A virtual pathway reduced the need for physical review in patients with a suspected scaphoid fracture

Abstract

Objectives: Suspected scaphoid fractures are a common reason for referral from the emergency department tofracture clinics. Few patients actually have a fracture. Cross sectional imaging has the potential to improveearly diagnosis and reduce unneccessary immobilisation. The aim of this audit was to investigate theeffectiveness of a virtual pathway, incorporating early magnetic resonance imaging (MRI) scan, for suspectedscaphoid fractures. The secondary aim was to investigate whether the accuracy of other clinical signs, such asanatomical snuffbox pain on wrist ulnar deviation, was sufficient to reduce the number of patients requiring aMRI scan.Methods: A prospective audit was undertaken of 123 patients in an emergency department and associatedminor injuries unit. These patients were managed with an early MRI scan. Where no significant injury wasfound, they were discharged after a phone call from a virtual fracture clinic nurse.Results: There were 16 (13%) true scaphoid fractures. MRI scanning showed other injuries including significantsoft tissue injuries (13%), other carpal fractures (17%) and fractures of the distal radius (19.5%). The numberof clinical appointments required was 0.42 per patient. Eighty patients did not have any face-to-face review.Other clinical examination techniques, such as anatomical snuff box pain on ulnar deviation of the wrist werenot sufficiently sensitive or specific to reduce the need for MRI scanning or review.Conclusions: A virtual fracture clinic pathway and early MRI scanning reduced face-to-face reviews andunneccesary immobilisation. Clinical examination techniques are not sufficiently sensitive to reduce the needfor scanning.