Streamlining Definitive Care for Occult Scaphoid Fractures: A Retrospective Review of the Workup of Scaphoid Nonunions and Applying Lessons Learned

Abstract

Introduction The process for working up scaphoid fractures from frontline providers to the specialty care clinic is variable. Initial imaging can often be negative and the management algorithm is not clearly defined. Delays in diagnosis are a contributing factor to scaphoid nonunion. Fractures may not be identified by frontline providers on initial presentation because of radiographically occult injuries. If not treated promptly, scaphoid fractures may be complicated by nonunion, avascular necrosis, and osteoarthritis. Materials and Methods Retrospective review of scaphoid nonunions from 2017 to 2018 in a single tertiary care institution after internal review board approval was obtained (NMCSD.QI.2019.0003). Cases were identified using an ICD 10 search for “scaphoid (navicular) fracture non-union” and subtypes. Charts were examined for time between injury and presentation, injury and diagnosis, initial radiologic workup, and limited duty (LIMDU). Nonparametric statistical analysis for linear and categorical data was conducted using SPSS. A subgroup of patients who had a delay in diagnosis of greater than 30 days upon entering the medical system was further analyzed and identified as the “delayed diagnosis” cohort. Results In total, 30 patients with scaphoid nonunion were identified. Overall, 35% of patients had negative initial X-rays and averaged 42.1 days until diagnosis. In total, 100% of patients required at least one LIMDU period, averaging 1.4 periods, for a total of 6,404 days and 16% went on to a physical evaluation board (PEB). In 9 (30%) of these patients, injury was initially not identified upon entering the medical system resulting in average of 139.7 days until diagnosis; this became known as the delayed diagnosis subgroup. Further analysis of the delayed diagnosis subgroup demonstrated significantly more initial negative X-rays (P < .005) at a rate of 77% (7/9). A delay in diagnosis was significantly associated with PEB (R = 0.4, P = .031) with 33% of these patients going on to a PEB. Conclusions Delayed diagnosis of a scaphoid fracture is a contributing factor for excessive light duty, high rates of LIMDU utilization, and ultimately medical separation of service members. Overall, in all patients who had scaphoid nonunions, the average time to diagnosis was 42.1 days with 35% of patients presenting with negative initial imaging. A delayed diagnosis subgroup was identified and notable for a higher rate of initial negative X-rays, an average of 139.7 days until diagnosis, and a 33% PEB rate. In total, 77% of patients with a delay in diagnosis of more than 30 days had an initial negative X-ray. An evidence-based algorithm for diagnosing occult scaphoid fractures may prevent delays in diagnosis, thus increasing the readiness of active duty service members.

Clinical Faceoff: Strategies for Management of Suspected Scaphoid Fractures

“…According to that definition, our experience is that around 5% of MRI-detected fractures are nonunions benefiting from delayed surgery, even when most are immobilized in a cast within 2 weeks [4]. One study used billing codes to identify 30 scaphoid waist nonunions diagnosed at the Naval Medical Center in San Diego over a 2-year period and noted that 10 of 28 with wrist radiographs at the time of initial presentation had no visible scaphoid fracture [12]. It is also plausible that the risk of nonunion in these radiographically invisible fractures is greater without prompt cast immobilization.…”