The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 12

Scientific Articles | December 01, 2006

Diagnosis of Scaphoid Fracture Displacement with Radiography and Computed Tomography

Santiago Lozano-Calderón, MD¹; Philip Blazar, MD²; David Zurakowski, PhD³; Sang-Gil Lee, MD¹; David Ring, MD¹

¹ Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
² Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
³ Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115

View Disclosures and Other Information

In support of their research for or preparation of this manuscript, one or more of the authors received an unrestricted grant from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Dec 01;88(12):2695-2703. doi: 10.2106/JBJS.E.01211

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

Background: Displacement is an important risk factor for nonunion of scaphoid wrist fractures. We compared computed tomography with radiographs with regard to their ability to detect displacement.

Methods: Six blinded observers rated thirty scaphoid fractures (ten displaced and twenty nondisplaced) with use of radiographs and computed tomography. The radiographs were evaluated separately from the computed tomography scans and then, in a third evaluation, the two imaging studies were reviewed simultaneously. The evaluations were repeated four weeks later. Observers were asked to evaluate specific measures of fracture displacement and then to judge the fracture as being displaced or nondisplaced.

Results: Intraobserver reliability was better for computed tomography alone and the combination of radiographs and computed tomography than it was for radiographs alone (kappa values, 0.65, 0.63, and 0.54, respectively; all p < 0.001). The interobserver reliability was also better for computed tomography alone and the combination of radiographs and computed tomography than it was for radiographs alone (kappa values, 0.43, 0.48, and 0.27, respectively; all p < 0.001). The average sensitivity was 75% for radiographs alone, 72% for computed tomography alone, and 80% for both; the average specificity was 64%, 80%, and 73%, respectively; the average accuracy was 68%, 77%, and 75%, respectively. The positive predictive values (assuming a 5% prevalence of fracture displacement) were low (0.10, 0.13, and 0.16) and the negative predictive values were high (0.97, 0.98, and 0.99) for the radiographs, computed tomography, and combined modality.

Conclusions: Computed tomography improves the reliability of detecting scaphoid fracture displacement but has a more limited effect on accuracy, which remains <80%. The utility of computed tomography scans for diagnosing scaphoid fracture displacement is affected by the low prevalence of fracture displacement. This study suggests that computed tomography scans are useful for ruling out displacement but not for diagnosing it. We recommend that all scaphoid fractures be evaluated with computed tomography in order to rule out displacement.

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

Figures in this Article

Scaphoid fractures are notoriously prone to nonunion^1-6 The factors most strongly associated with a greater risk of nonunion of a fracture of the middle third, or waist, of the scaphoid are fracture displacement, a delay in diagnosis, and inadequate protection^6-9. Radiographic criteria for displacement have been described but not validated^2,9. Computed tomography scanning in the plane of the scaphoid provides detailed images that might improve the diagnosis of fracture displacement or instability^10-16. We tested the hypothesis that computed tomography increases the reliability and accuracy of the diagnosis of scaphoid fracture displacement.

Materials and Methods

Materials and Methods | Results | Discussion | References

Between 1999 and 2004, one surgeon (D.R.) treated patients with an isolated fracture of the scaphoid according to the following protocol: (1) all patients had computed tomography of the scaphoid in planes defined by the long axis of the scaphoid as described by Sanders¹⁶, (2) patients with no evidence of displacement on radiographs or computed tomography according to the interpretation of the treating surgeon and a musculoskeletal radiologist were treated with either cast immobilization or percutaneous screw fixation without arthroscopic visualization according to the patient's preference, and (3) patients in whom fracture displacement was suspected on the basis of radiographs and computed tomography images had percutaneous screw fixation monitored and assisted with wrist arthroscopy.

With use of this protocol, ten fractures were confirmed to be displaced and unstable (defined as movement of the fracture site with radial and ulnar deviation) with use of arthroscopy. Twenty consecutive fractures were defined by the treating surgeon and musculoskeletal radiologist as nondisplaced on the basis of radiographs and computed tomography scans. A protocol for the use of these computed tomography scans was approved by our Human Research Committee.

Six observers at three different levels of training (two senior residents, two hand surgery fellows, and two attending hand surgeons) evaluated the images for the presence or absence of fracture displacement. The images were blinded and randomly ordered. Each observer evaluated the images twice with a four-week interval between evaluations. Each evaluation was performed in three rounds. In the first round, the observers examined radiographs alone; in the second, they examined computed tomography images alone; and in the third, they examined both radiographs and computed tomography images simultaneously.

In addition to an overall judgment regarding fracture displacement, the observers were asked to evaluate for the presence or absence of the following factors^12,15-18: (1) gapping of the fracture fragments of =1 mm; (2) translation of the fracture fragments of =1 mm; (3) the presence of any angular displacement of the fracture site (evaluated on computed tomography only), with only angular displacement causing a gap, and not impaction into a more angled alignment, considered; and (4) dorsal tilting of the lunate of >15° with respect to the radius on a true lateral radiograph with the third metacarpal parallel to the radius.

Statistical Analysis

The kappa statistic was used as the chance-corrected measure of agreement and was interpreted according to the benchmark definitions of Landis and Koch¹⁹; 95% confidence intervals were calculated to provide a range of expected values in the population²⁰. The intraobserver and interobserver reliability were determined by calculating a kappa value for each level of experience as well as overall for all fifteen pairs of surgeons on the basis of multi-rater kappa. Multi-rater kappa summarizes the strength of agreement for all possible comparisons between surgeons including the same and mixed types of experience levels²⁰.

To assess the sensitivity, specificity, and accuracy of radiography and computed tomography for the detection of scaphoid displacement, the gold standard for a truly displaced fracture was defined as (1) a fracture that was suspected of being displaced on radiographic investigation and confirmed to be displaced and unstable at wrist arthroscopy or (2) a fracture with no gapping or angular or translational displacement on radiographs or computed tomography images according to the interpretation of the treating surgeon and a musculoskeletal radiologist. Without arthroscopic visualization of all of the fractures, we cannot be certain that all fractures that were diagnosed as nondisplaced were in fact stable; however, in the opinion of the treating surgeon, neither routine surgery nor routine arthroscopy could be mandated for nondisplaced fractures on the basis of current evidence^3,17,21-25.

Standard formulas were used to calculate the sensitivity, specificity, and accuracy of each modality overall and according to the level of training, with 95% confidence intervals constructed with use of Pratt's normal approximation method for binomial proportions²⁶. The positive predictive value and negative predictive value were determined with use of Bayes' theorem, which requires an a priori estimate of the prevalence (pretest probability) of displacement of scaphoid fractures. The positive predictive value is the patient's probability of having a displaced fracture when the test is positive for displacement, and the negative predictive value is the probability of a patient having a nondisplaced fracture when the test is negative for displacement. The predictive values of any imaging modality depend critically on the prevalence of the characteristic in the patients being tested; hence use of the appropriate Bayesian analysis is important. For the determination of positive and negative predictive values, we estimated an average prevalence of displacement of 5% on the basis of the best available data²⁷. The positive predictive value was calculated²⁸ as [sensitivity × prevalence]/[(sensitivity × prevalence) + (1 — specificity) × (1 — prevalence)], and the negative predictive value was calculated²⁸ as [specificity × (1 — prevalence)]/[(1 — sensitivity) × (prevalence + specificity) × (1 — prevalence)].

Statistical analysis was performed with use of the SPSS statistical package (version 13.0; SPSS, Chicago, Illinois). A power analysis was conducted with nQuery Advisor (version 6.0; Statistical Solutions, Saugus, Massachusetts) to establish the number of scaphoid fractures required for comparing sensitivity values among the imaging modalities. A sample size of thirty scaphoid fractures (ten displaced) evaluated by each of six surgeons yielded 180 cases each for radiographic analysis, computed tomography analysis, and the combination of radiographic and computed tomography analyses (a total of 540 cases) and provided 90% power (a = 0.05, ß = 0.10) to detect significant differences of 10% in each performance characteristic (sensitivity, specificity, accuracy, positive predictive value, and negative predictive value) among the three imaging protocols with use of chi-square analysis. The criterion for significance was defined as p < 0.01 (two-tailed) to protect against type-I errors due to multiple group comparisons.

Results

Materials and Methods | Results | Discussion | References

Intraobserver Reliability

Intraobserver reliability was moderate for the radiographic analysis (? = 0.54, 95% confidence interval = 0.18 to 0.94, p < 0.001), substantial for the computed tomography analysis (? = 0.65, 95% confidence interval = 0.32 to 1.00, p < 0.001), and substantial for the combination of radiographic and computed tomography analyses (? = 0.63, 95% confidence interval = 0.29 to 0.97, p < 0.001) (Fig. 1). Analysis of intraobserver reliability according to the level of training revealed significant but relatively limited and somewhat inconsistent differences. Attending surgeons had substantial intraobserver agreement for all modalities, whereas fellows had substantial agreement for two modalities (radiographs and the combined modality) and residents had it for only one (computed tomography alone) (Table I).

View Larger

TABLE I Kappa Intraobserver Reliability in Evaluating Fracture Displacement According to Level of Training

	Radiography	Computed Tomography	Radiography and Computed Tomography
Attendings
Observer 1	0.84	0.83	0.84
Observer 2	0.40	0.64	0.53
Average	0.63	0.74	0.68
Level of agreement*	Substantial	Substantial	Substantial
Fellows
Observer 1	0.73	0.67	0.66
Observer 2	0.61	0.52	0.60
Average	0.67	0.60	0.63
Level of agreement*	Substantial	Moderate	Substantial
Residents
Observer 1	0.24	0.92	0.71
Observer 2	0.49	0.53	0.46
Average	0.36	0.72	0.58
Level of agreement*	Fair	Substantial	Moderate

Based on the benchmarks for interpreting the strength of the kappa statistic described by Landis and Koch¹⁹.

Add to My JBJS

TABLE I Kappa Intraobserver Reliability in Evaluating Fracture Displacement According to Level of Training

	Radiography	Computed Tomography	Radiography and Computed Tomography
Attendings
Observer 1	0.84	0.83	0.84
Observer 2	0.40	0.64	0.53
Average	0.63	0.74	0.68
Level of agreement*	Substantial	Substantial	Substantial
Fellows
Observer 1	0.73	0.67	0.66
Observer 2	0.61	0.52	0.60
Average	0.67	0.60	0.63
Level of agreement*	Substantial	Moderate	Substantial
Residents
Observer 1	0.24	0.92	0.71
Observer 2	0.49	0.53	0.46
Average	0.36	0.72	0.58
Level of agreement*	Fair	Substantial	Moderate

Based on the benchmarks for interpreting the strength of the kappa statistic described by Landis and Koch¹⁹.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1:: Bar graph showing the average interobserver and intraobserver reliability (among six observers) for the diagnosis of displacement of scaphoid fractures with use of radiography (X-Ray), computed tomography (CT Scan), and radiography combined with computed tomography (X-Ray + CT Scan). (Reprinted with permission of David Ring.)

Interobserver Reliability

Interobserver reliability is shown in Figure 1. The multi-rater kappa reliability was 0.27 (95% confidence interval, ? = 0.17 to 0.36; p < 0.01) (fair agreement) for the radiographic analysis, 0.43 (95% confidence interval, ? = 0.30 to 0.55; p < 0.01) (moderate agreement) for the computed tomography analysis, and 0.48 (95% confidence interval, ? = 0.37 to 0.57; p < 0.01) (moderate agreement) for the combination of radiographic and computed tomography analyses (Table II). Therefore, the agreement between surgeons was 48% above chance level for the combination of radiographic and computed tomography analyses.

View Larger

TABLE II Kappa Interobserver Reliability in Evaluating Fracture Displacement According to Level of Training and Overall*

Imaging Study	Attendings	Fellows	Residents	Multi-Rater Kappa†
Radiography	0.32 (fair)	0.22 (poor)	0.25 (poor)	0.27 (fair)
Computed tomography	0.49	0.60	0.47	0.43
Radiography and computed tomography	0.60	0.64	0.56	0.48

All kappa values are moderate in strength according to the benchmarks described by Landis and Koch¹⁹, except where indicated in parentheses. †Multi-rater kappa based on all fifteen pairwise comparisons among the six surgeons as an overall indication of interobserver reliability.

Add to My JBJS

TABLE II Kappa Interobserver Reliability in Evaluating Fracture Displacement According to Level of Training and Overall*

Imaging Study	Attendings	Fellows	Residents	Multi-Rater Kappa†
Radiography	0.32 (fair)	0.22 (poor)	0.25 (poor)	0.27 (fair)
Computed tomography	0.49	0.60	0.47	0.43
Radiography and computed tomography	0.60	0.64	0.56	0.48

With respect to specific measures of displacement on radiographs, tilting of the lunate (? = 0.30, 95% confidence interval = 0.10 to 0.50) and a fracture gap of =1 mm (? = 0.29, 95% confidence interval = 0.19 to 0.29) had the highest interobserver reliability (both values indicate fair agreement, p < 0.001). Angular displacement (? = 0.16, 95% confidence interval = 0 to 0.25, p < 0.01) showed poor agreement but was significant (Table III) (Fig. 2).

View Larger

TABLE III Kappa Reliability in Evaluating Different Parameters with the Imaging Modalities

	Radiography	Computed Tomography	Radiography and Computed Tomography
Gapping of fragments of =1 mm	0.29*	0.30*	0.39*
Translation of fragments of =1 mm	0.16	0.27	0.23
Angular displacement	0.16*	0.44*	0.38*
Tilting of lunate	0.30*		0.02

Significant (p < 0.01).

Add to My JBJS

TABLE III Kappa Reliability in Evaluating Different Parameters with the Imaging Modalities

	Radiography	Computed Tomography	Radiography and Computed Tomography
Gapping of fragments of =1 mm	0.29*	0.30*	0.39*
Translation of fragments of =1 mm	0.16	0.27	0.23
Angular displacement	0.16*	0.44*	0.38*
Tilting of lunate	0.30*		0.02

Significant (p < 0.01).

View Large | Download Slide(.ppt)
Add to My JBJS

Bar graph showing the average interobserver reliability (kappa value) for each parameter used for the diagnosis of displacement of scaphoid fractures with use of radiography (X-Ray), computed tomography (CT Scan), and radiography combined with computed tomography (X-Ray + CT Scan). An asterisk indicates that the factor was a significant predictor of displacement (p < 0.01). (Reprinted with permission of David Ring.)

With respect to specific measures of displacement on computed tomography scans, angular displacement of the fracture had the greatest interobserver reliability (? = 0.44, 95% confidence interval = 0.18 to 0.60, p < 0.001, moderate agreement), followed by fracture gapping of =1 mm (? = 0.30, 95% confidence interval = 0.16 to 0.44, p < 0.01, fair agreement), and translation of fragments (? = 0.27, 95% confidence interval = 0.01 to 0.54, p < 0.64, poor agreement) (Table III) (Fig. 2).

With use of the combined modality, the highest interobserver reliability was achieved in the analysis of gapping of fragments of =1 mm (? = 0.39, 95% confidence interval = 0.27 to 0.51, p < 0.01) and angular displacement (? = 0.38, 95% confidence interval = 0.22 to 0.54, p < 0.01). The criteria with the lower rates of reliability when this imaging modality was used were translation of fragments of =1 mm (? = 0.23, 95% confidence interval = 0.03 to 0.43, p = 0.02) and tilting of the lunate (? = 0.02, 95% confidence interval = 0.28 to 0.32, p = 0.86); both had poor reliability (Table III and Fig. 2).

Sensitivity, Specificity, and Accuracy

The sensitivity of radiography alone (75% [95% confidence interval = 67% to 88%]) and radiography combined with computed tomography (80% [95% confidence interval = 70% to 94%]) was greater than that of computed tomography alone (72% [95% confidence interval = 58% to 87%]) for detecting scaphoid fracture displacement (Fig. 3). The specificity of computed tomography alone (80% [95% confidence interval = 72% to 87%]) was greater than that of radiographs alone (64% [95% confidence interval = 52% to 70%]) and that of radiographs eyp computed tomography (73% [95% confidence interval = 65% to 89%]). The accuracy of computed tomography alone (77% [95% confidence interval = 70% to 83%]) was greater than that of radiographs, either alone (68% [95% confidence interval = 60% to 74%]) or in combination with computed tomography (75% [95% confidence interval = 67% to 82%]). The level of training affected specificity and accuracy more than sensitivity (Table IV).

View Larger

TABLE IV Diagnostic Performance Characteristics for Discerning Fracture Displacement According to Imaging Modality and Experience*

	Sensitivity (%)	Specificity (%)	Accuracy (%)
Radiography
Attendings	75 (62-85)	75 (59-87)	75 (63-85)
Fellows	75 (62-85)	52 (36-68)	60 (46-72)
Residents	75 (62-85)	65 (48-79)	68 (55-80)
Computed tomography
Attendings	75 (50-91)	90 (76-97)	85 (73-93)
Fellows	75 (50-91)	65 (48-79)	68 (55-80)
Residents	65 (40-85)	85 (70-94)	78 (66-88)
Radiography and computed tomography
Attendings	80 (56-94)	85 (70-94)	83 (71-92)
Fellows	80 (56-94)	62 (46-77)	68 (55-80)
Residents	80 (56-94)	72 (56-85)	75 (62-85)

The 95% confidence intervals determined by the normal approximation method are given in parentheses.

Add to My JBJS

TABLE IV Diagnostic Performance Characteristics for Discerning Fracture Displacement According to Imaging Modality and Experience*

	Sensitivity (%)	Specificity (%)	Accuracy (%)
Radiography
Attendings	75 (62-85)	75 (59-87)	75 (63-85)
Fellows	75 (62-85)	52 (36-68)	60 (46-72)
Residents	75 (62-85)	65 (48-79)	68 (55-80)
Computed tomography
Attendings	75 (50-91)	90 (76-97)	85 (73-93)
Fellows	75 (50-91)	65 (48-79)	68 (55-80)
Residents	65 (40-85)	85 (70-94)	78 (66-88)
Radiography and computed tomography
Attendings	80 (56-94)	85 (70-94)	83 (71-92)
Fellows	80 (56-94)	62 (46-77)	68 (55-80)
Residents	80 (56-94)	72 (56-85)	75 (62-85)

The 95% confidence intervals determined by the normal approximation method are given in parentheses.

View Large | Download Slide(.ppt)
Add to My JBJS

Bar graph showing the sensitivity, specificity, and accuracy with use of radiography (X-Ray), computed tomography (CT Scan), and radiography combined with computed tomography (X-Ray + CT Scan). (Reprinted with permission of David Ring.)

View Large | Download Slide(.ppt)
Add to My JBJS

Bar graph showing the positive and negative predictive values for the diagnosis of displacement of scaphoid fractures, assuming a 5% prevalence of such displacement, with use of radiography (X-Ray), computed tomography (CT Scan), and radiography combined with computed tomography (X-Ray + CT Scan). (Reprinted with permission of David Ring.)

According to Bayes theorem, the positive and negative predictive values were 0.10 and 0.97 for radiographs alone, 0.16 and 0.98 for computed tomography alone, and 0.13 and 0.99 for the combined use of both modalities (Figs. 4, 5-A, and 5-B). There was no substantial difference in the negative predictive value among the modalities. In other words, all of them are good for ruling out displacement but not for ruling it in. Computed tomography alone and in combination with radiographs displayed better positive predictive values than radiographs alone; however, the values were still extremely low.

View Large | Download Slide(.ppt)
Add to My JBJS

Curve displaying changes in the positive and negative predictive values of computed tomography for the diagnosis of displacement according to variation in prevalence rates. Sensitivity and specificity were maintained constant at 72% and 80%, respectively. (Reprinted with permission of David Ring.)

Discussion

Materials and Methods | Results | Discussion | References

Displacement is the variable most strongly associated with failure of a scaphoid fracture to heal^2,3,17,29,30. It is therefore crucial to use a diagnostic modality that can accurately detect displacement. Filan and Herbert⁴ noted poor correlation between radiographic signs of displacement and operative findings. It has been suggested that other, more sophisticated and more expensive imaging modalities, such as magnetic resonance imaging, trispiral tomography, and computed tomography can been used to assess fractures with more accuracy^{10,11,14,16,18}; however, few data clarifying this issue have been published.

The only study assessing scaphoid fracture displacement of which we are aware compared radiographs and magnetic resonance imaging scans². In a series of fifty patients, Bhat et al.² found that the only three fractures that failed to heal were diagnosed as displaced on magnetic resonance imaging; however, there were too few displaced fractures for their analysis to be meaningful and reliable. They found translation and gapping of the fracture fragments in the sagittal plane to be the most reliable factors for defining displacement on the magnetic resonance imaging scans.

In our study, computed tomography scans of the scaphoid improved the intraobserver and interobserver reliability of the diagnosis of fracture displacement. The interob-server reliability of specific indicators of displacement was much greater when computed tomography was used than when radiographs were used alone, with angulation at the fracture site on computed tomography scans being the most reliable indication of displacement. Some observers tended to overdiagnose displacement on both the computed tomography scans and the radiographs (making it a more sensitive and less specific indicator) and others tended to underdiagnose it (making it less sensitive and more specific), but these tended to balance out into a relatively uniform accuracy.

View Large | Download Slide(.ppt)
Add to My JBJS

Curve displaying changes in the positive and negative predictive values of the combination of radiography and computed tomography for the diagnosis of displacement according to variation in prevalence rates. Sensitivity and specificity were maintained constant at 80% and 73%, respectively. (Reprinted with permission of David Ring.)

The combination of radiography and computed tomography was, on the average, the best modality for diagnosis of scaphoid displacement: it had high sensitivity, lower specificity than computed tomography alone, and high accuracy that was as high as that for computed tomography alone. This profile is optimal since it would be better to overdiagnose rather than underdiagnose displacement given the potential consequences of inadequate treatment of a displaced fracture. The analysis by level of training revealed limited and inconsistent findings but suggested improved intraobserver reliability, specificity, and accuracy (but not sensitivity) with increasing level of training and experience.

The positive and negative predictive values provided very useful information. The fact that scaphoid fracture displacement is relatively uncommon magnifies the shortcomings of diagnostic imaging. In this setting, false-positive diagnoses of displacement are more common than actual displacements, making images that are positive for displacement much more difficult to interpret. On the other hand, the relatively low prevalence of displacement increases the value of images that do not show displacement. If an image does not show displacement, it is very unlikely to be present.

The lack of arthroscopic confirmation of nondisplaced fractures is a weakness of our study because it is possible that some fractures that were considered to be nondisplaced were displaced or unstable. Another study limitation is that accuracy (i.e., the probability of a correct test result) was based on one decision threshold (present or absent) with false-positive and false-negative results treated as equally undesirable. When evaluating the accuracy of any given test, the surgeon wants to know the probability of a patient with a positive test result having the condition (the positive predictive value) and the probability of a patient with a negative test result not having the condition (a negative predictive value). These measures are functions of both the intrinsic accuracy of the test and the prevalence of the condition (i.e., pretest probability). Although an advantage of predictive values is that they quantify how well the test result predicts the true status (e.g., displacement or no displacement), knowledge of prevalence is required. We are considering other indices of diagnostic accuracy such as likelihood ratios, which reflect the amount of evidence that a particular test or imaging modality provides in favor of the presence of the condition relative to the absence of the condition. These measures do not depend on an estimate of prevalence although they do have other limitations with respect to interpretation of diagnostic test information³¹.

These findings confirm our practice of routinely using computed tomography scanning of the scaphoid, in addition to radiographs, as a good noninvasive method of determining the presence or absence of displacement in patients who are considering nonoperative treatment of a scaphoid fracture. ?

References

Materials and Methods | Results | Discussion | References

Berna JD, Abaledejo F, Sanchez-Canizares MA, Chavarria G, Pardo A, Pellicer A. Scaphoid fractures and nonunions: a comparison between panoramic radiography and plain X-rays. J Hand Surg [Br].1998;23: 328-31.23328 1998 [PubMed][CrossRef]

Bhat M, McCarthy M, Davis TR. Oni JA, Dawson S. MRI and plain radiography in the assessment of displaced fractures of the waist of the carpal scaphoid. J Bone Joint Surg Br.2004;86: 705-13.86705 2004 [PubMed][CrossRef]

Eddeland A, Eiken O, Hellgren E, Ohlsson NM. Fractures of the scaphoid. Scand J Plast Reconstr Surg.1975;9: 234-9.9234 1975 [PubMed][CrossRef]

Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br.1996;78: 519-29.78519 1996 [PubMed]

Kozin SH. Incidence, mechanism, and natural history of scaphoid fractures. Hand Clin.2001;17: 515-24.17515 2001 [PubMed]

Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. J Am Acad Orthop Surg.2000;8: 225-31.8225 2000 [PubMed]

Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ. Acute fractures of the scaphoid. Treatment by cast immobilisation with the wrist in flexion or extension? J Bone Joint Surg Br.1999;81: 91-2.8191 1999 [CrossRef]

Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br.1991;73: 828-32.73828 1991 [PubMed]

Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br.1989:71: 307-10.71307 1989

Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd, Linscheid RL. Scaphoid malunion. J Hand Surg [Am].1989;14: 679-87.14679 1989 [CrossRef]

Bain GI, Bennett JD, MacDermid JC, Slethaug GP, Richards RS, Roth JH. Measurement of the scaphoid humpback deformity using longitudinal computed tomography: intra- and interobserver variability using various measurement techniques. J Hand Surg [Am].1998;23: 76-81.2376 1998 [CrossRef]

Jonsson K, Jonsson A, Sloth M, Kopylov P, Wingstrand H. CT of the wrist in suspected scaphoid fracture. Acta Radiol.1992;33: 500-1.33500 1992

Moritomo H, Viegas SF, Elder KW, Nakamura K, Dasilva MF, Boyd NL, Patterson RM. Scaphoid nonunions: a 3-dimensional analysis of patterns of deformity. J Hand Surg [Am].2000;25: 520-8.25520 2000 [CrossRef]

Nakamura R, Imaeda T, Horii E, Miura T, Hayakawa N. Analysis of scaphoid fracture displacement by three-dimensional computed tomography. J Hand Surg [Am].1991;16: 485-92.16485 1991 [PubMed][CrossRef]

Plancher KD. Methods of imaging the scaphoid. Hand Clin.2001;17: 703-21.17703 2001 [PubMed]

Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg [Am].1988;13: 182-7.13182 1988 [PubMed][CrossRef]

Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res.1980;149: 90-7.14990 1980

Topper SM. Magnetic resonance imaging of the humpback scaphoid: the technique and a mathematical performance evaluation. Am J Orthop.1999; 28: 639-43.28639 1999 [PubMed]

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics.1977;33: 159-74.33159 1977 [PubMed][CrossRef]

Siegel S, Castellan NJ Jr, editors. Nonparametric statistics for the behavioral sciences. 2nd ed. New York: McGraw-Hill; 1988. p 284-91.284 1988

Altman DG. Why we need confidence intervals. World J Surg.2005;29: 554-6.29554 2005 [PubMed][CrossRef]

Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br.1981;63: 225-30.63225 1981

Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid fractures. J Hand Surg [Br].1988;13: 77-9.1377 1988 [PubMed]

Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid. J Bone Joint Surg Am.1989;71: 354-7.71354 1989

Barton NJ. Twenty questions about scaphoid fractures. J Hand Surg [Br].1992;17: 289-310.17289 1992 [PubMed]

Calandra JJ, Goldner RD, Hardaker WT Jr. Scaphoid fractures: assessment and treatment. Orthopedics.1992;15: 931-7.15931 1992 [PubMed]

Blythe CR. Approximate binomial confidence limits. J Am Stat Assoc.1986; 81: 843-55.81843 1986 [CrossRef]

Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg.1999;33: 423-6.33423 1999 [CrossRef]

Altman DG, Bland JM. Diagnostic tests 2: predictive values. BMJ.1994; 309: 102.309102 1994 [PubMed]

Thorleifsson RJ, Karlsson J, Sigurjonsson K. Fractures of the scaphoid bone. A follow-up study. Arch Orthop Trauma Surg.1984;103: 96-9.10396 1984 [CrossRef]

Dawson JS, Martel AL, Davis TR. Scaphoid blood flow and acute fracture healing. A dynamic MRI study with enhancement with gadolinium. J Bone Joint Surg Br.2001;83: 809-14.83809 2001 [PubMed][CrossRef]

Topics

fracture ; wrist fractures, navicular bone

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

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.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Diagnosis of Scaphoid Fracture Displacement with Radiography and Computed Tomography'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Diagnosis of Scaphoid Fracture Displacement with Radiography and Computed Tomography'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Santiago Lozano-Calderón, Philip Blazar, David Zurakowski, Sang-Gil Lee, David Ring; Diagnosis of Scaphoid Fracture Displacement with Radiography and Computed Tomography. The Journal of Bone & Joint Surgery. 2006 Dec;88(12):2695-2703.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment