46 e-mail (where one could be found) or by post. A minimum of two reminders were sent to maximise participation. Data were collected using Internet-based survey soft- ware (www.surveymonkey.com) and included the most common management strategy used for patients with possible occult scaphoid fracture (from a range of options, see Table 1) and whether there was a written ED guideline regarding management of such cases. The outcome of interest was the most common management strategy for possible occult scaphoid fractures. Data are reported as descriptive statistics. This project was approved by Western Health under the NHRMC Quality Assurance Guidelines. Results 61 responses were received, representing a response rate of 73%. The most common management reported was immobilisation in a backslab (23, 38%) or full cast (19, 32%) with clinical assessment and re-X-ray in 7–10 days. CT scan within 7 days was used by 9 (15%), bone scan within 7 days by 6 (10%) and MRI within 7 days by 3 (5%). One ED reported same/next day CT (Table 1). Eighty-three percent of sites reported not having a written guideline/protocol for this condition. Discussion The rate of occult scaphoid fractures in cohorts of patients with clinical evidence suggestive of scaphoid fracture but Table 1 Management options and reported frequency Management strategy Backslab (half-cast) with assessment and re-X-ray at 7–14 days Plaster cast (full) with assessment and re-X-ray at 7–14 days Backslab with early CT (within 7 days) Backslab with early bone scan (within 7 days) Backslab with early MRI (within 7 days) Support bandage with early MRI (within 7 days) Support bandage with early CT (within 7 days) Plaster cast (full) with early CT (within 7 days) Plaster cast (full) with early bone scan (within 7 days) Support bandage with re-assessment at 1 week, with further tests only if symptoms or signs persist Support bandage with assessment and re-X-ray at 7–14 days Plaster cast (full) with early MRI (within 7 days) Support bandage with early bone scan (within 7 days) Other Same/next day CT Int J Emerg Med (2010) 3:45–47 normal initial X-rays is reported to be 0–16% [2–4], weighted average 3.7% (95% CI 2.5–5.6%). In the subgroup who prove to have a fracture, the rate of delayed/non-union is low (10–20%) [2]. Nonetheless, non- union or avascular necrosis can result in significant morbidity. Traditional treatment for suspected occult scaph- oid fracture is cast immobilisation with clinical re- assessment and re-X-ray at 7–10 days [1]. That approach, however, has been suggested to be over-treatment, with a very low rate of significant fractures at the cost of significant time lost from work or school [5–7]. It has been suggested that symptomatic treatment with follow-up within 2 weeks for these cases is sufficient [6, 8, 9]. We found that most Australasian EDs continue to use plaster immobilisation for this patient group (backslab or full cast, 70%) and that uptake of alternative imaging modalities is only moderate (30%). Very few EDs are using same day/ next day imaging for this group. The high use of immobi- lisation is at odds with reported UK practice, where only 46% of EDs reported routinely using plaster immobilisation for X-ray-negative suspected scaphoid fracture [10]. A few clinical studies have compared management strategies for this patent cohort. CT, MRI and bone scan have all been shown to be effective in the diagnosis of occult scaphoid fractures [11], but to date no studies have shown additional benefit from early advanced imaging for hard clinical outcomes. At present, the logical role for advanced imaging is for patients with persistent symptoms and normal follow-up X-rays. There is a clear need for further research comparing combinations of the various immobilisation and imaging strategies and reporting clinical outcomes (including time off work and time immobilised) and cost-effectiveness Frequency (N, %) 23, 38% 19, 32% 6, 10% 5, 8% 2, 3% 1, 1.7% 1, 1.7% 1, 1.7% 1, 1.7% 1, 1.7% 0 0 0 1, 1.7%