Patient-directed follow-up for the clinical scaphoid fracture
Aims: Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial ra...
| Main Authors: | , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
The British Editorial Society of Bone & Joint Surgery
2024-02-01
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| Series: | Bone & Joint Open |
| Subjects: | |
| Online Access: | https://online.boneandjoint.org.uk/doi/epdf/10.1302/2633-1462.52.BJO-2023-0119.R1 |
| _version_ | 1797289600090112000 |
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| author | Abhishek Chaturvedi Heather Russell Matthew Farrugia Mark Roger Amit Putti Paul J. Jenkins Stephen Feltbower |
| author_facet | Abhishek Chaturvedi Heather Russell Matthew Farrugia Mark Roger Amit Putti Paul J. Jenkins Stephen Feltbower |
| author_sort | Abhishek Chaturvedi |
| collection | DOAJ |
| description | Aims: Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods: We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results: From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion: A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122. |
| first_indexed | 2024-03-07T19:07:27Z |
| format | Article |
| id | doaj.art-6f72da3af7024e389fec21ba77a99b82 |
| institution | Directory Open Access Journal |
| issn | 2633-1462 |
| language | English |
| last_indexed | 2024-03-07T19:07:27Z |
| publishDate | 2024-02-01 |
| publisher | The British Editorial Society of Bone & Joint Surgery |
| record_format | Article |
| series | Bone & Joint Open |
| spelling | doaj.art-6f72da3af7024e389fec21ba77a99b822024-03-01T06:37:37ZengThe British Editorial Society of Bone & Joint SurgeryBone & Joint Open2633-14622024-02-015211712210.1302/2633-1462.52.BJO-2023-0119.R1Patient-directed follow-up for the clinical scaphoid fractureAbhishek Chaturvedi0Heather Russell1Matthew Farrugia2Mark Roger3Amit Putti4Paul J. Jenkins5Stephen Feltbower6Department of Trauma and Orthopaedics, University Hospital Wishaw, Wishaw, UKDepartment of Trauma and Orthopaedics, Forth Valley Royal Hospital, Larbert, UKDepartment of Trauma and Orthopaedics, Arrowe Park Hospital, Wirral, UKDepartment of Radiology, Forth Valley Royal Hospital, NHS Forth Valley, Larbert, UKDepartment of Trauma and Orthopaedics, Forth Valley Royal Hospital, NHS Forth Valley, Larbert, UKDepartment of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UKDepartment of Emergency Medicine, Forth Valley Royal Hospital, NHS Forth Valley, Larbert, UKAims: Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods: We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results: From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion: A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122.https://online.boneandjoint.org.uk/doi/epdf/10.1302/2633-1462.52.BJO-2023-0119.R1scaphoidfracturecost-effectivenessimagingmrioccultscaphoid fracturesmri scanningimmobilizationcliniciansmalunionswristradiographyemergency physiciansnon-unionswrist in a splint |
| spellingShingle | Abhishek Chaturvedi Heather Russell Matthew Farrugia Mark Roger Amit Putti Paul J. Jenkins Stephen Feltbower Patient-directed follow-up for the clinical scaphoid fracture Bone & Joint Open scaphoid fracture cost-effectiveness imaging mri occult scaphoid fractures mri scanning immobilization clinicians malunions wrist radiography emergency physicians non-unions wrist in a splint |
| title | Patient-directed follow-up for the clinical scaphoid fracture |
| title_full | Patient-directed follow-up for the clinical scaphoid fracture |
| title_fullStr | Patient-directed follow-up for the clinical scaphoid fracture |
| title_full_unstemmed | Patient-directed follow-up for the clinical scaphoid fracture |
| title_short | Patient-directed follow-up for the clinical scaphoid fracture |
| title_sort | patient directed follow up for the clinical scaphoid fracture |
| topic | scaphoid fracture cost-effectiveness imaging mri occult scaphoid fractures mri scanning immobilization clinicians malunions wrist radiography emergency physicians non-unions wrist in a splint |
| url | https://online.boneandjoint.org.uk/doi/epdf/10.1302/2633-1462.52.BJO-2023-0119.R1 |
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