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The “Clinical Scaphoid Fracture.” -A Prospective Study Of Outcomes.

Rustom Adi Mody*, Ben Clift

Consultant Orthopaedic Surgeon
Ninewells Hospital and Medical School
, University of Dundee, Dundee, Scotland

Address for Correspondence:
Dr. Rustom Adi Mody
Consultant Orthopaedic Surgeon
Ninewells Hospital and Medical School
, University of Dundee

Phone: +9714-3344003


Duncan and Thurston’s seminal research paper written 20 years ago, demonstrated that the actual number of scaphoid fractures amongst all cases diagnosed clinically was very small. Three more research studies over the next 10 years concurred with his findings. However, specialist clinics still receive a large number of referrals from the A&E labelled as clinical scaphoid fractures. 
To improve this situation, this study was undertaken at Ninewells hospital, Dundee. The objective was to analyze the clinical value of various tests and thus formulate a new set of guidelines for the A&E staff to follow. 
Patients and Methods: 58 subjects were followed up to assess how many were actually scaphoid fractures after being referred as clinical fractures. With this the specificity and sensitivity of various tests could also be reviewed and compared with literature. 
Results: Only one of the 58 patients was found to have a scaphoid fracture on the fourteenth day after initial normal radiographs. Most examination variables were high in sensitivity, but had poor specificity. 
Conclusions: More variables could not be examined due to daily changes in the A&E staff and no fixed protocol. The value of higher modalities of imaging was also reviewed only on the basis of current literature. The level of clinical skills in the management of scaphoid fractures was fund to be unsatisfactory.
Keywords: Scaphoid; ‘Clinical fracture’.

J.Orthopaedics 2007;4(2)e15



How many radiologically negative wrist injuries turn out to be true clinical scaphoid fractures? This is the primary question this paper addresses. If this number is unacceptably low, what can we do to improve it? This question will also be tackled

Between 1985 and 1995, four large studies1 showed the percentage of clinically suspected scaphoid fractures, being actual fractures to be between 0% and 6.48%. Duncan and Thurston’s seminal paper2 reviewed 108 patients who were immobilised for a clinically suspected scaphoid fracture. On follow-up it was discovered that not a single patient had had a scaphoid injury. This led them to refer to this entity as an illusionary diagnosis.

Material and Methods :

This study was conducted at the specialist clinics of Ninewells hospital, Dundee. All 58 patients who attended the fracture clinic between September 2005 and February 2006, after being diagnosed as a suspected scaphoid injury the previous day in the A&E, were included in the study.

The patients’ were followed up clinically and radiologically for a minimum of three weeks so as to arrive at a definitive diagnosis. The choice and number of clinical tests and manoeuvres employed by the A&E staff was also reviewed.

For the statistical analysis, data was explored for distribution and extreme values. Descriptive statistical methods were used including histograms for continuous data and tables for categorical data. Where appropriate means and standard deviations were presented otherwise the median was given.

Results :

Of the 58 study subjects, 13 had scaphoid fractures, but only one patient was a true clinical scaphoid fracture who was radiologically negative on days 1 and 2, and then showed evidence of a scaphoid fracture on day 14.

As each potential variable was looked at individually, the results are similarly displayed.

Age Distribution- The age distribution in the study subjects ranged from nine to 83 (Figure 1). Amongst the confirmed fracture patients the ages ranged from 15 years to 61 years with a mean of 31.5 years.   

Figure 1- The age distribution of study subjects

Delay in Presentation- This ranged from one hour to 336 hours with three exceptionally outlying values for patients who presented five, ten and fourteen days after the injury. To get the most statistically accurate picture the median was calculated which was measured as 10 hours (Figure 2).

Figure 2- The median delay in presentation shown as a red line

Mechanism of Injury- The commonest mechanism described by the patients was a fall on an outstretched hand with a dorsiflexion strain on the wrist. 45 of the 58 study subjects described this mechanism. Of the 13 fracture patients, all described this mechanism.

Also noteworthy is that over 30% of the scaphoid fracture group were indulging in a sporting activity at the time of injury. 

Site of Pain- The anatomical snuff box (ASB) was the commonest site of pain described by patients (Table 1). Sites such as the lower end of the radius, the radial styloid and the base of the thumb have been labelled as ‘other’

Site of pain Anat. Snuff box only Anat. Snuff box & other Other
In study subjects (58) 22 (37.9 %) 31 (53.4 %) 5 (8.7 %)
In scaphoid fracturepatients (13) 7 (53.8%) 5 (38.4%) 1(7.8%)
(No pain)

Table 1- Incidence of pain in the anatomical snuff box

History of Previous Injury- Three (23%) of the thirteen fracture patients had a history of previous scaphoid fractures or fractures adjacent to the scaphoid. 

Presence of Swelling- This is displayed in Table 2.   

Presence of swelling Anat. Snuff box Diffuse over wrist Nil
In study subjects (58) 8 (13.7%) 24 (41.3) 26 (45%)
In scaphoid fracture patients (13) 3 (23%) 5 (38.5%) 5 (38.5%)

Table 2- Incidence of swelling

Presence of Local Redness- The appearance of signs of inflammation over the wrist and ASB are shown in Table 3   

Presence of local redness Yes No
In study subjects (58) 18 (31%) 40 (69%)
In scaphoid fractureIn scaphoid fracture patients (13) 3 (23%) 10 (77%)

Table 3- Incidence of local redness

Radiographs at Presentation- 41 (70.6%) of the study subjects were X-rayed on presentation. Amongst those X-rayed, the primary diagnoses made by the A&E staff are displayed in Table 4.

Suspected scaphoid fracture 4 (9.7%)
Obvious scaphoid fracture 6 (14.6%)
No abnormality detected (NAD) 30 (73.2%)
Other injuries 1 (2.5%)

Table 4- Primary radiographic diagnoses in the A&E

Follow-up Radiographs- 51 patients were deemed warranting a follow-up radiograph to attain a definitive diagnosis. 

Additional Information-Three cases of scaphoid fractures were missed by A&E staff and reported as NAD on radiographs.

 Four cases of scaphoid fractures were not X-rayed in the A&E.

Seven (54%) scaphoid fractures were diagnosed in follow-up clinics.

Three cases of scaphoid fractures were not X-rayed in the A&E, and were diagnosed by X-rays on day-2.

One case of scaphoid fracture was not X-rayed in the A&E, and was diagnosed by X-rays on day-14.

Two cases were interpreted as NAD by A&E staff on radiographs and then diagnosed as fractures by the fracture clinic staff on day-2.

One case was diagnosed as NAD on days 1 and 2 and then diagnosed as a scaphoid fracture on day-14.

Four cases of fresh scaphoid fractures were diagnosed by the A&E staff.

Discussion :

This study demonstrates that no one piece of history or clinical test will conclusively prove or disprove a scaphoid fracture, hence the examiner must be careful that he asks all the relevant questions and performs all the tests with an acceptably high level of sensitivity and specificity. 

The age of the patient guides us as scaphoid fractures are rarely seen in extremes of ages. These age groups usually suffer a distal radial injury.

The mean delay in presentation even in the fracture group was 26.15 hours hence the junior doctor should not assume lesser importance in these patients. 

The mechanism of injury in this study was always a fall on an outstretched hand with a forced dorsiflexion at the wrist. However studies by Leslie and Dickson and Clay et al both showed a 3% incidence of a hyper-flexion being the mechanism of injury3. The present study had two (3.4 %) patients give a similar mechanism history with clinical features of a possible scaphoid injury. 

The site of pain located at the ASB in 93% of the cases. However apart from ASB tenderness, other commonly employed tests such as scaphoid tubercle tenderness (Freeland, 1989) and scaphoid compression tenderness(Chen, 1989) could not be evaluated in this study due to the inconsistency in their usage. R.Grover4 in 1996 published his results on the reliability of these three signs (Table 5). This shows us that even though these tests are very sensitive, their specificity is low.

  Sensitivity %   (95% confidence limits) Specificity  % (95% confidence limits)
ASB tenderness 100% 29% (23-35%)
ST tenderness 83% (70-96%) 51% (44-58%)
SC tenderness 100% 80% (74-86%)

Table 5 – Sensitivities and specificities of ASB, ST and SC tenderness as indicators of   fracture in patients with suspected scaphoid injury (R.Grover, 1996)

The presence of swelling was found to be an equivocal finding. This concurs with the findings of Waizenegger et al5 who stated that swelling and discolouration around the anatomical snuff box is more common in cases with scaphoid fractures than without, but not enough to be statistically or clinically significant.

The presence of local redness and raised local temperature were both found to be of no practical information.

The importance of taking radiographs in the A&E is demonstrated by the fact that scaphoid fracture cases were not X-rayed in the A&E. Most cases of scaphoid fractures are diagnosed on presentation radiographs, very few required follow-up radiographs for their diagnosis (Dias J.J. et al,)6

Follow-up radiographs were only required in one patient in this study.

The usefulness of higher modalities of imaging was beyond the scope of this study. However literature does seem to support their role in indicated patients

In conclusion, the findings of Tai C.C. et al.7paint a current picture-

In 2005, they studied the management of suspected scaphoid fractures in A&E departments in the U.K. They conducted a survey on 146 A&E senior house officers (SHO) in 50 different hospitals. Their findings were -

55.8% SHO’s performed only one clinical test to diagnose suspected scaphoid fractures

41% were unable to cite the number of the radiographic views taken

Only 10% of departments have direct access to further radiological investigation

Wide variation in early treatment with 46% receiving scaphoid casts

54% SHO’s were not aware of any local guidelines for management of suspected scaphoid fractures in their departments

92% were not aware of the existence of the 1992 British association for accident and emergency medicine (BAEM) guidelines.

They concluded that the clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory.

This paper therefore demonstrates the need for a new set of guidelines to be laid down for the management of suspected scaphoid fractures in the A&E department.

Reference :

  1. Gow K.: Immobilisation of suspected scaphoid fractures. BestBET: 2000.

  2. Duncan DS and Thurston AJ: Clinical fracture of the carpal scaphoid - an illusionary diagnosis. Journal of Hand Surgery (Br) : 10: 375-6. 1985

  3. Barton N.J.: Twenty questions about scaphoid fractures. Journal of Hand Surgery    (Br): 17: 289-310. 1992

  4. Grover R: Clinical assessment of scaphoid injuriesand the detection of fractures. Journal of Hand Surgery (Br): 21B: 3: 341-343. 1996

  5. Waizenegger M, Barton N.J., Davis T.R.C. et al.: Clinical signs in scaphoid fractures. Journal of Hand Surgery (Br): 19: 743-747. 1994.

  6. Dias JJ, Thompson J, Barton NJ et al.: Suspected scaphoid fractures. The value of radiographs. Journal of Bone and Joint Surgery (Br); 72: 98-101. 1990

  7. Tai C.C. et al.: Management of suspected scaphoid fractures in accident and emergency departments - time for new guidelines. Annals of the Royal College of Surgeons of England: 87 (5): 353-357. 2005


This is a peer reviewed paper 

Please cite as :Rustom Adi Mody :The “Clinical Scaphoid Fracture.” -A Prospective Study Of Outcomes.

J.Orthopaedics 2007;4(2)e15





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