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Emergency and Acute Medicine – Scaphoid Fractures
A scaphoid fracture is the most common fracture of the carpal bones and typically occurs after a fall on an outstretched hand (FOOSH). The scaphoid plays a key stabilizing role between the proximal and distal carpal rows, so injury to this bone can lead to significant long-term complications such as arthritis, malunion, or avascular necrosis (AVN). Fractures most commonly occur at the waist (middle third, 70–80%), followed by the proximal and distal thirds. Because the blood supply enters distally, fractures closer to the proximal pole have a much higher risk of AVN.
Clinically, patients usually present with wrist pain after trauma, especially after FOOSH. The most important physical finding is tenderness in the anatomic snuffbox, which is highly sensitive (≈90%) but not very specific. Additional findings include pain with axial loading of the thumb, tenderness over the scaphoid tubercle, and reduced wrist or thumb range of motion. Despite these signs, diagnosis can be tricky because 10–15% of fractures are not visible on initial X-rays, making clinical suspicion crucial.
Initial imaging includes wrist radiographs (PA, lateral, oblique, and scaphoid views), but a normal X-ray does not exclude a fracture. If suspicion remains high, the injury should be treated as a fracture, and repeat imaging in 7–10 days or advanced imaging (MRI or bone scan) should be arranged. MRI is particularly useful as it can detect fractures within a few days of injury.
Management in the emergency setting focuses on immobilization and prevention of complications. Any patient with snuffbox tenderness should be placed in a thumb spica splint, even if imaging is negative. Nondisplaced fractures are typically managed conservatively with immobilization, while displaced fractures (>1 mm) have a high risk of nonunion (up to 50%) and usually require surgical fixation. All suspected or confirmed cases should have orthopedic follow-up within 7–10 days.
A key clinical pitfall is missing the diagnosis—patients presenting with what seems like a simple wrist sprain may actually have a scaphoid fracture. Failure to immobilize can result in avascular necrosis, chronic pain, and long-term disability. Therefore, when in doubt, always treat as a fracture until proven otherwise.
Emergency and Acute Medicine – Scaphoid Fractures
A scaphoid fracture is the most common fracture of the carpal bones and typically occurs after a fall on an outstretched hand (FOOSH). The scaphoid plays a key stabilizing role between the proximal and distal carpal rows, so injury to this bone can lead to significant long-term complications such as arthritis, malunion, or avascular necrosis (AVN). Fractures most commonly occur at the waist (middle third, 70–80%), followed by the proximal and distal thirds. Because the blood supply enters distally, fractures closer to the proximal pole have a much higher risk of AVN.
Clinically, patients usually present with wrist pain after trauma, especially after FOOSH. The most important physical finding is tenderness in the anatomic snuffbox, which is highly sensitive (≈90%) but not very specific. Additional findings include pain with axial loading of the thumb, tenderness over the scaphoid tubercle, and reduced wrist or thumb range of motion. Despite these signs, diagnosis can be tricky because 10–15% of fractures are not visible on initial X-rays, making clinical suspicion crucial.
Initial imaging includes wrist radiographs (PA, lateral, oblique, and scaphoid views), but a normal X-ray does not exclude a fracture. If suspicion remains high, the injury should be treated as a fracture, and repeat imaging in 7–10 days or advanced imaging (MRI or bone scan) should be arranged. MRI is particularly useful as it can detect fractures within a few days of injury.
Management in the emergency setting focuses on immobilization and prevention of complications. Any patient with snuffbox tenderness should be placed in a thumb spica splint, even if imaging is negative. Nondisplaced fractures are typically managed conservatively with immobilization, while displaced fractures (>1 mm) have a high risk of nonunion (up to 50%) and usually require surgical fixation. All suspected or confirmed cases should have orthopedic follow-up within 7–10 days.
A key clinical pitfall is missing the diagnosis—patients presenting with what seems like a simple wrist sprain may actually have a scaphoid fracture. Failure to immobilize can result in avascular necrosis, chronic pain, and long-term disability. Therefore, when in doubt, always treat as a fracture until proven otherwise.
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