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ACAD-AE-MED  June 2004

ACAD-AE-MED June 2004

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Subject:

Re: is it a scaphoid fracture?

From:

Rowley Cottingham <[log in to unmask]>

Reply-To:

Accident and Emergency Academic List <[log in to unmask]>

Date:

Sat, 26 Jun 2004 06:11:00 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (91 lines)

> This is a multi-part message in MIME format.
>
> ------=_NextPart_000_003B_01C45890.684EB4E0
> Content-Type: text/plain;
>         charset="iso-8859-1"
> Content-Transfer-Encoding: quoted-printable
>
> Do you have any references for this?
>
> By the way on presentation we only do wrist views and then only proceed
> =
> to doing scaphoid views if they are still symptomatic at 10-14 days. =
> Saves on time and radiation on first visit.
>
> Ray McGlone
> Lancaster

I thought that Ruth Brown did a good study 8 or 9 years ago that showed that people with a painful
wrist and no X-ray changes should not be put into POP. I remember it being published in the
Journal, but a couple of searches have not shown anything. Interestingly, the bestBETS site says
there is not yet enough evidence to decide:

http://www.bestbets.org/cgi-bin/bets.pl?record=00097

The major problem I find is that the physical examination is inadequate. The currently accepted
physical sign is useless, and so every person with a bit of wrist tenderness gets scaphoid views. I
review lots of these, and there are two usual scenarios.

1. The person had a sprained wrist which is clearly apparent clinically. However, as the wrist has
been immobilised religiously in a Futuro splint there is now additional discomfort from stiffness.

2. The person has a previously unrecognised radial styloid fracture. This is usually very evident on
the original Xrays at review.

More rarely, some other hand bone has been fractured. I have only encountered a couple of missed
scaphoids in my career and I missed one myself at review as it was clinically normal. The patient
returned at about 12 weeks with recurrent pain. He was X rayed and a displaced # was now evident.
This could not be seen on the original films, even with the benefit of hindsight. I rarely Xray at the
second visit if I can avoid it but proceed directly to bone scan.

There is increasing interest in the use of ultrasound with this reported in the last few days:

 J Hand Surg [Am]. 2004 May;29(3):400-5.


"Ultrasound for the early diagnosis of clinically suspected scaphoid fracture.

Senall JA, Failla JM, Bouffard JA, van Holsbeeck M.

Division of Hand Surgery, Department of Orthopaedic Surgery, Detroit, MI, USA.

PURPOSE: To test the ability of ultrasound to diagnose clinically suspected occult scaphoid
fractures. METHODS: Eighteen wrists in 18 patients with an average age of 35 years (range, 10-77
years) were seen in the emergency room, each with a single traumatic wrist injury, snuffbox
tenderness, swelling, and a negative wrist x-ray result. They were evaluated in this prospective,
blind, controlled study by physical examination, x-ray, and high-resolution ultrasound. One hand
surgeon performed the examination, and ultrasounds were read by a musculoskeletal radiologist.
Patients were immobilized in a thumb spica splint and then seen in the office 1 to 14 days after the
emergency room visit, at which time a repeat physical examination, wrist x-ray, and the single
investigative ultrasound were done using the opposite wrist as a control. All patients were
immobilized and evaluated until symptoms resolved or x-ray showed scaphoid fracture site
resorption or callus, in which case they were kept immobilized until healed. RESULTS: Ultrasound
identified correctly 7 of 9 cases that were eventually positive for scaphoid fracture on plain x-ray.
Ultrasound was read correctly as negative in 8 of 9 x-ray-negative cases; this was statistically
significant. The 1 false-positive case had radioscaphoid arthrosis and radial wrist swelling.
Sensitivity was 78% and specificity was 89%. The positive predictive value was 88% and negative
predictive value was 80%. CONCLUSIONS: We recommend that high-frequency ultrasound be
used to investigate occult suspected scaphoid fractures because of its ability to allow early
diagnosis and to eliminate the need for a more invasive or expensive diagnostic test in most cases."

I think that both the sensitivity and specificity are too poor for this to be useful (the sample size is
sadly far too small, of course, and the power calculations cannot be right) but we do need to think
more about diagnostics than plain film.

The main question I have is about the evidence supporting the use of the positively unhelpful
Futuro splint. The use of these appears to be purely custom and practice. I simply put the arm in a
high sling (no tubigrip) and advise movement within the limits of discomfort after analgesia. A week
later the sprained wrist is much improved and easy to distinguish from ongoing morbidity.  I
challenge anyone to find a paper recommending their use.

I would challenge Nick Barton's comment about mobilisation as the lesion we are trying to prevent
is avascular necrosis of the proximal pole, which is a result of the nutrient artery no longer
perfusing it. The damage to an artery cannot be seen on any plain Xray, and a little bit of movement
later is not going to cause the same damage as the original fall did. It's the same shroud-waving
argument as the old chestnut that 2mm of neck flexion is going to destroy a spinal cord. Remember -
in science there are no experts, only evidence.

Rowley Cottingham.

Consultant in Emergency Medicine.

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