Fractures of the scaphoidBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1908 (Published 27 May 2020) Cite this as: BMJ 2020;369:m1908
All rapid responses
This is an important and nicely illustrated article as missed scaphoid fracture remains the most commonly missed fracture that leads to a clinical negligence claim. To give a radiological perspective; In my experience of providing expert opinion on the radiographs of missed scaphoid fracture, the fracture is almost invariably visible on review of the initial radiographs, making the reporter the obvious target for allegations of negligence. However, allegations of negligence ensue when the negative initial report is taken at face value without consideration of the continuing symptoms suffered by the patient and without then considering review of existing or repeat radiology and with a consequent delay that results in avoidable harm to the patient.
A radiological report, as with any medical test, has a false positive and false negative rate. It should be appreciated that it is at best a subjective interpretation of an appearance as perceived on a single occasion, and may have been produced by a reporter that is overworked, constantly interrupted, overdue a coffee break and not primarily a musculoskeletal specialist.
The article recommends 4 projection radiographs ("scaphoid views") as the initial radiological study in suspected scaphoid fracture, stating "The UK National Institute for Health and Care Excellence (NICE) also recommends an MRI scan for investigating clinically suspected scaphoid fractures where the initial radiographs are normal". This is incorrect; the NICE guidance states "Consider MRI for first line imaging in people with suspected scaphoid fractures following a thorough clinical examination." The latter approach would significantly reduce the initial false negative rate of radiological reports (as opposed to the actual appearances) of plain radiographs.
Competing interests: No competing interests