Cost-Effectiveness of Immediate MR Imaging Versus Traditional Follow-Up for Revealing Radiographically Occult Scaphoid Fractures
|
|
- Osborn Wilson
- 7 years ago
- Views:
Transcription
1 Theodore. Dorsay 1 Nancy M. Major Clyde. Helms Received May 15, 2001; accepted after revision June 25, Presented at the annual meeting of the merican Roentgen Ray Society, Seattle, pril May ll authors: Department of Radiology, Duke University Medical Center, Erwin Rd., Rm. 1504, Durham, NC ddress correspondence to T.. Dorsay. JR 2001;177: X/01/ merican Roentgen Ray Society Cost-Effectiveness of Immediate MR Imaging Versus Traditional Follow-Up for Revealing Radiographically Occult Scaphoid Fractures OJECTIVE. For suspected scaphoid fractures with no radiographic evidence of fracture, treating symptoms with immobilization and radiographic follow-up has long been the standard of care. Modified MR imaging of the wrist is offered at our institution in screening for radiographically occult scaphoid fractures at the time of initial presentation to the emergency department. We show the advantages and comparative costs of this modified protocol versus a traditional protocol. MTERILS ND METHODS. Our modified protocol consists of coronal thin-section T1-weighted and fast spin-echo T2-weighted MR images with fat saturation. review of the literature was performed to assess the accuracy of clinical examination, radiography, and other modalities in the evaluation of scaphoid fractures of the wrist. Charges for this procedure are compared with charges for traditional follow-up. RESULTS. Three of four patients with positive results at clinical examination and negative findings on initial radiographs will be needlessly immobilized and monitored. The charges to the patient at our institution for screening MR imaging of the wrist are $770. The total charges to the patient with the traditional protocol, which would not be necessary with screening MR imaging, are $677 or more if a diagnosis is not made at this time. one scanning or routine MR imaging is often eventually used. CONCLUSION. Cost analysis at our institution suggests the two protocols are nearly equivalent from a financial standpoint. The loss of productivity for patients who are unnecessarily in casts or splints may be substantial. Screening MR imaging of the wrist in this setting is becoming accepted at our institution in a manner similar to screening MR imaging of the hip. M R imaging screening for occult fractures of the hip has been shown to be a cost-effective procedure [1, 2]. Referring clinicians often encounter resistance to a similar screening MR imaging study to rule out occult scaphoid fractures of the wrist (negative radiographic findings with a high level of clinical suspicion). We present data from our institution showing the advantages and comparative costs of this route versus traditional casting and follow-up radiography. Materials and Methods review of the literature of the last 6 years was undertaken to evaluate the positive predictive value of the clinical examination for scaphoid fracture. In addition, we attempted to assess the negative predictive value of initial negative radiographic findings in the setting of strong clinical suspicion. Modified MR imaging of the wrist is offered at our institution at the time of initial presentation to screen for radiographically occult scaphoid fractures. MR imaging is performed on a 1.5-T magnet (General Electric Medical Systems, Milwaukee, WI) with a dedicated wrist coil. This shortened study consists of 3-mm (0.3-mm gap) coronal T1-weighted spinecho (TR range/te range, /20 30; 2 excitations) and T2-weighted fast spin-echo (TR/TE range, 4000/80 120; 2 excitations) images with fat saturation and a matrix of Fracture is identified as a linear area of low signal intensity on T1- and T2- weighted images (Fig. 1). Similar sequences have proven accurate for detecting fracture in both the hip and the wrist [1 4]. We compared charges for the clinical protocol when using screening MR imaging with traditional charges for follow-up, which include charges for the initial orthopedic consultation in the emergency department, casting in the emergency department, a follow-up orthopedic appointment in 7 10 days, repeated wrist radiography, and, often, office fluoroscopy. ctual case scenarios are presented to emphasize particular points. Cases were drawn from our MR imaging database for the 6-year period During JR:177, December
2 Dorsay et al. that time, 334 wrist studies were performed; seventeen (5%) were performed to rule out scaphoid fracture. Eight (47%) of these 17 were performed in the most recent year, 2000, which indicates increasing use of MR imaging in this scenario. Results Our review of the literature for the last 6 years showed the positive predictive value of the clinical examination (clinical suspicion that warranted a wrist series or images of the scaphoid bone to rule out scaphoid fracture) varies widely (Table 1). The positive predictive value ranged from 13% to 69%, with a weighted average of 21%. These figures suggest that four of five patients will not have a scaphoid fracture. Our review of the recent literature to evaluate the negative predictive value of negative initial radiographs in the setting of strong clinical suspicion, found a range of 50 87%, with a weighted average of 74% (Table 2). These figures imply that three of every four patients with negative findings on initial radiographs will likely undergo needless immobilization. The charge (professional and technical) to the patient at our institution for screening MR Fig year-old man with injury sustained while boxing 2 3 months previously who presented with continued generalized wrist pain and stiffness. Scaphoid fracture of wrist was not visible on initial radiograph and remained radiographically occult during entire course of therapy., Coronal T2-weighted fast spin-echo MR image (TR/TE, 4000/72) with fat saturation shows nondisplaced fracture as distinct linear focus of low signal intensity (arrow ) with surrounding bright edema., T1-weighted spin-echo coronal MR image (500/11) obtained at same time as shows that fracture line (arrows) is slightly less evident in surrounding low-signal-intensity edema. TLE 1 Positive Predictive Value (PPV) of Clinical Examination in Recent Studies of Scaphoid Fractures Study Year Positive Clinical Examination a True-Positive b PPV of Clinical Examination (%) Grover [19] Thorpe et al. [15] Munk et al. [20] Gaebler et al. [4] Parvizi et al. [21] Tiel-van uul et al. [13] Roolker et al. [5] Roolker et al. [7] Tiel-van uul et al. [12] Cook et al. [16] Lepisto et al. [18] Total Weighted average PPV c 21 a Number of patients with strong suspicion of scaphoid fracture at clinical examination. b Number of cases with scaphoid fracture confirmed by gold standard (MR imaging, bone scanning, or long-term radiographic follow-up [varied among studies]). c Total positive clinical examinations divided by total true-positive scaphoid fractures. imaging of the wrist is $770. The reduction from a charge of $1256 for standard wrist MR imaging is achieved primarily through reduction of the technical component. The clinical protocol for treatment of suspected scaphoid fracture is summarized in a flowchart (Fig. 2) JR:177, December 2001
3 MR Imaging of Radiographically Occult Scaphoid Fractures TLE 2 Study Negative Predictive Value (NPV) of Negative Findings on Wrist Radiographs in Recent Studies of Patients Having Clinical Examination with Strong Clinical Suspicion of Scaphoid Fracture Year a Number of patients with strong suspicion of scaphoid fracture at clinical examination but negative findings on wrist radiographs. b Number of cases with negative radiographic findings and with negative findings for scaphoid fracture confirmed by gold standard (MR imaging, bone scanning, or long-term radiographic follow-up [varied among studies]). c Total positive clinical examinations, negative radiography divided by total true-negative scaphoid fractures. The potential added charges to the patient who follows a traditional protocol that are negated by the application of screening MR imaging of the wrist in the emergency or acute care setting are summarized in Tables 3 and 4. The following actual case scenarios are offered. Charges that may have been avoided by initial screening MR imaging are in parentheses or brackets. Positive Clinical Examination, NPV of Clinical Negative True-Negativeb Examination (%) Radiography a Cook et al. [16] Tiel-van uul et al. [12] Lepisto et al. [18] Roolker et al. [7] Tiel-van uul et al. [13] ayer et al. [14] retlau et al. [17] Fowler et al. [3] Total Weighted average NPV c 74 Fig. 2. Flowchart shows clinical pathways available to clinician in setting of positive (+) clinical examination (CE) for scaphoid fracture (e.g., fall on outstretched hand and snuffbox tenderness). indicates negative. Case Scenario 1 Day 1. The patient was a 23-year-old woman who flipped and fell backward onto her outstretched arm and presented with elbow and wrist pain (Fig. 3). Radiographs at the urgent care center showed a nondisplaced fracture of the radial neck. No wrist fracture was identified, but snuffbox tenderness was present. The patient s wrist was splinted ($154), and she was referred to an orthopedist. Day 6. t orthopedic follow-up ($135), the patient had swelling and point tenderness in the snuffbox region. The orthopedic report stated: Given the snuff box tenderness, the patient was placed in a short arm thumb spica bandage [$159] for possible scaphoid fracture. I will have the patient return to the clinic in one week. t that point, we will remove the thumb spica and reexamine her wrist. If she s continuing to have scaphoid tenderness, repeat x-ray will be obtained to determine whether or not there is any fracture line evident within the scaphoid. If there s no fracture line evident and she s continuing to have tenderness, then we will obtain either a bone scan or MR imaging to fully evaluate for nondisplaced scaphoid fracture. Day 13. The patient s cast was removed. She continued to have tenderness in the snuffbox region. Radiographs ($130) of the wrist showed a mild degree of irregularity on the radial aspect of the scaphoid bone but no obvious fracture line. The patient s wrist was placed in a thumb spica cast. MR imaging was ordered. Day 24. Complete wrist MR imaging ($1256) showed increased T2 and decreased T1 signals throughout the scaphoid bone, which are compatible with edema. focal area of linear decreased signal intensity on T1- and T2-weighted images extended through the proximal pole of the scaphoid bone, which is compatible with a nondisplaced fracture. Day 27. The patient returned to the clinic ($72) for the MR imaging results, which showed a scaphoid fracture. The cast was not changed because it was in good condition. Day 41. The cast was removed. The patient continued to have some tenderness and swelling around the scaphoid bone on the dorsal aspect of a wrist. Radiographic findings were again negative. The patient s wrist was re-placed in a short arm thumb spica splint. Summary. This scenario shows a situation in which 24 days were required to arrive at the diagnosis of scaphoid fracture. lthough the wrist was treated appropriately in the face of snuffbox tenderness, additional charges of $578 were incurred before definitive diagnosis was made at MR imaging. The additional expense of full MR imaging of the wrist ($486) versus a screening protocol was JR:177, December
4 Dorsay et al. incurred. s late as day 41, follow-up radiographs showed negative results. Case Scenario 2 Day 1. The patient was a 16-year-old boy who fell onto his outstretched hand, incurring a dorsiflexion injury to the right wrist (Fig. 4). He was seen at a family medical clinic, where radiographs were obtained that raised the question of a possible scaphoid fracture. The patient s hand was splinted ($154), and he was referred to an orthopedist. Day 2. t orthopedic consultation ($135), the patient had mild tenderness over the region of the scaphoid bone, but only with firm pressure. Under office fluoroscopy ($150), a fracture was not seen. The clinical impression questioned a nondisplaced scaphoid fracture versus a sprain of the right wrist. Fig year-old woman who fell backward onto outstretched arm and presented with wrist pain., Initial radiograph fails to reveal scaphoid fracture., T2-weighted fast spin-echo coronal MR image (TR/TE, 4000/72) with fat saturation obtained 24 days after initial radiograph shows diffuse heterogeneous high signal intensity (arrow ) throughout scaphoid bone. C, T1-weighted coronal MR image (500/14) through scaphoid bone obtained at same time as shows subtle linear focus of low signal intensity (arrow ) across mid waist of scaphoid bone. TLE 3 Possible dditional Charges to Patient with Traditional Protocol a Procedure Cost Emergency department splint $154 Wrist radiographs, 3 views $85 Scaphoid radiographic series $45 Orthopedic services Emergency department $108 consultation Outpatient office visit b $135 Wrist fluoroscopy in office $150 Total $677 a For working up scaphoid fracture with negative initial radiographic findings. b New patient, moderate severity, 30 min. Possible Charges of Traditional Follow-Up Protocol for TLE 4 Radiographically Occult Scaphoid Fracture Versus Modified Screening MR Imaging of the Wrist Procedure Cost Traditional protocol Follow-up, 1st appointment $677 Follow-up, 2nd appointment $547 Nuclear bone scanning $639 Routine MR wrist imaging $1,256 Screening MR wrist imaging $770 Since the wrist was minimally symptomatic, it was suggested to try a little immobilization with a short arm thumb spica cast [$159] and return in ten to 14 days for the re-x-ray. If the radiographs are completely normal and he has no tenderness would then discontinue the cast. If the radiographs are still suspicious but not confirmatory, would recommend CT scan. Day 10. The orthopedic report stated: I was notified of the patient s dissatisfaction with his current splint. He was sent to hand therapy to have a different type of splint made. [H]is MR imaging was scheduled for the 25th and the patient did not want to wait that long because of his inability to write in his current splint. MR imaging is moved up to the 20th. I suggested they put the cast back on as a splint until he can have the study and if the study is negative, then he does not need anything. Day 13. MR imaging of the wrist showed a nondisplaced fracture through the scaphoid waist. Day 16. The orthopedic report stated: In light of the MR images revealing a scaphoid fracture, the patient was brought back to the clinic today for examination, fluoroscopy and casting. On the office fluoroscopy [$150], the scaphoid is definitely fractured. Summary. This scenario shows that the orthopedic surgeon s initial direction was to perform radiographic follow-up and splinting only, then to perform CT if still unsure. The orthopedic surgeon was possibly swayed by initial negative findings on office fluoroscopy. MR imaging was recommended as a more sensitive study, and a full study was scheduled. Possibly because of inexperience with MR imaging, the clinician performed one further office fluoroscopy that confirmed the fractured scaphoid on day 16. Screening MR imaging ($770) would have prevented $589 in office charges plus an additional $486 from the cost of full wrist MR imaging that was performed. Case Scenario 3 Day 1. The patient was a 14-year-old boy who fell on his right face and ulnar wrist (Fig. 5). C 1260 JR:177, December 2001
5 MR Imaging of Radiographically Occult Scaphoid Fractures On presentation to the emergency department, he was found to have fractures of his right facial bones and the ulnar styloid of his right wrist. His right wrist was then placed in a splint ($154), and an orthopedic consultation was ordered. Day 10. fter orthopedic evaluation, the right wrist splint was removed. The right wrist had tenderness over the ulnar styloid, and the distal radial ulnar joint showed trepidation with stress. Radiographs of the right wrist ($85) again showed a nondisplaced fracture of the ulnar styloid. The clinician s impression was right wrist sprain with associated ulnar styloid fracture, possible disruption of the distal radioulnar joint, and possible disruption of the triangular fibrocartilage complex. The orthopedic report stated: The patient should continue to wear the brace for protection. I have suggested that we obtain MR imaging of the right wrist to further clarify his pathology. He Fig year-old boy who fell onto outstretched hand and incurred dorsiflexion injury to right wrist. Patient was seen at family medical clinic, where radiographs were obtained that raised possibility of scaphoid fracture., Radiograph obtained at initial visit is inconclusive., T2-weighted fast spin-echo coronal MR image (TR/TE, 4233/72) with fat saturation through scaphoid bone, obtained with flex coil through casting material 13 days after initial radiography, shows obviously poor signal-to-noise ratio. Even with this limitation, linear low-signal-intensity focus (straight arrow ) surrounded by high-signal-intensity edema is seen. Contusion of distal radial metaphysis is incidentally observed (curved arrow ). C, T1-weighted coronal MR image (500/14) through scaphoid bone obtained at same time as shows that low-signal-intensity fracture line is not well visualized in equally low-signal-intensity region of edema (white arrow ). Contusion of distal radial metaphysis (black arrow ) is again noted. C C Fig year-old boy who fell on wrist., Initial radiograph reveals no evidence of scaphoid fracture. Subtle band of sclerosis (arrows) that most likely represents torus fracture was missed on initial interpretation., T2-weighted fast spin-echo coronal MR image (TR/TE, 4000/74.2) with fat saturation through scaphoid bone, obtained 11 days after initial radiography, reveals linear lowsignal-intensity focus (black arrow ) surrounded by high-signal-intensity edema. Diffuse bright edema of distal radial metaphysis suggests torus fracture (white arrow ). C, T1-weighted coronal MR image (500/14) through scaphoid bone obtained at same time as shows low-signal-intensity fracture line is not well visualized in equally lowsignal-intensity region of edema (white arrow ). Diffuse low-signal-intensity edema of distal radial metaphysis again suggests torus fracture (black arrow ). JR:177, December
6 Dorsay et al. will return after the study for final diagnosis and disposition. Day 12. The orthopedic report stated: Complete MR imaging ($1298) of the right wrist and hand is reviewed. He is noted to have a nondisplaced scaphoid body fracture. The triangular fibrocartilage has a small nondisplaced tear. His ulnar styloid fracture is visible. Day 17. The orthopedic report stated: The patient s right wrist is somewhat improved in terms of local tenderness. He s placed into a short arm thumb spica cast. He will follow-up in this office in four weeks for removal of his cast and then x-ray of hand and wrist out of cast. Summary. This scenario shows the inability of even the orthopedic surgeon to initially suspect the presence of scaphoid fracture in the setting of a generalized wrist injury (ulnar styloid fracture and possible distal radioulnar disruption). MR imaging clearly showed not only the ulnar styloid fracture but also the radiographically occult scaphoid fracture and triangular fibrocartilage injury. Distal radioulnar joint disruption was discounted on the basis of MR imaging. The patient s wrist was not fully encased in a cast until day 17. Case Scenario 4 The patient was a 20-year-old man who presented with mild snuffbox tenderness after a fall on outstretched hands during basketball practice (Fig. 6). Initial radiographic findings were negative. The patient s wrist was splinted. MR imaging of the wrist was performed later that day, revealing a normal scaphoid. The patient returned to normal activity without negative consequences. Summary. This scenario shows the usefulness of immediate MR imaging in avoiding inconvenience to the patient and decreasing hindrances to productivity. Discussion Isolated nondisplaced fracture of the carpal scaphoid bone is a frequently seen injury in the emergency department and acute care setting. pproximately 7% of scaphoid fractures are not visible on initial radiographs [3, 4]. If the injury is correctly diagnosed within the first week of trauma and the wrist immobilized, the more serious complication of nonunion can be prevented [3 7]. Colles-type short arm (thumb) spica cast is adequate for treating nondisplaced scaphoid wrist fractures. For suspected scaphoid fractures with no radiographic evidence of fracture, treating symptoms with radiographic follow-up has long been the standard of care [8, 9]. s our review of the literature indicated, positive findings at clinical examination and subsequent negative wrist series may lead to unnecessary outpatient follow-up appointments, unnecessary immobilization, and additional exposure to radiation. This additional radiation exposure includes office fluoroscopy, which is often used by the consulted orthopedic surgeon when follow-up radiographs have negative results, adding to patient expense and radiation dosage. To our knowledge, no substantial work in the literature addresses the sensitivity and specificity of fluoroscopy in the setting of negative radiographic findings. Frequently, further negative imaging results occur at the first follow-up appointment in the continued setting of a positive physical examination. Tiel-van uul et al. [10 13] found 25% of scintigraphically confirmed scaphoid fractures followed up for at least 1 year could not be confirmed by radiography. second follow-up appointment may incur charges (up to $547) nearing those of the initial appointment by virtue of similar repeated diagnostic procedures and recasting. one scanning, which is more sensitive and more specific, has been advocated by many as an alternative to immobilization and follow-up [10 14]. The cost at our institution ($639) would approach that of unnecessary clinical imaging and therapeutic follow-up (Tables 3 and 4). In practice, however, this examination is frequently ordered as a more complex study (e.g., with flow studies) with increased charges. dditionally, we can find no case of nuclear bone scanning being used on an emergent basis, thus again resulting in casting of the patient s wrist for at least some time. Many recent studies suggest equal sensitivity and better (sometimes 100%) specificity for MR imaging in accurately detecting radiographically occult scaphoid fractures [3, 4, 15, 16]. On MR imaging, the fracture line will appear as a discrete focus of linear low T1 and T2 signals. dditionally, a diffuse low T1 signal and a high T2 signal are seen in the surrounding scaphoid bone, representing marrow edema. However, bone marrow edema alone does not represent fracture but rather contusion. The T1- and T2-weighted images are often complementary in cases with subtle findings. Diffuse bright edema on T2-weighted MR images (Fig. 3) and low-signal-intensity edema on T1-weighted images (Fig. 5) may obscure a subtle fracture line that is seen on the other sequence. Fowler et al. [3] compared the sensitivity and specificity of MR imaging for detection of radiographically occult scaphoid fractures with that of bone scintigraphy. In 40 patients, bone scanning and MR imaging findings were in agreement. In three patients, a discrepancy existed between the imaging modalities; in all three cases, MR imag- Fig year-old man with mild snuffbox tenderness after falling on outstretched hands during basketball practice., Initial wrist radiograph shows negative findings., T1-weighted coronal MR image (TR/TE, 500/11) through scaphoid bone, obtained 2 days after initial radiographs, shows no evidence of trauma. T2-weighted images were similarly unremarkable JR:177, December 2001
7 MR Imaging of Radiographically Occult Scaphoid Fractures ing was found to be more sensitive and more specific. Thorpe et al. [15] concluded that MR imaging showed better interobserver agreement for scaphoid injury and fewer false-positive results than bone scanning. Cook et al. [16] studied 18 skeletally immature patients who had presented to the emergency department within 2 days of acute wrist trauma. Those authors reported normal findings on initial MR images to have a negative predictive value of 100%. Of 10 patients with a scaphoid abnormality on MR imaging, six had fractures and four had regional bone marrow edema. Initially, eight of 10 fractures were radiographically occult, although some eventually became evident on later studies. Those lesions with bone marrow edema did not progress to fractures. Clearly, in the setting of continued clinical symptoms and negative radiographic findings, MR imaging not only can exclude scaphoid fractures if not present but also can elucidate other causes for pain. retlau et al. [17] found that MR imaging also revealed a fracture of the capitate bone in one patient, a fracture of the triquetrum in two patients, and a bone bruise of one or more of the carpal bones in eight patients. Lepisto et al. [18] found MR imaging showed a wide spectrum of additional lesions in the wrist that were not detected by routine radiographic analysis. These lesions included seven fragmented triangular fibrocartilages, four torn scapholunate ligaments, and one torn triquetral lunate ligament. one bruises of other carpal bones and seven other carpal fractures were also detected. Cook et al. [16] found seven patients with evidence of extensor tenosynovitis on MR imaging. Thorpe et al. [15] found frequent occurrences of ligamentous injury and carpal instability at MR imaging that were not evident on scintigraphy. further advantage of MR imaging is the ability to image through casting material. This need occurs frequently when imaging takes place after the patient s initial presentation. Imaging through casting material requires a larger coil than the wrist coil (usually a flex or knee coil), resulting in a diminished signal-to-noise ratio. lthough not esthetically as pleasing, the images are diagnostic in our experience (Fig. 3). Fast short tau inversion recovery images may be substituted for fast spin-echo images with fat saturation if necessary. Cost and practicality naturally preclude the use of MR imaging as a first-line diagnostic study; however, the limited wrist protocol we have described that is now being used at our institution brings costs in line with the costs of bone scanning and the traditional first follow-up appointment (Tables 3 and 4). dditionally, this limited MR imaging can be performed in less than 30 min (including setup; 10 min of actual scanning time), which allows flexibility for same-day imaging in our institution. We have found increasing acceptance among the emergency department physicians, which is similar to our experience with MR imaging for occult hip fractures. We conclude that this limited wrist MR imaging protocol (in the setting of suspected scaphoid fracture and negative initial radiographic findings) is nearly as cost-effective as traditional follow-up and immobilization. ssuming the current standard of care (watchful immobilization) is applied, most patients with positive findings at clinical examination and negative radiographic results ( 75% by our review) will undergo needless casting (and possibly recasting), which compromises both lifestyle and productivity. Follow-up appointments additionally result in lost wage-earning hours (often a full day) or increased day-care expenses. When lost productivity and income to the patient are considered, screening MR imaging is favored at initial presentation. This practice has always been the case for the elite athlete, as in case scenario 4. The presence of multiple scanners and technologists make possible the rapid scheduling of this 30-min (or less) procedure. In the outpatient setting, performing MR imaging in the same day may be slightly more difficult. s two of our case scenarios showed, a savings of time and money is possible even if the MR imaging is performed before the first orthopedic appointment. References 1. Deutsch L, Mink JH, Waxman D. Occult fractures of the proximal femur: MR imaging. Radiology 1989;170: Haramati N, Staron R, arax C, Feldman F. Magnetic resonance imaging of occult fractures of the proximal femur. Skeletal Radiol 1994;23: Fowler C, Sullivan, Williams L, McCarthy G, Savage R, Palmer. comparison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid waist fracture. Skeletal Radiol 1998;27: Gaebler C, Kukla C, reitenseher M, Trattnig S, Mittlboeck M, Vecsei V. Magnetic resonance imaging of occult scaphoid fractures. J Trauma 1996;41: Roolker W, Tiel-van uul MM, ossuyt PM, et al. Carpal box radiography in suspected scaphoid fracture. J one Joint Surg r 1996;78: Roolker L, Tiel-van uul MM, ossuyt PP, Dijkstra PF, van Grieken HJ, roekhuizen TH. The value of additional carpal box radiographs in suspected scaphoid fracture. Invest Radiol 1997; 32: Roolker W, Maas M, roekhuizen H. Diagnosis and treatment of scaphoid fractures: can nonunion be prevented? rch Orthop Trauma Surg 1999;119: Schubert HE. Scaphoid fracture: review of diagnostic tests and treatment. Can Fam Physician 2000;46: Ohiorenova D, Whitwell DJ. Occult scaphoid fracture: need to avoid complacency case report and literature review. J Trauma 1996;41: Tiel-van uul MM, van eek EJ, roekhuizen H, akker J, os KE, van Royen E. Radiography and scintigraphy of suspected scaphoid fracture: a long-term study in 160 patients. J one Joint Surg r 1993;75: Tiel-van uul MM, Roolker W, roekhuizen H, Van eek EJ. The diagnostic management of suspected scaphoid fracture. Injury 1997;28: Tiel-van uul MMC, Roolker W, Verbeeten W Jr, roekhuizen H. Magnetic resonance imaging versus bone scintigraphy in suspected scaphoid fracture. Eur J Nucl Med 1996;23: Tiel-van uul MM, roekhuizen TH, van eek EJ, ossuyt PM. Choosing a strategy for the diagnostic management of suspected scaphoid fracture: a cost-effectiveness analysis. J Nucl Med 1995;36: ayer LR, Widding, Diemer H. Fifteen minutes bone scintigraphy in patients with clinically suspected scaphoid fracture and normal x-rays. Injury 2000;31: Thorpe P, Murray D, Smith FW, Ferguson J. Clinically suspected scaphoid fracture: a comparison of magnetic resonance imaging and bone scintigraphy. r J Radiol 1996;69: Cook P, Yu JS, Wiand W, Cook J II, Coleman CR, Cook J. Suspected scaphoid fractures in skeletally immature patients: application of MRI. J Comput ssist Tomogr 1997;21: retlau T, Christensen OM, Edstrom P, Thomsen HS, Lausten GS. Diagnosis of scaphoid fracture and dedicated extremity MRI. cta Orthop Scand 1999;70: Lepisto J, Mattila K, Nieminen S, Sattler, Kormano M. Low field MRI and scaphoid fracture. J Hand Surg r 1995;20: Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. J Hand Surg r 1996;21: Munk, Frokjaer J, Larsen CF, et al. Diagnosis of scaphoid fractures: a prospective multicenter study of 1,052 patients with 160 fractures. cta Orthop Scand 1995;66: Parvizi J, Wayman J, Kelly P, Moran CG. Combining the clinical signs improves diagnosis of scaphoid fractures: a prospective study with follow-up. J Hand Surg r 1998;23: JR:177, December
Scaphoid and Other Wrist Injuries in the Emergency Department
CLINICAL PRACTICE GUIDELINE Scaphoid and Other Wrist Injuries in the Emergency Department SCOPE (Area): SCOPE (Staff): Emergency Department and Fracture Clinic Medical, Nursing, Patient Service Assistants
More informationChpter 2 Nonoperative Management of Non-displaced Acute Scaphoid Fracture
Chpter 2 Nonoperative Management of Non-displaced Acute Scaphoid Fracture Megan Tomaino and Thomas B. Hughes Case Presentation The patient is a 15-year-old male with a history of left wrist pain following
More informationDIAGNOSING SCAPHOID FRACTURES. Anthony Hewitt
DIAGNOSING SCAPHOID FRACTURES Anthony Hewitt Introduction Anatomy of the scaphoid Resembles a deformed peanut Articular cartilage covers 80% of the surface It rests in a plane 45 degrees to the longitudinal
More informationRADIOGRAPHIC EVALUATION
Jeff Husband MD Objectives Evaluate, diagnose and manage common wrist injuries due to high energy trauma in athletes Appropriately use radiographs, CT scans and MRI Know when to refer patients for additional
More informationUlnar sided Wrist Pain
Ulnar sided Wrist Pain 1 Susan Cross, 1 Anshul Rastogi, 2 Brian Cohen, 1 Rosy Jalan 1 Dept of Radiology, Barts Health NHS Trust, London, UK 2 London Orthopaedic Centre Contact: susan.cross@bartshealth.nhs.uk
More informationScaphoid Fractures- Anatomy And Diagnosis: A Systemic Review Of Literature
Article ID: WMC001268 ISSN 2046-1690 Scaphoid Fractures- Anatomy And Diagnosis: A Systemic Review Of Literature Corresponding Author: Dr. Dharm Meena, junior resident, orthopaedics, PGIMER, E 402, MDH,PGIMER,CHANDIGARH,
More informationINJURIES OF THE HAND AND WRIST By Derya Dincer, M.D.
05/05/2007 INJURIES OF THE HAND AND WRIST By Derya Dincer, M.D. Hand injuries, especially the fractures of metacarpals and phalanges, are the most common fractures in the skeletal system. Hand injuries
More informationMusculoskeletal Trauma of the Wrist
September 2000 Musculoskeletal Trauma of the Wrist Murat Akalin, Harvard Medical School, Year- IV Gillian Lieberman, MD The Wrist Most common site of injury in entire skeleton Distal radius and ulna fractures
More informationCommon wrist injuries in sport. Chris Milne Sports Physician Hamilton,NZ
Common wrist injuries in sport Chris Milne Sports Physician Hamilton,NZ Overview / Classification Acute injuries Simple - wrist sprain Not so simple 1 - Fracture of distal radius/ulna 2 - Scaphoid fracture
More informationScaphoid Fracture of the Wrist
Page 1 of 6 Scaphoid Fracture of the Wrist Doctors commonly diagnose a sprained wrist after a patient falls on an outstretched hand. However, if pain and swelling don't go away, doctors become suspicious
More informationWRIST EXAMINATION. Look. Feel. Move. Special Tests
WRIST EXAMINATION Look o Dorsum, side, palmar- palmar flex wrist to exacerbate dorsal swellings o Deformity e.g. radial deviation after colles, prominent ulna o Swellings e.g. ganglion o Scars, muscle
More informationFractures around wrist
Fractures around wrist Colles Fracture Smiths fracture Barton s fracture Chauffer s fracture Scaphoid fracture Lunate dislocation Vivek Pandey Colles fracture Definition: Fracture of the distal end radius
More informationDistal Radius Fractures. Lee W Hash, MD Affinity Orthopedics and Sports Medicine
Distal Radius Fractures Lee W Hash, MD Affinity Orthopedics and Sports Medicine The Problem of Distal Radius Fractures Common injury: >450,000/yr. in USA High potential for functional impairment and frequent
More informationWrist Fractures. Wrist Defined: Carpal Bones Distal Radius Distal Ulna
Wrist Fractures Wrist Fractures Wrist Defined: Carpal Bones Distal Radius Distal Ulna Wrist Fractures Wrist Joints: CMC Intercarpal Radiocarpal DRUJ drudge Wrist Fractures Wrist Fractures: (that we are
More informationPERILUNATE AND LUNATE DISLOCATIONS
PERILUNATE AND LUNATE DISLOCATIONS Rebecca Morris Advanced Practitioner Plain Film Reporting March 2011 Perilunate and Lunate dislocations Introduction Definition Anatomy Clinical presentation Mechanism
More informationTHE WRIST. At a glance. 1. Introduction
THE WRIST At a glance The wrist is possibly the most important of all joints in everyday and professional life. It is under strain not only in many blue collar trades, but also in sports and is therefore
More informationCommonly Missed Fractures in the Emergency Department
Commonly Missed Fractures in the Emergency Department Taylor Sittler MS IV - UMASS Images courtesy of Jim Wu, MD, Sanjay Shetty, MD and Mary Hochman, MD Diagnostic Errors in the ED Taylor Sittler, MS IV
More informationMost active and intricate part of the upper extremity Especially vulnerable to injury Do not respond well to serious trauma. Magee, 2008. pg.
PTA 216 Most active and intricate part of the upper extremity Especially vulnerable to injury Do not respond well to serious trauma Magee, 2008. pg. 396 28 bones Numerous articulations 19 intrinsic muscles
More informationX-ray (Radiography) - Bone
Scan for mobile link. X-ray (Radiography) - Bone Bone x-ray uses a very small dose of ionizing radiation to produce pictures of any bone in the body. It is commonly used to diagnose fractured bones or
More informationHand and Upper Extremity Injuries in Outdoor Activities. John A. Schneider, M.D.
Hand and Upper Extremity Injuries in Outdoor Activities John A. Schneider, M.D. Biographical Sketch Dr. Schneider is an orthopedic surgeon that specializes in the treatment of hand and upper extremity
More information3.1. Presenting signs and symptoms; may include some of the following;
Title: Clinical Protocol for the management of Forearm and Wrist injuries. Document Owner: Deirdre Molloy Document Author: Deirdre Molloy Presented to: Care & Clinical Policies Date: August 2015 Ratified
More informationWrist and Hand. Patient Information Guide to Bone Fracture, Bone Reconstruction and Bone Fusion: Fractures of the Wrist and Hand: Carpal bones
Patient Information Guide to Bone Fracture, Bone Reconstruction and Bone Fusion: Wrist and Hand Fractures of the Wrist and Hand: Fractures of the wrist The wrist joint is made up of the two bones in your
More informationIFSSH Scientific Committee on. Wrist Biomechanics and Instability
IFSSH Scientific Committee on Wrist Biomechanics and Instability Chair: Hisao Moritomo (Japan) Committee: Emmanuel Apergis (Greece) Guillaume Herzberg (France) Scott Wolfe (USA) Jose Maria Rotella (Argentina)
More informationAdult Forearm Fractures
Adult Forearm Fractures Your forearm is made up of two bones, the radius and ulna. In most cases of adult forearm fractures, both bones are broken. Fractures of the forearm can occur near the wrist at
More informationYouth Thrower s Elbow
Youth Thrower s Elbow Description Youth Thrower s elbow is an inflammatory condition involving the growth plate of the humerus, near the inner elbow at the medial epicondyle.(figure 1) This condition is
More informationRadial Head Fracture Repair and Rehabilitation
1 Radial Head Fracture Repair and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: The elbow is a complex joint due to its intricate functional anatomy. The ulna, radius
More informationCommon Pediatric Fractures. Quoc-Phong Tran, MD UNSOM Primary Care Sports Medicine Fellow November 6, 2014
Common Pediatric Fractures Quoc-Phong Tran, MD UNSOM Primary Care Sports Medicine Fellow November 6, 2014 Pediatric fractures 20% of injured kids found to have fracture on evaluation Between birth and
More informationSPECT/CT Wrist. Wrist pain 3/27/2012
Wrist pain Wrist joint - complicated anatomy complex biomechanics Imaging and management of wrist pain presents a significant challenge Significant economic burden SPECT/CT Wrist HK Mohan GSTT London Intra-capsular
More informationRunning Head: Salter Harris Fractures 1
Running Head: Salter Harris Fractures 1 Salter Harris Classification of Growth Plate Fractures November 15 th, 2011 Salter Harris Fractures 2 Abstract Salter-Harris Classifications are a straightforward
More informationSports Injuries of the Foot and Ankle. Dr. Travis Kieckbusch August 7, 2014
Sports Injuries of the Foot and Ankle Dr. Travis Kieckbusch August 7, 2014 Foot and Ankle Injuries in Athletes Lateral ankle sprains Syndesmosis sprains high ankle sprain Achilles tendon injuries Lisfranc
More informationNERVE COMPRESSION DISORDERS
Common Disorders of the Hand and Wrist Ryan Klinefelter, MD Associate Professor of Orthopaedics Department of Orthopaedics The Ohio State University Medical Center NERVE COMPRESSION DISORDERS 1 Carpal
More informationMEDICAL CENTRES AND SCANS
MEDICAL CENTRES AND SCANS Lúnasa 2013 MEDICAL, SCIENTIFIC AND WELFARE COMMITTEE INTRODUCTION Technology is a critical component of modern day sports medicine. Whilst providing a cutting edge in terms of
More informationASSOCIATE PROFESSOR BO POVLSEN Emeritus Consultant Orthopaedic Surgeon Guy s & St Thomas Hospitals NHS Trust GMC no. 3579329
ASSOCIATE PROFESSOR BO POVLSEN Emeritus Consultant Orthopaedic Surgeon Guy s & St Thomas Hospitals NHS Trust GMC no. 3579329 Consultant Orthopaedic Surgeon London Bridge Hospital Medico-Legal Secretary:
More informationIn Practice Whole Body MR for Visualizing Metastatic Prostate Cancer
In Practice Whole Body MR for Visualizing Metastatic Prostate Cancer Prostate cancer is the second most common cancer in men worldwide, accounting for 15% of all new cancer cases. 1 Great strides have
More informationESSENTIALPRINCIPLES. Wrist Pain. Radial and Ulnar Collateral Ligament Injuries. By Ben Benjamin
ESSENTIALPRINCIPLES Wrist Pain Radial and Ulnar Collateral Ligament Injuries By Ben Benjamin 92 MASSAGE & BODYWORK FEBRUARY/MARCH 2005 Ulnar Collateral Ligament Radial Collateral Ligament Right wrist,
More informationThe Emergent Evaluation and Treatment of Hand and Wrist Injuries
The Emergent Evaluation and Treatment of Hand and Wrist Injuries Michael K. Abraham, MD, MS a,b, *, Sara Scott, MD a,c KEYWORDS Hand and wrist injuries Emergency physician Emergent evaluation Treatment
More informationCERVICAL SPINE CLEARANCE
DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care
More informationWrist Fracture. Please stick addressograph here
ORTHOPAEDIC UNIT: 01-293 8687 /01-293 6602 UPMC BEACON CENTRE FOR ORTHOPAEDICS: 01-2937575 PHYSIOTHERAPY DEPARTMENT: 01-2936692 GUIDELINES FOR PATIENTS FOLLOWING WRIST FRACTURE Please stick addressograph
More informationFracture Care Coding September 28, 2011
Fracture Care Coding September 28, 2011 Julie Edens Leu, CPC, CPCO, CPMA, CPC-I 1 Disclaimer Every reasonable effort has been made to ensure that the educational material provided today is accurate and
More informationThe 10 Most Common Hand Pathologies In Adults. 1. Carpal Tunnel and Cubital Tunnel
The 10 Most Common Hand Pathologies In Adults Bobbi Jacobsen PA C 1. Carpal Tunnel and Cubital Tunnel CARPAL TUNNEL (median nerve) ( ) Pain and numbness Distal, proximal radiating Sensory disturbance Distribution
More informationWe studied 45 patients with 46 fractures of the
Patterns of healing of scaphoid fractures THE IMPORTANCE OF VASCULARITY R. W. Kulkarni, R. Wollstein, R. Tayar, N. Citron From the St Helier Hospital, Carshalton, England We studied 45 patients with 46
More informationClinical guidance for MRI referral
MRI for cervical radiculopathy Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected: cervical radiculopathy
More informationAnkle Injury/Sprains in Youth Soccer Players Elite Soccer Community Organization (ESCO) November 14, 2013
Ankle Injury/Sprains in Youth Soccer Players Elite Soccer Community Organization (ESCO) November 14, 2013 Jeffrey R. Baker, DPM, FACFAS Weil Foot and Ankle Institute Des Plaines, IL Ankle Injury/Sprains
More informationElbow Injuries and Disorders
Elbow Injuries and Disorders Introduction Your elbow joint is made up of bone, cartilage, ligaments and fluid. Muscles and tendons help the elbow joint move. There are many injuries and disorders that
More informationName them. Clenched Fist A-P
Sports Injuries Not To Misdiagnose LtCol Fred H. Brennan, Jr., DO, FAOASM, FAAFP, FACSM Head Team Physician, University of New Hampshire Deputy Commander, 157 th Medical Group, Pease ANGB To improve the
More informationDiagnosis of Acromioclavicular Joint Injuries
PO Box 15 Rocky Hill, CT 06067 (860) 463-9003 Chiroeducation@aol.com www.chirocredit.com ChiroCredit.com is proud to present a section from one of our continuing education programs: Physical Diagnosis
More informationMusculoskeletal MRI Technical Considerations
Musculoskeletal MRI Technical Considerations Garry E. Gold, M.D. Professor of Radiology, Bioengineering and Orthopaedic Surgery Stanford University Outline Joint Structure Image Contrast Protocols: 3.0T
More informationArthroscopy of the Hand and Wrist
Arthroscopy of the Hand and Wrist Arthroscopy is a minimally invasive procedure whereby a small camera is inserted through small incisions of a few millimeters each around a joint to view the joint directly.
More informationWe compared the long-term outcome in 61
Fracture of the carpal scaphoid A PROSPECTIVE, RANDOMISED 12-YEAR FOLLOW-UP COMPARING OPERATIVE AND CONSERVATIVE TREATMENT B. Saedén, H. Törnkvist, S. Ponzer, M. Höglund From Stockholm Söder Hospital,
More informationWrist Fractures: What the Clinician Wants to Know 1
What the Clinician Wants to Know Charles A. Goldfarb, MD Yuming Yin, MD Louis A. Gilula, MD Andrew J. Fisher, MD Martin I. Boyer, MD Index terms: Bones, CT, 43.1211 Wrist, fractures, 43.41 Wrist, MR, 43.12141,
More informationCommon Hand and Wrist Conditions: When to Refer? Dr Tim Heath
Common Hand and Wrist Conditions: When to Refer? Dr Tim Heath Difficult Balance Many hand conditions can be managed non-operatively / simply Missed injury or delayed diagnosis not uncommon Common Problems
More informationWrist and Hand Injuries Keep Your Edge: Hockey Sports Medicine 2015 Toronto, Canada August 28-30
Wrist and Hand Injuries Keep Your Edge: Hockey Sports Medicine 2015 Toronto, Canada August 28-30 Steven E. Rokito, MD Division Chief, Sports Medicine, NSLIJ Associate team orthopedist NY Islanders Wrist
More informationPatient Prep Information
Stereotactic Breast Biopsy Patient Prep Information Imaging Services Cannon Memorial Hospital Watauga Medical Center Table Weight Limits for each facility Cannon Memorial Hospital Watauga Medical Center
More informationWhether a physician is
ILLUSTRATIONS BY SCOT BODELL Hand and Wrist Injuries: Part I. Nonemergent Evaluation JAMES M. DANIELS II, M.D., M.P.H., Southern Illinois University School of Medicine, Quincy, Illinois ELVIN G. ZOOK,
More informationRadiological diagnosis of injuries following Fall on outstretched hand (FOOSH)
snap to grid Radiological diagnosis of injuries following Fall on outstretched hand (FOOSH) Core Radiology Clerkship Beth Israel Deaconess Medical Center Ziad Obermeyer, MS4 Gillian Lieberman, MD 18 September
More informationForearm Fractures 09/18/2013. Mechanism: Usually a fall on an outstretched arm. Incidence. Mechansim
September 20, 2013 Amanda Taylor PA-C Children s Orthopaedics of Louisville Forearm Fractures Incidence 40-50% of all pediatric fractures Mechansim Wide range of mechanism Mechanism: Usually a fall on
More information.org. Ankle Fractures (Broken Ankle) Anatomy
Ankle Fractures (Broken Ankle) Page ( 1 ) A broken ankle is also known as an ankle fracture. This means that one or more of the bones that make up the ankle joint are broken. A fractured ankle can range
More informationInsufficiency fracture of the tibial plateau : An often missed diagnosis
Acta Orthop. Belg., 2006, 72, 587-591 ORIGINAL STUDY Insufficiency of the tibial plateau : An often missed diagnosis Narayana PRASAD, Judy M. MURRAY, Deepak KUMAR, Stephen G. DAVIES From the Royal Glamorgan
More informationThe Dilemmas of a Scaphoid Fracture: A Difficult Diagnosis for Primary Care Physicians
Clinical Review Article The Dilemmas of a Scaphoid Fracture: A Difficult Diagnosis for Primary Care Physicians Ryan Nishihara, MD Scaphoid fractures account for 2% to 7% of all orthopedic fractures, 1
More informationScaphoid Non-union. Dr. Mandel Dr. Gyomorey. May 3 rd 2006
Scaphoid Non-union Dr. Mandel Dr. Gyomorey May 3 rd 2006 Introduction Scaphoid fracture incidence: 8-38/100,000 Non-union 5% (0-22%) Adams and Leonard (1928) first described operative treatment of the
More information.org. Lisfranc (Midfoot) Injury. Anatomy. Description
Lisfranc (Midfoot) Injury Page ( 1 ) Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of the injury can vary from simple
More informationBack & Neck Pain Survival Guide
Back & Neck Pain Survival Guide www.kleinpeterpt.com Zachary - 225-658-7751 Baton Rouge - 225-768-7676 Kleinpeter Physical Therapy - Spine Care Program Finally! A Proven Assessment & Treatment Program
More informationWhiplash injuries can be visible by functional magnetic resonance imaging. Pain Research and Management Autumn 2006; Vol. 11, No. 3, pp.
Whiplash injuries can be visible by functional magnetic resonance imaging 1 Bengt H Johansson, MD FROM ABSTRACT: Pain Research and Management Autumn 2006; Vol. 11, No. 3, pp. 197-199 Whiplash trauma can
More informationImaging of Lisfranc Injury
November 2011 Imaging of Lisfranc Injury Greg Cvetanovich, Harvard Medical School Year IV Agenda Case Presentation Introduction Anatomy Lisfranc Injury Classification Imaging Treatment 2 Case Presentation
More informationShoulder Pain and Weakness
Shoulder Pain and Weakness John D. Kelly IV, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 11 - NOVEMBER 2004 For CME accreditation information, instructions and learning objectives, click here. A
More informationASOP Exams PO Box 7440 Seminole, FL 33775. The Manual of Fracture Casting & Bracing Exam 80% Passing ID # Name Title. Address. City State Zip.
The Manual of Fracture Casting & Bracing Exam 80% Passing ID # Name Title Address City State Zip Tel# Email Certification Organization Cert# Mail a copy of your completed exam to: ASOP Exams PO Box 7440
More informationAugust 1st, 2006. Scaphoid Fractures. Dr. Christine Walton, PGY 2 Orthopedics
August 1st, 2006 Scaphoid Fractures Dr. Christine Walton, PGY 2 Orthopedics Injury Patterns to the Carpal Bones 1) Perilunate pattern injuries 2) Axial pattern injuries 3) Local impaction/avulsion injuries
More informationDOCKET NO. 453-03-3331.M5 MDR Tracking No. M5-03-0917-01 TEXAS IMAGING AND DIAGNOSTIC BEFORE THE STATE OFFICE CENTER PETITIONER
DOCKET NO. 453-03-3331.M5 MDR Tracking No. M5-03-0917-01 TEXAS IMAGING AND DIAGNOSTIC BEFORE THE STATE OFFICE CENTER PETITIONER V. OF CONTINENTAL CASUALTY COMPANY RESPONDENT ADMINISTRATIVE HEARINGS DECISION
More informationRadiologic Science Degree Completion Program. 2011-2012 Assessment Report
Radiologic Science Degree Completion Program 2011-2012 Assessment Report I. Introduction II. III. Mission, Objectives, and Student Learning Outcomes a. Radiologic Science Degree Completion Program Mission
More informationPediatric Sports Injuries of the Wrist and Hand. Sunni Alford, OTR/L,CHT Preferred Physical Therapy
Pediatric Sports Injuries of the Wrist and Hand Sunni Alford, OTR/L,CHT Preferred Physical Therapy Wrist injuries TFCC ECU/ FCU tendonitis Instability Growth Plate Fractures Ulnar abutment syndrome Triangular
More informationMR Imaging of the Anatomy of and Injuries to the Lateral and Posterolateral Aspects of the Knee
Downloaded from www.ajronline.org by 37.44.192.158 on 07/15/16 from IP address 37.44.192.158. opyright RRS. For personal use only; all rights reserved Pictorial Essay MR Imaging of the natomy of and Injuries
More informationOsteochondritis Dissecans of the Knee Sonographically Guided Percutaneous Drilling
Technical dvance Osteochondritis Dissecans of the Knee Sonographically Guided Percutaneous Drilling Juan D. erná-serna, MD, Francisco Martinez, MD, Manuel Reus, MD, Juan D. erná-mestre, MD Objective. The
More informationMaricopa Integrated Health System: Administrative Policy & Procedure
Maricopa Integrated Health System: Administrative Policy & Procedure Effective Date: 03/05 Reviewed Dates: 09/05, 9/08 Revision Dates: Policy #: 64500 S Policy Title: Cervical & Total Spine Clearance and
More informationTreat to Target Approach in Rheumatoid Arthritis: UK perspective. Dr Deirdre Shawe, North Hampshire Hospital, Basingstoke, UK
Treat to Target Approach in Rheumatoid Arthritis: UK perspective Dr Deirdre Shawe, North Hampshire Hospital, Basingstoke, UK What is the target? To achieve remission or low disease activity in Rheumatoid
More informationWestmount UCC 751 Victoria Street South, Kitchener, ON N2M 5N4 519-745-2273 Fairway UCC 385 Fairway Road South, Kitchener, ON N2C 2N9 519-748-2327
K-W URGENT CARE CLINICS INC. Westmount UCC 751 Victoria Street South, Kitchener, ON N2M 5N4 519-745-2273 Fairway UCC 385 Fairway Road South, Kitchener, ON N2C 2N9 519-748-2327 OPEN Mon-Fri 8am-5pm, Sa
More informationThe Wrist I. Anatomy. III. Wrist Radiography Typical wrist series: Lateral Oblique
monteleoneg@wvuh.com The Wrist I. Anatomy The wrist is a complex system of articulations comprising 27 articular surfaces among the radius, ulna, carpus, and metacarpals. It is generally agreed that the
More informationCalcaneus (Heel Bone) Fractures
Copyright 2010 American Academy of Orthopaedic Surgeons Calcaneus (Heel Bone) Fractures Fractures of the heel bone, or calcaneus, can be disabling injuries. They most often occur during high-energy collisions
More information.org. Tennis Elbow (Lateral Epicondylitis) Anatomy. Cause
Tennis Elbow (Lateral Epicondylitis) Page ( 1 ) Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can
More informationMissed Radiologic Injuries
Missed Radiologic Injuries Michelle Lin, MD Associate Residency Director, UCSF-SFGH Emergency Medicine Residency Assistant Clinical Professor of Medicine, UC San Francisco San Francisco General Hospital,
More informationThe Elbow, Forearm, Wrist, and Hand
Elbow - Bones The Elbow, Forearm, Wrist, and Hand Chapters 23 & 24 Humerus Distal end forms the medial & lateral condyles Lateral: capitulum Medial: trochlea Radius Ulna Sports Medicine II Elbow - Bones
More informationGeorge E. Quill, Jr., M.D. Louisville Orthopaedic Clinic Louisville, KY
George E. Quill, Jr., M.D. Louisville Orthopaedic Clinic Louisville, KY The Ankle Sprain That Won t Get Better With springtime in Louisville upon us, the primary care physician and the orthopaedist alike
More informationComparison Of Ct And Plain Film For The Postoperative Assessment Of Scaphoid Fracture Healing
Yale University EliScholar A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine January 2011 Comparison Of Ct And Plain Film For The Postoperative
More informationAAOS Guideline of The Diagnosis and Treatment of Osteochondritis Dissecans
AAOS Guideline of The Diagnosis and Treatment of Osteochondritis Dissecans Summary of Recommendations The following is a summary of the recommendations in the AAOS clinical practice guideline, The Diagnosis
More informationA Patient's Guide to Arthritis of the Finger Joints
Introduction A Patient's Guide to Arthritis of the Finger Joints When you stop to think about how much you use your hands, it's easy to see why the joints of the fingers are so important. Arthritis of
More informationScaphoid Fractures 1
1 Scaphoid Fractures Scaphoid Fractures Introduction Anatomy Biomechanics History Clinical examination Radiographic evaluation DDx Classification Treatment Complications 2 Scaphoid fractures Introduction
More informationTest Request Tip Sheet
With/Without Contrast CT, MRI Studies should NOT be ordered simultaneously as dual studies (i.e., with and without contrast). Radiation exposure is doubled and both views are rarely necessary. The study
More informationAn Integrated Approach to Lung Cancer in a Community Setting
An Integrated Approach to Lung Cancer in a Community Setting The multidisciplinary thoracic clinic at Erie Regional Cancer Center by Jan M. Rothman, MD, and Shelley D. KuBaney, RN, OCN 40 OI May June 2013
More informationTreatment Guide Understanding Elbow Pain. Using this Guide. Choosing Your Care. Table of Contents:
Treatment Guide Understanding Elbow Pain Elbow pain is extremely common whether due to aging, overuse, trauma or a sports injury. When elbow pain interferes with carrying the groceries, participating in
More informationTreatment Guide Understanding Hand and Wrist Pain. Using this Guide. Choosing Your Care
Treatment Guide Understanding Hand and Wrist Pain With how much we rely on our hands, there s no wonder hand and wrist pain can be so disabling and frustrating. When this pain interferes with typing on
More informationSports Injury Treatment
Sports Injury Treatment Participating in a variety of sports is fun and healthy for children and adults. However, it's critical that before you participate in any sport, you are aware of the precautions
More informationSports Related Injuries of the Hand, Wrist and Elbow. Melissa Nayak, M.D. Department of Orthopaedics Division of Sports Medicine
Sports Related Injuries of the Hand, Wrist and Elbow Melissa Nayak, M.D. Department of Orthopaedics Division of Sports Medicine Injury triage History, mechanism of injury (MOI) Assess extent of swelling,
More informationAbstract Objective: To review the mechanism, surgical procedures, and rehabilitation techniques used with an athlete suffering from chronic anterior
Abstract Objective: To review the mechanism, surgical procedures, and rehabilitation techniques used with an athlete suffering from chronic anterior glenohumeral instability and glenoid labral tear. Background:
More informationUpper extremity fractures are
Common Forearm Fractures in Adults W. SCOTT BLACK, MD, University of Kentucky Department of Family and Community Medicine, Lexington, Kentucky JONATHAN A. BECKER, MD, University of Louisville Department
More informationHamstring Apophyseal Injuries in Adolescent Athletes
Hamstring Apophyseal Injuries in Adolescent Athletes Kyle Nagle, MD MPH University of Colorado Department of Orthopedics Children s Hospital Colorado Orthopedics Institute June 14, 2014 Disclosures I have
More informationImaging of Hand in Rheumatoid Arthritis with CR, US and MRI. Azar Bahrami, PGY4 Radiology Rounds Jan, 31, 2007
Imaging of Hand in Rheumatoid Arthritis with CR, US and MRI Azar Bahrami, PGY4 Radiology Rounds Jan, 31, 2007 Introduction RA most common type of inflammatory Arthritis with prevalence of 1% Accurate and
More informationSonography of Partial-Thickness Quadriceps Tendon Tears With Surgical Correlation
Article Sonography of Partial-Thickness Quadriceps Tendon Tears With Surgical Correlation Samuel La, MD, David P. Fessell, MD, John E. Femino, MD, Jon A. Jacobson, MD, David Jamadar, MB, BS, Curtis Hayes,
More informationMeasure Title X RAY PRIOR TO MRI OR CAT SCAN IN THE EVAULATION OF LOWER BACK PAIN Disease State Back pain Indicator Classification Utilization
Client HMSA: PQSR 2009 Measure Title X RAY PRIOR TO MRI OR CAT SCAN IN THE EVAULATION OF LOWER BACK PAIN Disease State Back pain Indicator Classification Utilization Strength of Recommendation Organizations
More informationICD-9 and ICD-10 ORTHOPEDIC
ICD-9 and ICD-10 ORTHOPEDIC Payers and Providers Partnering for Success Shannon Chase, CPC, AHIMA Approved ICD-10-CM/PCS Trainer July 2014 ICD-9 & ICD-10 - ORTHOPEDIC AGENDA Importance of Documentation
More information9 DISTAL RADIUS AND ULNA FRACTURES
9: DISTAL RADIUS AND ULNA FRACTURES Rockwood and Wilkins Fractures in Children 9 DISTAL RADIUS AND ULNA FRACTURES PETER M. WATERS Classification Anatomy Physeal Injuries Diagnosis Treatment Options Complications
More information