Just me being confused, that's all. Trying to resolve my confusion. So we're going to do the two talks all in one. And I think these type of classifications, the top was orientation. I'm not sure that's a useful concept or not, but at the time it was thought to be mechanically useful, the Powell's classification. And I think the Herbert classification is very useful because it gets into issues like stability and fibrous union. I mean, he had a good sense of the things that matter, I think, but it gets a little overwhelming having so many different types to look at. And then you see a picture like this where people are trying to break it into fifths or areas that are probably too small to resolve reliably and accurately, even with modern imaging. So for me, classification's simple. Almost all of them are waist fractures. If you try to study scaphoids and you try to study proximal pole or distal tubercle, good luck, they're very, very uncommon. I've been trying to study them for 15 years. And even the waist fractures aren't as common as we think. But almost most of it's waist. There's some tubercle fractures. This one, and then they're often smaller than that. And the proximal pole fractures. And trying to figure out the line between proximal pole and waist sometimes is not easy. We're working on that as well. And the key element, I think, that we've recognized is displacement. I'll talk about instability as well. That's a little bit less clear, but a fracture with a crack in it, bone with a crack in it. And the analogy I use is like a broken bat. A baseball player swings and breaks his bat. It looks like a good bat to you and I, but he goes and gets another one. It's got a crack in it. It doesn't work as well, but it's solid. You can swing it, as opposed to one that shatters and flies across the field. So that's a displaced fracture versus a non-displaced fracture. So how do we define displacement? There's a bit of argument on that. And how do we measure it? I define it more or less as I just described. Whether it's still together as one bone or not. And the problem is, the case, again, it's just confusion. So this is a person I took care of. And at first, I'm not even sure the guy has a fracture. But if you look close, you can see a fracture. It's hard to see. There's no translation. There's no signet ring sign. There's no DZ. I'll go back. There's no DZ. And that's a CT scan. And Bob Strouk wrote an evidence-based medicine article that I recommend to you, for me, because he was trying to deal with this. I mean, if this one obviously has a translation vorally, this is clearly unstable and displaced. But you'll see some of these impacted. If it's impacted and angulated and angled at the top, but stable, if it moves as one and angled at the top, is that displaced or non-displaced? How much of a gap is displacement? This is probably about one or two millimeters, but is one too much? So we don't really know. But I think this fracture has a different prognosis than the ones that are just a crack. And this is what it looks like when you look through the mid-carpal joint. You can move it around and stick a probe in it, and it's gapped and moved apart. So we got interested in this. And what we do is we just talk with people about meetings like this. Somebody may come up to me after this talk. And we say, this is what we're looking at. This is what we're interested. Well, there was a group in Sweden. They were Danish guys in Sweden that were doing this study. It's a pretty crazy study. You can do different things in different cultures. They scoped every single fracture. They scoped suspected fractures. They scoped everything. And it was part of a protocol to look at these things. So they had this fracture, which I think everybody would agree is hard to see. I had to put a big arrow on there. And then look at it on a CT scan. That is very hard to see. And it's a decent cut. Maybe there are other cuts. And then you open up, and then that looks, there's cartilage intact here. And you can't move it. So that's, I think that counts as a nondisplaced fracture. And then here's one. You can see it a little bit more, but still not very impressive. Still not impressive on the CT scan. And this one moves. So what this means, I don't know. But when we looked at their data, and then we had some data where we did some of them, we offered people surgery. And then when they did surgery, we scoped them as well. But we didn't scope every fracture. We put our data together, and we found that there were fractures that were unstable that were nondisplaced on CT scan. Now, what does that mean? I don't know. Does that affect healing or prognosis? Does that guide treatment? Nobody knows. That's a totally unanswered question. Personally, if I see this on a CT scan, I'm gonna recommend nonoperative treatment. But there is this issue to be resolved. So I think the classification's relatively straightforward. We're mostly talking about waist fractures. The distal ones are mostly, the tubercle are the different from the distal waist. And then the proximal, polar, and unusual type of fracture that we're not sure right where the cutoff point is. The displacement is the most important factor in union and prognosis, but we don't have a reference standard for displacement. And we're not sure how to define it and how to measure it. The best we can do is CT scan in the plane of the scaphoid, but even that isn't perfect. The next step, we're looking at whether we could see movement on a fluoroscopy. So we're starting to enroll people and get a CT scan as sort of the reference standard, not doing a scope on everybody, and then putting under the fluoro in the office and seeing whether we can see it move. Only enrolled one or two patients in that, but that's the kind of things that we're thinking about. And then it's a long way off from deciding whether what that has anything to do with prognosis.

scaphoid fractures

classification

displacement

CT scans

fluoroscopy