Virtual management of clinically suspected scaphoid fractures

Stirling, Paul; Simpson, Cameron J.; Ring, David; Duckworth, Andrew D.; McEachan, Jane E.

doi:10.1302/0301-620x.104b6.bjj-2021-1464.r2

Cited by 12 publications

(17 citation statements)

References 37 publications

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“…Of these, 7% (13 of 189) were reviewed, after which no fractures were diagnosed. Evaluation at 1 year identified high levels of satisfaction, excellent patient-reported outcomes, and no symptomatic nonunions [19].…”

Section: Discussionmentioning

confidence: 99%

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Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis

Bulstra,

van Boxel,

Crijns

et al. 2023

Clin Orthop Relat Res

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Background In the setting of a suspected scaphoid fracture, MRI may result in overdiagnosis and potential overtreatment. This is in part because of the low prevalence of true fractures among suspected fractures, but also because of potentially misleading variations in signal that may be more common than fracture-related signal changes. To better understand the risk of overdiagnosis, we first need insight into the relative prevalence of useful and potentially distracting signal changes among patients with a suspected scaphoid fracture. Question/purpose What is the proportion of signal changes representing definite and possible scaphoid fractures relative to other types of signal changes on MRI among patients with a suspected scaphoid fracture? Methods In a retrospective study in an orthopaedic trauma clinic associated with a Level I trauma center, we evaluated MR images of patients 16 years and older with a clinically suspected scaphoid fracture. At our institution, patients with symptoms and signs of a possible scaphoid fracture and negative radiographs undergo MRI scanning. Between January 1, 2012, and September 1, 2019, a total of 310 patients 16 years or older had an MRI to evaluate a suspected scaphoid fracture. Exclusion criteria included a scaphoid fracture that was visible on radiographs before MRI as reported by the radiologist (four patients), no available radiographs before MRI (two), MRI more than 3 weeks after injury (28), unknown date of injury (nine), and repeat or bilateral MRI scans (11), leaving 256 MR images for analysis. Sixty percent (153) of patients were women, and the median age was 34 years (IQR 21 to 50 years). The images were taken a median of 8 days (IQR 2 to 12 days) after injury. MR images were screened for the presence of scaphoid signal changes. We identified the following patterns of signal change with a reliability of kappa 0.62: definite scaphoid fracture, possible scaphoid fracture, signal in the waist area other than possible or definite fractures, and other signal changes. A definite scaphoid fracture was defined as a linear, focal, and bicortical signal abnormality, with adjacent edema and a relatively transverse orientation relative to the scaphoid long axis. The transverse linear signal was visible on more than one cut in multiple planes. A possible scaphoid fracture had a transverse linear signal on more than one cut on sagittal or coronal planes, with or without adjacent edema. Results Six percent (16 of 256) of MR images were categorized as revealing definite (2% [four of 256]) or possible (5% [12 of 256]) scaphoid fractures, whereas 29% (74 of 256) were categorized as revealing nonspecific signal changes at the waist (14% [35 of 256]) and other areas (15% [39 of 256]). Of the 51 patients with scaphoid waist signal changes, 69% (35) were categorized as having distracting and potentially misleading MRI findings. Conclusion The high prevalence of signal changes that are distracting and potentially misleading, the low prevalence of signal changes that clearly represent a scaphoid fracture, and the low pretest odds of a true fracture among patients with a suspected scaphoid fracture illustrate that routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment. Two alternative strategies are supported by preliminary evidence and merit additional attention: more-selective use of MRI in people deemed at higher risk according to a clinical prediction rule and strategies for involving the patient in decisions regarding how to manage the notably small risk of future symptomatic nonunion. Level of Evidence Level IV, diagnostic study.

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Section: Discussionmentioning

confidence: 99%

“…Ethical approval for this study was obtained from the Southern Adelaide Clinical Human Research Ethics Committee (SAC HREC EC00188l; reference number 257. 19).…”

Section: Ethical Approvalmentioning

confidence: 99%

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis

Bulstra,

van Boxel,

Crijns

et al. 2023

Clin Orthop Relat Res

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“…Patients were also asked ‘how normal is your hand?’ before and after surgery and recorded responses on a VAS from 0–100. This ‘normal hand score’ has recently been introduced as a single item adjunct to conventional PROMs in Dupuytren’s disease (Stirling et al., 2021) and suspected scaphoid fractures (Stirling et al., 2022b) and has been shown to have good correlation with hand function and patient satisfaction (Stirling et al., 2021). Patients self-reported any complications using a free text box on the postoperative questionnaire.…”

Section: Methodsmentioning

confidence: 99%

The effect of diabetes mellitus on the outcome of surgery for cubital tunnel syndrome

Stirling

Harrison

McEachan

2022

J Hand Surg Eur Vol

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The aims of this study were to investigate the effect of diabetes mellitus (DM) on patient-reported outcome measures (PROMs) and satisfaction after surgery for cubital tunnel syndrome (CuTS). Pre- and 1-year postoperative QuickDASH, normal hand, and satisfaction scores were prospectively collected from 107 patients over a 6-year period. Patients without DM reported a significant QuickDASH improvement after surgery (preoperative 34.1 versus postoperative 20.5; p < 0.001), but patients with DM did not (preoperative 46.5 versus postoperative 43.2; p = 0.554). Postoperative QuickDASH (43.2 versus 20.5) and normal hand (65 versus 80) scores were significantly worse in patients with DM. Satisfaction rates were excellent in both groups (88% versus 82%; p = 0.480). Our study showed that surgery for CuTS did not lead to an improvement in QuickDASH score in patients with DM and consequently patients with DM reported worse postoperative PROMs compared with those without. However, lack of improvement in PROMs does not affect patient satisfaction. Level of evidence: IV

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“…Immobilisation can cause pressure sores, stiffness and muscle atrophy4 as well as restricting the ability to work. This also imposes a substantial burden on fracture clinic services and has unquantifiable societal costs 5…”

Section: Introductionmentioning

confidence: 99%

“…Only 13% of NHS hospitals currently offer MRI directly from the ED for patients with a suspected fracture 13. Other pathway approaches include direct discharge from the ED with follow-up in a virtual clinic 5. However, all such pathways would benefit from being able to risk-stratify patients based on their likelihood of scaphoid fracture to increase the prevalence of confirmed cases among patients with suspected fractures.…”

Section: Introductionmentioning

confidence: 99%

Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies

et al. 2023

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BackgroundPlain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging.MethodsThis systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies.ResultsEight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7).ConclusionNo single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.Trial registration numberCRD42021290224.

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Virtual management of clinically suspected scaphoid fractures

Cited by 12 publications

References 37 publications

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis

The effect of diabetes mellitus on the outcome of surgery for cubital tunnel syndrome

Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies

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