Scaphoid fracture: Difference between revisions

 
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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==
*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.