Scaphoid Wrist Fracture


Article Author:
Zara Hayat


Article Editor:
Matthew Varacallo


Editors In Chief:
Laurie Graham
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/3/2019 3:58:21 PM

Introduction

Scaphoid fractures are the most common of the carpal fractures and tend to occur in younger, active individuals. They account for 2-7% of all fractures and 60-70% of carpal bone fractures.[1] Scaphoid fractures are not uncommonly missed initially on clinical and radiographic examination.   These injuries can be misdiagnosed initially as a simple wrist sprain.  

This misdiagnosis can lead to increased morbidity for the patient as the risks of non-union can be high (14-50% if displaced). If left untreated, arthritis, deformity, and instability invariably develop within five years which can lead to significant disability. As these injuries often happen in young, active patients, the associated morbidity and cost implications secondary to disability are significant.

Etiology

Patients typically present with wrist pain following a fall onto an outstretched hand. Axial loading of the wrist with it in forced hyperextension and radial deviation can cause the fracture as the scaphoid impacts on the dorsal rim of the radius. Contact sports and road traffic accidents are also common causes.

Epidemiology

Scaphoid fractures predominantly affect young adults, with a mean age of 29 years.[2] There is a higher incidence in males. They are unusual in the pediatric population and the elderly population where the physis or distal radius, respectively, are more likely to fracture first. Scaphoid fractures account for 15% of acute wrist injuries.

Pathophysiology

The scaphoid is one of, and the largest of, the eight carpal bones.[3] Anatomically, the scaphoid has proximal and distal poles with a waist between the two. Blood supply to the scaphoid bone is predominantly from branches of the radial artery (dorsal carpal branch). These enter the dorsal ridge and supply the 80% of proximal pole via retrograde flow. The second source is from the superficial palmar arch, a branch of the volar radial artery, which enters at the distal tubercle and supplies the distal pole. The retrograde nature of the blood supply means that fractures at the waist of the scaphoid leave the proximal pole at high risk of avascular necrosis.[4]

The majority of fractures (approximately 65%) occur at the waist, with a quarter at the proximal third and 10% the distal third.

The incidence of avascular necrosis carries a strong association with the location of the fracture; the proximal segment has a 100% rate of AVN, reducing to 33% at the distal segment of the scaphoid.

History and Physical

Scaphoid fractures most commonly cause pain and swelling at the base of the thumb in the anatomic snuffbox. 

Patients will typically present with wrist pain with a recent history of trauma. Pain is often centered on the radial side of the wrist and is worse with movement. There may be associated swelling and reduced range of motion. It is important to ascertain if the patient is a smoker as this increases the risk of non-union by approximately 20%.[5]

Examination of the wrist should follow the “look, feel, move” pattern. Deformity is unlikely unless there is associated carpus dislocation, for example, perilunate dislocations. It is important to palpate over the distal radius and ulna and metacarpals to assess for any associated injury. Classically, there is tenderness in the anatomic snuffbox dorsally, especially with waist fractures). The snuffbox is the area between the first and third extensor compartments. Radially lies abductor pollicis longus and extensor pollicis brevis. To the ulnar side is the extensor pollicis longus. There may also be tenderness over the scaphoid tubercle on the volar aspect, which can be felt as the bony prominence radial to flexor carpi radialis at the level of the distal palmar crease. Tenderness usually presents in one of three locations:

  1. The volar prominence at the distal wrist for distal pole fractures
  2. Anatomic snuffbox for waist or mid-body fractures
  3. Distal to Lister's tubercle for proximal pole fractures

The scaphoid compression test is a more sensitive test and involves placing the examining index finger and thumb over each pole of the scaphoid and compressing. This maneuver is likely to elicit pain in the presence of a fracture. Pain in the anatomical snuff box on ulnar deviation of the wrist suggests scaphoid fracture. 

Evaluation

There are no particular laboratory tests but if surgery is to be done then routine blood work, including full blood count, urea, and electrolytes, clotting screen and group and save, may be of benefit.

Initially, it is necessary to obtain AP and lateral views of the wrist alongside scaphoid views, taken with the wrist at approximately 30 degrees of extension and 20 degrees of ulnar deviation. Estimates are that up to 25% of scaphoid fractures are not evident on initial plain radiographs. If a high clinical suspicion exists, the wrist should undergo immobilization in a splint or cast for 7-14 days and plain radiographs repeated. If early confirmation is needed, bone scans can be done to diagnose occult fractures at 72 hours post-injury. 

Persisting clinical suspicion with negative repeat radiographs warrants Magnetic Resonance Imaging (MRI) or Computed Tomography (CT).[6] MRI is the most sensitive means of diagnosis and can also identify any associated ligamentous injury or bone edema/contusions.[7] A recent meta-analysis estimated 97.7% sensitivity and 99.8% specificity.[8] 

CT scan, although it has high sensitivity and specificity, fractures with less than 1 mm displacement can be missed.

Treatment / Management

Suspected fractures in those with positive clinical findings on examination but negative radiographs should have a followup with films repeated in 7-14 days. If pain persists and radiographs are still normal, then further imaging in the form of MRI or CT should be undertaken. Pain management with assistance of pharmacist should be considered.

Nonoperative management

Fractures which are non-displaced and within the distal third of the bone can be managed non-operatively with immobilization in a cast.[9] There is active debate as to whether a long or short arm cast is optimal and whether a thumb spica should be included to immobilize the thumb, but there is no evidence currently to suggest one option is better than the other.[10]

The cast usually needs to remain on for six weeks with repeat radiographs taken at this time to assess for union. Time to union varies depending on the location of the fracture. The distal-third would be expected to heal within 6-8 weeks, middle-third within 8-12 weeks and proximal third within 12-24 weeks.  The relative increase in time to healing while moving from distal to proximal is secondary to the tenuous blood supply and retrograde arterial flow.

Surgical fixation

Indications for operative management include:

  • Displacement greater than 1mm
  • An intrascaphoid angle greater than 35 degrees (humpback deformity)
  • A radiolunate angle of more than 15 degrees
  • Transcaphoid perilunate dislocation
  • Proximal pole fractures
  • Comminuted fractures
  • Non displaced waist fractures in individuals that need to return quickly to work/sport
  • Nonunion or avascular necrosis

Surgical fixation involves the insertion of a single or multiple screws and can be done percutaneously or via an open procedure. The latter is preferable for non-unions and those fractures that exhibit gross displacement with the former for acute, minimally displaced fractures.

Technique

Positioning of the screw is crucial and should be in the middle third of the central axis of the scaphoid; this provides the most stability, reduces time to union and improves alignment.

Access to the scaphoid can be via a dorsal or volar approach. The decision is made based on surgeon preference and location of the fracture. The volar approach uses the interval between flexor carpi radialis and the radial artery and is the optimal approach for waist and distal pole fractures. It has the benefits of allowing exposure of the entire scaphoid and radioscapholunate ligament and is least damaging to the vascular supply. The dorsal approach is preferred for proximal pole fractures but places the vascular supply at greater risk of injury.

Nonunion

Treatment of scaphoid non-union is approachable in a variety of ways.[10] Early on in its course, open reduction and internal fixation with bone grafting can is an option.  Bone graft can be sourced from the distal radius or the iliac crest.

Alternative treatments include excision of the proximal fragment, total or partial arthrodesis (fusion), radial styloidectomy or proximal row carpectomy. These are salvage procedures and usually considered when there is evidence of arthritis of the radio-carpal joint.

Differential Diagnosis

  • Distal radius fracture
  • Other carpal bone fractures
  • Scapholunate dissociation
  • Dequervain’s tenosynovitis
  • Osteoarthritis
  • Tendonitis

Pertinent Studies and Ongoing Trials

There remains much debate within the literature regarding the management of undisplaced scaphoid waist fracture; whether early operative intervention has better outcomes compared to conservative management in a cast. There have been numerous systemic reviews exploring this question, but insufficient evidence exists to inform management of waist fractures adequately.[11][12][13][14][15] Several studies reported earlier return to function following surgery although there was a higher incidence of complications, albeit minor ones. There is currently a pragmatic multi-center randomized controlled trial underway in the UK evaluating whether early fixation of nondisplaced scaphoid waist fractures leads to improved patient outcome compared to later fixation of those initially managed conservatively.

Toxicity and Side Effect Management

Pain can usually be managed according to the WHO pain ladder with paracetamol (acetaminophen) initially alongside non-steroidal anti-inflammatory drugs (NSAIDs) provided there are no contra-indications. If this fails to control the pain, then weak opioids such as codeine can be introduced before progressing to stronger opioids such as morphine. These may be indicated in the initial post-operative period.  

Prognosis

Scaphoid fracture with displacement <1 mm has a union rate of 90%. The prognosis is worse if the fracture is displaced, with a missed diagnosis, or if the fracture is in the proximal pole. If left untreated, the risk of chronic pain with associated reduced range of motion and grip strength is more likely to occur.

Complications

  • Nonunion - This is the most likely complication arising from missed scaphoid fractures. The risk is higher in those that are very displaced or have associated carpal fractures. These will generally require operative intervention with screw fixation. There are three stages:

1 – Radioscaphoid arthritis

2 – Scaphocapitate arthritis

3 – Lunocapitate arthritis

Scaphoid non-union advanced collapse (SNAC) is the end stage and is managed with wrist fusion or proximal row carpectomy.

  • Avascular necrosis - The incidence of this is approximately 30-40%. This is most likely to affect the proximal pole
  • Scapholunate dissociation
  • Delayed union - typically 90-95% if operatively managed fracture unites, but if there is doubt, CT scan may be needed to confirm union.

Postoperative and Rehabilitation Care

Physiotherapy is a requirement whether the fracture undergoes operative or non-operative management. Physical therapy helps the patient to regain range of motion and wrist strength. In the early stages, swelling predominates, and it is important to keep the hand elevated with active finger, elbow, and shoulder movements encouraged to avoid stiffness. After immobilization (for conservatively managed fractures or post-operatively), the wrist stiffens, and physiotherapy is vital for safely increasing the range of movement. Active range of motion alongside pronation and supination exercises are encouraged once the cast comes off.

Post-operatively, the wrist is usually immobilized initially in a below elbow back slab and then converted to a full cast at two weeks after wound review and repeating plain film radiographs. They remain in the full cast until six weeks postoperatively when plain radiographs will be repeated, and the cast removed if there are radiological signs of bone healing. A wrist splint for a further six weeks may be indicated to protect the wrist.

Return to sport and driving can usually safely take place from 3 months.

Deterrence and Patient Education

Wrist protection in the form of a removable splint may be of benefit if the patient takes part in high-risk activities where a fall on an outstretched hand may be more likely. Smoking cessation is recommended to optimize fracture healing both for those managed operatively and non-operatively. Where fractures have occurred, patients should be informed of the risk of degenerative arthritis.

Pearls and Other Issues

General practitioners and emergency medicine doctors should be vigilant to scaphoid fractures to ensure that they are not missed and referred appropriately to the orthopedic team. Neglect of injury for over four weeks increases nonunion rates almost tenfold.

Enhancing Healthcare Team Outcomes

Emergency department doctors and general practitioners should work in conjunction with radiologists and orthopedic doctors to minimize the chances of missing these fractures. A multi-disciplinary team approach is vital in managing these fractures, and early physiotherapy and hand therapy involvement will help improve outcome. The patient should have direct involvement at all stages of discussion, and the risks and receive proper education regarding the benefits of conservative versus operative management.


  • Image 1763 Not availableImage 1763 Not available
    Contributed by Scott Dulebohn, MD
Attributed To: Contributed by Scott Dulebohn, MD

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Scaphoid Wrist Fracture - Questions

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What is the most commonly fractured carpal bone?



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A patient falls on his right wrist while walking on an ice patch. He reports increasing pain in his wrist area and says the pain is worse when he moves his hand. On examination, the wrist appears normal, but there is pain on movement of the wrist. The pain is directly located in the snuffbox. X-rays of the wrist show no abnormality. What is the treatment of choice for the patient?



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A patient fell on his outstretched hand yesterday while skiing. He complains of pain in his wrist. On exam, there is minimal edema of the wrist, tenderness at the anatomic snuffbox and over Lister tubercle, and decreased strength secondary to pain. Neurovascular function is intact. Which of the following is most likely?



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A patient fell on his outstretched hand yesterday while skiing. He complains of pain in his wrist. On exam, there is minimal edema of the wrist, tenderness at the anatomic snuffbox, and decreased strength secondary to pain. Neurovascular function is intact. X-rays of the wrist, including scaphoid views, are negative. What is the appropriate management of this patient?



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A patient with suspected scaphoid fracture is treated with a short arm thumb spica cast. Two weeks later the x-ray shows a non-displaced fracture of the proximal pole of the scaphoid. Which of the following would be appropriate?



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What does pain over the anatomic "snuff box" possibly indicate?



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Which of the following traumatic fractures is most prone to non-union?



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A patient falls on his right wrist while skating. He complains of increasing pain in his wrist area and says the pain is worse when he moves his hand. On examination, the wrist appears normal, but there is pain on movement of the wrist. The pain is directly located in the snuffbox. X-rays of the wrist show no abnormality. What is the best treatment for this patient?



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Scaphoid fracture can be accompanied by a rupture of which artery?

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A patient who suffered a fall on her outstretched right hand 2 days ago and now has right wrist pain with anatomical snuffbox tenderness likely has:



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An elderly female fell on her outstretched hand on ice. She presents to the ER with pain in her left wrist joint. Except for some ecchymosis, nothing significant is found on physical exam. She has pain in the snuff box. Plain x-rays of the wrist are unremarkable. The treatment is:



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Following a long night at the Embassy Bar, a student tripped and fell with his hand outstretched. Radiographic examination revealed that a bone was fractured, and this information was substantiated by palpation over the anatomical snuffbox. Which of the following was fractured?



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A patient fell very awkwardly and afterwards had pain in the left wrist. You discover that the pain is worst in the radial deviation position of the wrist and that there is tenderness between the tendons of extensor pollicis longus and abductor pollicis longus distal to the radial styloid process. Your patient most likely has a fracture of the:



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Broadway Joe, a member of the jet set, fractured his scaphoid bone while warding off an advancing linebacker with his outstretched hand. Which of the following suggests this diagnosis?



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A 22-year-old male complains of worsening pain in his left wrist over the past week. The pain is non-radiating and limited to the anterolateral portion of his wrist. He reports that his pain is mildly improved with NSAID use, but it provides no permanent relief. Upon further questioning, he reveals that he is a college football player and states he first experienced these symptoms after diving to catch a pass. He has no significant past medical history and takes no other medications. His vital signs are normal. The physical exam reveals radial-sided tenderness in his left hand with a weak pincer grasp. His right hand appears normal. Radiographic imaging is shown below. What is the best next step in the management of this patient's condition?

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A 17-year-old male patient presents to his primary care provider with two days of unrelenting right wrist pain. The pain began during a high school basketball game in which the patient went up to block a shot, but ended up falling onto his extended right wrist. The patient grimaces when his wrist is passively extended and withdraws when the provider palpates between the tendons of the abductor pollicis longus and extensor pollicis brevis. The patient is sent to get radiographs of his wrist. Fracture at what anatomical landmark of this bone would indicate the need for surgical fixation?

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A 17-year-old male reports to his primary care provider one day after a skateboarding accident. He complains of aching pain in his wrist. On physical exam, the patient experiences tenderness when the provider palpates the wrist between the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. What is the most likely mechanism of injury that resulted in this patient's injury?



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Scaphoid Wrist Fracture - References

References

Hove LM, Epidemiology of scaphoid fractures in Bergen, Norway. Scandinavian journal of plastic and reconstructive surgery and hand surgery. 1999 Dec;     [PubMed]
Dinah AF,Vickers RH, Smoking increases failure rate of operation for established non-union of the scaphoid bone. International orthopaedics. 2007 Aug;     [PubMed]
Yin ZG,Zhang JB,Kan SL,Wang XG, Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. The Journal of bone and joint surgery. British volume. 2012 Aug;     [PubMed]
Dias J,Brealey S,Choudhary S,Cook L,Costa M,Fairhurst C,Hewitt C,Hodgson S,Jefferson L,Jeyapalan K,Keding A,Leighton P,Rangan A,Richardson G,Rothery C,Taub N,Thompson J,Torgerson D, Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) protocol: a pragmatic multi-centre randomised controlled trial of cast treatment versus surgical fixation for the treatment of bi-cortical, minimally displaced fractures of the scaphoid waist in adults. BMC musculoskeletal disorders. 2016 Jun 4     [PubMed]
Tang A,Varacallo M, Anatomy, Shoulder and Upper Limb, Hand Carpal Bones . 2018 Jan     [PubMed]
Erwin J,Varacallo M, Anatomy, Shoulder and Upper Limb, Wrist Joint . 2018 Jan     [PubMed]
Mallee WH,Wang J,Poolman RW,Kloen P,Maas M,de Vet HC,Doornberg JN, Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. The Cochrane database of systematic reviews. 2015 Jun 5     [PubMed]
Karantanas A,Dailiana Z,Malizos K, The role of MR imaging in scaphoid disorders. European radiology. 2007 Nov     [PubMed]
Dias JJ,Wildin CJ,Bhowal B,Thompson JR, Should acute scaphoid fractures be fixed? A randomized controlled trial. The Journal of bone and joint surgery. American volume. 2005 Oct     [PubMed]
Cooney WP 3rd,Dobyns JH,Linscheid RL, Nonunion of the scaphoid: analysis of the results from bone grafting. The Journal of hand surgery. 1980 Jul     [PubMed]
Doornberg JN,Buijze GA,Ham SJ,Ring D,Bhandari M,Poolman RW, Nonoperative treatment for acute scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. The Journal of trauma. 2011 Oct     [PubMed]
Yin ZG,Zhang JB,Kan SL,Wang P, Treatment of acute scaphoid fractures: systematic review and meta-analysis. Clinical orthopaedics and related research. 2007 Jul     [PubMed]
Buijze GA,Doornberg JN,Ham JS,Ring D,Bhandari M,Poolman RW, Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. The Journal of bone and joint surgery. American volume. 2010 Jun     [PubMed]
Symes TH,Stothard J, A systematic review of the treatment of acute fractures of the scaphoid. The Journal of hand surgery, European volume. 2011 Nov     [PubMed]
Modi CS,Nancoo T,Powers D,Ho K,Boer R,Turner SM, Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures--a systematic review. Injury. 2009 Mar     [PubMed]

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