Orthopedics Book

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Scaphoid Fracture

Aka: Scaphoid Fracture, Navicular Fracture, Fracture of Scaphoid Bone of Wrist, Fracture of Navicular Bone of Wrist
  1. See Also
    1. Wrist Injury
    2. Hand Injury
    3. Fall on Outstretched Hand (FOOSH)
  2. 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. Rarely occurs in young children
      1. Scaphoid protected by supportive cartilage in young children
      2. Distal Radius Fracture or physeal Fractures are more common
  3. 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
  4. 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]
  5. 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
  6. 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)
  7. 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)
  8. 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
    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%
  9. 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
  10. 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
  11. Management: Immobilization Techniques
    1. Thumb Spica Splint
    2. Thumb Spica Short Arm Cast
      1. Neutral position
      2. Hand in position as if holding can
    3. Long Arm Cast
  12. 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
  13. 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
  14. 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
  15. Prognosis
    1. Delayed healing or non-union in 5% Scaphoid Fractures
  16. 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]

Fracture of scaphoid bone of wrist (C0272654)

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
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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