Evaluating the management of scaphoid injuries – From the emergency department to the fracture clinic

Abstract

Aim: To evaluate the assessment and decision making in suspected scaphoid fractures by emergency medicine orthopaedic staff. Introduction: Scaphoid fracturesmayprogress to chronic arthrosis and this has led to over-treatment of clinically suspected scaphoid fractures. Currently, there is a lack of consensus regarding clinical and radiological tests used for diagnosis. Materials and methods: Casenotes were identified by ICD codes for patients with wrist, scaphoid and distal radius injuries (n=142)whopresented to our institution between01/02/2007 and 31/07/2007. Patients with suspected or confirmed scaphoid fracture, who attended subsequent fracture clinic, were included in the analysis (n=38). Data analyzed included the grade of assessor, adequacy of clinical examination, adequacy of radiographs, mode of treatment and clinical outcome. Results: In the emergency department, 50% (n=19/38) of patients were reviewed by an Emergency Nurse Practitioner or junior doctor. Scaphoid views were taken in 71% (n=27). Clinical examination was complete in 21% (n=8). Thirty-two percent (n=12) had a scaphoid fracture on initial radiography. Ninety-two percent (n=35) were immobilized in plaster of Paris. No patient was discussed with the orthopaedic team. The mean time to fracture clinic was 12 days. In fracture clinic, clinical examination was complete in 27% (7/26) of those with negative initial radiographs. Fifty-fivepercent (n=14)underwent repeat plain radiography. Two further scaphoid fractures were identified. Twenty-nine percent were discharged after their first clinic attendance. Conclusion: Management of potential scaphoid injuries have been shown to be sub-optimal. This has led to unnecessary plaster cast immobilization and follow-up inmany cases. However, the potentially disasterous consequences affecting a young and active population justify current evidence based guidelines to address management shortfalls.