Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic.Aims
Methods
In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs. In this retrospective cohort study, patients were included if a radiologist diagnosed a fracture on a radiograph requested by the GP from August to October 2019 (control group) or August to October 2020 (research group), on weekdays between 8.30 am and 4.00 pm. The study compared various outcomes between groups, including the length of the initial hospital visit, frequency of hospital visits and medical procedures, extent of imaging, and healthcare expenses.Aims
Methods
The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures. A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis.Aims
Methods
The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT.Aims
Methods
The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk.Aims
Patients and Methods
To evaluate whether an ultra-low-dose CT protocol can diagnose
selected limb fractures as well as conventional CT (C-CT). We prospectively studied 40 consecutive patients with a limb
fracture in whom a CT scan was indicated. These were scanned using
an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography
In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected
cases were compared with 16 C-CT scans matched for age, gender and
type of fracture. Studies were assessed for diagnosis and image
quality. Descriptive and reliability statistics were calculated.
The total effective radiation dose for each scanned site was compared.Aims
Patients and Methods
The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.Objectives
Methods
Current studies on the additional benefit of using computed tomography
(CT) in order to evaluate the surgeons’ agreement on treatment plans
for fracture are inconsistent. This inconsistency can be explained
by a methodological phenomenon called ‘spectrum bias’, defined as
the bias inherent when investigators choose a population lacking
therapeutic uncertainty for evaluation. The aim of the study is
to determine the influence of spectrum bias on the intra-observer
agreement of treatment plans for fractures of the distal radius. Four surgeons evaluated 51 patients with displaced fractures
of the distal radius at four time points: T1 and T2: conventional
radiographs; T3 and T4: radiographs and additional CT scan (radiograph
and CT). Choice of treatment plan (operative or non-operative) and
therapeutic certainty (five-point scale: very uncertain to very
certain) were rated. To determine the influence of spectrum bias,
the intra-observer agreement was analysed, using Kappa statistics,
for each degree of therapeutic certainty. Objectives
Methods
We describe the routine imaging practices of
Level 1 trauma centres for patients with severe pelvic ring fractures, and
the interobserver reliability of the classification systems of these
fractures using plain radiographs and three-dimensional (3D) CT
reconstructions. Clinical and imaging data for 187 adult patients
(139 men and 48 women, mean age 43 years (15 to 101)) with a severe
pelvic ring fracture managed at two Level 1 trauma centres between July
2007 and June 2010 were extracted. Three experienced orthopaedic
surgeons classified the plain radiographs and 3D CT reconstruction
images of 100 patients using the Tile/AO and Young–Burgess systems.
Reliability was compared using kappa statistics. A total of
115 patients (62%) had plain radiographs as well as two-dimensional
(2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films
only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and
eight patients (4.3%) had no available images. The plain radiograph
was limited to an anteroposterior pelvic view. Patients without
imaging, or only plain films, were more severely injured. A total
of 72 patients (39%) were imaged with a pelvic binder Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17)
and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient
for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to
their complexity, the increasing use of early treatment such as
with pelvic binders, and the absence of imaging altogether in important
patient sub-groups, such as those who die early of their injuries. Cite this article:
An MR scan was performed on all patients who presented to our hospital with a clinical diagnosis of a fracture of the proximal femur, but who had no abnormality on plain radiographs. This was a prospective study of 102 consecutive patients over a ten-year period. There were 98 patients who fulfilled our inclusion criteria, of whom 75 were scanned within 48 hours of admission, with an overall mean time between admission and scanning of 2.4 days (0 to 10). A total of 81 patients (83%) had abnormalities detected on MRI; 23 (23%) required operative management. The use of MRI led to the early diagnosis and treatment of occult hip pathology. We recommend that incomplete intertrochanteric fractures are managed non-operatively with protected weight-bearing. The study illustrates the high incidence of fractures which are not apparent on plain radiographs, and shows that MRI is useful when diagnosing other pathology such as malignancy, which may not be apparent on plain films.
