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Scaphoid (Navicular) Fractures

By Danielle Campagne, MD , Assistant Clinical Professor, Department of Emergency Medicine, University of San Francisco - Fresno

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Scaphoid fractures usually result from wrist hyperextension. They may not be visible on initial x-rays. Complications can be severe.

The scaphoid is the most commonly injured carpal bone. Scaphoid fractures usually result from wrist hyperextension, typically during a fall on an outstretched hand. They can disrupt the blood supply to the proximal scaphoid. Osteonecrosis is thus a common complication, even when initial care is optimal, and can cause disabling, degenerative arthritis of the wrist.

Symptoms and Signs

The radial wrist is swollen and tender. If patients have these symptoms, scaphoid fracture should be considered. More specific signs include

  • Pain during axial compression of the thumb

  • Pain during wrist supination against resistance

  • Particularly tenderness in the anatomic snuffbox during ulnar wrist deviation

The anatomic snuffbox is palpated just distal to the radius between the extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus tendons.

Diagnosis

  • Plain x-rays

  • MRI

  • If a scaphoid fracture is suspected and imaging is nondiagnostic, presumptive treatment with a thumb spica splint

Initially, plain x-rays (anteroposterior, lateral, and oblique views) are taken but are often normal. In a recent meta-analysis, false-negative rates in most series ranged from 6 to 18% for plain x-rays (1).

If x-rays are normal but a fracture is still suspected, MRI can be done. MRI is being increasingly used to diagnose scaphoid fractures because it is more accurate than CT or bone scanning in the acute setting (1).

If a fracture is suspected clinically and imaging is nondiagnostic, it is treated with a thumb spica splint (see Figure: Thumb spica splint.). Then, if the patient is still in pain or if the wrist is tender when examined after 1 to 2 wk, follow-up plain x-ray is taken.

Pearls & Pitfalls

  • If clinical findings suggest a scaphoid fracture, do MRI or immobilize with thumb spica splint, even if no fracture is evident on x-ray.

Thumb spica splint.

Diagnosis reference

Treatment

  • Thumb spica cast

Many nondisplaced fractures can be treated definitively with a thumb spica cast, which is worn for up to 6 to 8 wk.

Sometimes open reduction and internal fixation (ORIF) is required.

Key Points

  • Scaphoid fractures usually result from wrist hyperextension, typically during a fall on an outstretched hand.

  • These fractures can disrupt the blood supply to the proximal scaphoid; thus, osteonecrosis is a common, sometimes disabling complication.

  • Take anteroposterior, lateral, and oblique x-rays; if imaging is normal or nondiagnostic but clinical findings suggest a scaphoid fracture, do MRI or immobilize with thumb spica splint.

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