Scaphoid fracture

Background

• Most commonly fractured carpal bone
• Occurs via FOOSH or axial load directed along thumb's metacarpal
• Avascular necrosis
  • Most commonly a/w proximal fractures (blood supply enters the distal part of the bone)

Clinical Features

• Pain along radial aspect of wrist
• Localized tenderness in anatomic snuffbox
• Pain elicited by axial pressure directed along thumb's metacarpal

Imaging

Scaphoid waist fracture

Scaphoid pseudarthrosis, before and after treatment with Herbert screw.

• X-ray
  • Obtain both standard and scaphoid views
  • Up to 10% of initial radiographs fail to detect a fx
• MRI
  • Gold-standard in cases in which high index of suspicion remains despite negative x-ray

Differential Diagnosis

Carpal fractures

AP view

• Scaphoid fracture
• Lunate fracture
• Triquetrum fracture
• Pisiform fracture
• Trapezium fracture
• Trapezoid fracture
• Capitate fracture
• Hamate fracture

Management

• All patients with clinical suspicion should be treated regardless of xray findings
• Assess for instability:
  • Oblique fx
  • >1mm of displacement
  • Rotation
  • Comminution
  • Carpal instability pattern is present
• Immobilize
  • Stable fracture: short-arm thumb spica splint in dorsiflexion and radial deviation
  • Unstable fracture: long-arm thumb spica splint

Disposition

• Refer to a hand surgeon b/c may lead to osteonecrosis if not properly recognized/treated
• 25% of those with initially neg xray will actually have a fracture (typically found on delay xray or other modality)

See Also

• Carpal fractures

Source

• Tintinalli