Scaphoid fracture
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Scaphoid fracture - diagnosis

Clinical examination and plain x-rays are known to be poor at identifying scaphoid fractures immediately after the injury. Retrospective studies suggest that 10-33% of patients with a proven fractured scaphoid had no fracture visible on the initial plain films1,2 In patients with clinical findings suggestive of fractured scaphoid, and normal scaphoid views, current practice in many institutions is to immobilise in plaster for 10 days before a repeat clinical examination and plain x-ray3 This practice has evolved to minimise the risk of long-term morbidity associated with missed fracture of scaphoid: osteoarthritis of the wrist4, long-term functional disability and chronic pain5

It is also known that relatively few 2-15%6,7 of patients immobilised will subsequently be shown to have a fracture. Therefore many patients are unnecessarily immobilised. This is a condition that typically afflicts young active patients8 , and may incur a significant cost to the individual and community in terms of lost working days. Furthermore, prolonged plaster immobilisation and activity restriction can result in a significant loss of bone mineral and muscle mass in a few weeks9.

Current practice & use of CPGs is variable.

Only a minority of institutions have protocols for diagnosis & management of scaphoid injuries and current practice is variable.10 The studies in the literature advocate various diagnostic options .11
  • Plaster immobilisation and repeat examination & x-rays in 10 days,
  • Bone Scan (Day 4 or Day 10),
  • MRI (early or Day 10),
  • Ultrasound11
  • CT

Go to our evidence page for a more detailed literature review on each of the modalities.

There are several studies advocating that MRI is the new reference standard, although even some of the larger studies have been questioned12-14 Recent evidence suggested that radiologists are reluctant to recommend MRI, with much support for the use of plain film radiography with the modality being praised for its ease, 24-h availability, low cost and reproducibility, 15

References

[5]        Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the ED: scaphoid fracture. The American journal of emergency medicine. 2001; 19: 310-6.
[6]        Waizenegger M, Wastie ML, Barton NJ, Davis TR. Scintigraphy in the evaluation of the "clinical" scaphoid fracture. Journal of hand surgery (Edinburgh, Scotland). 1994; 19: 750-3.
[8]        Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. The Journal of the American Academy of Orthopaedic Surgeons. 2000; 8: 225-31.
[9]        Pillai A, Jain M. Management of clinical fractures of the scaphoid: results of an audit and literature review. Eur J Emerg Med. 2005; 12: 47-51.
[12]      Brydie A, Raby N. Authors' reply. Br J Radiol. 2003; 76: 923-a-24.
[14]      Robinson P. Gold--now you see it, now you don't. Br J Radiol. 2003; 76: 923-.
[15]      Trigg M, Reeves PJ. The efficacy of plain films vs MRI in the detection of scaphoid fractures. Radiography. 2007; 13: 56-64.
 

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