Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures

Steven Pincus, MBBS, BSc; Merle Weber, MBBS; Alex Meakin, MBBS; Ross Breadmore, MBBS, M Med; David Mitchell, MBBS; Luke Spencer, MBBS; Nathan Anderson; Phil Catterson, BN, MBA; Steve Farish, BSc, Med; Jaycen Cruickshank, MBBS, MCR

Disclosures

Western J Emerg Med. 2009;10(4):227–232 

In This Article

Abstract and Introduction

Abstract

Objective: We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.
Methods: This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with "clinical scaphoid fracture": a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.
Results: Eighty patients completed the study protocol in a regional emergency department. In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.
Conclusion: This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.

Introduction

The traditional approach to diagnosis of scaphoid fracture is based upon a combination of historical clinical signs that are sensitive but not specific.[1,2] When combined with dedicated scaphoid radiographs in acute wrist injury, this process fails to diagnose a scaphoid fracture in 7–36% of cases.[3–10] Clinical scaphoid fracture is defined as patients with suspected fracture not seen on initial radiographs, a mechanism of injury consistent with scaphoid fracture, and anatomical snuff box tenderness. Historically these were immobilized for 10–14 days, before re-examination and repeat radiographs. Early definitive diagnosis has the potential to avoid unnecessary immobilization. Our center has previously demonstrated the potential benefit of computerized tomography (CT) scanning in the early diagnosis of scaphoid fractures.[11] This follow-up study examined the implementation of a Clinical Practice Guideline (CPG) incorporating early CT in patients with clinical scaphoid fracture. We did not review patients with wrist and scaphoid fractures seen on x-rays. Previous research in our center made it difficult to compare the CPG outcomes to a historical control.

Our primary hypothesis was that early CT with this CPG would avoid unnecessary immobilization. We also hypothesized that this would result in early return to normal duties and satisfied patients.

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