Scaphoid Fracture

Aka: Scaphoid Fracture

1. See Also
   1. Wrist Injury
   2. Hand Injury
2. Epidemiology
   1. Scaphoid is most common Carpal BoneFractured
   2. Represents 5% of all wrist injuries
   3. Most commonly affects males 18-40 years old
   4. Rarely occurs in young children
   5. Usually occurs as a workplace injury or sports injury
3. Mechanism
   1. Fall on Outstretched Hand
      1. Exacerbated by wrist dorsiflexion
      2. Exacerbated by wrist radial deviation
4. Complication
   1. Primary: Blood supply enters distal portion of Scaphoid
      1. Avascular Necrosis of proximal fragment
      2. Fracture Non-union
   2. Secondary to non-union or avascular necrosis
      1. Decreased grip strength
      2. Decreased range of motion
      3. Ostearthritis of radiocarpal joint
5. Symptoms
   1. Dorsal radial Wrist Pain
      1. Deep, dull ache
   2. Provocative factors
      1. Wrist movement
      2. Gripping or squeezing objects
6. Signs
   1. See Wrist Exam
   2. Diagnosis may be difficult (no obvious deformity)
   3. Keep high level of suspicion in "Wrist Sprain"
   4. See Scaphoid Fracture Signs
      1. Anatomic Snuffbox Tenderness (wrist ulnar deviated)
      2. Scaphoid Tubercle Tenderness (wrist in extension)
7. Differential Diagnosis
   1. Injury
      1. See Fall on Outstretched Hand
      2. Distal Radius Fracture (e.g. Colles Fracture)
         1. Radius is weaker than Scaphoid in young and elderly
      3. Scapholunate Dissociation
   2. Wrist Overuse (i.e. De Quervain's Tenosynovitis)
   3. Arthritis (e.g. Rheumatoid Arthritis)
8. Radiology
   1. Wrist XRay
      1. Standard Views: AP and lateral view, obliques
      2. Scaphoid view
         1. Anteroposterior view (dorsal-volar angle)
         2. Supination to 30 degrees
         3. Ulnar deviation
      3. Test Sensitivity: 86% (variable)
         1. Tiel-van Buul (1993) J Hand Surg 18:403-6
      4. Timing of XRay
         1. Normal initially in non-displaced Fracture
            1. Thumb Spica Cast if clinical suspicion
            2. Repeat Wrist XRay in 2 weeks
         2. Fracture visible in 2-4 weeks with decalcification
   2. Wrist Bone Scan or Wrist MRI Indications
      1. High clinical suspicion and
      2. Negative Wrist XRay at 2 weeks
9. Course
   1. Delayed immobilization 1-2 weeks risks non-union
   2. Radial artery supply impacts healing time
      1. Proximal Scaphoid Fracture (15%)
         1. Greater risk of avascular necrosis
         2. Nondisplaced Fractures heal in over 12 weeks
      2. Middle Scaphoid Fracture (75-80%)
         1. Nondisplaced Fracture heals in 8-10 weeks
      3. Distal Scaphoid Fracture (5-10%)
         1. Nondisplaced Fracture heals in 8-10 weeks
10. Management: Algorithm
    1. High Clinical Suspicion without radiological evidence
       1. Apply Thumb Spica Splint for 2-3 weeks
       2. Repeat Wrist XRay after 2-3 weeks
    2. Scaphoid Fracture on initial or follow-up Wrist XRay
       1. Nondisplaced distal pole Fracture
          1. Short arm Thumb Spica Cast for 6 weeks
          2. Consider not including thumb in cast (nondisplaced)
             1. Clay (1991) J Bone Joint Surg 73:828-32
       2. Proximal pole Fracture
          1. Long Arm Cast for 8-12 weeks
       3. Middle third Fracture
          1. First: Long Arm Cast for 6 weeks
          2. Next: Short arm thumb spica for 2-4 more weeks
             1. Repeat Wrist XRay every 2-4 weeks
             2. Continue immobilization until union by Wrist XRay
       4. Displacement of Fracture fragments
          1. First: Long Arm Cast for 6 weeks
          2. Next: Short Arm Cast for an additional 6 weeks
11. Management: Immobilization Techniques
    1. Thumb Spica Splint
    2. Thumb Spica Short Arm Cast
       1. Neutral position
       2. Hand in position as if holding can
    3. Long Arm Cast
12. Prognosis
    1. Delayed healing or non-union in 5% Scaphoid Fractures
13. Orthopedic referral indications
    1. All proximal third Fractures
       1. High risk for nonunion
       2. High risk avascular necrosis
    2. Displaced Fractures (>1mm gap)
    3. All Angulated Scaphoid Fractures
14. Follow-up
    1. Days 1-2: Cast follow-up by phone or clinic visit
       1. Is cast too tight?
    2. Cast Removal
       1. Wrist XRay repeated
       2. Re-apply cast for 2-4 weeks if Fracture line visible
       3. Refer if Fracture line seen after additional Casting
15. References
    1. Greene (2001) Essentials Musculoskeletal Care, p. 252-4
    2. Perron (2001) Am J Emerg Med 19(4):310-6
    3. Phillips (2004) Am Fam Physician 70(5):879-84