Difference between revisions of "Scaphoid fracture"

(all people treated with suspicion)
(Evaluation)
 
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*Most commonly fractured carpal bone
 
*Most commonly fractured carpal bone
 
*Occurs via FOOSH or axial load directed along thumb's metacarpal
 
*Occurs via FOOSH or axial load directed along thumb's metacarpal
 +
*Most common fracture at the waist of the scaphoid
 
*Avascular necrosis
 
*Avascular necrosis
**Most commonly a/w proximal fractures (blood supply enters the distal part of the bone)
+
**Most commonly associated with proximal fractures (blood supply enters the distal part of the bone)
  
 
==Clinical Features==
 
==Clinical Features==
 +
[[File:Snuffbox2017.jpg|thumb|Anatomical snuff box]]
 
*Pain along radial aspect of wrist
 
*Pain along radial aspect of wrist
 
*Localized tenderness in anatomic snuffbox
 
*Localized tenderness in anatomic snuffbox
 
*Pain elicited by axial pressure directed along thumb's metacarpal
 
*Pain elicited by axial pressure directed along thumb's metacarpal
  
==Imaging==
+
==Differential Diagnosis==
 +
{{Carpal fractures}}
 +
 
 +
==Evaluation==
 +
[[File:Scaphoid waist fracture.gif|thumb|Scaphoid waist fracture]]
 +
[[File:Scaphoid-Pseudarthrose1.jpg|thumb|Scaphoid pseudarthrosis, before and after treatment with Herbert screw.]]
 +
===Workup===
 
*X-ray
 
*X-ray
 
**Obtain both standard and scaphoid views
 
**Obtain both standard and scaphoid views
**Up to 10% of initial radiographs fail to detect a fx
+
**Up to 10% of initial radiographs fail to detect a fracture
 
*MRI
 
*MRI
 
**Gold-standard in cases in which high index of suspicion remains despite negative x-ray
 
**Gold-standard in cases in which high index of suspicion remains despite negative x-ray
  
==Differential Diagnosis==
+
===Diagnosis===
{{Carpal fractures}}
+
[[File:Scaphoid.jpg|thumb|Scaphoid fractures occur in three locations: (A) Distal tubercle, (B) waist, and (C) proximal pole.]]
 
 
==Management==
 
*All patients with clinical suspicion should be treated regardless of xray findings
 
 
*Assess for instability:
 
*Assess for instability:
**Oblique fx
+
**Oblique fracture
 
**>1mm of displacement
 
**>1mm of displacement
 
**Rotation
 
**Rotation
 
**Comminution
 
**Comminution
 
**Carpal instability pattern is present
 
**Carpal instability pattern is present
*Immobilize
+
 
**Stable fracture: short-arm [[thumb spica splint]] in dorsiflexion and radial deviation
+
==Management==
**Unstable fracture: long-arm [[thumb spica splint]]
+
''All patients with clinical suspicion should be treated regardless of x-ray findings''
*Refer to a hand surgeon b/c may lead to osteonecrosis if not properly recognized/treated
+
{{General Fracture Management}}
 +
 
 +
===Immobilization===
 +
*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 because 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)<ref>Gemme S and Tubbs R. What Physical Examination Findings and Diagnostic Imaging Modalities Are Most Useful in the Diagnosis of Scaphoid Fractures? Annals of Emergency Medicine. 2015. 65(3):308-309.</ref>
 +
*Repeat Wrist and scaphoid X-rays should be obtained 2-3 weeks after initial injury to assess for fracture if suspicion is high.
 +
*Immobilization may be required for at least 6-12 wks
  
 
==See Also==
 
==See Also==
 
*[[Carpal fractures]]
 
*[[Carpal fractures]]
  
==Source==
+
==References==
*Tintinalli
+
<references/>
  
[[Category:Ortho]]
+
[[Category:Orthopedics]]

Latest revision as of 04:46, 18 September 2019

Background

  • Most commonly fractured carpal bone
  • Occurs via FOOSH or axial load directed along thumb's metacarpal
  • Most common fracture at the waist of the scaphoid
  • Avascular necrosis
    • Most commonly associated with proximal fractures (blood supply enters the distal part of the bone)

Clinical Features

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

Differential Diagnosis

Carpal fractures

AP view

Evaluation

Scaphoid waist fracture
Scaphoid pseudarthrosis, before and after treatment with Herbert screw.

Workup

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

Diagnosis

Scaphoid fractures occur in three locations: (A) Distal tubercle, (B) waist, and (C) proximal pole.
  • Assess for instability:
    • Oblique fracture
    • >1mm of displacement
    • Rotation
    • Comminution
    • Carpal instability pattern is present

Management

All patients with clinical suspicion should be treated regardless of x-ray findings

General Fracture Management

Immobilization

Disposition

  • Refer to a hand surgeon because 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)[1]
  • Repeat Wrist and scaphoid X-rays should be obtained 2-3 weeks after initial injury to assess for fracture if suspicion is high.
  • Immobilization may be required for at least 6-12 wks

See Also

References

  1. Gemme S and Tubbs R. What Physical Examination Findings and Diagnostic Imaging Modalities Are Most Useful in the Diagnosis of Scaphoid Fractures? Annals of Emergency Medicine. 2015. 65(3):308-309.