Secrets in scaphoid fractures

Scaphoid fractures are among the most common wrist fractures of patients in the emergency room. Chapter 1 shows that over the last few decades several classification systems and imaging technologies have been proposed for scaphoid fractures. Reliable prediction model of fracture union cannot be provided. In Chapter 2 scaphoid fractures were imaged using 3D imaging techniques. A new simplified classification was proposed; 1) proximal pole fractures, (2) a range of waist fractures, and (3) distal tubercle fractures. In Chapter 3 the simplified scaphoid fracture classification was taken in use in a database study and inter-observer study. It shows to be easily reproducible. In Chapter 4 radiographs and CT-scans are used to diagnose proximal pole fractures using an interobserver study. This study suggests that CT-scans do not meaningfully improve the reliability of diagnosis of fracture location or displacement. In Chapter 5 we tested the agreement between observers on the extent of union of a scaphoid waist fracture on CT. We concluded there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT. In Chapter 6 we studied if physicians can determine if a scaphoid fractures are acute or nonunited using radiographs and CT-scans. We found that distinction of nonunions from acute fractures of the scaphoid is reliable without a CT. In Chapter 7 new imaging modality, the I-Space, a virtual reality system, was used diagnosing occult scaphoid fractures. Results of this study suggest that the I-space is a modality with a fast learning curve and a potential clinical usefulness

Does a Comparison View Improve the Reliability of Staging Wrist Osteoarthritis?

Background: Radiological grading of wrist osteoarthritis associated with scaphoid nonunion advanced collapse (SNAC) can be difficult. A comparison radiograph of the contralateral healthy wrist and an educational training in the various SNAC stages may improve reliability. Our purposes were to evaluate the difference in the reliability: (1) between observers who rate SNAC wrists with and without a comparison radiograph; and (2) between observers who receive training prior to ratings and those who do not. Methods: In this cross-sectional survey study, 82 fully trained orthopedic or hand surgeons rated anteroposterior radiographs of 19 patient wrists following a scaphoid nonunion based on SNAC stages 0 to 4. Observers were randomized online in 4 groups: one group rated unilateral views without training, a second group unilateral views with training, a third group bilateral views without training, and a fourth group bilateral views with training. Training included a 1-page clarification of the SNAC stages. Interobserver agreement was calculated using kappa statistics. Results: There was no significant difference between agreement between observers who rated unilateral radiographs (κ = 0.55) and who rated bilateral radiographs (κ = 0.58) (P =.14), nor between agreement between observers who received training (κ = 0.59) and who did not (κ = 0.54) (P =.058). Conclusions: The use of an additional comparison view and/or training does not seem to be clinically relevant in SNAC staging. There is room for improvement in the way we assess patients with SNAC wrists

Reliability of Diagnosis of Partial Union of Scaphoid Waist Fractures on Computed Tomography

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to "eyeball" measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (kappa = 0.34). Agreement on the location of bony bridging was slight (kappa = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level Ill, diagnostic study

Inter-observer agreement between 2-dimensional CT versus 3-dimensional I-space model in the diagnosis of occult scaphoid fractures

textabstractBackground: The I-Space is a radiological imaging system in which Computed Tomography (CT)-scans can be evaluated as a three dimensional hologram. The aim of this study is to analyze the value of virtual reality (I-Space) in diagnosing acute occult scaphoid fractures. Methods: A convenient cohort of 24 patients with a CT-scan from prior studies, without a scaphoid fracture on radiograph, yet high clinical suspicion of a fracture, were included in this study. CT-scans were evaluated in the I-Space by 7 observers of which 3 observers assessed the scans in the I-Space twice. The observers in this study assessed in the I-Space whether the patient had a scaphoid fracture. The kappa value was calculated for inter- and intra-observer agreement. Results: The Kappa value varied from 0.11 to 0.33 for the first assessment. For the three observers who assessed the CT-scans twice; observer 1 improved from a kappa of 0.33 to 0.50 (95% CI 0.26-0.74, P=0.01), observer 2 from 0.17 to 0.78 (95% CI 0.36-1.0, P < 0.001), and observer 3 from 0.11 to 0.24 (95% CI 0.0-0.77, P=0.24). Conclusion: Following our findings the I-Space has a fast learning curve and has a potential place in the diagnostic modalities for suspected scaphoid fractures