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Diagnostic value of ultrasound in scaphoid fractures
Printea’in Great Britain
Injury (1991) 22, (5), 397-399
397
Diagnostic value of ultrasound
in scaphoid fractures
T. G. Christiansen, C. Rude, K. K. Lauridsen and 0. M. Christensen Orthopaedic
Department,
Herlev Hospital, Denmark
Diagnostic ultrasound was used in 103 patients with a clinic&y suspeckd fracture of the scaphoid bone in order to achievean early diagnosis. There were 48 women and 55 men aged lC-75 years (mean 31.4 years) k.ded with ultrasound. Qf Ihe patients, 72 were tested within 3 days afkr injuy the remainder between 4 and 42 days. Fracture was confirmed radiologically in 27. We found hat the ultrasound test, applied with a frequmcy of I MHZ and intensity of 0.5 W/cd and 2.0 W/d for 30 s, had a setkfivity of 3 7 per cent and a specificity of 61 per cent. We thus conclude that ul~asound is not suitable for early diagnosis of scaphoid fradure.
Introduction Between 2 per cent and 6 per cent of fractures of the scaphoid bone are not visible on the initial radiographs (Mazet and Hohl, 1963; Leslie and Dickson, 1981; Thorleifsson et al., 1984; Christiansen et al., 1988). The usual procedure is to splint the wrist and take radiographs 10 days later. If fracture is still clinically suspected but not radiologically confirmed, splintage is continued and radiographs are taken after a further IO days. To prevent unnecessary immobilization and to clarify the diagnosis earlier, new methods have been tried: special radiographs, scintigraphy, regional scintimetry, liquid crystal thermography and zonography (Olsen et al., 1983; Bak et al., 1987; Hosie et al., 1987). Most recently, Shenouda and England (1987) and Bedford et al. (1982) have used ultrasound with different intensities and frequencies. The aim of this prospective study was to examine the diagnostic value of ultrasound when scaphoid fracture is suspected, and to establish the most suitable intensity, 0.5 and 2.0 W/cmZ, with application of a I MHz frequency for 30 s.
Patients The study comprised all patients presenting at the casualty department between November 1987 and August 1988 with clinical signs of scaphoid fracture: aching in the anatomical snuffbox, aching on supination/pronation against pressure and reduced grasp strength. (0 1991 Butterworth-Heinemann 0020-1383/91/050397-03
Ltd
At first presentation, all the patients underwent the routine radiological procedure of the department, i.e. radiographs of the wrist taken in the positions of the anteroposterior, lateral, 10” rotated, tilted 15” distally and tilted 30’ distally. A low dorsal plaster splint was applied to the underarm from the elbow to the interphalangeal joint of the thumb. A total of 72 patients was tested within 3 days of the injury, and the remainder between 4 and 42 days after injury. A total of 103 patients was examined, 48 females and 55 males, mean age 3 1 years (range 10-75 years). Fracture was equally distributed between the right and the left wrist.
Methods A Sonopuls 434 ultrasound unit was used with a fixed frequency of 1 MHz, continuous waves, and an intensity of 0.5 respectively 2.0 W/cmZ. The investigator did not know the intensity or the outcome of the radiographic examination. The test was first carried out in water, preboiled to avoid refIection of the air in the water (Figure I.), and then with gel (Figure2). Both wrists were tested. The result was considered positive if the patient could feel any difference between the normal and the injured wrist with regard to aching, pain, paraesthesia, or discomfort when the test was carried out in either or both media.
Results Fracture of the scaphoid bone was radiographically confirmed in five females, mean age 50 years (range 37-67 years), and in 22 males, mean age 26 years (range 12-75 years). Bilateral fracture was not found. One patient had an avulsion, two had fracture through the distal third of the scaphoid bone, 23 in the central part, and one through the proximal third. Four of the 27 fractures were not visible on the initial radiographs and were first diagnosed 11,15,19 and 21 days after the injury. Ultrasound was negative in two and positive in the other two. As shown in Fipre3, 17 of the 27 patients with
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
398
Figure 1. Illustration
Figure 2. Illustration of the test carried out with gel.
of the test carried out in water.
Table I. Relation between sex and outcome of the ultrasound test in patients with radiologically confirmed fracture of the scaphoid bone
Number of patients
0
Ultrasound positive Postive test Negative test Total
O 1 2 3.4
5
5 6 7Days
1<<2
>2 Weeks
Days/weeks from injury Figure 3. Number of days/weeks from injury to ultrasonic test in patients with fracture of the scaphoid bone.
result. There was no fractures had a negative ultrasound difference in the test results of males and females (TableI). No definite correlation was found between the test result, the test medium, and the intensity (i%bleII). Of the 76 patients without radiological confirmation of fracture, the ultrasound test was false-positive in 30 (TableIII). Sensitivity and specificity were found to be 37 per cent and 61 per cent, respectively.
Discussion Several studies (Mazet and Hohl, 1963; Leslie and Dickson, 1981; Thorleifsson et al., 1984; Christiansen et al., 1988) have shown that scaphoid fracture is later confirmed
Total
Females
Males
2 3 5
14
10 17
22
27
8
radiologically in only a-few of the patients presenting with clinical signs but with normal initial radiographs. Early diagnosis is therefore desirable, if unnecessary immobilization and monitoring are to be avoided. Bedford et al. (1982) applied ultrasound with an intensity of 0.5-1.5 W/cm2 and a frequency of I MHz, and only 3 per cent of their results were false-negative. Shenouda and England (1987) applied an intensity of 3 W/cm” and a frequency of 3 MHz, and they found a positive correlation between ultrasound and radiographs in 93 per cent of their patients. Like Bedford et al. (1982), we used a water-based coupling medium and, like Shenouda et al. (x987), water as the medium. Shenouda et al. (1987) applied ultrasound over SOS, whereas no time is given by Bedford et al. (1982). In our study we used an application time of 30s, in order to eliminate the risk of side-effects (thermal damage and blockage of the blood circulation (Dyson and Pond, 1973)), and this may explain our results. We expected the variations of pressure in the tissues, presumably the cause of the subjective feeling of aching, tingling, or discomfort, to occur within 30 s, and the positive test results, in fact, appeared within a few seconds. Most of the patients in our study were tested within the first 3 days of injury, whereas Bedford et al. (1982) and Shenouda et al. (1987) first tested their patients 2 weeks and 3 weeks after the injury. None of the patients with an initial negative ultrasound test later came out with a positive test. In our sample, the ultrasound test had a sensitivity of 37 per cent and a specificity of 61 per cent, and we therefore conclude that the ultrasound test, as carried out in the present study, is not suitable for early diagnosis of scaphoid fractures.
399
Christiansen et al.: Diagnostic value of ultrasound in scaphoid fractures Table II. Outcome of the ultrasound between injury and the test
test in 27 patients with radiologically
confirmed fracture indicating the patient and the time interval
No. of days from injury to ultrasound
test
Intensity Medium _
W/cm2
Water
i 0.5
0
1
2
3
4
DB
CH
BF
MB
-
BM
-
CH
BF cx BF BF 2 CD AP
AA 3 Vo AU BS BV 4 7
2.0 ( 0.5 Gel 2.0 Total positive test
1 -
Negative test
Total negative test No. of patients with radiological confirmation of fracture
6
7
c.2 Weeks
> 2 Weeks
0 1
CH 1 zo AB cc cu 4 5
2 4
Radiological staph id fracture Ultrasound positive Ultrasound negative Total
-
AA CQ
Table III. Outcome of the ultrasound test in patients radiologically confirmed scaphoid fracture and in patients normal radiographs
0 BO BR
BJ
2 2
1 1
with with
Normal radiograph
Total
10
30
40
17
46
63
27
76
103
References Bak B., Bruun F., Christensen J. et al. (1987) Diagnosticering af scaphoideum frakturer. Ugeskr. Laeger 49, 1327. Bedford A. F., Glasgow M. M. and Wilson J. N. (1982) Ultrasonic assessment of fractures and its use in the diagnosis of the suspected scaphoid fracture. Itijury 14, 180. Christiansen T. G., Nielsen R. and Christensen 0. M. (1988) Helingstid for OS scaphoideum manus fraktur. Ugeskr. Laeger 150,538.
5
Total
4
-
-
-
-
AM
0 CZ
AF 1 -
1 1
0 1
1 AN AX
-
3
Go
6
Go 1 Al
5 10 17
2 3
1 2
17 27
Dyson M. and Pond J. B. (1973) Biological effects of therapeutic ultrasound. Reumatol. Rehab. 12, 209. Hosie K. B., Wardrope J., Cosby A. C. et al. (1987) Liquid crystal thermography in the diagnosis of scaphoid fractures. Arch. Emerg. Med. 4, 117. Jorgensen T. R., Andersen J. H., Thommesen P. et al. (1979) Scanning and radiology of the carpal scaphoid bone. Acfa Otthop. Stand. 50,663. Leslie I. J. and Dickson R. A. (1981) The fractured carpal scaphoid. 1. Boneloinf Swrg. 63B, 225. Lindequist S. and Larsen C. F. (1986) Radiography of the carpal scaphoid. Acfa Radiol. Diag. 2 7, 97. Mazet R. and Hohl M. (1963) Fractures of the carpal navicuiar. 1. Bone]oinf Surg. 45A, 82. Olsen N., Schousen P., Dirksen H. et al. (1983) Regional scintimetry in schaphoid fractures. Acfa Orthop. Stand. 54,380. Shenouda N. A. and England J. P. S. (1987) Ultrasound in the diagnosis of scaphoid fractures. 1. Hand Srrrg. 12, 43. Thorleifsson R., Karlsson J. and Sigurjonsson K. (1984) Fractures of the scaphoid bone. Arch. Orfhop. Trauma Surg. 103, 96. Paper accepted
5 December
1990.
Requesfs for reprints should be addressed fo: Thorbjom Christiansen, Robjergvej 5, 3200 Helsinge, Denmark.
Gantzel
Injury (1991) 22, (5), 397-399
397
Diagnostic value of ultrasound
in scaphoid fractures
T. G. Christiansen, C. Rude, K. K. Lauridsen and 0. M. Christensen Orthopaedic
Department,
Herlev Hospital, Denmark
Diagnostic ultrasound was used in 103 patients with a clinic&y suspeckd fracture of the scaphoid bone in order to achievean early diagnosis. There were 48 women and 55 men aged lC-75 years (mean 31.4 years) k.ded with ultrasound. Qf Ihe patients, 72 were tested within 3 days afkr injuy the remainder between 4 and 42 days. Fracture was confirmed radiologically in 27. We found hat the ultrasound test, applied with a frequmcy of I MHZ and intensity of 0.5 W/cd and 2.0 W/d for 30 s, had a setkfivity of 3 7 per cent and a specificity of 61 per cent. We thus conclude that ul~asound is not suitable for early diagnosis of scaphoid fradure.
Introduction Between 2 per cent and 6 per cent of fractures of the scaphoid bone are not visible on the initial radiographs (Mazet and Hohl, 1963; Leslie and Dickson, 1981; Thorleifsson et al., 1984; Christiansen et al., 1988). The usual procedure is to splint the wrist and take radiographs 10 days later. If fracture is still clinically suspected but not radiologically confirmed, splintage is continued and radiographs are taken after a further IO days. To prevent unnecessary immobilization and to clarify the diagnosis earlier, new methods have been tried: special radiographs, scintigraphy, regional scintimetry, liquid crystal thermography and zonography (Olsen et al., 1983; Bak et al., 1987; Hosie et al., 1987). Most recently, Shenouda and England (1987) and Bedford et al. (1982) have used ultrasound with different intensities and frequencies. The aim of this prospective study was to examine the diagnostic value of ultrasound when scaphoid fracture is suspected, and to establish the most suitable intensity, 0.5 and 2.0 W/cmZ, with application of a I MHz frequency for 30 s.
Patients The study comprised all patients presenting at the casualty department between November 1987 and August 1988 with clinical signs of scaphoid fracture: aching in the anatomical snuffbox, aching on supination/pronation against pressure and reduced grasp strength. (0 1991 Butterworth-Heinemann 0020-1383/91/050397-03
Ltd
At first presentation, all the patients underwent the routine radiological procedure of the department, i.e. radiographs of the wrist taken in the positions of the anteroposterior, lateral, 10” rotated, tilted 15” distally and tilted 30’ distally. A low dorsal plaster splint was applied to the underarm from the elbow to the interphalangeal joint of the thumb. A total of 72 patients was tested within 3 days of the injury, and the remainder between 4 and 42 days after injury. A total of 103 patients was examined, 48 females and 55 males, mean age 3 1 years (range 10-75 years). Fracture was equally distributed between the right and the left wrist.
Methods A Sonopuls 434 ultrasound unit was used with a fixed frequency of 1 MHz, continuous waves, and an intensity of 0.5 respectively 2.0 W/cmZ. The investigator did not know the intensity or the outcome of the radiographic examination. The test was first carried out in water, preboiled to avoid refIection of the air in the water (Figure I.), and then with gel (Figure2). Both wrists were tested. The result was considered positive if the patient could feel any difference between the normal and the injured wrist with regard to aching, pain, paraesthesia, or discomfort when the test was carried out in either or both media.
Results Fracture of the scaphoid bone was radiographically confirmed in five females, mean age 50 years (range 37-67 years), and in 22 males, mean age 26 years (range 12-75 years). Bilateral fracture was not found. One patient had an avulsion, two had fracture through the distal third of the scaphoid bone, 23 in the central part, and one through the proximal third. Four of the 27 fractures were not visible on the initial radiographs and were first diagnosed 11,15,19 and 21 days after the injury. Ultrasound was negative in two and positive in the other two. As shown in Fipre3, 17 of the 27 patients with
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
398
Figure 1. Illustration
Figure 2. Illustration of the test carried out with gel.
of the test carried out in water.
Table I. Relation between sex and outcome of the ultrasound test in patients with radiologically confirmed fracture of the scaphoid bone
Number of patients
0
Ultrasound positive Postive test Negative test Total
O 1 2 3.4
5
5 6 7Days
1<<2
>2 Weeks
Days/weeks from injury Figure 3. Number of days/weeks from injury to ultrasonic test in patients with fracture of the scaphoid bone.
result. There was no fractures had a negative ultrasound difference in the test results of males and females (TableI). No definite correlation was found between the test result, the test medium, and the intensity (i%bleII). Of the 76 patients without radiological confirmation of fracture, the ultrasound test was false-positive in 30 (TableIII). Sensitivity and specificity were found to be 37 per cent and 61 per cent, respectively.
Discussion Several studies (Mazet and Hohl, 1963; Leslie and Dickson, 1981; Thorleifsson et al., 1984; Christiansen et al., 1988) have shown that scaphoid fracture is later confirmed
Total
Females
Males
2 3 5
14
10 17
22
27
8
radiologically in only a-few of the patients presenting with clinical signs but with normal initial radiographs. Early diagnosis is therefore desirable, if unnecessary immobilization and monitoring are to be avoided. Bedford et al. (1982) applied ultrasound with an intensity of 0.5-1.5 W/cm2 and a frequency of I MHz, and only 3 per cent of their results were false-negative. Shenouda and England (1987) applied an intensity of 3 W/cm” and a frequency of 3 MHz, and they found a positive correlation between ultrasound and radiographs in 93 per cent of their patients. Like Bedford et al. (1982), we used a water-based coupling medium and, like Shenouda et al. (x987), water as the medium. Shenouda et al. (1987) applied ultrasound over SOS, whereas no time is given by Bedford et al. (1982). In our study we used an application time of 30s, in order to eliminate the risk of side-effects (thermal damage and blockage of the blood circulation (Dyson and Pond, 1973)), and this may explain our results. We expected the variations of pressure in the tissues, presumably the cause of the subjective feeling of aching, tingling, or discomfort, to occur within 30 s, and the positive test results, in fact, appeared within a few seconds. Most of the patients in our study were tested within the first 3 days of injury, whereas Bedford et al. (1982) and Shenouda et al. (1987) first tested their patients 2 weeks and 3 weeks after the injury. None of the patients with an initial negative ultrasound test later came out with a positive test. In our sample, the ultrasound test had a sensitivity of 37 per cent and a specificity of 61 per cent, and we therefore conclude that the ultrasound test, as carried out in the present study, is not suitable for early diagnosis of scaphoid fractures.
399
Christiansen et al.: Diagnostic value of ultrasound in scaphoid fractures Table II. Outcome of the ultrasound between injury and the test
test in 27 patients with radiologically
confirmed fracture indicating the patient and the time interval
No. of days from injury to ultrasound
test
Intensity Medium _
W/cm2
Water
i 0.5
0
1
2
3
4
DB
CH
BF
MB
-
BM
-
CH
BF cx BF BF 2 CD AP
AA 3 Vo AU BS BV 4 7
2.0 ( 0.5 Gel 2.0 Total positive test
1 -
Negative test
Total negative test No. of patients with radiological confirmation of fracture
6
7
c.2 Weeks
> 2 Weeks
0 1
CH 1 zo AB cc cu 4 5
2 4
Radiological staph id fracture Ultrasound positive Ultrasound negative Total
-
AA CQ
Table III. Outcome of the ultrasound test in patients radiologically confirmed scaphoid fracture and in patients normal radiographs
0 BO BR
BJ
2 2
1 1
with with
Normal radiograph
Total
10
30
40
17
46
63
27
76
103
References Bak B., Bruun F., Christensen J. et al. (1987) Diagnosticering af scaphoideum frakturer. Ugeskr. Laeger 49, 1327. Bedford A. F., Glasgow M. M. and Wilson J. N. (1982) Ultrasonic assessment of fractures and its use in the diagnosis of the suspected scaphoid fracture. Itijury 14, 180. Christiansen T. G., Nielsen R. and Christensen 0. M. (1988) Helingstid for OS scaphoideum manus fraktur. Ugeskr. Laeger 150,538.
5
Total
4
-
-
-
-
AM
0 CZ
AF 1 -
1 1
0 1
1 AN AX
-
3
Go
6
Go 1 Al
5 10 17
2 3
1 2
17 27
Dyson M. and Pond J. B. (1973) Biological effects of therapeutic ultrasound. Reumatol. Rehab. 12, 209. Hosie K. B., Wardrope J., Cosby A. C. et al. (1987) Liquid crystal thermography in the diagnosis of scaphoid fractures. Arch. Emerg. Med. 4, 117. Jorgensen T. R., Andersen J. H., Thommesen P. et al. (1979) Scanning and radiology of the carpal scaphoid bone. Acfa Otthop. Stand. 50,663. Leslie I. J. and Dickson R. A. (1981) The fractured carpal scaphoid. 1. Boneloinf Swrg. 63B, 225. Lindequist S. and Larsen C. F. (1986) Radiography of the carpal scaphoid. Acfa Radiol. Diag. 2 7, 97. Mazet R. and Hohl M. (1963) Fractures of the carpal navicuiar. 1. Bone]oinf Surg. 45A, 82. Olsen N., Schousen P., Dirksen H. et al. (1983) Regional scintimetry in schaphoid fractures. Acfa Orthop. Stand. 54,380. Shenouda N. A. and England J. P. S. (1987) Ultrasound in the diagnosis of scaphoid fractures. 1. Hand Srrrg. 12, 43. Thorleifsson R., Karlsson J. and Sigurjonsson K. (1984) Fractures of the scaphoid bone. Arch. Orfhop. Trauma Surg. 103, 96. Paper accepted
5 December
1990.
Requesfs for reprints should be addressed fo: Thorbjom Christiansen, Robjergvej 5, 3200 Helsinge, Denmark.
Gantzel