Scaphoid Fractures

[X-ray]

I was going to reply in the other thread but it got a bit long so I reckon Karlos's wrist deserves its own thread :-)

@ Karlos

By the looks of that scaphoid (if it is your wrist in your avatar), you are heading for a non-union. At my last placement I worked with one of the top guys in the world for scaphoid fractures, a guy called Nicholas Goddard. He fixes scaphoid fractures with a small screw with opposing threads to draw the two poles together. In some cases he takes some bone from the pelvis and injects it into the drilled channel to encourage bone mineralisation across the fracture. Here is how they set it up. Note the chinese finger traps (who says you can't have some pranks in the operating room):



Basically that allows a 360 degree X-ray access around the wrist. If he wants to do full motion X-ray filming he can just twirl the hand at the top. I would burn him a video CD for each case so he could collaborate with some dudes in the US about the placement of the screw. Here you can see the setup with the X-ray unit. In the inset I have magnified the image from screen A. The white arrows point to the distal and proximal ends of the scaphoid. You can see the fracture in between. The red arrow is the screw and the yellow arrow is the screwdriver.



Usually when somebody has a suspected scaphoid fracture (and the fracture cannot be seen) they re-X-ray the guy after 10 days to see if it has displaced. Some centers do macro-radiography for this (I was down in Basingstoke a few weeks ago and they were using a precision skull radiography unit for this). If the thing is displaced then they've proved the fracture and they might take steps to manipulate it in plaster and see if it unites. If the displacement is marked initially or if it is unresolved after a while (a non-union), then surgery is the best bet in my humble opinion. The scaphoid bone has a bad blood supply. It enters at the distal pole of the scaphoid and travels proximally towards the proximal pole. A fracture through the waist of the scaphoid (like what I see in the avatar) can compromise that blood supply and if that remains compromised for some time, you can get an avascular condition in which the proximal pole is wasted or degenerates. That means osteoarthritis in the wrist and some loss of dexterity. Even in the left hand it is a problem.

So I would keep tabs on that if I was you.

Edit: for those of you who are thinking 'What the hell is a scaphoid bone?'...it is one of the bones in the wrist near the base of the thumb in an area called the anatomical snuff-box. See here for a detailed description. In fact palpation of the snuff-box is one of the clinical tests they do to check for tenderness that can be as a result of a scaphoid fracture.

[X-ray]

Good luck old bean, hopefully you won't have to be drilled.

[X-ray]

"...Once it set, seeing the rock hard, black fabric I could only think of bloodline's sock..."
------------------------------------------------------

  :roflmao:

Ja, jokes aside though you gotta keep tabs on that scaphoid. I guarantee you, if there is any messing about in the land of human bones, that scaphoid is the one that usually starts the ruckus. It is what you might call 'a well-lippy bone.' In fact it is the resident Chav in the human skeleton...

[X-ray]

@ Vincent

"...That's pure dead brilliant like..."
-------------------------------------------------------


But is he bovered, mate?
Look at his face, does he look bovered?
Are you disrespecting his family though?
He ain't bovered, yeah...I told ya, he ain't bovered! Does he look bovered?
Face, bovered, face...bovered. Does he look bovered mate?
Ask him if he is bovered. Go on, ask him, he'll tell ya!
He ain't bovered mate!!!

[X-ray]

Ja. I understand how you feel about that. You can imagine how we have to bite our tongues here. We get these 'generously-proportioned' individuals here for X-rays, usually for lumbar spine and knees and they seem to be oblivious to the fact that their weight is a major contributing factor to their ailments. Some of them cannot be X-rayed on the table (table limits are around 150kg). And there is much rolling of eyes and sighing when we battle to get the pictures we need. It's no picnic, no sir.
And then you get the dude who reckons his problem is worse than everybody else's. We had one such guy who had minor injuries from an accident (he was walking) and he demanded to be seen by the doctor immediately. We told him that the doctors were busy in the resus bay because we had one gunshot chest and another patient who went through a windscreen in a high speed accident. They were both unconscious. Even so, this guy wanted the doctors to leave those patients and come and see to him right away.
 :roll:

[X-ray]

@ Hyperspeed

"...I wish doctors would use the MRI scanners more. I'm not totally at one with the idea of sitting in front of a machine whilst everyone else runs for cover behind leaded glass with bullet proof vests on..."
----------------------------------------------------------

Due to the physics of MRI, bone cannot be visualised with enough detail to evaluate fractures and lesions. X-rays are king for that purpose. Ionising radiation is only used in the pursuit of a diagnosis when the benefits of the information that will be revealed outweigh the risks associated with that radiation dose. Radiographers are trained to justify the use of radiation in the form of X-rays to support or exclude a particular diagnostic question.
In addition to that, an MRI scan takes about half an hour minimum and you have to make safety arrangements beforehand to avoid putting a guy in the magnet with potentially ferrous items in his body.
X-rays are much quicker, more widely available and there are no special hazards other than the radiation dose itself. According to our consultant radiologist, an abdminal X-ray is equivalent in dose to a total of four months living in the UK (background radiation). The radiographic exposure of an abdominal X-ray is around 74kV and 40mAs (a beam produced from a potential difference of 74,000 volts and comprised of photons derived from electrons that were present in 40 milliamps over 1 second, or possibly 20 milliamps over 2 seconds.

Karlos's scaphoid X-rays were probably done at only 55kV and about 4mAs per shot. There are 4 standard scaphoid views and if he had them all, he still wouldn't get the dose from one abdominal X-ray. So the dose is minimal, innit?

And then you gotta talk about cost. An MR scan is BIG bucks and there is a waiting list of note. Karlos's scaphoid (although it means a lot to him) is small potatoes in the big picture. They will be scanning dudes with suspected herniated spinal discs long before they put his wrist anywhere near the magnet.

I suspect we are going to rely on X-rays for a very long time in diagnosing fractures.

[X-ray]

@ Doobrey

"...Just got back from the docs with a badly scratched eyeball..."
--------------------------------------------------------

Hope you don't have any metal stuck in there, did you get a helping of radiation too? Gotta keep my pals in a job, you know   :lol:

[X-ray]

The strength of the magnetic field ranges from 0.5 to 3 Tesla in MRI units used for medical diagnosis. That is a strong magnet!
I doubt that a few coins would kill somebody but there have been deaths associated with small oxygen bottles flying into the bore of the magnet while there was a patient on the table.
A few years ago I attended a course on Magnetic Resonance Imaging and we were shown several examples of MRI accidents such as floor buffer machines and office chairs pulled into the bore. There were a few oxygen bottles too. They showed us how they got one of the oxygen bottles out: by using a Land Rover! They had to attach a rope to the bottle and tow it out. When the bottle was free of the bore of the machine, it remained suspended in mid-air and the rope was fully taut.
Then last year I conducted a few experiments here in London to see whether certain bullets had ferrous properties and therefore could possibly pose a hazard if the patient went for an MR scan. I had to make a special perspex and wood enclosure for the bullets and I ended up crawling into the bore with the test tool and bullets, and my digital camera. I had to hold that camera with both hands because the battery is ferrous. The magnet was so strong that it operated the zoom of the camera without me touching anything. When I got into the mouth of the bore the image turned into a blue snow, it was compressed vertically, and then the camera shut down and could not be powered back on for ten minutes!
I'll see if I can find pics of that.
Stronger magnets of the order of 10 Tesla to 20 Tesla have been used to levitate organic materials. One of the things they have successfully levitated is a small frog. So you can imagine how powerful that magnet is! (But they are't approved for medical use and the bore is very small)

Here is where they levitated the live frog:

http://www.hfml.ru.nl/froglev.html

[X-ray]

@ Metalman

That is great info, thanks! (Can I have a link or source too please). One of the things I intend to do with shotgun pellets is X-ray them to see if there is an appreciable density difference as seen radiologically, so we can exclude ferrous pellets. If you are a a shotgun owner or if you know someone who has samples of each of those pellet types (they would all have to be the same size) then let me know, because I would be interested in buying them. I would be willing to pay for the whole cartridge + your time + postage to UK. The only thing is you would have to slice the hull open and give me just the pellets because if there is any propellant together with the projectiles I am likely to have problems with customs.

[X-ray]

@ Karlos

I don't think you can get that without a prescription, and even then you might take a hit in concentration.

[X-ray]

@ Cece

I hope you got a pelvis X-ray: you might have a cheeky little inferior pubic ramus fracture. There are others too...don't take a chance.

[X-ray]

Don't worry, it's nice hardware.

My nose tells me you are getting screwed, it's just a question of Herbert vs Acutrak

[X-ray]

Now Cece, I hope you listened to Uncle X-ray and got that pelvis X-rayed, cos I tell you frankly and sincerely that whenever a pelvis can pull a cheeky stunt it will.
Don't mess about, get yourself a dose of good old New York photons.

[X-ray]

"...This is the NHS we're talking about. It'll probably be a one inch brass one from B&Q..."
----------------------------------------------------------

Hehe no it's not that bad in the NHS. All the scaphoid screws I have seen were at NHS hospitals. You can get a nice shiny screw for your scaphoid. The only thing I can't guarantee is whether you can get one with a Burberry pattern