Role of MRI in the diagnosis and management of patients with clinical scaphoid fracture.

PURPOSE: The American College of Radiologists (ACR) recognises the value of magnetic resonance imaging (MRI) as the investigation of choice in patients with a clinically suspected scaphoid fracture but normal plain radiographs. The Royal College of Radiologists (RCR) in the UK produces no similar guidelines, as evidenced by the inconsistent management of such cases in hospitals around the UK. In discussion with our musculoskeletal radiologists, we implemented new guidelines to standardise management of our patients and now report our findings. METHODS: A consecutive series of 137 patients referred to the orthopaedic department with clinically suspected scaphoid fracture but normal series of plain radiographs were prospectively followed up over a two-year period. We implemented the use of early MRI for these patients and determined its incidence of detected scaphoid injury in addition to other occult injuries. We then prospectively examined results of these findings on patient management. RESULTS: Thirty-seven (27%) MRI examinations were normal with no evidence of a bony or soft-tissue injury. Soft-tissue injury was diagnosed in 59 patients (43.4%). Of those, 46 were triangular fibrocartilage complex (TFCC) tears (33.8%) and 18 were intercarpal ligament injuries (13.2 %). Bone marrow oedema with no distinct fracture was discovered in 55 cases (40.4%). In 17 (12.5%) cases, this involved only the scaphoid. In the remainder, it also involved the other carpal bones or distal radius. Fracture(s) were diagnosed on 30 examinations (22.0%). CONCLUSIONS: MRI should be regarded as the gold standard investigation for patients in whom a scaphoid fracture is suspected clinically. It allows the diagnosis of occult bony and soft-tissue injuries that can present clinically as a scaphoid fracture; it also helps exclude patients with no fracture. We believe that there is a need to implement national guidelines for managing occult scaphoid fractures.

Pattern and mechanism of traumatic limb amputations after explosive blast: experience from the 07/07/05 London terrorist bombings.

BACKGROUND: Traumatic amputation of limbs caused by bomb blast carries a high mortality; we present our experience of 07/07 London terrorist bombing that resulted in a large number of survivors with amputated limbs. We think that the unique underground bombing, the shape of the carriages, and the enclosure by the underground tunnel caused amputation of the limb by the channeling of the blast wave as a result of the device being floor based, which resulted in lower-limb amputation without other fatal primary blast injuries. We present our results of the traumatic amputation in the fatalities and survivors as well as the possible mechanism and protective measure that could save lives. METHODS: Data for traumatic amputations were collected from several sources and made anonymous. Traumatic amputations were specifically classified in both the survivors and the fatalities. RESULTS: Our results have shown that 24.5% of those with traumatic amputations will survive. Most of the lower-limb amputations occurred in the shaft of the long bones. Only one person with an upper limb amputation survived the injuries. CONCLUSION: This study does not support the previously held belief that traumatic amputations from a bomb blast results from simple avulsions by the blast winds. However, it reinforces the belief that the principal mechanism of primary traumatic amputation of the limbs in such circumstances occurs primarily [corrected] from the direct coupling of blast waves, resulting in a fracture of the long bone rather than at a joint. This study is unique because it looks at the effects of blast at a very close range (<2 m) at the four London bombing scenes. LEVEL OF EVIDENCE: Epidemiological study, level V.