Immobilisation of suspected scaphoid fractures
Date First Published:
March 1, 2000
Last Updated:
June 30, 2000
Report by:
Kathryn Gow, Medical Student (Manchester Royal Infirmary)
Search checked by:
Rob Williams, Manchester Royal Infirmary
Three-Part Question:
In [patients with clinical signs of scaphoid fracture but no fracture on first x-ray] is [plaster casting] necessary for [immediate management and the prevention of long-term complications]?
Clinical Scenario:
A 25-year-old man attends the emergency department with a one-day-old wrist injury caused by falling onto his outstretched hand. He is tender in his anatomical snuff box and also on longitudinal thumb compression, but he is in very little pain on normal everyday movements. You send him for a scaphoid series of x-rays which reveal no fracture. You arrange for him to return to the department in two weeks time for a repeat radiological and clinical examination. You wonder whether his wrist should be immobilised in a plaster cast or whether a simple elastic support bandage will suffice.
Search Strategy:
Medline 1966-12/99 using the OVID interface.
Search Details:
[({exp fractures OR exp fractures, closed OR exp fractures, malunited OR exp fractures, ununited OR fracture$.mp} AND scaphoid$.mp) AND {exp casts, surgical OR cast$.mp OR plaster.mp OR exp splints OR splint$.mp OR exp immobilisation OR immobilisation.mp}] LIMIT to human AND english.
Outcome:
131 papers found of which 127 were irrelevant to the study question or of insufficient quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Clinical fracture of the carpal scaphoid - an illusionary diagnosis. Duncan DS and Thurston AJ. 1985 UK | 108 patients with a diagnosis of clinical fracture of the scaphoid | Retrospective survey | Proportion of patients found to have a fracture | 0 of 108 (0%) | |
| The suspected fracture of the scaphoid: a rational approach to diagnosis. DaCruz DJ, Bodiwala GG, Finlay DB. 1988 UK | 150 wrists immobilised on plaster with suspected scaphoid fracture | Retrospective survey | Fracture rate | 8 of 150 (5.33%) | |
| Clinical fracture of the carpal scaphoid - supportive bandage or plaster cast? Sjolin SU and Andersen JC. 1988 Denmark | 108 clinically suspected scaphoid fractures Plaster cast vs supportive bandage |
PRCT | Fracture rate | 7 of 108 | Only 2 weeks follow up |
| Sick leave for manual workers | 14 vs 4 days | ||||
| Suspected scaphoid fractures. Can we avoid overkill? Jacobsen S, Hassani G, Hansen D et al. 1995 Denmark | 231 clinically suspected scaphoid fractures | Retrospective survey | Proportion of patients found to have a fracture | 3 of 231 (1.3%) |
Author Commentary:
There is no direct evidence to answer the questions posed. The only PRCT shows that patients return to work sooner if they are treated with supportive bandage, but the follow-up was too short to show any complications of this approach. It appears that the adverse event rate (fracture) is low (1 - 5%)in the target population. In this subpopulation of fractures the adverse event rate (delayed union or non-union) is also low (10 - 20%) - thus the overall long-term complication rate for clinically suspected scaphoid fractures is tiny (0.1 - 1%). None of the studies include enough patients to show any effect on this.
Bottom Line:
There is no evidence to answer the question posed. Further work is needed in this area.
References:
- Duncan DS and Thurston AJ.. Clinical fracture of the carpal scaphoid - an illusionary diagnosis.
- DaCruz DJ, Bodiwala GG, Finlay DB.. The suspected fracture of the scaphoid: a rational approach to diagnosis.
- Sjolin SU and Andersen JC.. Clinical fracture of the carpal scaphoid - supportive bandage or plaster cast?
- Jacobsen S, Hassani G, Hansen D et al.. Suspected scaphoid fractures. Can we avoid overkill?