Makindo Medical Notes

Always document anatomical snuffbox tenderness and request dedicated scaphoid views if tenderness is present. In children under 14, obtain AP/Lateral views of the wrist only. Scaphoid fractures have a high complication rate if left untreated, with a 5-40% risk of avascular necrosis (AVN) or non-union.

About

• Scaphoid fractures are common in young, active individuals, often affecting people in their most productive years.
• Untreated fractures can lead to non-union and early arthritis, causing long-term disability.
• A scaphoid fracture may disrupt blood flow to the bone, increasing the risk of avascular necrosis (AVN).

Mechanism of Injury

• Typically occurs from a fall on an outstretched hand (FOOSH).
• Most common fracture locations: waist (65%), proximal pole (25%), and distal pole (15%).
• Other causes include trauma from skiing, snowboarding, or road traffic collisions (RTC).

Clinical Presentation

• Wrist swelling is often present, but bruising or deformity is rare.
• Anatomical snuffbox tenderness: Pain on palpation of the dorsal wrist in the anatomical snuffbox.
• Scaphoid tubercle tenderness: Pain on palpation of the scaphoid tubercle volarly (on the palmar side of the wrist).
• Scaphoid compression test: Pain is reproduced when axial pressure is applied through the thumb metacarpal.
• Pain with resisted pronation may also be present.

Investigations

• Scaphoid X-rays: Special scaphoid views are obtained, but 30% of fractures may not be visible initially.
• MRI: Highly sensitive for detecting occult fractures if X-rays are inconclusive.
• CT scan: High-resolution CT with 1mm slices along the scaphoid axis can aid in diagnosis, especially in complex fractures.

Complications

• Delayed union: Prolonged healing process due to poor blood supply.
• Non-union: Failure of the fracture to heal, often leading to long-term disability.
• Avascular necrosis (AVN): Death of bone tissue due to disrupted blood supply, particularly in proximal fractures.
• Osteoarthritis: Long-term complication resulting from non-union or AVN, leading to joint degeneration and pain.

Management

• Diagnosis: Scaphoid fractures may not be visible on initial X-rays, especially if non-displaced. If there is high clinical suspicion, immobilize the wrist in a cast and re-evaluate with follow-up X-rays in 10-14 days. Healing fractures will often become more apparent due to bone resorption along fracture lines.
• Non-operative: Cast immobilization for 6-12 weeks, especially in non-displaced fractures, followed by referral to a fracture clinic.
• Operative: Indicated for displaced fractures or non-unions. Surgical options include percutaneous screw fixation or open reduction and internal fixation (ORIF).

References

• Scaphoid Fracture (Orthobullets)
• Scaphoid Fractures and Nonunion (HSS)