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

The current management of scaphoid fractures in the emergency department across an Australian metropolitan public health service: A retrospective cohort study

BACKGROUND

Scaphoid fractures are commonly present to emergency departments (EDs), challenging medical practitioners to achieve accurate diagnosis and management. This is because of the prevalence of radiographically occult scaphoid fractures and complications associated with missed diagnoses. Clinical Guidelines are limited for treatment of suspected scaphoid fractures, and heterogeneity in the literature further complicates management. This study aimed to explore the differences in management between practitioners in the ED and determine if immobilizing clinically suspected scaphoid fractures is supported by current evidence. This study also aimed to establish if there are predictors to assist in the diagnosis of a scaphoid fracture in the ED.

METHODS

A retrospective cohort study analyzed clinical data from patient's charts who attended the ED for a scaphoid fracture in 2019. Using retrospective patient chart audits and a Data Extraction Form, the clinical data regarding the assessment, treatment, diagnosis, and follow-up outcomes were collected. Descriptive analysis and multivariable logistic regression were performed to assess current management and find out predictors of a scaphoid fracture.

RESULTS

There was significance between practitioners performing physical assessments and providing treatment (P < .001). Physiotherapists performed assessment and education combined treatment more frequently than nurse practitioners and doctors. Thirty-four cases (11.7%) were negative for fracture in ED and positive in follow-up at the orthopedic clinic. There was an estimated loss of income of $327,433.60 (Australian dollar) for 221 patients who missed work due to overtreatment with immobilization. The strongest predictors for a confirmed scaphoid fracture were of male gender (odds ratio, 3.2; 95% confidence interval, 2.1-5.0; P < .001) and a positive x-ray in ED (odds ratio, 36.6; 95% confidence interval, 17.4-77.0; P < .001).

CONCLUSION

Management of scaphoid fractures across the Gold Coast Hospital Health Service ED followed commonly accepted practices involving x-ray and immobilization; however, this conservative approach to management is associated with increased health costs and low rates of conversion to a confirmed scaphoid fracture. Male gender was the only significant predictor associated with a scaphoid fracture.

Evaluating cone-beam CT in the diagnosis of suspected scaphoid fractures in the emergency department: preliminary findings

OBJECTIVES

Scaphoid fractures are challenging to accurately diagnose with delayed and missed diagnoses risking poor patient outcomes. Cone beam CT (CBCT) is an emerging technology facilitating alternative access to multi-planar imaging. The aim of this study was to evaluate the use of early CBCT in the diagnosis of suspected scaphoid fractures presenting via the Emergency Department (ED).

METHODS

In this single centre the imaging pathway was adapted to include early CBCT in adult patients with a persisting high index of clinical suspicion for scaphoid fracture despite normal radiographs. Evaluation of referrals between September 2019 and February 2020 was undertaken. Statistical analysis and temporal pathway metrics were assessed including interrater agreement for CBCT and radiography examinations.

RESULTS

Over the six-month timeframe 100 CBCT wrist scans were performed on 99 adult patients. 94% of CBCT scans were performed within 1 day of referral. 25% of scans demonstrated acute injuries including 12 radius, 6 trapezium and 2 scaphoid fractures. For fracture, CBCT had a sensitivity of 96.2% and specificity of 100%. There was a highly significant difference in interobserver variation between fracture detection on CBCT and radiographs.

CONCLUSION

CBCT heralds the potential for early accurate diagnosis of radiocarpal fractures, at lower cost, shortening clinical pathways and reducing clinical risk in the ED.

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

INTRODUCTION

To compare the cost-effectiveness and patient impact between acute magnetic resonance imaging (MRI) management and conventional management in the diagnosis of occult scaphoid fractures in a rural setting.

METHODS

Consecutive patients presenting to a rural emergency department (ED) with a suspected scaphoid fracture were randomly assigned to either conventional management (6) or acute MRI management (10) (3 patients were excluded from the study analysis). All healthcare costs were compared between the two management groups and potential impacts on the patients' pain, mobility and lifestyle were also measured.

RESULTS

There were no significant differences between the two groups at baseline. There was one (10%) scaphoid fracture in the MRI group and none in the conventional group (P = 0.42). A larger proportion of other fractures were diagnosed in the MRI group (20% (2) vs. 16.7% (1), P = 0.87), as well as less clinic attendances (1 (0-2.25) vs. 4 (2.25-5)) and diagnostic services (1 (1-1.25) vs. 2 (1-3)). Median management costs were $485.05 (AUD) (MRI) and $486.90 (AUD) (conventional). The MRI group had better pain and satisfaction scores as well as less time of immobilisation, treatment and time off work.

CONCLUSION

MRI dramatically reduces the amount of unnecessary immobilisation, time of treatment and healthcare usage in a rural setting. The two protocols are suggested to be equivalent financially. When potential societal costs, the amount of unnecessary immobilisation, low prevalence of true fractures and patient satisfaction are considered, acute MRI should be the management technique of choice. Further studies are still required to assess the best method for managing bone bruise within the scaphoid.

Scaphoid fractures: a higher order analysis of clinical tests and application of clinical reasoning strategies

INTRODUCTION

The purpose of this study was to identify clinical tests for scaphoid fractures and, using a higher order analysis, to determine their diagnostic accuracy.

METHODS

A literature review of the databases CINAHL, Embase, Medline and PUBMED from 1980 to September 30, 2011 was conducted to obtain applicable literature on clinical tests used in identifying scaphoid fractures. Methodological quality was determined using the criteria for validity suggested by Sackett et al (2000). Using a random effects model, pooled positive likelihood ratios (PPLR) were established for any test evaluated in at least 3 published studies. Moderator analyses provided insight into heterogeneity of results.

RESULTS

Higher order analysis indicated that the scaphoid compression test, anatomical snuffbox tenderness and scaphoid tubercle tenderness demonstrated statistically significant ability to identify scaphoid fractures with PPLR of 2.37 (1.27-4.41), 1.52 (1.12-2.06) and 1.67 (1.33-2.09) respectively. Descriptive factors (gender and mechanism of injury) were also identified but did not demonstrate significant diagnostic ability. Pooled data revealed the existence of heterogeneity for the three clinical tests and descriptive factors, which could not be easily explained.

CONCLUSION

Three clinical tests with statistically significant diagnostic validity were identified. In isolation, the clinical significance of each is questionable. Further studies with description of sample characteristics, blinded assessments, and agreement on a reference standard are recommended.

Early MRI diagnostics for suspected scaphoid fractures subsequent to initial plain radiography

AIM

In the United Kingdom, diagnostic management of patients presenting to emergency department with a scaphoid injury varies. Follow-up plain radiographs, after an initial inconclusive X-ray, are common practice. We optimised the diagnostic pathway for these patients by focusing on the most appropriate diagnostic modality and on minimising the time to follow-up diagnostics.

MATERIALS AND METHODS

A baseline audit in the period 2008-2009 involving a total of 184 patients was conducted, and after the introduction of new local guidelines for scaphoid injury diagnostics, a follow-up audit involving 79 patients was undertaken in 2010-2012.

RESULTS

In the original audit, 130 patients had only scaphoid radiographs, of which 23 underwent initial and follow-up X-rays, and 107 initial-only radiographs. Of those 23, just one single patient (4%) displayed a scaphoid fracture. Others underwent three imaging procedures: initial radiographs, follow-up radiographs and either bone scan (41 patients) or MRI (13 patients). A further 6/41 (15%) and 4/13 (31%) fractures were detected by bone scan and MRI, respectively. In the re-audit, when MRI replaced follow-up X-rays and bone scans, 7 out of 77 (9%) patients were diagnosed with scaphoid fracture. Time from initial plain radiograph to follow-up MRI was reduced from an original mean of 36 to 14 days during the re-audit period.

CONCLUSION

The introduction of early MRI enhances scaphoid injury diagnostics and accelerates patient management. We therefore endorse the introduction of this approach on a wider scale through an update of the clinical guidelines for scaphoid injuries.

'Clinical scaphoid fracture': is it time to abolish this phrase?

INTRODUCTION

Most patients with post-traumatic painful wrists and negative radiographs are treated as having a clinical scaphoid fracture. Such cases are usually followed up with repeat radiographs. If the radiographs are inconclusive further imaging is done. However, this traditional approach results in the vast majority of patients being unnecessarily immobilised for an unspecified period, leading to loss of productivity and income to the patient and the community. A number of studies have highlighted the use of early CT or MRI scans to identify these fractures. The aim of this study was to evaluate our current practice in managing patients with suspected fractures of the scaphoid.

PATIENTS AND METHODS

A retrospective audit was carried out. The period studied was from January to August 2008. Fifty consecutive patients who were investigated for occult fractures of the scaphoid were included.

RESULTS

92% of the patients studied had a repeat radiograph in the fracture clinic. 84% of the patients had their wrists immobilised in a cast while awaiting further imaging. Only 6% had confirmed fracture of the scaphoid; all of these healed uneventfully. 76% of patients with negative scans had their wrists immobilised for an average period of 30.63 days.

CONCLUSIONS

It is time we rethink this dogmatic approach to patients with clinical signs but negative radiographs. We recommend that patients with a painful wrist following an injury and negative radiographs should be referred early to an appropriate clinician and earlier recourse to advanced imaging should be advocated.

Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis?

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians, we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a survey was sent to a random selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5% of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than nonphysicians.

Initial management of potential occult scaphoid fracture in Australasia

Aim

To characterise current management of adult patients with possible occult scaphoid fracture in Australasian emergency departments.

Methods

Internet-based survey of Directors of Emergency Medicine Training throughout Australasia. Data collected included the most common management used in ED for patients with possible occult scaphoid fracture and whether there was a guideline regarding management of such cases. Data are reported as descriptive statistics.

Results

61 responses were received (response rate 73%). The most common management reported was immobilisation in a backslab (23, 38%) or full cast (19, 32%) with clinical assessment and re-X-ray in 7–10 days. CT scan within 7 days was used by 9 (15%), bone scan within 7 days by 6 (10%) and MRI within 7 days by 3 (5%). Very few sites were using same day/next day CT or MRI. Eighty-three percent of sites reported not having a guideline/protocol for this condition.

Conclusion

The traditional approach to management of possible occult scaphoid fracture of immobilisation with re-X-ray at 7–10 days remains the most commonly used in Australasia, despite evidence that this is probably over-treatment with significant consequences for patients. The place of advanced imaging for investigation of potential scaphoid fractures requires further research.

Survey of the initial management and imaging protocols for occult scaphoid fractures in UK hospitals

OBJECTIVE

The aim of this research was to survey how occult fractures of the scaphoid bone are both imaged and managed initially.

MATERIALS AND METHODS

A total of 832 questionnaires were sent via e-mail to active associate members of the British Orthopaedic Association. Included was a series of questions regarding the timing of initial and subsequent orthopaedic review of this group of patients and the use of serial radiographs and second-line imaging techniques.

RESULTS

Nearly half of the UK's acute NHS trusts were represented (45%). The response rate was 16% (130 out of 832). Only 16% of respondents were aware of a local imaging protocol for the investigation of suspected fractures of the scaphoid. Ninety-four percent of respondents performed a second radiograph at first fracture clinic review. Fifty-eight percent used magnetic resonance imaging (MRI) as a second-line investigation; with computed tomography scan and radionuclide isotope bone scan being performed by 26% and 16% respondents, respectively.

CONCLUSIONS

The survey revealed a wide variation in the management of occult fractures of the scaphoid. MRI has been shown to be both sensitive and specific in diagnosing occult carpal bone fractures. There is a need to standardise the management of these injuries to ensure early diagnosis and limit unnecessary wrist immobilisation.

Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures

OBJECTIVE

We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.

METHODS

This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with "clinical scaphoid fracture": a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.

RESULTS

Eighty patients completed the study protocol in a regional emergency department. In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.

CONCLUSION

This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.

The role of bone scan in the diagnosis of carpal fracture in children

A retrospective study was performed to evaluate the role of bone scan in the management of wrist trauma in children with equivocal radiographic findings. Thirty-one out of the 50 children showed no fracture. Six of them were treated for a median period of 9 days on clinical grounds; the others were discharged with reassurance. Four patients with evidence of soft tissue injury received no further treatment. Six of the 12 patients with a fracture on bone scan were treated with a cast for more than 4 weeks. None of the patients developed any complications. Bone scan is helpful when the diagnosis of a carpal fracture in children is equivocal.

[The diagnosis of recent scaphoid fractures: review of the literature]

Fractures of the scaphoid are the most common carpal fractures. A review of the literature indicates that the prevalence of the fracture in the case of clinical suspicion is less than 50%. A quality X-ray examination remains essential as an initial diagnostic tool in the evaluation of scaphoid fractures. Its sensitivity varies from 59 to 79%. Patients with negative X-rays present with about 18.7% of scaphoid fractures; 5% of bruised scaphoid; 13% of radius fractures and 7% of miscellaneous bone lesions. If not treated promptly, a scaphoid fracture may be compounded by non-union with associated risk factors such as avascular necrosis and osteoarthritis. Considering these risks, patients with suspected scaphoid fracture with normal X-rays, routinely undergo wrist immobilization until imaging confirms or denies the presence of fracture. Consequently, more than half of the patients undergo wrist immobilization needlessly. This may have a negative impact on their professional life and personal activities while representing a high medical cost. MRI is the imaging technique of choice for suspicious or negatice X-rays. MDCT is less costly than MRI or bone scan, readily available and highly effective for trauma patients but is lacks accuracy and should be used with caution in this indication.

Scaphoid fractures: variation in radiographic views - a survey of current practice in the West of Scotland region

BACKGROUND

A variation seems to exist between hospitals with regard to the initial radiographic assessment of suspected scaphoid fractures.

MATERIALS AND METHODS

A survey of all acute hospitals in the West of Scotland was carried out to ascertain the current practice in the assessment of acute scaphoid fractures. Consultant radiologists and consultant orthopaedic surgeons from the same hospitals were requested to suggest the minimum number and type of views to be ideally performed for a routine scaphoid series.

RESULTS

Fourteen hospitals, 85 consultant orthopaedic surgeons and 60 consultant radiologists were contacted. Among the hospitals, 64.3% performed four views and 28.5% performed three views for a suspected scaphoid fracture. The commonly performed radiographs were lateral with the wrist neutral (85.7%) and postero-anterior oblique in ulnar deviation (78.5%). Of the consultant orthopaedic surgeons, 57.5% suggested four views, while 33.3% suggested three views. A lateral view with the wrist neutral (87.8%) and a postero-anterior view in ulnar deviation (51.5%) were considered most useful. Of the consultant radiologists, 68.4% suggested four views and 15.8% suggested three views. A lateral view with the wrist neutral (84.2%) and a postero-anterior view in ulnar deviation (52.6%) were considered most useful.

DISCUSSION

A lack of uniformity is found among orthopaedic consultants who request scaphoid views, radiographers who perform the views and radiology consultants who report on these. We feel a uniform system of radiographic evaluation of scaphoid fractures should be introduced, with a standardized number and type of views, in all hospitals to increase the familiarity of both terminology and visualization.