Scaphoid fracture as a "puncher's fracture"

Virtual management of clinically suspected scaphoid fractures

AIMS

The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service.

METHODS

All adult patients who presented with a clinically suspected scaphoid fracture that was not visible on radiographs at the time of presentation during a one-year period were eligible for inclusion in the pathway. Demographic details, findings on examination, and routine four-view radiographs at the time of presentation were collected. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year after presentation and included the abbreviated version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the EuroQol five-dimension five-level health questionnaire (EQ-5D-5L), the Net Promoter Score (NPS), and return to work.

RESULTS

A total of 221 patients were referred to the virtual pathway. Their mean age was 41 years (range 16 to 87) and there were 99 male patients (45%). A total of 189 patients (86%) were discharged with advice and 19 (9%) were recalled for clinical review: seven with an undisplaced scaphoid fracture, six with another fracture of the hand or wrist, two with a scapholunate ligament injury, and four in whom no abnormality was detected. A total of 13 patients (6%) initiated follow-up with the hand service: no fracture or ligament injury was identified in this group. PROMs were available for 179 patients (81%) at a mean follow-up of 19 months (range 13 to 33). The median QuickDASH score was 2.3 (interquartile range (IQR) 0 to 15.9), the median EQ-5D-5L was 0.85 (IQR 0.73 to 1.00), the NPS was 76, and 173 patients (97%) were satisfied with their treatment. There were no documented cases of symptomatic nonunion one year following injury.

CONCLUSION

We describe the introduction of a virtual pathway for the management of patients with a suspected scaphoid fracture. We found high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases. Cite this article: Bone Joint J 2022;104-B(6):709-714.

Diagnosis of Suspected Scaphoid Fractures

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Suspected scaphoid fractures are a diagnostic and therapeutic challenge despite the advances in knowledge regarding these injuries and imaging techniques. The risks and restrictions of routine immobilization as well as the restriction of activities in a young and active population must be weighed against the risks of nonunion that are associated with a missed fracture.

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The prevalence of true fractures among suspected fractures is low. This greatly reduces the statistical probability that a positive diagnostic test will correspond with a true fracture, reducing the positive predictive value of an investigation.

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There is no consensus reference standard for a true fracture; therefore, alternative statistical methods for calculating sensitivity, specificity, and positive and negative predictive values are required.

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Clinical prediction rules that incorporate a set of demographic and clinical factors may allow stratification of secondary imaging, which, in turn, could increase the pretest probability of a scaphoid fracture and improve the diagnostic performance of the sophisticated radiographic investigations that are available.

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Machine-learning-derived probability calculators may augment risk stratification and can improve through retraining, although these theoretical benefits need further prospective evaluation.

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Convolutional neural networks (CNNs) are a form of artificial intelligence that have demonstrated great promise in the recognition of scaphoid fractures on radiographs. However, in the more challenging diagnostic scenario of a suspected or so-called "clinical" scaphoid fracture, CNNs have not yet proven superior to a diagnosis that has been made by an experienced surgeon.

Incidence of Scaphoid Fractures and Associated Injuries at US Trauma Centers

Backgound  The scaphoid is the most commonly fractured carpal bone and often presents as a diagnostic challenge. Fractures can often go unnoticed on initial radiographic evaluation and clinical presentation can vary significantly among patients. Awareness of high-risk cohorts assists practitioners in making the appropriate clinical diagnosis of acute scaphoid fracture. Materials and Methods  The National Trauma Data Bank is the world's largest trauma data repository. Utilizing the 2016 public use file, we isolated scaphoid fractures by anatomic fracture location by utilizing International Classification of Diseases, 10th revision coding. Reported cases of distal pole (S62.01), waist (S62.02), and proximal pole (S62.03) were included. This data was then queried to determine trends in mechanism of injury, demographic information, and associated injuries. Results  There were a total of 968,665 patients with 2,769 cases of reported scaphoid fractures resulting in 286 scaphoid fractures per 100,000 person-years. Males were more likely to sustain a scaphoid fracture than females. The most commonly encountered associated injuries were distal radius fractures, distal ulnar fractures, and nonscaphoid carpal bone fractures, respectively. Conclusions  Scaphoid fractures presenting to trauma centers are more commonly reported among males and those involved in motor vehicle accidents or falls. Appropriate scaphoid-specific radiographic imaging should be obtained as well as wrist and elbow images to evaluate for concomitant injuries, especially distal radius fractures.

3D mapping of scaphoid fractures and comminution

OBJECTIVE

Acute and subacute scaphoid fractures were assessed using 3D computer tomography (CT). The aims were to describe fracture morphology, to map fractures onto a 3D scaphoid model and to correlate this to scaphoid anatomy.

MATERIALS AND METHODS

A retrospective, multicentre database search was performed to identify CT studies of acute and subacute scaphoid fractures. CT scans of scaphoid fractures less than 6 weeks from time of injury were included in this retrospective, multicentre study. CTs were segmented and converted into three-dimensional models. Following virtual fracture reduction, fractures were mapped onto a three-dimensional scaphoid model.

RESULTS

Seventy-five CT scans were included. The median delay from injury to CT was 29 days. Most studies were in male patients (89%). Most fractures were comminuted (52%) or displaced (64%). A total of 73% of displaced fractures had concomitant comminution. Waist fractures had higher rates of comminution and displacement when compared with all other fractures. Comminution was located along the dorsal ridge and the volar scaphoid waist.

CONCLUSION

Our study is the first to describe acute fracture morphology using 3D CT and to correlate comminution and displacement to fracture types. The dorsal ridge and volar waist need prudent assessment, especially in waist fractures.

Trapezoid Fracture Associated with Scaphoid Fracture in a Football Goalkeeper

Introduction

Trapezoid fractures are uncommon in sports. We presented a rare case of a trapezoid fracture associated with a scaphoid fracture caused by punching a ball in a football goalkeeper.

Case Presentation

A 19-year-old male who played as a football goalkeeper visited our hospital with complaints of sustained pain from the right wrist to the hand after punching a ball. Scaphoid fracture was diagnosed on plain radiographs, whereas trapezoid fracture was overlooked. Computed tomography revealed a displaced trapezoid fracture associated with a scaphoid fracture. Both fractures were successfully treated by open reduction and internal fixation using cannulated screws. Almost complete bone union was achieved at 5 months after surgery. The patient returned to play as a football goalkeeper.

Conclusion

The simultaneous occurrence of trapezoid and scaphoid fractures has never been reported. Trapezoid fractures are rare and can be overlooked on plain radiographs, as what happened in the present case, because the trapezoid is small and overlaps with other carpal bones on plain radiographs. If there is sustained pain in the wrist and hand after punching, combined trapezoid and scaphoid fractures should be considered as the possible injury.

Radiographic analysis of anatomic risk factors for scaphoid fractures; A case-control study

AIM

The purpose of this study was to investigate the role of anatomic variations in distal radius radiographic indices in patients with or without scaphoid fractures.

MATERIALS AND METHODS

Radial inclination (RI), volar tilt (VT), radial height (RH) and ulnar variance (UV) were measured on wrist radiographs of 320 patients with (Group I, n = 167) or without (Group II, n = 153) scaphoid fracture, fall on outstretched hand (FOOSH). Receiver operating characteristics (ROC) curve analysis was used to assess the diagnostic performance for each variable. Sensitivity (Sn), specificity (Sp), cutoff value, and area under the ROC curve were analyzed. Odds ratio was calculated for defined cutoff values.

RESULTS

The mean age of the groups was similar (29.3 ± 10.2 vs 31.1 ± 9.9 years, p = 0.060). RI (30.0 ± 2.9 vs 26.8 ± 2.3°) VT (11.4 ± 2.4 vs 10.5 ± 2.2°), RH (14.8 ± 2.1 vs 13.2 ± 1.9 mm), UV (-0.46 ± 1.7 vs 0.00 ± 1.5 mm) were higher in scaphoid fracture group (Gr I vs Gr II, p = 0.000, p = 0.000, p = 0.001, p = 0.012 respectively). Ulna minus variant was more prevalent in fracture group (p = 0.001). Optimal cutoff points for RI, VT, RH and UV in differentiating fractured and intact scaphoid were 28.6° (Sn = 81.0%, Sp = 26.3%), 12.2° (Sn = 80.4%, Sp = 67.1%), 14.85 mm (Sn = 80.4%, Sp = 52.1%) and 0 mm (Sn = 88.6%, Sp = 75.8%), respectively. Odds ratios for defined cutoff points for RI, VT, RH and UV were 10.4 (95% CI, 6.2-17.4), 1.8 (95% CI, 1.1-3.0), 3.7 (95% CI, 2.3-6.2) and 2.2 (95% CI, 1.3-3.7) respectively.

CONCLUSION

Increased RI, VT, RH and negative UV were found to be predisposing anatomical risk factors for scaphoid fracture when FOOSH.

Scaphoid fractures in the athlete

Scaphoid fractures are a common wrist injury, especially in athletes. Clinicians should have a high index of suspicion for a scaphoid fracture in any patient complaining of radial-sided wrist pain after a fall on an outstretched hand. Advanced imaging, including CT and MRI scans, may be useful in diagnosis and classification of fracture patterns. Treatment varies based on the fracture location, stability of the fracture, and predictability of the fracture to heal. Treatment involves either non-operative management with a thumb spica cast or brace, or operative fixation with a headless compression screw, k-wires, or scaphoid-specific plates. Return to play is dependent on many variables, including sport, fracture union, and ability to play with cast.

Management of Upper Extremity Injury in Divers

Modern competitive diving-especially platform diving-applies dramatic stress to the upper extremity. Some stress occurs during handstand-style takeoffs, but more force is delivered to the hand, wrist, elbow, and shoulder during hands-first entry. Hand positions that minimize the amount of splash result in forceful wrist extension. This repetitive impact can lead to chronic upper extremity pain and acute injuries that require operative intervention. Many divers use taping and bracing to prevent or treat this type of injury, but these are only modestly effective. Although minor injuries can improve with conservative management, carpal fractures and ligamentous injuries often require operative intervention.

Scaphoid fracture epidemiology

BACKGROUND

The current available literature related to scaphoid fracture epidemiology is inconsistent. The aim of this study was to describe the epidemiology of true scaphoid fractures in a defined adult population.

METHODS

Using a prospective database, we identified all patients who sustained a radiographically confirmed acute fracture of the scaphoid over a 1-year period. Age, gender, mechanism of injury, the Herbert fracture classification, and associated injuries were recorded and analyzed.

RESULTS

There were 151 scaphoid fractures diagnosed giving an annual incidence of 29 per 100,000 (95% confidence interval, 25–34). The median age of males was significantly younger when compared with females (p = 0.002), with a male (n = 105) predominance seen (p 0.001). Low-energy falls from a standing height were most common (40.4%), but with males being significantly more likely to sustain their fracture after a high-energy injury (p 0.001). The most common fracture was Herbert classification B2 (n =55, 36.4%), with unstable fractures more common in younger patients (p = 0.025) following a high-energy injury (p = 0.042).

CONCLUSIONS

We have reported the epidemiology of true scaphoid fractures, with young males at risk of sustaining a fracture. Knowledge of the true incidence of scaphoid fractures and an understanding of the demographic risk factors are essential when assessing the suspected scaphoid fracture, particularly when considering further imaging modalities.

A new mechanism of injury for scaphoid fractures: 'test your strength' punch-bag machines

We investigated the mechanism of injury in a consecutive series of 153 confirmed scaphoid fractures. We found that ten (6%) occurred as a result of using a 'test your strength' punch-bag machine, a device found in public houses and amusement arcades. Clinicians should be aware that scaphoid fractures can occur as a result of punching these machines or other similar objects.

Clinical result of operative treatment for scaphoid non-union in the skeletally immature: percutaneous versus open procedure

This article is a retrospective study of 13 cases of scaphoid non-union in skeletally immature patients. For the fracture fixation, three cases of stable fibrous union with minimal sclerosis, without deformity or cystic changes were considered for the percutaneous Herbert screw fixation. Ten cases were managed with the open reduction and internal fixation with or without bone grafting. The average union time was 10.5 weeks post-operatively. The average union time was lesser in percutaneous Herbert screw fixation group (nine weeks) than open procedure group (11.5 weeks). All cases achieved union without any supplemental procedures. According to Cooney's clinical scoring, 12 cases were rated excellent result and one good result. The percutaneous Herbert screw fixation for scaphoid non-union in skeletally immature patients can be a good treatment option when it is fibrous union with no deformity.

Treatment of acute scaphoid fractures: systematic review and meta-analysis

Whether operative treatment is a better option than nonoperative treatment for acute nondisplaced or minimally displaced fractures of the scaphoid is controversial. The type of cast that should be used for nonoperative treatment is not known. We performed a systematic review and meta-analysis of randomized and quasirandomized trials to evaluate the effect of operative versus nonoperative treatment and the effect of different casting methods for nonoperative treatment of acute scaphoid fractures on nonunion rate, return to work, grip strength, range of wrist motion, complications, patient evaluation, and incidence of osteoarthritis. Two investigators assessed trial quality and extracted data. Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.