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Scaphoid Fractures - epidemiology, diagnosis and treatment.

Jörgsholm, Peter LU (2015) In Lund University, Faculty of Medicine Doctoral Dissertation Series
Abstract (Swedish)
Popular Abstract in Swedish

Båtbenet är ett lite ben i handloven som är väsentlig för handledens funktion. Båtbenet

kan skadas om man ramlar och tar emot med handen, och den skadade är ofta en ung

man, som inte sällan håller på med sport. Man ser ingen felställning på handledens

utsida, men patienten upplever ofta smärta på handledens tummsida. Röntgen har svårt

att påvisa ett brott, eftersom båtbenet ligger djupt inne i handleden och skyms av de

andra handlovsbenen och dessutom måste röntgenstrålarna träffa exakt parallellt med

brottet, för att det ska synas. Båtbensbrott, som ej gipsas direkt, läker ofta inte och kan

då medföra kroniska handledsmärtor. För att... (More)
Popular Abstract in Swedish

Båtbenet är ett lite ben i handloven som är väsentlig för handledens funktion. Båtbenet

kan skadas om man ramlar och tar emot med handen, och den skadade är ofta en ung

man, som inte sällan håller på med sport. Man ser ingen felställning på handledens

utsida, men patienten upplever ofta smärta på handledens tummsida. Röntgen har svårt

att påvisa ett brott, eftersom båtbenet ligger djupt inne i handleden och skyms av de

andra handlovsbenen och dessutom måste röntgenstrålarna träffa exakt parallellt med

brottet, för att det ska synas. Båtbensbrott, som ej gipsas direkt, läker ofta inte och kan

då medföra kroniska handledsmärtor. För att inte riskera och missa att behandla ett

brott, så gipsar man alla personer med misstänkt båtbensbrott, även om den första

röntgenundersökningen inte visar något brott. Efter 2 veckor upprepar man

röntgenundersökningen, och då kan man se ett eventuellt brott eftersom läkning synas

på röntgen. Magnetkamera undersökning (MR) har däremot en stor träffsäkerhet när

det gäller att hitta båtbensbrott, men tyvärr är undersökningen fyra gånger så dyr och

tar lång tid.

Under en fyra-årsperiod (2004-03-01 till 2008-02-28) tillfrågades alla patienter, som

sökte på akutmottagningen vid Skånes universitetssjukhus i Malmö med ett misstänkt

båtbensbrott, om de ville delta i en forskningsstudie. Femhundratjugosex patienter

accepterade att delta och de utgör basen för denna avhandling. Våra två första studier

undersökte, hur mycket bättra MR är jämfört med vanlig röntgen och datoriserad

skiktröntgen (datortomografi, CT). Vi hittade enbart 7 av 10 båtbensbrott med vanlig

röntgen men mer än 9 av 10 båtbensbrott med CT undersökning. Hos barn (<18 år)

syntes enbart hälften av båtbensbrotten på vanlig röntgen. Många andra brott i

handloven hittades enbart med MR. I vår tredje studie gjorde vi titthålskirurgi på

patienter med båtbensbrott, och hittade förvånansvärt många ledbandsskador. Ett av

de absolut viktigaste ledbanden, det mellan båt- och månbenet, var helt av hos var fjärde

patient, och krävde åtgärd med fixering och lång tids gipsbehandling. I den fjärde studie

jämförde vi hur båtbensbrott såg ut på vanlig röntgen och CT, med hur brottet såg ut

när man opererade med titthålsteknik. Vi kunde konstatera att om båtbenet var brutit

med et mindre benfragment i mellan (splittrat brott), då var brottet mycket ostadigt,

och precis detta misstänkas förorsaka långsam eller utebliven läkning. I den sista studien

undersökte vi läkningstiden med röntgen och CT hos patienter med brott på mellersta

delen av båtbenet. Patienterna lottades till antigen att behandlas med gips eller opereras.

Operationen var med titthålsteknik och vi använde en liten special utvecklad skruv till

att drar ihop brottet. De patienter som lottades till gipsbehandling var gipsade i minst

80

6 veckor. Oavsett behandlingsmetod läkte brotten på samma tid, men de patienter som

opererades behövde bara ha gips i 1-2 veckor. Brott med förskjutning och/eller

splittring hade en benägenhet till att läka långsammare.

Sammanfattningsvis kan man säga att patienter med misstänkt båtbensbrott kan ha

många olika skador i handleden, och att vanlig röntgen är dålig på att hitta dessa skador.

En akut MR undersökning kan göra att ett stort antal patienter slipper onödig

gipsbehandling (cirka 250 patienter per år i Malmö med 280 000 invånare). Nittio

procent av alla enkla brott i mellersta delen av båtbenet, vilket är den vanligaste typen,

läker med sex veckors gipsbehandling. Patienter som opereras och enbart skall ha gips

en eller två veckor, bör undersökas med titthålsteknik för att utesluta att det finns en

alvarlig ledbandsskada, som kräver längre tids gipsning. (Less)
Abstract
Abstract The scaphoid is the most commonly fractured carpal bone. The diagnosis is difficult and untreated the

long-term results are poor. Approximately 10% do not unite even if they are treated properly. The aim of this thesis

was to study scaphoid fracture epidemiology, diagnosis and treatment. During a four-year period (2004-03-01 to

2008-02-28) all patients attending the Emergency Department at Skåne University Hospital in Malmö, due to

posttraumatic radial sided wrist pain, were invited to participate in a scaphoid fracture study. The basis for this thesis

consists of the 526 patients (531 wrists) who accepted to participate. First we assessed the diagnostic performance

of... (More)
Abstract The scaphoid is the most commonly fractured carpal bone. The diagnosis is difficult and untreated the

long-term results are poor. Approximately 10% do not unite even if they are treated properly. The aim of this thesis

was to study scaphoid fracture epidemiology, diagnosis and treatment. During a four-year period (2004-03-01 to

2008-02-28) all patients attending the Emergency Department at Skåne University Hospital in Malmö, due to

posttraumatic radial sided wrist pain, were invited to participate in a scaphoid fracture study. The basis for this thesis

consists of the 526 patients (531 wrists) who accepted to participate. First we assessed the diagnostic performance

of radiographs and CT with MRI as the reference standard. In paediatric patients (<18 years) fracture patterns were

studied in relation to skeletal maturity. Using arthroscopy we aimed at identifying factors, which could contribute

to prolonged union or non-union of scaphoid fractures. Finally, we evaluated time-to-union of scaphoid waist

fractures treated conservatively or by arthroscopy-assisted surgery. In the two diagnostic studies on adults and

paediatric patients (paper I-II) 390 wrists were enrolled for MRI investigation. We were able to show that

radiographs and CT scans are less sensitive in diagnosing carpal fractures compared to MRI. In particular

radiographs in paediatric patients had a poor sensitivity when diagnosing carpal fractures; however, CT had a good

sensitivity in finding scaphoid fractures regardless of patient age. We found more concomitant fractures than

previously described, and the most common carpal fracture combination was that of the scaphoid and the capitate.

Skeletal immature patients had a higher proportion of distal scaphoid fractures compared to the skeletal mature. In

the descriptive study using arthroscopy (paper III) 41 scaphoid waist fractures were included. We found, that

scapholunate ligament injuries were common with a complete rupture in 24% of the patients. Paper IV is a joint

venture with Harvard Medical School, Boston, USA. In 58 scaphoid fractures we were able to show, that

radiographic fracture comminution was strongly correlated to displacement and instability as judged by arthroscopy.

Scapholunate ligament injuries and fracture comminution may be of importance when deciding on treatment of

scaphoid fractures. Time-to-union based on CT was assessed in 65 scaphoid waist fractures in paper V. Of the nonor

minimally-displaced fractures 90% united after six weeks of conservative treatment. In a randomized subgroup

of non-displaced fractures we were not able to show any difference in time-to-union between conservatively and

surgically treated patients. The present thesis shows, that MRI is superior in diagnosing carpal fractures in adults

and children. Furthermore we found, that concomitant carpal fractures and ligament injuries are common in

patients with scaphoid fractures. Radial fracture comminution is strongly correlated to fracture instability. Finally

we recognized, that non- or minimally-displaced scaphoid waist fractures are best treated in a cast. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Hove, Leiv, University of Bergen, Norway
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Scaphoid fracture, carpal fracture, paediatric, radiography, CT, MRI, arthroscopy, scapholunate ligament injury, radial comminution, surgical treatment, conservative treatment, fracture union
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
pages
105 pages
publisher
Hand Surgery Research Group
defense location
Lilla Aulan, MFC, Malmö
defense date
2015-01-23 13:00
ISSN
1652-8220
ISBN
978-91-7619-086-9
language
English
LU publication?
yes
id
ee6c3682-1e04-4f00-a7b3-12efa4955e0d (old id 4905093)
date added to LUP
2015-01-07 10:34:13
date last changed
2016-09-19 08:44:50
@phdthesis{ee6c3682-1e04-4f00-a7b3-12efa4955e0d,
  abstract     = {Abstract The scaphoid is the most commonly fractured carpal bone. The diagnosis is difficult and untreated the<br/><br>
long-term results are poor. Approximately 10% do not unite even if they are treated properly. The aim of this thesis<br/><br>
was to study scaphoid fracture epidemiology, diagnosis and treatment. During a four-year period (2004-03-01 to<br/><br>
2008-02-28) all patients attending the Emergency Department at Skåne University Hospital in Malmö, due to<br/><br>
posttraumatic radial sided wrist pain, were invited to participate in a scaphoid fracture study. The basis for this thesis<br/><br>
consists of the 526 patients (531 wrists) who accepted to participate. First we assessed the diagnostic performance<br/><br>
of radiographs and CT with MRI as the reference standard. In paediatric patients (&lt;18 years) fracture patterns were<br/><br>
studied in relation to skeletal maturity. Using arthroscopy we aimed at identifying factors, which could contribute<br/><br>
to prolonged union or non-union of scaphoid fractures. Finally, we evaluated time-to-union of scaphoid waist<br/><br>
fractures treated conservatively or by arthroscopy-assisted surgery. In the two diagnostic studies on adults and<br/><br>
paediatric patients (paper I-II) 390 wrists were enrolled for MRI investigation. We were able to show that<br/><br>
radiographs and CT scans are less sensitive in diagnosing carpal fractures compared to MRI. In particular<br/><br>
radiographs in paediatric patients had a poor sensitivity when diagnosing carpal fractures; however, CT had a good<br/><br>
sensitivity in finding scaphoid fractures regardless of patient age. We found more concomitant fractures than<br/><br>
previously described, and the most common carpal fracture combination was that of the scaphoid and the capitate.<br/><br>
Skeletal immature patients had a higher proportion of distal scaphoid fractures compared to the skeletal mature. In<br/><br>
the descriptive study using arthroscopy (paper III) 41 scaphoid waist fractures were included. We found, that<br/><br>
scapholunate ligament injuries were common with a complete rupture in 24% of the patients. Paper IV is a joint<br/><br>
venture with Harvard Medical School, Boston, USA. In 58 scaphoid fractures we were able to show, that<br/><br>
radiographic fracture comminution was strongly correlated to displacement and instability as judged by arthroscopy.<br/><br>
Scapholunate ligament injuries and fracture comminution may be of importance when deciding on treatment of<br/><br>
scaphoid fractures. Time-to-union based on CT was assessed in 65 scaphoid waist fractures in paper V. Of the nonor<br/><br>
minimally-displaced fractures 90% united after six weeks of conservative treatment. In a randomized subgroup<br/><br>
of non-displaced fractures we were not able to show any difference in time-to-union between conservatively and<br/><br>
surgically treated patients. The present thesis shows, that MRI is superior in diagnosing carpal fractures in adults<br/><br>
and children. Furthermore we found, that concomitant carpal fractures and ligament injuries are common in<br/><br>
patients with scaphoid fractures. Radial fracture comminution is strongly correlated to fracture instability. Finally<br/><br>
we recognized, that non- or minimally-displaced scaphoid waist fractures are best treated in a cast.},
  author       = {Jörgsholm, Peter},
  isbn         = {978-91-7619-086-9},
  issn         = {1652-8220},
  keyword      = {Scaphoid fracture,carpal fracture,paediatric,radiography,CT,MRI,arthroscopy,scapholunate ligament injury,radial comminution,surgical treatment,conservative treatment,fracture union},
  language     = {eng},
  pages        = {105},
  publisher    = {Hand Surgery Research Group},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series},
  title        = {Scaphoid Fractures - epidemiology, diagnosis and treatment.},
  year         = {2015},
}