‘Clinical scaphoid fracture’: is it time to abolish this phrase?

Abstract

Most patients with post-traumatic painful wrists and negative radiographs are treated as having a clinical scaphoid fracture. Such cases are usually followed up with repeat radiographs. If the radiographs are inconclusive further imaging is done. However, this traditional approach results in the vast majority of patients being unnecessarily immobilised for an unspecified period, leading to loss of productivity and income to the patient and the community. A number of studies have highlighted the use of early CT or MRI scans to identify these fractures. The aim of this study was to evaluate our current practice in managing patients with suspected fractures of the scaphoid. A retrospective audit was carried out. The period studied was from January to August 2008. Fifty consecutive patients who were investigated for occult fractures of the scaphoid were included. 92% of the patients studied had a repeat radiograph in the fracture clinic. 84% of the patients had their wrists immobilised in a cast while awaiting further imaging. Only 6% had confirmed fracture of the scaphoid; all of these healed uneventfully. 76% of patients with negative scans had their wrists immobilised for an average period of 30.63 days. It is time we rethink this dogmatic approach to patients with clinical signs but negative radiographs. We recommend that patients with a painful wrist following an injury and negative radiographs should be referred early to an appropriate clinician and earlier recourse to advanced imaging should be advocated.