Accident and Emergency Expert Francis Morris Medicolegal Reports
Accident and Emergency ExpertFrancis Morris Medicolegal Reports

Suspected Scaphoid fractures

Identification and Management of Suspected Scaphoid Fractures in the Emergency Department

 

Wrist injuries are extremely common and area typically sustained by a Fall On the Out Stretched Hand or FOOSH injury.  A FOOSH causes hyperextension of the wrist and in simple terms can be responsible for one of  three common injuries which are:

 

  1. A fractured distal radius and ulna
  2. A fractured scaphoid
  3. A wrist sprain

Each of these conditions gives rise to a painful swollen wrist with limited movements and diminished grip strength.

The clinical approach adopted to differentiate between these three common diagnoses is to look for evidence of bony injury over the distal radius and ulna and over the carpal scaphoid bone.

The bony landmarks of the distal radius and ulna are usually readily appreciated even in a patient with a swollen wrist and evidence of bony tenderness at this site would indicate a fracture of the underlying bones and wrist X-rays  (two views) are indicated.  The bony landmarks when looking for a scaphoid fracture are the anatomical snuff box (ASB), the scaphoid tubercle (ST), and on axial compression of the thumb.

The currently accepted minimum standard of care involves palpating for scaphoid tenderness in the anatomical snuff and over the scaphoid tubercle in all wrist injuries to rule in or rule out clinical evidence of a scaphoid fracture.

The presence of scaphoid tenderness mandates that scaphoid X-rays (four views) are requested. It is widely recognised that between 3 or 4% of patients who fracture their scaphoid may have normal initial X-rays. Scaphoid X-rays provide the viewer with three good views of the scaphoid bone as opposed to wrist X-rays which only include one good view of the scaphoid bone. Increasing the number of views of the scaphoid improves the diagnostic accuracy of X-rays.  When scaphoid X-rays do not reveal an obvious fracture,  it is mandatory to immobilise the wrist with a recognised form of splinting and either review them at 10 to 14 days or request another imaging modality such as MRI or CT.  

Currently, it is the widespread practice of emergency medicine to review patients with suspected scaphoid fractures at 10 to 14 days to allow a reassessment of their symptoms and to re-X-ray the scaphoid bone.  The service providing this follow-up care varies from hospital to hospital but typically will be by either the orthopaedic team in the fracture clinic or the emergency department team in the returns clinic.  Patients who remain symptomatic in whom there is an ongoing concern of a scaphoid fracture who have a normal second set of X-rays should then undergo another imaging modality such as CT or MRI scanning. Increasingly, however, many hospitals have now cut out the 10 to 14 days wait and to provide alternative forms of imaging in patients with suspected scaphoid injuries within days of their initial presentation.

 

Patients with wrist injuries who have neither clinical or radiographic evidence of a fracture of the distal radius and ulna or scaphoid are managed as a wrist sprain.  

The emergency department approach to a wrist sprain is similar to that of an ankle sprain where the patient is treated symptomatically with the expectation that their symptoms were short-lived and self-limiting.   It is not standard nor routine practice for the emergency department to arrange MRI scanning for patients with soft tissue injuries to their wrist to help identify those few patients who will not settle in the short term with symptomatic treatment. Such patients are typically referred back to the community with the advice should their symptoms not significantly improve with time and settle within three months they should present to their general practitioner for a review.

Medico-legal points

  • A hyperextension injury to the wrist is commonly caused by a FOOSH injury which is responsible for the vast majority of wrist and scaphoid fractures.  

 

  • A fall on the outstretched hand may give rise to one of three common injuries which are:

 

 

  1. Fractured distal radius and ulna
  2. Fractured scaphoid
  3. Wrist sprain

 

  • Each of these conditions will give rise to a painful, swollen wrist with diminished wrist movements and grip strength. 

 

  • It is mandatory to assess and document the presence or absence of scaphoid tenderness in all wrist injuries.  

 

  • The basic minimum standard of assessment for scaphoid tenderness includes palpation in the anatomical snuff box (ASB), and over the scaphoid tubercle (ST)

 

 

  • The presence of scaphoid tenderness mandates scaphoid X-rays.
  • If the X-rays are normal then either a follow-up appointment at 10 to 14 days or alternative imaging e.g. MRI are mandatory.
  • Ref. Guideline for suspected scaphoid fractures in the Emergency Department RCEM

 

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