scaphoid fracture

File:Snuffbox2017.jpg

People with scaphoid fractures generally have snuffbox tenderness.

Focal tenderness is usually present in one of three places: 1) volar prominence at the distal wrist for distal pole fractures; 2) anatomic snuff box for waist or midbody fractures; 3) distal to Lister's tubercle for proximal pole fractures.

File:Scaphoid-Pseudarthrose1.jpg.]]

File:Scaphoid Fracture.png

Avascular necrosis (AVN) is one complication of scaphoid fracture. Since the scaphoid receives its arterial supply in a retrograde fashion (i.e. from distal to proximal pole), the part proximal to the fracture is usually affected.{{cite journal | vauthors = Tokyay A, Gunal I | title = Avascular necrosis of the distal pole of the scaphoid | journal = Case Reports in Plastic Surgery & Hand Surgery | volume = 2 | issue = 2 | pages = 40–42 | date = 2015-01-20 | pmid = 27252968 | pmc = 4623543 | doi = 10.3109/23320885.2015.1006633 }}

Risk of AVN depends on the location of the fracture.

• Fractures in the proximal third have a high incidence of AVN (~30%)
• Waist fractures in the middle third is the most frequent fracture site and has moderate risk of AVN.
• Fractures in the distal third are rarely complicated by AVN.

Non union can also occur from undiagnosed or undertreated scaphoid fractures. Arterial flow to the scaphoid enters via the distal pole and travels to the proximal pole. This blood supply is tenuous, increasing the risk of nonunion, particularly with fractures at the wrist and proximal end. If not treated correctly non-union of the scaphoid fracture can lead to wrist osteoarthritis.{{cn|date=August 2021}}

Symptoms may include aching in the wrist, decreased range of motion of the wrist, and pain during activities such as lifting or gripping. If x-ray results show arthritis due to an old break, the treatment plan will first focus on treating the arthritis through anti-inflammatory medications and wearing a splint when an individual feels pain in the wrist. If these treatments do not help the symptoms of arthritis, steroid injections to the wrist may help alleviate pain. Should these treatments not work, surgery may be required.{{Cite web|url = http://orthoinfo.aaos.org/topic.cfm?topic=A00012|title = Scaphoid Fracture of the Wrist|date = 2010|access-date = November 30, 2015|website = Ortho Info|publisher = American Academy of Orthopedic Surgeons| vauthors = Jones B |url-status = live|archive-url = https://web.archive.org/web/20151207043733/http://orthoinfo.aaos.org/topic.cfm?topic=A00012|archive-date = December 7, 2015}}

File:Scaphoid.jpg

Fractures of scaphoid can occur either with direct axial compression or with hyperextension of the wrist, such as a fall on the palm on an outstretched hand. Using the Herbert classification system, there are three main types of scaphoid fractures. 10%-20% of fractures are at the proximal pole, 60%-80% are at the waist (middle), and the remainder occur at the distal pole.{{cite web| vauthors = deWeber K |title=Scaphoid fractures|url=http://www.uptodate.com/contents/scaphoid-fractures?source=search_result&search=scaphoid+fracture&selectedTitle=1%7E18|website=UpToDate.com|url-status=live|archive-url=https://web.archive.org/web/20131029214923/http://www.uptodate.com/contents/scaphoid-fractures?source=search_result&search=scaphoid+fracture&selectedTitle=1%7E18|archive-date=2013-10-29}}{{Cite book| vauthors = Egol KA, Koval KJ, Zuckerman JD |title=Handbook of fractures|date=2015|publisher=Wolters Kluwer Health |isbn=978-145119362 6|edition=5th |location=Philadelphia |oclc=960851324 }}

File:FracScaTubercule.png

Scaphoid fractures are often diagnosed using plain radiographs and multiple views are obtained as standard.{{Cite web| vauthors = Jones J |title=Scaphoid series | work = Radiology Reference Article | publisher = Radiopaedia.org |url=https://radiopaedia.org/articles/scaphoid-series|access-date=2021-08-30 |language=en-US}} However, not all fractures are apparent initially.{{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons| vauthors = Sarwark JF |isbn=978-0892035793|location=Rosemont, Ill.|oclc=706805938}} In 1/4 of cases, the clinical examination suggests a fracture, but the X-ray does not show it, even though there is indeed a fracture.{{cite journal | vauthors = Suh N, Grewal R | title = Controversies and best practices for acute scaphoid fracture management | journal = The Journal of Hand Surgery, European Volume | volume = 43 | issue = 1 | pages = 4–12 | date = January 2018 | pmid = 29027844 | doi = 10.1177/1753193417735973 | doi-access = free }} Therefore, people with tenderness over the scaphoid (those who exhibit pain to pressure in the anatomic snuff box ) are often splinted in a thumb spica for 7–10 days at which point a second set of X-rays is taken. If a minimally displaced fracture was present initially, healing will now be apparent. Even then a fracture may not be apparent. A CT Scan can then be used to evaluate the scaphoid with greater resolution. The use of MRI, if available, is preferred over CT and can give one an immediate diagnosis.{{cite web|url=http://www.bestbets.org/bets/bet.php?id=877|title=BestBets: Magnetic resonance imaging of suspected scaphoid fractures|url-status=live|archive-url=https://web.archive.org/web/20100616165500/http://bestbets.org/bets/bet.php?id=877|archive-date=2010-06-16}} Bone scintigraphy is also an effective method for diagnosis fracture which do not appear on Xray.{{cite journal | vauthors = Yin ZG, Zhang JB, Kan SL, Wang XG | title = Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis | journal = Clinical Orthopaedics and Related Research | volume = 468 | issue = 3 | pages = 723–734 | date = March 2010 | pmid = 19756904 | pmc = 2816764 | doi = 10.1007/s11999-009-1081-6 }}

File:ScaphoidFrac2Mark.png|A subtle scaphoid fracture

File:ScaphoidFracDedMark.png|A more obvious scaphoid fracture on a scaphoid view X ray

File:Scaphoid fracture with a radiolucent line after 12 days.jpg|Radiolucency around a 12 days old scaphoid fracture that was initially barely visible.{{cite journal | vauthors = Jarraya M, Hayashi D, Roemer FW, Crema MD, Diaz L, Conlin J, Marra MD, Jomaah N, Guermazi A | display-authors = 6 | title = Radiographically occult and subtle fractures: a pictorial review | journal = Radiology Research and Practice | volume = 2013 | pages = 370169 | year = 2013 | pmid = 23577253 | pmc = 3613077 | doi = 10.1155/2013/370169 | doi-access = free }} [https://creativecommons.org/licenses/by/3.0/ CC-BY 3.0]

Treatment of scaphoid fractures is guided by the location in the bone of the fracture (proximal, waist, distal), displacement (or instability) of the fracture, and patient tolerance for cast immobilization.{{citation needed|date=October 2020}}

For non and minimally displaced fractures (up to 2mm) of the scaphoid waist, cast immobilisation (with surgical fixation for non-united fractures at 6 to 12 weeks) is as effective as immediate surgery fixation and results in less complications.{{cite journal | vauthors = Dias JJ, Brealey SD, Fairhurst C, Amirfeyz R, Bhowal B, Blewitt N, Brewster M, Brown D, Choudhary S, Coapes C, Cook L, Costa M, Davis T, Di Mascio L, Giddins G, Hedley H, Hewitt C, Hinde S, Hobby J, Hodgson S, Jefferson L, Jeyapalan K, Johnston P, Jones J, Keding A, Leighton P, Logan A, Mason W, McAndrew A, McNab I, Muir L, Nicholl J, Northgraves M, Palmer J, Poulter R, Rahimtoola Z, Rangan A, Richards S, Richardson G, Stuart P, Taub N, Tavakkolizadeh A, Tew G, Thompson J, Torgerson D, Warwick D | display-authors = 6 | title = Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial | journal = Lancet | volume = 396 | issue = 10248 | pages = 390–401 | date = August 2020 | pmid = 32771106 | doi = 10.1016/S0140-6736(20)30931-4 | s2cid = 221014238 | url = http://nrl.northumbria.ac.uk/id/eprint/42929/1/Final_SWIFFT_Manuscript_accepted_2020.04.16.pdf }}"{{cite journal | vauthors = Dias J, Brealey S, Cook L, Fairhurst C, Hinde S, Leighton P, Choudhary S, Costa M, Hewitt C, Hodgson S, Jefferson L, Jeyapalan K, Keding A, Northgraves M, Palmer J, Rangan A, Richardson G, Taub N, Tew G, Thompson J, Torgerson D | display-authors = 6 | title = Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT | language = EN | journal = Health Technology Assessment | volume = 24 | issue = 52 | pages = 1–234 | date = October 2020 | pmid = 33109331 | pmc = 7681317 | doi = 10.3310/hta24520 }}{{Cite journal |date=21 November 2024 |title=Is surgery the best option? Research provides alternatives |url=https://evidence.nihr.ac.uk/collection/is-surgery-the-best-option-research-provides-alternatives/ |journal=NIHR Evidence |type=Plain English summary |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_65060|doi-access=free }} The choice of short arm, short arm thumb spica or long arm cast is debated in the medical literature and no clear consensus or proof of the benefit of one type of casting or another has been shown; although it is generally accepted to use a short arm or short arm thumb spica for non displaced fractures.

Fractures that are more proximal take longer to heal. It is expected the distal third will heal in 6 to 8 weeks, the middle third will take 8–12 weeks, and the proximal third will take 12–24 weeks. The scaphoid receives its blood supply primarily from lateral and distal branches of the radial artery. Blood flows from the top/distal end of the bone in a retrograde fashion down to the proximal pole; if this blood flow is disrupted by a fracture, the bone may not heal. Surgery is necessary at this point to mechanically mend the bone together.{{citation needed|date=October 2020}}

Percutaneous screw fixation is recommended over an open surgical approach when it is possible to achieve acceptable bone alignment closed as minimal incisions can preserves the palmar ligament complex and local vasculature, and help avoid soft tissue complications. This surgery includes screwing the scaphoid bone back together at the most perpendicular angle possible to promote quicker and stronger healing of the bone. Internal fixation can be done dorsally with a percutaneous incision and arthroscopic assistance Slade JF 3rd, Gutow AP, Geissler WB. Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg Am. 2002;84-A Suppl 2:21-36. doi:10.2106/00004623-200200002-00003 or via a minimal open dorsal approach,{{cite journal |vauthors=Gutow AP |date=August 2007 |title=Percutaneous fixation of scaphoid fractures |journal=The Journal of the American Academy of Orthopaedic Surgeons |volume=15 |issue=8 |pages=474–485 |doi=10.5435/00124635-200708000-00004 |pmid=17664367 |s2cid=33543861}} or via a volar approach in which case slight excavation of the edge of the trapezium bone may be necessary to reach the scaphoid as 80% of this bone is covered with articular cartilage, which makes it difficult to gain access to the scaphoid.{{Cite web|url = https://www2.aofoundation.org/wps/portal/surgery?showPage=redfix&bone=Hand&segment=Scaphoid&classification=72-Scaphoid,%20Undisplaced&treatment=&method=Undisplaced%20waist%20fracture&implantstype=Percutaneous%20screw%20fixation&approach=&redfix_url=1291127800041&Language=en|title = Percutaneous Screw Fixation|access-date = November 30, 2015|website = AO Foundation| vauthors = Kastelec M |url-status = dead|archive-url = https://web.archive.org/web/20151208073534/https://www2.aofoundation.org/wps/portal/surgery?showPage=redfix&bone=Hand&segment=Scaphoid&classification=72-Scaphoid,%20Undisplaced&treatment=&method=Undisplaced%20waist%20fracture&implantstype=Percutaneous%20screw%20fixation&approach=&redfix_url=1291127800041&Language=en|archive-date = December 8, 2015}}

A non-union (pseudarthrosis) can occur in 2 to 5% of cases. {{cite journal | vauthors = Suh N, Grewal R | title = Controversies and best practices for acute scaphoid fracture management | journal = The Journal of Hand Surgery, European Volume | volume = 43 | issue = 1 | pages = 4–12 | date = January 2018 | pmid = 29027844 | doi = 10.1177/1753193417735973 | doi-access = free }}

In the aftermath, 90% of non-operated individuals return to sports, with 88% reaching their previous level. Among those who underwent surgery, the rate of returning to sports is 98%, and 96% return to their previous level. The average time observed for resuming sports is 14 weeks for non-operated individuals and 7 weeks for those who had surgery.{{cite journal | vauthors = Goffin JS, Liao Q, Robertson GA | title = Return to sport following scaphoid fractures: A systematic review and meta-analysis | journal = World Journal of Orthopedics | volume = 10 | issue = 2 | pages = 101–114 | date = February 2019 | pmid = 30788227 | pmc = 6379737 | doi = 10.5312/wjo.v10.i2.101 | doi-access = free }}

Fractures of the scaphoid are common in young males.{{cite book|title=Beasley's Surgery of the Hand|year=2003|publisher=Thieme New York|isbn=9781282950023|page=188}} They are less common in children and older adults because the distal radius is weaker contributor to the wrist and more likely to fracture in these age groups. Scaphoid fractures account for 50%-80% of carpal injuries.

These are also called navicular fractures (the scaphoid also being called the carpal navicular), although this can be confused with the navicular bone in the foot.{{cn|date=August 2021}}

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| ICD9 = {{ICD9|814}}.x1

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| eMedicineTopic = 844

| eMedicine_mult = {{eMedicine2|radio|747}} {{eMedicine2|plastic|318}} {{eMedicine2|pmr|127}}

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• [http://www.aafp.org/afp/20040901/879.html AAFP: Diagnosis and Management of Scaphoid Fractures]
• [http://www.wheelessonline.com/ortho/scaphoid_scaphoid_fracture Wheeless: Scaphoid fracture]

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Category:Bone fractures

Category:Injuries of wrist and hand

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