The Ruled-out Scaphoid Fracture on Computed Tomography Prevalence and the Therapeutic Management of Other Carpal Fractures

Suspicion of scaphoid fracture is a common topic in emergency medicine. If the radiograph is inconclusive, or there are typical symptoms suggestive of a scaphoid fracture despite a negative radiograph, further investigation with cross-sectional imaging is advocated. Because of its availability, computed tomography (CT) is the primary imaging method in most departments. In recent meta-analyses, CT has a pooled sensitivity of 93% and pooled specify of 99% to diagnose the scaphoid fracture (1). There are only sparse data about the prevalence of other carpal fractures in patients undergoing imaging the scaphoid with CT after trauma and the therapeutic consequences of these fractures. A retrospective analysis of 53 patients who underwent CT imaging of the wrist because of a clinically suspected scaphoid fracture was performed, despite a negative initial radiograph. The sample consisted of 36 men and 17 women with a mean age of 31.2 years presenting at our emergency department. All patients were examined between August 2009 and August 2011 using a 16-slice CT scanner (Activion ®, Toshiba Medical Systems, Tokyo, Ja-pan) with a slice thickness of 0.5 mm. Data sets were post-processed on a standard medical workstation (Vitrea 2®, Vital Images, Minnetonka, USA). The scans were primarily reported by four different consultant radiologists. All data sets were reassessed by the author to ensure the correct primary diagnosis. The electronic medical charts of all patients were reviewed. On admission all patients were examined by a board certified hand surgeon, who decided about further treatment. If a fracture was found on imaging, a follow-up was routinely performed after 4-8 weeks and the patients were instructed to present at the emergency department if there were the new pain, pain worsening, limitations in motion or other uncertainties in the further follow-up. No fractures were identified in 23 patients (43.3%). A scaphoid fracture was found in 14 patients (26.4%). Fif-teenth patients (28.2%) showed other fractures than the scaphoid (Figure 1). In nine out of 15 patients (60%), only the small flake fractures were found. In 6 patients, more than one carpal bone were affected. The triquetrum was the most affected carpal bone following the scaphoid. Only one patient showed a radio graphically occult fracture of the distal radius. Patients with scaphoid fractures were advised to undergo osteosynthesis to minimize the risk of pseudarthrosis. All patients showing fractures other than the scaphoid were treated conservatively with splinting and none of these patients received osteosynthesis at …