C L I N I C A L A S S E S S M E N T OF S C A P H O I D I N J U R I E S A N D T H E

D E T E C T I O N OF F R A C T U R E S
R. GROVER
From the Department of Accident and Emergencies, Guy's'Hospital, London, UK
Difficulty in interpreting X-rays following carpal injury emphasizes the importance of clinical
assessment in diagnosing scaphoid fractures. The classical sign of tenderness in the anatomical
snuffbox is not specific and leads to many unnecessary out-patient reviews. A prospective compari-
son was made between anatomical snuffbox, scaphoid tubercle and scaphoid compression tenderness
as indicators of scaphoid fracture in 221 patients with suspected scaphoid injury. Swelling was
determined by measuring the difference in circumference at the wrist joint to compare between
fracture and soft tissue injury.
Scaphoid compression tenderness was found to be the most accurate test with a sensitivity of
100% and a specificity of 80%. Swelling of the wrist joint was significantly greater when there
was a fracture, compared to soft tissue injury alone, even when the initial X-ray was normal. This
was independent of any physiological variation in circumference between dominant and non-
dominant sides.
Scaphoid compression tenderness is therefore suggested as the most accurate indicator of
scaphoid fracture and marked swelling should raise suspicion even if the X-ray is normal.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 3." 341-343

The scaphoid is the commonest wrist bone to be frac-
tured and accounts for 60 70% of all carpal fractures.
Early diagnosis of scaphoid fracture is essential for
effective treatment to be instituted. Radiographic diag-
nosis may be unreliable as some fractures are not seen
on initial X-ray, although this only occurs in 2% of all
scaphoid fractures (Leslie and Dickson, 1981 ). However,
normal bone markings may make exclusion of a fracture
difficult in many cases (Dias et al., 1990). Although
other methods of diagnosis including ultrasound
(Shenouda and England, 1987) and bone scintigraphy
(King and Turnbull, 1981) improve the diagnostic yield
they are expensive and clinical judgement is still
paramount.
The classic test for detecting scaphoid fracture is to
elicit tenderness in the anatomical snuffbox (ASB)
(Adams, 1983). However many patients without fracture
are tender there as a cutaneous branch of the radial
nerve crosses the floor of the snuffbox and pressure on
it may give rise to pain. Swelling occurs in the region
of the anatomical snuffbox following scaphoid fracture
(Apley and Solomon, 1982) but this has not been
measured or compared with the swelling which occurs
after soft tissue injury alone.
Other clinical tests hsed to diagnose scaphoid fracture
include: scaphoid tubercle (ST) tenderness (Freeland,
1989) and scaphoid compression (SC) tenderness (Chen,
1989). ST tenderness is elicited by putting pressure on
the scaphoid tubercle, located as a bony prominence
on the radial border of the carpal tunnel at its proximal
edge. It can be made more prominent by radial deviation
of the wrist. SC tenderness is elicited by holding the
patient's thumb and applying pressure along the axis of
its metacarpal that is transmitted to the scaphoid bone.
These three methods have not previously been compared
with each other to determine their accuracy.
A prospective study was therefore designed, firstly to
investigate which of these three methods would provide
the most accurate indicator of scaphoid fracture and
secondly to measure swelling at the level of the carpus
to see if it was greater in the presence of fracture than
soft tissue injury alone.
PATIENTS AND M E T H O D S
All patients who were suspected of having sustained a
scaphoid injury, with any form of localized tenderness,
were included in the study. The study ran over a 6
month period from August 1991 to February 1992, and
all consecutive attendances with suspected scaphoid
injury to Guy's Hospital were entered. The accident and
emergency (A & E) doctors were instructed in the three
methods of testing for scaphoid tenderness. The presence
or absence of scaphoid tenderness in the ASB, ST and
by SC were recorded on a standard proforma. The
circumference of the wrist was measured, 1 cm distal to
the ulnar styloid process on the injured and non-injured
sides. The side of the dominant hand was also recorded.
All the above parameters were assessed before X-ray
examination which consisted of four views: posteroan-
terior, lateral, and two oblique views taken in 45 ° of
pronation and supination. After clinical and radio-
graphic assessment patients were managed as follows:
1. Those with radiological evidence of fracture had
the wrist immobilized in a scaphoid plaster and were
followed up in the fracture clinic.
2. Those without radiological evidence of fracture
but with scaphoid tenderness were supported in a double
tubigrip bandage and repeat X-rays were performed at
10 days. If X-ray revealed a fracture the patient was
treated as in (1).

341
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All X-rays were reported by independent radiologists
who were unaware of the details of the study.
Correlation between X-ray findings and clinical tender-
ness in the ASB, ST and by SC was performed with
calculation of specificity and sensitivity rates for each
parameter. Comparison between these rates was made
by calculating the 95% confidence limits using the stan-
dard error of a proportion.
To determine if increased swelling was associated with
scaphoid fracture the difference in circumference
between the injured and non-injured sides was compared
in patients with proven fracture and those with soft
tissue injury. To confirm that any observed difference
was not due to natural variation in wrist measurement
between dominant and non-dominant sides, 100 con-
secutive patients presenting to A & E with an unrelated
disorder had their wrist circumferences measured. The
mean difference of this control group was then compared
to the patients with fracture and soft tissue injury.
Statistical analyses of these comparisons were performed
using Student's t test.
RESULTS
In a 6 month period 221 patients presented with a
suspected scaphoid injury. Twenty-nine patients (13%)
had a scaphoid fracture on X-ray, one of which was
initially occult but was shown 10 days after injury on
repeat X-ray. Of those with a definite fracture 20 were
men (69%) and their ages ranged from 13 to 58, with a
mean of 28 years. Nine were women (31%) and their
ages ranged from 19 to 64 with a mean of 36 years.
Table 1 illustrates the findings of ASB, ST and SC
tenderness in patients with scaphoid fractures and those
with soft tissue injury alone. Table 2 shows the sensitivity
and specificity rates calculated for these tests along with
the 95% confidence limits.
Table 1--Anatomical snuffbox (ASB), scaphoid tubercle (ST) and
scaphoid compression (SC) tenderness in patients suspected of having
scaphoid injury
Fracture No fracture
(total=29) (total= 192)
ASB tenderness 29 136
ST tenderness 24 94
SC tenderness 29 38
Table 2--Sensitivities and specifieities of anatomical snuffbox (ASB),
scaphoid tubercle (ST) and scaphoid compression (SC) tenderness as
indicators of fracture in patients with suspected scaphoid injury
Sensitivity % Specificity %
(95% confidence limits) (95% confidence limits)
ASB tenderness 100% 29% (23-35%)
ST tenderness 83% (70-96%) 51% (44-58%)
SC tenderness 100% 80% (74-86%)
THE JOURNAL OF HAND SURGERY VOL. 21B No. 3 JUNE 1996
Table 3--Comparison of mean difference in wrist circumference
Mean difference in Standard error
wrist circumference (ram) of the mean
Fracture (total =29) 13 2
No fracture (total = 192) 7 2
Control (total = 100) 4 2
t-test: Fracture vs no fracture P < 0.05
Fracture vs control P<0.01
No fracture vs control P < 0.05
The results comparing mean difference in wrist cir-
cumference are shown in Table 3. In radiologically
proven fracture a mean difference of 13 mm (SEM 2)
was found. This was significantly greater (P < 0.05) than
the patients with soft tissue injury alone whose mean
difference in circumference was 7 mm (SEM 2).
The mean difference in wrist circumference found
in the normal population was 4 m m (SEM 2).
Comparison between these and patients with wrist injury
confirmed that the observed difference was not due
simply to variation between circumference on dominant
and non-dominant sides. Patients with proven fractures
had a significantly greater mean difference in wrist
circumference compared to controls (P<0.01), as did
patients with soft tissue injury (P<0.05).
The one patient with proven fracture whose initial
X-ray was negative presented with positive ASB and SC
tenderness but not ST tenderness. However the mean
difference in wrist circumference on presentation to A
& E was 13 mm which was significantly greater than the
mean difference of the group with soft tissue injury
alone (i.e. greater than 2 SEM above the mean for the
patients with soft tissue injury alone).
DISCUSSION
Although wrist injuries are common in clinical practice
this study found that only 13% (29 cases) of patients
suspected of having a scaphoid injury actually had a
fracture. With the exception of one patient all fractures
were apparent on the initial X-ray taken after injury.
This incidence of occult fracture is low but is in accord-
ance with that found in larger series (Leslie and Dickson,
1981). However occult fractures may become unstable
and develop cystic change resulting in osteoarthritis and
significant disability (Mack et al, 1984) which therefore
emphasizes the importance of accurate clinical assess-
ment at the time of injury.
The standard method of assessment for scaphoid
fracture is to elicit tenderness in the anatomical snuffbox
and perform X-rays including scaphoid views. To
prevent unnecessary delay in the diagnosis of occult
fractures King and Turnbull (1981) suggested the use of
bone scanning. Although this method is 100% sensitive
and would reduce the disability of unnecessary casting,
it is costly and time consuming. Thus clinical assessment
sCAPHOID INJURIES
is not only essential for accurate diagnosis but also in
deciding which patients will benefit from further
investigations.
The classic sign of anatomical snuffbox tenderness
had a sensitivity of 100% but a specificity of only 29%
(95% confidence limits 23-35%). Scaphoid tubercle ten-
derness had a sensitivity of 83% (confidence limits
70-96%) and a specificity of 51% (confidence limits
44-58%). However scaphoid compression tenderness
had a sensitivity of 100% and a specificity of 80%
(confidence limits 74-86%). Therefore, both ASB and
SC tenderness were of equal sensitivity and both were
significantly more sensitive than ST tenderness. However
SC tenderness was significantly more specific than the
other two tests.
It has previously been shown that SC tenderness is
also of value in checking union after scaphoid fracture
as it changes from positive to negative with radiological
evidence of fracture healing (Chen, 1989). Of the three
methods of establishing scaphoid tenderness, SC is the
only method which can be performed without removing
a scaphoid cast.
This study also demonstrated that there was increased
swelling of the wrist in patients with scaphoid fractures
compared to those with soft tissue injury alone. We
excluded variation between dominant and non-dominant
sides as a confounding factor in this finding by examin-
ing this relationship in 100 controls who presented
without wrist injury. It was interesting to observe that
the one patient with occult scaphoid fracture had a
mean difference in wrist circumference which was above
the 95th centile for patients with soft tissue injury alone,
suggesting that a fracture had occurred.
343
Scaphoid compression tenderness is therefore rec-
ommended as the most accurate test for the clinical
diagnosis of scaphoid fracture. If there is marked swell-
ing at the wrist joint as well as positive scaphoid
compression tenderness then clinical suspicion of frac-
ture should be high even if the initial X-ray is normal.
Acknowledgements
The author wishe~ to thank Major-General N.G. Kirby, past consultant Accident
and Emergency Surgeon to Guy's Hospital, for his advice, and the other senior
house officers in the department for their help in assessing the patients.
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Accepted: 4 December 1995
R. Grover, FRCS, RAFT Institute of Plastic Surgery, Mount Vernon Hospital, Northwood,
MiddlesexHA6 2RN, UK.
© 1996 The British Society for Surgery of the Hand