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Scaphoid Injury Clinical Presentation

  • Author: Scott R Laker, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Apr 06, 2015
 

History

Scaphoid fracture can occur through 2 different mechanisms: a compression injury or a hyperextension (ie, bending) injury.

  • The compression injury from a more longitudinal load or impaction of the wrist leads to fracture of the scaphoid without displacement.
  • In a hyperextension injury, when tensile stresses generated and applied to the wrist exceed bone strength, a displaced fracture commonly results.
  • Other fractures or dislocations of the carpus and forearm occur in 17% of patients.
  • In many wrist sprain injuries, the dorsal rim of the radius and the waist of the scaphoid abut, resulting in a contusion of the scaphoid, or even the capsule, with resulting pain that can be provoked by deep palpation in the snuffbox.
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Physical

The patient with a scaphoid fracture often presents complaining of wrist pain and may be diagnosed as having a sprain of the wrist. In sports-related injuries, it is not uncommon for a fractured scaphoid to go unnoticed. Pain and tenderness are often on the radial side of the wrist. Pain often is exacerbated with wrist motion. The importance of increasing the number of clinical tests for this injury is vital; one study found that emergency department residents had difficulty naming diagnostic maneuvers beyond "snuffbox tenderness."

  • A reliable correlation exists between scaphoid fracture and pain provoked by deep palpation at the volar tubercle of the scaphoid, which is the first bony prominence distal to the volar distal radius.
    • A high positive correlation with scaphoid fracture exists when there is tenderness upon palpation at the snuffbox and volar tubercle.
    • Scaphoid fracture is not very likely when tubercle palpation does not provoke pain in the snuffbox.
  • Range of motion (ROM) is reduced, but not dramatically.
  • Swelling around the radial and posterior aspects of the wrist is common. If high forces are associated with the injury, ligamentous trauma is also possible.
  • These same findings may be present with ligamentous injuries of the wrist; thus, whenever findings are suggestive of a scaphoid fracture, the patient should be treated for a scaphoid fracture.

Special provocation maneuvers

See the list below:

  • Watson (scaphoid shift) test
    • The patient sits with the forearm pronated. The examiner takes the patient's wrist into full ulnar deviation and extension. The examiner presses the patient's thumb with his/her other hand and then begins radial deviation and flexion of the patient's hand.
    • If the scaphoid and lunate are unstable, the dorsal pole of the scaphoid subluxes over the dorsal rim of the radius and the patient complains of pain, indicating a positive test.
  • Scaphoid stress test
    • The patient sits while the examiner holds the patient's wrist with one hand, with the examiner applying pressure with his/her thumb over the patient's distal scaphoid. The patient then attempts radial deviation of the wrist.
    • If excessive laxity is present, the scaphoid is forced dorsally out of the scaphoid fossa of the radius with a resulting audible clunk and pain, indicating a positive test.
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Causes

Scaphoid fractures usually are an injury of young men and women, occurring after a fall, athletic injury, or motor vehicle accident.[1]

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Contributor Information and Disclosures
Author

Scott R Laker, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Medical Director, Lone Tree Health Center

Scott R Laker, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Irwin, MD Consulting Staff, Florida Orthopaedic Institute

Robert Irwin, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American College of Physicians, Association of Academic Physiatrists, North American Spine Society

Disclosure: Nothing to disclose.

Deborah Saint-Phard, MD Associate Professor, Department of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Director, CU Women's Sports Medicine Program, University of Colorado Denver School of Medicine, Aurora, Colorado

Deborah Saint-Phard, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Colorado Medical Society, Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR Senior Associate Dean, Associate Dean of Clinical Medicine, Consultant in Sports Medicine, Assistant Vice President of Program Development, Division of Health Sciences, DeBusk College of Osteopathic Medicine; Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, American Osteopathic Academy of Sports Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Maria Carmen E Espiritu, MD, PT Consulting Staff, Espiritu Clinic, Clinch Valley Medical Center

Maria Carmen E Espiritu, MD, PT is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Medical Association

Disclosure: Nothing to disclose.

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