Predicting Occult Scaphoid Fractures in the ED Using Clinical Features

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Clinical scenario

A 27-year old female presents to the emergency department (ED) after a fall onto her hand from a
motorized scooter. She has pain on the radial aspect of her left wrist and anatomical snuffbox.
However, the X-rays do not indicate an obvious scaphoid fracture.

Clinical question: What are the predictive clinical features for occult scaphoid fractures in patients with normal initial radiographs in the ED?


Scaphoid fractures commonly occur from a fall onto an outstretched hand (FOOSH)​1​ and
remains a challenge for ED physicians to clinically assess and manage, as they may be occult
and missed on initial radiographs.​2​ If left untreated, potential risks include non-union, avascular
necrosis, and development of osteoarthritis.​3​ There remains inconsistency regarding the
management of suspected scaphoid fractures, thus ED physicians use either a conservative
approach in which the patient is immobilized using a cast/splint or simple analgesia and
education.​2​ Current methods for determining scaphoid fractures includes the anatomical snuffbox
tenderness test (ASBT) as well as the scaphoid tubercle tenderness (STT), scaphoid compression
test (SCT), active range of motion, and pain on ulnar or radial deviation. Although previous
studies have examined clinical predictors of scaphoid fractures in wrist injuries, less evidence is
available for occult scaphoid fractures with normal radiographs.

A systematic review and meta-analysis by Coventry et al. 2023 involving eight diagnostic test
accuracy studies reports the following: ​4​

  • The pooled prevalence of occult scaphoid fractures in patients with both a clinical
    suspicion of scaphoid injury and normal initial radiographs was 9.0%.
  • The most useful clinical features for identifying occult scaphoid fractures included pain
    on supination against resistance (LR+ 45.0, 95% CI 6.5-312.5), supination strength 10%
    of contralateral side (LR+ 3.7, 95% CI 2.2-6.1), positive ulnar deviation test (LR+ 2.3,
    95% CI 1.8-3.0), pronation strength less than 10% of contralateral side (LR+ 2.0, 95% CI
    1.2-3.2), and extension less than 50% of contralateral side (LR+ 2.0, 95% CI 1.4-3.0).
  • Absence of anatomical snuffbox tenderness (LR- 0.2, 95% CI 0.0-0.7) and absence of
    supination strength loss (LR- 0.2, 95% CI 0.1-0.7) were most useful for reducing the
    likelihood of occult scaphoid fractures.

Future considerations

  • Although no subgroup analysis was performed, patient characteristics (age, sex,
    mechanism of injury, previous history of wrist injury) in combination with clinical
    features may better inform management in certain patient populations.
  • Future research should conduct multi-centric studies to validate these clinical features.
    Multinational studies are critical, as developing countries with limited technology and
    resources may rely heavily on physical examination and predictive positive clinical
  • Analgesic administration in the ED prior to clinical assessment should be considered, as
    analgesia may impact patient-reported pain and the respective outcomes of predictive
    clinical features.

Clinical bottom line

Pain on supination against resistance may be a useful criterion in suspected occult scaphoid
fracture; however, this requires further external validation. ED physicians must continue to
optimize the integration of relying on positive clinical features from physical examination,
determining additional imaging, and considering individual patient characteristics to inform next
steps and management.

The article was edited by Revathi Nair and copy-edited by George V. Kachkovski.


  1. 1.
    Sendher R, Ladd AL. The Scaphoid. Orthopedic Clinics of North America. Published online January 2013:107-120. doi:10.1016/j.ocl.2012.09.003
  2. 2.
    Chang MTK, Price M, Furness J, et al. The current management of scaphoid fractures in the emergency department across an Australian metropolitan public health service: A retrospective cohort study. Medicine. Published online July 15, 2022:e29659. doi:10.1097/md.0000000000029659
  3. 3.
    Amrami KK. Radiology Corner: Diagnosing Radiographically Occult Scaphoid Fractures—What’s the Best Second Test? Journal of the American Society for Surgery of the Hand. Published online August 2005:134-138. doi:10.1016/j.jassh.2005.05.001
  4. 4.
    Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. Published online May 11, 2023:576-582. doi:10.1136/emermed-2023-213119

Reviewing with the Staff

The clinical management of occult scaphoid fractures continues to pose a challenge for emergency physicians. Fractures that are not obvious on initial radiography are easily missed and can result in non-union and avascular necrosis if ED physicians choose to manage the injury conservatively. Alternatively, more aggressive clinical approaches can lead to inappropriate immobilization and surgery. Not only can inappropriate or missed diagnoses result in such adverse patient outcomes and long-term morbidity, suboptimal clinical management can also lead to possible medico-legal pursuits against physicians. Although additional advanced imaging can often be pursued for suspected occult scaphoid fractures, it can be challenging for ED physicians to balance the risk of negative patient outcomes with equitable and responsible use of further healthcare investigations and spending. Evaluation of the diagnostic accuracy of key special tests conducted during a patient\'s physical examination in the ED can assist with clinical management and ED physician decision-making in such challenging scenarios.

Dr. Eddy Lang, MD
Dr. Eddy Lang is the Academic Department Head and a Professor in the Department of Emergency Medicine at the Cumming School of Medicine, University of Calgary, and the Clinical Department Head for Emergency Medicine, Calgary Zone, Alberta Health Services. His areas of interest are knowledge translation, evidence-based medicine and operations research. He is a member of the GRADE working group and has led the development of GRADE-based clinical practice guidelines in pre-hospital care in the US as well as with the International Liaison Committee for Resuscitation. Dr. Lang is also an award-winning educator having received recognition at both the university, national and international levels. He also serves as Senior Editor for the Canadian Journal of Emergency Medicine, Associate Editor for both ACP Journal Club and the International Journal of Emergency Medicine. In addition, he is a member of the Canadian Task Force on Preventive Health Care (CTFPHC). Dr. Lang chaired the Canadian Association of Emergency Physicians Conference (CAEP) 2018 and he was appointed as the Scientific Director of the Emergency Strategic Clinical Network ESCN in Alberta in 2019. He co-chaired the 2007 Academic Emergency Medicine Consensus Conference on Knowledge Translation which remains an ongoing interest. Dr. Lang is Chaired the 2022 Preventing Overdiagnosis Conference in Calgary. He was also inducted as a Fellow of the Canadian Academy of Health Sciences in 2022 and became a certificant of the Canadian College of Physician Executives in the same year. He also writes a quarterly column for the Calgary Herald on Evidence-Based Medicine.

Conné Lategan

Conné is currently a second year medical student at the University of Alberta. She completed her Master's of Science in pediatric emergency medicine at the University of Calgary and has a passion for patient-oriented research. She has no conflicts of interest to declare.

Cassandra Chisholm

Cassandra is currently a medical student at the University of Alberta, with prior experience in prehospital care and a Master of Management. Her research interests lay in emergency medicine, prehospital care, and pain medicine. She has no conflicts of interest to declare.

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