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ACAD-AE-MED  June 2004

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Subject:

Re: is it a scaphoid fracture?

From:

Andy Webster <[log in to unmask]>

Reply-To:

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

Date:

Wed, 23 Jun 2004 20:31:59 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (301 lines)

My last statement was a bit tongue in cheek, I agree with what you say
below. Unfortunately I don't think we really know why some fractures do
not unite, as you said Nicholas Barton postulates mobilization as a
reason. As non union as an outcome in scaphoid fractures diagnosed after
2 normal x-rays is an uncommon event, it would be difficult to have the
definitive trial to prove the ideal way to manage these injuries. A hand
surgeon locally feels that the fractures that go onto non union would
probably occur whether you immobilized them or not. Local practice in
some hospitals is 2 normal x-rays, and then left at probably not
fractured.

What is the non-union rate of scaphoid fractures immobilized within 4
weeks? (I appreciate it will vary depending on the series reported).

Andy Webster
+44 226750279 (home)
+44 7989 587971 (mobile)


-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Nick Jenkins
Sent: 23 June 2004 19:57
To: [log in to unmask]
Subject: Re: is it a scaphoid fracture?

Nicholas Barton in his book "Current management of scaphoid fractures.
Twenty questions answered" (2002) has X-rays / scans of scaphoid
fractures
which are not visible on plain films at 2 weeks yet subsequently
non-unite -
it is postulated that this occurred because they were allowed to
mobilise.
Now whether that is the case or not, that documentation compiled by an
eminent hand surgeon is going to make you uncomfortable when cross
examined
in the legal setting!  As I mentioned in an earlier post on the thread
the
literature suggests that they are 'safe' to mobilise for the first month
but
after that time they are at risk of delayed or non-union - even, it
would
seem, if they were initially undisplaced.  It would take some pretty
robust
evidence to the contrary to make me adopt an 'undisplaced therefore
never
worry approach'.



Nick Jenkins
A&E Consultant, Abergavenny
http://www.ae-nevillhall.org.uk <http://www.ae-nevillhall.org.uk/>








-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Andy Webster
Sent: 23 June 2004 19:07
To: [log in to unmask]
Subject: Re: is it a scaphoid fracture?



Playing devil's advocate if the first +/-second set of scaphoid views
are
negative. Any further scaphoid fractures identified will turn out to be
undisplaced  fractures with a low risk of complications why bother with
MRI/CT/or bone scan. Manage symptomatically in a splint and review
patients
who are still symptomatic at 2-3 months for complications?



Andy Webster

+44 226750279 (home)

+44 7989 587971 (mobile)



-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of ADRIAN FOGARTY
Sent: 23 June 2004 13:02
To: [log in to unmask]
Subject: Re: is it a scaphoid fracture?



Fine, but if you x-rayed them with scaphoid views from the outset then
you
wouldn't even need to splint them.



A

Ray McGlone <[log in to unmask]> wrote:

I've been doing it for 15 years as departmental policy and not had any
problems yet........ as they are initially splinted.



Ray

----- Original Message -----

From: ADRIAN  <mailto:[log in to unmask]> FOGARTY

To: [log in to unmask] <mailto:[log in to unmask]>

Sent: Tuesday, June 22, 2004 8:53 PM

Subject: Re: is it a scaphoid fracture?



Yes, I can get something for you, Ray. I wouldn't recommend skipping
scaphoid views on first visit however, particularly in the vulnerable
age
group (this fracture is very rare in children and the over 40s) as
standard
wrist views will often miss an obvious waist fracture.



AF

Ray McGlone < [log in to unmask] <mailto:[log in to unmask]> >
wrote:

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

----- Original Message -----

From: ADRIAN FOGARTY <mailto:[log in to unmask]>

To: [log in to unmask] <mailto:[log in to unmask]>

Sent: Tuesday, June 22, 2004 4:50 PM

Subject: Re: is it a scaphoid fracture?



And that's precisely why it's no longer recommended to plaster the
x-ray-negative suspected scaphoid fracture. Those that do end up
becoming
visible fractures are inevitably undisplaced and do much better with
mobilisation.



AF

Simon Odum < [log in to unmask]
<mailto:[log in to unmask]> > wrote:

I suspect not as they were all undisplaced.

-----Original Message-----
From: Accident and Emergency Academic List on behalf of Andy Webster
Sent: Tue 22/06/2004 09:49
To: [log in to unmask]
Cc:
Subject: Re: is it a scaphoid fracture?



Would those have had any risk of complication if you had just treated
them in a splint, or even left open to the fresh air!!

Andy Webster
+44 226750279 (home)
+44 7989 587971 (mobile)


-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Simon Odum
Sent: 22 June 2004 07:09
To: [log in to unmask]
Subject: Re: is it a scaphoid fracture?

I normally explain that I am going to x-ray them, but the fracture may
not show up on this x-ray, so either way they are leaving with a suppor!
t
(POP or futuro depending on x-ray) and they are followed up by our
physio practitioner at 2 weeks post presentation.

Interestingly (and anecdotally!) we have had 4 or 5 fractured scaphoids
that were not radiologically evident until 6-8 weeks post injury but
were followed up due to persistent symptoms and were all treated in POP.

Simon Odum

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Doc Holiday
Sent: 21 June 2004 23:29
To: [log in to unmask]
Subject: Re: is it a scaphoid fracture?

Adrian wrote:

The majority of patients who have "tenderness" in the snuffbox following
a
fall on the outstretched hand DO NOT turn out to have a scaphoid
fracture. I
think it's completely wrong then to tell everyone "you have a scaphoid
fracture" as Doc has described. There are myriad other reasons for
having
ASB tenderness; scaphoid fracture! is but one, and is much less common
than a
simple wrist sprain for example.

---> I was being brief for the sake of clarity... Which is the reason
for
the confusion... Don't literally say "it's broken 100% and I will not
change
my mind". Merely ACT as if it is FOR THE TIME BEING and give the patient
the
clear impression that FOR NOW, it is how you'll treat it.

---> As your (far) greater experience than mine (no sarcasm) will tell,
when
one has to appologise for or defend juniors who've made a booboo in this
case, it's always for NOT treating a fracture as a fracture. Complaints
from
patients about treatment of their sprain as a fracture are rare and
financially un-embarrassing.

So in summary then, if x-rays are negative, tubigrip or the like
followed by
A&E review 7-10 days later where many are then discharged. If x-rays are
positive, simple backslab and refer to orthopod who has an i! ! nterest
in
ope! rating on these.

--> And where, pray tell, does one still find tubigrip nowadays? And
why?

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