Scaphoid fractures

by Pieter Jordaan, Neil Kruger & Duncan McGuire

Learning Objectives

  1. Maintain a high index of clinical suspicion; acute fractures can be missed on plain X-ray.
  2. Repeat X-ray after 10-14 days if a scaphoid fracture is suspected.
  3. Untreated scaphoid fractures can lead to non-union.
  4. A scaphoid non-union can lead to wrist arthritis.

Definition and anatomy

The scaphoid is the most commonly fractured carpal bone. The scaphoid’s blood supply enters from distal and flows retrograde, making the scaphoid vulnerable to avascular necrosis and non-union.

Scaphoid wrist fracture, associated with a peri-lunate dislocations

Mechanism of injury

A fall on an outstretched hand, with wrist extension and axial load on the wrist.

Differential diagnosis

Diagnosis

Maintain a high index of suspicion.

History

The patient will present with radial sided wrist pain following trauma with the injury mechanism as described above.

Examination

Observe for swelling over the dorsum of the wrist and the anatomic snuffbox. Palpate the dorsum of the wrist over the proximal scaphoid, in the anatomic snuffbox and volar over the scaphoid tubercle for pain. Circumduction of the thumb will be painful as well as axial compression of the thumb.

Special investigations

Imaging

Plain X-rays, asking for scaphoid views and should include a posteroanterior (PA) and lateral of the wrist, ulnar deviation PA and supination oblique views. A CT scan is suitable for fracture morphology, but should only be requested by the treating surgeon. MRI is the most sensitive investigation for picking up occult scaphoid fractures. If a scaphoid fracture is suspected clinically, but the X-ray does not show a fracture, then the patient must be placed in a backslab and seen again after 10-14 days for a repeat examination and X-ray. If earlier confirmation is required, then an MRI scan should be performed.

Management

Non-surgical

The majority of undisplaced fractures will heal if immobilised in a below-elbow cast. No benefit has been shown if the thumb is included in the cast (traditional scaphoid cast).

Surgical

All displaced fractures should be treated surgically with either percutaneous or open reduction and screw fixation.

Complications

Pitfalls

References

Hammert WC, Calfee RP, Bozentka DJ, Boyer MI; 2010; ASSH Manual of Hand Surgery; Lippincott, Williams and Wilkins (Wolters Kluwer); Philadelphia, USA.

Miller MD; 2008; Review of Orthopaedics, 5th edition; Elsevier; Philadelphia, USA.

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS; 2017; Green’s Operative Hand Surgery, 7th Edition; Elsevier; Philadelphia, USA.

Assessment

A 20-year-old mountain biker presents after a fall and complains of radial-sided wrist pain. He is very tender in the anatomic snuffbox, and any thumb movement is painful. What is your next step?

  1. Refer to an orthopaedic surgeon.
  2. Splint the wrist and tell him to rest
  3. Do a CT wrist.
  4. Do a wrist X-ray, including scaphoid views.
  5. Do a wrist MRI.

The correct answer is (D), do a wrist X-ray including scaphoid views.