1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Introduction

MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit.

Method

A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period.

Results

he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort.

Conclusions

Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

Reproducibility of the Gartland classification for supracondylar humeral fractures in children

PURPOSE

To evaluate the intra- and inter-observer reproducibility of the Gartland radiographic classification for supracondylar humeral fractures in children.

METHODS

Anteroposterior and lateral radiographs of 50 supracondylar humeral fractures in children were graded on 2 separate occasions by 4 orthopaedic surgeons according to the Wilkins modification of the Gartland classification. Data were analysed by calculating the Kappa values for intra- and inter-observer agreement to indicate the reproducibility of the classification.

RESULTS

There was moderate inter-observer agreement, except for poor agreement over type I fractures. Type II fractures only showed fair to moderate agreement. Type III fractures and the flexion group showed good to very good agreement. Intra-observer agreement was good to very good.

CONCLUSION

Surgeons should treat paediatric supracondylar humeral fractures based on an assessment of the degree of displacement rather than by employing the Gartland classification.

Lipoma arborescens of the knee

Lipoma arborescens (diffuse articular lipomatosis) is a rare, benign intra-articular lesion of unknown aetiology. It is characterised by villous proliferation of the synovium and diffuse replacement of the subsynovial tissue by mature fat cells. It forms part of the differential diagnosis for a slowly progressive chronically swollen knee. We present a very rare case of bilateral involvement of the knee and discuss the symptoms, diagnosis and treatment of this condition.

Kinemax total knee arthroplasty: trial by template

A retrospective radiologic study of Kinemax total knee arthroplasty templates is presented to establish their accuracy. The preoperative and postoperative radiographs of 49 Kinemax total knee arthroplasties were assessed using the Kinemax template. The size of the actual component used was compared with that predicted from the preoperative and postoperative radiographs. The preoperative radiograph template was accurate in 57% of cases, but the postoperative radiograph template was accurate in only 41%. Preoperative radiologic templating is of questionable benefit as part of preoperative management for patients undergoing Kinemax total knee arthroplasty.

Eponyms - are they relevant?

This study was performed to investigate the value of eponyms of fractures amongst orthopaedic/casualty trainees. Our results show eponyms are not favoured.

Resection arthrodesis of the shoulder with autogenous fibular bone grafts

We report the results of wide local excision of stage II8 proximal humeral tumors followed by reconstruction with parallel nonvascularized fibular bone grafts in three patients. Mean follow-up was 5 years (range 3 years to 8 years, 6 months). The pathologic diagnosis was osteogenic sarcoma in two patients and Ewing's sarcoma in one. The rotator cuff and deltoid were excised to achieve a wide margin around these tumors. All patients remain free from disease. They were able to return to previous work and sport activities. Two had a fracture of the graft; one fell from a mountain bike and the other fell at work. The former fracture united; the latter fracture required fixation and bone grafting to achieve union. By Enneking's 30-point functional evaluation, all three patients were in the excellent category with scores of 25, 26, and 28. We conclude that for the treatment of malignant tumors of the shoulder region with muscle involvement, excision followed by arthrodesis with parallel autogenous fibular bone grafts provides a method of retaining satisfactory upper limb function and acceptable cosmesis.

Pseudoaneurysm of the superficial femoral artery. An unusual complication following rotationplasty

A 21 year old man presented with pain and swelling around the right knee. Staging studies and open biopsy provided a diagnosis of malignant fibrous histiocytoma, stage II B. A wide local excision followed by prosthetic reconstruction was not possible because of extensive involvement of the quadriceps muscle with tumor. Therefore the patient underwent wide local excision of the tumor and rotationplasty, providing functionally a transtibial amputation. Postoperatively (Day 44) a critical ischaemia of the foot developed, and angiography revealed a pseudoaneurysm of the superficial femoral artery at the level of the tibial condyle. The patient underwent successful arterial reconstruction and the bones united. The etiology of this pseudoaneurysm appears to be related to the presence of the coiled superficial femoral artery abutting the medial tibial condyle flare. This complication may be prevented by ensuring that the condylar flare be contoured, and then an adequate cushion of soft tissue be interposed between artery and bone at this level.

Elbow lengthening after total prosthetic arthroplasty: Observations and clinical implications

We have carried out a radiologic study to determine the effect on limb length of inserting the components of a total elbow joint replacement arthroplasty. The preoperative and postoperative radiographs of 27 consecutive patients undergoing total elbow joint replacement arthroplasty with the Kudo prosthesis were studied. In all cases lengthening across the elbow was found. Both ulnar and humeral lengthening were observed. A mean length increase of 8.6 mm (range 2 to 17 mm) was recorded. Ulnar lengthening contributed to overall lengthening by a significantly greater amount than humeral lengthening. We correlated the degree of lengthening observed with clinical measurements in this series of patients but found no significant differences. Operative maneuvers are suggested to accommodate this length increase, to achieve soft-tissue balance, and to avoid potential complications such as ulnar neuropathy and joint instability.

Outcome of dislocation after hemiarthroplasty for fractured neck of the femur

An analysis of 20 cases of dislocation from 1000 consecutive hemiarthroplasties performed for fractured femoral necks is presented. A simple scoring system for prefracture status and mobility is described. The overall 6-month mortality rate of 65 per cent after dislocation is discussed.