Scaphoid Fracture

General

Most common carpal bone fracture
Commonly missed, often an occult fracture
Retrograde blood supply

At risk for nonunion and avascular necrosis
10% risk of nonunion for nondisplaced waist fractures treated nonoperatively
50% risk of nonunion for displaced waist fractures treated nonoperatively

Immobilization & WB Status

Thumb spica splint
Non-weight-bearing injured arm

Disposition

Closed fracture: follow up with orthopedic surgery within 1 week

Express the importance of follow up to the patient, given risk for avascular necrosis of this fracture pattern (frequently requires outpatient surgery)

Open fracture (extremely rare): consult to orthoapedic surgery; admission

Mechanism

Have a high index of suspicion for wrist pain & snuffbox tenderness
Commonly: fall on outstretched arm, MVC, contact sports

Timing of injury

Missed injuries can lead to scaphoid nonunion and arthritis

Other locations of pain
Often occurs with other fractures of the distal radius and carpal bones
Numbness/Tingling
Hand dominance
Profession
Tobacco use

Poor healing potential and higher risk of osteonecrosis

Vitals

Wrist swelling
Pain on the radial side of the wrist
Anatomic snuffbox tenderness

Poke holes or punctate wounds that probe deep → open fracture

Do not miss this; if seen, immediately give IV cefazolin (2-3g)

Motor Exam:

Median Nerve/ Anterior interosseous nerve (AIN)

Flexion of wrist, fingers, thumb
“A-OK sign” = AIN

Tests flexion of thumb IP joint (FPL) and flexion of index DIP joint (FDP)

Radial nerve/ Posterior interosseous nerve (PIN)

Extension of wrist, fingers, thumb

“Thumbs up” = PIN

Tests extension of thumb IP and MCP joints (EPL)
Palm on flat surface and lifting/extending thumb off the surface is also a good test for PIN (tests extension of thumb MCP joint (EPL))

Ulnar nerve

Finger abduction (spread fingers, “peace sign”), finger adduction, cross fingers (“promise”)

Sensory Exam:

Median, Radial, Ulnar nerve distributions

Radial: Dorsal first web space
Median: Volar distal index finger
Ulnar: Volar distal small finger

Vascular exam:

Radial artery, Ulnar artery
Capillary refill to digits

Extension of digits and wrist

Often pain limited at the wrist

Flexion of the digits and wrist

Often pain limited at the wrist

Pain exacerbated with circumduction of the wrist

Dorsal pain in the anatomic snuffbox
Volar pain over the scaphoid tubercle
Scaphoid compression pain when an axial load is applied through the thumb (1st) metacarpal

Radiographs AP/lateral/oblique of involved wrist, hand, and forearm

Up to 25% of scaphoid fractures are not visible on radiographs

Treat the patient for occult fracture as these can be subtle injuries that are very difficult to see on initial imaging

Ensure there is not a concomitant perilunate dislocation or lunate dislocation

Special views to consider

Scaphoid view: -30 degrees of wrist extension, 20 degrees of ulnar deviation
Clenched fist view: AP radiograph while grasping a pen or pencil

CT scan

Provides details of other carpal bone fractures
Helpful in cases where clinical index of suspicion is high with equivocal X-rays

MRI - rarely necessary in the ED

Most sensitive for occult fractures

Medical Decision Making

Concern for a Scaphoid Fracture :

*** is a *** y/o ***-hand dominant ***M/F with hx of ***, who presents with an injury to the *** upper extremity and concern for a scaphoid fracture after mechanism***. On exam, the patient is neurovascularly intact. There is pain in the anatomic snuff box and pain with axial loading of the thumb. The injury is closed and isolated. Radiographs do not reveal an obvious fracture line. Given the clinical presentation consistent with an occult scaphoid fracture, the patient was placed in a thumb spica splint. The patient will follow up with orthopedic surgery within one week for repeat evaluation.

Radiographically Visible Closed Scaphoid Fracture :

*** is a *** y/o ***-hand dominant ***M/F with hx of ***, who presents with an injury to the *** upper extremity after mechanism***, found to have scaphoid fracture. On exam, the patient is neurovascularly intact. There is pain in the anatomic snuff box and pain with axial loading of the thumb. The injury is closed and isolated. Radiographs ***. The patient was placed in a thumb spica splint. The patient will follow up with orthopedic surgery within one week for repeat evaluation.

Open Scaphoid Fracture :

*** is a *** y/o ***-hand dominant ***M/F with hx of ***, who presents with an injury to the *** upper extremity after mechanism***, found to have an open scaphoid fracture. On exam, the patient is neurovascularly intact. There is a ***cm laceration on the *** aspect of the wrist which probes to fracture. A dose of ancef (***2/3g) was given immediately and gross contaminants were irrigated out of the wound at bedside. Radiographs revealed ***. Orthopaedics was consulted and the patient was made npo. The patient last ate at ***.

Open scaphoid fracture:

Consult orthopedic surgery
NPO
Ensure IV cefazolin (2-3g) were given
Assess tetanus status

Gustillo-Anderson chart for antibiotic type and dose

Depending on the size of the soft tissue defect may require gentamicin as well

Clinically suspected OR known scaphoid fractures:

WB Status: Non-weight-bearing injured hand and wrist
Diet: Regular
Analgesia: short course of narcotic pain medication, tylenol (scheduled)

Ex: 5mg oxycodone q4 - 15 pills

Immobilization

Thumb spica splint

Thumb in neutral position as if holding a can of soda

Disposition: Home with follow up in orthopedic surgery clinic in 1 week

Materials For Splints

Thumb Spica Splint Walkthrough

Procedure Walkthroughs:

Thumb spica splint

Position: as if holding a can of soda
Apply soft padding liberally over the thumb, wrist, and distal forearm

Split the plaster/orthoglass longitudinal with its length on one side

After wetting, use the split end to cocoon the first ray with the hand in the position as if holding a can of soda
Make sure to keep plaster/Ortho-Glass off skin
Wrap the splint with an elastic or nonelastic wrap based on personal or institutional preference

Procedure Notes:

PROCEDURE NOTE Closed treatment of carpal scaphoid (navicular) fracture; without manipulation

PRE-PROCEDURE DIAGNOSIS: fracture of the *** scaphoid

POST-PROCEDURE DIAGNOSIS: Same (refer above)

PROCEDURALIST: ***

ANESTHESIA: None

NAME OF PROCEDURE: Closed treatment of carpal scaphoid (navicular) fracture; without manipulation

PROCEDURE IN DETAIL:
The risks and benefits of the procedure were discussed at length with the patient. Risks discussed included but were not limited to post-procedural pain, stiffness, numbness, and tingling. Following informed verbal consent after discussion of risks and benefits, the patient agreed to proceed with the procedure. A timeout was performed.

A well-padded thumb spica splint was applied to the injured hand. Post splint radiographs showed unchanged alignment after the in-situ splinting. The patient's neurovascular status was consistent with baseline.

COMPLICATIONS: ***

DISPOSITION: Discharged home with follow up with orthopaedic surgery in 1 week for repeat evaluation

Common ICD-10 Codes	Brief Description
S62.0	Fracture of navicular [scaphoid] bone of wrist
S62.01	Fracture of distal pole of navicular [scaphoid] bone of wrist
S62.02	Fracture of middle third of navicular [scaphoid] bone of wrist
S62.03	Fracture of proximal third of navicular [scaphoid] bone of wrist

Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Yealy, D. M., Meckler, G. D., & Cline, D. (2016). Injuries to Bones and Joints In Tintinalli's emergency medicine: A comprehensive study guide (Eighth edition.) (pp1863-1864). New York: McGraw-Hill Education.
Davenport M. Procedures for orthopedic emergencies. In: Bond M, ed. Orthopedic Emergencies: Expert Management for the Emergency Physician. Cambridge: Cambridge University Press; October 31, 2013.