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Scaphoid Fracture
From WikiSM
Other Names
- Scaphoid non union
- Occult scaphoid fracture
Background
- This page refers to fractures of the Scaphoid bone
History
Epidemiology
- Scaphoid is most commonly fractured carpal bone (need citation)
- 10% of all hand fractures and 60% of all carpal fractures (need citation)
- 15% of wrist fractures (need citation)
- Males > females
Introduction
Palpation of the (A) snuff box and (B) scaphoid tubercle[1]
General
- Proximal 80% of scaphoid receives retrograde blood flow from dorsal carpal branch of the radial artery
- Distal 20% receives blood supply from superficial palmar arch
- Retrograde blood supply makes scaphoid particular susceptible to avascular necrosis and nonunion
Location (need citation)
- 65% occur in the waist
- 25% proximal 1/3rd
- 10% distal 1/3rd
Etiology
- Traumatic injury which typically involves fall on outstretched hand
- Wrist is hyper-extended with radial deviation
Risk Factors
- Needs to be updated
Differential Diagnosis
Carpal Bone Fractures
- Scaphoid Fracture
- Lunate Fracture
- Triquetrum Fracture
- Pisiform Fracture
- Trapezium Fracture
- Trapezoid Fracture
- Capitate Fracture
- Hamate Fracture
Differential Diagnosis Wrist Pain
- Fractures
- Dislocations
- Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
- Carpometacarpal Joint Dislocation
- Distal Radioulnar Joint Dislocation
- Lunate Dislocation
- Perilunate Dislocation
- Instability & Degenerative
- Tendinopathies & Ligaments
- Neuropathies
- Pediatric Considerations
- Distal Radial Epiphysitis (Gymnast's Wrist)
- Torus Fracture
- Arthropathies
- Cartilage
- Vascular
- Other
Clinical Features
Predictive characteristics of index tests (click to enlarge)[2]
History
- Patients will some history of trauma
- Will complain of wrist pain or thumb pain, worse with movement or activity
Physical Exam: Physical Exam Wrist
- These 3 exam findings reported to be 100% sensitive, 74% specific for scaphoid fracture in first 24 hours following injury[3]
- Scaphoid compression test
- Snuffbox tenderness
- Palpation of the volar scaphoid tubercle
- Pain with resisted pronation
Special Tests
- Scaphoid Shift Test: apply pressure to scaphoid with ulnar and radial deviation
- Clamp Sign: Patient will form a clamp with the opposite thumb and index finger over scaphoid
- Scaphoid Compression Test: Apply an axial load down the thumb to compress the scaphoid
Evaluation
Radiographs
- Standard Radiographs Wrist
- 3 view radiographs often sufficient
- Scaphoid view: PA view in ulnar deviation
- If negative but suspicious, repeat in 2-3 weeks
MRI
- Most sensitive for occult fractures
- Can evaluate for other soft tissue pathology
CT
- Useful for assessing
- Fracture fragments
- Extent of collapse
- Pre-operative planning
Bone Scan
- Falling out of favor, remains an option
Classification
Herbert and Fisher's Classification of Scaphoid Fractures
- Type A: Stable acute fractures
- A1: Tubercle fracture
- A2: Incomplete waist fracture
- Type B: Unstable acute fractures
- B1: Distal oblique fractures
- B2: Complete or displaced waist fracture
- B3: Proximal pole fracture
- B4: Transscaphoid perilunate dislocation fracture
- B5: Comminuted fracture
- Type C: Delayed union
- Type D: Established nonunion
- D1: Fibrous union
- D2: Pseudoarthrosis
Management
Nonoperative
- Indications
- Stable, nondisplaced (majority)
- Normal radiographs with high index of suspicion
- Suspected Fracture
- In patients with normal radiographs, but a high degree of clinical suspicion,
- Patients should be placed in a thumb spica splint with repeat radiographs in roughly 1-2 weeks
- Confirmed Fracture
- Management decisions should be made in consultation with an orthopedic surgeon
- The majority of scaphoid fractures are nondisplaced or minimally displaced
- Can be treated with immobilization for 8-12 weeks in a thumb spica cast
Operative
- Indications
- Unstable fractures: proximal pole, >1 mm displacement
- Displaced waist and proximal pole scaphoid fractures
- High risk of delayed union, nonunion, or avascular necrosis
- Technique
- Percutaneus screw fixation
- Open reduction, internal fixation
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/Work
- Dictated by physician
- Minimum 6 weeks
Prognosis and Complications
Prognosis
- Nonoperative
- >90% of union in scaphoid fractures with <1 mm displacement (need citation)
Complications
- Avascular Necrosis
- Non-union
- Scaphoid Nonunion Advanced Collapse
See Also
Internal
- Forearm Pain (Main)
- Wrist Pain (Main)
- Hand Pain (Main)
- Hand and Wrist Anatomy (Main)
- Physical Exam Wrist
External
References
- ↑ Hackney, Lauren A., and Seth D. Dodds. "Assessment of scaphoid fracture healing." Current reviews in musculoskeletal medicine 4 (2011): 16-22.
- ↑ Coventry, Laura, et al. "Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies." Emergency Medicine Journal (2023).
- ↑ Parvizi J, Wayman J, Kelly P, Moran CG. Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br. 1998 Jun; 23(3):324-7
