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Scaphoid Fracture Review

Wednesday, May 10, 2017   (0 Comments)
Posted by: Douglas Gregerson, DC, DACBR
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Scaphoid Fracture Review


Wrist trauma is very common. It may be seen in automobile accidents, slip and falls or athletic injuries. The most common fracture at the wrist is the scaphoid fracture. It may not always be easy to diagnose immediately on plain film x-ray. The fracture line may sometimes not be visible for up to three weeks on x-ray. Other imaging modalities such as MRI or radionuclide bone scan may show the fracture much earlier, however. Figure 1 demonstrates what appears to be a normal scaphoid on the left, in a patient with wrist trauma the preceding day. Two weeks later, the fracture line is obvious (circled linear lucency). A delay in diagnosis may increase the likelihood of a serious complication such as avascular necrosis.


The most common site of scaphoid fracture is through the waist, the middle of the scaphoid. Less likely the proximal or distal poles are involved. The most common mechanism is a fall on an outstretched hand with carpal extension and radial deviation. 30% of scaphoid fractures may be occult initially. A patient presenting with a complaint of radial wrist pain after trauma, particularly athletes, should be examined radiographically for the presence of scaphoid fracture. If the initial films are negative, but there is strong clinical suspicion of fracture, there are several recourses for follow-up. A radionuclide bone scan may be performed. There may be a false positive in 6-16% (1) of cases, however. However, false negatives do not occur on bone scan. Another option is to re-x-ray in 7-10 days. Over time, resorption at the fracture site will result in a widening of the fracture line and make it more apparent. MRI examinations generally will show even a non-displaced fracture early on, as well as surrounding bone marrow edema. The use of MRI may be efficacious, even with the increased cost of the examination. The loss of productivity by placing patients in a cast prophylactically while waiting to re-x-ray may outweigh the financial cost of the MRI examination.


Figure 2 is a T-1 coronal image of the wrist in a patient with wrist pain following automobile trauma. The arrow points to a clear fracture line through the waist of the scaphoid, with less obvious surrounding bone marrow edema. The STIR image (figure 3) makes the bone marrow edema more conspicuous, as evidenced by the increased intraosseous signal in comparison with the low signal normal marrow.


Avascular necrosis is a potential major complication of scaphoid fracture. This has been reported to occur in up to 15% of cases. Due to the vascular supply of the scaphoid, the more proximal the fracture line, the greater the likelihood of avascular necrosis. Figure 4 demonstrates a fracture with a widened area of ill-defined lucency and the characteristic increased density in the proximal necrotic fragment.


Another major complication of long standing scaphoid fracture is radiocarpal degenerative arthrosis. Figure 5 demonstrates marked thinning of the radiocarpal articulation with advanced collapse. There is pressure erosion of the medial articular surface of the radius with a large subchondral cyst in the distal radius. The avascular fragment of the scaphoid appears dense and is rotated.


To avoid complication, scaphoid fractures should be identified as early as possible. The standard radiographic examination consists of the PA, oblique, ulnar deviation and lateral views. The ulnar deviation x-ray view may be very useful in visualizing the fracture, as it may distract the fragments and make the fracture line more obvious. If a fracture is not readily identified, the options previously detailed may reveal an occult fracture. MRI examinations should include some type of fat suppressed sequence, in addition to the standard spin echo sequences, in order to identify bone marrow edema.


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1.  Yochum T.R.,Rowe L.J.: Essentials of Skeletal Radiology, ed 3. Philadelphia, Lippincott Williams & Wilkins, 2005


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