management of suspected scaphoid fractures with normal x - rays at emergency department ( ed ) presentation is a common clinical challenge . there has long been concern that failure to identify and immobilise a scaphoid fracture might result in avascular necrosis or non - union with significant functional impact for the patient and potential medico - legal risk for the practitioner . traditional management would see the patient immobilised in a plaster cast for 714  days followed by clinical examination and re - x - ray to identify fractures not visible on the initial films . that approach can been challenged on two fronts : whether cast immobilisation while awaiting clinical review is justified and the role of alternative imaging modalities at or near the time of initial presentation . the aim of this project was to characterise current management of adult patients with possible occult scaphoid fracture in australasia . this was an internet - based survey of directors of emergency medicine training ( demt ) throughout australasia as identified from the australasian college for emergency medicine web - site ( www.acem.org.au ) . demts are the designated supervisors of specialist training at hospitals accredited for training , both metropolitan and rural ( one / hospital ) . as such , they are easily identifiable , experienced specialists with a good understanding of clinical practice within the ed in which they work . participants were sent an invitation to participate in the confidential on - line survey by e - mail ( where one could be found ) or by post . data were collected using internet - based survey software ( 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 . table  1management options and reported frequencymanagement strategyfrequency ( n , % ) backslab ( half - cast ) with assessment and re - x - ray at 714  days23 , 38%plaster cast ( full ) with assessment and re - x - ray at 714  days19 , 32%backslab with early ct ( within 7  days)6 , 10%backslab with early bone scan ( within 7  days)5 , 8%backslab with early mri ( within 7  days)2 , 3%support bandage with early mri ( within 7  days)1 , 1.7%support bandage with early ct ( within 7  days)1 , 1.7%plaster cast ( full ) with early ct ( within 7  days)1 , 1.7%plaster cast ( full ) with early bone scan ( within 7  days)1 , 1.7%support bandage with re - assessment at 1  week , with further tests only if symptoms or signs persist1 , 1.7%support bandage with assessment and re - x - ray at 714  days0plaster cast ( full ) with early mri ( within 7  days)0support bandage with early bone scan ( within 7  days)0othersame / next day ct1 , 1.7% management options and reported frequency this project was approved by western health under the nhrmc quality assurance guidelines . 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 710  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% ) . eighty - three percent of sites reported not having a written guideline / protocol for this condition . the rate of occult scaphoid fractures in cohorts of patients with clinical evidence suggestive of scaphoid fracture but normal initial x - rays is reported to be 016% [ 24 ] , weighted average 3.7% ( 95% ci 2.55.6% ) . in the subgroup who prove to have a fracture , the rate of delayed / non - union is low ( 1020% ) . traditional treatment for suspected occult scaphoid fracture is cast immobilisation with clinical re - assessment and re - x - ray at 710  days . 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 [ 57 ] . 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% ) . the high use of immobilisation is at odds with reported uk practice , where only 46% of eds reported routinely using plaster immobilisation for x - ray - negative suspected scaphoid fracture . ct , mri and bone scan have all been shown to be effective in the diagnosis of occult scaphoid fractures , 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 outcomes . there is no evidence that lack of access to advanced imaging impacts adversely on clinical outcome . the weight of evidence would suggest that this is over - treatment and that a simple bandage is sufficient . as this was a survey , the management strategy reported may not be that actually used . the traditional approach to management of possible occult scaphoid fracture of immobilisation with re - x - ray at 710  days remains the most commonly used in australasia , despite evidence that this is probably over - treatment with significant consequences for patients .
aimto characterise current management of adult patients with possible occult scaphoid fracture in australasian emergency departments.methodsinternet-based survey of directors of emergency medicine training throughout australasia . 
 data collected included the most common management used in ed for patients with possible occult scaphoid fracture and whether there was a guideline regarding management of such cases . 
 data are reported as descriptive statistics.results61 responses were received ( response rate 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 710  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% ) . 
 very few sites were using same day / next day ct or mri . 
 eighty - three percent of sites reported not having a guideline / protocol for this condition.conclusionthe traditional approach to management of possible occult scaphoid fracture of immobilisation with re - x - ray at 710  days remains the most commonly used in australasia , despite evidence that this is probably over - treatment with significant consequences for patients . 
 the place of advanced imaging for investigation of potential scaphoid fractures requires further research .