Updated: 10/25/2017

Scaphoid Fracture

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Questions
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Snapshot
  • A 27-year-old man falls from standing height and lands on his outstretched left hand. He complains of severe left wrist pain and immobility secondary to pain. On exam, he has tenderness over the anatomic snuffbox. A radiograph of his left wrist is shown and demonstrates a fracture of the proximal pole of the scaphoid.
Introduction
  • Clinical definition
    • fracture of the scaphoid bone
  • Epidemiology
    • incidence
      • most common carpal bone fracture
  • Etiology
    • fall from standing height on an outstretched hand
    • high-energy trauma is less common
  • Pathoanatomy
    • normal anatomy
      • the scaphoid is one of four bones in the proximal carpal row of the wrist
        • other three are the lunate, triquetrum, and pisiform 
      • articulations
        • radius proximally
        • lunate medially
        • trapezium, trapezoid, and capitate distally
      • anatomic subdivisions
        • proximal third
        • middle third (waist)
        • distal third
      • vascular supply
        • dorsal carpal branch of radial artery supplies proximal 80% of the scaphoid via retrograde flow
          • the proximal scaphoid is the most likely to undergo avascular necrosis (AVN) due to its tenuous retrograde blood supply 
        • superficial palmar branch of radial artery supplies distal 20% of the scaphoid
    • fracture location
      • 65% scaphoid waist
      • 25% proximal third 
      • 10% distal third
        • the distal third is the most common site for young children due to the ossification pattern
  • Prognosis
    • favorable
      • stable non-displaced fracture
    • unfavorable
      • unstable displaced fracture
Presentation
  • Symptoms 
    • radial wrist pain
  • Physical exam
    • anatomic snuffbox tenderness dorsally 
    • scaphoid tubercle tenderness volarly 
    • pain with resisted pronation
Imaging
  • Radiography 
    • indications
      • always indicated if the fracture is suspected
      • initial radiographs may be negative
        • if clinical suspicion is high, should repeat radiographs 2-3 weeks after the injury 
    • findings
      • fracture line through the scaphoid
  • MRI 
    • indications
      • most sensitive imaging modality within first 24 hours
      • can be used if initial radiographs are negative
    • findings
      • best modality to demonstrate associated ligamentous injuries
      • allows for assessment of the vascular integrity of proximal pole of scaphoid if AVN is suspected
Differential
  • Distal radius fracture 
    • fracture will be evident on an AP and/or lateral radiograph of the wrist
    • more likely in older patients
  • Wrist sprain
    • ligamentous injury in the absence of a fracture will be evident on MRI 
Treatment
  • Non-operative
    • thumb spica cast immobilization
      • indications
        • stable non-displaced fractures
        • normal radiographs but a high index of suspicion for occult fracture
  • Operative
    • percutaneous pin fixation vs open reduction and internal fixation (ORIF)
      • indications
        • unstable fractures
        • proximal pole fractures
        • comminuted fractures
        • vertical oblique fractures
Complications
  • AVN
    • most common in proximal injuries due to a retrograde blood supply
  • Non-union
    • Scaphoid non-union advanced collapse (SNAC)
      • progressive wrist arthritis due to chronic scaphoid non-union
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.MK.4666) A 46-year-old woman presents to the emergency department after a fall onto an outstretched wrist. You palpate over the anatomical snuff box, but there is no significant tenderness. Your attending orders a radiograph (Figure A). Which are the bones indicated by the red arrows?
Review Topic

QID: 107092
FIGURES:
1

Scaphoid and lunate

10%

(1/10)

2

Scaphoid and hamate

0%

(0/10)

3

Scaphoid and capitate

80%

(8/10)

4

Capitate and hamate

0%

(0/10)

5

Hamate and lunate

10%

(1/10)

M1

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