Ann R Coll Surg Engl 2008; 90: 488-491 488Carpal injuries are common presentations to emergency departments, general practitioners and orthopaedic clinics. The scaphoid bone is the most commonly injured of the carpal bones accounting for 50-80% of carpal injuries and predominantly occurs in young. healthy individuals.
1,2Scaphoid fractures are the most problematic to diagnose in a clinical setting because it can take up to 6 weeks for scaphoid fractures to become conclusive on plain X-ray films. It is estimated that up to 40% of scaphoid fractures are missed at first presentation. 3,4 A recent metaanalysis of scaphoid fractures calculated that the positive predictive value of clinical examination (those who proved to be 'clinical scaphoid' warranted X-rays of scaphoid views who subsequently had scaphoid fracture) is in the range 13-69% with an average of 21%.
5This means that four out of five patients without a fracture will be unnecessarily immobilised before radiological diagnosis is confirmed.
Patients and MethodsWe conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a district general hospital. Patients with negative X-ray findings but positive clinical signs for scaphoid injury satisfied the criteria for CT. We defined clinical signs for a scaphoid injury as tenderness over the anatomical snuffbox, pain on axial loading of first metacarpal and tenderness over scaphoid tubercle in the presence of normal plain films and included patients whose plain X-rays proved inconclusive.Patients with clinical indications of scaphoid fracture but negative plain films had their wrists immobilised in a scaphoid cast in the accident unit while awaiting a hand clinic appointment.CT scans, where necessary, were carried out on the same day as review on the first presentation to the fracture