The importance of prompt diagnosis and treatment of scaphoid fractures

I have written before about the importance of prompt diagnosis and treatment of different types of fractures in A&E departments.  I have seen a number of misdiagnosis cases involving a particular type of fracture, to the scaphoid bone in the wrist joint, and write to set out some of the issues in such cases.

What is a scaphoid fracture and how does it occur?

The scaphoid bone is one of the 8 carpal bones in your wrist.  The scaphoid sits near to the base of your thumb and is said to be the carpal bones which links together and stabilises all of the carpal bones.

The scaphoid bones if the most common bones to be fractured and the most common way it is fractured is when someone falls and naturally puts out their hand to break their fall and then lands on their outstretched hand.

A scaphoid fracture will usually cause symptoms of pain in the wrist area, sometimes with associated bruising or swelling.  There is a particular area of the wrist called the anatomical snuffbox (a depression in the skin on the back of the hand near to the base of the thumb) which is often tender when the scaphoid bone has been fractured.  There can also be reduced movement in the wrist.

The fracture is usually diagnosed by x-ray or other mode of imaging, such as MRI scan.  It is not always picked up by x-ray because of the location of the bone and therefore sometimes it will be treated as a suspected fracture depending on other symptoms.

Treatment of scaphoid fractures

Fractures will either be displaced (where the broken bone fragments have moved out of position) or non-displaced (where the broken bone fragments have not moved out of position).

Treatment will usually entail either putting the wrist and arm in a plaster cast to immobilise it for a period of about 8-12 weeks, or surgery.  Treatment options will depend on whether the fracture is displaced or non-displaced and also the patient’s own circumstances.

Complications of scaphoid fractures

If a scaphoid fracture is not promptly diagnosed and treatment provided then the patient can suffer complications which can sometimes lead to long-term problems.  These include:

• Delayed or non-union of the bone fragments.  This can lead to the patient having to wear a plaster cast for longer and/or surgery.
• The bone fragments can heal together in the wrong position.  This can cause pain and restricted movement in the wrist and can require surgery to correct.
• Avascular Necrosis.  This is where the fracture causes interruption to the blood supply to the scaphoid bone preventing healing and eventually leading to ‘death’ of the bone.
• Arthritis in the area where the fracture was suffered.  The risk of suffering arthritis is more likely if the fracture is not diagnosed and treated promptly.

Guidance for diagnosing and treating scaphoid fractures

The majority of patients who suffer injury to the wrist, particularly after an obvious fall, will likely go to their local Accident & Emergency (A&E) department for advice and treatment.  As the scaphoid bone is the most common bone to be fractured in such circumstances, it is often missed, and as the complications of missed or delayed diagnosis of the fracture can lead to long term complications, the Guidelines in Emergency Medicine Network (GEMNet) produced best practice guidelines in September 2013 for the management of patients with suspected scaphoid fractures in A&E departments.

The guidelines presents “a summary of the best available evidence to guide the management of adult patients who present to the ED with a suspected scaphoid fracture”.

The guidelines include a simple flowchart for the management of such patients which suggests: where a patient presents with (1) a history compatible with a possible fracture; and (2) examination reveals tenderness in the relevant area, then the patient should have an x-ray with scaphoid view.

If the x-ray reveals a fracture they should be placed in a cast and given orthopaedic follow up.

If the x-ray does not reveal a fracture then the wrist should be immobilised in a cast or splint and an MRI scan arranged. If the MRI reveals no fracture then the patient can be discharged.

Our experience

I and my colleagues have acted for a number of patients making medical negligence claims for compensation for injuries suffered as a result of misdiagnosis or delayed diagnosis of scaphoid fractures.

The issues in such cases usually involve:

• failing to perform an x-ray when a patient has symptoms compatible with a scaphoid fracture; or
• mis-interpreting an x-ray which actually show a scaphoid fracture; or
• failing to a arrange follow-up once a fracture has been diagnosed.

When our clients are then diagnosed some weeks and even months later they have usually suffered some complication, for example the bone starting to heal in the wrong position which causes them to require more extensive treatment, a longer recovery and potentially long-term pain or restricted movement.

It is positive that GEMNet have recognised this as an area where further guidance is beneficial and it is hoped this guidance will reduce cases of missed or delayed diagnosis of scaphoid fractures.