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Three Part Question

In [a patient with an MRI diagnosis of a bone bruise of the scaphoid] is [wrist immobilisation] necessary in order [to avoid long term complications]?

Clinical Scenario

A 30 year old man is investigated for a clinical scaphoid fracture (normal initial plain X-Rays)with an MRI scan. The scan reveals a bone bruise of the scaphoid. You wonder whether it is safe to allow him free of splintage or whether this will put him at risk of the complications associated with scaphoid fractures.

Search Strategy

Medline 1950 to present using OVID interface. (scaphoid.mp. OR exp scaphoid bone.) AND (bone bruis$.mp). The references cited by relevant papers were also checked and retrieved where they appeared to be releavant.

Search Outcome

The search revealed a total of 79 results. 2 papers were found to be relevant and a further 2 identified as a result of examining the citations of these papers

Comment(s)

MRI scanning has been increasingly used to investigate the ‘clinical scaphoid fracture’ i.e. the patient who clinically has a fractured scaphoid yet has normal plain X-Rays. This has resulted in the phenomenon of bone bruising, bone marrow oedema without evidence of fracture, being recognised and a consequent therapeutic dilemma as to whether or not this radiographic abnormality requires on-going splintage in order to prevent the complications that follow un-splinted scaphoid fractures. Asymptomatic non-union of the scaphoid and its subsequent progression to degenerative change is well recognised (Lindstrom G and Nystrom A. The natural history of scaphoid non-union, with special reference to “asymptomatic” cases. Journal of Hand Surgery, 17B: 697-700. 1992) and La Hei et al. (2007) queried whether or not the scaphoid bone bruise was a precursor of scaphoid non-union. Whilst 3 of the studies, including that of La Hei, found clinical and/or radiological evidence of improvement in the patients studied, and whilst it would be intuitive to suggest that none of these cases developed long-term complications, the absence of long-term radiological assessment does not allow the conclusion that the scaphoid bone bruise is not followed asymptomatic long-term complications to be made. The only study to undertake late radiological follow up was that of Cook et al. (1997) and, whilst none of the cases in this study developed long-term complications, the study population was paediatric and the numbers were small. Further studies including long-term radiological assessment would be required in order determine whether or not bone bruising of the scaphoid predisposes to long-term complications.

Clinical Bottom Line

There is in insufficient evidence to demonstrate that it is safe to treat these cases free of immobilisation.