Coventry et al evaluated patients with an occult scaphoid fracture for clinical features that can aid in the diagnosis. A delay in immobilization of the wrist can cause non-union, while immobilizing everyone is unwarranted. The authors are from the University of Warwick, University of Oxford, John Radcliffe Hospital, Royal Infirmary of Edinburgh, and the University of Edinburgh.
Patient selection: hand and wrist trauma, normal X-ray, clinical suspicion of scaphoid fracture
Prevalence of scaphoid fracture despite normal wrist X-ray: 7-9%
Most accurate clinical predictor: pain when examiner moves the wrist from pronation to supination against resistance (sensitivity 100%; specificity 98%).
Additional findings seen with occult fracture:
(1) supination strength < 10% of contralateral side (non-injured)
(2) pain on ulnar deviation
(3) pronation strength < 10% of contralateral side (non-injured)
Absence of tenderness in the anatomical snuffbox reduces the likelihood of an occult scaphoid fracture. Exclusion of an occult fracture was not possible on clinical exam alone.
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