1. SYB 3 Marni Scheiner

3. Scaphoid Fracture Most common type of wrist fracture Location: Radial aspect of the hand just distal to the radius itself 65% at the waist 15% proximal pole 10% distal body Results mainly from a fall on an outstretched arm proximal carpal row Fx > distal carpal row Fx http://ptclinic.com/medlibrary/images/v2/ScaphoidFr acture.gif

4. Scaphoid Fracture Mechanism of injury fall on the outstretched arm with the wrist in dorsiflexion. Symptoms/Exam Findings History of fall/trauma Pain localized to radial aspect of wrist (anatomic snuffbox); increased with palpation Dorsoradial swelling ROM and grip strength reduced Any tenderness in the snuffbox should be treated as a scaphoid fracture until proven otherwise Mechanism of injury fall on the outstretched arm with the wrist in dorsiflexion. Symptoms/Exam Findings History of fall/trauma Pain localized to radial aspect of wrist (anatomic snuffbox); increased with palpation Dorsoradial swelling ROM and grip strength reduced Any tenderness in the snuffbox should be treated as a scaphoid fracture until proven otherwise

5. Scaphoid Fracture Radiographic Findings Standard Radiographs PA, true lateral, and scaphoid view Scaphoid View: PA with wrist in full pronation and ulnar deviation Shows scaphoid in its most longitudinal axis; separates it on radiograph from shadows of the distal radius. If questionable Fx alignment on plain radiographs, an MRI or CT scan should be obtained to correctly identify the amount of displacement Radiographic Findings Standard Radiographs PA, true lateral, and scaphoid view Scaphoid View: PA with wrist in full pronation and ulnar deviation Shows scaphoid in its most longitudinal axis; separates it on radiograph from shadows of the distal radius. If questionable Fx alignment on plain radiographs, an MRI or CT scan should be obtained to correctly identify the amount of displacement

6. Scaphoid Fracture Should evaluate for signs of ligament disruption (*esp scapholunate ligament). "Terry Thomas” Sign Normal space b/w scaphoid and lunate bones = 1-2mm Terry Thomas Sign widened space (>3 mm) between the scaphoid and the lunate accentuated in PA of closed hand in a fist with ulnar deviation important since it is a cause of chronic wrist pain and disability if left untreated. www.rcsed.ac.uk/.../hand/scapholunate_diss.htm

7. Scaphoid Fracture Suspected fracture with negative plain radiographs: If compressed or minimally displaced, initial radiographs may be negative. Traditional approach: immobilization followed by additional radiographs (7-10 days). CT/MRI For definitive Dx in Pt can not tolerate any unnecessary immobilization (ex. a competitive athlete) CT scan more readily available MRI less costly More information about ligamentous or other possible injuries Suspected fracture with negative plain radiographs: If compressed or minimally displaced, initial radiographs may be negative. Traditional approach: immobilization followed by additional radiographs (7-10 days). CT/MRI For definitive Dx in Pt can not tolerate any unnecessary immobilization (ex. a competitive athlete) CT scan more readily available MRI less costly More information about ligamentous or other possible injuries

8. Scaphoid Fracture Complications Malunion Delayed Union Nonunion *AVASCULAR NECROSIS (AVN) Osteonecrosis is more common in scaphoid Fx’s than most other bones; 15-30% of all scaphoid fractures most commonly involves the proximal pole blood supply runs from distal to proximal leading to the possibility of non-union or osteonecrosis of the proximal pole Complications Malunion Delayed Union Nonunion *AVASCULAR NECROSIS (AVN) Osteonecrosis is more common in scaphoid Fx’s than most other bones; 15-30% of all scaphoid fractures most commonly involves the proximal pole blood supply runs from distal to proximal leading to the possibility of non-union or osteonecrosis of the proximal pole

9. Scaphoid Fracture Treatment If Fx displaced (≥ 1 mm) and/or significantly increased or decreased scapholunate angle immobilize in a thumb spica splint and referred for orthopedic evaluation. Non-displaced fractures (<1 mm) short-arm thumb-spica cast typically for six to 10 weeks. Fractures at the waist or proximal third could be given more substantial immobilization in a long-arm cast. If immobilization is not an option, operative fixation is suggested. Athletes: rigid protection for 2 months after radiographic healing. Treatment If Fx displaced (≥ 1 mm) and/or significantly increased or decreased scapholunate angle immobilize in a thumb spica splint and referred for orthopedic evaluation. Non-displaced fractures (<1 mm) short-arm thumb-spica cast typically for six to 10 weeks. Fractures at the waist or proximal third could be given more substantial immobilization in a long-arm cast. If immobilization is not an option, operative fixation is suggested. Athletes: rigid protection for 2 months after radiographic healing.