eMedicine Specialties > Radiology > Musculoskeletal

Wrist, Scaphoid Fractures and Complications

Author: Carol A Boles, MD, Associate Professor, Associate in the Surgical Sciences - Orthopaedic Surgery, Department of Radiology, Section of Musculoskeletal Radiology, Wake Forest University Baptist Medical Center
Contributor Information and Disclosures

Updated: Nov 16, 2007

Introduction

Background

The scaphoid is the most frequently fractured carpal bone, accounting for 71% of all carpal bone fractures. Scaphoid fractures often occur in young and middle-aged adults, typically those aged 15-60 years. About 5-12% of scaphoid fractures are associated with other fractures, and approximately 1% of scaphoid fractures are bilateral. The importance of scaphoid fracture diagnosis is clear when one realizes that 90% of all acute scaphoid fractures heal if treated early. (See also the eMedicine articles Scaphoid Injury; Carpal Fractures; Fractures, Wrist; and Hand, Fractures and Dislocations: Wrist.)

Pathophysiology

The primary mechanism of injury to the scaphoid bone is a fall on an outstretched hand. A scaphoid fracture is part of a spectrum of injuries based on the following 4 factors:

  • Direction of the 3-dimensional loading
  • Magnitude and duration of the force
  • Position of the hand and wrist at the time of injury
  • Biomechanical properties of ligaments and bones

These factors affect the end result of the fall: distal radius fracture, ligamentous injury, scaphoid fracture, or a combination of these.

Frequency

United States

Approximately 345,000 new scaphoid fractures occur each year in the United States.

Mortality/Morbidity

Concurrent fractures about the wrist occur in 5-12% of scaphoid fractures. The most frequently encountered fractures are radial styloid fractures, triquetrum fractures, capitate fractures, or transcarpal perilunate fracture-dislocations (see Image 1). Concurrent fractures of the distal radius are infrequent. When they do occur, the distal radius fracture determines the outcome and dictates treatment (see Image 2). Additional fractures are more common in young individuals and in persons with associated high-impact injuries than they are in other individuals. In 1 study, associated radial head fractures were found in 6% of all scaphoid fractures. (See also the eMedicine article Perilunate Fracture Dislocations.)

Complications of scaphoid fractures can include malunion, delayed union and nonunion, and avascular necrosis (AVN). Osteonecrosis is more common in scaphoid fractures than in most other bones because of the blood supply to this bone. Please refer to the discussion in Anatomy.

  • Malunion
    • Subsequent radiographic evaluation of scaphoid fractures should be used to assess complications.
    • Malunion may lead to limited motion about the wrist, decreased grip strength, and pain.
    • The most frequent pattern of malunion is a persistent angular deformity, or a humpback deformity.
    • An angular deformity can be quantified by using the intrascaphoid angle. In the sagittal plane, the proximal and distal articular surfaces of the scaphoid are identified and a line is drawn perpendicular to this (similar to the way the line for the lunate is determined in evaluating capitolunate and scapholunate angles). Because these do not usually intersect, perpendicular lines can be drawn to measure this angle. An abnormal intrascaphoid angle is greater than 35°. An intrascaphoid angle that is greater than 45° is associated with a poor clinical outcome. Often, this angulation is associated with a dorsal intercalated segmental instability (DISI).
    • Although case reports of spontaneous correction of scaphoid malunion in children exist, the scaphoid has little potential for remodeling when compared with the rest of the pediatric skeleton.
    • Malunion is usually treated with osteotomy and bone grafting to correct the length and angular deformity. Ligamentous instability is treated at the same time.
  • Delayed union and nonunion
    • Delayed union is a union that is incomplete after 4 months of cast immobilization. Nonunion is an unhealed fracture with smooth fibrocartilage covering the fracture site. Synovial fluid is present in the interval.
    • About 10-15% of all scaphoid fractures do not unite. Some degree of delayed union or nonunion occurs in nearly all proximal-pole fractures and in 30% of scaphoid waist fractures.
    • Delayed union is anticipated if fracture treatment is delayed for several weeks. The risk of nonunion increases after a delay of 4 weeks. These delays may be related to the patient's failure to seek treatment for a presumed sprain, but they are more frequently related to improper or incomplete immobilization or a failure to diagnose and treat the acute fracture (see Image 3).
    • Fracture instability, often unrecognized, is a common cause of delayed union and nonunion. Other factors that influence healing are fracture location, degree of displacement, instability, and osteonecrosis.
    • As many as 30% of scaphoid fractures develop increased density of the proximal pole. This frequently is reversible, and it is no longer considered to be a sign of impending nonunion or osteonecrosis. It is often seen with delayed union, and it is thought to be related to relative ischemia in the proximal pole (see Image 4).
    • Sakuma and colleagues evaluated magnetic resonance imaging (MRI) findings in scaphoid nonunion.1 They found no difference in the appearance of the MRI scan in 7 patients with a plain radiographic finding of increased opacity of the proximal pole and in 25 patients with normal opacity in the proximal pole.
    • Delayed union or persistent motion about the fracture may lead to cyst formation about the fracture. Healing leads to the ingrowth of granulation tissue and to eventual bone formation.
    • Radiographic hallmarks of nonunion are the following: sclerosis at the fracture site, cystic cavitation, displacement of more than 1 mm, local tenderness, and a persistent, lucent line that is usually wider than 2 mm. The sclerotic margins, although characteristic, may become evident only after several months or years as the pseudoarthrosis matures. Osteonecrosis of the proximal pole may or may not be present. Fibrosis and adhesions may decrease mobility about the nonunion, but all nonunions are considered unstable (see Image 5).
    • Arthrography has been used to differentiate pseudoarthrosis from fibrous union. Contrast material flows between the fracture fragments when a true pseudoarthrosis is present.
    • Polytomography and computed tomography (CT) scanning have been used to evaluate osseous bridging.
    • MRI is not an adequate evaluation for nonunion. T1-weighted MRI scans have been reported to show low signal intensity in the distal and/or proximal fragments when they are not united with a variable, T2-weighted appearance. The investigators reported normal marrow signal intensity in 8 of 10 instances in which there was radiographic union; however, radiographs and CT scans showed union in 2 instances in which MRI scans demonstrated decreased signal intensity in the proximal pole.
    • A nonunion of the scaphoid tubercle is typically asymptomatic and often not treated. If symptomatic, these fractures may be fixed with Kirschner wires (K-wires), or the fragment may be removed. Also, removal of an adjacent inflamed bursa may successfully treat symptomatic nonunion.
    • Treatments of delayed union and nonunion vary. If the delayed union is stable and less than 6 months old relative to the time of injury, prolonged cast immobilization with or without electrical stimulation may be used. Several methods of internal fixation and surgical techniques exist; none have universally good results. The treatment of choice for a symptomatic nonunion is the placement of a bone graft and fixation.2 Occasionally, intercarpal fusion and excision of the proximal pole or entire scaphoid are used as treatment methods. Rarely, proximal row carpectomy is performed. Many surgeons treat all nonunions rather than only the symptomatic ones because chronic nonunions are associated with secondary osteoarthritis.
    • Results of studies by Mack and colleagues3 and Ruby and coauthors4 have suggested that the natural history of scaphoid nonunion is early arthritis. Their studies have been criticized for their selection bias, with the suggestion that neither the incidence of truly asymptomatic nonunion without early degenerative change nor the time interval to the development of arthritis is known.
    • Some patients with a scaphoid nonunion continue to work without symptoms for as long as 20 years. It is primarily believed that arthritis eventually becomes symptomatic and that it should be prevented if possible.
    • Radiographically, healing across a nonunion may be difficult to evaluate. Cystic lucencies often become less obvious over time, but they may persist. These lucencies are more likely on the radial side of the scaphoid. If lucencies on 1 side of the fracture are resolving, healing is likely.
    • Success rates for the treatment of nonunion are as high as 82%. Initial failure is typically treated with reattempted bone grafting.
  • Avascular necrosis
    • Osteonecrosis occurs in 15-30% of all scaphoid fractures, and in these instances, it most commonly involves the proximal pole. The more proximal the fracture line is, the greater the chance that osteonecrosis will develop. This decreases the probability that the blood supply to the proximal pole will be preserved.
    • A bone graft is often placed in an attempt to promote healing, although some physicians consider AVN to be a contraindication to bone grafting. The radiographic hallmark of osteonecrosis is collapse and fragmentation (see Image 6).
    • MRI evaluation of scaphoid osteonecrosis may be useful, but it is not 100% sensitive or specific. Cerezal and colleagues described the complex patterns of signal-intensity changes in the proximal pole.5 Their results suggest that the entire fragment may not be uniformly vascularized or avascularized. In the study, nonenhanced MRI had a sensitivity of 36%, a specificity of 78%, and an accuracy of 68% in the preoperative evaluation of the proximal fragment's vascular status. Contrast-enhanced imaging had a sensitivity of 66%, a specificity of 88%, and an accuracy of 83%. Qualitative assessment of enhancement on fat-suppressed, T1-weighted images was used. The degree of vascularity (rather than its complete absence or presence) may prove to be useful in determining the likelihood of successful bone grafting in the presence of AVN.
    • Sakuma and colleagues evaluated the signal intensities of nonunion on T1- and T2-weighted MRI scans and correlated the findings with the success of bone grafting.1 Signal intensity was divided into 3 levels: normal (equal to that of the rest of bone marrow), slightly decreased (less than that of bone marrow but greater than that of cortex), and decreased (less than that of cortex). Both sequences were important. In patients with decreased signal intensity on T1- and T2-weighted sequences, no healing occurred. The healing rate was 75% with hypointensity on T1-weighted images and slight hypointensity on T2-weighted sequences, 92% with slight hypointensity on T1-weighted images and isointensity on T2-weighted images, and 100% with slight hypointensity on T1- and T2-weighted images or with hypointensity on T1-weighted images and isointensity on T2-weighted images.
    • Further outcome studies are needed because the prognosis depends on the amount of devascularized bone, the size of the proximal fragment, and bone integrity. In the femoral head, changes in AVN have been shown to be reversible. Successful surgery leads to the reestablishment of the viability of the proximal pole as it heals.
  • Arthritis
    • Follow-up studies in patients with previous scaphoid fractures, especially those with nonunion or malunion, should be used to evaluate for the presence of arthritis.
    • Arthritis may involve the radioscaphoid joint, especially with AVN, as well as adjacent joints. Long-standing scaphoid nonunion may result in carpal collapse, a condition known as scaphoid nonunion advanced collapse (SNAC) wrist; this is similar to scapholunate advanced collapse (SLAC) wrist, which is found with chronic scapholunate ligament tears (see Images 5-6). This pattern may present 4-5 years or more than 20 years after the initial injury. Degenerative changes are usually first found in the radioscaphoid joint, subsequently occurring in the scaphocapitate joint and, after that, in the lunocapitate joint. Most patients who have SNAC wrist with nonunion of the middle or distal third also have DISI. (See also the eMedicine article Scapholunate Advanced Collapse.)

Age

Scaphoid fractures often occur in young and middle-aged adults, typically those aged 15-60 years. In adults, 70% of scaphoid fractures involve the waist; 10-20%, the distal pole; 5-10%, the proximal pole; and 5%, the tubercle. Historically, the distribution in children is different, with about 52% involving the tubercle; 33%, the distal third; and 15%, the waist. Proximal-pole fractures are rare, and most of them heal without complication. However, because the number of children who participate in organized sports has risen, the distribution of fractures in children has become similar to that in adults.

Anatomy

The scaphoid lies at the radial border of the proximal carpal row, but its elongated shape and position allow bridging between the 2 carpal rows, and it acts as a stabilizing rod. The scaphoid articulates with the radius, lunate, capitate, trapezoid, and trapezium. As a result, nearly the entire surface is covered with hyaline cartilage. Vessels may enter only at the sites of ligamentous attachment: the flexor retinaculum at the tubercle, the volar ligaments along the palmar surface, and the dorsal radiocarpal and radial collateral ligaments along the dorsal ridge.

The dorsal and volar branches of the radial artery provide the blood supply to the scaphoid. The primary blood supply comes from the dorsal branch of the radial artery, which divides into 2-4 branches before entering the waist of the scaphoid, along the dorsal ridge. The branches course volarly and proximally within the bone, supplying 70-85% of the scaphoid. The volar scaphoid branch also enters the bone as several perforators in the region of the tubercle; these supply the distal 20-30% of the bone (see Image 7).

Presentation

With a fall on an outstretched hand, the wrist is extended, and the forearm is pronated at the time of impact. With impact on the thenar side of the wrist, the result is dorsiflexion and radial deviation. In contrast to distal radius fractures, scaphoid fractures may result from more distal impact of forces focused at the intercarpal joint, with subsequent increased force across the scaphoid waist (see Image 8). This same mechanism may lead to ligamentous injury, notably scapholunate dissociation, rather than fracture.

Fractures of the distal pole and tubercle are often caused by a direct impact or blow. Typically, no ligamentous injury occurs. Avulsion fractures may be seen along the radial surface at the attachment sites of the radial collateral ligament, the result of forced ulnar deviation. Stress fractures of the scaphoid waist may occur with repeated stress on the scaphoid. These fatigue fractures are usually incomplete and typically occur in gymnasts and shot-putters.

Scaphoid fractures have been classified according to various criteria. For example, they can be grouped according to the anatomic location, as follows (see Image 9):

  • Tubercle fractures - These are usually uncomplicated, and if nonunion occurs, they are frequently asymptomatic.
  • Distal-pole fractures - Such fractures are usually uneventful. This group can be subdivided into the following:
    • Fractures that involve the articulation with the trapezium and trapezoid
    • Fractures that do not involve this articulation
  • Proximal-pole fractures - The more proximally located the fracture plane is, the greater the risk of delayed union, nonunion, and AVN.2

Scaphoid fractures can also be classified according to the plane of fracture with respect to the long axis of the scaphoid, being grouped into horizontal oblique, transverse, and vertical oblique fractures (see Image 10). Increased shear forces in vertical oblique fractures may prolong the time for fracture healing.

Another classification system categorizes scaphoid fractures according to the time of injury and subsequent healing, as follows:

  • Acute
  • Delayed union - An incomplete union after 4 months of cast immobilization.
  • Nonunion - An unhealed fracture with smooth, polished surfaces of fibrocartilage.

This classification system is used in treatment planning, because a delayed union may be successfully treated with prolonged casting, whereas a nonunion requires internal fixation. About 90% of all acute scaphoid fractures heal if treated early.

The most important classification scheme distinguishes stable scaphoid fractures from unstable ones (see Image 11).

  • Stable fractures - These are incomplete or, if they appear complete, are likely to have an incompletely disrupted articular surface (that is, intact overlying cartilage). Neither displacement nor motion about the fracture occurs with wrist motion. Stable fractures are not associated with ligamentous injury. They are treated with immobilization alone, although stable fractures usually heal regardless of the type of treatment and can even do so without treatment.
  • Unstable fractures - These are complete fractures with motion about the fracture site. Findings that indicate instability include cortical offset greater than 1 mm, fracture angulation, associated ligamentous injury, and motion with ulnar or radial deviation. Ligamentous injury most frequently involves the scapholunate ligament; the scapholunate interval may widen, or a DISI pattern may be seen on a lateral view. Unstable fractures require fixation; it is impossible to maintain reduction of an unstable fracture with cast immobilization alone.

Preferred Examination

Radiographic evaluation of a scaphoid fracture begins with conventional radiography. Bone scintigraphy has had a role in the initial evaluation of wrist trauma, although CT scanning and MRI have been used with increasing frequency in initial and follow-up evaluations of the fracture and its complications. Early diagnosis of a scaphoid fracture is important because nonunion is more likely if treatment is delayed. The initial assessment of stability influences management; a careful evaluation is required.

Limitations of Techniques

CT scanning is excellent in the initial evaluation of a scaphoid fracture, particularly in a high-performance athlete in whom initial radiographic findings are normal. Also, CT scanning can demonstrate healing, which is sometimes misleading on radiographs, particularly with hardware in place.

Instead of CT scanning, MRI can be used as a screening tool for patients with negative radiographic results. Also, magnetic MRIs may define bone contusions rather than fracture as the source of pain. It has been used in the evaluation of complications, particularly osteonecrosis, but care should be emphasized in the diagnosis of avascularity, because some ischemia is expected in the proximal pole after waist and proximal-pole fractures. Typically, MRI is not useful in the evaluation of healing.

Differential Diagnoses

Radius, Distal Fractures
Wrist, Perilunate Injuries

Other Problems to Be Considered

When displacement occurs about the scaphoid fracture, ligamentous injury and instability should be suspected. Posttraumatic instability typically involves the proximal carpal row, which acts as a link between the distal radius and distal carpal row. This instability may be static or dynamic. With static instability, the patient is unable to position the carpal bones normally, and the abnormal alignment is readily visible on routine radiographs. With dynamic instability, the carpal alignment appears normal on radiographs, but it becomes abnormal in certain positions or with motions of the wrist.

The most common carpal instability pattern is scapholunate dissociation. It is frequently the first radiographic sign to suggest instability. However, although the scapholunate ligament may be disrupted, the scapholunate interval may be normal. A scapholunate distance of 2-3 mm or more on a routine posteroanterior (PA) view suggests elongation and possible disruption of the scapholunate ligament. A distance greater than 4 mm is considered to be diagnostic of a scapholunate ligament disruption, although this distance should be viewed in the context of the other intercarpal distances.

Recognition of carpal instability is important and helpful in treatment planning, because such instability reflects a more serious injury. Instability patterns may not be recognized on the initial radiographs and should be evaluated with every follow-up study. Intercarpal collapse may predispose the patient to nonunion and degenerative arthritis.

More on Wrist, Scaphoid Fractures and Complications

Overview: Wrist, Scaphoid Fractures and Complications
Imaging: Wrist, Scaphoid Fractures and Complications
Follow-up: Wrist, Scaphoid Fractures and Complications
Multimedia: Wrist, Scaphoid Fractures and Complications
References
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Further Reading

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Keywords

navicular fractures, wrist fracture, humpback deformity, persistent angular deformity, intrascaphoid angle, dorsal intercalated segmental instability, DISI

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Contributor Information and Disclosures

Author

Carol A Boles, MD, Associate Professor, Associate in the Surgical Sciences - Orthopaedic Surgery, Department of Radiology, Section of Musculoskeletal Radiology, Wake Forest University Baptist Medical Center
Carol A Boles, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

William R Reinus, MD, MBA, FACR, Professor of Radiology, Temple University; Chief of Musculoskeletal and Trauma Radiology, Vice Chair, Department of Radiology, Temple University Hospital
William R Reinus, MD, MBA, FACR is a member of the following medical societies: American College of Physician Executives, American College of Radiology, American Roentgen Ray Society, Missouri State Medical Association, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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