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Scaphoid Fracture

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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

Left palmer view of the scaphoid bone
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

Differential Diagnosis Wrist Pain


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


Evaluation

Possible scaphoid fracture with subtle lucency in the waist
Chronic scaphoid fracture with severe degenerative changes
CT of chronic scaphoid fracture with nonunion

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


See Also

Internal

External


References

  1. Hackney, Lauren A., and Seth D. Dodds. "Assessment of scaphoid fracture healing." Current reviews in musculoskeletal medicine 4 (2011): 16-22.
  2. Coventry, Laura, et al. "Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies." Emergency Medicine Journal (2023).
  3. 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
Created by:
John Kiel on 10 June 2019 01:01:55
Last edited:
7 June 2023 08:16:52
Categories:
Trauma | Osteology | Wrist | Upper Extremity | Fractures | Acute