Figure 1. Anteroposterior image of injured wrist.
Figure 2. Lateral image of wrist.
Figure 3. Scaphoid view of wrist with no apparent injury.
A 13-year-old boy presents with right wrist pain after falling to the ice during a hockey game 2 days ago. He was able to play through the injury during the game but the next day he noticed worsening pain and an inability to turn a doorknob. On physical examination of the right wrist, the patient has mild swelling over the dorsal wrist and tenderness to palpation over the anatomic snuffbox (Figures 1-3).
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Patients that present with a suspected scaphoid injury with negative radiograph evidence of injury create a treatment dilemma for providers. Treating the injury as a suspected occult fracture or obtaining immediate advanced imaging is the controversial next step. Up to 30% to 40% of scaphoid fractures are missed with clinical examination and initial radiograph, and a missed diagnosis can lead to long-term complications.1,2
Anatomical snuffbox tenderness is the most sensitive physical examination finding for identifying scaphoid fractures. Many providers treat patients with snuffbox tenderness with wrist immobilization because of a suspected fracture. However, treating all suspected scaphoid fractures as true fractures can result in unnecessary immobilization, lost time from sports and/or work, and potentially post-immobilization stiffness. Obtaining an immediate image (ie, magnetic resonance imaging [MRI]) is the most cost-effective option and provides the best outcomes. A negative MRI, for example, avoids the expense of further follow-up visits and repeat radiographs. If an immediate MRI is not available or unaffordable, a reasonable approach would be to repeat the physical examination and radiographs 2 weeks after the initial office visit.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.
1. Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. J Bone Joint Surg Am. 2015;97(22):1860-1868. doi:10.2106/JBJS.O.00099
2. Stirling PH, Strelzow JA, Doornber JN, White TO, McQueen MM, Duckworth AD. Diagnosis of suspected scaphoid fractures. JBJS Rev. 2021;9(12). doi:10.2106/JBJS.RVW.20.00247