Updated: 11/30/2019

Scaphoid Fracture

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Snapshot
  • A 28-year-old man trips while running and lands on his outstretched left hand. He experiences immediate-onset, severe left wrist pain and inability to flex or extend his wrist. On exam, he has point tenderness dorsally over the anatomic snuffbox. A radiograph of his left wrist demonstrates a fracture of the proximal pole of the scaphoid.
Introduction
  • Clinical definition
    • fracture of the scaphoid bone
      • "scaphoid" is derived from the Greek word for "boat" due to its boat-like appearance
  • Epidemiology
    • incidence
      • most common carpal fracture
    • demographics
      • adolescents and young adults
      • more common in males than females
  • Etiology
    • fall from standing height on an outstretched hand
    • high-energy trauma is less common
  • Pathoanatomy
    • normal anatomy
      • the scaphoid is one of four bones in the proximal carpal row of the wrist
        • other three are the lunate, triquetrum, and pisiform
      • articulations
        • radius proximally
        • lunate medially
        • trapezium, trapezoid, and capitate distally
      • anatomic subdivisions
        • proximal third
        • middle third (waist)
        • distal third
          • the scaphoid tubercle is part of the distal third
      • vascular supply
        • dorsal carpal branch of radial artery supplies proximal 80% of the scaphoid via retrograde flow
          • the proximal scaphoid is the most likely to undergo avascular necrosis (AVN) due to its tenuous retrograde blood supply
        • superficial palmar branch of radial artery supplies distal 20% of the scaphoid
    • fracture location
      • 65% scaphoid waist
      • 25% proximal third 
      • 10% distal third
        • the distal third is the most common site in young children due to the ossification pattern
  • Associated conditions
    • ligamentous injury (wrist sprain)
      • scaphoid attaches to many wrist ligaments which can be torn in scaphoid fractures
  • Prognosis
    • favorable
      • stable non-displaced fracture
    • unfavorable
      • unstable displaced fracture
      • AVN
Presentation
  • Symptoms
    • radial wrist pain
  • Physical exam
    • anatomic snuffbox tenderness dorsally
    • scaphoid tubercle tenderness volarly
    • pain with resisted pronation
Imaging
  • Radiography  
    • indications
      • always indicated if the fracture is suspected
      • standard anteroposterior (AP), lateral, and oblique views of the wrist may not demonstrate the fracture
        • dedicated scaphoid views may be needed to visualize the fracture
      • initial radiographs may be negative
        • if high clinical suspicion, repeat radiographs are indicated 2-3 weeks after the injury 
    • findings
      • fracture line through the scaphoid
  • Computerized tomography (CT) 
    • indications
      • can be used if initial radiographs are negative
        • less sensitive than MRI
      • better than radiography to demonstrate healing
    • findings
      • can demonstrate fracture lines, fragment sizes, and extent of bony collapse
  • Magnetic resonance imaging (MRI) 
    • indications
      • most sensitive imaging modality within first 24 hours
      • can be used if initial radiographs are negative
    • findings
      • can best demonstrate associated ligamentous injuries
      • allows for assessment of the vascular integrity of proximal pole of scaphoid if AVN is suspected
Differential
  • Distal radius fracture
    • fracture will be evident on an AP and/or lateral radiograph of the wrist
    • more likely in older patients
  • Wrist sprain
    • ligamentous injury in the absence of a fracture will be evident on MRI 
Treatment
  • Non-operative 
    • thumb spica cast immobilization
      • indications
        • stable non-displaced fractures
        • normal radiographs but a high index of suspicion for occult fracture
  • Operative
    • percutaneous pin fixation vs open reduction and internal fixation (ORIF) 
      • indications
        • unstable fractures
          • displaced fractures
          • proximal pole fractures
          • comminuted fractures
          • vertical or oblique fractures
Complications
  • Avascular necrosis 
    • most common in proximal injuries due to a retrograde blood supply
  • Non-union
  • Scaphoid non-union advanced collapse (SNAC)
    • progressive wrist arthritis due to chronic scaphoid non-union
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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