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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.
[({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.

Search Outcome

131 papers found of which 127 were irrelevant to the study question or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Duncan DS andThurston 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%)
DaCruz DJ et al 1988 UK	150 wrists immobilised on plaster with suspected scaphoid fracture	Retrospective survey	Fracture rate	8 of 150 (5.33%)
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
Jacobsen S et al 1995 Denmark	231 clinically suspected scaphoid fractures	Retrospective survey	Proportion of patients found to have a fracture	3 of 231 (1.3%)

Comment(s)

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.

Clinical Bottom Line

There is no evidence to answer the question posed. Further work is needed in this area.

References

1. Duncan DS and Thurston AJ. Clinical fracture of the carpal scaphoid - an illusionary diagnosis. J Hand Surg (Br) 1985;10:375-6.
2. DaCruz DJ, Bodiwala GG, Finlay DB. The suspected fracture of the scaphoid: a rational approach to diagnosis. Injury 1988;19:149-52.
3. Sjolin SU and Andersen JC. Clinical fracture of the carpal scaphoid - supportive bandage or plaster cast? J Hand Surg (Br) 1988;13:75-6.
4. Jacobsen S, Hassani G, Hansen D et al. Suspected scaphoid fractures. Can we avoid overkill? Acta Orthop Belgica 1995;61:74-8.