Scaphoid Fracture

Patients typically present after a fall onto an outstretched hand and complain of pain and swelling in the radial aspect of the wrist, worsened by motion. Gross deformity is not usually seen. The most common physical examination finding is tenderness with palpation over scaphoid tubercle or in the anatomic snuffbox. Radiographs should be obtained in all patients with suspected scaphoid injury, including AP, lateral, and oblique views, as well as PA ulnar deviation or scaphoid views (Fig. 30-24). Importantly, radiographs are often negative shortly after immediate injury and up to 14 days; radiographs should be repeated in 2 weeks if suspicion remains high. Because a fracture is suspected, interim splinting or casting is necessary. Other diagnostic tests may be obtained if repeat x-ray films are negative after 2 weeks and the patient is still symptomatic, or if definitive diagnosis is needed sooner than the planned 2-week follow-up. These tests may include radionuclide bone scan (usually positive within 2-3 days of injury), CT, or MRI.

Treatment of scaphoid fracture is initiated if suspicion is high, even though radiographs are initially negative. If fracture is ruled out at follow-up visits, treatment is adjusted accordingly. Nondisplaced scaphoid fractures are treated with cast immobilization. Thumb spica casting is essential, but whether the initial cast needs to be a long-arm or short-arm variety is controversial. Studies have shown decreased time to union and reduced rates of delayed union and nonunion with a long-arm thumb spica cast (Gellman et al., 1989). However, union rates of up to 95% with short-arm casting have been reported. A combination, with a long-arm cast for the initial 6 weeks followed by short-arm casting from 6 weeks until radiographic healing is present, addresses both these key issues.

Healing rates and average healing time depend on location of the fracture because the blood supply differs throughout the scaphoid. Nondisplaced distal pole fractures tend to receive a better blood supply and have a healing rate of close to 100%, with average healing time of 10 to 12 weeks. Scaphoid waist fractures have a healing rate of 80% to 90%, with average healing also 10 to 12 weeks. Proximal pole fractures have a healing rate of only 60% to 70%, with average healing time of 12 to 20 weeks. Poor outcomes (i.e., nonunion, malunion) in any scaphoid fracture are more likely to occur if the diagnosis or appropriate treatment is delayed; this is why it is important to initiate treatment based on suspicion of injury with normal radiographs.

Fractures that are displaced (>1 mm) can be treated with closed immobilization, but the risk of poor outcome is high. These fractures should be referred to an orthopedic surgeon for consideration of surgical fixation.

EVIDENCE-BASED SUMMARY

• One controlled study showed significant benefit of steroid injections for DeQuervain's tenosynovitis. Because of a limited number of patients and limited quality supportive studies, however, definitive recommendations cannot be made (Peters-Veluthamaningal et al., 2009a) (SOR: B).

• Pain and symptoms of people with "trigger finger" may improve with a corticosteroid injection (Peters-Veluthamaningal et al., 2009b) (SOR: A).

• Bone scintigraphy and MRI have equally high sensitivity and high diagnostic value for excluding scaphoid fracture. However, MRI

is more specific and better for confirming scaphoid fracture (Yin et al., 2009) (SOR: A). We believe additional studies are needed to assess diagnostic performance of CT.

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