• Clinical science

Scaphoid fracture

Summary

The scaphoid bone is the most commonly fractured carpal bone. Fractures are most often localized in the middle third of the scaphoid bone. Generally, scaphoid bone fractures result from indirect trauma when an individual falls onto the outstretched hand with a hyperextended and radially deviated wrist. Pain when applying pressure to the anatomical snuffbox is highly suggestive of a scaphoid bone fracture. X-ray is the initial test of choice for diagnosis. Computer tomography and magnetic resonance imaging may be indicated, if x-ray findings are negative but clinical suspicion is high. Treatment can be conservative (e.g, wrist immobilization) or in certain cases surgical (e.g., proximal pole fracture). Complications include nonunion and avascular necrosis.

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Clinical features

  • History of falling onto the outstretched hand; with a hyperextended and radially deviated wrist [3]
  • Pain when applying pressure to the anatomical snuffbox and scaphoid tubercle (a palpable bony prominence on the inferior lateral edge of the scaphoid bone)
  • Minimal reduction in the range of motion (except in dislocated fractures)
  • Decreased grip strength
  • Painful pinching and grasping
  • Pain can be induced through axial compression along the first metacarpal (scaphoid compression test). [3]

When pain occurs in the anatomical snuffbox after trauma, the injury should be treated as a scaphoid fracture until proven otherwise.

Diagnostics

  • Best initial test: x-ray of the wrist in a posteroanterior, lateral, 45° oblique, and possibly scaphoid view
  • If initial x-ray is negative, one of the following:
    • If the patient is not willing to immobilize the wrist: MRI of the wrist [5]
    • If the patient is willing to immobilize the wrist: cast the wrist and repeat an x-ray in 10–14 days
  • If repeat x-ray is normal but continued clinical suspicion of scaphoid fracture: MRI of the wrist

Scaphoid fractures are often undetectable on the initial x-ray.

Differential diagnoses

Lunate dislocation [6][7]

Transscaphoid perilunate dislocation

The differential diagnoses listed here are not exhaustive.

Treatment

Complications

Fractures in the distal third tend to heal better because of the retrograde blood supply reaching the bone from the distal pole.

We list the most important complications. The selection is not exhaustive.

  • 1. Alshryda S, Shah A, Odak S, Al-Shryda J, Ilango B, Murali SR. Acute fractures of the scaphoid bone: Systematic review and meta-analysis. The Surgeon. 2012; 10(4): pp. 218–229. doi: 10.1016/j.surge.2012.03.004.
  • 2. Garala K, Taub NA, Dias JJ. The epidemiology of fractures of the scaphoid. The Bone & Joint Journal. 2016; 98-B(5): pp. 654–659. doi: 10.1302/0301-620x.98b5.36938.
  • 3. Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004; 70(5): pp. 879–84. pmid: 15368727.
  • 4. Malović M, Pavić R, Milošević M. Treatment of Trans-Scaphoid Perilunate Dislocations Using a Volar Approach With Scaphoid Osteosynthesis and Temporary Kirschner Wire Fixation. Mil Med. 2011; 176(9): pp. 1077–1082. doi: 10.7205/milmed-d-10-00419.
  • 5. Beeres FJP, Rhemrev SJ, den Hollander P, et al. Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. J Bone Joint Surg Br. 2008; 90-B(9): pp. 1205–1209. doi: 10.1302/0301-620x.90b9.20341.
  • 6. Bhatia M, Sharma A, Ravikumar R, Maurya VK. Lunate dislocation causing median nerve entrapment. Medical journal, Armed Forces India. 2017; 73(1): pp. 88–90. doi: 10.1016/j.mjafi.2015.12.006.
  • 7. Wingelaar M, Newbury P, Adams NS, Livingston AJ. Lunate Dislocation and Basic Wrist Kinematics. Eplasty. 2016; 16: p. ic37. pmid: 27610210.
  • 8. Wickramasinghe NR, Duckworth AD, Clement ND, Hageman MG, McQueen MM, Ring D. Acute Median Neuropathy and Carpal Tunnel Release in Perilunate Injuries Can We Predict Who Gets a Median Neuropathy?. Journal of hand and microsurgery. 2015; 7(2): pp. 237–40. doi: 10.1007/s12593-015-0189-z.
  • 9. Pinho AB, Sobania RL. Perilunate carpal dislocation. Clinical evaluation of patients operated with reduction and percutaneous fixation without capsular-ligament repair. Revista Brasileira de Ortopedia (English Edition). 2017; 52(4): pp. 402–409. doi: 10.1016/j.rboe.2017.06.007.
  • 10. Cowell GW, Ng CY, Tiemessen CH, Phillips JE. Transscaphoid perilunate dislocation - a tale of two carpals?. Case Reports. 2011; 2011(aug24 1): pp. bcr0720114513–bcr0720114513. doi: 10.1136/bcr.07.2011.4513.
  • 11. Scalcione LR, Gimber LH, Ho AM, Johnston SS, Sheppard JE, Taljanovic MS. Spectrum of Carpal Dislocations and Fracture-Dislocations: Imaging and Management. American Journal of Roentgenology. 2014; 203(3): pp. 541–550. doi: 10.2214/ajr.13.11680.
  • 12. Gupta V, Rijal L, Jawed A. Managing scaphoid fractures. How we do it?. Journal of Clinical Orthopaedics and Trauma. 2013; 4(1): pp. 3–10. doi: 10.1016/j.jcot.2013.01.009.
  • 13. deWeber K. Scaphoid fractures. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/scaphoid-fractures. Last updated July 6, 2016. Accessed December 12, 2016.
  • 14. Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Reviews. 2020; 5(2): pp. 96–103. doi: 10.1302/2058-5241.5.190025.
  • 15. Steinmann SP, Adams JE. Scaphoid fractures and nonunions: diagnosis and treatment. Journal of Orthopaedic Science. 2006; 11(4): pp. 424–431. doi: 10.1007/s00776-006-1025-x.
  • 16. Severo AL, Lemos MB, Lech OLC, Barreto Filho D, Strack DP, Candido LK. Bone graft in the treatment of nonunion of the scaphoid with necrosis of the proximal pole: a literature review. Revista Brasileira de Ortopedia (English Edition). 2017; 52(6): pp. 638–643. doi: 10.1016/j.rboe.2016.11.011.
  • Müller M. Chirurgie für Studium und Praxis (2012/13). Medizinische Verlags- und Informationsdienste; 2011.
  • UpToDate. http://www.uptodate.com. Updated January 1, 2012.
last updated 10/26/2020
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