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Scientific Articles   |    
Diagnostic Performance of Radiographs and Computed Tomography for Displacement and Instability of Acute Scaphoid Waist Fractures
Geert A. Buijze, MD1; Peter Jørgsholm, MD2; Niels O.B. Thomsen, MD, PhD2; Anders Björkman, MD, PhD2; Jack Besjakov, MD, PhD2; David Ring, MD, PhD1
1 Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
2 Departments of Hand Surgery (P.J., N.O.B.T., and A.B.) and Radiology (J.B.), Skåne University Hospital, University of Lund, SE-205 02 Malmö, Sweden
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Investigation performed at the Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and the Departments of Hand Surgery and Radiology, Skåne University Hospital, University of Lund, Malmö, Sweden

This article was chosen to appear electronically on September 26, 2012, in advance of publication in a regularly scheduled issue.



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Nov 07;94(21):1967-1974. doi: 10.2106/JBJS.K.00993
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Abstract

Background: 

Fracture displacement is the most important factor associated with nonunion of a scaphoid waist fracture. We evaluated the performance characteristics of radiographs and computed tomography (CT) in the diagnosis of intraoperative displacement and instability of scaphoid waist fractures using wrist arthroscopy as the reference standard.

Methods: 

During a six-year period (2004 to 2010) at two institutions, forty-four adult patients with a scaphoid waist fracture underwent arthroscopy-assisted operative fracture treatment at a mean of nine days (range, two to twenty-two days) after injury. Subjects included all of those with a displaced scaphoid fracture seen on radiographs and a selection of patients with a nondisplaced scaphoid fracture. All patients had preoperative radiographs and CT. Arthroscopy with up to 5 kg of traction was the reference standard for fracture displacement and instability.

Results: 

The reference standard (arthroscopy) led to a diagnosis of twenty-two displaced fractures (all unstable) and twenty-two nondisplaced fractures (seven unstable). Displacement was diagnosed in eleven patients (25%) with the use of radiographs and in twenty (45%) with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative displacement were 45%, 95%, and 70%, respectively, with the use of radiographs and 77%, 86%, and 82%, respectively, with CT. The sensitivity, specificity, and accuracy for diagnosing intraoperative instability were 34%, 93%, and 55%, respectively, with the use of radiographs and 62%, 87%, and 70%, respectively, with CT. Assuming a 10% prevalence of fracture displacement and instability among all scaphoid waist fractures, the positive and negative predictive values for displacement were 53% and 94%, respectively, with the use of radiographs and 39% and 97% with CT whereas the positive and negative predictive values for instability were 36% and 93%, respectively, with radiographs and 34% and 95% with CT.

Conclusions: 

Radiographs and CT scans cannot be relied on to accurately diagnose intraoperative scaphoid fracture displacement or instability compared with arthroscopic examination. The influence, with regard to the risk of nonunion, of intraoperative instability of a scaphoid fracture that is seen to be nondisplaced on radiographs or CT is currently unknown.

Level of Evidence: 

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

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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