True scaphoid fractures of the wrist are difficult to diagnose in children. In 5–40% of cases, a scaphoid fracture may not be detectable on initial X-ray, some fractures may take up to six weeks to become evident. Since missing a scaphoid fracture may have serious implications, many children with a suspected or “clinical” scaphoid fracture, but normal radiographs, may be over-treated. The purpose of this study was to identify predictors of true scaphoid fractures in children. A retrospective cohort study was performed using electronic medical records for all patients over a two-year period presenting to a tertiary paediatric hospital with hand or wrist injury. Charts were identified by ICD-10 diagnostic codes and reviewed for pre-specified inclusion and exclusion criteria. Patients with either a clinical or true scaphoid fracture were included. When a scaphoid fracture was suspected, but imaging was negative for fracture, the diagnosis of a clinical scaphoid fracture was made. True scaphoid fractures were diagnosed when a fracture was evident on any modality of medical imaging (X-ray, CT, MRI) at any time post-injury. Over the two-year study period, 148 patients (60 scaphoid fractures, 88 non-fractures) met inclusion and exclusion criteria for review. Mean (±SD) age was 13±2 years and 52% were male. The left wrist was injured in 61% of cases. Of the 60 true scaphoid fractures, mean age was 14±2 years, and 69% were male. Fracture location was primarily at the waist (48%) or distal pole (45%) of the scaphoid. Sports were the prevailing mechanism of injury. Six (11%) underwent surgery. Multivariate logistic regression demonstrated that older age, male gender, and right-sided injury were predictors of scaphoid fracture with odds ratios of 1.3 (95% CI: 1.1–1.6, p=0.005), 2.8 (95% CI: 1.3–6, p=0.007), and 2.4 (95% CI: 1.1–5.2, p=0.025). Older age, male gender, and right-sided injury may be predictors of scaphoid fractures in children. Further evidence to support this may enable the formulation of clinical guidelines or rules to reduce the overtreatment of children presenting with a clinical scaphoid fracture

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future.

Cite this article: Bone Jt Open 2021;2(5):301–304.

After a fracture of the distal radius, the bone segments may heal in a suboptimal position. This condition may lead to a reduced hand function, pain and finally osteoarthritis, sometimes requiring corrective surgery. The contralateral unaffected radius is often used as a reference in planning of a corrective osteotomy procedure of a malunited distal radius. In the conventional procedure, radiographs of both the affected radius and the contralateral radius have been used for planning. The 2D nature of radiographs renders them sub-optimal for planning due to overprojection of anatomical structures. Therefore, computer-assisted 3D planning techniques have been developed recently based on CT images of both forearms. The accuracy of using the contralateral forearm for CT based 3D planning the surgery of the affected arm and the optimal strategy for planning have not been studied thoroughly. To estimate the accuracy of the planned repositioning using the contralateral forearm we investigated bilateral symmetry of corresponding radii and ulnae using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography scan of both forearms. The left radius and ulna were segmented to create virtual 3 dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored CT-image of the contralateral side. This allowed estimation of the accuracy by calculation of relative displacements (Δx, Δy, Δz) and rotations (Δψx, Δψy, Δψz) required to align the left bone with the right bone segments as a reference. We also investigated the relationship between longitudinal length differences in radius and ulna and utilised this relationship to arrive at an optimal planning of the length of the affected radius after surgery. Relative differences in displacement and orientation parameters after planning based on the contralateral radius were (Δx, Δy, Δz): −0.81±1.22 mm, −0.01±0.64 mm, and 2.63±2.03 mm; and (Δψx, Δψy, Δψz): 0.13°±1.00°, −0.60°±1.35°, and 0.53°±5.00°. The same parameters for the ulna were (Δx,Δy, Δz): −0.22±0.82 mm, 0.52±0.99 mm, 2.08±2.33 mm; and (Δψx, Δψy, Δψz): −0.56°±0.96°, −0.71°±1.51°, and −2.61°±5.58°. The results also point out that there is a strong linear relationship between absolute length differences (Δz) of the radius and ulna among the individuals. Since we observed substantial length difference of the longitudinal bone axes of both forearms in healthy individuals, including the length difference of the adjacent forearm bones in the planning turned out to be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies. The improved planning markedly reduces length positioning variability, (from 2.9± 2.1 mm to 1.5 ± 0.6 mm). We expect this approach to be valuable for 3-D planning of a corrective distal radius osteotomy. Awareness of the level of bilateral symmetry is important in reconstructive surgery procedures when the contralateral unaffected side is used as a reference for planning and evaluation. Bilateral asymmetry may introduce length errors into this type of preoperative planning that can be reduced by taking into account the concomitant ulnae asymmetry

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.