Suspected Scaphoid Fractures

Forearm Backslab (Volar Wrist Half Cast) Elevation of the Limb

  1. Apply basic ATLS principles and consider the mechanism of injury. Usually a high energy fall on an outstretched hand. This is common in the younger active patient with a history of a motorbike or cycling accident.
  2. If there is any stigmata of compartment syndrome or a vascular threatened limb, refer immediately.
  3. Consider the whole upper limb as this might be simultaneously involved:
    • Screen the neck
    • Screen the Brachial plexus & clavicle
    • Screen the shoulder
    • Screen the elbow
  4. Check for tenderness in the anatomical snuffbox and scaphoid tubercle. Passive radial deviation of the wrist will cause discomfort.
  5. Consider a scapho-lunate ligament injury or even a peri-lunate fracture dislocation in high energy injuries.
  6. Request the following x-rays views for a suspected scaphoid fracture:
    • PA wrist
    • Lateral wrist
    • 30 degree supination in ulnar deviation
    • PA in ulnar deviation
    • Clenched fist AP wrist

X-Ray Evaluation

  1. Make sure there is no dislocation of the lunate (dislocation of lunate from lunate fossa in radius) or a peri-lunate dislocation (dislocation of capitate with or without other fractures). Use the Gilula lines to guide your eyes to pick up dislocations.
  2. X-ray of a suspected scaphoid fracture
  3. If there is an obvious fracture in the scaphoid with more than 1mm displacement, apply a volar half wrist cast and refer to an orthopaedic hand surgeon immediately.
  4. If there is an undisplaced fracture, apply a volar half wrist cast and the patient can follow up within the next week at a orthopaedic hand surgeon
  5. If there is no obvious fracture with strong suspicion of scaphoid fracture, apply a volar half wrist cast and arrange an appointment with an orthopaedic hand surgeon within the next week.

Definitive Management

  1. Counsel patient in the acute setting about the prolonged healing period and casting. Due to retrograde blood flow and no periosteal sleeve (completely covered with cartilage), there is a risk of non-union and avascular necrosis. These complications are more commonly seen in proximal pole and waist fractures.
  2. Rough guideline for casting periods to advise patient:
    • Proximal pole fractures : 10 – 12 weeks
    • Waist fractures : 8 – 10 weeks
    • Tubercle (distal fractures) : 6 – 8 weeks
  3. immobilisation of scaphoid fracture
    X-Ray of scaphoid bones
  4. Fracture or not?
    If there is a high suspicion of a fracture, the hand surgeon will request an MRI to confirm the diagnosis considering the prolonged period of immobilisation.
  5. Is surgery necessary?
    Surgery is indicated if there is displacement of 1mm or more. A screw is usually positioned put across the fracture to stabilise it. The wrist is usually casted for 6 weeks only.