CT for Occult Scaphoid Fracture

Washington University Emergency Medicine Journal Club– April 20th, 2023


You are working a shift in EM-2 one weekend when you encounter Mr. S, a right-handed 38-year old man with no significant past medical history who presents with right wrist pain. He had had a few drinks the previous evening to celebrate his birthday and was in his way to bed when he tripped over a rug and fell forward onto both hands. He has no pain in his left wrist, but describes moderate pain in his right lateral wrist without radiation. He was able to work all day doing manual labor on a construction site, but the pain grew worse as the day progressed. 

On examination, he has no deformity, swelling, or ecchymosis. There is mild tenderness over the lateral aspect of the wrist and over the anatomical snuffbox with no pain on axial load of the thumb (How Trustworthy Are Clinical Examinations and Plain Radiographs for Diagnosis of Scaphoid Fractures?). X-rays of the wrist (three views) are negative for acute fracture. 

Based on current practice (and UK guidelines) you go to discuss immobilization with the patient given the high risk of an occult fracture, with the plan for repeat imaging in 2 weeks. The patient is concerned about immobilization leading to loss of work and wages, as well as his current lack of insurance leading to an inability to obtain appropriate follow-up. Given these concerns, you discuss with your attending the possibility of obtaining a CT scan to help rule out fracture in a more timely fashion. Your attending cites a previous review from Academic Emergency Medicine‘s Evidence-Based Diagnostics series by a Dr. Carpenter (a name that vaguely rings a bell, but you just can’t place) suggesting that CT cannot rule out fracture. While an MRI is more accurate, it is also more time-consuming and expensive. You wonder if there is additional information that could help this patient potentially avoid unnecessary immobilization without risking long-term functional loss… 

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Article 1: Pincus S, Weber M, Meakin A, Breadmore R, Mitchell D, Spencer L, Anderson N, Catterson P, Farish S, Cruickshank J. Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures. West J Emerg Med. 2009 Nov;10(4):227-32. PMID: 20046238; PMCID: PMC2791722. Answer Key.

Article 2: Ilica AT, Ozyurek S, Kose O, Durusu M. Diagnostic accuracy of multidetector computed tomography for patients with suspected scaphoid fractures and negative radiographic examinations. Jpn J Radiol. 2011 Feb;29(2):98-103. doi: 10.1007/s11604-010-0520-3. Epub 2011 Feb 27. PMID: 21359934. Answer Key.

Article 3: Carpenter CR, Pines JM, Schuur JD, Muir M, Calfee RP, Raja AS. Adult scaphoid fracture. Acad Emerg Med. 2014 Feb;21(2):101-21. doi: 10.1111/acem.12317. PMID: 24673666. Answer Key.

Article 4: Memarsadeghi M, Breitenseher MJ, Schaefer-Prokop C, Weber M, Aldrian S, Gäbler C, Prokop M. Occult scaphoid fractures: comparison of multidetector CT and MR imaging–initial experience. Radiology. 2006 Jul;240(1):169-76. doi: 10.1148/radiol.2401050412. Erratum in: Radiology. 2007 Mar;242(3):950. PMID: 16793977. Answer Key.

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