Predictors of fracture following suspected injury to the scaphoid

Abstract

A prospective study was performed to develop a clinical prediction rule that incorporated demographic and clinical factors predictive of a fracture of the scaphoid. Of 260 consecutive patients with a clinically suspected or radiologically confirmed scaphoid fracture, 223 returned for evaluation two weeks after injury and formed the basis of our analysis. Patients were evaluated within 72 hours of injury and at approximately two and six weeks after injury using clinical assessment and standard radiographs. Demographic data and the results of seven specific tests in the clinical examination were recorded. There were 116 (52%) men and their mean age was 33 years (13 to 95; SD 17.9). In 62 patients (28%) a scaphoid fracture was confirmed. A logistic regression model identified male gender (p = 0.002), sports injury (p = 0.004), anatomical snuff box pain on ulnar deviation of the wrist within 72 hours of injury (p < 0.001), and scaphoid tubercle tenderness at two weeks (p < 0.001) as independent predictors of fracture. All patients with no pain at the anatomical snuff box on ulnar deviation of the wrist within 72 hours of injury did not have a fracture (n = 72, 32%). With four independently significant factors positive, the risk of fracture was 91%. Our study has demonstrated that clinical prediction rules have a considerable influence on the probability of a suspected scaphoid fracture. This will help improve the use of supplementary investigations where the diagnosis remains in doubt.

Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures

“…probability of true scaphoid fracture is hard to know, some investigators have tried to develop clinical prediction rules for this probability of true fracture after suspected injury to the scaphoid. 14,30 It is important to note that our results are most relevant to the US societal context and on the basis of the societal perspective. Costs of healthcare and lost productivity differ between different countries.…”

“…The prevalence of true fracture among suspected scaphoid fracture was derived from studies that prospectively or consecutively recruited at least 50 patients with suspected scaphoid fractures and confirmed scaphoid fracture with MRI or radiographs with follow-up of at least 6 weeks. 4,6,[14][15][16][17][18][19][20][21][22] The weighted mean (the numbers of patients with a clinical condition reported in different studies were summed and then divided by the sum of the total number of patients in each study) was used as the baseline value, and the range obtained from these studies was used for the sensitivity analysis. One prospective study provided the probability of positive clinical signs of patients with suspected scaphoid fracture at 2 weeks after injury.…”

“…One prospective study provided the probability of positive clinical signs of patients with suspected scaphoid fracture at 2 weeks after injury. 14 We derived test performance characteristics from 3 meta-analyses. [23][24][25] Two studies 23,24 pooled the estimates of performance characteristics of MRI, CT, and bone scan for diagnosing a suspected scaphoid fracture using the repeat radiographs as the reference standard.…”

Sideline Coverage

“…1,23 Prereduction radiographs are likely unnecessary when experienced clinicians suspect an anterior shoulder dislocation. 28,32 There is some evidence that certain clinical findings may predict upper extremity fractures in injured athletes 5,6,13,16,26,40 ; however, decision rules for other injuries about the shoulder and wrist need further study before they can help guide sideline treatment.…”

“…Magnetic resonance imaging is of greater diagnostic value in patients with higher probability of fracture. 13 A prospective study of 260 patients was used to develop predictive demographic and clinical risk factors of scaphoid fractures. 13 The probability of fracture was 91% in patients with 4 positive results: (1) anatomic snuff box pain on ulnar deviation of the wrist within 72 hours of injury, (2) scaphoid tubercle tenderness at 2 weeks, (3) sports-related injury, and (4) male sex.…”