Adult Scaphoid Fracture

Abstract

ObjectivesScaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency medicine (EM) imaging studies for scaphoid fracture has not been previously described in the EM literature. Plain x‐rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial‐sided tenderness on physical examination. This study was a meta‐analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x‐ray in adult emergency department (ED) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after ED discharge.MethodsA medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED and EMBASE. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS‐2) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta‐analysis was conducted using Meta‐DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (LRs) for predictors of scaphoid fracture detected on follow‐up in patients with normal ED x‐rays.ResultsA total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non‐ED settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall QUADAS‐2 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult ED patients with concern for scaphoid injuries, nondiagnostic index x‐rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (LR– = 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (MRI) is superior to bone scan, computed tomography (CT), or ultrasound (US) to both rule in and rule out scaphoid fractures. Both MRI and CT share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.ConclusionsExcept for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. MRI is the most accurate imaging test to diagnose scaphoid fractures in ED patients with no evidence of fracture on initial x‐rays. If MRI is unavailable, CT is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.

Carpal and scaphoid fracture incidence in south-eastern Australia: an epidemiologic study

“…Annual incidence rates for all ages of 23-43 per 100,000 persons per year have been reported [7]. Scaphoid fractures are also problematic because diagnosis and treatment are difficult [8,9]. Scaphoid fractures are often complicated by non-union, osteonecrosis, tendon injuries and/or carpal tunnel syndrome, resulting in functional morbidity and eventual arthritic degeneration [7][8][9].…”

“…Scaphoid fractures are also problematic because diagnosis and treatment are difficult [8,9]. Scaphoid fractures are often complicated by non-union, osteonecrosis, tendon injuries and/or carpal tunnel syndrome, resulting in functional morbidity and eventual arthritic degeneration [7][8][9]. Additionally, presentation may be delayed when the injury is attributed to a wrist sprain instead of a more serious fracture event [10], resulting in higher levels of complications when treatment is commenced.…”

Review article: Best practice management of closed hand and wrist injuries in the emergency department (part 5 of the musculoskeletal injuries rapid review series)

“…This review identified recent and consistent evidence to support the early use of MRI for suspected scaphoid fractures, as earlier confirmation of diagnosis contributes to reduced immobilisation time, healthcare utilisation and costs . An Australian pilot study in a regional ED setting supported these results, indicating that MRI within 1–3 days following the ED presentation dramatically reduced unnecessary immobilisation and time off work, time of treatment and healthcare usage in their setting, with better patient pain and satisfaction scores than controls .…”

Improving the Quality of Imaging in the Emergency Department

“…In essence, a test does not add value to the care of the patient if neither a positive nor a negative test result will change the probability of a given diagnosis. Determining whether a diagnostic imaging test has the potential to affect estimates of disease probability requires knowledge not only of the test characteristics of the imaging modality, but also of the underlying pretest probability of disease, which depends on the diagnostic attributes of history, physical examination, and laboratory tests—parameters that are often understudied in ED settings …”

“…Other examples from emergency medicine (EM) have been reported. Carpenter and colleagues investigated imaging for possible occult scaphoid fracture and determined that magnetic resonance imaging has the potential to change treatment if the pretest suspicion for fracture is above 0.4%, with a treatment threshold of 80%. Similarly, Taylor and Lalani identified that imaging has the potential to change management for suspected small bowel obstruction if the pretest probability is greater than 1.5%, with a treatment threshold for nasogastric intubation of 20.7%.…”