Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures.
OBJECTIVE
We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.


METHODS
This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with "clinical scaphoid fracture": a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.


RESULTS
Eighty patients completed the study protocol in a regional emergency department. In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.


CONCLUSIONS
This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.
Pincus
Steven
S
Emergency Department, Ballarat Health Services, Ballarat, Victoria, Australia.
Weber
Merle
M
Meakin
Alex
A
Breadmore
Ross
R
Mitchell
David
D
Spencer
Luke
L
Anderson
Nathan
N
Catterson
Phil
P
Farish
Steve
S
Cruickshank
Jaycen
J