eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Scaphoid Injury

Author: Scott R Laker, MD, Staff Physician, Department of Rehabilitation, University of Colorado Health Sciences Center
Coauthor(s): Deborah Saint-Phard, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Director, Active Women's Health at CU Sports Medicine Program, University of Colorado Denver; Maria Carmen E Espiritu, MD, PT, Consulting Staff, Espiritu Clinic, Clinch Valley Medical Center; Robert Irwin, MD, Consulting Staff, Florida Orthopaedic Institute
Contributor Information and Disclosures

Updated: Aug 22, 2008

Introduction

Background

Scaphoid fracture is the most common type of bone fracture in the carpus (ie, wrist). Frequently, however, the diagnosis of this scaphoid injury is delayed; a delay in the diagnosis and treatment of a scaphoid fracture may alter the prognosis for union, increase the risk of avascular necrosis, and dramatically increase the long-term likelihood of arthritis.

Related eMedicine topics:
 Avascular Necrosis
Fracture, Wrist
Hand, Fractures and Dislocations: Wrist
Scapholunate Advanced Collapse
Wrist, Scaphoid Fractures and Complications

Related Medscape topic:
 Resource Center Fracture

Pathophysiology

Anatomic considerations

The carpus contains 8 small bones, which are arranged in 2 rows, proximal and distal. The proximal bones, from the radial to the medial side, are the scaphoid, lunate, triquetrum, and pisiform. Only the scaphoid and lunate articulate with the radius; thus, these 2 bones transmit the entire force of a fall on the hand to the forearm. The distal bones are, starting from the radial side, the trapezium, trapezoid, capitate, and hamate.

Blood supply

Anatomically, the scaphoid may be divided into proximal, middle (termed the waist), and distal thirds. Most of the blood supply to the scaphoid enters distally. The proximal part of the scaphoid has no blood vessels entering it, depending instead on vessels that pierce the midportion. Fractures of the proximal third of the scaphoid account for 20% of scaphoid fractures, those of the middle portion account for 60%, and fractures of the distal part make up the remaining 20%. Diminished blood flow to the proximal pole is noted in about one third of fractures at the waist level. This reduced blood supply may result in avascular necrosis of the proximal pole of the scaphoid. Almost 100% of proximal pole fractures result in aseptic necrosis. Displaced scaphoid fractures have a nonunion rate of 55-90%.

Fall onto outstretched hand

The usual mechanism of injury is a fall onto the outstretched hand (FOOSH) that results in forceful dorsiflexion and impaction of the scaphoid against the dorsal rim of the radius. This mechanism explains why snuffbox tenderness is so common, even in the absence of a scaphoid fracture. Conventional medical wisdom dictates that snuffbox tenderness should be equated with a scaphoid fracture unless radiographs prove otherwise. If initial radiographs do not show fracture, follow-up radiographs should be obtained in 7-14 days, because the fracture line may be more visible after some resorption.

Frequency

United States

Scaphoid fracture has been reported in people aged 10-70 years, although it is most common in young adult men following a fall, athletic injury, or motor vehicle accident.

Mortality/Morbidity

The scaphoid has no ligamentous or tendinous attachments, but joint compressive forces, trapezial-scaphoid shear stress, and capitolunate rotation moments exert control on the scaphoid. Therefore, scaphoid fractures have a high incidence of nonunion (8-10%), frequent malunion, and late sequelae of carpal instability and posttraumatic arthritis.

  • A higher incidence of aseptic necrosis and nonunion is noted with fractures of the proximal pole of the scaphoid, because no blood vessels enter it.
  • A scaphoid fracture can present as a nondisplaced, stable fracture or as a displaced, unstable fracture. Displaced fractures frequently are associated with ligamentous tears in the wrist and require thorough evaluation and follow-up.

Race

No known correlation exists between race and scaphoid fracture.

Sex

Scaphoid injuries are more common in men than in women.

Age

Scaphoid fracture is uncommon in children because the physis of the distal radius usually fails first, resulting in Salter type I or II fractures of the distal radius. Similarly, in elderly patients, the distal radial metaphysis usually fails before the scaphoid can fracture.

Clinical

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.

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

  • 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.

Causes

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

More on Scaphoid Injury

Overview: Scaphoid Injury
Differential Diagnoses & Workup: Scaphoid Injury
Treatment & Medication: Scaphoid Injury
Follow-up: Scaphoid Injury
References
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References

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Further Reading

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Keywords

scaphoid injury, scaphoid, scaphoid fracture, scaphoid fractures, broken wrist, wrist fracture, scaphoid bone, wrist surgery, scaphoid waist fracture, avascular necrosis, aseptic necrosis, os scaphoideum, scaphoideum, scaphoid necrosis, os naviculare manus, navicular, navicular bone of hand, navicular bone injury

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Contributor Information and Disclosures

Author

Scott R Laker, MD, Staff Physician, Department of Rehabilitation, University of Colorado Health Sciences Center
Scott R Laker, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Deborah Saint-Phard, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Director, Active Women's Health at CU Sports Medicine Program, University of Colorado Denver
Deborah Saint-Phard, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Colorado Medical Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

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.

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, American College of Physicians, Association of Academic Physiatrists, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

J Michael Wieting, DO, MEd, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Sports Medicine, Associate Director of Physician Assistant Training Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
J Michael Wieting, DO, MEd is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Sports Medicine, American College of Sports Medicine, American Osteopathic Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Association of Academic Physiatrists, and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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