Electronic Letters to:

Upper Limb: F. J. P. Beeres, S. J. Rhemrev, P. den Hollander, L. M. Kingma, S. A. G. Meylaerts, S. le Cessie, K. A. Bartlema, J. F. Hamming, and M. Hogervorst Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures J Bone Joint Surg Br 2008; 90-B: 1205-1209 [Abstract] [Full text] [PDF]

eLetters: Submit a response to this article

Electronic letters published:

Authors' reply:

Frank J.P. Beeres, Steven J. Rhemrev, Peter den Hollander, Lucas M. Kingma, Sven A. G. Meylaerts, Saskia le Cessie, Kees A. Bartlema, Jaap F. Hamming, and Mike Hogervorst   (16 October 2008)

Snuffbox tenderness at two weeks does not equate to scaphoid fracture

Onur Berber, Ziad Harb and Quamar Bismil   (15 September 2008)

Authors' reply: 16 October 2008
Frank J.P. Beeres, Resident Surgery Medical Centre Haaglanden, Steven J. Rhemrev, Peter den Hollander, Lucas M. Kingma, Sven A. G. Meylaerts, Saskia le Cessie, Kees A. Bartlema, Jaap F. Hamming, and Mike Hogervorst Send letter to journal: Re: Authors' reply: f.j.p.beeres{at}lumc.nl Frank J.P. Beeres, et al.	Sir We thank Onur Berber et al for their response to our paper. The gold standard was one of the most challenging problems in our study. Undisplaced scaphoid fractures heal, primarily, without callus formation and not all fractures are apparent on repeat radiographs. Consequently, both radiographs and clinical union throughout follow-up were used in the reference standard. Plain radiographs (six weeks after injury) and physical examination during follow-up were used as a reference standard for patients with a discrepancy between MRI and bone scintigraphy. A fracture was considered present if there was radiological evidence six weeks after injury. Fractures were also considered present in cases of persistent clinical signs of a fracture after two weeks (in combination with either a positive bone scintigraphy or MRI) in combination with absence of radiological evidence of a fracture six weeks after injury. Fractures were only considered absent if neither clinical signs nor radiographic evidence of a fracture after six weeks were present. We did not assume that the presence of ongoing tenderness at two weeks alone is pathognomonic of a fracture. In patients with persistent clinical signs, in combination with a positive MRI or bone scintigraphy, the presence of a scaphoid fracture cannot be eliminated and fracture treatment is warranted. Therefore, according to our reference standard, these patients were scored as fractures. F.J.P. Beeres, Resident Surgery, Medical Centre Haaglanden, The Hague, The Netherlands. S.J. Rhemrev, P. den Hollander, L.M. Kingma, S.A.G. Meylaerts, S. le Cessie, K.A. Bartlema, J.F. Hamming, M. Hogervorst.
Snuffbox tenderness at two weeks does not equate to scaphoid fracture 15 September 2008
Onur Berber, SHO Orthopaedics and Trauma Department of Orthopaedics, St Georges Hospital, Ziad Harb and Quamar Bismil Send letter to journal: Re: Snuffbox tenderness at two weeks does not equate to scaphoid fracture onurberber{at}yahoo.co.uk Onur Berber, et al.	Sir, We read with interest the recent paper by Beeres et al. This article highlights important issues with regards to the diagnosis of scaphoid fractures. In particular the use of the traditional bone scan versus modern MRI scanning is evaluated. We note that in the contingency calculations the authors made several assumptions: 1. If MRI and bone scintigraphy both showed a fracture, the final diagnosis was fracture.1 If MRI and bone scintigraphy both showed no fracture, the final diagnosis was no fracture.2 Where there was a discrepancy between MRI and bone scintigraphy, plain radiographs (six weeks after injury) and physical examination during follow-up were used to make the final diagnosis. If any clinical sign remained abnormal after two weeks (tenderness in the anatomical snuffbox or pain when applying axial pressure to the thumb or index finger) and/or there was radiological evidence of a fracture six weeks after injury, the final diagnosis was fracture. For the third group, i.e. discrepancy between MRI and bone scan, we would agree that a delayed radiograph showing a fracture line confirms the diagnosis. However, we do not think that it is reasonable to assume that the presence of ongoing tenderness at two weeks is pathognomonic of fracture. These patients could have many other regional or systemic causes of snuffbox pain.1-4 Clearly, such an assumption would influence the specificity and sensitivity values. O. Berber, SHO Orthopaedics and Trauma, Z. Harb, Q. Bismil, Department of Orthopaedics, St Georges Hospital Tooting, London, UK. 1. Steinberg BD, Kleinman WB. Occult scapholunate ganglion: a cause of dorsal radial wrist pain. J Hand Surg [Am] 1999;24:225-31. 2. Fealy MJ, Lineaweaver W. Intraosseous ganglion cyst of the scaphoid. Ann Plast Surg 1995;34:215-7. 3. Gabel G, Bishop AT, Wood MB. Flexor carpi radialis tendinitis. Part II: Results of operative treatment. J Bone Joint Surg [Am] 1994;76:1015-8. 4. Crosby EB, Linscheid RL, Dobyns JH. Scaphotrapezial trapezoidal arthrosis. J Hand Surg [Am] 1978;3:223-34.