Diagnosis and Management of Scaphoid Fractures
Injury: Scaphoid Fracture
Mechanism of Injury
Typically occurs with a fall on to an outstretched hand. The most common type of injury to the carpal bones in the wrist is a scaphoid fracture. Can be seen in any sport but is often seen with extreme sports such as motocross or BMX.
Most individuals will have pain at the base of the thumb in an area called the "anatomical snuffbox"(see below). Other symptoms may include decreased grip strength as well as pain opening containers. An evaluation should be done to assess the nerves and the blood flow to the wrist as well as look for swelling over the anatomical snuffbox. The patient can be asked to give a thumbs up, make an "Ok" sign, and spread their fingers against resistance to grossly assess nerve function. Also, the pulse should be checked as well as fingertips monitored to check for good blood flow to the area. An x-ray is usually done first, but the fracture can be difficult to spot. An MRI is the optimal test to confirm the diagnosis when it is not clear on a simple x-ray. If a scaphoid fracture is suspected based on pain, but x-rays are negative, a fracture is still possibly the cause of pain. The next step would be a period of immobilization with repeat x-ray and evaluation for pain in approximately 2 weeks. If pain has resolved and x-rays are still negative, the patient likely has no fracture. If the x-rays are negative, but the pain is still present the patient can undergo the full course of treatment as a precautionary measure or proceed with an MRI.
Scaphoid fractures can occur in children and adults. Non-operative treatment typically consists of a short arm thumb spica cast that immobilizes the thumb. The patient should be continually evaluated for resolution of pain and complete radiographic signs of healing of the scaphoid bone. Generally, the period of immobilization is approximately 6 - 8 weeks, with a slightly shorter period for children. Surgical treatment is initiated if the fracture is felt to be unstable or the fracture gap is greater than 1-2 mm. However, some professional athletes with stable and non-displaced fractures may choose to pursue surgical intervention in order to reduce the time off of sports.
There is a unique aspect of the blood blow to the scaphoid bone. The blood supply enters the bone in the distal portion (d above). Therefore, if the fracture occurs through the center of the bone it can disrupt the blood supply to the proximal portion (p above). The unique blood flow to the scaphoid bone can put it at risk for delayed healing, non-healing or break down of the bone called osteonecrosis.
Return to Play
Return to play after a scaphoid fracture may require protective padding or bracing due to stiffness or weakness of the wrist.
There is evidence to suggest that athletes with stable and non-displaced fractures may benefit from surgical intervention in order to reduce the time off of sports and potentially have improved function compared with a non-surgical approach.
Anatomical Snuffbox Tenderness with a Scaphoid Fracture