Slideshow
-
Figure 1. Scaphoid view of the wrist taken 2 days after the injury.
-
Figure 2. Repeat radiograph taken 4 weeks after the injury.
A 45-year-old construction worker presents with wrist pain after a fall. The patient is unable to lift objects off the ground or turn a doorknob with his right hand since the fall. On physical examination, he has tenderness to palpation over the anatomical snuffbox of the right wrist. He is placed in a thumb spica cast for 4 weeks and returns to the office for repeat radiographic imaging. Scaphoid view of the wrist taken 2 days after the injury is shown in Figure 1; a repeat radiograph taken 4 weeks after the injury is shown in Figure 2. The images show bone resorption has occurred at the fracture site since the initial x-rays. The patient prefers nonoperative treatment if possible.
Submit your diagnosis to see full explanation.
The scaphoid bone is a problematic bone to fracture given its tenuous blood supply and its predilection for not healing. The blood supply to the scaphoid flows in a distal to proximal direction, which causes scaphoid waist and proximal pole fractures to be more likely to form a non-union.
Treatment of scaphoid waist fractures remains controversial but, in general, less than 2 mm of displacement can be considered for conservative treatment with cast immobilization. Wearing a cast for a minimum of 8 weeks is generally recommended for the management of scaphoid waist fractures. Computed tomography (CT) scan can be performed at 8 weeks to see if a bridging callus is present.1 If there is significant bridging callus present then mobilization of the wrist may begin.
Practically speaking, not every patient can get a CT, therefore factors such as anatomical snuffbox tenderness and interval healing seen on radiographic imaging are important factors. High-risk patients such as those who work in construction or athletes generally require 12 to 14 weeks of immobilization. Immobilization and serial radiographs every 3 weeks or so should be continued until there are radiographic signs of healing, which may take up to 4 to 6 months in some cases.1
Bone resorption is common to see in scaphoid waist fractures at 4 to 6 weeks but this generally improves after 4 to 6 weeks later and can be confirmed on repeat radiographs.2 Concerning signs on imaging that the fracture may be forming a non-union include lack of interval healing, sclerosis of the fracture, cystic changes, increasing bone resorption on subsequent radiographs, and further displacement.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Li NY, Dennison DG, Shin AY, Pulos NA. Update to management of acute scaphoid fractures. J Am Acad Orthop Surg. 2023 Jun 16. Online ahead of print. doi:10.5435/JAAOS-D-22-01210
2. Fan S, Suh N, Grewal R. Observation of bony resorption during scaphoid fracture healing: a case series. J Hand Surg Eur Vol. 2020;45(8):874-876. doi:10.1177/1753193420923269
QUESTION
