Symptoms of a scaphoid fracture typically include pain and tenderness in the area just below the base of the thumb. Fractures of the scaphoid must be recognized and treated quickly, as prompt treatment by immobilization or surgical fixation increases the likelihood of the bone healing in anatomic alignment, thus avoiding mal-union or non-union. Not a lot is known in literature about this specific type of avulsion fracture and the treatment. Journal of Hand Surgery (British and European Volume). http://hjdbulletin.org/files/archive/pdfs/681.pdf. 2013;4(1):3-10. doi:10.1016/j.jcot.2013.01.009, 5. (yellow arrow). (1-3), The Mayo classification system for scaphoid fractures is organized according to anatomic location in the scaphoid bone: proximal third, middle third (waist), distal third (Fig. (OBQ09.56) These symptoms may worsen when you try to pinch or grasp something. This is a frequent injury among snowboarders and active children who participate in sports. The scaphoid bone is one of the carpal bones in your hand around the area of your wrist. Diagram by Nirali Dave. Anatomical snuffbox tenderness, pain on axial compression of the thumb, and scaphoid tubercle tenderness have extremely high sensitivity for scaphoid fractures, but have variable specificity. How we do it? Cock-up wrist splint and immediate return to sport as tolerated by pain, Steroid injection of the snuffbox, taping of the wrist and return to sport, Percutaneous screw fixation of the nondisplaced fracture, Scapholunate ligament repair and percutaneous pin fixation. Prosser AJ, Brenkel IJ, Irvine GB. No deformity is identified and the hand is completely neurovascularly intact. Efort Open Reviews. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. (OBQ08.111) Anatomic snuffbox swelling, scaphoid tubercle tenderness, and pain with axial pressure on the first metacarpal bone are sensitive but not specific tests for diagnosing scaphoid fractures. 1. Acute scaphoid fractures : Guidelines for diagnosis and treatment. Avulsion fractures of the scaphoid tubercle, which are extra-articular, are relatively rare. Scaphoid shift test: reproduction of pain with dorsal-volar shifting of the scaphoid The Watson test: painful dorsal scaphoid displacement as the wrist is moved from ulnar to radial deviation with palmar pressure on the tuberosity. Dorsal Carpal Branch of Radial Artery enters scaphoid bone through the dorsal ridge and provides 70-80% of the blood supply with thinner branches proximally. Plain radiograph of the wrist demonstrating subtle fracture of the waist of the scaphoid (yellow arrow) and nondisplaced fracture of the scaphoid tubercle (red arrow). Rhemrev S, Ootes D, Beeres F, Meylaerts S, Schipper I. The correct diagnosis is only rarely made by radiologists or surgeons at the time of the fracture, because of failure to recognize this entity. For patients with a clinically suspected scaphoid fracture but normal radiographs, the next step is … Clementson M, Björkman A, Thomsen NOB. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. 4-5); therefore, healing of a distal tubercle fracture usually proceeds without complication. International CME for Today's Radiologist. 2003;61(3,4). A. The scaphoid tubercle can therefore be easily and accurately palpated on the palmaraspect ofthe radially deviated wrist. Diagram by Nirali Dave. The most sensitive clinical sign of scaphoid fracture is anatomical snuffbox tenderness, but it has low specificity (ie, a high rate of false positives) The first line investigation is a four-view scaphoid radiograph series, but negative radiography does not rule out fracture. Over a 10-month period 246 patients were seen who were suspected of having a scaphoid injury. Because there is excellent vascularity found in the distal third of the scaphoid bone, patients with scaphoid tubercle fractures are normally treated with immobilization in a thumb spica short cast, with full recovery taking about 4-6 weeks. Slightly displaced fracture of the distal scaphoid tubercle/pole. Dorsal view of scaphoid blood supply. 2. Skeletal Radiology. Some surgeons recommend a cast for 4 to 6 weeks while others treat their patients with a removable brace. The most common injury of the scaphoid is a fracture (break), usually caused when a person falls with the hand stretched out to brace him or herself (a natural reaction). Figure 5. Puopolo SM, Rettig ME. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education. They are very commonly referred to orthopaedics, due to diagnostic uncertainty; however, only around 1 in 10 referred patients actually have a scaphoid fracture. A 22-year-old male snowboarder falls on an outstretched hand and presents with the radiograph shown in Figure A. 2003;61(3,4). (4) Distal tubercle fractures are rare, accounting for only 5% of all scaphoid fractures and are visualized on x-rays as avulsed small radiovolar fragments of the distal tip. Scaphoid fractures are quite common, but they can be difficult to detect. (1,2), The initial imaging modality used to diagnose scaphoid fractures is plain radiography, however x-rays can miss up to 30% of fractures in the acute setting. Scaphoid fractures predominantly affect young adults, with a mean age of 29 years. (OBQ09.36) Kaewlai R, Avery LL, Asrani AV, et al. Delays may compromise healing. 2011;40(7):869-875. doi: 3. These injuries can also be associated with radial fractures, especially in older populations, but unless a scaphoid injury is considered it is unlikely to be diagnosed. Bulletin of the NYU Hospital for Joint Diseases. (6), Because there is excellent vascularity found in the distal third of the scaphoid bone, patients with scaphoid tubercle fractures are normally treated with immobilization in a thumb spica short cast, with full recovery taking about 4-6 weeks. The scaphoid tubercle The flexor carpi radialis (FCR) tendon The incision line can be marked on the skin in line with the FCR tendon, starting at the scaphoid tubercle, and running proximally for about 2 cm. Acute scaphoid fractures : Guidelines for diagnosis and treatment. (6,7), 1. Complications may include nonunion of the fracture, avascular necrosis, and arthritis. Figure 2: The scaphoid outlined in red. Increased risk of posterior interosseous nerve injury, Decreased risk of injury to the APL tendon, Increased risk of injury to the EPL tendon, Decreased risk of screw prominence above subchondral bone. Of these, proximal third fractures account for 10% of all scaphoid fractures, waist fractures account for 70%, and distal third fractures account for 20%. (OBQ05.130) 2013;4(1):3-10. doi: 5. Current methods of diagnosis and treatment of scaphoid fractures. Occult fractures of the scaphoid: the role of ultrasonography in the emergency department. Displaced scaphoid fractures, on the other hand, have to be treated more aggressively, since they are, of course, more complicated to heal. Improved motion and grip strength after 2 years. Since the remainder of the scaphoid bone depends on the blood supply from the distal third of the scaphoid, vascular disruption due to a scaphoid waist fracture may result in complications such as nonunion, avascular necrosis, and chronic radiocarpal osteoarthritis. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. The localization of a scaphoid fracture is the decisive criterion in the prognosis of fracture healing and, therefore, for the choice of the therapeutic procedure. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Conversely, scaphoid fractures of the proximal third and waist can have more protracted healing timelines. Pseudarthrosis of the scaphoid tubercle is a rare condition resulting from a fracture in an unusual location in the scaphoid bone, and it is important because it affects the young and active population. Gupta V, Rijal L, Jawed A. Journal of Clinical Orthopaedics and Trauma. Alternatively, pain with digital pressure over the scaphoid tubercle may indicate scaphoid fracture. Scaphoid is most frequently fractured carpal bone, often occurring after a fall onto an outstretched hand Diagnosis can generally be made by dedicated radiographs but CT or MRI may be needed for confirmation Treatment may require a prolonged period of cast immobilization, percutaneous surgical fixation, or microsurgical graft reconstruction Occult fractures of the scaphoid: the role of ultrasonography in the emergency department. The longitudinal axis of the scaphoid lies in an anteroposterior plane, perpendicular to the remainder of the carpal bones, in the radially deviated wrist. Skeletal Radiology. A scaphoid (navicular) fracture is a break in one of the small bones of the wrist. Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment? In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Scaphoid fracture is not very likely when tubercle palpation does not provoke pain in the snuffbox. Scaphoid fractures are much more common in adolescents than younger children. There is a reported prevalence between 9 and 33% of occult scaphoid fractures. Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Swelling was determined by measuring the difference in circumference at the wrist joint to compare between fracture and soft tissue injury. Approximately 10% have an associated fracture. Platon A, Poletti P-A, Aaken J, et al. Managing scaphoid fractures. Nearly 2/3 of all scaphoid fractures occur at the waist, with 15% occurring at the proximal pole, 10% at the distal pole, and 8% at the tuberosity. 14 The scaphoid tubercle is the palpable prominence at the level of the distal flexor crease of the extended and radial‐deviated wrist (Data Supplement S2, available as supporting information in the online version of this paper). On exam, she has focal tenderness over the wrist snuffbox. The cowboy wants to return to competitive riding tomorrow. Symptoms can … The scaphoid tubercle can therefore be easily and accurately palpated on the palmar aspect of the … wrist. A radiograph and CT image are shown in Figures A and B. 2020;5(2):96-103. doi:10.1302/2058-5241.5.190025, 7. Fractures of the scaphoid may involve the body, the tubercle or be avulsions of bone fragments. Rhemrev S, Ootes D, Beeres F, Meylaerts S, Schipper I. There is a higher incidence in males. A 27-year-old professional cowboy is thrown from a bull during the rodeo and lands on his hand. The anatomic snuffbox is generally tender and swelling may occur. Scaphoid Fracture: Causes, Symptoms, Diagnosis, and Treatment More unstable scaphoid fractures often require open operative treatment that can still result in complications such as delayed or nonunion. The scaphoid (Figure 2) articulates with the radius and four carpal bones (lunate, trapezium, trapezoid, and … Platon A, Poletti P-A, Aaken J, et al. Scaphoid fracture is a break in the scaphoid bone, one of the small bones in your wrist. This study wasdevised to determine if tenderness over the scaphoid tubercle (ST) wassuperior to ASBtenderness in identifying definite fractures. Using a screw placed in the central axis of the scaphoid into the subchondral bone, Using a supplementary K-wire transfixing the distal pole of the scaphoid to the capitate, Using a screw placed in the dorsal axis of the scaphoid into the subchondral bone, Using a larger diameter screw placed in the dorsal axis of the scaphoid, Using a larger diameter screw placed in the volar axis of the scaphoid. Articular Fractures of the Distal Scaphoid. 2011;40(7):869-875. doi:10.1007/s00256-010-1086-y, 3. Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Diagram by Nirali Dave. Scaphoid is most frequently fractured carpal bone, often occurring after a fall onto an outstretched hand, Diagnosis can generally be made by dedicated radiographs but CT or MRI may be needed for confirmation, Treatment may require a prolonged period of cast immobilization, percutaneous surgical fixation, or microsurgical graft reconstruction, 8 per 100,000 females, 38 per 100,000 males, transverse fracture patterns are considered more stable than vertically or obliquely oriented fractures, SNAC (Scaphoid Nonunion Advanced Collapse), complex 3-dimensional structure described as resembling a boat, skiff, and twisted peanut, oriented obliquely from extremity's long-axis (implications for advanced imaging techniques), > 75% of scaphoid bone is covered by articular cartilage, articulates with radius, lunate, trapezium, trapezoid, and capitate, dorsal carpal branch (branch of the radial artery), enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal, superficial palmar arch (branch of volar radial artery, creates vascular watershed and poor fracture healing environment, link between proximal and distal carpal row, both intrinsic and extrinsic ligaments attach and surround the scaphoid, the scaphoid flexes with wrist flexion and radial deviation and extends during wrist extension and ulnar deviation (same as proximal row), Herbert and Fisher Classification (based on fracture stability), Unstable, acute fractures (distal oblique, complete waist, proximal pole, trans-scaphoid and perilunate associated fractures), Delayed union characterized by cyst formation and fracture widening, Mayo classification (based on location of fracture line), Russe Classification (based on fracture pattern), high or low energy fall onto outstretched hand, rarely any ecchymosis, hematoma, or gross deformity, positive test when pain reproduced with axial load applied through thumb metacarpal, 87-100% sensitivity and 74% specificity when all three tests positive within 24 hours of injury, neutral rotation PA and lateral, semi-pronated (45°) oblique view, 30 degree wrist extension, 20 degree ulnar deviation, if radiographs are negative (27%) and there is a high clinical suspicion, specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours, most sensitive for diagnosis occult fractures < 24 hours, immediate identification of fractures / ligamentous injuries, proximal pole AVN best determined on T1 sequences, CT scan with 1mm cuts along scaphoid axis, best modality to evaluate fracture location, angulation, displacement, fragment size, extent of collapse, and, progression of nonunion or union after surgery, 62% sensitivity and 87% specific for determining stability and fracture, less effective than bone scan and MRI to diagnose occult fracture, stable nondisplaced fracture (majority of fractures), normal radiographs but there is a high level of suspicion, displacement > 1 mm without significant angulation or deformity, to allow decreased time to union, faster return to work/sport, similar total costs compared to casting, significantly displaced fracture patterns, scaphoid fractures associated with perilunate dislocation, accuracy of reduction correlated with rate of union, nonunion rates increase with delayed immobilization of > 4 weeks after injury, immobilization maintained until radiographic fracture healing demonstrated, usually no sooner than 8 weeks, may be required for up to 12-14 weeks for high-risk fracture patterns/patients, athletes should not return to play until imaging shows a healed fracture, formal therapy following immobilization to regain range of motion, care must be taken to avoid EPL tendon and to preserve the blood supply when entering the dorsal ridge, limit exposure to the proximal half of the scaphoid, percutaneous has higher risk of unrecognized screw penetration of subchondral bone, avoids jeopardizing scaphoid blood supply, uses the interval between the FCR and the radial artery, careful capsule management to allow closure and restoration of RSC ligament, has also been described to aid in anatomic reduction, precise wire placement in central axis to guide cannulated screw, do not violate scaphotrapeziotrapezoidal joint cartilage, rigidity is optimized by long screw placed down the central axis of the scaphoid, oblique fluoroscopic images to confirm placement and appropriate screw length, allows direct visualization and reduction at fracture site, 5-10% following immobilization, higher rates for proximal pole fractures, vertical oblique fracture pattern, displacement >1mm, advancing age, nicotine use, vascularized or nonvascularid bone grafting procedures, many studies showing 100% in proximal fifth fractures with immobilization, flexion of distal fragment and extension of proximal fragment due to pull of scapholunate interosseous ligament creating shortened bone with humpback deformity, no clear indications supporting operative versus non-operative treatment, Subchondral bone penetration with arthrosis due to prominent hardware, seen following mini-open fixation techniques, incidence has decreased with use of fluoroscopy, revision surgical fixation versus implant removal following union, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). Journal of Clinical Orthopaedics and Trauma. (OBQ06.16) A radiograph is provided in Figure A. Volar view of scaphoid blood supply. FOOSH (fall on outstretched hand) is the most common mechanism of scaphoid fracture although other mechanisms can include blunt scaphoid trauma as well as repeat stress type injury. Prosser AJ, Brenkel IJ, Irvine GB. Scaphoid fractures occur most frequently in the middle third (scaphoid waist). Kaewlai R, Avery LL, Asrani AV, et al. Scaphoid fractures are among the most common upper extremity injuries. The evidence-based literature suggests that magnetic resonance imaging (MRI) is the most suitable secondary imaging modality due to the ability to evaluate the bone marrow directly and to … 2020;5(2):96-103. doi: 7. Managing scaphoid fractures. Which of the following is the best next step in management? Distal of the scaphoid tubercle, the incision angles towards the base of the thumb, over the scaphotrapezial joint. A scaphoid fracture is a break of the scaphoid bone in the wrist. Small associated bony chip. Tenderness in the anatomical snuff box (ASB) has long been accepted as an indicator of a possible scaphoid fracture. Detailed Description: Fractures of the distal scaphoid tubercle are uncommon and seem relatively benign. A prospective comparison was made between anatomical snuffbox, scaphoid tubercle and scaphoid compression tenderness as indicators of scaphoid fracture in 221 patients with suspected scaphoid injury. Abstract. Radiographics : a review publication of the Radiological Society of North America, Inc. 2008;28(6):1771-1784. doi:10.1148/rg.286085511, 4. Efort Open Reviews. In these cases, the healing time can extend to as long as six months or longer, depending on the severity of the fracture. Type in at least one full word to see suggestions list, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, 2018 Orthopaedic Summit Evolving Techniques, Screw that Scaphoid - Brian D. Adams, MD (OSET 2018), California Orthopaedic Association Annual Meeting - 2018, Scaphoid Fractures- Tips and Tricks - Jeffrey Yao, MD (COA 2018, 9.2), Proximal pole of scaphoid fracture in a 21M. Discussion Avulsion fracture of the scaphoid tuberosity is common in children and young adults." Approximately 75% of the arterial supply is from branches of the radial artery through vascular perforations on the dorsal surface near the tubercle and waist. What is the proper treatment of her injury? B. Coronal CT scan of the wrist demonstrating the minimally displaced fracture of the scaphoid tubercle (red arrow). Current methods of diagnosis and treatment of scaphoid fractures. 4,5 Despite the many reports on the clinically important … Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Mayo Clinic Scaphoid Fracture Classification: Scaphoid bone fractures are classified by anatomic position. D. Coronal CT scan of the wrist demonstrating the minimally displaced fracture of the waist of the scaphoid. Introduction. Scaphoid fractures have been well-reported as a challenge to diagnose and treat. Copyright © 2021 Lineage Medical, Inc. All rights reserved. Patients with scaphoid fractures usually present with severe wrist pain, swelling, and decreased range of motion following high-energy trauma. C 6 , 7 International Journal of Emergency Medicine. Plain radiographs taken soon after the injury may not reveal a fracture, but the clinician should assume one is present until definitive proof otherwise is obtained. Clementson M, Björkman A, Thomsen NOB. If imaging indicates a non-displaced scaphoid waist fracture, minimally invasive percutaneous screw fixation has achieved promising results. Scaphoid fractures account for 15% of acute wrist injuries. Anatomic snuffbox tenderness is a highly sensitive test for scaphoid fracture, whereas scaphoid compression pain and tenderness of the scaphoid tubercle tend to be more specific. 2011;4(1):1-8. doi:10.1186/1865-1380-4-4. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. neutral wrist position decreases force through the lunate fossa, extended wrist position increases force through the lunate fossa, neutral wrist position increases force through the scaphoid fossa, extended wrist position increases force through the scaphoid fossa, wrist position has no effect on force transmission. 2011;4(1):1-8. doi: "Minnie" Award for the Most Effective Radiology Educator. Fracture of volar tuberosity of navicular [scaphoid] bone of wrist Fracture of distal pole of navicular [scaphoid] bone of wrist ICD-10-CM S62.015A is grouped within Diagnostic Related Group(s) (MS-DRG v 38.0):
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