Clinical assessment of scaphoid injuries and the detection of fractures

Difficulty in interpreting X-rays following carpal injury emphasizes the importance of clinical assessment in diagnosing scaphoid fractures. The classical sign of tenderness in the anatomical snuffbox is not specific and leads to many unnecessary out-patient reviews. A prospective comparison was made between anatomical snuffbox, scaphoid tubercle and scaphoid compression tenderness as indicators of scaphoid fracture in 221 patients with suspected scaphoid injury. Swelling was determined by measuring the difference in circumference at the wrist joint to compare between fracture and soft tissue injury. Scaphoid compression tenderness was found to be the most accurate test with a sensitivity of 100% and a specificity of 80%. Swelling of the wrist joint was significantly greater when there was a fracture, compared to soft tissue injury alone, even when the initial X-ray was normal. This was independent of any physiological variation in circumference between dominant and non-dominant sides. Scaphoid compression tenderness is therefore suggested as the most accurate indicator of scaphoid fracture and marked swelling should raise suspicion even if the X-ray is normal.