Scaphoid fracture

From WikEM
Jump to: navigation, search

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

  • 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

Evaluation

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

Management

  • All patients with clinical suspicion should be treated regardless of xray findings
  • Assess for instability:
    • Oblique fracture
    • >1mm of displacement
    • Rotation
    • Comminution
    • Carpal instability pattern is present
  • Immobilize

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.