The utility of a bone scan in the diagnosis of clinical scaphoid fracture

doi:10.1016/0736-4679(94)90432-4

The Journal of Emergency Medicine

Volume 12, Issue 5, September–October 1994, Pages 709-712

https://doi.org/10.1016/0736-4679(94)90432-4 Get rights and content

Abstract

The incidence of true scaphoid fracture and the value of radionuclide scan was evaluated in a 1-year retrospective review of 54 emergency department patients with a preliminary diagnosis of clinical scaphoid fracture (snuff box tenderness and negative initial X-ray study). All emergency department charts of patients with a discharge diagnosis of clinical scaphoid fracture were reviewed to determine the number ultimately found to have a true scaphoid fracture and to ascertain how the diagnosis was actually achieved. All patients were managed by immobilization in a thumb spica cast for a period of 10–14 d, with repeat clinical assessment and radiographs at that time. The diagnosis of true scaphoid fracture was confirmed radiographicaliy at the time of reassessment or, in the case of persistent tenderness and negative repeat radiographs, by the use of a technetium bone scan. In our study group, only 8 of 54 patients (14.8%) were found to have a final diagnosis of true scaphoid fracture. In 75% ( $68$ ) of these patients, the diagnosis was made by technetium bone scans, as the radiographs remained negative at the time of reassessment. In addition, a bone scan revealed the presence of two previously unsuspected fractures (one distal radius fracture and one triquetral fracture) in two patients with continued clinical tenderness. This study confirms the previously reported low incidence of scaphoid fractures in patients with a diagnosis of clinical scaphoid fracture. It also demonstrates the importance of technetium bone scan as a diagnostic tool of increased sensitivity, as compared to traditional radiographs, in detecting the presence of scaphold fractures and in detecting other clinically unsuspected fractures in this group of patients.

References (11)

A. Ganel et al.
Bone scanning in assessment of fractures of the scaphoid
J Hand Surg.
(1979)
J.F. Waeckerle
A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures
Ann Emerg Med.
(1987)
I.J. Leslie et al.
The fractured carpal scaphoid
J Bone Joint Surg (Br)
(1981)
D.A. Morgan et al.
A prospective study of 100 consecutive carpal scaphoid fractures
Aust N Z J Surg.
(1984)
H. Chin et al.
Wrist and forearm

There are more references available in the full text version of this article.

Cited by (25)

Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries
2010, Emergency Medicine Clinics of North America
Citation Excerpt :
Even with appropriate films, fractures of the scaphoid can be subtle and difficult to visualize. Conservative estimates suggest that 10% to 20% of these fractures will not be visible on any view in the acute setting.64,72,73 One prospective trial estimated found the sensitivity of initial radiographs for diagnosing scaphoid fracture to be 86%.74
The diagnosis of recent scaphoid fractures: Review of the literature
2007, Journal de Radiologie
Les fractures du scaphoïde sont fréquentes. L’étude de la littérature montre que, devant une suspicion clinique de fracture du scaphoïde, la prévalence de cette lésion estinférieure à 50 %. Un bilan radiographique standard de qualité doit rester la première étape diagnostique. Il détecte les fractures du scaphoïde avec une sensibilité variant entre 59 et 79 %. Les patients avec des radiographies normales ont en moyenne une fracture du scaphoïde dans 18,7 % des cas, une contusion du scaphoïde dans 5 % des cas, une fracture du radius dans 13 % des cas et une autre fracture dans 7 % des cas. Une fracture du scaphoïde mal traitée conduit à des complications dont le retentissement professionnel et sociétal est élevé. Dans la stratégie classique, pour prévenir ce risque, les patients présentant une suspicion de fracture du scaphoïde dont le bilan radiographique initial est normal bénéficient d’une immobilisation pendant 10-15 jours, voire 6 semaines. Plus de 50 % de ces patients subissent donc une immobilisation et un arrêt de travail inutiles. L’IRM représente la méthode diagnostique idéale en cas de radiographies normales ou douteuses. Le scanner volumique présente une précision plus faible que l’IRM et son analyse doit rester prudente.
Fractures of the scaphoid are the most common carpal fractures. A review of the literature indicates that the prevalence of the fracture in the case of clinical suspicion is less than 50%. A quality X-ray examination remains essential as an initial diagnostic tool in the evaluation of scaphoid fractures. Its sensitivity varies from 59 to 79%. Patients with negative X-rays present with about 18.7% of scaphoid fractures; 5% of bruised scaphoid; 13% of radius fractures and 7% of miscellaneous bone lesions. If not treated promptly, a scaphoid fracture may be compounded by non-union with associated risk factors such as avascular necrosis and osteoarthritis. Considering these risks, patients with suspected scaphoid fracture with normal X-rays, routinely undergo wrist immobilization until imaging confirms or denies the presence of fracture. Consequently, more than half of the patients undergo wrist immobilization needlessly. This may have a negative impact on their professional life and personal activities while representing a high medical cost.
MRI is the imaging technique of choice for suspicious or negatice X-rays. MDCT is less costly than MRI or bone scan, readily available and highly effective for trauma patients but is lacks accuracy and should be used with caution in this indication.
Orthopedic trauma: Office management of major joint injury
2006, Medical Clinics of North America
Citation Excerpt :
Additional views improve the sensitivity for diagnosing scaphoid fractures [61] or carpal ligament injuries. Because up to 15% of scaphoid fractures are missed with plain radiographs, bone scan may be used to make the diagnosis [62]. MRI is increasingly used when high clinical suspicion for injury persists in the face of negative plain radiographs.
Ultrasound for the early diagnosis of clinically suspected scaphoid fracture
2004, Journal of Hand Surgery
To test the ability of ultrasound to diagnose clinically suspected occult scaphoid fractures.
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.
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%.
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.
Evaluation and management of the high-risk orthopedic emergency
2003, Emergency Medicine Clinics of North America
Orthopedic pitfalls in the ED: Scaphoid fracture
2001, American Journal of Emergency Medicine
Citation Excerpt :
Even with appropriate films, fractures of the scaphoid can be subtle and diffucult to visualize. Conservative estimates suggest that 10% to 20% of these fractures will not be visible on any view in the acute setting.8,19,20 A typical wrist series includes a PA and lateral of the wrist.
Wrist injuries are frequently encountered in the emergency department. When a patient presents with such an injury, the possibility of scaphoid fracture must be at the top of the differential for the emergency practitioner. Unfortunately, these injuries can be missed on first presentation, as they are frequently radiographically occult. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. The emergency physician needs to be vigilant for scaphoid fracture and be aggressive in both its diagnosis and treatment to avoid this practice pitfall. This review examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician. (Am J Emerg Med 2001;19:310-316. Copyright © 2001 by W.B. Saunders Company)

View all citing articles on Scopus

View full text

The utility of a bone scan in the diagnosis of clinical scaphoid fracture

Abstract

J Hand Surg.

Ann Emerg Med.

The fractured carpal scaphoid

J Bone Joint Surg (Br)

A prospective study of 100 consecutive carpal scaphoid fractures

Aust N Z J Surg.

Wrist and forearm