Management of suspected scaphoid fractures in accident and emergency departments – time for new guidelines

Abstract

INTRODUCTION The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid.SUBJECTS AND METHODS We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures. RESULTS The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines. CONCLUSIONS The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients.

Early MRI versus conventional management in the detection of occult scaphoid fractures: what does it really cost? A rural pilot study

“…There was only one confirmed scaphoid fracture in the total study population (demonstrated in the MRI group) and a total of 4 fractures, suggesting 75% of patients in this study were needlessly immobilised. These results mirror other studies, which suggest that the prevalence of true fractures is low 8, 10. MRI also detected other injuries outside of the scaphoid that may go undetected using conventional management techniques.…”

“…A clinically important proportion of scaphoid fractures are not demonstrated on a radiograph immediately after injury. Several authors have suggested that fractures of the scaphoid are occult in about 16% of cases on initial radiographs 8, 9, 10, 11…”

“…It is standard practice for patients to be immobilised in a plaster cast for 10–14 days, followed by repeated clinical examination and repeat radiographs 1, 7, 13, 14, 15. Patients may undergo serial radiographs and clinical review at intervals over several weeks until a definitive diagnosis is made 5, 8, 9, 12. It has been argued that the prevalence of true fractures is low, with 3 out of 4 patients needlessly immobilised 10, 12, 16.…”

“…Patients may be unable to work or perform their daily activities, with resultant loss of earnings. Unnecessary hospital attendance, diagnostic tests and plaster casting may result in costs to the patient, the hospital and society 1, 5, 8, 15…”

Diagnosis and treatment of scaphoid fracture

“…This type of injury also accounts for accounts for 1:10,000 attendances annually in Uk Emergency Departments (UK) (Tai, 2005). Between 5 -12 % of scaphoid fractures are related to other fractures (Malik et al, 2010).…”