Reducing time from presentation to diagnosis of scaphoid fractures with cone beam CT: a before-and-after study

Scaphoid fractures comprise approximately 50-70% of carpal bone fractures but can be difficult to detect on initial plain film radiographs. A delayed diagnosis can lead to a high rate of non-union, avascular necrosis and Complex Regional Pain Syndrome. Current literature supports cone beam CT (CBCT) (within 10-14 days) as an effective method for diagnosing scaphoid fractures. We implemented an early outpatient CBCT pathway, prior to specialist review, with the aim to increase the proportion of patients with suspected scaphoid fracture undergoing CBCT within 7 days.

We designed an ambulatory pathway for suspected scaphoid fractures in the Emergency Department (ED) in which outpatient CBCT was requested by emergency medicine clinicians. A retrospective audit of current management of these patients was performed between 1 August 2022 and 31 October 2022 (prepathway period). A list of patients who underwent CBCT performed for the indication 'suspected scaphoid or carpal bone fracture' in the hospital was obtained and screened. Implementation of the pathway took place in February 2023 and was reviewed by continuous audit monitoring from 1 March 2023 to 31 May 2023 (postpathway period).

Prepathway implementation, 54 patients underwent CBCT. Following implementation of our pathway, the number of CBCTs performed in the hospital for this clinical indication increased to 111 (postpathway). The proportion of patients undergoing CBCT within 7 days increased from 11.1% (6/54) to 91.8% (102/111) (p<0.000). There was a 71.9% reduction in fracture clinic attendances (50/54 (92.6%) prepathway and 23/111 (22.5%) post pathway (p<0.000).

We successfully implemented an ambulatory pathway for suspected scaphoid fractures in the ED that significantly increased the proportion of patients with suspected scaphoid fractures undergoing early (<7 days) CBCT and definitive care.