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A large number of patients treated in the emergency room present symptoms compatible with fracture of the scaphoid, but with normal radiographs. The high probability of progression to post-traumatic wrist arthritis of a undiagnosed scaphoid fracture and the considerable difficulty of treatment associated with the high cost of pseudarthrosis of the scaphoid makes the discussion about which would be the most cost-effective protocol for the diagnosis of these injuries.
It was recently published in the magazine Bone and Joint Open a study with the objective of analyzing the number of patients with normal radiographs who had scaphoid fractures diagnosed with magnetic resonance imaging (MRI).
RM for scaphoid invoices
Was developed at the university hospital of Oxford a prospective cohort study in which all patients diagnosed with fractures of the X-rays or suspected scaphoid (history compatible plus anatomical snuffbox or scaphoid tubercle pain) after wrist trauma between September 2018 and 2019. Suspected patients with normal radiographs underwent wrist MRI.
Of a total of 337 patients, 62 had a clear initial diagnosis with physical examination and radiographs (39 scaphoid fractures, pseudarthrosis, carpal tunnel syndrome, etc.). Of the 275 suspected cases, 17 were not referred to RM. Of the remaining 258, 22 did not undergo the examination because their symptoms improved and 23 refused to participate in the research. Five patients did not tolerate the examination.
At the end, of the 208 patients who underwent MRI, 148 had abnormalities on the examination, 27 of which were scaphoid fractures (13% of those who underwent MRI), 45 fractures of other bones (22%), 13 contusions of the scaphoid (6%), 42 contusions of other bones or ligament injury (20%) and 21 only with degenerative changes. This meant that 41% (27 out of 66) of scaphoid fractures were not apparent on radiographs.
Also read: Immobilization or fixation temporary external fracture-dislocation of the ankle?
Contusions of the lunate or capitate were seen in almost 25% of scaphoid fractures on MRI. In addition, scapholunate ligament injuries were commonly associated with scaphoid fractures or contusions.
In our reality
The diagnosis of scaphoid fractures many of the It is sometimes challenging and the possibility of stiffness due to unnecessary immobilization and the possibility of pseudarthrosis and complications due to the absence of an adequate diagnosis must be weighed in the balance for decision making. However, not all hospitals have the use of MRI in the emergency room for immediate use.
For the orthopedist, every possible resource that can be used in the hospital in which he works is important when we are talking about a “treacherous” bone like the scaphoid. Often, the use of computed tomography, which is more accessible in most health units, is enough to clarify the diagnosis. In cases with high suspicion without radiological diagnosis, immobilization until reassessment in 10 to 14 days is of paramount importance to avoid progression to cases with high probability of pseudarthrosis.
See more: Cost x benefit of topical antibiotics in orthopedic post-trauma infections
Author:
Physician by UERJ ⦁ Orthopedics and Hand Surgery at INTO ⦁ Master’s Student in Applied Sciences to the Musculoskeletal System (INTO)
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The PEBMED Portal is intended for physicians and other health professionals. Our contents inform recent panoramas of medicine.
If you are interested in publishing your curriculum on the internet, connecting with patients and increasing your differentials, create a free profile on AgendarConsulta, PEBMED’s partner site.
If you are interested in more content and courses aimed at medical residency, get to know Medcel , the PEBMED partner site
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