There has been increasing interesting in redesigning the pathway for managing suspected scaphoid fractures. It was the subject of presentation and discussion session at the Summer SCOT Meeting 2022.
New pathways have been successfully implemented in:
- NHS Fife
- NHS Forth Valley
The establishment of Virtual Scaphoid Pathways is supported by the NHS Scotland Centre for Sustainable Delivery (CfSD) via the ACRT (Active Clinical Referral Triage) Team.
Occult Scaphoid Fractures
The scaphoid is one of the wrist (carpal) bones. It can be broken (fractured) in a fall onto an outstretched hand (FOOSH). In a small number of cases there might be an undisplaced break that cannot be seen on x-rays taken at the time of injury.
Undisplaced breaks of the scaphoid usually heal without the need for surgery. There can be cases when the break doesn’t heal. In some cases this can lead to arthritis of the wrist. The scaphoid sometimes doesn’t heal when the fracture is displaced, or in certain locations (due to the unusual bloods supply of the bone).
Due to the difficulty spotting a fracture on early x-rays and worries that a missed, untreated, fracture might lead to complications, orthopaedic surgeons have traditionally taken a very cautious path and immobilised all suspected injuries initially.
Where a break is suspected, the team traditionally arrange a further appointment for more x-rays at two weeks. In some centres, an early MRI scan is arranged for all suspected fractures.
Current “known knowns” about suspected scaphoid fractures
Despite an extensive literature base, there is no good longitudinal follow-up data available describing how many suspected scaphoid fractures are subsequently shown to have a fracture, and of them, how many go onto a complication.
It is also known that clinical examination is not specific at detecting true fractures. There are no good clinical findings that can exclude a fracture. Higher energy injuries, such as falls from greater height, RTAs, bikes and sports are risk factors. Re-examination of an immobilised wrist after two weeks is usually unhelpful as the wrist will remain sore due to immobilisation.
Scottish evidence, from the NHS Fife Virtual Scaphoid Pathway, has been supportive of the safety of its rollout (Stirling et al, Virtual Management of Clinically Suspected Scaphoid Fractures, JBJS 2022).
Balancing Risks and Benefits
It is very common for clinicians to balance risks of disease and complication, with the burden of over-diagnosis and treatment. FOOSH injuries are extremely common. Over cautious treatment of such injuries as suspected scaphoid fractures has the potential to lead to:
- Patient confusion
- Unnecessary immobilisation
- Outpatient clinic attendance burden
- Radiology department burden for repeat x-rays
- Radiology department burden for MRIs (even if accelerated “scaphoid’ protocols are used)
How did redesigned pathways come to exist?
The clinicians involved observed the very low rate of true scaphoid fractures in the population of suspected scaphoid fractures. They also noted no cases of significant non-union, malunion or arthritis (SNAC wrist). Therefore a redesigned clinical pathway was introduced in NHS Fife.
Virtual fracture clinics have become increasingly popular over the last decade and have shown to improve access and reduce the burden of unnecessary review on both patient and clinicians. Concerns about missing other injuries via VFCs have not been substantiated by the literature or changes in medicolegal claim properties.
What are the components of a successful “Virtual Scaphoid Pathway”
- Good initial clinical assessment by a doctor or ENP in the ED/MIU, along with obtaining four radiographic views (when indicated by ASB tenderness or pain on thumb telescoping or balloting the scaphoid).
- Radiology review for discrepancies in ED/MIU diagnosis (to detect actual fractures or other injuries that were missed on initial assessment)
- Virtual fracture clinic review by orthopaedic team to review ED/MIU history/examination and radiographs. Potential to identify higher risk patients who may benefit from earlier review (i.e. higher energy injury)
- Provision of removal wrist splint (without thumb spica)
- Provision of verbal and written information about pathway
- Opt-In availability to hand/wrist clinic if there are ongoing wrist symptoms >2 weeks from injury, with early F2F and repeat XRs/MRI as appropriate.
- Shorter immobilisation for most patients
- Patient empowerment to monitor recovery and opt-in
- Fewer out-patient fracture clinic appointments
- Fewer repeat x-rays
- Reduced requirement for MRI scanning