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Scaphoid Fractures – Spoon-Feed Version

July 22, 2020

Written by Vivian Lei

Spoon Feed
Scaphoid fractures are the most common carpal bone injury, yet they are still commonly missed. Maintain a high clinical suspicion for scaphoid injury even with negative radiographs.

Why does this matter?
Missed scaphoid injuries can result in non-union, most of which are symptomatic and require surgical treatment. Non-union often leads to post-traumatic osteoarthritis, which negatively affects quality of life through chronic pain, stiffness, and loss of function. 

Scaphoid Fracture Fast Facts

  • The typical mechanism of injury is forced hyperextension of the wrist (e.g. fall on outstretched hand).

  • A careful clinical exam includes assessment for anatomic snuffbox tenderness, scaphoid tubercle tenderness, and a positive thumb longitudinal compression test.

    • Tenderness in the “anatomic snuffbox” of the wrist is 87-100% sensitive but has low specificity.

    • Combining the three tests within 24 hours of injury has been shown to have up to 100% sensitivity and 74% specificity.

  • Obtain a four-view series of scaphoid radiograph.

    • PA view

    • Lateral view

    • Oblique view with wrist pronated 45 degrees

    • PA view with wrist in ulnar deviation and beam angle at 20 degrees

  • Sensitivity of scaphoid radiographs in the first week of injury is only 80%, so a negative x-ray does not rule out a fracture.

  • If initial imaging is normal but clinical suspicion of scaphoid fracture remains, further imaging is essential.

    • MRI wrist scans have the highest sensitivity and specificity (94.2% and 97.7%, respectively).

    • Consider early advanced imaging as there is evidence to support overall cost savings as well as reduction in unnecessary immobilization.

  • In the ED, suspected and confirmed scaphoid fractures should be immobilized and referred to an orthopedic specialist for re-evaluation.

Fractures of the scaphoid. BMJ. 2020 May 27;369:m1908. doi: 10.1136/bmj.m1908. 

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