The suspected fracture of the scaphoid: a rational approach to diagnosis

It has been the policy of the accident and emergency department in Leicester to treat all clinically suspected fractures of the carpal scaphoid in plaster for 2 weeks, even after negative radiology. A preliminary audit of policy revealed that 150 wrists had been immobilized in plaster during a 6-month period and yet only eight fractures of the scaphoid were identified in this group. In order to reduce the degree of 'overkill' a new policy was introduced for the management of the clinically suspected, radiologically negative fracture of the scaphoid and results were assessed prospectively. The new policy was based on resting all such injuries in broad arm slings until review by a more senior member of staff was possible, always within 1 week. Results indicate that it is easier to make a definitive soft tissue diagnosis a few days after such injuries and, therefore, the number of plasters applied dropped substantially. Not all fractures of the scaphoid were apparent on initial radiographs, but despite this it was possible to treat all such injuries appropriately on the strength of their clinical signs when reviewed. The new scheme of management is recommended for general use in accident and emergency departments on the strength of a prospective study of 111 patients with pain after injury, tenderness and swelling in the anatomical snuffbox.