Scaphoid Fracture
Scaphoid Fracture - Adult
- Most common carpal fracture (70%), followed by triquetral and trapezium
- Initial x-ray (full scaphoid series): Specificity is 100% but Sensitivity is 80%
- Pre-test probability of scaphoid fracture in patient with scaphoid wrist pain and non-diagnostic x-rays is about 25% (17-38% across 4 studies in this meta-analysis)
Physical Exam
| Physical Exam | Positive LR [95% CI] | Negative LR [95% CI] |
|---|---|---|
| Clamp Sign | 8.6 [0.51-147.0] | 0.40 [0.14-1.18] |
| Resisted Supination Pain | 6.1 [0.04-10.86] | 0.09 [0.00-11.9] |
| Thumb Compression Pain | 2.0 [1.1-3.5] | 0.24 [0.06-0.99] |
| Vibration Pain | 1.8 [0.9-3.4] | 0.56 [0.24-1.32] |
| “Clinical Examination” | 1.8 [0.08-2.9] | 0.22 [0.80-2.90] |
| Scaphoid Tubercle | 1.7 [1.3-2.1] | 0.23 [0.09-0.56] |
| Snuffbox Tenderness | 1.5 [1.1-2.1] | 0.15 [0.05-0.43] |
| Ulnar Deviation Pain | 1.4 [0.8-2.4] | 0.53 [0.13- >1] |
| Swelling | 1.3 [0.07-2.1] | 0.76 [0.36-1.48] |
| Radial Deviation Pain | 1.0 [0.9-1.2] | 0.97 [0.67-1.40] |
| Discoloration | 0.9 [0.3-2.8] | 1.0 [0.73-1.38] |
| Resisted Pronation | 0.09 [0.6-1.3] | 1.44 [0.54-3.87] |
- Clamp sign: Ask the patient “Exactly where does it hurt?” The patient will form a clamp with opposite thumb and index finger on both sides of the thumb
- Pain with resisted supination: Hold the hand of the injured extremity with the patient’s forearm in neutral position. Patient attempts to supination, resulting in pain when the examiner resists.
| Imaging | Positive LR [95% CI] | Negative LR [95% CI] |
|---|---|---|
| Xray fat pad on initial xray | 2.7 [1.4-5.2] | 0.24 [0.07-0.79] |
| Fat pad on 10-14 day follow up x-ray | 4.7 [1.6-14.4] | 0.67 [0.50-0.89] |
| Bone scan | 6.6 [3.9-11.1] | 0.11 [0.05-0.23] |
| Ultrasound (radiologist performed) | 5.6 [3.0-10.5] | 0.27 [0.13-0.56] |
| CT | 15.4 [8.8-27.0] | 0.23 [0.16-0.34] |
| MRI | 22.0 [11.9-40.1] | 0.09 [0.04-0.19] |
NOTE: There is limited usefulness for LR’s with wide CIs.
Management Plan Based on XRay Findings
- Displaced (>1 mm) or proximal pole frature: Orthopedic/Hand consult in ED
- Non- or minimally displaced fracture: Splint and Ortho/Hand clinic follow up in 5-7 days
- Suspected fracture but non-diagnostics xrays:
- Thumb spica splint
- Follow up with primary care physician or Ortho/Hand clinic for repeat exam and potentially repeat x-rays within 10-14 days
Pearls
- The clinical exam has high sensitivity but low specificity
- MRI is the most sensitive and specific imaging modality, but cost-benefit must be balanced with patient’s economic loss from being splinted or a missed fracture.
- Avascular necrosis and nonunion can occur leading to carpal instability and osteoarthritis
- Those at greatest risk: Displaced or initially missed scaphoid fractures
References
Carpenter C, Pines J, Schuur J, Muir M, Calfee R, Raja A. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-121. [PubMed]
