from ECU 249.8 to ECU 166.7 in Strategy C. For thisreason, overall costs between strategies differ marginally(ECU 273.7, ECU 317.7 and ECU 316.1 in Strategies A, Band C, respectively).

The average period of immobilization is longest in Strategy B (8.6 wk) and shortest in Strategy A (5.7 wk). Theprolonged period of immobilization in Strategy C (6.9 wk)can be explained by the optimal sensitivity of the bonescan, leading to 12 wk of immobilization of 44% of patients,i.e., those with a scaphoid fracture.

Since it is generally accepted that simple, noninvasiveand cheap methods are initially preferred, the optimaltiming of bone scintigraphy becomes clinically relevant. Asour analysis suggests, the benefit of performing bone scintigraphy is greatest for patients in whom initial radiographyyielded a nondiagnostic or a normal test outcome.

Analysis of the incremental costs incurred to save onenonunion showed that the use of bone scintigraphy in patients with negative initial radiographs costs approximatelyone-third of the price of using repeated radiography up to 6wk after injury, and is therefore more cost-effective. Im

plementation of additional carpal box radiography (17)may improve the sensitivity of the radiographs, leading toa better cost-effective option, but this needs further clinicalevaluation before it can be included in a cost-effectiveness

analysis.In conclusion, this cost-effectiveness analysis suggests

that, at present, the most efficient approach appears to bea combination of first-day scaphoid radiography and bone

scintigraphy. The initial investigation should be scaphoidradiography. In case of a recognized scaphoid fracture, thepatient should be treated in a plaster cast for 12 wk. If theinitial radiographs are negative or inconclusive, the patientis immobilized and bone scintigraphy is indicated. A normal bone scan rules out scaphoid fractures and plaster

treatment may be discontinued. In patients with a positivebone scan, we advocate continuation of treatment for aperiod of 12 wk.

REFERENCES

1. Eddeland A, Eiken O, Hellgren E, Ohlsson N. Fractures of the scaphoid.Scarni J Plast Reconstr Surg 1975;9:234-239.

2. Langhoff O, Andersen JL. Consequences of late immobilization of scaphoidfractures. / Hand Surg 1988;13B:77-79.

3. Dias JJ, Brinkel IJ, Finlay DBL. Patterns of union in fractures of the waistof the scaphoid. J Bone Joint Surg 1989;71B:307-310.

4. Leslie IJ, Dickson KA. The fractured carpal scaphoid. Natural history andfactors influencing outcome. J Bone Joint Surg 1981;63B:225-230.

5. Dias JJ, Thompson J, Barton NJ, Gregg PJ. Suspected scaphoid fractures.The value of radiographs. J Bone Joint Surg 1990;72-B:98-101.

6. Duncan DS, Thurston AJ. Clinical fracture of the carpal scaphoid—anillusionary diagnosis. / Hand Surg 1985;10-B:375-377.

7. Schmidt CH, Deininger HK. Die Maskierte fraktur im röntgenbildund ihrnachweis durch die skelettszintigraphie. Radiologe 1985;25:104-107.

8. Tiel-van Buul MMC, van Beek EJR, Bonn JJJ, Gubler FM, BroekhuizenAH. The value of radiographs and bone scintigraphy in suspected scaphoidfracture—a statistical analysis. / Hand Surg ¡Brj1993;18:403-406.

9. Tiel-van Buul MMC, van Beek EJR, Broekhuizen AH, Nooitgedacht EA,Davids HP, Bakker AJ. Diagnosing scaphoid fractures: radiographs cannotbe used as a gold standard. Injury 1992;23:77-79.

10. Ganel A, Engel J, Oster Z, Farine I. Bone scanning in the assessment offracture of the scaphoid. J Hand Surg 1979;4:540-543.

11. Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J NucíMed 1979;20:1227-1231.

12. Rolfe EB, Garvie NW, Kahn MA, Ackery DM. Isotope bone imaging insuspected scaphoid trauma. BrJ Radial 1981;54:762-767.

13. Tiel-van Buul MMC, van Beek EJR, Broekhuizen AH, Bakker AJ, Bos KE,

van Royen EA. Radiography and scintigraphy of suspected scaphoid fracture—along-term study in 160patients./ßoneJiSu/g/Br/ 1993;75B:61-65.

14. Young MRA, Lowry JH, Laird JD, Ferguson WR. Technetium-99m-MDPbone scanning of injuries of the carpal scaphoid. Injury 1988;19:14-17.

15. Sy WM, Bay R, CámaraA. Hand images. / NucíMed 1977;18:419-424.16. Critchfield GC, Willard KE. Probablistic analysis of decision trees using

Monte Carlo simulation. Med DecísMaking 1986;6:85-92.17. Tiel-van Buul MMC, van Beek EJR, Dijkstra PF, Bakker AJ, Griffioen

FMM, Broekhuizen AH. Radiography of the carpal scaphoid—experimental evaluation of the Carpal Box and first clinical results. Invest Radiai1992;27:954-959.

EDITORIAL

Diagnosis of Scaphoid Fractures: The Role of NuclearMedicine

The scaphoid is the most commonly fractured carpal bone; ac

counting for almost 90% of all carpalfractures in many series (1,2). Fallingon the outstretched hand is the mostcommon mechanism of injury (1,3),and pain in the anatomic "snuffbox"

is the classical clinical symptom (4).

Received Sept. 2,1994; accepted Oct. 10,1994.For correspondence or reprints contact: Lawrence

Holder, MD, University of Maryland Medical Center,Department of Radiology, Division of Nuclear Medicine, 22 South Greene Street, Baltimore, MD 21201-

1595.

The scaphoid acts as a multifunctionallink between the proximal and distalcarpal rows. Major alterations in thekinematics of the wrist occur whenfractures of this carpal bone do notheal properly (5,6). This accounts forthe continued interest in early, accurate diagnosis, cost-effective manage

ment and therapeutic algorithms.In this issue of the Journal, Tiel-van

Buul et al. present a cost-based anal

ysis of several different theoreticaldiagnostic management strategies for

patients with suspected scaphoid fracture (7). We believe that their mainconclusion implying that routine"... use of bone scintigraphy in the

diagnostic management of scaphoidfractures is. . . cost effective" is not

justified and is based on incompleteand biased assumptions, a selectiveuse of the literature and a failure toincorporate significant knowledge regarding the anatomy, physiology, bio-

mechanics and natural history ofscaphoid fracture (5). In this editorial,

48 The Journal of Nuclear Medicine •Vol. 36 •No. 1 •January 1995

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we review some of these underlyingfactors and indicate their importancein valid outcome and cost-effective

analyses.The mechanism of injury (applied

forces) coupled with the irregularshape of the scaphoid and the alignment of the scaphoid across the planeof motion of the mid-carpal joint re

sults in almost two of three scaphoidfractures involving the waist, with almost half being transversely oriented(1). Approximately 15% of fracturesoccur in the tuberosity, 10% in thedistal pole and 5% in the proximal pole(1 ). In this same series and others (8),healing has been related to the location of the fracture. Fractures of thetuberosity, distal pole and horizontaloblique fractures of the waist almostuniversally unite, with nonunion occurring in proximal pole, vertical oblique waist and transverse waist fractures. The rate of union, thedevelopment of AVN and the development of nonunion and progressiveosteoarthritis are also related to thecombined extraosseous and in-

traosseous blood supply of the scaphoid. This has been recently reviewed(5). Approximately 30% of fracturesof the middle third and nearly 100% ofthose of the proximal fifth of thescaphoid are associated with osteone-crosis of the proximal pole. These bi-

omechanical and vascular considerations suggest that "lumping" of all

scaphoid fractures, as is done in Tiel-

van Buul et al. (7), is an inadequatestratification for outcomes research orcost effectiveness analysis.

There is no doubt that late immobilization of scaphoid fractures, definedas a delay in treatment of greater thanfour weeks, significantly increases thefrequency of nonunion, which was45% (10 out of 22) in one series compared with 5% (6 out of 118) in patients who were immobilized on theday of injury (8). Importantly, in 36patients in this series in whom immobilization was delayed from 1 to 28days, there were no cases of nonunion. The 5% nonunion rate in thosepatients immediately treated emphasizes that factors such as the level ofthe fracture, the degree of comminu

tion, the degree of collapse and thepresence of AVN are more significantthan a delay of 1-28 days. Tiel-van

Buul et al. also say that in patientswhere the diagnosis was not immediately made, a nonunion rate of up to88% was reported (their reference #2,(8)) (7). That 88% represents datawhich Langhoff (8) quotes from astudy by Eddeland in 1975, in which88% of 42 fractures which had a delayin treatment of greater than 4 wk develop nonunion (9). Tiel-van Buul et

al. did not report that Eddeland, in thesame study, had 11 patients treatedwith a delay of 1-4 wk, none of which

developed nonunion. Therefore, webelieve Tiel-van Buul et al. use of the

term immediate is misleading anddoes not provide a rationale for routine immediate radionuclide bone imaging in patients with initially normalradiographs.

Is the early diagnosis of scaphoidfracture as difficult or as unreliable assuggested by Tiel-van Buul et al? Arethe consequences of even a 28-day de

lay in immobilization significant? Wedo not think so. The patient population and results described in the current article (7) have been previouslyreported in more detail (10). Seventypatients with hot spots in the scaphoidwere considered to have fractureswith 41 reported to have initially positive radiographs for a sensitivity of59%. Cumulative sensitivities after 2and 6 wk radiographs were 71% and80%. Other authors (1,11,12) reportmuch higher sensitivities for initialand follow-up plain radiographie diag

nosis. Leslie, for example, evaluated222 consecutive fresh fractures. Ninety-eight percent were visible on first

radiographs, with the remaining 2%becoming visible during the first 2week of treatment in a cast (1 ). Careful reading of those authors quoted byTiel-van Buul et al. as suggesting

lower sensitivities on initial radiographs (12,13) is revealing. Dias et al.(13), did not describe what threeviews constituted their x-ray examina

tion. They did not indicate the numberpresent, or sensitivity or specificity ofdiagnosis of fractures in their 60 setsof initial and interval radiographs

which they presented to different observers for evaluation. Current practice (4) emphasizes a skilled physicalexamination, which usually can pinpoint the scaphoid as the problem;eliminating many patients with normalradiographs whose bone scans showhot spots in the distal radius or othercarpal bones (67% in Tiel-van Buul etal. series) (70). The initial radio-

graphic examination described byTiel-van Buul et al. in their supporting

articles (10,15,16) seem to be modifiedRusse views, which were initially described in 1960 (3). Tiel-van Buul et

al. used a PA with closed fist, a PAoblique supinated, a PA oblique pr-

onated and a true lateral view. Thestandard examination in the U.S. today is described by Totty et al. in the"Traumatized Hand and Wrist" (17),

Rogers, in Skeletal Radiology (18),and in most standard orthopedictrauma texts (79). It includes a PAwith hand and wrist flat, oblique 45°

supinated (from the palm down position), lateral and a PA with as muchulnar deviation as possible with thecentral beam angled 15°-20°towardsthe elbow. Rogers states that, "many

authorities believe that the posteroan-

terior projection with ulnar deviationof the hand and wrist should be obtained for evaluation of every traumatized wrist" (78). The absence of the

navicular fat stripe (20) or the presence of soft-tissue swelling on the dor-

sum of the wrist (27) have been described as findings which shouldsuggest possible scaphoid fracture atthe time of initial injury and lead to theperformance of additional plain radiographs such as PA and ulnar deviationviews with a clenched fist if the routine series is normal. Radiographie series, incomplete by our current standards, may account for the lower rateof detection on plain radiography usedby Tiel-van Buul et al. in their schema

(7). That lower rate would contributeto an analysis based on incorrect assumptions, and therefore result in incorrect conclusions.

Although there is still some controversy (1,4) about the need for andtype of immobilization necessarywhen the initial complete plain film

Diagnosisof ScaploidFractures•Holderet al. 49

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examination is normal (1), most practitioners use a short or long arm thumbspica cast. After 10 days to 2 wk, thecast is removed and another physicalexamination is performed. If painand/or tenderness persists, a secondx-ray series is usually done. If still

negative, other imaging studies maybe warranted. Diagnostic aggressiveness after 2 wk of immobilization ispatient-lifestyle and patient-symptom

dependent. More severe pain in a professional basketball player may warrant radionuclide bone scanning ormultiplanar CT scanning, while milderpain in a sedentary, retired patientmay call for symptomatic therapy andanother 2 wk of immobilization. Asplint is often substituted for the cast(4). There are no controlled studies inthe literature that demonstrate any superiority of MRI to CT scanning.Complex-motion plain-radiographic

tomography is an excellent way to image the scaphoid, but most of theseaging units have given way to CTscanners.

In the small number of patients inwhom further imaging workup may beindicated, we prefer to use radionuclide bone imaging to document ascaphoid fracture or to find anotherosseous source of pain referred to thesnuffbox area. The technique (22-24)

and the sensitivity (2,25,26) of radionuclide bone imaging is well established. When x-rays are normal after 2

to 4 wk, the likelihood of fracture islow so that scanning is done primarilyto detect a metabolically active bonebruise-type of lesion in the scaphoid,

to locate another abnormal focus ofactivity which can aid the referringphysician in therapy planning, or toexclude a more serious occult injuryin a high level athlete. Even Tiel-van

Buul et al. suggest a very high specificity (98%) of the scaphoid hot spotfor the presence of fracture; this isbased upon more of their own work(14,15) and has not been confirmed byothers (25,29).

Tiel-van Buul et al. (7,10) did not

provide the demographics of the 160patients they studied. In that study,they used a hot spot on scan as thestandard of reference for the presence

of a fracture, and therefore reported aprevalence of 44%; which they thenused for their clairvoyant strategy inthis paper (7). It is well-known that

prevalence is highly dependent uponthe patient population studied. Fallingon the outstretched hand typically results in scaphoid fracture in youngadults aged 15-40. Older women usu

ally suffer Colles fracture of the distalradius and children often have epiph-

yseal plate fractures or torus fracturesof the distal radius. The prevalence ofscaphoid fracture in patients with painin the scaphoid region who are referred for radiographs from our emergency room is less than 5%. Thesepatients are not routinely seen by specialized hand surgeons prior to radiography.

Radionuclide bone imaging is indeed accurate for the diagnosis of occult fracture. It is noninvasive andconvenient for patients. However, ithas not been established that its routine use in all patients with initiallynegative radiograph is cost-effective.

Lawrence E. HolderMichael E. MulliganThomas E. Gillespie

University of MarylandSchool of Medicine

Baltimore, Maryland

REFERENCES

1. Leslie IJ, Dickson RA. The fractured carpalscaphoid. Natural history and factors influencing outcome. J Bone Joint Surg 1981;63B:225-

230.2. Rolfe EB, Garvie NW, Kahn MA, Ackery DM.

Isotope bone imaging in suspected scaphoidtrauma. BrJ Radial 1981;54:762-767.

3. Russe O. Fracture of the carpal navicular. JBone Joint Surg 1960;42A:759-768.

4. Amadio PC, Taleisnik J. Fractures of the carpalbones. In: Green DP, ed. Operative hand surgery, 3rd edition. New York: Churchill Livingstone, 1993:799-860.

5. Gelberman RH, Wolock BS, Siegel DB. Fractures and non-union of the carpal scaphoid.Current concepts review. J Bone Joint Surg1989;71A: 1560-1565.

6. Fisk GR. An overview of the wrist. Clin Orthop1980;149:137-144.

7. Tiel-van Buul MMC, Broekhuizen TH, vanBeek EJ, et al. Which strategy for the diagnostic management of suspected scaphoid fracture?A cost-effectiveness analysis. J NucíMed 1994;35:45-48.

8. Langhoff O, Andersen JL. Consequences oflate immobilization of scaphoid fractures. JHand Surg 1988;13B:77-79.

9. Eddeland A, Eiken 0, Hellgren E, Ohlsson N.

Fracture of the scaphoid. Scand J Plast Recon-strSurg 1975:9:234-239.

10. Tiel-van Buul MMC, van Beek EJR, Broekhui

zen AH, Bakker AJ, Bos KE, van Royen EA.Radiography and scintigraphy of suspectedscaphoid fracture—along-term study in 160 patients. J Bone Joint Surg (Br) 1993;75B:61-65.

11. Dickson RA, Leslie IJ. Conservative treatmentof the fractured scaphoid. In: Razemon JP, FiskGR, eds. The wrist. Edinburg: Churchill Livingstone, 1988:80-87.

12. Duncan DS, Thurston AJ. Clinical fracture ofthe carpal scaphoid—an illusionary diagnosis. JHand Surg 1985;10B:375-377.

13. Dias JJ, Thompson J, Barton NJ, Gregg PJ.Suspected scaphoid fractures. The value of radiographs. J Bone Joint Surg 1990;72B:98-101.

14. Tiel-van Buul MMC, van Beek EJR, Broekhui

zen AH, Nooitgedacht EA, Davids HP, BakkerAJ. Diagnosing scaphoid fractures: radiographscannot be used as a gold standard. Injury 1992;23:77-79.

15. Tiel-van Buul MM, van Beek EJR, Dijkstra PF,

et al. Significance of a hot spot on the bone scanafter carpal injury—evaluation by computed tomography. EwJ NucíMed 1993;20:159-164.

16. Tiel-van Buul MM, van Beek EJR, Borm JJJ, et

al. The value of radiographs and bone scintigraphy in suspected scaphoid fracture. A statistical analysis. J Hand Surg 1993;18B:403-406.

17. Totty WG, Gilula LA. Imaging of the hand andwrist. In: Gilula LA, ed. The traumatized handand wrist. Radiographie and anatomic correlation. Philadelphia: W.B. Saunders, 1990;1-18.

18. Rogers LF. Radiology of skeletal trauma, 2nded. New York: Churchill Livingstone, 1992:839, 874, 889.

19. Ruby L. Fractures and dislocations of the carpus. In: Browner BD, Jupiter JB, Levine AM,et al., eds. Skeletal trauma. Philadelphia: W.B.Saunders, 1992:1025-1062.

20. Terry DW, Ramin JE. The navicular fat stripe:a useful roentgen feature for evaluating wristtrauma. AJR 1975;124:25-28.

21. Carver RA, Barrington NA. Soft-tissue changes

accompanying recent scaphoid injuries. ClinRadial 1985;36:423-425.

22. Maurer AH, Chen DC, Camargo EE, et al. Utility of three-phase skeletal scintigraphy in sus

pected osteomyelitis: concise communication./NucíMed 1981;22:941-949.

23. Maurer AH. Nuclear medicine in the evaluationofthehandandwnsLHand Ones 1991;183-200.

24. Patel N, Collier BD, Carrera GF, et al. Highresolution bone scintigraphy of the adult wrist.Clin NucíMed 1992;17:449-453.

25. Ganel A, Engel J, Oster Z, Farine I. Bone scanning in the assessment of fracture of the scaphoid. J Hand Surg 1979;4:540-543.

26. Matin P. The appearance of bone scans following fractures, including immediate and long-term studies. J NucíMed 1979;20:1227-1231.

27. Tiel-van Buul MMC, van Beek EJR, Borm JJJ,

Gubler FM, Broekhuizen AH. The value of radiographs and bone scintigraphy in suspectedscaphoid fracture—a statistical analysis. JHand Surg (Br) 1993;18:403-406.

28. King JB, Turnbull TJ. Scaphoid infractions andspurious scaphoid fractures. J Bone Joint Surg1982;64B:250-251.

29. Wilson AW, Kurer MHJ, Peggington JL, et al.Bone scintigraphy in the management of x-raynegative potential scaphoid fractures. ArchEmergMed 1986;3:235-242.

50 The Journal of Nuclear Medicine •Vol. 36 •No. 1 •January 1995

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1995;36:48-50.J Nucl Med.   Lawrence E. Holder, Michael E. Mulligan and Thomas E. Gillespie  Diagnosis of Scaphoid Fractures: The Role of Nuclear Medicine

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