Scaphoid Fracture

Aka: Scaphoid Fracture, Navicular Fracture, Fracture of Scaphoid Bone of Wrist, Fracture of Navicular Bone of Wrist

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II. Epidemiology

  1. Scaphoid is most common Carpal BoneFractured
  2. Represents 5% of all wrist injuries
  3. Usually occurs as a Workplace Injury or Sports Injury
  4. Most commonly affects males 18-40 years old
    1. With aging, distal radius is weaker and more commonly Fractured
  5. Children
    1. Typically occur at age 12 to 15 years and older
    2. Uncommon in age <10 years old (unless severe Traumatic Injury)
    3. Rarely occurs in young children
      1. Scaphoid protected by supportive cartilage in young children
      2. Distal Radius Fracture or physeal Fractures are more common

III. Mechanism

  1. Scaphoid and Lunate Bones are only wrist bones with articulation with radius
    1. Fall on an outstretched hand transmits force to the Scaphoid Bone (and Lunate Bone)
  2. Fall on Outstretched Hand
    1. Exacerbated by wrist radial deviation
    2. Exacerbated by wrist dorsiflexion >95 degrees
      1. Proximal pole of Scaphoid is trapped between Capitate, radius and palmar capsule
      2. Distal pole is able to move freely
  3. Many Scaphoid Fracture patients do not have a history of fall on an outstretched hand
    1. Traffic accidents and sports injuries account for 60% of cases

IV. Precautions

  1. Missed Scaphoid Fractures are among the most common upper extremity injuries resulting in Malpractice claims
    1. Harrison (2015) Eur J Emerg Med 22(2):142-3 [PubMed]
    2. Ring (2015) Injury 46(4): 682-6 +PMID:25697859 [PubMed]

V. Symptoms

  1. Dorsal radial Wrist Pain
    1. Deep, dull ache
  2. Provocative factors
    1. Wrist extension
    2. Gripping or squeezing objects with pain and loss of strength

VI. Signs

  1. See Wrist Exam
  2. Diagnosis may be difficult (no obvious deformity)
  3. Keep high level of suspicion in "Wrist Sprain"
  4. See Scaphoid Fracture Signs
    1. Scaphoid tenderness (LR- 0.15)
      1. Anatomic Snuffbox Tenderness (wrist ulnar deviated)
      2. Scaphoid Tubercle Tenderness (wrist in extension)
    2. Pain on axial pressure of First Metacarpal bone
    3. Decreased grip strength
    4. Pain on resisted supination (LR- 0.09)

VII. Differential Diagnosis

  1. Injury
    1. See Fall on Outstretched Hand
    2. Distal Radius Fracture (e.g. Colles Fracture)
      1. Radius is weaker than Scaphoid in young and elderly
    3. Scapholunate Dissociation (or Scapholunate Tear)
      1. Scapholunate widening >3 mm
    4. Carpometacarpal Dislocation
      1. Carpometacarpal widening >1-2 mm
    5. Lunate Fracture
  2. Wrist Overuse (i.e. De Quervain's Tenosynovitis)
  3. Arthritis (e.g. Rheumatoid Arthritis)

VIII. Imaging

  1. Wrist XRay
    1. Standard Views: AP and lateral view, obliques
    2. Scaphoid view
      1. Anteroposterior view (dorsal-volar angle)
      2. Supination to 30 degrees
      3. Ulnar deviation
    3. Test Sensitivity: 86% (variable, may be as low as 11%)
      1. Inadequate to exclude Scaphoid Fracture (only useful if positive)
      2. Tiel-van Buul (1993) J Hand Surg 18:403-6 [PubMed]
    4. Timing of XRay
      1. Normal initially in non-displaced Fracture
        1. Thumb Spica Cast if clinical suspicion
        2. Repeat Wrist XRay in 10-14 days (bony sclerosis not evident until that time)
      2. Fracture visible in 2-4 weeks with decalcification
    5. Types in Children
      1. Type 1: Pure chondral injury (age <9 years)
      2. Type 2: Osteochondral injury (age 9 to 11 years)
      3. Type 3: Near Complete Ossification (age >11 years)
  2. Advanced Imaging: Wrist CT, Wrist MRI or Wrist Bone Scan
    1. Indications
      1. High clinical suspicion and
      2. Negative Wrist XRay at 2 weeks
    2. Efficacy: Bone Scan
      1. Test Sensitivity: 100%
      2. Test Specificity: 75%
    3. Efficacy: CT
      1. Test Sensitivity: 83-85%
    4. Efficacy: MRI
      1. Test Sensitivity: 95% (as of 10 days; only 80% on first day following injury)
      2. Test Specificity: 99%

IX. Course

  1. Delayed immobilization 1-2 weeks risks non-union
  2. Radial artery supply impacts healing time
    1. Proximal Scaphoid Fracture (15%)
      1. Greater risk of avascular necrosis
      2. Nondisplaced Fractures heal in over 12 weeks
    2. Middle Scaphoid Fracture (75-80%)
      1. Nondisplaced Fracture heals in 8-10 weeks
    3. Distal Scaphoid Fracture (5-10%)
      1. Nondisplaced Fracture heals in 8-10 weeks

X. Management: Immobilization Techniques

  1. Thumb Spica Splint
    1. Typically applied in first 5-7 days of injury until swelling decreases and cast may be applied
  2. Thumb Spica Short Arm Cast
    1. Neutral position
    2. Hand in position as if holding can
  3. Short Arm Cast WITHOUT thumb immobilization
    1. Consider in non-displaced or minimally displaced Scaphoid Fractures (consult local experts)
    2. Appears equivalent to Thumb Spica Casting in healing rates, union, longterm function and pain
    3. Allows patient to have better hand function during Casting
    4. Deck (2022) Am Fam Physician 105(3): 307-8 [PubMed]
    5. Buijze (2014) J Hand Surg Am 39(4):621-7 +PMID: 24582846 [PubMed]

XI. Management: Algorithm

  1. High Clinical Suspicion without radiological evidence
    1. Apply Thumb Spica Splint for 2-3 weeks
    2. Repeat Wrist XRay after 2-3 weeks
    3. Consider early MRI (may be cost effective compared with empiric Splinting and orthopedic referral)
      1. Karl (2015) J Bone Joint Surg Am 97(22):1860-8 +PMID:26582616 [PubMed]
  2. Scaphoid Fracture on initial or follow-up Wrist XRay
    1. Nondisplaced distal pole Fracture
      1. Short arm Thumb Spica Cast for 6 weeks
      2. Consider not including thumb in cast (nondisplaced)
        1. Clay (1991) J Bone Joint Surg 73:828-32 [PubMed]
    2. Proximal pole Fracture
      1. Long Arm Cast for 8-12 weeks
    3. Middle third Fracture
      1. First: Long Arm Cast for 6 weeks
      2. Next: Short arm thumb spica for 2-4 more weeks
        1. Repeat Wrist XRay every 2-4 weeks
        2. Continue immobilization until union by Wrist XRay
    4. Displacement of Fracture fragments
      1. First: Long Arm Cast for 6 weeks
      2. Next: Short Arm Cast for an additional 6 weeks

XII. Management: Orthopedic referral indications

  1. All proximal third Fractures
    1. High risk for nonunion
    2. High risk avascular necrosis
  2. Displaced Fractures (>1mm gap)
  3. All Angulated Scaphoid Fractures

XIII. Management: Follow-up

  1. Days 1-2: Cast follow-up by phone or clinic visit
    1. Is cast too tight?
  2. Cast Removal
    1. Wrist XRay repeated
    2. Re-apply cast for 2-4 weeks if Fracture line visible
    3. Refer if Fracture line seen after additional Casting

XIV. Complications

  1. Primary: Blood supply enters distal portion of Scaphoid and Fracture interrupts flow to the proximal Scaphoid Bone
    1. Avascular Necrosis of proximal fragment (20-50% of missed Scaphoid Fracture)
    2. Fracture Non-union
  2. Secondary to non-union or avascular necrosis
    1. Decreased grip strength
    2. Decreased range of motion
    3. Ostearthritis of radiocarpal joint

XV. Prognosis

  1. Delayed healing or non-union in 5% Scaphoid Fractures
  2. Functional outcomes after immobilization versus surgical repair are similar in non-displaced Scaphoid Fractures at one year
    1. Johnson (2022) Bone Joint J 104-B(8): 953-62 [PubMed]

XVI. References

  1. Greene (2001) Essentials Musculoskeletal Care, p. 252-4
  2. Weinstock and DeLaney in Herbert 19(6): 5-6
  3. Carpenter (2014) Acad Emerg Med 21(2):101-21 +PMID:24673666 [PubMed]
  4. Perron (2001) Am J Emerg Med 19(4):310-6 [PubMed]
  5. Phillips (2004) Am Fam Physician 70(5):879-84 [PubMed]
  6. Shehab (2013) Am Fam Physician 87(8): 568-73 [PubMed]

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