Scaphoid tubercle tenderness: a better indicator of scaphoid fractures?

Abstract

SUMMARYTenderness in the anatomical snuff box (ASB) has long been accepted as an indicator of a possible scaphoid fracture. The longitudinal axis of the scaphoid lies in an anteroposterior plane, perpendicular to the remainder of the carpal bones, in the radially deviated wrist. The scaphoid tubercle can therefore be easily and accurately palpated on the palmar aspect of the radially deviated wrist.This study was devised to determine if tenderness over the scaphoid tubercle (ST) was superior to ASB tenderness in identifying definite fractures.Over a 10-month period 246 patients were seen who were suspected of having a scaphoid injury. Thirty (12%) were eventually proven to have definite fracture. Tenderness in the ASB had a sensitivity rate of 90% (95% confidence limits 80-100%) and specificity of 40% (33-47%) as an indicator of a definite fracture. ST tenderness had a sensitivity of 87% (75-99%) and specificity of 57% (50-64%). There is therefore no significant difference in the sensitivity between ASB and ST tenderness but ST tenderness is significantly more specific. However, the presence of either ASB or ST tenderness should be used in order to identify all fractures. Patients with neither ASB nor ST tenderness require symptomatic treatment only.

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

“…For example, whereas Grover 12 found the SCT to be 100% sensitive and 80% specific, Esberger 14 showed that it only had sensitivity of 71% and specificity of 22%. On the other hand, Freeland 15 found that the STT had a sensitivity of 87% and specificity of 57%, which notably, is more specific than the widely accepted ASB tenderness test. Pain over ASB on pronation followed by ulnar deviation of the affected wrist also gave a specificity of only 52%.…”

“…17,20,29 However, continued immobilisation without a definitive diagnosis may extend over several weeks, during which the patient is unable to live and work normally. Recent studies have shown that the incidence of proven scaphoid fractures from clinically suspected scaphoid fractures is only 2-12% 2,3,15,19 and, therefore, the need to treat all patients in full scaphoid cast is questionable. DaCruz et al 19 demonstrated that by resting all suspected scaphoid injuries in a broad arm sling initially and reassessing them within a week, the number of patients that required cast immobilisation was significantly reduced.…”

Adult Scaphoid Fracture

“…Fifteen studies published between 1982 and 2009 assessed the diagnostic accuracy for various physical examination tests, either in isolation or in combinations, including signs such as swelling or discoloration, as well as symptoms like anatomical snuffbox tenderness, scaphoid tubercle tenderness, clamp sign, resisted pronation or supination, thumb compression-induced pain, and US pain. 5,14,[17][18][19][21][22][23]39,[41][42][43][44][45][46] None were from the United States, and 12 were from Europe. These were all prospective case series, and 11 were ED-based, while two were orthopedic clinic studies and two did not report their clinical settings.…”

“…Alternatively, pain with digital pressure over the scaphoid tubercle may indicate scaphoid fracture. 14 The scaphoid tubercle is the palpable prominence at the level of the distal flexor crease of the extended and radial-deviated wrist (Data Supplement S2, available as supporting information in the online version of this paper). The Watson test, also called "the scaphoid shift," actually evaluates scapholunate pathology, but has been reported as a test for scaphoid fracture.…”

Comminuted Fractures of the Femoral Neck and Scaphoid

“…The patient also had point tenderness to palpation in the anatomical snuff box of the left wrist. 1 Due to concern for hip and wrist fractures, which are often radiographically occult initially after injury, the physical therapist ordered radiographs of the left …”