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Clinical Summary

The scaphoid is the most common carpal bone fractured. Injuries result from either a fall on an outstretched dorsiflexed hand or an axial load along the thumb’s metacarpal. Misdiagnosis of a scaphoid fracture can result in delayed healing or avascular necrosis due to lack of a direct blood supply to the bone’s proximal portion. Tenderness on anatomic snuffbox palpation is common. Exam of the wrist in ulnar deviation exposes more of the scaphoid to palpation within the snuffbox. Eliciting pain in this area when the patient resists supination or pronation of the hand or pain with axial pressure directed along the thumb’s metacarpal is also suggestive of injury. Negative radiographs do not rule out an occult scaphoid fracture.

Management and Disposition

Initial management includes adequate radiographic evaluation followed by ice, elevation, and a thumb spica splint. Referral to a hand specialist is essential.

Pearls

  1. Patients in whom there is a clinical suspicion of an occult scaphoid fracture should receive a thumb spica splint and a repeat examination in 7 to 10 days.

  2. Avascular necrosis can lead to disabling arthritis.

  3. Magnetic resonance imaging (MRI) is the gold standard for diagnosis.

FIGURE 11.33

Scaphoid Fracture. Fracture of the waist, or middle third, of the scaphoid. These injuries can be associated with delayed healing and avascular necrosis. (Photo contributor: Alan B. Storrow, MD.)

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