Mano y muñeca

Clinical Faceoff: Strategies for Management of Suspected Scaphoid Fractures

In the United Kingdom, guidelines issued by the National Institute for Health and Clinical Research (NICE) suggest the routine use of MRI when a scaphoid fracture is suspected based on interview, examination findings, and normal scaphoid-specific radiographs [5]. This clinical scenario is often referred to as a “suspected scaphoid fracture” [16]. An alternative strategy for managing suspected scaphoid fractures is based on the management of other fractures that predictably heal (such as metacarpal fractures and isolated nondisplaced or minimally displaced radial head fractures) and is premised on the idea that if a fracture is likely to heal without serious sequelae, then overtreatment represents a risk as great as undertreatment. The alternative pathway for the care of patients who present to emergency departments with a history, signs, and symptoms potentially consistent with scaphoid fracture involves providing patients with information about the expected course of recovery and specific instructions about how to seek more care if desired (Supplemental Fig. 1; This approach has been used with good success in Fife, Scotland [18]. Of course, many surgeons still disagree with this approach and favor routine use of MRI when a scaphoid fracture is suspected, as recommended by NICE [5], and that disagreement is the topic of this Clinical Faceoff in this month’s Clinical Orthopaedics and Related Research®.

The suspected scaphoid fracture scenario has similarities to other diagnostic dilemmas and essentially amounts to a tussle over the relative potential benefits and harms of a strategy that errs toward potential over- or underdiagnosis. The potential for harm cannot be reduced to zero. And the evaluation of diagnostic tests for suspected scaphoid fractures must contend with the absence of a consensus reference standard for diagnosing true fractures among suspected fractures, which is also a source of unresolvable uncertainty. The routine MRI approach prefers early diagnosis to enable early reassurance and movement for most patients, while immobilizing the fractures and accepting a potential for some overdiagnosis. This approach is akin to what most surgeons would think is wise for a “can’t miss” diagnosis of limb- and life-threatening pathophysiology, such as compartment syndrome or necrotizing fasciitis. The contrary approach does not investigate to achieve an early diagnosis and allows patients to self-manage, accepting a small potential for underdiagnosis and undertreatment in order to limit potential overinvestigation and overdiagnosis. This is more akin to protocols like screening for prostate cancer in older men [13].

We have invited advocates of these two approaches to “face off” over the issues surrounding management of a suspected scaphoid fracture. Both are academic hand and upper extremity surgeons in the United Kingdom. Ben Dean FRCS, PhD is an avid scaphoid researcher based in Oxford, England, and champion of the United Kingdom’s NICE criteria that recommends routine MRI for suspected scaphoid fractures. Jane McEachan FRCS is a specialist hand surgeon in Fife, Scotland, who extended and modified the virtual fracture clinic developed in the UK, originally designed for fractures that heal predictably, to an application for suspected scaphoid fractures. Our hope is to clarify specific ethical principles, emphasize patients’ values in the context of this decision, and see how new findings from experimental data might influence decision-making and guidance in this and other similar circumstances.

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