# Auditing the Early Management of Suspected Scaphoid Fractures in Comparison With the National Agreed Standard: A Retrospective Study

## TL;DR

This study examines how suspected scaphoid fractures are managed in a UK hospital and finds that most patients are immobilized unnecessarily despite negative X-rays.

## Contribution

The study provides a detailed audit of scaphoid fracture management practices against national standards in a UK hospital setting.

## Key findings

- 95.2% of patients underwent a four-view scaphoid radiograph series, but 82.3% had alternative diagnoses.
- The false-negative rate of initial radiographs was 22.7%, and the false-positive rate was 5.2%.
- 88.6% of confirmed fractures were treated conservatively, with 95.5% achieving union.

## Abstract

Introduction

Scaphoid fractures are the most common carpal bone injury and a frequent reason for wrist immobilisation following trauma. However, many patients with clinical suspicion of scaphoid fracture are immobilised despite negative radiographs, and ultimately have alternative diagnoses. This study aimed to evaluate early management, imaging, and outcomes for patients presenting with suspected scaphoid fractures at a District General Hospital (DGH) in the United Kingdom (UK), comparing practice with current British Society for Surgery of the Hand (BSSH) standards.

Methods

A retrospective audit was conducted of all adults presenting between January 2023 and December 2024 with suspected scaphoid fracture. Primary audit outcomes included compliance with seven-day referral to the fracture clinic, and whether a four-view scaphoid radiograph series was performed. Secondary and additional cohort data were collected on demographics, clinical features, and outcomes.

Results

A total of 248 patients were included (mean age 47.5 years; 56.5% female). Most injuries resulted from a fall on an outstretched hand (n = 208, or 83.9%). Review within seven days occurred in 68.5% (n = 170) of cases, and 95.2% (n = 236) underwent a dedicated four-view scaphoid radiograph series. A scaphoid fracture was confirmed in 44 patients (17.7%), while 82.3% had alternative diagnoses. The false-negative rate of initial radiographs was 22.7% (10/44; 95% CI 11.5-37.8%), and the false-positive rate was 5.2% (13/248; 95% CI 2.8-8.8%). Advanced imaging was obtained in 29.0% of patients, including computed tomography (CT) and magnetic resonance imaging (MRI), with median time at 36.5 and 30 days, respectively. The median time to exclusion of a scaphoid fracture by a consultant in a specialist orthopaedic clinic was 18.5 days (mean 27.5 days). Among confirmed fractures, 88.6% were treated conservatively, and 95.5% achieved union. There were no cases of avascular necrosis.

Conclusion

Although compliance with early review and imaging standards was high, most patients were immobilised without a true fracture, reflecting persistent overtreatment. Earlier MRI access, improved documentation, and clearer immobilisation protocols may reduce unnecessary treatment, enhance diagnostic efficiency, and strengthen alignment with national standards for suspected scaphoid fractures.