Scaphoid

Scenario

A 30 Year old male presents to the emergency department after a night out, during which he fell onto an outstretched hand, with tenderenss over his anatomical snuffbox. The following X-Ray is obtained.

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This is an AP and scaphoid view plane film radiograph of a skeletally mature individual. The most obvious abnormality is that there is a scaphoid waist fracture. 

  • Major blood supply is the dorsal carpal branch (radial artery). Supplies proximal 80% of scaphoid via retrograde blood flow
  • Superficial palmar arch (volar radial artery) distal 20% of scaphoid

Mayo classification (based on location of fracture line)

1

Distal tubercle

2

Distal articular surface

3

Distal third

4

Middle third

5

Proximal third

 

  • Radiographs
    • Neural rotation PA
    • Lateral
    • Semi-pronated
    • Scaphoid view (30 degree wrist extension, 20 ulnar deviation)
  • MRI most sensitive/specific
  • Displacement >1mm
  • Scapholunate angle >60 degrees
  • Lunocapitate angle >15 degrees
  • Intrascaphoid angle >20 degrees
  • Proximal pole fracture
  • Fractures associated with peri-lunate dislocation
  • Delayed union

This is the angle between the long axis of the scaphoid and the mid axis of the lunate on sagittal imaging of the wrist. Normal = 45-60 degrees

This is the angle between the mid axis of the lunate and the mid axis of the capitate. Normal = 0-15 degrees.

This is the angle between a line drawn perpendicular to a line between the proximal and distal pole of the scaphoid. An increased angle suggests scaphoid collapse.

I would have a discussion with the patient. Un-displaced fractures of the scaphoid waist have a 10% risk of non-union. I would explain this to the patient. I would explain that operative vs non operative outcome at 12-16 weeks show no different in terms of function, ROM and grip strength. However if need for early return to work then percutaneous screw fixation may be advantageous. 

Operative or conservative management

Short arm cast excluding the thumb for 6 weeks

Operative treatment If indication for surgery.

No difference between operative and non-operative management of scaphoid waist fractures that are <2mm displaced.