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Updated: Dec 28 2021

Scaphoid Fracture

Images fx ct.jpg fx mri.jpg
  • 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
  • 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
  • Prognosis
    • Favorable
      • stable non-displaced fracture
    • Unfavorable
      • unstable displaced fracture
      • AVN
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