II. Epidemiology
- Scaphoid is most common Carpal BoneFractured
- Represents 5% of all wrist injuries
- Usually occurs as a Workplace Injury or Sports Injury
- Most commonly affects males 18-40 years old
- With aging, distal radius is weaker and more commonly Fractured
- Children
- Typically occur at age 12 to 15 years and older
- Uncommon in age <10 years old (unless severe Traumatic Injury)
- Rarely occurs in young children
- Scaphoid protected by supportive cartilage in young children
- Distal Radius Fracture or physeal Fractures are more common
III. Mechanism
-
Scaphoid and Lunate Bones are only wrist bones with articulation with radius
- Fall on an outstretched hand transmits force to the Scaphoid Bone (and Lunate Bone)
- Fall on Outstretched Hand
- Many Scaphoid Fracture patients do not have a history of fall on an outstretched hand
- Traffic accidents and sports injuries account for 60% of cases
IV. Precautions
- Missed Scaphoid Fractures are among the most common upper extremity injuries resulting in Malpractice claims
V. Symptoms
- Dorsal radial Wrist Pain
- Deep, dull ache
- Provocative factors
- Wrist extension
- Gripping or squeezing objects with pain and loss of strength
VI. Signs
- See Wrist Exam
- Diagnosis may be difficult (no obvious deformity)
- Keep high level of suspicion in "Wrist Sprain"
- See Scaphoid Fracture Signs
- Scaphoid tenderness (LR- 0.15)
- Anatomic Snuffbox Tenderness (wrist ulnar deviated)
- Scaphoid Tubercle Tenderness (wrist in extension)
- Pain on axial pressure of First Metacarpal bone
- Decreased grip strength
- Pain on resisted supination (LR- 0.09)
- Scaphoid tenderness (LR- 0.15)
VII. Differential Diagnosis
- Injury
- See Fall on Outstretched Hand
- Distal Radius Fracture (e.g. Colles Fracture)
- Radius is weaker than Scaphoid in young and elderly
- Scapholunate Dissociation (or Scapholunate Tear)
- Scapholunate widening >3 mm
- Carpometacarpal Dislocation
- Carpometacarpal widening >1-2 mm
- Lunate Fracture
- Wrist Overuse (i.e. De Quervain's Tenosynovitis)
- Arthritis (e.g. Rheumatoid Arthritis)
VIII. Imaging
-
Wrist XRay
- Standard Views: AP and lateral view, obliques
-
Scaphoid view
- Anteroposterior view (dorsal-volar angle)
- Supination to 30 degrees
- Ulnar deviation
-
Test Sensitivity: 86% (variable, may be as low as 11%)
- Inadequate to exclude Scaphoid Fracture (only useful if positive)
- Tiel-van Buul (1993) J Hand Surg 18:403-6 [PubMed]
- Timing of XRay
- Normal initially in non-displaced Fracture
- Thumb Spica Cast if clinical suspicion
- Repeat Wrist XRay in 10-14 days (bony sclerosis not evident until that time)
- Fracture visible in 2-4 weeks with decalcification
- Normal initially in non-displaced Fracture
- Types in Children
- Type 1: Pure chondral injury (age <9 years)
- Type 2: Osteochondral injury (age 9 to 11 years)
- Type 3: Near Complete Ossification (age >11 years)
- Advanced Imaging: Wrist CT, Wrist MRI or Wrist Bone Scan
- Indications
- High clinical suspicion and
- Negative Wrist XRay at 2 weeks
- Efficacy: Bone Scan
- Test Sensitivity: 100%
- Test Specificity: 75%
- Efficacy: CT
- Test Sensitivity: 83-85%
- Efficacy: MRI
- Test Sensitivity: 95% (as of 10 days; only 80% on first day following injury)
- Test Specificity: 99%
- Indications
IX. Course
- Delayed immobilization 1-2 weeks risks non-union
- Radial artery supply impacts healing time
X. Management: Immobilization Techniques
-
Thumb Spica Splint
- Typically applied in first 5-7 days of injury until swelling decreases and cast may be applied
- Thumb Spica Short Arm Cast
- Neutral position
- Hand in position as if holding can
-
Short Arm Cast WITHOUT thumb immobilization
- Consider in non-displaced or minimally displaced Scaphoid Fractures (consult local experts)
- Appears equivalent to Thumb Spica Casting in healing rates, union, longterm function and pain
- Allows patient to have better hand function during Casting
- Deck (2022) Am Fam Physician 105(3): 307-8 [PubMed]
- Buijze (2014) J Hand Surg Am 39(4):621-7 +PMID: 24582846 [PubMed]
XI. Management: Algorithm
- High Clinical Suspicion without radiological evidence
- Apply Thumb Spica Splint for 2-3 weeks
- Repeat Wrist XRay after 2-3 weeks
- Consider early MRI (may be cost effective compared with empiric Splinting and orthopedic referral)
- Scaphoid Fracture on initial or follow-up Wrist XRay
- Nondisplaced distal pole Fracture
- Short arm Thumb Spica Cast for 6 weeks
- Consider not including thumb in cast (nondisplaced)
- Proximal pole Fracture
- Long Arm Cast for 8-12 weeks
- Middle third Fracture
- First: Long Arm Cast for 6 weeks
- Next: Short arm thumb spica for 2-4 more weeks
- Repeat Wrist XRay every 2-4 weeks
- Continue immobilization until union by Wrist XRay
- Displacement of Fracture fragments
- First: Long Arm Cast for 6 weeks
- Next: Short Arm Cast for an additional 6 weeks
- Nondisplaced distal pole Fracture
XII. Management: Orthopedic referral indications
XIII. Management: Follow-up
- Days 1-2: Cast follow-up by phone or clinic visit
- Is cast too tight?
- Cast Removal
- Wrist XRay repeated
- Re-apply cast for 2-4 weeks if Fracture line visible
- Refer if Fracture line seen after additional Casting
XIV. Complications
- Primary: Blood supply enters distal portion of Scaphoid and Fracture interrupts flow to the proximal Scaphoid Bone
- Avascular Necrosis of proximal fragment (20-50% of missed Scaphoid Fracture)
- Fracture Non-union
- Secondary to non-union or avascular necrosis
- Decreased grip strength
- Decreased range of motion
- Ostearthritis of radiocarpal joint
XV. Prognosis
- Delayed healing or non-union in 5% Scaphoid Fractures
- Functional outcomes after immobilization versus surgical repair are similar in non-displaced Scaphoid Fractures at one year
XVI. References
- Greene (2001) Essentials Musculoskeletal Care, p. 252-4
- Weinstock and DeLaney in Herbert 19(6): 5-6
- Carpenter (2014) Acad Emerg Med 21(2):101-21 +PMID:24673666 [PubMed]
- Perron (2001) Am J Emerg Med 19(4):310-6 [PubMed]
- Phillips (2004) Am Fam Physician 70(5):879-84 [PubMed]
- Shehab (2013) Am Fam Physician 87(8): 568-73 [PubMed]
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Related Studies
Concepts | Injury or Poisoning (T037) |
SnomedCT | 208389006, 157223002, 31975004 |
English | Fracture of scaphoid, Fractured scaphoid, navicular fracture wrist, fractures navicular wrist, fracture of scaphoid, scaphoid fracture, Fracture;scaphoid, fractures scaphoid, of scaphoid fracture, fracture scaphoid, scaphoid bone fracture, Fracture of scaphoid bone of wrist (diagnosis), fracture of scaphoid bone of wrist, fracture carpal bone scaphoid, Fracture of scaphoid (disorder), Fracture of navicular bone of wrist, Fracture of scaphoid bone of wrist, Fracture of scaphoid bone, Fracture of navicular bone of wrist (disorder), fracture; scaphoid, fractured scaphoid |
Dutch | scaphoideus fractuur, fractuur; scafoïd |
French | Scaphoïde fracturé |
German | gebrochenes Kahnbein |
Italian | Scafoide fratturato |
Portuguese | Escafóide fracturado |
Spanish | Escafoides fracturado, fractura de hueso escafoides de muñeca, fractura de hueso escafoides de muñeca (trastorno), fractura del hueso navicular de la muñeca, fractura del hueso escafoides de la muñeca, fractura del hueso escafoides de la muñeca (trastorno) |
Japanese | 舟状骨骨折, シュウジョウコツコッセツ |
Czech | Zlomená člunkovitá kost |
Hungarian | Scaphoideum-törés |