Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures

Outcome of follow-up computed tomography of suspected occult scaphoid fracture after normal radiography

PURPOSE

To evaluate the rate of missed scaphoid fractures on follow-up computed tomography (CT) for suspected occult scaphoid fracture after normal radiography with residual radial-sided wrist pain.

METHODS

In a retrospective analysis, wrist CT during a five-year period was analyzed. The CT examinations and radiological reports were re-evaluated. Available clinical findings and radiologic follow-up performed during a period of a minimum of three years served as outcome reference.

RESULTS

In total, 178 examinations had been performed on 174 patients for suspect scaphoid fracture, 67 men and 107 women, showing 15 and 6 scaphoid fractures, respectively; a statistically significant sex difference (p = 0.0024). In 157 examinations, no scaphoid fracture was detected on CT, instead 29 other wrist or carpal bone fractures were found. On follow-up, no missed scaphoid fractures were found. Before CT, 124 of the 157 patients had been treated with a cast. After CT, 35 patients continued with cast treatment for a median of 14 days.

CONCLUSIONS

CT appears to be a reliable method for evaluating suspect scaphoid fracture as part of a diagnosis-treatment regimen including pain immobilization with a plaster cast.

Resource Utilization and the Use of Bone Stimulators among Operatively and Nonoperatively Managed Scaphoid Nonunion Patients

The prevalence of bone stimulator use among nonoperatively and operatively managed scaphoid nonunion patients is unknown. We hypothesize that bone stimulators are a relatively underutilized treatment for scaphoid nonunion patients.

Methods

We used the 2009-2017 Truven Marketscan Research Databases to identify patients with closed scaphoid fractures and performed an analysis of variance test to determine resource utilization and bone stimulator use among these patients.

Results

A total of 36,611 patients with scaphoid fractures were identified: 30,143 were managed nonoperatively and 6468 were managed operatively. Nonunion was diagnosed in 500 (1.66%) nonoperatively and in 1211 (19%) operatively managed patients. Bone stimulators were used in less than 2% of nonoperatively and operatively managed scaphoid nonunion patients.

Conclusion

Lack of trust in the technology and heterogenous (and occasionally burdensome) requirements for insurance approval are barriers to bone stimulator use; however, surgeons should examine how this technology may fit into the treatment algorithm for these difficult cases.

Musculoskeletal radiologist-level performance by using deep learning for detection of scaphoid fractures on conventional multi-view radiographs of hand and wrist

OBJECTIVES

To assess how an artificial intelligence (AI) algorithm performs against five experienced musculoskeletal radiologists in diagnosing scaphoid fractures and whether it aids their diagnosis on conventional multi-view radiographs.

METHODS

Four datasets of conventional hand, wrist, and scaphoid radiographs were retrospectively acquired at two hospitals (hospitals A and B). Dataset 1 (12,990 radiographs from 3353 patients, hospital A) and dataset 2 (1117 radiographs from 394 patients, hospital B) were used for training and testing a scaphoid localization and laterality classification component. Dataset 3 (4316 radiographs from 840 patients, hospital A) and dataset 4 (688 radiographs from 209 patients, hospital B) were used for training and testing the fracture detector. The algorithm was compared with the radiologists in an observer study. Evaluation metrics included sensitivity, specificity, positive predictive value (PPV), area under the characteristic operating curve (AUC), Cohen's kappa coefficient (κ), fracture localization precision, and reading time.

RESULTS

The algorithm detected scaphoid fractures with a sensitivity of 72%, specificity of 93%, PPV of 81%, and AUC of 0.88. The AUC of the algorithm did not differ from each radiologist (0.87 [radiologists' mean], p ≥ .05). AI assistance improved five out of ten pairs of inter-observer Cohen's κ agreements (p < .05) and reduced reading time in four radiologists (p < .001), but did not improve other metrics in the majority of radiologists (p ≥ .05).

CONCLUSIONS

The AI algorithm detects scaphoid fractures on conventional multi-view radiographs at the level of five experienced musculoskeletal radiologists and could significantly shorten their reading time.

KEY POINTS

• An artificial intelligence algorithm automatically detects scaphoid fractures on conventional multi-view radiographs at the same level of five experienced musculoskeletal radiologists. • There is preliminary evidence that automated scaphoid fracture detection can significantly shorten the reading time of musculoskeletal radiologists.

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.

Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review

OBJECTIVES

Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population.

METHODS

Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494).

RESULTS

Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated.

CONCLUSIONS

This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.

Value of the 45-degree reverse oblique view of the carpal palm in diagnosing scaphoid waist fractures

OBJECTIVES

To investigate the value of 45° reverse oblique view of the carpal palm in diagnosing scaphoid waist fracture and displacement.

METHODS

Eighty-four patients with wrist injury and plain radiography including posteroanterior, lateral, Stecher, and 45° reverse oblique view of the wrist were analyzed for the detection rate in diagnosing scaphoid fractures and displacement. The degree of difficulty in the four views for detecting the scaphoid waist fracture and displacement was rated on a five-grade Likert scale.

RESULTS

Among 84 patients, scaphoid waist fractures occurred in 43, and fracture displacement in 32. A significantly (P<0.01) greater rate of detecting the scaphoid waist fracture was found in the Stecher, and 45° reverse oblique view than in the posteroanterior and lateral views. The rate of detecting fracture displacement was significantly (P<0.01) greater in the Stecher and 45° reverse oblique view than in the posteroanterior and lateral views. The Stecher view had a significantly (P = 0.006) lower rate of detecting fracture displacement than the 45° reverse oblique view. It was significantly (P<0.001) easier to identify the scaphoid waist fracture and displacement with the 45° reverse oblique view and the Stecher view than with the posteroanterior and lateral view. The 45° reverse oblique view had the easiest degree to identify the scaphoid waist fracture displacement, followed by the Stecher view, the posteroanterior and the lateral view (P<0.001).

CONCLUSIONS

The 45° reverse oblique view clearly shows the scaphoid oblique view in the long axis for better observation of the scaphoid waist fracture and displacement.

Ultra-low-dose cone-beam CT compared to standard dose in the assessment for acute fractures

PURPOSE

Multi-detector computed tomography (MDCT) is superior in fracture detection than conventional radiography; however, dose is increased. Cone-beam computed tomography (CBCT) offers higher spatial resolution and lower dose than MDCT. Manufacturers offer an ultra-low-dose algorithm. This study compares the diagnostic accuracy of the ultra-low-dose CBCT (ULDCBCT) with that of the standard-dose CBCT (SDCBCT).

MATERIALS AND METHODS

In total, 64 patients were scanned with both the SDCBCT and the ULDCBCT protocols. Both studies were reported by two consultant radiologists with fellowship training in emergency radiology separated in time. The reporter recorded a diagnosis of fracture or normal and diagnostic confidence using a 5-point Likert scale. The gold standard was taken as the SDCBCT. Reporters were blinded to the indication and the SDCBCT report. Cases of discrepancy were resolved by consensus.

RESULTS

There were 34 fractures and 30 cases had no fracture. Several fractures were missed using the UDCBCT, and there were also several cases of overdiagnosis. ULD was inferior to SD for fracture diagnosis (p < 0.00001). The diagnostic accuracy of ULDCBCT was 82.8% (75.1-88.9 CI). The diagnostic accuracy of plain radiograph was 64% (55.1-75.7% CI). Diagnostic confidence was reduced; the mean confidence for SDCBCT was 4.68 vs 4.12 for ULDCBCT (p < 0.001). The Kappa for interobserver agreement was 0.6.

CONCLUSION

ULDCBCT is inferior to SDCBCT in fracture detection and confidence is reduced. For diagnostic studies, the standard dose should be used.

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.

Incremental diagnostic value of color-coded virtual non-calcium dual-energy CT for the assessment of traumatic bone marrow edema of the scaphoid

OBJECTIVES

To investigate the diagnostic accuracy of color-coded dual-energy CT virtual non-calcium (VNCa) reconstructions for the assessment of bone marrow edema (BME) of the scaphoid in patients with acute wrist trauma.

METHODS

Our retrospective study included data from 141 patients (67 women, 74 men; mean age 43 years, range 19-80 years) with acute wrist trauma who had undergone third-generation dual-source dual-energy CT and 3-T MRI within 7 days. Eight weeks after assessment of conventional grayscale dual-energy CT scans for the presence of fractures, corresponding color-coded VNCa reconstructions were independently analyzed by the same six radiologists for the presence of BME. CT numbers on VNCa reconstructions were evaluated by a seventh radiologist. Consensus reading of MRI series by two additional radiologists served as the reference standard.

RESULTS

MRI depicted 103 scaphoideal zones with BME in 76 patients. On qualitative analysis, VNCa images yielded high overall sensitivity (580/618 [94%]), specificity (1880/1920 [98%]), and accuracy (2460/2538 [97%]) for assessing BME as compared with MRI as reference standard. The interobserver agreement was excellent (κ = 0.98). CT numbers derived from VNCa images were significantly different in zones with and without edema (p < 0.001). A cutoff value of - 46 Hounsfield units provided a sensitivity of 91% and specificity of 97% for differentiating edematous scaphoid lesions. Receiver operating characteristic curve analysis revealed an overall area under the curve of 0.98.

CONCLUSIONS

Qualitative and quantitative analyses showed excellent diagnostic accuracy of color-coded VNCa reconstructions for assessing traumatic BME of the scaphoid compared to MRI.

KEY POINTS

• Color-coded virtual non-calcium (VNCa) reconstructions yield excellent diagnostic accuracy in assessing bone marrow edema of the scaphoid. • VNCa imaging enables detection of non-displaced fractures that are occult on standard grayscale CT. • Diagnostic confidence is comparable between VNCa imaging and MRI.

Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway

We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent (n = 602) with a low clinical suspicion were discharged and 35% (n = 320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666.Level of evidence: III.

An Evidence-Based Approach to Casting and Orthosis Management of the Pediatric, Adolescent, and Young Adult Population for Injuries of the Upper Extremity: A Review Article

OBJECTIVE

Review the use of upper-extremity orthoses and casts after injuries to the wrist and hand in the pediatric, adolescent, and young adult population. The common injuries reviewed include pediatric distal radius fractures, scaphoid fractures, metacarpal fractures, mallet fingers, volar plate injuries of the proximal interphalangeal (PIP) joint, and ulnar collateral ligament (UCL) tears of the thumb metacarpophalangeal (MCP) joint.

DATA SOURCES

We conducted a literature review from 1985 to 2016 of upper-extremity orthotic interventions. Non-English language citations and animal studies were excluded. Citations from retrieved studies were used to identify other relevant publications. This review included cases of common injuries to the upper extremity, which required orthotic intervention.

MAIN RESULTS

Immobilization recommendations for nonsurgical pediatric distal radius fractures, nonsurgical metacarpal fractures, mallet fingers, and UCL tears of the thumb MCP include a removable orthosis. Nondisplaced scaphoid fracture orthosis recommendations include initial immobilization in a nonremovable short-arm thumb spica cast. Volar plate injuries of the PIP joint require buddy straps for healing.

CONCLUSIONS

The literature demonstrates the effectiveness of removable orthoses in healing, patient satisfaction, and time to return to activity after many common upper-extremity injuries. Removable orthoses should be considered an equal or superior treatment method to cast immobilization, immobilization of additional joints, or longer periods of immobilization.

Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis

BACKGROUND

The quantification of the costs of ankle fractures and their associated treatments has garnered increased attention in orthopaedics through cost-effectiveness analysis. The purpose of this study was to prospectively assess the direct and indirect costs of ankle fractures in operatively and nonoperatively treated patients.

METHODS

A prospective, observational, single-center study was performed. Adult patients presenting for an initial consult for an ankle fracture were enrolled and were followed until recurring indirect costs amounted to zero. Patients completed a cost form at every visit that assessed time away from work and the money spent in the last week on transportation, household chores, and self-care due to an ankle fracture. Direct cost data were obtained directly from the hospital billing department.

RESULTS

Sixty patients were included in this study. With regard to patient characteristics, the mean patient age was 46.5 years, 55% of patients were female, 10% of patients had diabetes, and 17% of patients were active smokers. Weber A fractures composed 12% of fractures, Weber B fractures composed 72% of fractures, and Weber C fractures composed 18% of fractures. Operatively treated patients (n = 37) had significantly higher total costs and direct costs compared with nonoperatively treated patients (p < 0.01). In all patients, losses from missed work accounted for the largest portion of total and indirect costs, with a mean percentage of 35.8% of the total cost. The mean period preceding return to work of the 39 employed patients was 11.2 weeks. Longer periods of return to work were significantly associated with surgical fixation and having less than a college-level education (p < 0.05). The mean time for recurring observed costs to cease was 19.1 weeks.

CONCLUSIONS

In patients treated operatively and nonoperatively, the largest discrete cost component was a specific indirect cost. Indirect costs accounted for a mean of 41.3% of the total cost. Although the majority of the direct costs of ankle fractures are accrued in the period immediately following the injury, indirect cost components will regularly be incurred for nearly 5 months and often longer. To capture the full economic impact of these injuries, future research should include detailed reporting on an intervention's impact on the indirect costs of ankle fractures.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness of Immediate Magnetic Resonance Imaging In the Management of Patients With Suspected Scaphoid Fracture: Results From a Randomized Clinical Trial

OBJECTIVES

Given the limited diagnostic accuracy of radiographs on presentation to the emergency department (ED), the management of suspected scaphoid fractures remains clinically challenging and poses an unknown economic burden to healthcare systems. We aimed to evaluate the cost-effectiveness of immediate magnetic resonance imaging (MRI) in the management of patients presenting with suspected scaphoid fracture to an ED in England.

METHODS

A pragmatic, randomized, single-center trial compared the use of immediate MRI in the ED against standard care with radiographs only. Participants' use of healthcare services and costs were estimated from primary care and secondary care databases and questionnaires at baseline, 1, 3, and 6 months postrecruitment. Costs were compared using generalized linear models and combined with quality-adjusted life years (QALYs, based on the EQ-5D-5L) to estimate cost-effectiveness at 6 months postrecruitment. Cost-effectiveness acceptability curves and bootstrapping techniques were used to estimate the probability of cost-effectiveness at different willingness-to-pay (WTP) thresholds. Four deterministic sensitivity scenarios were considered around key parameters.

RESULTS

The MRI intervention dominated standard care in the base case and all 4 deterministic sensitivity scenarios, costing less and achieving more QALY gains, with a probability of 100% of being cost-effective at 6 months using the conventional United Kingdom WTP thresholds of £20 000 to £30 000 per QALY.

CONCLUSION

The use of immediate MRI is a cost-effective intervention in the management of suspected scaphoid fractures in a Central Hospital in London. Routine clinical practice at our institution has been changed to include the intervention.

The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study

Purpose

While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED).

Methods

In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED.

Results

A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied.

Conclusion

Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED.

Electronic supplementary material

The online version of this article (10.1007/s00068-019-01194-2) contains supplementary material, which is available to authorized users.

Imaging for Acute and Chronic Scaphoid Fractures

The scaphoid is the most commonly fractured bone in the wrist but 20% to 40% of scaphoid fractures are radiographically occult. Delayed or misdiagnosis can have significant consequences with late complications such as nonunion, malunion, or the development of avascular necrosis in the proximal pole. After initial negative radiographs, advanced cross-sectional imaging, including CT and MRI, ultimately may provide more accurate and rapid diagnosis than conventional radiography. With chronic fractures, the preferred modality depends on the clinical question. New techniques are evolving that will further advance imaging for diagnosis and treatment of scaphoid fractures.

Diagnosis and Management of Acute Scaphoid Fractures

The scaphoid is the most commonly fractured carpal bone; despite its frequent injury, the diagnosis of fracture can be complicated by the presence of normal radiographs at the time of presentation. Clinical intuition can be increased by physical examination and immediately available modalities such as ultrasound within the emergency department. Definitive diagnosis should be made with computed tomography and magnetic resonance to verify the presence of displacement. This article provides an overview of the incidence and presentation of acute scaphoid fractures with a surgical focus on percutaneous dorsal screw fixation.

Use of Decision Analysis and Economic Evaluation in Upper Extremity Surgery: A Systematic Review

BACKGROUND

Decision analysis allows clinicians to apply evidence-based medicine to guide objective decisions in uncertain scenarios. There is no comprehensive review summarizing the various decision analysis tools used. The authors aimed to appraise and review the decision analytic models used in hand surgery.

METHODS

A search of English articles on the PubMed, Ovid, and Embase databases was performed. All articles, regardless of date of publishing, were considered. Two reviewers, based on strict inclusion criteria, independently assessed each article.

RESULTS

The search resulted in 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to medical indications, with scaphoid fractures (n = 6) and carpal tunnel syndrome (n = 5) being the most commonly reported. Included articles used decision analysis (n = 15) and/or economic analyses (n = 23) to discuss diagnostic strategies or compare treatments. The three most common outcomes reported were utility (n = 12), cost per quality-adjusted life-year (n = 16), and quality-adjusted life-years (n = 16). The decision analysis models compared diagnostic strategies, management options, and novel treatments.

CONCLUSIONS

Decision analysis is increasingly popular in hand surgery. It is useful for comparing surgical strategies through evaluation of quality-of-life outcomes and costing data. The most common model was a simple decision tree. The quality of decision analysis models can be improved with the addition of sensitivity analysis. Surgeons should be familiar with the principles of decision analysis, so that complex decisions can be evaluated using rigorous probabilistic models that combine risks and benefits of multiple strategies.

Incorporating Cone-Beam CT Into the Diagnostic Algorithm for Suspected Radiocarpal Fractures: A New Standard of Care?

OBJECTIVE. The purpose of this study was to assess the result of adding cone-beam CT to the standard imaging algorithm for patients with suspected radiographically occult traumatic radiocarpal fractures. SUBJECTS AND METHODS. A prospective review was performed on all patients who had cone-beam CT investigation of acute wrist pain after normal initial radiographs. Patients with no identified fractures were clinically reassessed and referred for MRI if concern for a fracture persisted. RESULTS. In all, 117 patients were assessed; 50.4% had fractures identified with a total of 67 radiographically occult fractures. One fracture was identified on MRI that was not seen on cone-beam CT. Cone-beam CT had sensitivity of 98.3% (95% CI, 91.1-100%), specificity of 100% (95% CI, 93.7-100%), positive predictive value of 100%, and negative predictive value of 98.3% (95% CI, 89.1-100%). Accuracy was 99.1% (95% CI, 95.3-100%). CONCLUSION. Incorporating cone-beam CT into routine clinical practice as part of a standardized diagnostic algorithm yielded a 50% fracture detection rate in patients with negative wrist radiographs but ongoing clinical concern for radiocarpal fracture. Cone-beam CT provides more diagnostic information than radiographs at a lower radiation dose than conventional MDCT. Given the poor accuracy of radiographs for acute radiocarpal fractures and the high fracture prevalence in this cohort, we feel that cone-beam CT should be regarded as the new standard of care in the investigation of these patients.

The utility of cross-sectional imaging in the management of suspected scaphoid fractures

INTRODUCTION

Scaphoid fractures are the commonest carpal bone fracture. If untreated they pose significant risk to patients, thus if a scaphoid fracture is suspected, patients are managed with immobilisation. Although scaphoid fractures may be difficult to diagnose on plain radiography, sometimes for months after injury, ongoing radiographic surveillance is preferred due to its low upfront cost. Patients in immobilising casts for long periods experience significant personal and social ramifications such as difficulty working and self-caring. This study examines whether cross-sectional imaging by computed tomography (CT) or magnetic resonance imaging (MRI) is quicker than serial X-ray surveillance at allowing a scaphoid fracture to be either excluded or confirmed.

METHODS

A retrospective record review was performed of the 1709 patients who presented to Royal North Shore Hospital in 2015 with wrist injuries, finding 104 patients clinically suspicious for a fractured scaphoid.

RESULTS

All patients were examined by X-ray during their initial hospital presentation, providing 33.7% of final diagnoses in 0.6 ± 1.7 days. However, if initial X-ray proved inconclusive, subsequent serial X-ray surveillance made a final diagnosis after a mean of 24.1 ± 17.2 days, with some being immobilised for up to 67 days before diagnosis. Cross-sectional imaging significantly reduced diagnosis time to 9.8 ± 5.8 days (P = 0.0016), with a maximum immobilisation time of 24 days.

CONCLUSION

Cross-sectional imaging allows for faster scaphoid fracture diagnosis than X-ray. We propose a protocol for scaphoid fracture diagnosis wherein patients undergo two episodes of X-ray separated by 7 days, followed by a single MRI if clinical suspicion remains, minimising unnecessary immobilisation.

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.].

Single-shot CT after wrist trauma: impact on detection accuracy and treatment of fractures

OBJECTIVE

To evaluate accuracy of fracture detection and therapeutic impact of a single-shot CT protocol as a primary imaging tool in all patients with clinical suspicion of wrist injury, and evaluate the resulting impact on therapy.

MATERIALS AND METHODS

We performed a single-institution study on all patients with suspicion of fractures of the wrist and carpus. All patients underwent conventional radiography, thereafter single-shot wrist CT, and then 1-year follow-up. Physicians and radiologists prospectively scored likelihood of fracture presence on a five-point scale before and after CT. Three surgeons proposed a treatment regimen (functional, cast, reduction, or operative) based on clinical and radiological data, first with knowledge of conventional radiography, and then with knowledge of CT. The reference standard for fracture presence was based on all data. We performed receiver operating characteristic (ROC) analyses and calculated proportion of wrists with treatment changes due to CT imaging.

RESULTS

Ninety-eight patients participated (63% female, mean age 53, range, 18-87 years old) with 100 wrist CTs. Conventional radiography detected true-positive fractures in 45, and CT in 61 wrists. The areas under the curve for fracture detection were 0.85 (95% CI 0.77-0.93) for conventional radiography and 0.97 (95% CI 0.93-1.00) for CT. Treatment changed in 24 (24%, 95% CI 16-33%) - 31 (31%, 95% CI 23-41%) wrists, mostly involving a decrease in the rate of cast immobilization.

CONCLUSIONS

Single-shot CT in patients with clinical suspicion of wrist injury increases accuracy of fracture detection. This has a significant impact therapy in this population, mainly on cast immobilization.

TRIAL REGISTRATION

We registered the study at www.clinicaltrials.gov , NL43482.091.13.

The economic evidence for advanced imaging in the diagnosis of suspected scaphoid fractures: systematic review of evidence

Given the limitations of conventional radiography in the diagnosis of suspected scaphoid fractures on presentation, advanced imaging, particularly magnetic resonance imaging, is a useful additional investigation. We carried out a systematic review of the economic evidence for the use of advanced imaging in the management of suspected scaphoid fractures. Fifteen articles were included in the review. Owing to the heterogeneity of study designs, the type and timing of interventions and the economic analyses performed, direct comparisons between the 15 studies were difficult. From a health care perspective, little could be concluded regarding the economic implications of the use of advanced imaging in clinical practice. However, from a societal perspective, the evidence favours the use of advanced imaging in the management of suspected scaphoid fractures as it does appear to lead to overall cost-savings.

Rationale and design of the SMaRT trial: A randomised, prospective, parallel, non-blinded, one-centre trial to evaluate the use of magnetic resonance imaging in acute setting in patients presenting with suspected scaphoid fracture

Background Wrist injury is a common presentation to the Emergency Department in the United Kingdom. Among these injuries, the scaphoid is the most common fractured carpal bone. However, given the limited ability of conventional radiography to accurately diagnose a suspected scaphoid fracture on presentation, its diagnosis and management remain challenging. Despite the vast clinical evidence supporting the superior accuracy of magnetic resonance imaging, there is little to no evidence around the real-world clinical and economic impact of immediate magnetic resonance imaging in the management of suspected scaphoid fractures. Methods Review of design and implementation challenges associated with the identification and subsequent recruitment of eligible patients, implementation of a novel clinical pathway in an acute setting, rationale behind the primary and secondary outcomes selected and measurement of the primary outcome. Results The Scaphoid Magnetic Resonance Imaging in Trauma trial is a single-site prospective, randomised, non-blinded, parallel design trial that aims to evaluate the use of immediate magnetic resonance imaging in the management of patients presenting to the acute setting with suspected scaphoid fractures. The primary outcome is the total 3-month cost per patient associated with the diagnosis and treatment of suspected scaphoid fractures. It is hypothesised that the immediate use of magnetic resonance imaging, a more accurate but expensive imaging modality, in patients with negative findings in the initial four-view radiography, will reduce the overall National Health Service costs by promoting definitive care and avoiding unnecessary diagnostic and treatment procedures. Other rationale design considerations in the recruitment, randomisation, data acquisition and intervention implementation are also discussed. Several of these challenges derive from real-world operational issues associated with the provision of magnetic resonance imaging in an intrinsically complex acute setting. Staff engagement during the trial's planning phase, combined with an extensive training programme rolled out prior to the trial's launch, were essential to raise staff awareness and engagement. Given the acute nature of the clinical condition, the latter was deemed essential as the eligibility assessment, recruitment, randomisation and treatment allocation processes all need to happen in a very tight time frame. Limitations Findings from the Scaphoid Magnetic Resonance Imaging in Trauma trial might not be generalisable to other National Health Service hospitals, foreign healthcare systems nor patient presentations outside normal magnetic resonance imaging working hours. Conclusion The Scaphoid Magnetic Resonance Imaging in Trauma trial was designed to evaluate the costs, patient satisfaction and clinical outcomes around the management of suspected scaphoid fractures and ultimately provide solid evidence on which to base the United Kingdom and international clinical practice. This article discusses the steps considered in the design of this novel trial, with particular emphasis on the issues and lessons learned during the planning and implementation stages.

Management of Scaphoid Fractures

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole.

SUMMARY

The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.

Proximal Femoral Nail Antirotation Versus Reverse Less Invasive Stabilization System-distal Femur for Treating Proximal Femoral Fractures: A Meta-analysis

The aim of this study was to compare the effectiveness and safety of 2 surgical techniques that are used to treat proximal femoral fractures.A systematic literature search (up to December 2014) was conducted in Medline, Embase, PubMed, and The Cochrane Central Register of Controlled Trials to screen for studies comparing proximal femoral nail antirotation (PFNA) with less invasive stabilization system-distal femur (LISS-DF) for proximal femoral fractures. Two authors independently assessed the methodological quality of the included studies and extracted data. Surgical information and postoperative outcomes were analyzed.A total of 7 studies with 361 patients who satisfied the eligibility criteria included 3 randomized controlled trials and 4 case-controlled trials associated with PFNA versus LISS in treating proximal femoral fractures. Our results demonstrated that there was a significant reduction in hospital stay and time to weight-bearing ambulation and bone healing for PFNA compared with LISS (odds ratio [OR] -1.48, 95% confidence interval [CI] -2.92 to -0.05; OR -7.08, 95% CI -8.32 to -5.84; OR -2.71, 95% CI -4.76 to 0.67). No statistically significant difference was observed between the 2 groups for operative time, blood loss volume, Harris hip score, and incidence of complications.Based on the results of this analysis, we inferred that PFNA is safer and more effective than reverse LISS-DF in patients undergoing osteosynthesis for proximal femoral fractures, and that PFNA is associated with reduced hospital stays and reduced time to weight-bearing ambulation and bone healing. Nonetheless, in certain cases in which PFNA is not suitable due to abnormal structure of the proximal femur or particularly unstable fractures, the LISS plate technique could be a useful alternative.