All fractures › Elbow, forearm & wrist

Scaphoid fracture

AO/OTA 72

Waist fracture

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The scaphoid links the two carpal rows. Its blood supply enters distally (dorsal branch of the radial artery) and flows backwards, so the proximal pole may die after a waist fracture. It is the most commonly missed fracture of the wrist.

Scaphoid waist fracture. Arrow: fracture across the waist of the scaphoid. — Gilo1969, CC BY 3.0, via Wikimedia Commons.

Mechanism

Fall on the outstretched, radially deviated hand; young adults.

Clinical findings

Tenderness in the anatomical snuffbox and over the scaphoid tubercle; pain on axial compression of the thumb.

Imaging

Scaphoid series: PA in ulnar deviation, lateral, 45° semipronated oblique.
Clinical suspicion with normal films: cast and repeat at 10–14 days, or better MRI now (or CT).
CT to measure displacement and the humpback deformity.

Scaphoid series (PA in ulnar deviation, lateral, obliques). Normal X-rays with clinical suspicion: MRI (or CT) early rather than repeated plain films.

Classification

Location: Tubercle, distal third, waist (most common), proximal pole (worst healing).
Herbert: A acute stable, B acute unstable, C delayed union, D non-union.
Displacement: > 1 mm step, humpback deformity or lunate extension (DISI) = unstable.

Types shown in 3D

Tubercle: Distal tubercle avulsion: extra-articular, heals well in a short cast.
Distal third: Good blood supply: heals in 6 weeks of cast if undisplaced.
Waist: The most common (about 65%). Undisplaced: cast 6–8 weeks; displaced (> 1 mm, humpback): headless compression screw.
Proximal pole: The blood enters distally and flows backwards: high risk of non-union and avascular necrosis. Fix with a screw.

Treatment

Non-operative: Undisplaced waist and distal fractures: below-elbow cast (thumb free or included) for 6–8 weeks, then CT to confirm union.
Operative: Displaced fractures, proximal pole fractures, delayed presentation, athletes who want early return: headless compression screw along the central axis (percutaneous volar or dorsal). Non-union: open reduction, bone graft (vascularised for avascular proximal poles) and screw.

Aftercare

Confirm union on CT before heavy loading.

Complications

Non-union → SNAC wrist (scaphoid non-union advanced collapse)
Avascular necrosis of the proximal pole