Simple tests may ease scaphoid fracture assessment

By Lynda Williams

Researchers have devised a clinical prediction rule that can help physicians assess patients with a suspected scaphoid fracture.

Patients are most likely to have fracture confirmed if they are male (odds ratio [OR]=4.9), are injured while playing sport (OR=4.2), describe anatomical snuff box (ASB) pain on ulnar deviation of the wrist within 72 hours of injury , and if they have scaphoid tubercle tenderness 2 weeks later (OR=8.8), report Andrew Duckworth (Royal Infirmary of Edinburgh, UK) and co-workers.

For patients with all four factors, the likelihood of fracture was 91%, but the predictive value fell to just 34% for three factors, and 10% for two factors.

"This fact, combined with the limitations of even the most sophisticated imaging and the lack of a consensus reference standard for a true scaphoid fracture, means that the diagnosis of a scaphoid fracture should be considered a probability rather than a certainty," the team emphasizes in the British volume of the Journal of Bone and Joint Surgery.

The researchers examined 223 patients with a suspected or radiologically confirmed scaphoid fracture, and followed up the group at 72 hours, and 2 and 6 weeks. Half (52%) of the patients were male and the average age was 33 years.

Overall, scaphoid fracture was confirmed in 28% of the patients.

Of note, fracture was not confirmed in any patients who were free from ASB pain within 72 hours of injury, the researchers say.

Defining patients with the four risk factors as high risk for fracture, Duckworth and team suggest that "these patients would benefit from repeat assessment by a senior member of staff and referral for further imaging if radiographs are negative. "

They add: "Lower risk patients would initially either be discharged or splinted, and then re-evaluated two weeks after injury."

The researchers believe their clinical prediction rule will help physicians to decide if patients require magnetic resonance or computed tomography. They also note that it is easier to apply than previously described tests for scaphoid fracture, such as extension reduction or loss of supination strength.

"We feel the clinical prediction rules we have set out are easy to implement in the clinical setting," they conclude.

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