Scaphoid fracture

  • It is more common in young adults but rare in children and in elderly people. (MCQ)
  • Commonly, the fracture occurs through the waist of the scaphoid (MCQ)
  • Clinical vignette:
    • Pain and swelling over the radial aspect of the wrist following a fall on an out-stretched hand, in an adult, should make one suspect strongly the possibility of a scaphoid fracture. (MCQ)
    • On examination, one may be able to elicit tenderness in the scaphoid fossa* (anatomical snuff box). (MCQ)
    • A force transmitted along the axis of second metacarpal may produce pain in the region of the scaphoid bone. (MCQ)
  • Radiological features:
    • X ray views to see scaphoid fracture
      • oblique view of the wrist (MCQ)
      • antero-posterior view
      • lateral view
    • What is next step in management in a clinically suspected case of scaphoid fracture if the fracture is not seen on X Ray ? (A high yield MCQ in PG Medical entrance)
      • If a fracture is strongly suspected, X-rays should be repeated after 2 weeks
      • Sometimes, it is just a crack fracture and is not visible on initial X-rays.
      • If no fracture is seen even at 2 weeks, no further treatment is required.
    • Treatment
      • The treatment of a scaphoid fracture is essentially conservative
      • The affected hand is immobilised in a scaphoid cast for 3-4 months. (MCQ)
      • Scaphoid cast:
        • This is a cast extending from below the elbow to the metacarpal heads, includes the thumb, up to the inter-phalangeal joint. (MCQ)
        • The “wrist is maintained in a little dorsiflexion and radial deviation (glass holding position). (MCQ)
      • In widely displaced fractures, open reduction and internal fixation using a special compression screw (Herbert’s screw) is required(MCQ)
      • Complications
      • Avascular necrosis:
      • In fractures through the waist, there is high probability of the proximal fragment becoming avascular(MCQ)
      • The patient complains of pain and weakness of the wrist
      • On the X-ray one finds non-union of the fracture with sclerosis and crushing of the proximal pole of the scaphoid.
      • Treatment:
        • If the patient is symptomatic, the avascular segment of the bone is excised
        • In some cases, the wrist develops osteoarthritis, and is treated accordingly
      • Delayed and non-union:
        • A high proportion of cases of fractures of the scaphoid go into delayed or non-union.
        • Causes of delayed or non-union
          • imperfect immobilization
          • synovial fluid hindering the formation of fibrinous bridge between the fragments
          • impaired blood supply to one of the fragments.
        • In delayed union, the fracture, line may persist on X-ray even after 4-6 months(MCQ)
        • In non-union, distinct radiological features present are
          • rounding of the fracture surfaces
          • the fracture becomes rather sharply defined
          • cystic changes occur in one or both fragments.
        • In a late case of non-union, changes of wrist osteoarthritis such as joint space reduction, osteophyte formation may also be seen.
        • Treatment:
          • In a case where functions are not much impaired, nothing needs to be done.
          • In a case where there is wrist pain and weakness of grip, operative intervention is necessary.
          • For delayed union, bone grafting is sufficient.
          • For non-union(MCQ)
            • the type of operation depends upon the presence of associated osteoarthritis of the radio-carpal joint
            • Once osteoarthritis happens, it is too late to expect relief by aiming at fracture union alone.
            • An excision of part of the radio-carpal joint, or its fusion may be required.
          • Wrist osteoarthritis: (MCQ)
            • osteoarthritis of the wrist develop as a result of avascular  necrosis   or  non-union.
            • In some, excision of the styloid process of the radius is done
            • in extreme cases, wrist arthrodesis may be required.


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