The clinical scaphoid fracture: early computed tomography as a practical approach

Up to 40% of scaphoid fractures are missed at initial presentation as clinical examination and plain radiographs are poor at identifying scaphoid fractures immediately after the injury. Avoiding a delay in diagnosis is essential to prevent the risk of non-union and early wrist arthritis. We demonstrate the use of CT scanning for the early confirmation of a scaphoid fracture.

We conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a small district general hospital. We performed a CT scan on all 'clinical scaphoid' patients who had negative plain X-ray films.

Overall, 70% of patients had a CT scan within 1 week of injury and not from date of accident and emergency attendance; 83% of patients had a CT scan within 2 weeks of injury. Of 118 patients identified, 32% had positive findings and 22% of 'clinical scaphoid' patients had scaphoid fractures. The proportion of positive findings for an acute scaphoid fracture was 68%. Additional pathologies identified on CT were capitate, triquetral and radial fractures.

Our audit shows that it is practical to perform CT on suspicious scaphoid fractures in a small district general hospital. We identified an extremely high false-negative rate for plain X-rays and demonstrate that the appropriate use of CT at initial fracture clinic attendance with 'clinical scaphoid' leads to an earlier diagnosis and reduces the need for prolonged immobilisation and repeated clinical review.