Clinical Signs in Scaphoid Fractures

Waizenegger, M.; Barton, N. J.; Davis, T. R. C.; Wastie, M. L.

doi:10.1016/0266-7681(94)90249-6

Cited by 66 publications

(35 citation statements)

References 8 publications

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“…Fifteen studies published between 1982 and 2009 assessed the diagnostic accuracy for various physical examination tests, either in isolation or in combinations, including signs such as swelling or discoloration, as well as symptoms like anatomical snuffbox tenderness, scaphoid tubercle tenderness, clamp sign, resisted pronation or supination, thumb compression-induced pain, and US pain. 5,14,[17][18][19][21][22][23]39,[41][42][43][44][45][46] None were from the United States, and 12 were from Europe. These were all prospective case series, and 11 were ED-based, while two were orthopedic clinic studies and two did not report their clinical settings.…”

Section: History and Physical Examinationmentioning

confidence: 99%

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Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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ObjectivesScaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency medicine (EM) imaging studies for scaphoid fracture has not been previously described in the EM literature. Plain x‐rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial‐sided tenderness on physical examination. This study was a meta‐analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x‐ray in adult emergency department (ED) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after ED discharge.MethodsA medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED and EMBASE. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS‐2) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta‐analysis was conducted using Meta‐DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (LRs) for predictors of scaphoid fracture detected on follow‐up in patients with normal ED x‐rays.ResultsA total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non‐ED settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall QUADAS‐2 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult ED patients with concern for scaphoid injuries, nondiagnostic index x‐rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (LR– = 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (MRI) is superior to bone scan, computed tomography (CT), or ultrasound (US) to both rule in and rule out scaphoid fractures. Both MRI and CT share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.ConclusionsExcept for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. MRI is the most accurate imaging test to diagnose scaphoid fractures in ED patients with no evidence of fracture on initial x‐rays. If MRI is unavailable, CT is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.

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Section: History and Physical Examinationmentioning

confidence: 99%

“…Physical examination signs of swelling and discoloration are not useful to rule in or rule out scaphoid fracture. 43 Table 2 summarizes the diagnostic accuracy of physical examination signs and symptoms for scaphoid fracture.…”

Section: History and Physical Examinationmentioning

confidence: 99%

Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

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“…It is estimated that up to 40% of scaphoid fractures are missed at first presentation. 3,4 A recent metaanalysis of scaphoid fractures calculated that the positive predictive value of clinical examination (those who proved to be 'clinical scaphoid' warranted X-rays of scaphoid views who subsequently had scaphoid fracture) is in the range 13-69% with an average of 21%. 5 This means that four out of five patients without a fracture will be unnecessarily immobilised before radiological diagnosis is confirmed.…”

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confidence: 99%

The Clinical Scaphoid Fracture: Early Computed Tomography as a Practical Approach

Nguyen

Chaudhry

Sloan

et al. 2008

annals

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Ann R Coll Surg Engl 2008; 90: 488-491 488Carpal injuries are common presentations to emergency departments, general practitioners and orthopaedic clinics. The scaphoid bone is the most commonly injured of the carpal bones accounting for 50-80% of carpal injuries and predominantly occurs in young. healthy individuals. 1,2Scaphoid fractures are the most problematic to diagnose in a clinical setting because it can take up to 6 weeks for scaphoid fractures to become conclusive on plain X-ray films. It is estimated that up to 40% of scaphoid fractures are missed at first presentation. 3,4 A recent metaanalysis of scaphoid fractures calculated that the positive predictive value of clinical examination (those who proved to be 'clinical scaphoid' warranted X-rays of scaphoid views who subsequently had scaphoid fracture) is in the range 13-69% with an average of 21%. 5This means that four out of five patients without a fracture will be unnecessarily immobilised before radiological diagnosis is confirmed. Patients and MethodsWe conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a district general hospital. Patients with negative X-ray findings but positive clinical signs for scaphoid injury satisfied the criteria for CT. We defined clinical signs for a scaphoid injury as tenderness over the anatomical snuffbox, pain on axial loading of first metacarpal and tenderness over scaphoid tubercle in the presence of normal plain films and included patients whose plain X-rays proved inconclusive.Patients with clinical indications of scaphoid fracture but negative plain films had their wrists immobilised in a scaphoid cast in the accident unit while awaiting a hand clinic appointment.CT scans, where necessary, were carried out on the same day as review on the first presentation to the fracture

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“…4 Most scaphoid fractures are diagnosed without difficulty by examination of radiographs, and the subsequent management is straightforward. 5 However, it is known that some scaphoid fractures may be imperceptible on initial radiographs [5][6][7] due to the unique shape and position of the scaphoid in the carpus. 8 Furthermore, there is a high interobserver variability in the interpretation of radiographs of suspected scaphoid fractures.…”

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confidence: 99%

Management of suspected scaphoid fractures in accident and emergency departments – time for new guidelines

Tai

Ramachandran²,

McDermott³

et al. 2005

Ann R Coll Surg Engl

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INTRODUCTION The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid.SUBJECTS AND METHODS We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures. RESULTS The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines. CONCLUSIONS The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients.

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Clinical Signs in Scaphoid Fractures

Cited by 66 publications

References 8 publications

Adult Scaphoid Fracture

Adult Scaphoid Fracture

The Clinical Scaphoid Fracture: Early Computed Tomography as a Practical Approach

Management of suspected scaphoid fractures in accident and emergency departments – time for new guidelines

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