6-week follow up three patients (4.4%) were referred for MRI to investigate persistent symptoms with no bony injuries identified.

CONCLUSIONS

CBCT scans enabled a rapid pathway for the diagnosis or exclusion of scaphoid fractures, identifying other fractures and facilitating early treatment. The rapid pathway also enabled those with no bony injury to start rehabilitation, suggesting that patients can be safely discharged with safety-net advice following a CBCT scan.