We agree and compliment the authors on a comprehensive review of the literature. It has been highlighted in many articles that there needs to be a policy change in our management of suspected scaphoid fractures.
As stated in the article, bone scintigraphy and magnetic resonance imaging (MRI) are superior to repeat X-rays. MRI and bone scintigraphy are similar in diagnosing occult injuries and shortening the immobilisation. MRI has the advantage that it diagnoses ligamentous injuries.1,2 Bone scanning is relatively inexpensive at around £10 for the isotope. It detects occult carpal fractures other than scaphoid. Activity at fracture may correlate with prognostic features.
There are many difficulties in accessing early MRI compared to bone scintigraphy.
There has been controversy over the immobilisation of scaphoid fractures.3,4 This would offer an explanation for the difference in management.
Our protocol is that the suspected scaphoid patient is immobilised in a Colles backslab after negative primary scaphoid X-ray. The patient returns in 10–14 days for review by a senior accident and emergency team member in clinic. If a scaphoid fracture is still suspected, a Colles cast is used and a bone scan is performed within 3 days. Repeat X-rays are not requested. The patient is seen in fracture clinic within a week by the orthopaedic team with the bone scan results. This process has been audited and presented; it is recommended as part of a department protocol for those sites where nuclear medicine is available.5
Footnotes
References
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